April 29, 2013
by Dr. Dino Pappas
The weather is warming up and out comes the endurance athletes (runners, bikers and triathletes) again. The old aches and pains re-emerge. An endurance athlete that can’t participate in their sport anymore is kind of like a dog owner that’s lost their dog (depressed). For more on that analogy, click here (http://thecfim.com/rest-fixes-bad-mechanics).
We will see posts on social media asking for treatment advice. All the advice comes with good intent. The intent is to help someone hurting. The intent is to keep the injured person active. The intent is to keep the injured person enjoying something that they are passionate about (endurance sports). Some advice is better than others. Some advice is just flat out wrong. Some advice is just humorous.
One of the topics sure to generate buzz is chronic IT Band Syndrome. The IT Band is a dense band of connective (soft) tissue that runs down the outside part of the thigh. It runs from the hip and crosses the knee joint. There is even fascial (soft tissue) attachments to the pelvis. The band meshes with fibers of the tensor fascia latae (TFL), gluteus maximus and gluteus medius (1). The IT Band is a powerful stabilizer of the entire lower extremity. The purpose of the band is to proper rigid support to the thigh bone (femur) during gait (walking) and to stabilize the shin bone (tibia) from excessive internal rotation (1). The band has dense and strong fascial connections directly into the femur (thigh bone).
IT Band
Recent research has investigated the role and anatomy of the IT Band and fascia. Research has recently found that dense connective tissue and fascia is extremely difficult to mobilize or deform with hands on manual therapies (2, 3). We have found that fascia and the IT Band is so dense and so strong that it is extremely resistant to stretching and other soft tissue mobilization techniques (Active Release, Graston, Sound Assisted Soft Tissue Mobilization, Gua Sha, Myofascial Release, Foam Rolling etc.). For those that don’t know, the above mentioned soft tissue techniques attempt to reduce soft tissue adhesion and soft tissue restriction.
Soft tissues (muscles, tendons, ligaments, fascia, etc.) respond to repeated chronic stress by tightening/restricting/adhering. Repeated stress overloads the tissues causing an energy crisis. The cells and tissues cannot receive sufficient oxygen, cannot exchange waste products, and have trouble producing energy to fuel cellular processes. The net result is the tissue shortens/tightens/restricts/adheres. It would seem logical that methods to undo this process as those mentioned above would work for Chronic IT Band Syndrome; however, consider that the IT Band is extremely resistant to lengthening. Undesirable results such as tissue tearing and inflammation would occur in order to create sufficient force to permanently deform/loosen/mobilize these tissues (3).
In fact, the majority of the benefit with soft tissue mobilization and lengthening methods are probably neurological (3). In other words, the tissues of the IT Band aren’t lengthening like in other tissues, but the tolerance towards aggressive soft tissue methods increases. The nervous system learns to adapt to the demands placed on the tissue. We see this routinely with stretching. The tissue lengthens during the stretch but length gains recede (1, 5, 6). Research has consistently shown that the benefits of stretching are mostly neurological with the person adapting to the stretch (7). Tissue lengthening via stretching is short lived (1, 5, 6). Athletes with chronic IT Band Syndrome have probably tried aggressive soft tissue work and stretching and had some success due to neurological adaptations, but this hasn’t been enough to resolve the problem because the IT Band resists lengthening.
Look familiar? This stretch hasn’t worked too well either. Probably because the IT Band resists lengthening!
One of the best evidence based tools for chronic IT Band Syndrome is glut strengthening. Glut strengthening has been shown to be an effective tool by reducing pain in 22/24 runners given a 6 week program of hip abductor/glut exercises (8). Additionally, the pain reduction correlated to improved strength of the glut/hip abductor muscles. Eccentric control over the hip is a known mechanism to improve mechanics, increase tolerance to activities, increase tolerance to sports, improve sports performance and reduce pain. Many of the chronic cases have tried some form of glut strengthening, to some benefit, but have not yet overcome the chronic pain.
Good entry level glut exercises that haven’t worked to this point either.
So here’s the deal, the patients have come to our office already having tried many of the “best” treatments available including soft tissue mobilization methods and glut strengthening with limited or no benefit. What could they possibly receive in our office that would help? What additionally could we offer? Do they have to live with this chronic pain?
The best thing we could offer at this point is a fresh perspective. Maybe the problem isn’t tight/adhered/restricted tissues. Maybe the problem isn’t a strength problem either. Maybe the problem is something else that no one has checked to this point. Maybe the problem is the knee joint itself has lost the normal ability to go from one movement (flexion) to another (extension).
The knee joint looses the ability to extend (straighten), especially the last little bit (terminal extension). As the joint looses the ability to straighten, the muscles around the joint respond by increasing tone (tightening). The increased tone produces mechanical irritation at the knee that we perceive to be IT Band Syndrome based on the location of the pain, but the reason for this is completely different than muscle adhesions, restricted tissues, muscle weakness or muscle imbalances. Increased tone to the IT Band with reports of knee pain is therefore an effect, with the cause being loss of normal joint motion, particularly terminal knee extension. Restoring terminal knee extension is critical to reducing the pain, restoring function and getting the athlete quickly and safely back into their endurance sport.
If you’ve been hampered by a chronic case of IT Band Syndrome and have missed time away from your sport, please call our office at 708-532-CFIM (2346) for a consult. A simple motion and exercise maybe all that’s needed to get you back running or biking or running/biking/swimming again. “Why Put Off Feeling Good?”
References
1. Michaud, T.C. (2011) Human Locomotion: The conservative management of gait-related disorders. Newton, Mass: Newton Biomechanics
2. http://www.ncbi.nlm.nih.gov/pubmed/18723456
3. http://www.rolfingtaichilondon.com/ARTICLES/fascial%20plasticity%20schleip.pdf
4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2614693/
5. http://www.ncbi.nlm.nih.gov/pubmed/20075147
6. http://www.ncbi.nlm.nih.gov/pubmed/10862546
7. http://www.ncbi.nlm.nih.gov/pubmed/16476913