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Tendinopathy and Iliotibial Band Syndrome: Understanding Pathology Informs Treatment Craig R. Denegar, Ph.D., P.T., A.T.,C. Professor and Associate Department Head Director, Doctor of Physical Therapy Program Department of Kinesiology University of Connecticut [email protected]
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Page 1: Tendinopathy and Iliotibial Band Syndrome: …...Tendinopathy and Iliotibial Band Syndrome: Understanding Pathology Informs Treatment Craig R. Denegar, Ph.D., P.T., A.T.,C. …

Tendinopathy and Iliotibial Band Syndrome: 

Understanding Pathology Informs Treatment

Craig R. Denegar, Ph.D., P.T., A.T.,C.Professor and Associate Department Head Director, Doctor of Physical Therapy Program Department of KinesiologyUniversity of [email protected]

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Invitation

Address the contemporary use of

one or more therapeutic modalities

2EATA 2010

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Premise

At the foundation of therapeutic

interventions for musculoskeletal

conditions lies a diagnosis

(medical, functional)

3EATA 2010

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Purpose

Consider therapeutic interventions from a perspective of new understandings of two relatively common musculoskeletal conditionsHighlight the links between diagnosis from a tissue and biomechanical perspective and treatment recommendations

4EATA 2010

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Tendinopathy

Tendinosis

or

Tendinitis

Implication of “itis”

Implications of labeling in treatment

5EATA 2010

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What it is: A closer look at a degenerative process

UltrasonographyFiber disorganization

Hypoechoic islands

Increased fluid volume

Increased diameter

Neovascularization

6EATA 2010

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Transverse View 5 cm prox insertion

7EATA 2010

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Neovascularization 

From: Hoksrud A. et

al. Ultrasound-guided

sclerosis of neovessels

in painful chronic

patellar

tendinopathy: a

randomized

controlled trial. Am J

Sports Med. 2006;

34:1738-46.9EATA 2010

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Collagen Organization: H&E

10EATA 2010

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Signs and Symptoms

Pain

Why is tendinopathy painful?

Stiffness

What does loss of stiffness imply?

11EATA 2010

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Neovascularization

Not always present

Resolution has been associated with

symptom relief

May be present in asymptomatic

individuals

12EATA 2010

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What it is not: highlights of the literature

“There is some scientific support in the

literature for the diagnosis of tenosynovitis

and tendinosis as a pathologic entity. Actual

inflammation of tendon tissue consistent with

tendonitis has not been seen clearly in patho-

anatomic studies”Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of

tendonitis: an analysis of the literature. Med Sci Sports Exerc 1999

31:352-3

13EATA 2010

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What it is not: bottom line

Tendinopathy is not an inflammatory condition based upon contemporary understanding of an acute inflammation > repair process.

PGEs elevated but not neutrophil, macrophage counts

14EATA 2010

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Treatments suggested for “itis” 

Ultrasound & phoresis(how many have used US to treat a tendinopathy?)

NSAIDs

Friction massage

LLLT

Exercise

Superficial heat and cold

15EATA 2010

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Ultrasound etc.

“Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit for tendinopathy.”

Wilson JJ, Best TM Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005

Why would we treat a non-inflammatory condition with anti-inflammatory medication or suggest we promote resolution of an inflammatory condition with ultrasound, especially in light of the absence of evidence of efficacy?

16EATA 2010

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Friction massage

No benefit but limited to ECRB and ITB –further investigation needed

Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003528. DOI:10.1002/14651858.CD003528.

17EATA 2010

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NSAIDs

NSAIDs are recommended for short-term pain relief but have no effect on long-term outcomes.

Wilson JJ, Best TM Common overuse tendon

problems: A review and recommendations for

treatment. Am Fam Physician. 2005

18EATA 2010

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NSAIDs

“Overall, a short course of NSAIDs appears a reasonable option for the treatment of acute pain associated with tendon overuse, particularly about the shoulder. There is no clear evidence that NSAIDS are effective in the treatment of chronic tendinopathy in the long term.”

Andres BM, Murrell GAC. Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clin Orthop Relat Res. 2008 466: 1539–1554.

19EATA 2010

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LLLT

Mixed resultsSystematic reviews do not support use of LLLT for tendinopathyResults may be parameter specific

See: Bjordal JM, et al. A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. 2008; 9: 75.

