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__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I check for IT flexibility, check overall body posture, and if there appears to be some IT, hamstring, hip flexor imbalances, I send them off to physios, massage therapists/chiros. There may be some LLD problems. I am not as quick to adjust for LLD with raises as I used to having experienced some correction myself from having my shoulder and neck imbalances straightened out...that is, when I received massage and physio/chiro treatment for chronic neck, shoulder problems, my LLD resolved by more than 50%. Also helped relax my hips for all ADL (actvities of daily living).
Naturally, fot malaignment must be throughly investigated. I see IT problems for in all types of feet.
I encourage stretching daily after showerss/bath and after running
Freeman
So we basically have 3 answers from a podiatry view.
a.Pronation
b.LLD
c.All of the above
By reading the general theme of things here it seems answer c is the golden answer for all biomechanical issues. Low back pain, PFD, foot pain etc, the works. Put them all in orthotics and heel lift and everything will be resolved.
My suggestion is look, and look real hard to see how many studies show orthotics effectively manage ITB syndrome. Real deal studies, not some dude sitting there showing some pathetic case history of how he solved one case of ITB syndrome with a pair of orthotics.
Look at the biomechanics. Read the paragraphs in the link Craig referenced talking about running speed, the time spent with the knee bent through the angle of 20-30 degrees. Learn about the impingment zone of the knee. Understand how people run, their technique and its influence on knee progression. Maybe an orthotic can't fix where the foot strike position is relative to the body. Wouldn't that blow your mind. None of the above can help you with that. Not a, b, or c. So if foot placement becomes relavent to the degree of knee flexion and the timing of knee flexion so to cause an increase duration of time in the impingement zone your orthotic and lift may do nothing?? Does that mess with your head!
Anyways i am off for a leisurely run this evening. Should be nice presuming i keep my knee out ot the impingement zone for long enough. Should i run with my orthotics, my heel lift(i strike midfoot) or both?
DaFlip
This forums' intent is for podiatrist and healthcare professionals to post Q&A and topics to help further there ability to treat their patients effectively.
My reply simply points out that in my clinical experience of patients suffering from I.T.B many of them have either a Bi/unilateral over pronation issue or a L.L.D.
When I treat these patients with a suitably prescribed lift,orthotic or both coupled with stretches for the I.T.B and any other muscle tightness or imbalances,there symptoms resolve.
Is this psychological? It is unlikely.Who knows whos right and whos wrong,but do you think that we should only post replys to needy clinicians on the basis of documented evidence alone
Clinical experience must count for something,surely!!!
Do orthotics cure all I.T.B problems? absolutely not. They are however a popular choice for me in the right situation cos I get good results.
I have always suggested strengthening excercises and stretching (and orthotics if needed if nowt else worked )
any other ideas
Yehuda
Here is my protocol for treating iliotibial band syndrome (ITBS):
1. Have the runner start icing the symptomatic area of the ITB for 10-15 minutes before running and then 20 minutes after the run (if they can run at all). If they can't run, ice 20 min twice daily.
2. If they appear to be maximally pronated at the subtalar joint (STJ) during running then I will add a varus heel and medial arch pad of adhesive felt to their running shoe sockliner to attempt to get the STJ to allow more "smooth pronation" during the first half of stance phase (i.e. support phase) of running.
3. Make certain the running shoes are not excessively worn at the posterior-lateral heel, if they are, then get newer dual density midsole running shoes.
4. Have them not run on a cambered surface, they should run on a level surface. Have them run on as soft of a surface as possible (i.e. grass, all-weather track, dirt, treadmill)
5. Do ITB stretches BID to TID.
Most runners respond very well to #2. Foot orthoses may be indicated for more permanent correction of the abnormal mechanics causing the condition.
By the way, I'm one of the "pathetic dudes" that has about about 500 case histories of treating this condition successfully with medial heel and arch pads and/or orthoses over the past 20+ years of practice.
I agree with you, Scott, why the undue negativity from Da Flip? Why is Da Flip afraid to share his real name with us?? Really makes me wonder about how some people's brains work!!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kev,
my negative feelings at the moment appear to be manifesting as negative posts. I feel these negative vibes coming off me which gives me the impression people feel i am a negative person, they question how my brain works and worst of all they question who i really am. I'll need to go for a run to chill out from the harsh questioning i am receiving. I will also have a little rest from our discussion as i recover from my negativity and hopefully return as a happier person. This may mean at a later date i can discuss the 501 people i have treated successfully for ITB syndrome without using orthotics at all.
