Runner's knee

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What is ITB?

ITB (iliotibial band), i.e. the iliotibial band, is the side part of the wide fascia (fascia lata) that strictly covers the thigh muscles. It is a strong, inelastic collagen structure of connective tissue, up to approx. 6 cm wide. ITB extends on the lateral part of the thigh between the upper pelvis and the lateral condyle of the tibia. It begins in the pelvic area, on the iliac crest, connected by three tendon strands coming from the muscles: the broad fascia tensioner and the gluteal muscles (gluteus great and gluteus middle), which ensure the appropriate tension of the band. It then runs along the lateral surface of the thigh, attaching on the way to the roughened line of the femoral shaft, successively to the lateral epicondyle of the femur, lateral patellas and ends at the anterolateral side of the tibia condyle (the so-called Gerdi's tubercle).

The task of the iliotibial band is to inhibit the adduction movement in the hip joint and to stiffen the knee joint in an upright position. By connecting with the collateral ligament and the biceps muscle of the thigh, it provides stabilization of the knee from the outside.

Causes of the iliotibial band syndrome (ITBS)

Until recently, the conflict of the band with the lateral epicondyle of the femur was reported as the cause of the formation of the iliotibial band syndrome. It was believed that the band during repeated flexion and extension movements of the knee "jumped" over the epicondyle, causing inflammation in the surrounding structures of the knee (synovial bursa).

Numerous studies on the anatomical structure of the strand confirmed that not only the strand does not move to a significant extent in relation to the epicondyle, but is attached to it by special fibrous legs and there is no possibility of friction between these structures. It has been shown that the strand is pressed against the epicondyle, and the source of pain is not the inflamed strand. The immediate cause of pain in this area is the pressure of the shortened and taut band on the highly innervated and vascularized layer of connective tissue lying in the area of ​​the lateral epicondyle of the femur.

During hard training, the jogging stride pattern is duplicated, which causes increasing overload of individual muscle groups. The constant use of the same muscles, cumulative overloads and the lack of adequate regeneration after exercise as a consequence lead to a muscular imbalance in the structures that make up the iliotibial band (the broad fascia tensioner muscle, the great gluteus muscle and the medium buttock muscle). As a result, the thigh abductors are weakened, especially the middle gluteus muscle, which is responsible for stabilizing the pelvis when it is supported on one leg. The failure of this muscle leads to its function being taken over by the synergistic muscles, which in this case are the tensioner of the broad fascia and the gluteus great muscle. The joint connection of these muscles with the iliotibial belt means that at the moment of the support phase, all the tension is transferred to the belt, and its excessive activity leads to pain in the epicondyle of the femur.

Diagnostics of the iliotibial band syndrome (ITBS)

The diagnosis of ITBS syndrome is possible after collecting a detailed history and on the basis of the clinical examination of the patient, during which it is necessary to assess the possible shortening of the iliotibial band and to check its compression pain on the femoral condyle with the knee flexion and extension movements. In addition, it is also necessary to assess the structure and mechanics of the entire lower limbs in order to exclude other pathologies within the knee, e.g. patellofemoral syndrome, traumatic fracture, biceps tendon inflammation or damage to the lateral meniscus. If the band is shortened and we are dealing with pain that occurs when the structure is pressed (the most intense when the knee is bent up to 30 degrees), then we can be sure that we are dealing with ITBS. If in doubt, perform an ultrasound of the knee or an MRI of the knee joint.

Iliobibial band syndrome (ITBS) risk factors

In order to explain the source of the ailment, it is necessary to evaluate the lower limb as a whole. The cause of ITBS usually lies outside the knee joint itself - you have to look for it "one floor" above or "one floor" below.

The main factor causing the formation of the iliotibial band syndrome are primarily common training errors, which include:

lack of proper warm-up and training preparation,
too much effort while running, overtraining,
improper technique of the practiced discipline,
poorly selected shoes (worn out shoes and the lack of their shock-absorbing function - wear of the middle layer of the sole on the outer side),
neglecting breaks for walking during a long run,
lack of adequate regeneration after training.