20EATA 2010

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LLLT

Bottom line – we have much to learn regarding LLLT and the treatment of tendinopathy

Additional data are needed before LLLT with specific treatment parameters (wavelength, dose etc.) can be recommended for general care

21EATA 2010

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Exercise

Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound.

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise British Journal of Sports Medicine 2007;41:188-198

22EATA 2010

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Effective treatment ‐ exercise

Achilles and patellaEvidence of response to progressive eccentric loading

Less benefit with insertional Achilles pathology often including bursitis, Haglund’s deformity

23EATA 2010

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Effective treatment‐exercise

Evidence of benefit of closed chain incline squat in management of patella tendinopathyPosterior tibialis: preliminary evidence of benefit with brace (FAO)-> orthotic and eccentric loading

24EATA 2010

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A New Approach

Glyceryl Trinitrate Patches

Evidence of effectiveness – new solution based on a new understanding of tendon pathology ?

Paoloni et al. Topical Glyceryl TrinitrateApplication in the Treatment of Chronic Supraspinatus Tendinopathy:A Randomized, Double-Blinded, Placebo-Controlled Clinical Trial . Am J Sports Med. 2005;33:806–813

25EATA 2010

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GTN

GTN reduced pain with activity at 12 & 24 wks, reduced night pain at 12 wks, reduced tenderness at 12 wks, decreased pain after the hop test at 24 wks, and increased ankle plantar flexor mean total work compared with the baseline 24 wks. 78% of GTN group were asymptomatic with activities of daily living at six months, compared with 49%) in placebo group. The mean effect size for all outcome measures was 0.14.

Paoloni et al. Topical Glyceryl Trinitrate Treatment of Chronic Noninsertional Achilles Tendinopathy. JBJS (Am) 2004; 86:916-922

26EATA 2010

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GTN

Kane et al. Topical Glyceryl Trinitrate and NoninsertionalAchilles Tendinopathy: A Clinical and Cellular Investigation. Am J Sports Med. 2008;36:1160-3.

“This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperativetherapy.”

27EATA 2010

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Concerns with “Recovery”

Resolution of symptoms does not imply structural repairEvidence of repair

Decrease diameterResolution of vascular in-growthImproved fiber organization and resolution of hypoechoic islands

No treatment universally effective –fuller understanding of pathology needed to advance treatment

28EATA 2010

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Current best practice? EdUReP+

Educate the patient

Unload – active rest, brace as indicated

Glyceryl Trinitrate Patch?

Reload – eccentric training

Prevent – training errors, too rapid of a return to sport

29EATA 2010

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A new tale: complaint of lateral knee pain

Active graduate student in good health

Pain on lateral aspect of right knee 10d

Insidious onset

Unable to run more than 1½ miles

before onset of disabling pain

30EATA 2010

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Physical examination of right knee

Full motion

No effusion

No laxity

Exquisitely tender over lateral

femoral condyle

31EATA 2010

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Diagnosis?

If you hear hoof beats think

of horses!!

32EATA 2010

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Nothing tricky 

Athlete evaluated as experiencing

Iliotibial Band Friction Syndrome

What is it?

How is the condition best treated?

33EATA 2010

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Iliotibial Band Friction Syndrome

34EATA 2010

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Varying opinions on the etiology of the injury

EATA 2010 35

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Biomechanics

With knee extension, the ITB is anterior to the

lateral femoral epicondyle

With greater than 30 degrees

of knee flexion, the ITB is

posterior to the lateral

femoral epicondylehttp://emedicine.medscape.com/article/307850-overview

36EATA 2010

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From PT Corner

What is a possible cause of iliotibialband friction syndrome?Overuse may cause shortening of the ITB. The knee goes from flexion to extension and excessive pressure from the ITB causes friction over the lateral femoral epicondyle. This repeated motion produces inflammation of the underlying structures and causes pain.

http://www.nismat.org/ptcor/itb_stretch/37EATA 2010

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Iliotibial band syndrome

The continual rubbing of the band over

the lateral femoral epicondyle, combined

with the repeated flexion and extension

of the knee during running may cause the

area to become inflamed.

http://en.wikipedia.org/wiki/Iliotibial_band_syndrome

38EATA 2010

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Sports Injury Clinic

Runners Knee (Iliotibial band

syndrome)

http://www.sportsinjuryclinic.net/cybertherapist/front

/knee/irunnersknee.html syndrome)

39EATA 2010

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E‐medicine from Web MD

When the knee flexes, the ITB moves posteriorly along the lateral femoral epicondyle. Contact against the condyle is highest between 20° and 30° (average 21°), so when the band is excessively tight or stressed, the ITB rubs more vigorously. The space deep to the ITB is believed to have an adventitial bursal extension from the synovial capsule.

http://emedicine.medscape.com/article/1250716-overview

40EATA 2010

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Treatment??

