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I have ITB syndrome...so what now?



Knee pain.


The inevitable bane of all runners, cyclists, hikers and….well, just about everyone. All adults (and unfortunately some adolescents as well) will experience some degree of knee pain or discomfort at least once in their entire life and unfortunately, many out there live with knee pain on a daily basis.


Knee pain, the symptom, can be due to many causes.


Some are easier to “fix” than others. Some will haunt you to a certain degree for a long time. And some knee pains will force you to change a sport that you are passionate about. Fortunately, all knee pains can be managed and if adequate care was given early enough, can be kept at bay for many long years to come.


For this post, we shall look into Iliotibial Band Syndrome (or more casually known as ITB syndrome), its typical presentation and causes, common remedial therapies that can be done on your own and when you need to stop kidding yourself and get your knee pain checked by a medical professional.


What is Iliotibial band (ITB)?


- ITB is a connective tissue (a mixture of both muscle and fascia) that starts at the side of the pelvis, runs along the lateral aspect of the thigh crossing both the hip joint and the knee joint, connects to other muscles and fascia then attaches to the bony edge of the side of the leg (tibia).

- The ITB functions by stabilizing the the knee and prevent it from caving in. Because of the proximity to the body edges at the knee, it may start rubbing against the bony parts due to the repeated knee flexion and extension, thus becoming inflamed and painful.


Presentation of ITBS?


- Initially it will start as mild pain at the outside of the knee that you notice after the end of your run/bike (insert linear motion physical activity of choice), and it progresses to pain occurring midway of your activity. Subsequently the pain will be felt at the start of the activity.

- Eventually it will worsen to pain even at rest if no intervention was under taken and worst case scenario, it will interfere with daily activities (walking, squatting at toilet, sitting and getting up from low chair etc). You may see some fullness at the outer part of the knee and it will be tight and painful to touch.

- Sometimes, you can feel a very hard thick band at the outer knee which is painful. The pain can sometimes be reproduced by moving your hips sideways and also bending and extending knee.


Who usually suffers from ITBS?


- Any activity that involves repeated knee flexion (bending) and extension may cause you to suffer from ITBS be it running/cycling/hiking/walking/squatting/swimming (breaststroke).

- But with the current rise in popularity of running where every weekend you are bound to find several running races (road or trail) around Klang Valley (and other parts of the country), plenty of runners commit the cardinal sin of overuse, which is: too much, too soon, too fast, too often.

- What predisposes one to ITBS are (1) anatomical issues, (2) training errors, (3) muscle imbalance esp of the gluteus (buttock).

- Anatomical à high arch or flat foot causing over pronation, excessive foot strike force, leg length imbalance, knees caving in (genu valgus)

- Training issues/errors à sudden increment in mileage, not including strength training in training plan especially strengthening of the hip muscles, running on banked surface (for example going only in one direction while track running), inadequate (or none at all) warm up/cool down, excessive uphill and/or downhill training, feet in “toe-in” position at excessive angle when cycling, not including stretching post training

- Muscle imbalance à weak hip abductor muscles (weak glutes), weak core strength, inflexibility of muscles (be it hip, quads, hamstring or calve muscles)


Management of ITBS


- For all musculoskeletal injuries (which includes ITBS as well), you can do no wrong with applying the R.I.C.E. therapy first (R: rest, I: ice, C: compress, E: elevate)

- Give and take about 3-6 weeks of around 50% reduction in mileage or duration of your activity of choice, while adhering to the R.I.C.E. therapy, and starting physical therapy such as:

- (1) Hip strengthening exercises

- (2) Foam rolling

- (3) Stretching of tight muscles

- (4) Cross training to maintain cardiovascular fitness

- (5) Core strengthening and stability exercises


For certain cases, prescription of orthotics or a change of shoes may help.

Special note: When it comes to foam rolling, the most common error I see many people do is that they foam roll directly over the ITB itself which can be extremely pain and to a large degree, pointless as the ITB is an inflexible fascia unlike muscle. It would be more beneficial (and a lot more bearable) to foam roll the (1) outer aspect of quadricep (vastus lateralis and tensor fascia lata) and (2) outer aspect of hips (gluteus muscle). For those who enjoy regular deep tissue massages, getting a sports masseuer to massage the above 2 areas will also relieve the symptoms when done on a regular basis. For some of my patients, I do dry needling to release the tightness in certain muscles (usually the glutes, vastus lateralis and the tensor fascia lata) to ease the symptoms.


Going to seek medical attention


- If having exhausted all the above and there is no relieve in symptoms at all within 6 weeks, please seek out your friendly Sports Medicine Physician to have your knee properly assessed.

- In my own practice, after going through the clinical history, physical examinaton and radiologically (thickening of the inflamed tissue on ultrasound) confirming the diagnosis of ITBS, at further assessment for a sports person, I also assess for:


(1) muscle imbalance and functional strength (weakness and/or tightness of the front and back thigh muscles, weakness in hip muscles, flexibility of the muscles from hip until calves, adequate mobility of all joints of lower limb)

(2) pattern of wear from shoes (to see where most force of foot strike is, whether there is over or under pronation during running, whether there is more foot strike force on 1 side versus the other)

(3) basic running gait (does the hip fall during foot strike, does the knee cave inwards, is there too much heel strike, is there adequate mobility of the ankle, does the feet crosses over midline, is stride frequency adequate).


- I will then have a clearer picture of what needs to be “fixed” before formulating the physical therapy prescription, specific to you and sending you off to the physiotherapists (or sometimes, directly to the physical trainer).


- Discussion regarding future fitness plans are also important as it gives the physician an idea of a timeline in managing your injury and get you back to racing, and it also allows the patient to better manage his or her expectation.


- In certain cases, where patient has exhausted all modalities but the pain persist, there is an option of corticosteroid injection to the superficial region of the ITB at area of most tenderness under ultrasound guidance. Reason this injection is not recommended to be done as a “blind” method (without ultrasound) is that the corticosteroid can weaken the structures that it is being injected into, in this case it would be the ITB and may later lead the tissue tearing, thus worsening the condition.







p/s: I actually did some videos on this on my secondary Instagram (I had to be so extra by having 2 IG accounts - for now. Please head on over to @tri.doc.on.board and scroll about). Unfortunately my iPhone SE is a tad wonky and the video quality is shitty.

No...I'm not upgrading phone anytime soon (the iPhone SE is still the best phone IMHO).

And youtube (despite being a BS abyss) has plenty of resources if you look properly.


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