1. The Prognosis of Iliotibial Band Syndrome: Short vs. Long-term Recovery
Morgan Toland, SPT
June 28, 2016

2. Clinical Question
Two patient scenarios with diagnosis of iliotibial band syndrome (ITBS)
1. 47 yo male cyclist/runner, better after 3 PT visits
2. 24 yo male runner, PT since end of April
Why do some runners with ITBS recover after just several treatments, opposed to those who require weeks-months of physical therapy?
What variables determine a shorter recovery in runners with ITBS?
I came up with my clinical question after seeing 2 different patients both with ITBS who presented very differently
One was an older recreational cylcist/runner who was better after just 3 sessions over the course of 2 weeks
The other was a younger more avid runner who has been coming to PT for months

3. Background ITBS one of most common overuse injuries of lower extremity
Leading cause of lateral knee pain in runners
1.6-12% of all running-related injuries
Anatomy
Originates in fibers of gluteus maximus, medius, and TFL to act as lateral stabilizer against hip adduction
Inserts distally on Gerdy’s tubercle

4. What Causes ITBS?
Exact etiology unclear and is likely a combination of factors
Proposed mechanisms:
Sudden increase in mileage
Continuous friction between ITB and lateral femoral condyle  irritation
Maximal impingement after HS at ~30° knee flexion
Gluteus medius weakness
Premature firing and overuse of TFL and ITB
Increased hip ADD and IR
Increased rearfoot eversion
Talar ADD causes tibial IR

5. Article 1
Nohren, B., Davis, I., & Hamill, J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech, 22,
Prospective study

6. Purpose
Compare lower extremity kinematic and kinetic variables of interest in female runners who develop ITBS vs. those who do not
Hypothesis: those who develop ITBS will demonstrate greater peak hip ADD, knee IR, rearfoot eversion, and no difference in knee flexion at heel strike

7. Methods Subjects Data collection
Female runners years, 20+ miles per week
400 participants recruited over the course of 4 years
Injury free at baseline
Data collection
Instrumented gait analysis during stance phase
Retro-reflective markers on pelvis, thigh, shank, foot
Run 25 m walkway at 3.7 m/s under force plate
Followed monthly via for two years
Mileage
Running-related injuries (diagnosed by medical professional)

8. Methods (contd. ) 18 participants developed ITBS Control group:
18 age and mileage-matched runners
No previous hip or knee injury
Instrumented gait analysis repeated
Kinematic variables
Peak hip ADD, knee IR, rearfoot eversion, knee flexion at HS
Kinetic variables
Peak hip ABD, knee ER, rearfoot inversion moments
Injured leg of ITBS compared to right leg of control

9. Results Significant differences in ITBS:
Increased hip ADD and knee IR during landing
Remained more ADD and IR throughout stance
Greater femoral ER
Lower peak RF eversion
Landed in slight inversion, but similar pattern to control throughout stance
No significant differences between groups:
Rearfoot inversion moments
Hip ABD moment
Knee flexion at HS
Support of hypothesis
Greater hip ADD and knee IR
Rejection of hypothesis
Less rearfoot eversion than control
No significant differences in any of moments
Landed in

10. Discussion Greater hip ADD  increased strain on ITB
Inability to control hip with ABD due to weakness?
However, no differences in ABD moments found
Difference in timing vs. magnitude of activation?
Niemuth et al. 2005: weak hip ABD of injured leg
Is weakness cause or result of injury?
Increased knee IR  moves insertion of ITB medial
Increased compression against lateral condyle
No bursa to protect ITB from sheering
Knee IR comes from either femoral ER or tibial IR
Greater femoral ER, less tibial IR
Hip musculature imbalances?
Co-contraction of internal and external rotators of hip required to keep femoral head in acetabulum during stance
Glut min, anterior fibers of glut med, TFL all ABD and IR the femur
Inadequate activation  increased femoral ER and ADD

11. Clinical Takeaway No data included regarding recovery Longer recovery?
Faulty running mechanics
Increased hip ADD and knee IR at HS

12. Article 2
Fredericson, M., Cookingham, C.L., Chaudhari, A.M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S.A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3),

13. Purpose
Compare injured limb hip abductor strength vs. healthy limb and control strength
Does the correction of strength deficits (if present) lead to a successful return to running?

