Pain Management

An In-Depth Look of IT Band Syndrome

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What is the IT Band?
The iliotibial (IT) band is composed of a strong group of fibers or fascia (a form of connecting tissue) that starts at the top of the pelvis (most notably at the iliac crest, near the major pelvic bone) and runs down the lateral side of the leg and connects to the patella, fibula, and tibia (shinbone). Fibers from the gluteal (buttock) muscles and the hip joint muscles attach to the IT band, which directs and coordinates muscle function and stabilizes the knee during running or walking. At the part of the knee where the tendon passes, there is a small sac (bursa sac) between the bone and the tendon: “The bursa functions like a water balloon to reduce friction and wear of the tendon against the bony bump” (Mason MD). This sac is important, as it “allows the Iliotibial band to glide over the end of the femur.” (Wedro, MD, FACEP, FAAEM)

IT Band Syndrome
Excessive friction on this “bump” leads to inflammation in both the tendon and/or bursa (tendonitis, bursitis): “In patients with iliotibial band syndrome, magnetic resonance imaging (MRI) studies have shown that the distal iliotibial band becomes thickened and that the potential space deep to the iliotibial band over the femoral epicondyle becomes inflamed and filled with fluid” (Khaund et al, 2005). This is a rather technical way of saying that the IT band swells up and causes distress to many areas, specifically across the knee and in the bursa sac. If ignored, it usually takes an average of four weeks before the serious symptoms of ITBS (as well as the rapid onset) make any activity or workout nearly impossible. ITBS (also called ITBFS for Iliotibial Band Friction Syndrome) is a typical injury for runners, cyclists, weight-lifters, hikers, and those who use their knees and thighs often during their physical occupation. ITBS can be caused by any repetitive use that moves the IT band out of place, applies friction to the bony part of the knee, and strains or “stresses” the IT band. Repetitive, improper use, or overuse (more on overuse found later in this reading) puts the IT band at risk of injury. Although the symptoms generally sound the same in most patients, the location of the pain varies. Pain locations have been described by sufferers as anywhere between the hip area, to the knee bone, and the shin area. This just illustrates that ITBS can take on many painful forms which makes it even harder to identify and diagnose. In the realm of sports medicine, it is generally accepted that ITBS is caused by overuse and the conventional remedy is training and exercise adjustment. However there is an ever-growing world of information on treatment of the symptoms and pain alleviation.

