1. 1. What is the most effective conservative management to facilitate return to sport for runners with IT band syndrome? A Review of the Literature
2. 2. Non-traumatic overuse injury of the knee caused by repeated flexion and extension of the knee that creates irritation in the structures around the knee 8
3. 3. ITBS is one of the leading causes of lateral knee pain in runners (1.6-12%)5 how do YOU treat it?
4. 4. Hip abductor strengthening IT band stretching Modalities (ice, ultrasound, E-stim) Foam rolling for the ITB Rest Corticosteroid injections Deep transverse friction massage to ITB Shoe orthotics Common Interventions for ITBS
5. 5. ITB: a thickening of the facia lata Connected to femur along the linea aspera from the greater trochanter to, and including, the lateral epicondyle of the femur by coarse fibrous bands. TFL and a substantial portion of the gluteus maximus and medius insert directly into the ITB There is no bursa interposed between the ITB and distal lateral femur. Insertion: lateral femoral condyle, gerdys tubercle, Based apon an anatomical examination of the IT band in 12 cadavers performed by Falvey, et al. in 2010:
6. 6. There is no bursa between the ITB and the lateral femoral epicondyle! Rather, there is an area of richly vascularized adipose tissue that contains pressure-sensitive pacinian corpuscles. (Noble, 1980; Orava et al., 1991; Muhle et al., 1999 MRIs have confirmed these results Ekman et al., 1994; Nishimura et al., 1997
7. 7. Based on dissections of 1 orangutan, 3 chimpanzees, 1 gorilla, 1 bear, and other 4-legged animals, Kaplan (year) concluded that, although all quadruped animals have tensor fascia latae or gluteus maximus muscles, they do not all have an ITB. This suggests the ITBs function is as an independent stabilizer of the lateral knee joint, essential for erect posture.
8. 8. Hip abductor strength Hip and knee biomechanics Hip adduction Knee internal rotation Subtalar eversion Choice of running shoe Running surface
9. 9. Pinshaw, et al, 1984: Most runners with ITBS spent more than 90% of their training time running long distances at low speed wearing new balance shoes and mainly running on tar and dirt roads.
10. 10. Sharp or burning pain on the lateral aspect of knee Exacerbated by running, especially downhill Most severe when knee is bent 30-45
11. 11. Around 30 of knee flexion during foot strike and early stance phase TFL and gluteus maximus are eccentrically contracting to decelerate leg Greatest amount of strain on the IT band Pain!
12. 12. Falvey, et al. 2010 Concludes that the thick fibrous bands connecting the ITB to the femur along the linea aspera down to the lateral epicondyle prevent lateral movement of the band over the femoral condyle. Supported by findings of Fairclough, et al. 2007.
13. 13. MRIs performed by Fairclough, et al show that the ITB moves medially so that it is compressed against the lateral epicondyle at 30 degrees flexion, and is pulled away from it at full extension.
14. 14. Fairclough, et al. (2007) Supports findings of no bursa Suggests that the pain is a result of compression of the highly vascularized adipose tissue between the tract and the epicondyle, which may contain large numbers of pressure sensitive Pacinian corpuscles.
15. 15. History Presentation Special Tests Noble Compression Test Obers Test of Renne
16. 16. Dynamed, 2 newCINAHL32 results, 14 new Pubmed results: 41 Total of 57 results, 40 were excluded based on abstract 8 studies were included Total of 17 results, 9 were excluded based on full text
17. 17. 1. Study (authors, year) 1.Inclusion/ ExclusionCriteria 2.Description& Adherence 3.Measures 4.Masking 5.Appropriate Statistics 6.Dropout 7.Confounding/ Biases TOTALQUALITY SCORE LEVELOFEVIDENCE Beers, et al. 2008 4/7 IV Falvey, et al. 2010 (Part 1) 4/7 V Falvey, et al. 2010 (Parts 2 &3) 4/7 III Fredericson, et al. 2002 4/7 IV Study (authors, year) 1.Participant Description 2.I.V.sdefined 3.Conditions defined 4.D.Vsdefined 5.Reliabilityof measures 6.Assessor blinded 7.Baseline stability 8.Designstated 9.Datapoints 10.Replication 11.Visual analysis 12.Appropriate graphs 13.Statistical analysis 14.Stats appropriate TOTAL QUALITY SCORELEVELOF EVIDENCE Schriber, et al. 2011 3/1 4 IV
18. 18. Collectively, the results of the studies investigating conservative management of ITBS support the effectiveness of several interventions: 1. NSAIDS 2. Corticosteroid injections followed by rest 3. Hip abduction and pelvic drop exercises 4. Programs to enhance neuromuscular control of the hip
19. 19. Conflict between studies emerged on the topic of stretching the iliotibial band Falvey, et al: stretching the iliotibial band may not result in actual tissue lengthening Fairclough, et al: fibrous connections to the femur make stretching of the ITB unlikely Stretching in combination with rest, ice, and strengthening will increase the IT bands compliance (Fredericson et al 2002, Neohren et al, Van der worp et al,).
