Iliotibial Band Syndrome | Knee pain in Runners
In this article Katherine L. Worsnick, MPAS, PA-C of Caring Medical Regenerative Medicine Clinics discusses the various challenges with determining a correct diagnosis and treatment plan for Iliotibial Band Syndrome (ITBS) or IT Band Syndrome. While patients can develop Iliotibial Band Syndrome following hip replacement surgery, this article will focus on runners.
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There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone) which causes the irritation and inflammation of the tissue. It is this location which also gives IT Band Syndrome its more easier to understand name of “Runner’s Knee.”
- Sometimes the typical treatment approach of rest, NSAIDS, and physical therapy are helpful to relieve the pain of Iliotibial Band Syndrome, however these treatments do not address what caused the inflammation and irritation in the first place – knee instability, so recurrence is common.
- In a case history presented by Naval doctors, excessive cortisone injections not only failed to treat the the problem but caused a iliotibial band rupture.(1)
- Prolotherapy, Neurofascial Prolotherapy and Platelet Rich Plasma therapy to the injured IT band will strengthen the tissue, effectively repairing the IT band and allowing the athlete to confidently return to their sport.
Hip and Knee Dynamics – Runners
Studies comparing female distance runners and female recreational runners with ITBS to healthy controls, found that the ITBS group exhibited significantly greater hip adduction and knee internal rotation (the knee hip complex rotating inwards) than control groups. The theory is that these combined motions created excessive strain to the ITB as it attempted to decelerate hip adduction and knee internal rotation causing compression and the ITBS lowest connection points to the bottom of the femur/thigh bone.(2)
Supporting this is a recent case history from the Cleveland Clinic Rehabilitation and Sports Therapy suggesting that problems of Iliotibial band syndrome were connected to to the dynamic between increased hip rotation and knee internal rotation.
Dutch researchers also supported this idea of rotation by suggesting that female runners demonstrate a greater internal rotation angle while running than male counterparts, that is why they are more likely to develop iliotibial band syndrome. 
As with the friction theory, the hip-knee rotation dynamic involves the tendons and irritation and inflammation in the tissue.
The issue of muscle strength and weakness
Some studies concentrate on changing the running style, or length of stride to help to alleviate the symptoms of ITBS. However, a literature review of many studies conducted by the University of Brighton in the United Kingdom concluded:
- “It appears unlikely that abnormal biomechanics at the foot or tibia is responsible for increasing tension in the ITB.”
- “There is currently no evidence to suggest that reduced muscle strength plays a role in the aetiology of ITBS.”
- And another, “Weakness of hip abductors does not seem to play a role in the etiology of Iliotibial Band Syndrome in runners, since dynamic and static strength measurements did not differ between 10 healthy runners and 10 runners with Iliotibial Band Syndrome, and differences between hip abduction and adduction were the same. Strengthening of hip abductors seems to have little effect on the prevention of Iliotibial Band Syndrome in runners.”
Symptoms and traditional treatment of iliotibial band syndrome
ITBS symptoms vary from patient to patient and may range from a:
- Stinging sensation just above the knee to swelling or thickening of the tissue in the area where the band moves over the femur.
- The stinging sensation just above the knee joint is typically felt on the outside of the knee or along the entire length of the IT band. This severe excruciating pain in the lateral knee makes running very difficult.
- Sometimes there is a crunching or grating sound where the iliotibial band rubs over the femur.
- Pain may not occur immediately during activity, but may intensify over time, or at the end of a run.
- Pain is most commonly felt when the foot strikes the ground, and pain often persists even after the patient has stopped running.
- Pain may also be present above and below the knee, where the IT band and the tibia attach.
As we alluded to above and in the medical journal Arthroscopic Therapies doctors write, “Conservative management including rest from activity, equipment modification, oral nonsteroidal anti-inflammatory drug (NSAID) use, and physical therapy is the mainstay of treatment initially, refractory cases do exist. Surgical options include percutaneous release, open release, ITB Z-lengthening, and an arthroscopic technique.” These are procedures that cut the IT Band to “release” tension. “Assuming the inflammation in the tissue connecting the ITB band to the lateral femoral epicondyle is the culprit of ITB pain, this tissue can be removed with an arthroscopic shaver.”
Difficulty in treating and diagnosing Iliotibial Band Injury
University researchers in the Netherlands, publishing in the journal Sports Medicine suggest to treat IT Band injury, doctors need to know what its causes are and to be able to diagnose it. “Iliotibial band syndrome is the most common injury of the lateral [outer] side of the knee in runners, with an incidence estimated to be between 5% and 14%. In order to facilitate the evidence-based management of Iliotibial band syndrome in runners, more needs to be learned about the aetiology, diagnosis and treatment of this injury. . . The methodological quality of research into the management of Iliotibial Band Syndrome in runners is poor and the results are highly conflicting.”
Doctors at the University of California Irvine also wrote of the problems of unresolved iliotibial band syndrome misdiagnosis. They suggest that when orthotic devices failed to deliver favorable results in IT Band Syndrome, it may be suggesting a different diagnosis – potentially popliteal tendinitis or lateral meniscus tear. It is important that the runner has a physical examination and discusses with the doctor a detailed history to reach an accurate diagnosis.
Prolotherapy for Iliotibial Band Syndrome
Since the iliotibial band goes from the hip area across the knee area, it traverses two joints. If either of these two joints is weakened or has ligament laxity, the tibia and/or femur will move excessively. This will put extra stress on the iliotibial band. In runners with iliotibial band syndrome, Prolotherapy would be recommended into and around their knees and hips.
If the hip is evaluated and considered stable, then an athlete with iliotibial band syndrome will get Prolotherapy to the area on the tibia where the iliotibial band attaches. If there are other parts of the iliotibial band that are tender on the athlete besides the attachments, then these areas are treated with the components of Comprehensive Prolotherapy, including Neurofascial Prolotherapy, and/or Platelet Rich Plasma to increase healing to the area. Typically 3-6 visits of Prolotherapy are needed. The treatments can be done weekly, if necessary. Generally after two treatments the athlete starts working out again.
The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. For the athlete with chronic lateral knee pain, an evaluation by a Prolotherapist is warranted. We have treated many cases of iliotibial band syndrome in athletes (mostly runners) successfully with Prolotherapy.
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