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Symptoms and Causes
Some of the symptoms of ITBS are pain and/or swelling on the IT band above the outer knee joint. Redness or a “warm” sensation may also be present. While some individuals describe the affliction as a “tingling sensation”, others may express an intense soreness or inflammation. This could be why ITBS is difficult to diagnose at times. During the beginning of exercise, athletes will sometimes experience pain that might decline after warm-up. However, this pain may eventually increase and be present throughout an activity. If this sounds familiar, it is possible you may suffer from ITBS. Pain is typically felt when the foot hits the ground and may be present above or below the knee. Again, this type of pain can be expressed in many different areas with a variety of sensation and pain. Activities like running down hills or stairs may be extremely painful, as well as running or walking on hard surfaces: “Burning, aching pain and palpatory tenderness on the outside of the knee” can also be present “every time it is bent or straightened out.” (Pajaczkowski) ITBS is found in many athletes or in individuals who play sports with repetitive knee-bending activities like running or cycling. When runners experience ITBS, it is often the result of incorrect training techniques. In fact, 60% of all running injuries are the result of training errors (Hreljac A., 2004). Incorrect techniques may include abrupt “changes in the amount, frequency or intensity of the training”. Also, not getting enough rest is a factor. Most athletes know the importance in restoring the body through adequate sleep and relaxation. If you feel as if your training is more than you can handle at any given time, don’t let pride ruin your body. Give yourself a break and your body will reward you. Most coaches will not ask for more than what you are capable of, but nobody is perfect. If you feel that you are putting yourself at risk of further injury, inform your coach or your boss that it might be time for you to take a break. Don’t force yourself to work through the pain; further damage to this area will only lead to bigger problems in the future. Although runners commonly deal with ITBS, generally any activity where an individual uses their knees can lead to friction on the bursa sac, leading to inflammation and ITBS. Rowers and hikers are susceptible to ITBS as well. It’s almost impossible for a hiker to be on flat stable ground for an entire hike (mother nature just isn’t built that way unfortunately) and the main issues a hiker should be concerned about are terrain and distance. Inadequate warm-up and cool-down techniques in hiking (and pretty much in any of these activities) may also lead to a case of ITBS. As with other athletes, proper stretching is pertinent before attempting a long hike. The IT band is susceptible to injury from the constant lifting and placing of feet on uneven ground, accompanied with the turning of corners (which moves the knee repetitively). Certain swimming exercises like the breaststroke, water polo or even treading water use the muscles that stretch the IT band and cause improper friction. Tennis players are also susceptible due all the crouching, running, and turning during a match. ITBS can affect even those who might not consider themselves “athletes” because any activity that requires repetitive movement (like walking up and down the stairs) puts pressure on the IT band and can result in pain and inflammation. Knee pain is the most common symptom of ITBS. This may be largely due to the fact that everybody uses their knees on a daily basis; athlete or not. Occupational or construction jobs, such as roofing, carpeting, etc., force a person to repetitively use their knees and can be a factor that leads to ITBS. Any job that requires a person to climb up and down stairs is also a detrimental factor to developing ITBS. The way you crouch and bend at the knees can create ITBS, as well as general pain in your knees. These types of activities are very strenuous on the IT band (especially around the area that glides over the knee) and overtime can create painful problems. Another factor to watch out for is wearing improper footwear at work; it can be hazardous over time because you are not receiving adequate support for the knees.

Treatments
Although it is classified as an overuse injury, there are several factors that can lead to ITBS. However, an individual who suffers from IT Band syndrome should treat the impairment as you would treat an overuse injury. Some of the following tips may provide you with relief if you are suffering from IT Band Syndrome Pain:

