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Iliotibial Band (ITB) Syndromes


Aspiring endurance athletes undergo hundreds of thousands repetitive movements to hone their style and techniques to maintain their efficiency. This scenario often leads to eventual domination of movements in one plane of motion. This creates an imbalance of some muscle groups leading to overuse of other tissues. In endurance athletes, especially runners and cyclists, the pursuit of efficiency of movement techniques to shave time off their personal best leads to sacrifices of motion, tightness and weakness of structures, resulting in limitations, compensations and eventual injury. In my experience of evaluating gait and motion of endurance athletes of all levels, I have seen numerous occurrences of lateral thigh pains from the hip to the knee, especially in runners and cyclists. This has led to frustration and impaired performance for these individuals.

Brief Perspective of the Hip Musculature

The most common contributing factor of lateral thigh pain is iliotibial band syndrome (ITBS) and tightness and weakness of the tensor fascia lata (TFL), gluteus medius or gluteus minimus, collectively referred as the lateral gluteal region. The iliotibial band spans close to the hip as a continuation of the TFL, gluteus medius and gluteus minimus. It continues distally to the knee where it splits into the iliopatellar band medially and the iliotibial tract laterally. The TFL originates at the anterior superior iliac spine and inserts into the ITB. The gluteus medius and gluteus minimus originate at the posterior ilium between the posterior and anterior gluteal lines and inserts into the greater trochanter. Isolated, these muscles abduct and internally rotate the femur. The gluteus medius’ anterior fibers assist in femoral internal rotation, while the posterior fibers assist in externally rotating the femur. In addition to these movements, the TFL also assists in hip flexion.

The issue with the traditional description of anatomy and kinesiology is the majority of muscle actions are described in the isolated muscle and joint in the open chain. These muscle actions are characterized by concentric contractions; yet for efficient movement to occur in human motion, the eccentric phase must occur prior to the concentric moment. It is true the aforementioned muscles perform the stated actions; however, their actions are vastly different in human motion.

The integrated activity of the gluteus medius, gluteus minimus and TFL function in three planes of motion by doing the following tri-plane actions:

In integrated function, the hip abductors decelerate motion in the frontal plane as the hip adducts, decelerates internal rotation in the transverse plane and assists in deceleration of hip flexion. Interestingly, the abductors of the weight bearing hip levels the pelvis during the swing phase of the opposite leg. This helps create the necessary height for the leg to swing through. Concomitantly, the opposite erector spinae of the weight bearing hip “pulls” up the swing leg hip to assist in maintaining a level pelvis.

The hamstrings decelerate hip flexion in the sagittal plane, internal rotation of the knee in the transverse plane and help to stabilize the pelvic girdle in the frontal plane. The gluteus maximus reduces hip flexion in the sagittal plane, internal rotation in the transverse plane and hip adduction in the frontal plane. It is the integration and synchronization of all these muscles that produce the “symphony of motion “of human gait.

The action of the lateral gluteals can be described like a sling that lengthens in the frontal plane to decelerate the lateral motion of the hip when in mid-stance and weight bearing. In this phase, the hip moves laterally, lengthening these muscles, and they slow the motion in the frontal plane, then reflexively contract to assist through the remainder of gait. The mid-stance is a critical phase, as a transition occurs from an internally rotated lower extremity to beginning the acceleration phase of gait when external rotation of the femur and hip occur. The lateral gluteals region must have adequate strength through the eccentric phase of gait so the gluteals and TFL are fully loaded by lengthening first before they shorten and accelerate action. If these structures do not fully perform their functional lengthening, they will gradually shorten and then weaken, as they are not going through the eccentric moment before the concentric moment. If this happens, other structures take over to decelerate frontal plane action, and overuse ensues. To better develop an understanding of human motion, let’s delve into the characteristics of human motion more deeply.

Characteristics of Human Motion

The majority of literature in the fitness industry has created exercise programs that cause force production, or concentric contractions, prior to force reduction, the eccentric phase. Contrarily, in pure human motion, muscles first move through the eccentric phase and have the action be decelerated before the concentric phase, which produces acceleration in force in order for movements to be efficient and effective.