20. 20. One stretch was found to be particularly effective by Fredericson, et al. Limitations: Indirect measurement of ITB length: stretch was estimated based on the angular changes in markers on the skin. Small sample size
21. 21. Falvey, et al: performed these 3 stretches on cadavers and athletes. In vivo, strain was increased on the ITB (especially for stretch C), but no lengthening of the ITB was found in either group.
22. 22. YES! Supported by two level III studies and three level IV studies Increased hip adduction and foot strike has consistently been shown to be associated with ITBS symptoms Hip abductor strengthening has been shown to decrease hip adduction at foot strike and decrease ITBS symptoms
23. 23. Selkowitz, et al. 2013: Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine- Wire Electrodes
24. 24. The most effective exercises for activating gluteus medius and superior fibers of gluteus maximus with minimal contraction of the TFL. These were shown to be more effective than hip hikes, lunges, squats, and step ups.
25. 25. Gunter and Schwellnus, 2004. Local corticosteroid infiltration effectively decreases pain during running in the first two weeks of treatment in patients with recent onset ITBS.
26. 26. Schwellnus, et al. randomly divided 20 subjects into two groups. Group 1: rest, ice 2x/day, stretching, and ultrasound Group 2: Same treatment, with the addition of deep transverse friction massage Results showed reduced pain levels after 7 days of treatment in both groups, no significant difference between groups. Authors concluded that the addition of DTFM did not alter the therapeutic outcome of ITBS.
27. 27. No research directly looks at foam rolling and its effects on decreasing symptoms of ITBS Foam rolling has been shown to reduce arterial stiffness and improve vascular endothelial function (Okamoto, et al. 2013).
28. 28. Most research has used these treatments in conjunction with others, so there is no way to determine their individual effectiveness or lack of.
29. 29. Overall, the quality of research into the management of ITBS in runners is poor and results are highly conflicting Future study designs need to be improved to prevent selection bias and increase generalizability of findings Highly supported interventions: hip abductor strengthening and corticosteroid injections Poorly supported interventions: ITB stretching, deep transverse tissue massage, No research to draw conclusions from: foam rolling, modalities, rest
30. 30. 1. Beers A, Ryan M, Kasubuchi Z, Fraser S, Taunton J. Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiother Can. 2008; 60:180-188. 2. Falvey EC, Clark RA, Franklyn-Miller A, Bryant AL, Briggs C, McCrory PR. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010; 20:580-587. 3. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10(3):169-75. 4. Fredericson M, White J, MacMohon J, Adriacchi A. Quantitative Analysis of the Relative Effectiveness of 3 Iliotibial Band Stretches. Arch Phys Med Rehab. 2002; 83:589-592. 5. Gunter P. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial * Commentary. British Journal of Sports Med. 2004;38(3):269-272. 6. Noehren B, Davis I, Hamill J. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomechanics. 2007;11(22):951-56. 7. Schriber R, Louw Q. The Effect of Gluteus Medius Training on Hip Kinematics in a Runner with Iliotibial Band Syndrome. SA J of Physiother. 2011; 67 (2): 23-28. 8. Van der worp MP, Van der horst N, De wijer A, Backx FJ, Nijhuis-van der sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012;42(11):969-92.