  • There a wealth of information regarding physical safety techniques while on the job. For instance, we’ve all heard the phrase, “Lift with your knees” when lifting heavy items at work. This is a safety measure to protect your lower and upper back muscles, as well as your spine. Just as there are safety techniques for the back, there are also safety techniques that can help prevent ITBS. It would be proactive to educate yourself on what kind of safety techniques there are in physical occupations; you should find information on anything from getting in and out of large construction equipment, to the proper way to walk up stairs. Don’t find yourself drowning in all the information out there; just teach yourself the important things that pertain to you and your occupation.
  • There are products such as occupational braces that can help support the areas that are most used. If you believe that your work is stressing your IT band consider using a brace or similar product.
  • Strengthening muscles near the IT band can provide support for the IT band. Not having the proper physical condition can lead to stress throughout the areas that the IT band support: “Weakness of the gluteus medius muscle causes the hip on that side to push out against the ITB, similar to pulling the string on a bow.” (Pajaczkowski). Strengthening this muscle can help alleviate the symptoms of ITBS with cure rates showing more than 90% (Niemuth, 2005: Fredericson, 2000). Some individuals achieve this strength by doing side steps with a resistance band tied around the ankles.
  • There is ample research to corroborate that weak hip muscles can be one of the leading causes of ITBS. Exercises like the “hip hike” in which you place the impaired leg on an upward step, then drop the opposite hip down and raise it as high as possible has proved to be effective in strength training.
  • If you are a runner and you have weak hip muscles, this can wear down your running form and add stress to the knee tissues. Exercises like “the clam” can help in this area. In this exercise the individual lies on their side with their knees at a 90 degree angle and while keeping your ankles together, rotate the afflicted knee towards the ceiling. Repeat this exercise as necessary. Strengthening the hip and gluteus muscles control the rotation of the femur and the position of the pelvis, and keep the IT band from being pulled away from the hip.
  • Consider typical icing and resting the area and possibly changing up your training routine. When using cold to reduce inflammation, apply for 10 to 15 minutes every 2 to 3 hours and immediately after any exercises or activity that exacerbate the symptoms of ITBS. Ice packs can be found in most markets and are fairly inexpensive.
  • Remember that heat can be your friend as well. Heating pads or “buddies” are effective and easy in application. Soaking in warm water (with or without bath salts) can also provide alleviation. Use heat before performing or stretching.
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  • Avoid repetition. It may sound simple but remember what routine may have led to the ITBS in the first place. For runners, it can be as easy as planning a different running route or maybe less running on a treadmill.
  • As mentioned earlier, poor running form is a likely culprit in ITBS. If you believe the way you run might explain your ITBS, consider consulting a professional to examine your running gait, mechanical form, and posture during motion to determine if there are any underlying problems in your technique. One of the most common issues is “overstriding” (taking too long of steps) and “strides that cross over the midline of the body.” (Heidloff, 2012). These issues are easily identifiable by a professional and sometimes a further analysis called “video gait analysis” may be performed. It may be more expensive for these services, but if you don’t know much about running technique and form, they can prove beneficial to an active, every day runner. It might be worth checking to see if a professional is available in or around the area in which you live. A video format of what you may be doing wrong is worth a lot. These analyses will show defects in stride, gait, landing, and other mechanical movement.
  • If you are constantly running on the shoulder of a road which is uneven, this can cause the leg to bend inward, stretching the IT band against the femur. If you are running consistently uphill or downhill, this too can stretch the band in ways that may cause ITBS.
  • Remember that treating ITBS may be as easy as switching up a routine. Consider taking a different running or jogging route or an entirely different terrain altogether. Techniques in training can be changed by decreasing training time, changing the stride length (in hikers, runners, etc), staying away from hills or stairs, and even changing the direction in which you run.
  • Coincidentally, sitting on a tennis ball placed around the buttocks and the thigh muscles seems to be a simple home remedy for some sufferers of ITBS. Also, it has been said that others have had success merely adding pressure and rolling a tennis ball around the top of the thigh muscle down around the knee. Compression can be your friend; however there are more than massaging techniques to help alleviate the pain created by ITBS.
  • If you are a cyclist, consider an alternative seat or the height position it is in.
  • There are a number of activities that can be altered to change the same repetitive motions that cause ITBS. If you climb stairs a lot during the day, consider researching information to make sure you are using proper technique. It seems simple enough to climb a set of stairs but most people won’t know that they are doing it “wrong” until they are already suffering from pain. The way your feet land in response with the ankle and how high you lift your thighs can impact the IT band and add unnecessary stressors to it.
  • If you find yourself in a crouching position most of the day due to your occupation, consider giving your knees (and your back) adequate rest in between. When you put your body in any position where the knee is turning back and forth repetitively, you increase your chances of creating friction on the IT band and the bursa sac near your knee joint. There is a lot of information regarding proper technique in occupational labor and there are many everyday steps you can take in preventing ITBS on and off the worksite.
  • Footwear and orthopedic issues have their place in causing ITBS. If your shoes are worn down, your foot may land in an awkward position which can cause stress to the knee and hip. Most shoes have a recommended mileage. If their life-span is up, it may be time to consider getting a new pair of athletic shoes. If an individual has arch or ankle problems, you may be required to obtain some orthopedic (orthotic) athletic shoes so that a runner or athlete’s gait is not affected. Keep in mind to try and experiment with different shoes. It may take a while to find the right corrective footwear for your specific activity, but don’t give up. It will be worth the wait in the long run to not have to deal with the symptoms of ITBS. If you are a runner, don’t forget that not all running shoes are designed for every terrain out there. Consider your shoes and if they match the terrain you jog or run on. You can also decide to switch the terrain you run on altogether. If an individual trains cross-country, they might try switching to a harder surface for a small amount of training. Again, make sure the shoes that you wear match the terrain you exercise on.