Muscle Pre-loading/Unloading

Dykyj’s classic work illustrates how a muscle exerting an opposite action assists in controlling motion. In human motion, the body actually moves in the opposite direction just before any efficient movement occurs toward the intended direction. This reaction causes the muscles first to stretch eccentrically, causing a deceleration of the motion. As this stretch is occurring, energy is stored in the muscle, creating a more forceful and efficient contraction prior to the intended movement. For example, from a seated position, place your feet directly beneath you as if you are preparing to rise from the chair. DO NOT bend forward or downward before rising; just stand straight upward. The movement is extremely difficult and inefficient. Some people cannot rise out of the chair. But why is such a relatively simple command so difficult to perform? The answer is the muscles did not move the opposite direction and first lengthen or pre-load and perform an efficient movement pattern. Yet, when the torso flexes forward and allows the pre-load to transform, the movement becomes smooth, efficient and easier to perform. Therefore, it can be said, the eccentric loading allows for greater energy conservation and efficient movements. In fact, eccentric contractions are 3-9 times more efficient than concentric contractions. The eccentric phase allows the muscle to lengthen, absorb forces and slow the motion, all necessary for ease of movement and muscle conditioning, all of which will reduce the risk of soft tissue injury and produce energy efficient movement patterns.

The concentric phase reacts by shortening the muscle and accelerating the motion. In the cycle of human motion, this is considered the unloading phase. The dilemma of a majority of exercise programs is most of the exercises are force producing and negate the loading phase. Therefore, in terms of human motion, efficient movement is characterized by the ability to control the transformation from the eccentric or deceleration phase to the concentric or acceleration phase.

ITB Confounding Issues Resulting of Lateral Hip Weakness

When an individual has presented for a gait and motion analysis to investigate the lateral thigh pain, it has been my experience that these people also suffer from tightness of the external hip rotators (often the piriformis) and tight hamstrings. It appears when the lateral gluteals become weak and do not perform their function, other muscles compensate and perform work in a fashion they are not suited to do, resulting in overuse issues. In the case of the tightness of the lateral thigh (i.e., ITB and TFL tightness), the gluteus medius and gluteus minimus have become tight and weak, thus not fully performing their function of deceleration of hip adduction in the frontal plane, hip extension in the sagittal plane and external hip rotation in the transverse plane. Therefore, the TFL becomes too dominant and assumes the role the lateral gluteals are lacking. With the adjoined fascia of the TFL and ITB, the ITB becomes taut, and lateral knee pain can ensue. In many of the clients I have been fortunate enough to serve, I have also found tightness of the deep external hip rotators and hamstrings to accompany the lateral thigh tightness of the ITB and TFL. The question of how this occurred is a complex one, and considering the philosophy of Gary Gray and David Tiberio, the site of the overuse injury is not the cause but the symptom. The cause is usually a joint level above or below the injury. My experience has found their advice to be quite true; therefore, I then investigate through my evaluations the hips and often look at the feet.

In normal gait conditions, at heel strike the foot is supinated and the calcaneus is inverted (turned in). The lower extremity and hip are externally rotated. As the ground accepts the foot, the foot pronates, which causes the calcaneus to evert in the frontal plane, the ankle to dorsiflex in the sagittal plane and the tibia, femur and hip to internally rotate in the transverse plane. As the hip moves over the foot in mid-stance, the hip internally rotates and adducts, which lengthens the lateral gluteal region to decelerate this action. If the foot does not fully pronate due to a myriad of reasons, the chain reaction through the hip does not occur, and the musculature up the chain is not fully functionally activated. As muscles possess the natural tendency to shorten, the lateral gluteals follow the physiological response and shorten and weaken over time. As the body strives to achieve the goals of the activity, it will compensate when adjacent muscle tissues are over-worked, and overuse injury transpires.

Another common scenario that needs to be explored is the hip motion and its functions, as this may be the cause of the malady. Bare in mind, the opposite hip may be the culprit, and when not fully eccentrically loading or concentrically unloading, it can result in incomplete range of motion of the affected hip and lower extremity. Likewise, the affected hip is usually tight in the frontal plane and can be the culprit.

Endurance Athletes and Form

In the athletes' pursuit of performance improvement, they undergo hundreds and thousands of repetitions on the road or in the saddle. Runners attempt to stay “tight and compact” in their running gait, and cyclists are set into a bike fit that often causes reduced motion in the hips and feet and can adversely affect proper chain reaction of normal gait patterns. It is crucial for these athletes, as well as all populations, to maintain an integrated tri-plane flexibility program.

