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W125: Advanced Therapeutic Exercises and Ultrasound-Guided Procedures for Iliotibial Band Syndrome John Vasudevan, MD 1* Michael Fredericson, MD 2 Robert Baker, PT, OCS 3 Yin-Ting Chen, MD 4 Eugene Roh, MD 2 Michael Khadavi, MD 2 Jacob Sellon, MD 5 1.Department of Physical Medicine & Rehabilitation, University of Pennsylvania, Philadelphia, PA. 2.Division of PM&R, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. 3.Emeryville Sports Physical Therapy, Emeryville, CA. 4.Department of Orthopaedics & Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD. 5.Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN. *Course Director

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Iliotibial Band Syndrome: Not just whatbut why John Vasudevan, MD PM&R Sports Medicine Assistant Professor, University of Pennsylvania November 2014

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Objectives 1.Define the anatomy and pathophysiology of iliotibial band syndrome (ITBS) 2.Learn the pearls of exam and treatment, and their supporting evidence 3.Understand common contributing factors

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ITBS: The What 2 nd most common cause of knee pain in runners Lateral knee pain, insidious, progressive Worse with hills, slower running speed Initially predictable at certain point of run, but then progresses Cause: friction of ITB against lateral femoral condyle Or (less likely) distal insertional pain at Gerdys tubercle Impingement zone at ~20-30 knee flexion Inflammation of IT bursaif it exists

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ITB Anatomy Definition: lateral thickening of the fascia lata in the thigh, dense fibrous tissue Has superficial and deep layers, enclosing tensor fascia latae prior to anchoring at iliac crest Receives majority of gluteus maximus tendon Superficial and deep layers, enclosing tensor fasciae

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TFL/ITB Anatomy Origin: Iliac crest just posterior to the anterior iliac spine Insertion: lateral femoral condyle, lateral retinaculum of knee, lateral patella, and Gerdys tubercle on lateral tibial plateau Innervation: superior gluteal, L4, L5, S1 Action: hip flexion, abduction, internal rotation

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IT Bursa? Anatomic Findings: ITB is firmly anchored to lateral femoral condyle More medial-lateral translation rather than anterior- posterior No bursa identified, but fibers integrated in fat pad between ITB and lateral femoral condyle Conclusion: Pain may be from compression of fat, not sliding over bursa Fairclough 2006; Falvey 2010

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IT Band & Bursa Fredericson 2011; Fairclough 2006

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IT Bursa arising from lateral recess of knee joint Jelsing 2013

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ITBS: The Why Anatomic Static: leg length discrepancy, genu varum, pes planus Dynamic: Tight TFL/ITB, weak hip abductors, tight heel cords, excess femoral/tibial internal rotation Training Considerations Cambered surfaces Downhill running Strauss 2013; *Fredericson 2005

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ITBS: The What Else Lateral meniscal tear Lateral compartment degenerative joint disease Biceps femoris tendinopathy Stress fracture Patellofemoral syndrome Lateral collateral ligament sprain/tear

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ITBS: Keys to Exam Palpate over LFC and Gerdys tubercle Ober Test Noble Compression Test Assess other contributing factors: Hip abductor weakness (single-leg squat) Heel cord tightness

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ITBS: Treatment NSAIDs beneficial with PT* Steroid injection^ (US-guidance?) Physical Therapy Transverse friction massage (no clear evidence)**; lateral retinacular release, medial patellar mobilization Gluteal strengthening The super-fun FOAM ROLLER! Surgical options (release, lengthening, resection of bursa) * Schwellnus 1991; **Schwellnus 1992; ^Gunter 2004; Ellis 2007; Strauss 2013

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Gaps in the Evidence No clear evidence to support: Stretching the ITB (role of TFL in ITB lengthening) Strengthening the Gluteus Medius Trigger Point Therapy BUT we suggest that strengthening will fail if myofascial restrictions persist Limited Evidence to support: NSAIDs and corticosteroid for short-term relief No study comparing US-guided to landmark-guided Surgical treatment options (debridement, resection)

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ITBS: Treatment Strauss 2013

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Conclusions 1.While evidence-base is limited or conflicting, outcomes with conservative treatment are very encouraging 2.Consider distal AND proximal factors 3.Dont just ask what, but why and what else to optimize results and prevent recurrence

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References Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM&R. 2011;3(6):550561. Carvalho ACA, Junior LH, Costa LOP, Lopes AD. The association between runners lower limb alignment with running-related injuries: a systematic review. British Journal of Sports Medicine. 2011;45(4):339339. Ellis R, Hing W, Reid D. Iliotibial band friction syndromea systematic review. Manual therapy. 2007;12(3):200208. 16. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of anatomy. 2006;208(3):309316. 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. Scandinavian journal of medicine & science in sports. 2010;20(4):580587. Ferber R, Hreljac A, Kendall KD. Suspected mechanisms in the cause of overuse running injuries: a clinical review. Sports Health: A Multidisciplinary Approach. 2009;1(3):242246. Fredericson M, Wolf C. Iliotibial band syndrome in runners. Sports Medicine. 2005;35(5):451459. Jelsing EJ, Maida E, Finnoff JT, Smith J. The Source of Fluid Deep to the Iliotibial Band: Documentation of a Potential Intra-Articular Source. PM&R. 2013. Junior LH, Carvalho ACA, Costa LOP, Lopes AD. The prevalence of musculoskeletal injuries in runners: a systematic review. British journal of sports medicine. 2011;45(4):351352.

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References Nielsen R, Buist I, Srensen H, Lind M, Rasmussen S. Training errors and running related injuries: a systematic review. International journal of sports physical therapy. 2012;7(1):58. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):4251. Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons. 2011;19(12):728736. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. British journal of sports medicine. 2002;36(2):95101. Tenforde AS, Sayres LC, McCurdy ML, Collado H, Sainani KL, Fredericson M. Overuse injuries in high school runners: lifetime prevalence and prevention strategies. PM&R. 2011;3(2):125131. Van der Worp MSc MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial Band Syndrome in Runners. Sports Medicine. 2012;42(11):969992. Van Gent RN, Siem D, van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British journal of sports medicine. 2007;41(8):469480.

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Thank you!