Image result for IT Band SyndromeMost stretching and strengthening exercises can be done at home. However, if pain persists even after home stretching, it may be important to consult a physician. Ask your physician questions such as: “Should I consider orthopedic shoes?” and “what alternative strengthening or stretching activities can I do at home?” Questions like these should help direct your physician to the right treatment that is specific for you. At the doctor’s office, they may perform what is called an “Ober’s test.” This is where a patient will lie down on the uninjured side of the body with your hip and knee at a 90 degree angle. If ITBS is present, you will have trouble moving the leg beyond the midline of your body and experience pain at the knee. Orthotic arch supports for those with flat feet may be prescribed to reduce friction to the bursa. Other options like knee sleeves can help keep the tendon or bursa warm during movement and alleviate inflammation.

IT Band Exercises:

  • Side Shuffle With your knees bent (in a squatting position) take ten steps side to side while facing the same direction. This is a lot like “crab walking” and some individuals place rubber loops or bands around their ankles while performing this exercise.
  • Side Leg Raise Lie down on the right side of your body and slowly lift your left leg 45 degrees and lower it back down. Keep the pelvis in a neutral position and perform as many repetitions as necessary.
  • Side Hip Bridge While on your side, keep your feet elevated and resting on a surface about 1-2 feet off the ground. Push your bottom foot down and lift your torso using your hip muscles while keeping the spine stable. Return to the start position and repeat as necessary.

IT Band Stretches:

  • Iliotibial Band stretch The Iliotibial band stretch is performed by leaning sideways against a wall (you can hold on to a chair or a countertop for stabilization). Then you stand on the leg that is aching (close to the wall) and cross your other leg in front of it. Let the ITBS hip drop out to the side of your body and against the wall, then lean away from the wall until you feel a stretch. Hold for about 15 to 30 seconds and repeat a few times. If done properly, you should look like you are doing the “I’m a little tea pot” dance against a wall. There are many other examples of this exercise online as well.
  • Hamstring wall stretch Lie on your back in a doorway and place your non-injured leg through the open door. Then place the ITBS leg up the wall to straighten out the knee. You should be able to feel the stretch in the back of your leg. Remember not to bend your knee or arch your back during this exercise. Try holding this stretch in place for up to a minute and, if necessary, repeat the process a few times.
  • The Piriformis stretch While on your side, keep your feet elevated and resting on a surface about 1-2 feet off the ground. Push your bottom foot down and lift your torso using your hip muscles while keeping the spine stable. Return to the start position and repeat as necessary. Lie on your back with your legs straight. Then lift the injured leg and bend the knee. With the opposing hand, reach over and lightly pull your knee toward the opposing shoulder. Keep the arm on the injured side of the body stretched out flat with your hand palm down on the floor. Hold this position for around 15 to 30 seconds and repeat 2 to 3 times as necessary.

