Dr John-David Kato DC, MSc, ACSM-RCEP, CSEP-CEP

The iliotibial band (ITB) is continuous part of the connective tissue that surrounds and supports the muscles of the thigh. The ITB is a thickening of this connective tissue which runs down the side of the thigh and adds additional support to the lateral aspect of the knee. It is named for its attachments from the ilium portion of the pelvis (ilio-) to the tibia, which is the leg bone just below the knee. The ITB also has attachments to the lateral epicondyle (see picture) of the femur (thigh bone) and to the kneecap. The muscles that can pull on the ITB are: the tensor fascia lata (TFL) and the gluteus maximus muscles. Pull on the TFL by these muscles can affect movement of the hip and the knee.

How ITB Friction Syndrome Occurs
When the knee is fully extended (as in standing) the ITB is in front of the lateral epicondyle. When the knee bends the ITB rubs over the lateral epicondyle of the knee at about 30˚ then ends up behind it. When this action is done repetitively the excessive friction produces an overuse injury at that lateral epicondyle. This causes pain, swelling with fluid buildup in to the space between the ITB and the femur, and over time thickening of the ITB itself.

Activities known to cause this kind of repetitive friction include cycling, skiing, hiking, and running. Curiously running speed does not seem to be a factor, however those who are susceptible to this injury are those with pre-existing biomechanical faults such as tightness of the ITB or weakness in certain muscles of the knee or lateral hip. Other factors include high weekly mileage, running along an incline (such as on a crowned road), and running downhill.

Symptoms of ITB Friction Syndrome
Initially it may take days to weeks for symptoms to develop. Some people are mislead because a sudden increase in amount of training seems fine at first and is not initially associated the symptoms because they develop later. The initial discomfort is more diffuse on the lateral aspect of the knee and is often felt during the running just as the heel strikes the ground as the runners extends their leg. If this injury is allowed to persist with continued training then in time the initial achy symptoms will progress to more painful and sharp. People at this point readily localize the pain to the lateral femoral epicondyle or the Gerdy’s tubercle (see picture) on the tibia. They often have to stop the aggravating activity because of the pain. At this point the creaking, like rubbing a balloon, may be felt (or heard) with knee movement. Lateral hip pain from trochanteric bursitis may be associated with ITB friction syndrome because of tightness of the ITB over the hip.

Examination and Diagnosis
An examination will lead to a proper diagnosis of ITB friction syndrome. The examination is also used to rule out other causes of lateral knee pain (popliteal tendonitis, biceps femoris tendonitis, lateral meniscal tear, arthritis, back or hip problems, etc), which could be mistaken for this injury. Laboratory and imaging test such as X-ray and MRI are generally not needed and are often not helpful.

The examination should be done in shorts so that both knees are clearly visible and movement is not restricted. If the patient is a runner then it is often useful for them to bring their running shoes. The examination includes assessing not only swelling and tenderness but for proper alignment and gait. Tenderness is often located about 2 cm above the joint line of the knee. The tension and strength of the different muscles of the feet, knee and hips should then be measured to delineate any weakness or imbalances that will be addressed in treatment. During palpation “trigger points” may be found in the quadriceps muscle, the gluteus medius muscle of the buttocks or the biceps femoris muscle of the hamstrings. Often pressing on these muscles can produce pain referred to the lateral aspect of the knee.

Several orthopedic tests (special manoevres that stretch or compress different parts of the body to identify injuries) are used to assess pain and/or tightness of the ITB. Such tests include the Renne test where the patient stands on the affected leg with the knee bent to 30 degrees. A positive result is a reproduction of the pain, or an increase in tenderness. Noble’s compression test involves having the patient lying on their back with the knees bent. The doctor compresses the ITB against the lateral epicondyle while the patient extends their knee. If this does not reproduce the pain, it suggests the injury is not related to friction of the ITB. The most common test is called Ober’s test. This test is done with the patient on their side and the thigh is lowered by the doctor to see how far the ITB will stretch. It must be done properly or it can be misinterpreted, but the test helps to determine the tension in the ITB. That being said, one can still have an ITB that is not tight but still have ITB friction syndrome.

Once a diagnosis is made and other causes of pain are ruled out, then treatment can be targeted to reduce pain and inflammation, improve the function of the joints and muscles, and recommendations for a more suitable training schedule can be given.

