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IntroductionThe iliotibial band (ITB) is the lat-

eral portion of the deep fascia of the thighwhich extends from the iliac crest to thelateral tibial tubercle, known as Gerdystubercle.1 It is described as an extremelystrong, thickened strip of fascia lata whichreceives tendinous reinforcements from the

tensor fascia lata and the lateral fibres ofgluteus maximus and serves to support theknee on its lateral aspect.2 According toSchafer, since the ITB crosses both the hipjoint and the knee joint, its affect on theknee is dictated by the position of the hip. When flexed, the knee depends uponmuscular support laterally by the ITB andbiceps femoris; medially by sartorius, gra-cilis, semimembranosis and semiten-dinosis, anteriorly by quadriceps femoris;and posteriorly by popliteus. The ITBlocks the knee into extension thereby pro-viding maximum stability with minimaleffort. It has been suggested that the ITBappeared phylogenetically with the devel-opment of upright posture.3 IliotibialBand Friction Syndrome (ITBFS) occursas a result of friction generated between

the distal ITB and the lateral femoral con-dyle. Successive flexion /extension of theknee induces this over use or misuse syn-drome as the ITB moves from its ante-rior position in relation to the femoralcondyle during knee extension to a poste-rior position in flexion.4 It has been sug-gested that the discomfort experienced inthe ITBFS may originate from contractureof the ITB itself, its insertion into Gerdys

tubercle, the bursa overlying the lateralfemoral condyle or the periosteum.5 ThePrevalence of ITBFS in distance runners

as compared to racquet sport athletessupport the proposed mechanisms of in-jury as being a sustained low grade inflam-matory reaction due to friction generatedby repetitive flexion/extension of the knee.

Clinical PresentationsMr. R. presented to my clinic with

pain on the lateral aspect of the right knee.His right thigh contained multiple triggerpoints throughout the fleshy portion of thequadriceps muscle. The hamstring mus-cles were all tested to be hypertonic. Thisindividual relayed information in theirclinical history that they had increased rap-idly their running distance. The runningdistance was increased from a comfortable

5 kilometre jog to a strenuous 10 kilome-tre run. The reason for the increase wasso that the patient may participate in acommunity marathon.

Clinical ExplanationPain on the lateral knee around the

cartilage line, as well as pain in the area ofthe greater trochanter after prolonged run-ning activities which is relieved by rest is

diagnostic of ITBFS.6 The discomfort be-comes limiting at a constant distance foreach individual. As a rule, runners can usu-ally complete one to two kilometres with-out pain after which the discomfort buildsrapidly, forcing the runner to stop andwalk back. Smooth, even paced runningespecially down grades, or using excessivestride lengths, aggravate ITBFS. Pro-longed walking on the other hand, doesnot cause onset of symptoms as a rule, al-though walking downhill may be un-comfortable.

There is rarely a history of directtrauma or twisting injury in ITBFS. Theonset of symptoms commonly coincides withthe modification in ones training program,

The Iliotibial Band Friction Syndrome

C.P. Ross Ph.D., D.C.,COHS, FRSH.1 and P.R. Saunders Ph.D., N.D., DHANP.2

1.Vice-President Academic, Canadian College of NaturopathicMedicine, 2300 Yonge Street, Toronto, Ontario M4P 1E4.2.Chief Naturopathic Medical Officer, Canadian College ofNaturopathic Medicine, 2300 Yonge Street, Toronto, OntarioM4P 1E4.

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with an increase in distance being the mostfrequent stimulus. In addition, increasedspeed, frequency of workouts and changing

to hilly terrain, pronated ankles and exces-sive wear on the outer sole of a shoe, havebeen implicated as causes of ITBFS.

Pain experienced in ITBFS is mostsevere during the heel strike phase of de-celeration and is relieved by a stiff leg-ged or full knee extension gait.1 Accord-ing to this author, pain is generated dueto the lack of ligamentous stability in thenon-fully extended knee and it is during

this time that the knee integrity is main-tained by muscular forces.

Repetitive flexion/extension of theknee especially on hilly terrain would putan added strain on these muscle groupsresulting in the formation of trigger pointsand contractures of the hamstrings, tricepssurae and ITB. These in turn, would leadto aberrant leg control and the character-istic semi-flexed knee posture at heel strike,

associated with ITBFS.

Diagnostic FindingsOn palpation, the ITB feels tight and

rigid with tenderness along its distal end(over lateral femoral condyle), and perhapsalso the hip.6 Ligamentous and meniscaltests will be negative, however single ormultiple trigger points will be elicited inthe lateral distal thigh (across ITB abovethe joint line). Gerdys tubercle will be sur-prisingly painful.1 Palpation of the lateralfemoral epicondyle during flexion/exten-sion may result in a creak sign as the ITBrubs over the femoral prominence.

An accurate diagnosis of ITBFS wouldinclude positive findings in the followingtests. Firstly, instruct the patient to jog tolocate the point of pain immediately prior

to examination. This will help localize thefocal point of irritation. Secondly, ask thepatient to support their weight on the af-fected leg while maintaining 30 degrees ofknee flexion. The ITB will be brought intodirect contact with the prominent lateralfemoral epicondyle and the pain will ensue.