Stretching

Ultrasound

Transverse friction

Etc.

41EATA 2010

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Second thoughts ?

Does the fascia become tight ?(or is there evidence that it can be substantially stretched?)The fascia is well anchored to the femur and does not rub on the femoral condyle!

42EATA 2010

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The functional anatomy of the iliotibial

band during flexion and extension of

the knee: implications for

understanding iliotibial band syndrome.

Fairclough et al, J Anat. 2006

Mar;208(3):309-16

43EATA 2010

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“the ITB is simply a thickened, lateral

part of the fascia lata. It completely

surrounds the thigh, is anchored to the

femoral shaft by the lateral

intermuscular septum and is continuous

with the patellar retinacula”

44EATA 2010

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“Furthermore, we have shown that the ITB is firmly attached to the distal femur by strong, obliquely orientated, fibrous strands that can be regarded as tendon entheses. Thus, the ITB is unlikely to roll forwards and backwards during flexion and extension of the knee, but could move slightly in a medial–lateral direction.”

45EATA 2010

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“The impression of a rolling movement

is likely to be an illusion created by a

sequential shifting of tensile load within

the ITB. Its fibres are tensioned in

sequence from anterior to posterior as

the knee flexes.”

46EATA 2010

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If the band does not roll across the

lateral femoral condyle what would

explain this commonly experienced and

widely recognized problem?

47EATA 2010

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Is Iliotibial band syndrome really a

friction syndrome? Fairclough et al

J Sci Med Sport. 2007 Apr;10(2):74-6

48EATA 2010

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“Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle.”

*bursitis cannot be ruled out but …….

49EATA 2010

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MR findings in iliotibial band syndrome.

Nishimura et al. Skeletal Radiol (1997)

26:533-537

“The MR finding suggested soft tissue

inflammation and/or edema rather than

focal fluid collection in a bursae”

50EATA 2010

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“Our view is that ITB syndrome is

related to impaired function of the hip

musculature and that its resolution can

only be properly achieved when the

biomechanics of hip muscle function are

properly addressed.”

51EATA 2010

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Treatment 

Iliotibial band friction syndrome – A

systematic review. Ellis, Hing, Reid. Man

Ther. 2007 Aug;12(3):200-8

EATA 2010 52

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Reviewed 4 reports investigating NSAIDs, deep friction massage, phonophoresis vsimmobilization, and corticosteroid injection

Outcome data confounded by other interventions (ice, stretching, rest)

53EATA 2010

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This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.

54EATA 2010

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Back to our patient

Very hypertonic over TFLTender along course of palpatably tight ITBPalpation, long-sit suggestive of right anterior innominate rotation, T-L junction hypomobilityAntecedents?

55EATA 2010

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Treatment

Mobilization of T-L jct, instruction in right knee to chest muscle energy and hip flexor muscle stretching 2-3 times each day. Initial treatment reduced TFL hypertonus and ITB tendernessResume activity as tolerated

56EATA 2010

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Outcome

Able to resume running without

limitation within 5 days

57EATA 2010

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Additional considerations

Runners – distance, surface, level of

fitness, heel strike angle

Cyclists – saddle height, cleat peddle

interface, distance

58EATA 2010

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Key points

Anatomical and MRI investigations suggest that pain over the lateral femoral condyleassociated with ITB friction syndrome is not associated with friction but rather fat pad entrapmentTensioning of the ITB is due to proximal muscle / joint dysfunctionTreatment should be directed at identifying and then treating the mechanical sources of ITB tensioning

59EATA 2010

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Bottom line

Understanding of the pathoetiology is essential to treatment decisionsA multimodal approach (injection, manual therapy, therapeutic exercise) may yield optimal (early return to full sport participation) treatment results

60EATA 2010

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Future directions

Value of local interventions

(corticosteroid injection, etc)

warrants investigation in light of a

revised view of the pain generator

61EATA 2010

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Questions and Discussion

EATA 2010 62

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Thank you !!

EATA 2010


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