John-David Kato is a Chiropractor and Clinical Exercise Physiologist practicing in Toronto. He frequently helps individuals who are affected by sports and recreational injuries.

By Dr John-David Kato DC, MSc, ACSM-RCEP, CSEP-CEP

Now that the snow and ice in Toronto’s parks is melting and, hopefully, the warm weather is here to stay many people are looking to head outdoors to get back into shape. The cold weather along with the holidays means many have not been exercising for months, have been eating more, and have gained a few extra unwanted pounds. So before you strap on your water bottle and start sprinting up the hills, here are some basic tips to make it your fitness endeavours smart, safe and enjoyable.

Treat yourself to a new pair of running shoes.
Whether you are running or walking, running shoes are lightweight and provide the support that you will probably need. I could spend a whole article talking about appropriate footwear, but basically the amount of support you need depends on the amount of walking/running you will be doing, and the amount of “flexibility” of your feet. What a lot of people do not realize is that the midsole, which provides much of the support breaks down with wear and with time. After six months to a year, the shoe has lost much of its support even if it has not been worn for a long time. And although many think that more cushioning in their shoes is best, this usually is not the case; most people need a stability running shoe.

Start your exercise with a 5-10 minute warm-up, and finish with a cool-down.
Starting your exercise session with light-intensity activity gets the body ready for exercise. This gets more of your blood into circulation so it can carry the oxygen and fuels to the working muscles and your heart. This makes the same workout feel more comfortable and less like work. It warms up connective tissues, such as ligaments and tendons, to help prevent injury. Similarly, bring your body gradually back to rest with a cool-down of the same duration. These are important for safety during a session of exercise, but are often skipped.

Exercise at a safe comfortable pace.
You have not exercised all winter long, do you expect you can start off with wind-sprints? No. That old slaying “no pain-no gain” does not apply here. For many sedentary people, brisk walking is enough of a challenge to get all the benefits of aerobic exercise. For these people starting off with sprinting, for example, is uncomfortable and makes it less likely that they will stick with it long term. Furthermore for these people there are very little further health benefits while injuries are more likely. If walking is too easy then add short intervals (30-60 seconds) of jogging interspaced within your walk. A good guideline is the “Talk Test”. If you are able to talk during the exercise then you are at a good pace. If you are gasping between groups of words then slow yourself down. If you are able to sing, then it is time to progress for sure.

Your progress should be gradual.
If you consider yourself “out of shape”, you might need to start off with as little as 10 minutes of exercise. If so, try a few sessions throughout the day. They add up, and research shows that they are comparable to exercising continuously for the same amount of time (trust me, that was my graduate thesis topic). Over time, you can increase the amount of exercise, but limit the increase to no more than 10% for the whole week. When you are ready, it is generally better to increase the duration of exercise than the intensity.

If you do get injured, get professional treatment.
Some of the common walking or running injures at the beginning of an exercise regimen are: plantar fasciitis, Achilles tendonitis, shin splints, patellofemoral syndrome (runner’s knee), iliotibial band syndrome (ITB syndrome), hamstring strain/pull, stress fracture, etc. These injuries might take a few weeks of exercise before they show up. They are often caused by old foot wear, not warming up, progressing too fast (see the above tips), or problems with joints motion and/or muscle imbalances. These injuries can stop you from exercising and enjoying the outdoors so do not let them linger or get worse. If it is not going away after about a week, if you are experiencing it earlier in your exercise, or you feel the pain later that day or next morning then get it examined by a qualified health care professional. You should have a proper examination, the diagnosis explained to you, a course of treatment including rehabilitation exercises to help prevent it from coming back.

Spring is a great time to get active and take advantage of the outdoors. Walking or easy jogging can be very enjoyable and will provide all of the health benefits of aerobic exercise. These general tips and guidelines should help you to get kick-started for spring fitness in a safe and enjoyable way.

John-David Kato is a chiropractor and clinical exercise physiologist working at the Rosedale Natural Health Clinic near the Yonge and St. Clair intersection. He trains people (both healthy and those with medical conditions) and treats a variety of injures to muscles and joints of the body. If you have any questions or would like a consultation please call: 416-926-0084.