There is also a group of anatomical and biomechanical factors that predispose to the development of an injury, and only the combination of several of them creates conditions for the occurrence of dysfunction. We include among them:

construction of the iliotibial band itself; shorter, more tense predisposes to ITBS;
muscle imbalance - weakening of the thigh abductors (in particular the gluteus medius muscle), which in turn leads to an increase in the tension of the band, and thus to increased pressure on the tissues under it;
imbalance between the strength of the muscles of the posterior (semimembrane and semitendinous muscle) and the anterior (quadriceps) of the thigh;
varus and valgus of the knees, excessive internal rotation of the tibia, flat feet, pronation of the forefoot;
asymmetrical position of the pelvis or lateral curvature of the spine in the lumbosacral section, resulting in asymmetrical work of the lower limbs and simulating a difference in their length,
excessive torso and pelvis tilt which causes stronger anti-gravitational tightening of the gluteal great muscle.

Symptoms of the iliotibial band syndrome (ITBS)

The main symptoms of the iliotibial band syndrome include:

characteristic in the history of burning, sharp, diffuse pain in the lateral compartment of the knee joint, between the lateral condyle of the femur and the lateral condyle of the tibia, pain sensations of patients can also be localized anywhere in the iliotibial band,
ailments that increase when running, climbing stairs and getting up from a sitting position, which is related to the activation of the gluteus muscle during these functions, which transmits its strength through the iliotibial band,
complaints increase when the knee is bent to 30 degrees and decrease during extension,
discomfort occurs with every training, almost the same distance and does not cease when the effort is continued,
swelling and redness at the site of the injury,
limb function limitation,
continuation of physical activity is significantly limited, and each attempt to undertake it ends up aggravating the injury and increasing pain.

Treatment of the iliotibial band syndrome (ITBS)

If you experience symptoms related to iliotibial band syndrome, you should act as soon as possible. Ignoring the first symptoms and trying to take up further physical activity usually result in worsening and intensification of symptoms and an extended period of convalescence and return to full fitness.

Treatment of this disease is usually conservative and consists in targeted rehabilitation. In the first stage of treatment, it is especially important to temporarily stop training or limit it to activities that do not cause ailments or introduce replacement training. Then, implement measures to control inflammation, pain and swelling in line with the RICE principle:

R - rest - rest,
I - ice - ice, cooling,
C - compression - pressure in case of swelling (using an elastic bandage or a tourniquet),
E - elevation - elevation of the injured limb.

Additionally, non-steroidal anti-inflammatory drugs (e.g. ibuprofen) can be used.

Once the inflammation, swelling and pain are under control, it's time for the main therapeutic work. At this stage, physical therapy should be aimed at relaxing the iliotibial band and strengthening the gluteus medius muscle. It is also time to identify the biomechanical factors and training errors that caused the ailments. This is a key element in minimizing the risk of recurrence.

Considering the massive structure of the iliotibial band and the broad fascia, the possibilities of their effective stretching are very limited. Therefore, the therapy is mainly aimed at restoring the proper mobility and tension of the band and restoring the correct muscle balance within the disorders. To achieve this, relaxation of the broad fascia tension muscle and the gluteus great muscle are used (transverse massage, myofascial techniques, post-isometric relaxation, taping) and deep massage of the iliotibial band. At this stage of rehabilitation, exercises are introduced to strengthen the weakened gluteus middle muscle, which is the main hip abductor and pelvic stabilizer. In addition, important elements of the therapy are also stretching other contracted muscle groups, improving neuromuscular control and practicing correct movement patterns.

Return to training should be done gradually and taking into account potential risk factors. Runners who wish to continue training while injured must remember to keep their activity levels below the pain threshold. In most cases, the treatment and recovery period do not last long, and stretching exercises - stretching, deep myofascial massage, taking into account the trigger points of the iliotibial band, and - importantly - exercises to strengthen the abductors of the lower limbs play an important role in the prevention of relapses.

If symptoms persist despite physiotherapy treatment, the orthopedic surgeon may consider injecting an anti-inflammatory agent. A steroid is administered under the aponeurosis, in the area of ​​the lateral epicondyle of the femur, which will reduce the inflammation of the tissues separating the band from the epicondyle.

In cases where the above-mentioned methods do not bring any effect, the pain lasts for about six months, and other causes of symptoms, apart from ITBS, have been excluded, surgical treatment should be considered, which consists in releasing the iliotibial band. The operating procedure is performed under the supervision of an experienced orthopedic surgeon under the control of an arthroscope. The doctor makes a small incision of the iliotibial band at the level of the lateral epicondyle of the femur, which aims to reduce the pressure of the shortened and taut band on the highly innervated and vascularized layer of connective tissue lying around the epicondyle. The release of tissues results in the reduction of inflammation and pain, and the patient returns to normal sports activities and training a few weeks after the surgery.

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