Thirdly, the patient sitting or supine,apply pressure 1-2 cm proximal to the lat-eral femoral condyle while the knee is in

90 degrees of flexion. Instruct the patientto slowly extend their leg. Pain experiencedduring running will be reproduced at 30degrees of flexion. Lastly, with the patientin a lateral recumbent position, have theaffected leg abducted to 20 degrees sev-eral times. This maneuver puts consider-able tension on the gluteus maximus andtensor fascia lata muscles which will elicitdiscomfort. In addition, Obers tests

should be performed to rule out contrac-ture of the ITB as a cause of pain. Radio-graphic analysis of the knee joint is typi-cally unremarkable.

Differential DiagnosesDegenerative Joint Disease of the kneeLateral meniscus involvement (cystic or torn)Capsular ligamentous sprain and avulsionDiscoid meniscus

Stress reactionPseudogout (calcium pyrophosphate)ChondromalaciaOsteonecrosis (lat. tibia, femur)Popliteus tendinitis

TreatmentSchafer recommends treating ITBFS

as an acute sprain with initial cryotherapyand adequate rest with ingestion of a non-steroidal anti-inflammatory to help relievethe inflammatory process. Trigger pointsshould be treated using cross fibre frictionmassage for several minutes as recom-mended by Simons.7 Treatments may beconcluded by interferential current therapyto achieve analgesia, followed by functionalmuscle stimulation for muscle reeducation.Bilateral passive and active stretching ex-

ercises for the tensor fascia lata, hamstringsand quadriceps should be prescribed. Caremust be taken to avoid exercises which maystrengthen the quadriceps. Chiropracticmanipulation restricted to the Lumbarspine in order to relieve subluxations inthe area are performed. Sacro-iliac mobi-

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The Iliotibial Band Friction Syndrome

lization and manipulation are executedrelative to the pelvic unleveling that hasensued. Training should be modified to

include non-percussive exercise such ascycling and swimming with ice massageof the affected areas following the activ-ity.1

Surgical release of the ITB or removalof the lateral femoral epicondyle have beenused with some success when conservativetreatment fails. However, return to fulland normal lower limb mechanics may notbe achieved.

Naturopathic Treatment:Naturopathic treatment of ITBFS

acutely would include bromelain, 500 mgqid between meals to reduce inflamma-tion, ascorbic acid 4g qd8 and glucosaminesulfate 500 mg qid9 to reduce inflamma-tion and promote tissue repair. Chronictreatment includes selenium 140-200 mg,alpha-tocopherol 400 IU10,11 and pyridox-

ine 100-250mg12 to reduce serotonin lev-els and increase of glutathione peroxidase.Local acupuncture points are GB 34, 33and 31, eyes of the knee, and ST 34 and36. Homeopathy would begin with Arnicamontana to reduce stiffness. Anti-inflam-matory botanicals include Salix alba, asource of salicylic acid, Harpogophytum

procumbens, Yucca spp, orally and topicallyslightly warmed Ricinus communisoil dur-ing rest periods. Although this case pre-sented with very local pain, in some indi-viduals removal of food sensitivities fromthe diet can be beneficial.

ImplicationsIliobitial band friction syndrome oc-

curs as a result of friction generated be-tween the distal iliotibial band and the lat-

eral femoral condyle. To preventreoccurrence of ITBFS the gait mechan-ics of the individual including footwearand terrain must be fully evaluated.

Clinical success can only be achievedthrough the analysis of all contributingfactors. Although this condition is one of

mechanical dysfunction and anatomicalrestriction, it certainly responds well to awhole myriad of treatment.

References:1. Schafer RC: Chiropractic Management of Sports

and Recreational Injuries. Baltimore, Williamsand Wilkins.1986.

2. Moore KL: Clinically Oriented Anatomy. 2ndEdition. Baltimore, Williams and Wilkins.1985.

3. Sutker AN, Barber FA, Jackson DW Pagliano, JW: Iliotibial Band Syndrome in DistanceRunners. Sports Medicine. 1985; 2: 447-451.

4. Renne JW: The Iliotibial Band Friction Syn-drome. Journal of Bone and Joint Surgery.1975: 57-A: 110-111.

5. Noble H, Hajek MR, Porter M: Diagnosisand Treatment of Iliotibial Band Tightnessin Runners. The Physician and Sports Medi-cine. 1982: 10(4): 67-74.

6. Levy AM: Whats Causing the Athletes LegPain? Diagnosis. 1988;10,3: 22-37.

7. Simons DG: Myofascial Pain Syndromes dueto Trigger Points: 1. Principles, Diagnosis, andPerpetuating Factors. Manual Medicine.1985; 1,3: 67-71.

8. Bland JH & Cooper: Osteoarthritis. SeminArthritis Rheum. 1984; 14(2):106-133.

9. Puljate JM, et al: Double-Blind Clinical Evalu-ation of Oral Glucosamine Sulphate inBasicTreatment of Osteoarthritis. Curr Med ResOpin. 1980; 7(2): 110-114.

10.Jameson S, et al: Pain Relief and SeleniumBalance inPatientswith Connective TissueDisease and Osteoarthritis. Nutr Res. Suppl.1985; 1: 391-397.

11.White G: Vitamin E Inhibition of PlateletProstaglandin Synthesis. Fed Proc. 1977; 36:350.

12.Bernstein A: Vitamin B6 in Neurology. AnnN Y Acad Sci. 1990; 85:250-260.