Iliotibial Band (ITB) Syndromes

Iliotibial Band (ITB) Syndromes:

Assessment and Corrective Exercise

By Chuck Wolf

The aspiring endurance athlete undergoes hundreds of thousands repetitive movements to hone the style and techniques, often to maintain their efficiency. This scenario often leads to eventual domination of movements in one plane of motion. This creates an imbalance of some muscle groups leading to overuse of other tissues. In endurance athletes, especially runners and cyclists, the pursuit of efficiency of movement techniques to shave time off their personal best leads to sacrifices of motion, tightness and weakness of structures, resulting in limitations and compensations and eventual injury. In my experience of evaluating gait and motion of endurance athletes of all levels, I have seen numerous occurrences of lateral thigh pains from the hip to the knee, especially in runners and cyclists. This has led to frustration and impaired performance for these individuals.

Brief Perspective of the Hip Musculature

The most common contributing factor of lateral thigh pain is iliotibial band syndrome (ITBS) and tightness and weakness of the tensor fascia lata (TFL), gluteus medius, or gluteus minimus, collectively referred as the lateral gluteal region. The iliotibial band spans close to the hip as a continuation of the TFL, gluteus medius, and gluteus minimus. It continues distally to the knee where it splits into the iliopatellar band medially and the iliotibial tract laterally.The TFL originates at the anterior superior iliac spine and inserts into the ITB. The gluteus medius and gluteus minimus originate at the posterior ilium between the posterior and anterior gluteals lines and inserts into the greater trochanter. Isolated, these muscles abduct and internally rotate the femur. The gluteus medius’ anterior fibers assist in femoral internal rotation, while the posterior fibers assist in externally rotating the femur. In addition to these movements, the TFL also assists in hip flexion. (1, 2, 3, 4, 5) The issue with the traditional description of anatomy and kinesiology is the majority of muscle actions are described in the isolated muscle and joint in the open chain. These muscle actions are characterized by concentric contractions, yet in human motion for efficient movement to occur, the eccentric phase must occur prior to the concentric moment. It is true the aforementioned muscles perform the stated actions; however their actions are vastly different in human motion.

The integrated activity of the gluteus medius, gluteus minimus, and TFL function in three planes of motion by doing the following tri-plane actions:

·  Assists in deceleration of hip adduction in the frontal plane,

·  Assists in deceleration of hip extension in the sagittal plane,

·  Assists in deceleration of external hip rotation in the transverse plane. (1, 2, 3, 4, 5)

In integrated function, the hip abductors decelerate motion in the frontal plane as the hip adducts, decelerates internal rotation in the transverse plane, and assists in deceleration of hip flexion. Interestingly, the abductors of the weight bearing hip levels the pelvis during the swing phase of the opposite leg. This helps create the necessary height for the leg to swing through. Concomitantly, the opposite erector spinae of the weight bearing hip “pulls” up the swing leg hip to assist in maintaining a level pelvis. (5)

The hamstrings decelerate hip flexion in the sagittal plane, internal rotation of the knee in the transverse plane and help to stabilize the pelvic girdle in the frontal plane. The gluteus maximus reduces hip flexion in the sagittal plane, internal rotation in the transverse plane, and hip adduction in the frontal plane. It is the integration and synchronization of all these muscles that produce the “symphony of motion “of human gait. (6)

The action of the lateral gluteals can be described like a sling that lengthens in the frontal plane to decelerate the lateral motion of the hip when in mid-stance and weight bearing. In this phase, the hip moves laterally, lengthening these muscles and they slow the motion in the frontal plane, and then reflexively contract to assist through the remainder of gait. The mid-stance is a critical phase, as a transition occurs from an internally rotated lower extremity to beginning the acceleration phase of gait when external rotation of the femur and hip occur. The lateral gluteals region must have adequate strength through the eccentric phase of gait so the gluteals and TFL are fully loaded by lengthening first before they shorten and accelerate action. If these structures do not fully perform their functional lengthening, the will gradually shorten and then weaken, as they are not going through the eccentric moment before the concentric moment. If this happens, other structures take over to decelerate frontal plane action and overuse ensues. To better develop an understanding of human motion, let’s delve into the characteristics of human motion more deeply.

Characteristics of Human Motion

The majority of literature in the fitness industry has created exercise programs that cause force production, or concentric contractions, prior to force reduction, the eccentric phase. Contrarily, in pure human motion, muscles first move through the eccentric phase and have the action be decelerated before the concentric phase which produces acceleration in force in order for movements to be efficient and effective.

Muscle Pre-loading/Unloading

Dykyj’s classic work illustrates a muscle exerting an opposite action assists in controlling motion. In human motion, the body actually moves in the opposite direction just before any efficient movement occurs toward the intended direction. (5, 6) This reaction causes the muscles first to stretch eccentrically causing a deceleration of the motion. As this stretch is occurring, energy is stored in the muscle creating a more forceful and efficient contraction prior to the intended movement. For example, from a seated position, place your feet directly beneath you as if you are preparing to rise from the chair…DO NOT bend forward or downward before rising, just stand straight upward. The movement is extremely difficult and inefficient. Some people cannot rise out of the chair. But why is such a relatively simple command so difficult to perform? The answer is the muscles did not move the opposite direction and first lengthen or pre-load and perform an efficient movement pattern. Yet, when the torso flexes forward and allows the pre-load to transform, the movement becomes smooth, efficient, and easier to perform. Therefore, it can be said, the eccentric loading allows for greater energy conservation and efficient movements. In fact, eccentric contractions are 3-9 times more efficient than concentric contractions. The eccentric phase allows the muscle to lengthen, absorb forces, and slow the motion, all necessary for ease of movement, and muscle conditioning, all of which will reduce the risk of soft tissue injury and produce energy efficient movement patterns.