It is important for the reader to remember the conditions stated above are looking at the actions that may produce the malady as a result of improper mechanics, acute injury, bony structure of the skeletal system or foot type. It is not in the scope of this article to delve into the numerous possibilities of what the causes are but to consider the chain reactions and the resultant issues. A thorough gait and motion evaluation, including health history, must be done to derive the causes.

Assessment

The assessment tools I use to perform gait and motion analysis are those consistent with Gary Gray’s Total Body Functional Profile. When a client presents for an evaluation, I first obtain a comprehensive health history, including injury and activity history. Following a brief discussion of their significant related issues, I view them walking to see the symmetry of the movements from the ground up. I first view hip action to see any asymmetry of hip extension/flexion in the sagittal plane, lateral excursion of the hip during mid-stance in the frontal plane and differences in rotation of the lower extremity and hip in the transverse plane. I then view foot action to notice symmetry, heel whip, the action of pronation and supination. Finally, I look at the torso and upper extremities to see if there are any significant differences in their motions. I try to view the client’s gait from the anterior, posterior and lateral aspects to get a feel from all angles. Then the client will walk at a fast but controlled pace to accentuate the motions of their walk. This often emphasizes the idiosyncrasies of their gait patterns and further provides information of symmetry and compensations. I use this to summarize my findings and thoughts. Typically, if there is lateral gluteal tightness, it can be seen from the fast walking pattern. Bear in mind, there are a myriad of conditions that affect gait that are not being addressed in the scope of this article.

If I want to see how the hips are affected in the frontal plane, I will ask the person to walk with an overhead bilateral arm medial reach. This is performed with a normal gait pattern, yet the client will have both arms overhead and reach overhead and medially to the lead leg. This emphasizes frontal plane action in the hips of the lead leg, and if tightness or asymmetry is observed, this can be a significant finding to lateral gluteal region tightness.

Figure 1. Frontal Plane Overhead Medial Reach Walk

The single leg balance anterior ipsilateral reach test creates an environment that causes the foot to pronate, which reactively creates lower extremity internal rotation and hip internal rotation, while measuring strength and range of motion of the gluteals in the sagittal and transverse planes. I use a measuring pole and tape measure to assess the distance reached and how low the client can go. This is an integrated assessment that evaluates the foot’s ability to pronate and the entire lower extremity’s ability to decelerate motion. I compare both sides for fluidity and symmetry of motion and total distances.

Figure 2. Single Leg Balance Ipsilateral Reach Test

By having the client stand about 20-24 inches from the wall, with the arm furthest from the wall, they will do an overhead reach. Observe for symmetry and fluidity of motion, but most importantly, watch their ability to allow the hip to excursion in the frontal plane. If the motion is compensated by excessive lateral flexion in the torso due to hip tightness in the frontal plane, that is indicative of tight lateral gluteals. If the client is able to attain the task, they should move about two inches further away from the wall and continue until their threshold is determined. This test often confirms findings to the overhead bilateral arm medial reach walk test.

Figure 3. Single leg balance frontal plane overhead reach

Corrective Exercise Techniques

Once I have the information from the evaluation, a corrective exercise and flexibility plan is created. My objectives are to enhance:

Wallbangers

The first prescribed exercise is Wallbangers. The objective is to promote lengthening and strengthening of the thoracic spine, hips, especially the lateral region and lower extremities. The rationale for this movement pattern is to lengthen and strengthen these muscle structures while enhancing movement through all three planes of motion, especially through the frontal plane. This exercise emphasizes the lateral gluteals, which are critical for stability in the frontal plane and balance. By lengthening muscles, the proprioceptors will be stimulated, balance will improve and range increased in the frontal plane for the client. When the gluteus medius and minimus are strengthened, the TFL will not be overloaded or over-tightened, thereby reducing the tension on the ITB. The step-by-step description of Wallbangers is: 