14. Methods Parameters Details Participants
24 collegiate & club long-distance runners
Ages (avg 27)
Diagnosis of ITBS
-Tenderness over lateral epicondyle
-Reproducible pain with knee flexion/extension
-No effusion, joint line tenderness, + McMurray’s
Exclusion criteria
History of knee injury, surgery, or symptoms of other knee pathology (PFPS, popliteus tendinitis, DJD)
Control
30 cross-country & track runners at Stanford University
No current spine or LE injury
No history of non-treated LE injury within past 5 years
Outcome measures
Hip abductor strength via hand-held dynamometer (HHD)
-Normalized for body weight and height
-Baseline vs. post-PT after 6-week rehab

15. ITBS Rehabilitation Program
1x/week for 6 weeks treated by same PT
NSAIDs prescribed until pain-free with ADL’s
Ultrasound with corticosteroid gel first 1-2 visits
Decrease inflammation
2 stretches for ITB holding 15 sec, performed 3x daily
Gluteus medius strengthening focus
Side-lying hip ABD and pelvic drops
Initially 1 set of 15 reps  3 sets of 30 reps after several weeks

16. http://www. physioadvisor. com

17. Bottom leg flexed for balance, top leg in slight hip ext/ER
Pelvic drop: standing on step on involved leg, lowering opposite pelvis
Mirror used initially for visual feedback to ensure proper technique

18. Results: ABD Torque (%BWh)
Males
Females
Pre-Rehab: Involved
6.86 ± 1.19
7.82 ± 1.93
Pre-Rehab: Non-involved
8.62 ± 1.16
9.82 ± 2.98
Control
9.73 ± 1.30
10.19 ± 1.19
Post-Rehab
10.38 = 51.4% increase
10.55 = 34.9% increase
All comparisons statistically significant (p<0.05)
Post-rehab:
22/24 runners pain-free, return to run program
No reoccurrence at 6mo follow-up
As you can see, the control group was stronger initially, but the ITBS had a drastic increase in strength after rehab
And this was actually related to a successful return to run in 22/24 participants
They also did not have any reoccurrence at the 6mo follow-up

19. Discussion
Runners with ITBS demonstrate weaker hip ABD muscles in involved limb
Why?
Running primarily sagittal plane sport
Less demand vs. sports requiring higher frontal/transverse plane movement
Requirements of gluteus medius during running
Eccentric contraction during HS to control hip ADD
Concentric contraction during remainder of stance phase and propulsion into swing
Gluteus medius weakness  decreased hip ABD control
Leads to increased hip ADD/IR  increased ITB strain
More vulnerable to impingement on lateral epicondyle during HS

20. Clinical Takeaway
Decrease in symptoms and return to run is associated with strengthening of hip abductors
Quicker recovery from ITBS?
Present with decreased hip ABD strength
Receive rehab program focused on hip strengthening
From this study,, it is evident that a decrease in symptoms & return to run is associated with strengthening of hip abductors
What I took from this study to relate back to my questions, is that those who develop ITBS due to hip musculature imbalances may recover quicker than others with different etiologies if receiving rehab program focused on hip strengthening

21. Article 3
Shamus, J., & Shamus, E. (2015). The management of iliotibial band syndrome with a multifaceted approach: a double case report. International journal of sports physical therapy, 10(3), 378.

