March 2009 Newsletter

IT-Band Friction Fallacy? by Erik Dalton

Iliotibial band friction syndrome (ITBFS) is typically described as lateral knee pain aggravated by lower limb activities such as running and cycling. As more and more people participate in exercise programs such as marathon running, mountain biking, spinning classes, and so on, reported incidences of IT-band syndrome continue to rise. But please ‘Don’t Get Married’ to all the proposed theories and conventional wisdom surrounding this complex syndrome.

It’s really irritating when scientific evidence makes a fool out of conventional wisdom…

Most of us attend workshops, read articles and blindly embrace so-called conventional wisdom while forsaking new discoveries which may lead to better clinical outcomes. In a wonderful book titled “A Clinical Guide to Sports Injuries” by Roald Bahr and Sverre Mæhlum (2004), IT-band syndrome is listed as a “less common” cause of knee pain than patellofemoral syndrome, quadriceps tendinopathy, meniscus injuries and knee instability. I’d like to add ‘posteriorly fixated fibular heads’ to that list. When prolonged biceps femoris (BF) myospasm glues down the intermuscular septa dividing BF from ITB, weird knee symptoms often appear. The combined forces of these two contractured muscles tug hard on the ITB…but also on the fibular head where the BF inserts (Fig 1).

Many researchers and clinicians are convinced that the pathoanatomy of IT-band friction syndrome is well known and well understood…but is it? Here’s an example where conventional wisdom might lead us down the wrong therapeutic path.

Conventional Wisdom

ITBFS is generally thought to be a non-traumatic overuse condition in which the distal aspect of the iliotibial band rubs over the lateral femoral epicondyle with repetitive knee flexion and extension. This ultimately leads to irritation of the iliotibial band, bursa and lateral synovial recess. In this model, the posterior, deeper ITB fibers are more vulnerable to back-and-forth rubbing on the knee’s lateral epicondyle. Supporters of this theory describe a dynamic “impingement zone” at approximately 30° of knee flexion where the ITB rolls back-and-forth over the lateral femoral epicondyle causing microfiber tearing. Given this information, therapists usually seek out the sore spot and begin cross-fiber frictioning the affected tissue to create more fibroblast activity and break down any old weak-linked adhesions. Others may elbow or stretch the iliotibial tract to take pressure off the supposed tear. Both of these approaches may be appropriate if IT-band fibers are really damaged.

New Science

In the Journal of Sports Science and Medicine (2007), a prestigious research team including Fairclough, Hayashi, Toumi, Lyons, Bydder, Phillips, Best, and Benjamin challenged the idea that excessive friction between the IT band and the lateral femoral epicondyle creates microscopic tears and 'inflames' the tract or a bursa. These researchers found that several basic anatomical ITB principles had been overlooked: (1) the IT band is not a discrete structure as is commonly depicted (see Fig. 2), but a thickened part of the fascia lata which envelops the thigh, (2) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands which are not pathological adhesions and, (3) a bursa is rarely present, but may be mistaken for the lateral recess of the knee.

These well-structured trials concluded that the ITB cannot create frictional forces by moving back and forth over the epicondyle during flexion and extension of the knee. They stated, “The perception of movement of the ITB across the epicondyle is an illusion caused by alternating tension in its anterior and posterior fibers”. Although the MR scans showed that the ITB did get compressed against the epicondyle at 30 degrees of knee flexion from internal tibial rotation, it always moved laterally as the knee extended. Therefore, it appears the ITB is prevented from rolling over the epicondyle…partly because of its femoral anchorage…and partly because it’s fibers are tightly bound to the tough enveloping fascia lata.

Although the team was able to induce slight medial-lateral movement, they proposed that ITB syndrome was primarily caused by increased compression of a highly vascularized and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle (Fig 3). They also theorized that ITB syndrome is related to impaired function of hip, leg and foot musculature and optimal healing requires proper biomechanical restoration to all lower quadrant musculoskeletal structures.

Treatment Options

Oddly, the two most common types of massage strokes used to relieve IT band syndrome (cross-fiber frictioning and ‘deep tissue stripping’) are probably not the best choices for relieving pain and restoring function. Cross-fiber frictioning in and around the knees’ lateral condyle is a wonderful technique if there is actual ITB tissue tearing. But compression injuries are more easily resolved by relieving tension to the highly innervated underlying tissues. Instead of “chasing the pain”, therapists must find and fix “kinks” along the kinetic chain such as pronated feet, valgus knees, and hip/pelvic imbalances.

Although myofascial stripping routines do help loosen the superficial fascia, attempting to lengthen an exceedingly dense and anchored IT tract is futile and shows a lack of understanding of the nature of this particular type of connective tissue. The iliotibial tract is a massive structure made of a substance with greater tensile strength than steel cable. It simply cannot be significantly elongated by rubbing, elbowing or stretching it. This tendinous ligament is one of the sturdiest structures in the body and, in my opinion, hammering on it is futile.

In addition to the structural integrative approach mentioned above, I’ve had some success treating stubborn IT-band pain using the following ‘fascial bag’ technique to relieve compressive forces binding down structures around the lateral condyle. Using fingers, knuckles and elbow, seek out and remove all fascial adhesions (inferior to superior) that may be binding the fascial envelopes of the IT-band, biceps femoris and vastus lateralis. Joint stretching techniques that restore tibial rotation and joint-play to fixated fibular heads are also helpful for treating other knee pain conditions which mimic IT-band friction syndrome.

Erik Dalton, Ph.D., created the Myoskeletal Alignment Techniques® and founded the Freedom From Pain Institute®. Dalton’s 29 years of study in massage, Rolfing® and osteopathy is taught worldwide through pain-management workshops and home-study courses approved by NCBTMB and Florida Board of Health.

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