One bright note on an otherwise negative day is seeing people comfortable enought to classify themselves as "one of the pathetic dudes".
over and out,
Michael Flip
Podiatrist
DaFlip
Kev,
my negative feelings at the moment appear to be manifesting as negative posts. I feel these negative vibes coming off me which gives me the impression people feel i am a negative person, they question how my brain works and worst of all they question who i really am. I'll need to go for a run to chill out from the harsh questioning i am receiving. I will also have a little rest from our discussion as i recover from my negativity and hopefully return as a happier person. This may mean at a later date i can discuss the 501 people i have treated successfully for ITB syndrome without using orthotics at all.
One bright note on an otherwise negative day is seeing people comfortable enought to classify themselves as "one of the pathetic dudes".
over and out,
Michael Flip
Podiatrist
DaFlip
Michael:
Thanks for providing a name behind the "mad" icon. By all means, please try to regain some positivity since podiatry provides many positive benefits to patients, provides many positive benefits to the podiatrist and also contains many individuals with positive outlooks on life. It sounds like you have a lot of knowledge to share with others, and this is a very positive thing. Put your knowledge to good use to help your patients and contribute your knowledge in forums such as this so that others can also be helped by your clinical experiences. Life is too short to spend it with a dark cloud hovering over your head every day.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I believe there are many appropriate things that will work for a patient in helping solve their It problems. Kevin has hit really well on that. I think it is important when assessing each patient that we 'major on those major' components which we see that we feel are relevant to that patient. You will know that of 5 ITBFS patients, that all 5 have similar historys in some aspects, but may differ significantly in others. A fullfilling aspect of dealing with runners (of which I am one),is developing a rich relationship with each of them where we problem solve. We adjust their stance with insole mods, orthotics and try various shoes, tinker with their form, and modify their training programs. A very significant component which has little do do with biomechanics, (I feel is equally important) is to listen to them and try to counsel them on some of the tough psychological issues of not running, overtraining, or restoring confidence and believing they will get better.
Generally, if the foot is near max pronation, I use a contra-lateral wedging with varus rearfoot post to modify internal rotation and valgus forefoot to shift CoP laterally in an attempt to reduce the force couple which the ITB (amongst other structures) has to provide counter-moment to at the knee. This couple is often magnified by running limb varus.
I find this in conjuction with activity modification, muscle work and RICE is often useful.
__________________ Science is the antidote to the poison of enthusiasm and superstition
I work in a running injury clinic so I see this stuff fairly regularly. Probably 70-80% of my patients are wearing one particular shoe that seems to cause a lot of problems - the Asics 2000 series (sorry to all the Asics fans out there - I'm just calling it as I see it). It seems to be particularly soft through the lateral rearfoot. Through heel strike the rearfoot is held in a varus position causing a varus strain through the lateral knee resulting in ITBFS. It's amazing what getting these people into a more appropriate shoe can do. The other areas that I address are foot mechanics (ie orthotics where appropriate), core stability (particularly strengthening gluteus medius), deep tissue massage/trigger points of the ITB, running speed (they are generally better off running faster due to the degree of knee flexion) and running surface (no downhill running, cambered running or running around a track). I will also initially use ice massage and a topical NSAID to settle it down. I have found addressing all these areas to be quite effective.
Interesting I also found a greater incidence of injuries with Asics esp Achilles Tendonitis, Interestingly Noakes feels that motion control shoes or shoes with to little cushioning will cause ITB problems
Do you see mainly longer distance runners with this condition? I'm a retired spritner who has long since been put out to stud. Suffered ITB problems once for a week or two. Solved with rest and ice in this case. Trying to remember what training I was doing around the time, but i think it was early in the winter season which meant I was doing a lot more "longer' sessions (almost all the training was done in flats with nothing under 200-300m up to a few 3 x 2km sessions (Yes, sprinters are soft))
Never suffered problem again, however never trainined again doing longer sessions (Changed coaches)
This is a condition primarily of distance runners - possibly we can add to that sprinters who try to run longer distances! The average long distance runner has a knee flexion of about 21 degrees at heel strike with the 'irritation' or 'friction' occuring with the knee flexed at about 30 degrees - i.e. just after heel strike. ITBFS is uncommon in sprinters because at heel strike, the knee is flexed beyond angles at which friction occurs. I have seen a couple of sprinters with this problem though, probably from running too many bends.