  1. Stand in the “stand tall” position, abdominals drawn in, with the feet about shoulder-width apart. Feet are pointed forward.
  2. Stand about 6-12 inches away from the wall. The distance will vary among clients depending upon their range of motion through rotation and strength of their lateral gluteals.
  3. With the right shoulder closest to the wall, reach out to the left. Be sure the client rotates the hips toward the left foot, flexes the knees, drops the hips and maintains a neutral lumbar spine.
  4. As the client reaches to the left, the natural reaction is for the right hip to move toward the wall. Let the client’s right hip “bang” into the wall and immediately return to the starting position. It is critical the client does NOT hold the reaching position, as this removes the elastic recoil tendency of the muscle and thereby removes the eccentric loading required in this movement pattern.  (The range of motion and rotation will vary depending upon the client’s ability to eccentrically load through the transverse and frontal planes. This action will become greater as the person improves range of motion, which will inherently and functionally improve strength.)
  5. Return to the start position by rotating the hips back to the left and to the upright position.
  6. Perform 8 repetitions and progress to 3 sets of 15 reps.
  7. Repeat with the left shoulder closest to the wall and the action requires reaching to the right.

Modified Matrix

The objective of the modified matrix is to promote lengthening and strengthening of the thoracic spine, hips and lower extremities with an emphasis in the transverse plane. This exercise movement pattern is unique in that it does not initially require much motion as it occurs with the feet in a stationary position. I often use this movement pattern with the senior population due to its relatively low level of mobility. However, there is still a large degree of motion in the transverse plane and this enhances range of motion and strength through the legs, hips and torso. 

The technique of the Modified Matrix is:

  1. Stand in the “stand tall” position, abdominals drawn in, with the feet about shoulder-width apart. Point the left foot to 12 o’clock and right foot at 3 o’clock.
  2. Position the right arm in the abducted and externally rotated posture.
  3. Rotate the hips toward the left leg and transfer weight to the left leg.
  4. Reach with the right hand to a point between the left hip and knee. As the client reaches, it is imperative they lower the hip as they flex the spine so that the loading will be felt in the hips, legs and low back. (The range of motion and rotation will vary depending upon the client’s ability to eccentrically load through the transverse plane. This action will become greater as the person improves range of motion, which will inherently and functionally improve strength.)
  5. Return to the start position by rotating the hips back to the left.  Be sure a weight transfer to the right leg occurs.
  6. Perform 8 repetitions and progress to 3 sets of 15 reps.
  7. Repeat with the left foot in the 9 o’clock position and the right foot in the 12 o’clock position. The left hand will then become the reach hand.

Frontal Plane Lunges

The efficient movement is dependent upon the strength of the lower extremity, hip and the range of motion of the internal hip rotators. The objective of Frontal Plane Lunges is to strengthen lower extremities while performing a dynamic movement pattern in the frontal plane. My rationale for these exercises is to develop improved range of motion and strength of the lower extremity in the frontal plane and to integrate the spinal motion and its relationship to the hip and leg. Much of this relationship depends upon body angles and its effect upon the subtalar joint motion. The hip abductors and hamstrings of the same side elongate in and resist the motion in the frontal plane, while the opposite side adductors assist by lengthening to decelerate the pelvis moving away from the thigh. Caution must be exerted when these patterns are performed, as the eccentric loading of the opposite adductors can cause spasms as these muscles are typically not accustomed to working eccentrically. It is HIGHLY advisable to start with 5-8 repetitions and gradually build to 2 sets of 15 reps.

The techniques of the frontal plane lunges and their variations are:

  1. Stand with the feet approximately shoulder width apart, knees slightly flexed and abdominals in the drawn-in position.
  2. Side step to the 9 o’clock position until the client feels the tension in the gluteals and lower extremities. If desired, a spinal flexion moment can be integrated into the movement pattern.
  3. Immediately return to the start position.
  4. Perform 5-8 repetitions, building to 15 repetitions as the individual gains strength. It is advisable to start the client with few repetitions, as the majority of people are weaker in hamstrings and lateral gluteal musculature in the frontal plane. It is very common for those who are new to this movement pattern to experience delayed-onset muscle soreness in the glutes and especially the proximal hamstrings.
  5. If desired, a spinal flexion moment can be integrated into the movement pattern.
  6. To develop strength of the erectors, spinal rotators and parascapular musculature, perform the above steps with a contralateral (opposite sided) reach. Depending upon the range of motion of the person’s thoracic spine, external hip rotators and opposite or weight loading glutes, the reach will be somewhat varied. This range will become greater as more flexibility in these structures is acquired. This movement pattern will cause emphasis of the peroneal group of the loading leg. This is due to the supination that will occur as a result of the external rotation of the distal lower extremity during the reach phase.
  7. To create emphasis on the pronators of the lower leg and lateral glutes, perform the transverse plane lunge with medial reach. This will cause pronation of the subtalar joint and an internal rotation reaction of the tibia, femur and hip.
  8. Repeat on the opposite side.
  9. Perform 5- 8 repetitions, building to 2-3 sets of 15 repetitions, depending on the needs and objectives of the client.