22. Purpose Etiology of ITBS is unclear
Friction between ITB and lateral epicondyle
Decreased ITB and iliopsoas extensibility
Abnormal LE kinematics
Variety of evidence regarding most effective treatment
Anti-inflammatory meds in initial stages
Is inflammation the actual source or even present?
Strengthening, neuromuscular re-education, manual therapy, stretching, shoes, training schedule
Utilize the concept of regional interdependence as the basis of treatment of ITBS through a comprehensive model in 2 case reports

23. Case 1: Background 36 yo female diagnosed with left ITBS
VAS: 9/10 stabbing pain at mile 2, forced to stop
Self-care
Static ITB stretching in standing & supine with strap
Foam roll before/after each run x 20 minutes
Previously running 2 marathons per year before children
Goal: able to run half-marathon

24. Physical Examination Major findings Hypothesis
Genu recurvatum and lordosis in standing
Limited lumbar spine AROM
L5 FRS, L on R sacral torsion, L innominate posteriorly rotated/outflare
Posterior fibular head at superior tibiofibular joint
Increased muscle tone
Psoas, piriformis, lateral gastrocnemius
Mild pronation bilaterally during gait analysis
Hypothesis
ITBS due to regional interdependence associated biomechanical & neuromuscular dysfunctions
Multifaceted approach > local approach

25. Day 1 Interventions Exercises Response after treatment MET
Grade III mobilization to superior tibiofibular joint
ITB myofascial release
Soft tissue mobilization to piriformis, lateral gastroc, psoas
Exercises
Upper/lower trunk rotation in side-lying
Isometric hip ABD/ADD
Postural re-education of knee position
Dynamic stretching
Verbal cues during gait retraining
Response after treatment
Ran 3 miles no pain (even ground, no cement)
VAS 0/10
No ITB tenderness

26. Day 3 – Treatment 2 Interventions Exercises Response after treatment
Soft tissue mobilization of psoas
Exercises
Side-lying hip ABD & clam shells
Lateral step downs for knee neuromuscular re-education
Instructed to run 3x per week, every other day
Response after treatment
No positional faults
Normal muscle tone
Running up to 5 miles without pain

27. Day 13 – Treatment 3 & Discharge
Increase to one long run no more than 25% of weekly total mileage
Progress long run every other week until able to run half-marathon

28. Discussion
Multifaceted approach based upon impairments found during exam is most effective in decreasing recovery time
Lumbosacral spine & LE joint mobilizations/techniques
Vaughn: isolated knee pain abolished after lumbosacral mobilization
Grassi et al: normalize weight distribution in LE after SI joint HVLA mobilization
Soft tissue mobilization
Immediate reduction in pain level
Inflammation may not be driving source
Strengthening
Neuromuscular re-education
Necessary for proper running form
Running analysis/retraining
Surface, shoes, training schedule

29. Putting It Together
Limited evidence regarding factors that determine a longer or shorter recovery from ITBS
Longer recovery possible factors:
Faulty mechanics
Increased hip ADD & knee IR during HS and stance
Psychosocial factors
Anxiety & stress about return to sport
Perception of pain and disability
No previous experience of injury or pain
Shorter recovery possible factors:
Etiology due to strength imbalance
Multifaceted approach that identifies specific impairments

30. Questions???

31. References
Fredericson, M., Cookingham, C.L., Chaudhari, A.M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S.A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3), Grassi Dde O, de Souza M.Z., Ferrareto S.B., Montebelo, M.I., Guirro E.C. Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint. Man Ther Oct 16;16(5): Niemuth, P. E., Johnson, R. J., Myers, M. J., & Thieman, T. J. (2005). Hip muscle weakness and overuse injuries in recreational runners. Clinical Journal of Sport Medicine, 15(1), Nohren, B., Davis, I., & Hamill, J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech, 22, Shamus, J., & Shamus, E. (2015). The management of iliotibial band syndrome with a multifaceted approach: a double case report. International journal of sports physical therapy, 10(3), 378. Taunton, J., Ryan, B., Clement, B., McKenzie, C., Lloyd-Smith, R., Zumbo, D., A retrospective case-control analysis of 2002 running injuries. Br. J. Sports Med Vaughn D.W. Isolated knee pain: a case report highlighting regional interdependence. J Orthop Sports Ther. 2008;38(1):