31. 31. Level IV Grade 4/7 Beers A, Ryan M, Kasubuchi Z, Fraser S, Taunton J. Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiother Can. 2008; 60:180-188. The purpose of this prospective, observational, before and after study was to quantitatively examine hip abductor strength in patients presenting with iliotibial band syndrome and to determine whether a multi- modal physical therapy approach, including hip abductor strengthening, might play a role in recovery. 16 participants were recruited, all presenting with a diagnosis of ITBS. Bilateral hip abductor strength was measured at 0, 2, 4, and 6 weeks using a hand held dynamometer. AMI (a quality of life tool designed specifically for sports medicine) was also administered with each strength assessment. Treatment intervention was designed by two experienced physiotherapists and consisted of three strengthening exercises, two ITB stretches, ultrasound to the area of discomfort, and muscle energy techniques to correct pelvic malalignment. Patients were also instructed to avoid painful activities until their pain was controlled. Results showed an increase in hip abductor strength, however, strength deficits on the affected side pre- intervention were just under significant values. Authors hypothesize that the lack of significant pre- intervention hip abductor weakness values may be due to the small sample size. Limitations of the study included small sample size, lack of control group, and multiple treatments coinciding. Authors concluded that while this study appears to support the inclusion of hip abductor strengthening into a rehabilitation program for ITBS, more research is needed. Clinically, it is hard to draw generalizable conclusions from this study, since its results were not determined to be significant and they could be attributed to any one of the multiple treatment interventions.
32. 32. Part 1: Level V Grade 4/7 Parts 2 and 3: Level III Grade 4/7 Falvey EC, Clark RA, Franklyn-Miller A, Bryant AL, Briggs C, McCrory PR. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010; 20:580-587. The purpose of this three part study was to quantitatively analyze iliotibial band (ITB) strain during movement in order to investigate the anatomical principles upon which a number of traditional treatments are based. The authors hypothesis was that many treatments aimed at decreasing local inflammation and stretching the ITB derive from an incorrect understanding of the relevant anatomy and pathology. Since this article addresses the efficacy of multiple conservative treatment interventions used for ITBS, it is applicable to our question of what the most effective treatment methods are to return to sport for runners with ITBS. The purpose of part 1 of this study was to map the anatomical landmarks and structure of the ITB on cadavers. Part 2 used a mechanical strain sensor to assess three different proposed ITB stretches on a cadaver. Part 3 assessed strain in the ITB during tensioning in vivo in professional athletes. Results of Part 1 included no discovery of any bursa beneath the ITB, which challenges treatments that are aimed at decreasing inflammation of the bursa. Other anatomical findings, including the presence of thick fibrous bands connecting the distal ITB to the lateral epicondyle, suggested that lateral movement of the ITB over the condyle is not possible, challenging the friction theory (ITBS symptoms are caused by friction of the band over the condyle). Results of part 2 suggested that a common stretch for the ITB (hip flexion, adduction, external rotation) created significant strain on the ITB band. However, results of part 3 indicate negligible displacement of the ITB/TFL junction during a TFL/ITB stretch. This study concludes that measures aimed at treating local inflammation and stretching the ITB are based on an incorrect understanding of the relevant anatomy and pathology. Clinically, this study provides mild evidence that stretching the ITB may not result in significant lengthening of the tissue, and that friction may not be the cause of ITBS symptoms. Limitations of this study include the old age and lack of medical and social history for the cadavers. Reliability and validity of many of the measures are not established, and they are not described in sufficient detail to allow for accurate replication. Measures were also highly dependent on the skill of the examiner.
33. 33. Level IV Grade 6/7 Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10(3):169-75. The purpose of this study was to examine hip abductor strength in long distance runners with ITBS. This study compared the injured limb strength to the non-affected limb and to the limbs of a control group of healthy long distance runners, as well as to determine whether a correction of strength deficits in the hip abductors of the affected runners yields successful return to running. The study demonstrates that runners with ITBS were weaker in hip abductor strength than a non-injured control group of runners, in comparison with their non-injured side. Both males and females who followed a six week physical therapy strengthening program for the injured limb achieved a level equal or greater than that of the non-injured limb, as well as controls at the end of the program. The strengthening program included two strengthening exercises, which were side lying hip abduction and pelvic drops (explained in detail in the study). Only one runner failed to make progress with their injury and quit running as a result, and the rest were able to successfully return to sport following the strengthening intervention. Since the program included modalities (ice, ultrasound, and electrical stimulation), rest, stretching, and strengthening and it is not clear that the strengthening program alone led to the increases in strength and whether or not the strengthening program alone facilitated successful return to running.