Integrated Flexibility

It has been my experience that approximately 85% of injuries I have seen are due to overuse of muscle tissue in response to tightness at adjacent muscles and joints. When joints become immobile and the accompanying musculature becomes shortened and tight, the proprioceptors become de-sensitized, and dysfunction can result. Joints become limited in motion, other structures will compensate to achieve the desired action. Studying human motion develops a deep appreciation for the myriad of intricacies that result from the relationship joints and muscles have upon each other. The three-dimensional interaction that occurs from the ground up through the body has tremendous impact upon optimal health and performance. 

Lateral Gluteal Stretches

The stretches I suggest to assist in improving motion in the lateral gluteals is True Stretch, Lateral Gluteal Stretch and Deep HER with Lat Stretch. The True Stretch was developed by Gary Gray and marketed by True Fitness. I advocate integrated flexibility to enhance the relationship of one joint to the next. For instance, in the lateral gluteal stretch, it is important to be sure the same side foot can reach optimal pronation, which will allow the hip to fully load eccentrically. If tightness occurs at the foot, this can inhibit the hip to reaching its optimal range of motion during pronation. The above integrated stretches are utilizing the True Stretch. These can be adapted by using a door jam or any stable vertical upright or pole.

A formula for effective range of motion improvement starts with gross movement patterns, such as 5-10 minutes of low level walking, jogging, cycling or other activities the client enjoys and can tolerate. This is followed by tri-planar movement patterns that are task specific, starting with abbreviated motions that resemble the desired activity and gradually increase in depth of the range of motion. This will allow the lengthening of muscles, sensitize the proprioceptors and enhance a greater range of motion.

For the athletic population, the warm-up session should be task oriented to enhance tri-planar motions. With various movement patterns incorporating forward/backward, diagonal, rotational movements, lunges, jumps and hops, a myriad of functional actions can enhance flexibility and not only increase range of motion but prepare the athlete for participation and reduce risk of injury.

After the workout session or event, it is advisable to then work on flexibility to lengthen muscles back to their resting state. I suggest holding the static stretch for 20-30 seconds and do each stretch twice. When doing static stretching, it should be multi-joint, multi-planar, utilizing multiple muscle groups. With this approach, the individual readies themselves for multi-dimensional motions for a lifetime.

References:

  1. Clark, Michael A., Focus On Function, A Scientific Approach to Functional Anatomy, 1999.
  2. Levin, Josh, Drake MD, David,  Cifu, MD, David, Biomechanics, March 2003, Vol. X, Number 3, pg. 22
  3. NASM, Lower Body Muscular Anatomy, 2000
  4. Inman, Verne, Human Walking, Williams & Wilkins, 1981
  5. Dykyj, Daria, Ph.D., “Anatomy of Motion”, Clinics in Podiatric Medicine and Surgery, July 1988, Vol. 5, No. 3
  6. Korr, I. M., 1976, Spinal Cord as an Organizer of the Disease Process, Carmel, CA: Academy of Applied Osteopathy Yearbook.
  7. Wolf, Chuck, MS, IDEA Personal Trainer, July-August, 2002, pg. 20-31.
  8. Gray, Gary, Total Body Functional Profile, Wynn Marketing, Adrian, Michigan, 2001
  9. Gottschalk, F. et al, The functional Anatomy of the Tensor Fascia Latae and Gluteus Medius and Minimus, Journal of Anatomy, 1989, pp. 179-189.
  10. Wolf, Chuck, Human Motion: A Pictorial Guide to Functional Integrated Training, 2002
  11. Chain Reaction Explosion Seminar, Wynn Marketing, Adrian, MI