It's possible doing your 'longer' sessions, you were striking with your heel which would increase your chances of ITBFS. If you were doing these sessions on the track (i.e. heel striking running around bends), that would have increased you chances again. The flats you were running in probably added to the problems. Even just suddenly increasing your mileage can cause ITBFS. You would have to think if it settled down pretty quickly with rest and ice, and hasn't troubled you since, that it probably was a training issue.
Dear All
I have often suffered from an ITB pain where it runs over the greater trochanter. This has been treated by a physio a number of times with treatment almost identical to ITBFS. But I have allways called this (GT/Hip pain) ITBS and have had many patients with the same (but none with knee ITBFS) who I have fitted orthoses and referred to physio mostly with good results. What is the correct term for this complaint. By the way running in the hills cross country never gives this hip ITB problem so I never run on the flat now.
Cheers Dave Smith
How confident are you all that you are actually dealing with ITB syndrome? How do you differentiate this from proximal LCL pathology?
Bit like sinus tarsi syndrome IMO; have we got the diagnosis right in the first place?
ITB syndrome at the knee very characteristically causes tenderness over the the course of the ITB and most commonly where the ITB passes over the lateral femoral epicondyle (LFE) of the knee. Since the LFE is also the point of origin of the lateral collateral ligament (LCL) of the knee, then this pain could, theoretically, be caused by irritation of the LCL. However, the midsubstance of the LCL is never tender in these patients with LFE tenderness. More importantly, when the knee is flexed and extended around about 30 degrees of knee flexion with thumb pressure ove the LFE, the ITB can be palpated as the most tender structure when it moves over the LFE. This leaves many of us to believe that it is the ITB that is symptomatic, not the origin of the LCL, when there is tenderness over the LFE.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Iliotibial band friction syndrome (ITBFS) has long been recognized as one of the most common lower-extremity injuries in athletes, especially in long-distance runners. Conservative therapy, including rest, ice, heat, stretching, and the use of anti-inflammatory medications, has been effective in helping athletes return to full competition, but athletes still miss much time in their sports because of ITBFS. The author presents a case of a 30-year-old distance runner with ITBFS whose symptoms were reduced with the help of osteopathic manipulative treatment, specifically the counterstrain technique. This technique allows for relief of pain at a tender point by moving the affected body part into its position of greatest comfort, aiding in the reduction of proprioceptor activity. In the present case, the tender point was located from 0 to 3 cm (most commonly 2 cm) proximal to the lateral femoral epicondyle. There is no prior documentation of the osteopathic manipulation of this specific tender point. Thus, this case report reflects an initial identification of the distal iliotibial band tender point and a new therapeutic modality for ITBFS.
What is your opinion of using a pronated device during the more acute stages to slacken the IT band? I have heard of some pts doing well with this, and others have mentioned a varus posted device at time actually increases their pain?
How do you approach it cycling?
Sorry for my ignorance, I am a 3rd year Podiatry student
What is your opinion of using a pronated device during the more acute stages to slacken the IT band? I have heard of some pts doing well with this, and others have mentioned a varus posted device at time actually increases their pain?
How do you approach it cycling?
Sorry for my ignorance, I am a 3rd year Podiatry student
Thanks,
Tim
Tim, it is encouraging to see someone not 'stuck' in one theory/practice, but thinking mechanically and daring to be pragmatic, on the basis of objective and subjective outcomes. There are not enough of your type in the medical and paramedical world today.
As for cycling, I have no idea. Maybe forefoot wedges can alter ITB functioning? Maybe pedal position and/or the position of its axis?
ITB syndrome at the knee very characteristically causes tenderness over the the course of the ITB and most commonly where the ITB passes over the lateral femoral epicondyle (LFE) of the knee. Since the LFE is also the point of origin of the lateral collateral ligament (LCL) of the knee, then this pain could, theoretically, be caused by irritation of the LCL. However, the midsubstance of the LCL is never tender in these patients with LFE tenderness. More importantly, when the knee is flexed and extended around about 30 degrees of knee flexion with thumb pressure ove the LFE, the ITB can be palpated as the most tender structure when it moves over the LFE. This leaves many of us to believe that it is the ITB that is symptomatic, not the origin of the LCL, when there is tenderness over the LFE.
IMO, a dysfunctional LCL could result in the ITB taking on a secondary stabilising role. More tensile forces, through the ITB acting as the main varus restraint must alter its (structure) tissue morphology over time and hence function.
I dont disagree with what you are saying KK, I just think that it is a gutsy move to be certain that the ITB friction syndrome exists to the exclusion of other lateral structures, particularly the LCL and/or superior tib-fib joint (which BTW is the most misunderstood potential source of knee pain IMO).