34. 34. Level IV, Grade 4/7 Fredericson M, White J, MacMohon J, Adriacchi A. Quantitative Analysis of the Relative Effectiveness of 3 Iliotibial Band Stretches. Arch Phys Med Rehab. 2002; 83:589-592. The purpose of this cross-sectional study was to compare the relative effectiveness of three common standing stretches for the iliotibial band (ITB). Participants were five elite-level distance runners. Each participant performed all three standing stretches three times in random order to prevent a warm-up phenomenon. Markers were placed on key anatomical landmarks on the LE, and biomechanical motion was captured with the 3D Biomotion laboratory camera system. Stretch of the ITB was extrapolated based upon the movement of the markers. Stretch A was performed by standing, extending and adducting the leg to be stretched. Subjects were then instructed to exhale while slowly flexing trunk to contralateral side, until good stretch was felt. Stretch was then held for 30 seconds, and measurements were taken for the last 5 seconds. Stretches B and C were the same, with the addition of hands clasped overhead (B) and arms extended diagonally downward (C). All three stretches showed significant change in ITB length, but stretch B was consistently most effective, in both average ITB length change and in average adduction moments at the hip and knee. Limitations of this study include its small sample size and the fact that ITB length was not directly measured, but rather estimated based on the changes in length from angular changes in markers. Clinically, this study may support adduction and extension of the leg in standing as an effective stretch for the iliotibial band, and gives evidence that clasping the arms overhead and flexing the trunk contralaterally will increase this stretch. To be more clinically relevant, this study could have compared this iliotibial band stretch with other common stretches used in practice today.
35. 35. Level II Grade 5/7 Gunter P. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial * Commentary. British Journal of Sports Med. 2004;38(3):269-272. This study served to analyze the effect of injecting a local single dose of corticosteroid (methylprednisolone) into the area between the lateral femoral condyle and the iliotibial band in runners with recent onset (within 14 days) of iliotibial band syndrome. A total of 18 runners participated in the study, 9 received injections and 9 received a placebo. Prior to injection, all runners were given a 30-minute treadmill test and asked to rate their pain every minute. At day 7 and 14 after injection, all runners were given a treadmill test again and asked to rate their pain every minute. Once the injections were all administered, participants were instructed not to run or cross-train until day 14 (outside of the two testing times), and were only permitted to ice the region twice per day. Total pain during run (a product of pain level multiplied by the time individuals ran during the testing periods) was show to significantly decrease in the group who received the injection from day 7 to day 14. From day 0 to 7 there was a trend toward a decrease in the total pain the subjects in the experimental group during running, and a significant improvement in pain during running in the experimental group compared with the group group in day 7 to 14. No long-term follow up was administered, so the long term effects of corticosteroid injection cannot be implicated by this study. The results of the study illustrate that injecting methylprednisolone decreased pain during running after 14 days, and the practical recommendation for treating runners is that local corticosteroid is effective and safe (as the participants did not report any adverse effects during the experiment) treatment of newly onset iliotibial band syndrome.