Image result for IT Band SyndromeMedications
Non-steroidal anti-inflammatory medications (NSAIDs) (ibuprofen, aspirin) or other minor pain relievers, such as acetaminophen are sometimes a last resort and there is a typical reason why they are such. Despite the basic fact that these medicines do nothing to reduce ITBS in general (only the pain that comes with it), they also come with great risk. The direction a sufferer with ITBS should be taking is one of restoration, not momentary gratification. An individual should seek treatment that will eliminate the problem of ITBS so that they are back to 100% in their activity. NSAIDs only mask the pain for a short period of time and (like most drugs) the amount you take steadily increases in order to achieve the same alleviation as before. This is where part of the risk comes in. In some cases, patients may be prescribed heavier, opioid medications. These drugs come with their own package of side-effects including anything from stomach and liver damage, to overdose and even death. Prescription and over-the-counter medication “was the leading cause of injury death in 2010; among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.” (Centers for Disease Control and Prevention, 2012). “The drug poisoning death rate is highest for adults aged 45–54” (National Center for Health Statistics, 2015). With facts like these, it is a wonder why sufferers still resort to this method. However, alternatives to medications and NSAIDs are steadily on the rise. This may be due to the testimonial lack of rejuvenation rate for pain pills. Topical solutions for pain relief are steadily increasing in treating ITBS. They are easy to apply and come without the risks of pills. Topical ointments provide relief and do not need a gradual increase in dosage. Not only do they provide risk-free treatment, topical solutions are fairly inexpensive. Search for topical solutions that provide more therapeutic ingredients such as Aloe Vera and other natural minerals. Products that contain Emu oil transfer through the skin faster. This is because Emu Oil is very transdermal in nature and matches the cellular structure of our skin, which allows it to penetrate through the skin and transfer necessary ingredients. Some solutions only provide menthol and may lack in ingredients that can prove beneficial. Choose a topical solution that’s right for you. Keep an open mind when searching for products like these; some of the bigger name products may actually do less than a product you haven’t heard of before. In the end, an ITBS sufferer should be able to find the right topical treatment that is specific for them. In some rare cases, if there is visible swelling or pain during movement that lasts more than three days, corticosteroid injections may be considered. This is where Corticosteroid medicine is inserted via needle into the joints (specifically into the femoral condyle) to temporarily reduce inflammation. Corticosteroid injection can be risky as they may create a series of other problems. Some issues with corticosteroid injections include: osteonecrosis (death of bone), joint infection, nerve damage, and even thinning of the skin around the injection site.

Conclusion
It is pertinent to remember that ITBS is often easily treatable and there is usually something fundamental and simple that an ITBS sufferer can do to get things back to normal: “Most patients respond to conservative treatment involving stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens” (Khaund et al, 2005). It is a catch-22 considering the wealth of information available about treating ITBS that it may be easy to become lost in all the treatment options. Remember to keep in mind how much your training technique can affect the IT band. Try to learn a few of the more simple treatment exercises and practice them at home when you can. Remember that rest is the only way to properly restore the body; pushing yourself too far can be disastrous in the long run. If areas are inflamed due to ITBS, use heat and cold applications to your advantage. Find topical solutions that alleviate pain quickly and use them before and after training or work. Use proper stretching techniques before and after repetitive use of the IT band. It not only helps with the pain later, but physically treats the afflicted area. Finally, understand your body’s limitations. This is probably the second underlying cause of ITBS (after poor training technique). Keep in mind your age, physical strength and endurance, body type, the amount of time and energy you spend training or working; this can prevent ITBS later in life. Although there is a lot of connection to ITBS and athletes understand that any activity, especially those on the job or worksite that use the IT band improperly, will apply tension to the IT band and cause problems. At the first signs and symptoms of ITBS, an individual should find treatment for the pain, as it has the tendency to gradually get worse if ignored. If you feel as if you have exhausted all of your options for at-home care and it seems like the pain has lasted longer than it should, consult your physician for further treatment. The road to recovery for you may be long or short, but the treatment options for ITBS are ever present.

References
1. R. Amadeus Mason M.D. Iliotibial Band Syndrome. Elsevier Science, 2003

2. Wedro, Benjamin, M.D. Iliotibial Band Syndrome, Medicine Health, 2015

3. Pajaczkowski, Jason A. M.D., Iliotibial Band Friction Syndrome Demystified

4. Hreljac A. Impact and Overuse Injuries in Runners. Med Sci Sports Ex. 2004 36(5):845-9.

5. Heidloff, Dave, IT Band Syndrome: The Top 5 Causes and Solutions, Athletico, 2015

6. Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System, 2010.

7. NCHS Data on Drug Poisoning Deaths, NCHS Fact Sheet, June 2015

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