The ITB is not a true active tissue; hence you cannot apply a resistance test to it with great certainty. Nor can you stretch it IMO, and apply a passive tensile test to it.
A bit like sinus tarsi syndrome, the clinical testing for it IMO is too press and guess for my liking.
How about ESWT for treatment of ITB syndrome? We use it for plantar fascitis, achillis tendonitis, lateral epicondylitis....should we expect to get similar results for recalcitrant ITB syndrome? I would be curious to see if anyone has heard of this being done yet.
From personal experience, I seem to be experiencing ITB syndrome since having my last 2 kids - hence my core stability is terrible. I never experienced it when I ran competitively, but that was before kids. I am also using orthotics though and have tried a heel lift - but my symptoms seem to come and go with these. It seems Pilates for the core stability and some Bodywork therapy on my assoc. triiger points are working best - my core is improving ans with it the pain is less frequent.
I hope this helps a little - and I apologise if I may have repeated some of the above - I only took a quick peek and some of the replies.
Treatment of Recalcitrant Iliotibial Band Friction Syndrome With Open Iliotibial Band Bursectomy: Indications, Technique, and Clinical Outcomes American Journal of Sports Medicine (in press)
Quote:
Background: Iliotibial band friction syndrome (ITBFS) is an overuse injury causing lateral knee pain. There is evidence that the pathological lesion is in fact an inflamed bursa underlying the iliotibial band (ITB) rather than an inflamed ITB itself.
Hypothesis: Resection of the bursa underlying the ITB in ITBFS patients will relieve their pain and allow them to return to their preinjury activity level.
Study Design: Case series; Level of evidence, 4.
Methods: We describe the technique of ITB bursectomy and report a minimal 20-month follow-up of patients who had ITB bursectomies performed by a single surgeon. The patients completed a survey detailing their preoperative and postoperative symptoms and activities.
Results: The senior author performed 12 consecutive cases of ITB bursectomies (12 patients). One was excluded from the study (previous microfracture). The average age at surgery was 32 years (standard deviation, 5; range, 24-41). There were 7 men and 4 women. Postoperatively, patients were able to return to their preinjury Tegner activity levels, and the visual analog pain scores decreased by an average of 6 points(P < .001). Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied. Nine of 11 patients said that knowing what they know now, they would have the surgery performed again for the same problem.
Conclusion: Iliotibial band bursectomy successfully reduces knee pain in patients with ITBFS and allows them to return to their preinjury level of activity. The great majority of patients were satisfied with the results of the procedure.
Here is my protocol for treating iliotibial band syndrome (ITBS):
1. Have the runner start icing the symptomatic area of the ITB for 10-15 minutes before running and then 20 minutes after the run (if they can run at all). If they can't run, ice 20 min twice daily.
2. If they appear to be maximally pronated at the subtalar joint (STJ) during running then I will add a varus heel and medial arch pad of adhesive felt to their running shoe sockliner to attempt to get the STJ to allow more "smooth pronation" during the first half of stance phase (i.e. support phase) of running.
3. Make certain the running shoes are not excessively worn at the posterior-lateral heel, if they are, then get newer dual density midsole running shoes.
4. Have them not run on a cambered surface, they should run on a level surface. Have them run on as soft of a surface as possible (i.e. grass, all-weather track, dirt, treadmill)
5. Do ITB stretches BID to TID.
Most runners respond very well to #2. Foot orthoses may be indicated for more permanent correction of the abnormal mechanics causing the condition.
By the way, I'm one of the "pathetic dudes" that has about about 500 case histories of treating this condition successfully with medial heel and arch pads and/or orthoses over the past 20+ years of practice.
I agree with you, Scott, why the undue negativity from Da Flip? Why is Da Flip afraid to share his real name with us?? Really makes me wonder about how some people's brains work!!
i agree with Kevin, this is excactly what we were taught in podiatric sports medicine by a dude called Dennis Reebok in South Africa, among other books were the law of running i think by subotnick, grade the pain and the corresponding resting times, apply the PRICEN & R approach and again keep the basics nothing fancy and the patient will be happy, i am just wondering how come we dont have simple universal treatment protocols?, Kevin, do proper antipronating running shoes still fancied with an alternative to working on the insole of it with necessary alterations?
Iliotibial band syndrome
, Kevin, do proper antipronating running shoes still fancied with an alternative to working on the insole of it with necessary alterations?
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