Iliotibial band syndrome (ITBS) - A common overuse injury of the knee in running and cycling

Iliotibial band syndrome (ITBS) - A common overuse injury of the knee in running and cycling

The iliotibial band (ITB) is a thick strip of fascia, a thickening of the hip musculature, spanning from the iliac crest to the lateral tibial tubercle (from the pelvis, over the hip, to the knee).1
As the knee bends and straightens, the ITB changes position. As the knee extends, the ITB sits in front of the lateral femoral epicondyle (outside of the knee), and as the knee bends, the ITB moves posteriorly.1

ITBS is a common injury of the lateral aspect of the knee.2 It is often associated with long distance running and cycling and is seen in military recruits.1,2 It is the second most common running injury, and in cycling accounts for 15-24% of all overuse injuries.2,3
Cycling involves a repetitive knee flexion and extension cycle. With repeated bending of the knee, the ITB slides over the lateral femoral epicondyle causing friction. Pain usually occurs at 30 degrees knee flex and has been termed the “impingement zone”.1,2  

New research is challenging this idea that friction occurs between the ITB and the lateral femoral epicondyle. It has been suggested that the tissue between the ITB and lateral femoral epicondyle is actually innervated, vascularized tissue, that when compressed, sends messages back up the tract to the muscles around the hip. This decreases the function of the muscles surrounding the hip. This suggests that the pain at the lateral knee is being caused by a weakness of the hip musculature on the sore side.4

Symptoms include pain or burning over the lateral knee. Acutely, pain will decrease when the activity is discontinued but will return upon return to sport.5

Knee overuse injuries in cyclists can be a result of poor cycling techniques, anatomical factors, bike fit errors and training faults.
Poor cycling techniques:
· Riding in a low gear using low cadence while trying to increase speed.6 It is more efficient to use a higher cadence over long distances minimizing power requirements.1,6
· Using an inefficient pedal stroke. Exerting maximum effort during the down stroke only and not pulling up on the up stroke.6
· Lack of body awareness such as patellar (knee cap) tracking and inadequate core strength.6

Anatomical factors: leg length discrepancy, varus knee alignment (bowed legs), muscle imbalance, and excessive pronation of the foot. These cause the ITB to tighten up resulting in increased friction.1,6
It was found that runners with weak hip abductors were more susceptible to ITBS. Weak hip abductors especially gluteus medius lead to decreased control of inward hip movements.5

Bike fit errors:6
· Riding with a seat that is too high. The seat height should be adjusted so that knee is in 15-30 degrees flexion when the pedal is at the bottom of the stroke.6
· Excessive toe-in position due to cleat position.

 Training faults:1,6
· Increasing the training mileage or changing the training terrain too abruptly i.e. increasing hill climbing too quickly.1,6

Treatment:7
· Acute: The goal of this stage is pain relief and to reduce inflammation.
- Activity modification: decrease activities that cause the repetitive knee flexion and extension.
- Ice the area for 10-15 minutes every 2-3 hours.
- Speak to your doctor or pharmacist regarding an anti-inflammatory to help decrease inflammation and pain.

Sub-acute: Speak to your physiotherapist regarding correction of biomechanical factors, ITB and surrounding muscle stretches, and reducing myofascial restrictions along the lateral hip and thigh.3

· Recovery and strengthening phase: Your physiotherapist will give you specific muscle balance exercises of the hip and knee.3,4  These will help strengthen your hip abductors.3

· Return to sport: approximately 4-6 weeks.7
- Activity may resume when the patient can perform the specific strengthening exercises without pain and has made any required modifications to cycling techniques, bike fit and anatomical factors.8

For more information about cycling or running injuries, please feel free to contact Deanna Bicego at Seva Physiotherapy. deanna@sevaphysio.com





References

1 Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. The Knee. 2003;10:103-109.

2 Ellis R, Hing W, Reid D. Iliotibial band friction syndrome - A systematic review. Manual Therapy. 2007;12:200-208.

3 Beers A, Ryan M, Kasubuchi Z, et al. Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiotherapy Canada. 2008:60:180-188.

4 Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport. 2007;10:74-76.

5 Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clinical Journal of Sport Medicine. 2000;10:169-175.

6 Dumont T. Bike fit and overuse injuries of the knee in cycling. The Interdivisional Review. 2006:24-26.

7 Fredericson M, Weir A. Practical Management of Iliotibial Band Friction Syndrome in Runners. Clinical Journal of Sport Medicine. 2006;16:261-268.

8 Khaund R, Flynn SH. Iliotibial Band Syndrome: A Common Source of Knee Pain. American Family Physician. 2005;71:1545-1550.

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