ITB Syndrome Case Study: Bringing Research Into Practice

I know how seriously running patients take their running when they are more in agony about the injury preventing them from running than the physical injury itself! Iliotibial band (ITB) syndrome is the second most common injury in runners (after PFPS), accounting for approximately 10% of running-related injuries in the US (1). ITB pain is highly prevalent in the running population, with female runners being more at risk of developing this condition than males.

The aetiology of ITB syndrome is not well understood, with many physiotherapists still believing that ITB pain is a ‘friction’ injury due to sliding and slipping of the ITB band over the lateral femoral condyle causing pain and inflammation. Many still believe that a ‘tight ITB’ needs to be stretched while others assume that the ITB is something that needs to be foam rolled, scraped with tools, deeply massaged and needs to be ‘released’ from this trap! Frustratingly, the confusion has led to a significant patient population suffering from ITB pain being treated unsuccessfully.

The aim of this case study blog is to underline how contemporary research guided and enhanced my ability to effectively treat ITB pain. It has been a year since I’ve subscribed to Physio Network’s Research Reviews and what better way to mark the ‘a-knee-versary’ by reporting how one of their reviews titled “Iliotibial band pathology: synthesising the available evidence for clinical progress”, written by the brilliant Tom Goom, helped me manage this stubborn condition of lateral knee pain in a female runner.

ITB Pain: Under-Researched and Misconstrued?

The ITB has been a tough one to crack (pun intended) for clinicians for a long time. The ITB, which is rather a thickening of the fascia, is part muscle, part ligament, part tendon and covers the thigh like tight wrap. A substantial part of the gluteus maximus muscle inserts into the ITB with the tensor fascia latae (TFL). With attachments at the pelvis and the knee, it runs along the length of the femur and attaches strongly to the lateral femoral condyle and then continues to the patella and inserts onto the Gerdy’s tubercle (2). Tom Goom states in his review that –

“ITB pain is thought to be the most common cause of lateral knee pain, and yet it’s a pathology that is poorly understood and drastically under-researched!” (3).

It was earlier thought that the friction resulted in the inflammation of an anatomical bursa, but now this theory is not supported by evidence. There’s a claim that it’s more of a compression injury than a friction injury. The adipose tissue between the IT band and the femur gets compressed as the knee bends past 30 degrees (functional ‘impingement zone’) which occurs usually early in the mid-stance phase of running (3).

I was surprised to read how the review challenged common treatment approaches for ITBS such as stretching and massage. After reading the review, I appreciated the fact that it was high time for me to get off the ITB band-wagon of stretching and foam rolling and look for active interventions to progressively load the ITB if I wanted to achieve better clinical outcomes for my patient.

The Case

The patient was a 38-year old female with sharp pain on the lateral aspect of her right knee which was getting worse on coming down the stairs at home. She was referred by the local orthopaedic doctor with a diagnosis of ‘Iliotibial band friction syndrome’. She mentioned that she was a keen runner and had completed 3 marathons per year before having her first baby. Her child is 2 years old now and she has been looking to get back into running and has been running on road as she wants to compete in a half-marathon early next year.

She reported that the pain started after she decided to run on a hill trail over a weekend. Over the next 2 weeks she noticed the pain getting worse. The pain always seemed to come on after about 3km into running and she feels the knee getting “tighter and tighter” which eventually forces her to stop. She felt that her knee might “snap”. X-rays were negative.

She had been doing some stretching and foam rolling after watching some videos on Instagram and some prescribed by a physiotherapist she saw before coming to me, and had an Ayurveda massage done which aggravated her symptoms. Manual muscle testing showed some generalised weakness in the hip abductors and external rotators on the right compared to the left side. Gait analysis showed a contralateral pelvic drop and hip adduction. The patient reported her recovery being impaired due to stress at home taking care of her child.

By this stage, it was becoming clear to me that the lack of clear understanding of the pathology by the practitioners she had been to, on top of the lack of education given to her, has led to ineffective therapeutic interventions doing more harm than good! My aim was to provide a structured rehabilitation program which would address the potential causative factors, progressively load the ITB and prevent it from becoming a persistent condition.

This is when I referred to the Physio Network review and it helped me manage the condition by providing a multifactorial approach with robust rehab options, rather than just a local approach.

The Review and the Treatment

The review is pretty clear in its message of challenging the theory of a ‘tight ITB’. It mentions that we should not be adding more compression to a potentially compressive injury. Therefore, out went the foam rollers and stretches from the decision-making process. The guiding philosophy became the need to build capacity and tolerance to the loads of the ITB. The review divides the rehabilitation program into phases which I applied as per the stage of recovery and symptoms response:

PHASE I – The ‘low-load’ phase (3x/week for 2 weeks)

The purpose of this phase was to calm stuff down. By providing well-tolerated loads we avoided deconditioning and flaring up of symptoms. Focus was on strengthening the hip musculature. Incline treadmill walking was introduced with 8% incline.

The strength program included:

1. Side lying hip abduction
2. Clamshell eccentrics
3. Donkey kicks
4. Supine single leg bridges

PHASE II – Moderate load phase, closed chain exercises (3x/week for 2 weeks)

I progressed to this phase once the patient reported pain was significantly less (2/10) while going downstairs. I continued with incline treadmill walking increasing the incline to 10% and exercise were performed till failure.

The strength program included:

1. Forward lunges
2. Step ups (glute focused)
3. Ipsilateral hip hikes (as seen here – https://www.youtube.com/watch?v=M88TWUyQTq8)
4. Mini squats (two legged to one legged)
5. Split squats (right leg placed behind)

PHASE III – Heavy load phase ; Introducing plyometrics (3x/week for 3 weeks)

The focus in this phase was to work on force absorption and energy storage, and increase tolerance to heavier load.

The strength program included:

1. Goblet squats
2. Single leg squats
3. Lateral hops
4. Agility ladder
5. Drop jumps
6. ‘Jog and stops’ on the right leg

Return to Running

Once the patient tolerated the aforementioned three phases well, a run/walk interval program was introduced. Plyometric exercises were gradually tapered away from the program and verbal cues were given to prevent reducing the ‘knee window’ and to take wider steps while running on a treadmill. Running volume was increased gradually (first run on flat road and then downhill).

The Outcome

The patient reported that her beliefs towards the injury changed drastically, as she does not constantly fear re-injuring herself and needing to stretch the ITB. She was able to run with little to no pain for 8km, 8 weeks after our first session together. She still manages to do her heavy-load exercises consistently and focuses more on her recovery and sleep. On 5-month follow up, she reported that she has been doing 15km runs every other weekend with no pain and she plans to incorporate hill runs over the next month increasing her mileage by 10% each week.

Conclusion

This review helped me approach a confusing injury with a new perspective which was patient-centred, progressive and effective. I was able to formulate a robust exercise plan based on the current evidence available and was successful in ensuring a safe return to running for my patient.

Physio Network’s Research Reviews challenge our biases and forces us to think outside the box. Physio Network tirelessly strives to elevate the quality of care and challenge the conventional methods of treatment by providing significant and easily digestible research reviews every month to help us keep up to date and up our game as physiotherapists.

Go and subscribe right now and come back to let me know your before and after, because I’m sure you’ll have something to say!