The concentric phase reacts by shortening the muscle and accelerating the motion. In the cycle of human motion, this is considered the unloading phase. The dilemma of a majority of exercise programs is most of the exercises are force producing and negate the loading phase. Therefore, in terms of human motion, efficient movement is characterized by the ability to control the transformation from the eccentric or deceleration phase to the concentric or acceleration phase.

ITB Confounding issues resulting of lateral hip weakness

When an individual has presented for a gait and motion analysis to investigate the lateral thigh pain, it has been my experience that these people also suffer from tightness of the external hip rotators (often the piriformis), and tight hamstrings. It appears when the lateral gluteals become weak and do not perform their function, other muscles compensate and perform work in a fashion they are not suited to do resulting in overuse issues. In the case of the tightness of the lateral thigh, i.e. ITB and TFL tightness, the gluteus medius and gluteus minimus have become tight and weak, thus not fully performing their function of deceleration of hip adduction in the frontal plane, hip extension in the sagittal plane, and external hip rotation in the transverse plane. (1, 2, 3, 4, 5) Therefore, the TFL becomes too dominant and assumes the role the lateral gluteals are lacking. With the adjoined fascia of the TFL and ITB, the ITB becomes taut and lateral knee pain can ensue. In many of the clients I have been fortunate enough to serve, I have also found tightness of the deep external hip rotators and hamstrings to accompany the lateral thigh tightness of the ITB and TFL. The question is how did this occur is a complex one, and considering the philosophy of Gary Gray, P. T. and David Tiberio, Ph.D., P.T., (11) the site of the overuse injury is not the cause but the symptom and the cause is usually a joint level above or below the injury. My experience has found their advice to be quite true; therefore, I then investigate through my evaluations the hips and often look at the feet.

In normal gait conditions, at heel strike the foot is supinated and the calcaneus is inverted (turned in). The lower extremity and hip are externally rotated. As the ground accepts the foot, the foot pronates which causes the calcaneus to evert in the frontal plane, the ankle to dorsiflex in the sagittal plane, and the tibia, femur, and hip to internally rotate in the transverse plane. As the hip moves over the foot in mid-stance, the hip internally rotates and adducts which lengthens the lateral gluteal region to decelerate this action. If the foot does not fully pronate due to a myriad of reasons, the chain reaction through the hip does not occur and the musculature up the chain is not fully functionally activated. As muscles possess the natural tendency to shorten, the lateral gluteals follow the physiological response and shorten and weaken over time. As the body strives to achieve the goals of the activity, it will compensate when adjacent muscle tissue are over-worked and overuse injury transpires.

Another common scenario that needs to be explored is the hip motion and its functions, as this may be the cause of the malady. Bare in mind, the opposite hip may be the culprit and not fully eccentrically loading or concentrically unloading, resulting in incomplete range of motion of the affected hip and lower extremity. Likewise, the affected hip is usually tight in the frontal plane and can be the culprit.

Endurance Athletes and Form

In the athlete’s pursuit of performance improvement, they undergo hundreds and thousands of repetitions on the road or in the saddle. Runners attempt to stay “tight and compact” in their running gait and cyclists are set into a bike fit that often causes reduced motion in the hips and feet. and can adversely affect proper chain reaction of normal gait patterns. It is crucial for these athletes, as well as all populations to maintain an integrated tri-plane flexibility program.

It is important for the reader to remember; those conditions stated above are looking at the actions that may produce the malady as a result of improper mechanics, acute injury, bony structure of the skeletal system, or foot type. It is not in the scope of this article to delve into the numerous possibilities of what the causes are, but to consider the chain reactions and the resultant issues. A thorough gait and motion evaluation, including health history, must be done to derive the causes.

Assessment

The assessment tools I use to perform gait and motion analysis are those consistent with Gary Gray’s Total Body Functional Profile. (8) When a client presents for an evaluation, I first obtain a comprehensive health history, including injury and activity history. Following a brief discussion of their significant related issues, I view them walking to see the symmetry of the movements from the ground up. I first view hip action to see any asymmetry of hip extension/flexion in the sagittal plane, lateral excursion of the hip during mid-stance in the frontal plane, and differences in rotation of the lower extremity and hip in the transverse plane. I then view foot action to notice symmetry, heel whip, the action of pronation and supination. Finally, I look at the torso and upper extremities to see if there are any significant differences in their motions. I try to view the client’s gait from the anterior, posterior and lateral aspects to get a feel from all angles. Then the client will walk at a fast, but controlled pace to accentuate the motions of their walk. This often emphasizes the idiosyncrasies of their gait patterns and further provides information of symmetry and compensations. I use this to summarize my findings and thoughts. Typically, if there is lateral gluteal tightness, it can be seen from the fast walking pattern. Bear in mind, there are a myriad of conditions that affect gait which are not being addressed in the scope of this article.

If I want to see how the hips are affected in the frontal plane, I will ask the person to walk with an overhead bilateral arm medial reach. This is performed with a normal gait pattern, yet the client will have both arms overhead and reach overhead and medially to the lead leg. This emphasizes frontal plane action in the hips of the lead leg and if tightness or asymmetry is observed, this can be a significant finding to lateral gluteal region tightness.

Single leg balance anterior ipsilateral reach test. This test creates an environment that causes the foot to pronate which reactively creates lower extremity internal rotation and hip internal rotation, while measuring strength and range of motion of the gluteals in the sagittal and transverse planes. I use a measuring pole and tape measure to assess the distance reached and how low the client can go. This is an integrated assessment that evaluates the foot’s ability to pronate and the entire lower extremity’s ability to decelerate motion. I compare both sides for fluidity and symmetry of motion and total distances