Knee Pain and ITB Syndrome

By Carl Petersen, PT & Catherine Fussel, PT

Iliotibial Band Friction Syndrome is one of the most common causes of knee pain. Though frequently found amongst runners, it is also seen in tennis players, cyclists and occasionally in skiers, weight lifters and soccer players.

The iliotibial band (ITB) is a thickened strip of fascia, or outer casing, of a muscle that runs up the outside of the thigh. It extends from the outside of the pelvis, above the hip, to just below the knee joint into the tibial bone. Two muscles insert into the ITB where it begins at the pelvis - the tensor fascia latae muscle and the large gluteus maximus muscle. The ITB's primary function is to stabilize the knee and hip during walking and running.

During its course from the pelvis to the knee, the ITB crosses over a bony prominence on the outside of the knee known as the Lateral Femoral Epicondyle (LFE). A bursa, a fluid filled sac that reduces friction, lies between the ITB and the bone. As the knee bends or flexes past 30 degrees, the ITB slides over the LFE and the bursa. As you straighten or extend the knee, the band slides back over the bony prominence. It is this repetitive sliding back and forth that causes irritation of the ITB and the underlying bursa causing Iliotibial Band Friction Syndrome.

ITB Friction Syndrome is an overuse injury. Pain results from inflammation of the iliotibial band itself and/or the bursa. Inflammation of the periosteum, the outer covering of the bone, can also occur, causing pain as well.

MECHANISM OF INJURY
Although ITB Friction Syndrome may simply be due to training errors like too rapid an increase in running distances, it is also commonly due to faulty biomechanics. The ITB spans two joints, the hip and the knee, making it susceptible to stress from a multitude of causes. For runners, these may include leg length discrepancies, often secondary to a rotated pelvis, excessive "bow-leggedness", over-pronation (flat feet) or excessive supination.

Over-pronation of the foot causes the tibia to turn inwards, tightening the ITB and putting it on extra stretch. While excessive supination of the foot decreases the foot's ability to absorb forces during running and walking transferring increased stress to the knee.

Common training errors that may lead to ITB friction syndrome include persistent running on uneven or canted surfaces and increased knee flexion from over striding such as during downhill running. Cyclists may have their cleats positioned so that they are turned in too much or their seat height may be too high.

Mal-alignment problems of the pelvis, knee and foot need to be assessed and corrected or else, despite your best efforts, ITB Friction Syndrome can become a chronic injury. Talk to a reputable physiotherapist or sport medicine practitioner to determine if your IT Band symptoms are being exacerbated by mal-alignment.

Lastly, although this syndrome is commonly caused by over-pronation or leg length discrepancies, it is often the fact that the iliotibial band itself is tight and short. As well, the muscles that insert into the ITB are weak and tight. This tightness, combined with the other factors, leads to excessive rubbing and irritation of the ITB and the underlying bursa and bone.

SIGNS & SYMPTOMS
Iliotibial band Friction Syndrome will usually present itself as pain and tenderness on the outside of the knee. It is probably the most common cause of lateral knee pain. However, because of the length of the ITB, pain may occur anywhere from the hip to the knee, with pain occasionally radiating down the leg to the ankle. Most sufferers cannot often pinpoint the exact location of the pain.

The amount of discomfort ranges from a dull ache to a sharp stabbing pain that is intense enough to stop an athlete half way through a run. The pain comes on most frequently mid-way through a run, often after climbing a hill, or after a run. The pain is most noticeable when descending stairs, walking or running downhill getting out of a car or rising from a chair.

KEEPING THE ITB HEALTHY
Physiotherapists at City Sports and Physiotherapy Clinics in Vancouver have suggested the following set of guidelines for treatment, rehabilitation and prevention to help regain and improve flexibility of the iliotibial band. Upon initial signs and symptoms of ITB friction syndrome follow the PRINCE rules; Protection, Rest, Ice, Non-steroidal anti-inflammatory medication, Compression and Elevation.

PREVENTION
It is important to choose appropriate foot-wear that is suited for your foot type. Either ask your physiotherapist to make sure your shoes are correct for you or go to a reputable running shoe store that can help fit you in the right shoe. Shoes tend to lose their cushioning and shock absorbing ability after approximately 500 miles. If you run regularly this can be as soon as 4-6 months, so keep track of your mileage and replace the shoes when necessary. Most importantly, in order to prevent the recurrence of ITB friction syndrome, it is essential that stretching is done daily, even on your rest days.

TRAIN SMART
Maintain a year-round fitness program to avoid sudden changes to your activity level. For acute ITB Friction Syndrome reduce the mileage by at least one-half or up to the point of pain for two weeks and ice regularly after each run or cycle. Runners should avoid hills. If you run on a track or even on the side of a cambered road, make sure you change directions to allow your leg to alternate canted surfaces. Cyclists should pedal easy (80 rpm or less) with little resistance for at least one week. Gradually increase the amount of activity. Runners should not exceed increasing their mileage or their run duration by greater than 5-10% per week.

STRETCH & STRENGTHEN
Fortunately, iliotibial band Friction Syndrome is probably the best example of an injury that responds well to stretching. However, because the ITB is a relatively in-elastic tissue, stretching must be done regularly and consistently even when symptoms have subsided. It is also equally important to remember to stretch the tensor fascia latae and the gluteus maximus muscles as they come together and form part of the ITB. As well, the hamstring and quadriceps muscles should be stretched as the fascial tissue connections contribute to IT Band tightness. Cyclists should stretch extra long since cycling tightens up the lateral quadricep and iliotibial band.

STRENGTH SMARTS
Strength is also an important factor in controlling Iliotibial Band Friction Syndrome. The tensor fascia latae and the gluteus maximus muscle, as well as the surrounding hip and knee musculature must be kept strong. Exercises such as the straight leg raise, mini squats and step-ups are good exercises. The gluteals are multipurpose muscles that not only extend and abduct the leg but also include a component of rotation.

WARNING SIGNS
Always listen to your body. At the first sign of Iliotibial Band Friction Syndrome, stop. By stopping activity and spending a couple of minutes stretching out the ITB you may be able continue running or cycling for a few more kilometres. Ice and stretch again after activity. If stretching does not ease the pain don't try and push through it – you can't.

If identified and treated early ITB Friction Syndrome may only delay your training for a week or two. However, if the pain in not heeded this can very quickly turn into a chronic injury that may take several months to heal.

SURGERY
Surgery is the final option if conservative methods do not work. Make sure you are seen by a skilled orthopaedic medicine specialist who is familiar with the condition. Unfortunately there is no guarantee that surgery can relieve all the symptoms and return an athlete to pre-injury level.

A couple of things to remember: first, if you have any doubts about your current fitness level, consult a physician before beginning any exercise program. Secondly, stretches for all muscle groups should be part of your routine.
Carl Petersen is a Partner at City Sports & Physiotherapy Clinics. He is Physiotherapist for the Canadian Alpine Ski Team, and Fitness Coach to ITF & ETA players.