ITB Syndrome

Additional considerations when treating lateral knee pain

Many peo­ple suf­fer from lat­er­al knee pain when exer­cis­ing and com­pet­ing in sport (1).

The med­ical expla­na­tion of this is often of a short or stiff ili­otib­ial band, and huge amounts of time are invest­ed in iso­met­rics, foam rolling, trig­ger point­ing, mas­sage or needling this struc­ture which seems so resis­tant to repair.

This arti­cle is going to present a few things that you may want to con­sid­er in addi­tion to the nor­mal old ITB treatment

First­ly, if we look at the anato­my of the ITB it’s ori­gins begin along the ili­ac crest as the glute max and TFL merge togeth­er and descend from the greater trochanter down to the lat­er­al aspect of the knee (2).

Clear­ly it can be worth invest­ing time releas­ing these mus­cles in addi­tion to an ITB stretch.

Sec­ond­ly and less known, is how the short head of the biceps femoris (lat­er­al ham­string) affects lat­er­al knee. It attach­es over the joint just pos­te­ri­or to the ITB and it’s fas­cial attach­ments blend into the ITB. You may wish to test the length, strength and feel of this mus­cle (3).

Third­ly, the ITB forms part of a strong lat­er­al fas­cial band that begins in the per­oneals of the low­er leg, through the ITB before ascends to the lat­er­al obliques, lat dor­si and beyond. Assess­ing the ROM, strength and qual­i­ty of these mus­cles would be ben­e­fi­cial to under­stand­ing how each mus­cle inter­acts with, and affects oth­er mus­cles with­in the fas­cial band (4).

These fas­cial bands are illus­trat­ed as sep­a­rate dis­tinct struc­tures in many texts such as Ida Rolf and Anato­my trains, yet in real­i­ty these fas­cial bands are inter-con­nect­ed like spi­ders webs to oth­er fas­cial bands and to oth­er struc­tures not illus­trat­ed (4).

When one con­sid­ers the per­oneals and their influ­ence on the lat­er­al fas­cial line, it might also be worth assess­ing foot type, foot fall and whether the per­son pro­pels with a high gear or low gear foot type (5). If they low gear (supinate dur­ing propul­sion) then this can cre­ate greater impact forces through the limb and increase tone along the per­oneals and lat­er­al fas­cial line straight up to the knee and ITB (5).

It can also be com­mon to hear of pro­fes­sion­als who release the lat­er­al quad as well as the ITB, after all it can be dif­fi­cult to know exact­ly when one ends and the oth­er begins (5).

You may be won­der­ing when I will men­tion the bio­me­chan­ics. Whether the per­son is quad dom­i­nant, TFL dom­i­nant, how well they run? Do they employ a heel strike, mid foot or fore foot land­ing? That my friends is a dis­cus­sion rid­dled with con­flict­ing and often very poor qual­i­ty research that flicks between dif­fer­ent par­a­digms that hap­pened to be pop­u­lar at dif­fer­ent time in our pro­fes­sion­al his­to­ry. It is also a top­ic of very detailed clin­i­cal rea­son­ing that is too long for this arti­cle. But go ahead and squab­ble as you wish!

Ref­er­ences

1. Maf­ful­li N, Wong J, Almekinders L.C. Types and epi­demi­ol­o­gy of tendinopa­thy. Clin­ics in Sports med­i­cine. 2003. 22(4): 675 – 692.

2. Ober F.R. the role of the ili­otib­ial band and fas­cia lata as a fac­tor in the cau­sa­tion of low back pain dis­abil­i­ties and sci­at­i­ca. The jour­nal of Bone and Joint Surgery. 1936 Jan. 18(1): 105 – 110.

3. Mar­shall J.L, Gir­gis F.J, Zelko R.R. The biceps femoris ten­don and its func­tion­al sig­nif­i­cance. The jour­nal of Bone and Joint Surgery. 1972 Octo­ber. 54(7): 1444 – 1450.

4. Rolf J.P. Rolf­ing: Re-estab­lish­ing the nat­ur­al align­ment and struc­tur­al inte­gra­tion of the human body for vital­i­ty and well-being. Heal­ing Arts Press. Octo­ber 11979

5. Myers.T.W. Anato­my Trains: Myofas­cial Merid­i­ans for man­u­al and move­ment ther­a­pists. Sec­ond edi­tion. Churchill Liv­ing­stone, Else­vi­er. 2009.