36. 36. Level III Grade 5/7 Noehren B, Davis I, Hamill J. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomechanics. 2007;11(22):951-56. The aim of this study was to prospectively compare lower extremity kinematics and kinetics between a group of female runners who develop ITBS compared to healthy, age and mileage matched controls. Since the etiology of ITBS is unclear and retrospective studies have suggested both distal and proximal mechanisms that may be involved in the development of ITBS, no prospective studies existed prior to the one of lower extremity kinematics and kinetics in runners who develop ITBS. The study began with a pool of 400 healthy female runners who run a minimum of 20 miles per week, between ages 18-45, free of injuries at the time of data collection. 18 developed ITBS and were matched with age and mileage controls with no history of knee pain. The researchers used an instrumental gait analysis with a motion analysis system at the beginning of the study and was able to compare the findings from the group that developed ITBS and the matched controls. They found that the ITBS group visually landed in greater hip adduction and remained more adducted through stance, and peak hip adduction angle was also found to be significantly greater. Hip abduction moment was not different and both groups exhibited nearly identical patterns. The ITBS group had peak knee internal rotation that was significantly greater, as well as greater femoral external rotation. The increased external rotation of the femur may be due to muscle imbalances at the hip. The study notes that co-contraction of internal and external rotators is necessary for stability of the femoral head in the acetabulum on loading. Since the gluteus minimus, anterior fibers of gluteus medius, and tensor fascia latae are all abductors and internal rotators of the femoral head, insufficient activity of them may lead to increased femoral external rotation. A subgroup within the ITBS group demonstrated excess eversion coupled with high tibial internal rotation and knee internal rotation. These subjects exhibited a distal mechanism for ITBS and may benefit from intervention to control the rearfoot motion, like a foot orthoses, though further studies would be needed to address the efficacy of this intervention. Ultimately the results suggest that interventions should be geared toward enhancing the strength and neuromuscular control of the hip, and should also include stretching the iliotibial band to increase the overall compliance of it.
37. 37. Level IV Grade 3/14 Schriber R, Louw Q. The Effect of Gluteus Medius Training on Hip Kinematics in a Runner with Iliotibial Band Syndrome. SA J of Physiother. 2011; 67 (2): 23-28. The purpose of this single subject case study (ABA design) was to analyze the effect of a gluteus medius strengthening program on hip control during the stance phase of running. The subject was a 21 year old male amateur runner diagnosed with ITBS. This study was determined to be relevant to our research question because it addresses the effectiveness of one of the most common (conservative) management methods used to facilitate return to sport for runners with ITBS. The strengthening program is based on the theory that there is a relationship between decreased hip control related to gluteus medius weakness and ITBS. Measures included biomechanical analysis of the hip joint angles in the frontal plane, isometric gluteus medius strength, and pain levels (visual analog scale). Pre- intervention, the subject demonstrated significantly increased hip adduction on the symptomatic side compared to the unaffected hip. After six weeks of intervention that included gluteus medius strengthening and transverse abdominal exercises for core stability, hip adduction decreased by 9.8 degrees on the affected side. This change was determined to be clinically significant despite large standard deviations (3.37 degrees) and limited sensitivity of the biomechanical analysis system. Clinically, this study alone holds minimal significance due to its small sample size and lack of control. The conclusion that the decrease in hip adduction was a result of the gluteus medius strengthening program cannot be made with confidence. The study does support the relationship between hip muscle weakness and the injury pattern in runners suffering from ITBS.
38. 38. Level III Grade 21/27 Van der worp MP, Van der horst N, De wijer A, Backx FJ, Nijhuis-van der sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012;42(11):969-92. . The purpose of this study is to provide a systematic review of literature on etiology, diagnosis and treatment of ITBS in runners. Since this study incorporates a review of the conservative treatment interventions used for ITBS and their efficacies, it is applicable to our question of what the most effective (conservative) management methods are to facilitate return to sport for runners with ITBS. The review found that hip/knee coordination and running style appear to be key factors to analyze to provide effective treatment of ITBS. Runners might also benefit from mobilization exercises to strengthen the hip, advice about running shoes and running surface. In one study, when compared with other groups, the group that received the same therapy as other groups (ultrasound, deep transverse friction massages, and daily stretching of the ITB) in addition to an anti-inflammatory and analgesic found that pain during running significantly decreased from day 3 onward. In addition, running time/distance on the treadmill running test significantly increased from day 0-7 in this group. Another study concluded that deep transverse friction massage did not alter the therapeutic outcome of ITBS. One study examined corticosteroid injection, both the control and intervention group were instructed not to run for 14 days post-injection and to ice the area for 30 minutes every 12 hours. Running pain was significantly decreased in the group that received the corticosteroid injection. Collectively, the results of five studies on the conservative treatment of ITBS provide evidence of the efficacies of various treatment modalities: pain medication/injection, stretching the IT band, hip abduction exercises and pelvic drops to strengthen the gluteus muscles, and advice about training/shoe inlays/ and shoes.