The knee is one of the most common sites of injury associated with running due to the chronic repetition and can cause several types of conditions, one being iliotibial band syndrome (ITBS) (10,12). ITBS is the primary cause of lateral knee pain in runners (15) and accounts for nearly 12% of all running-related injuries (2). ITBS can be caused by numerous factors such as increase in mileage, training on uneven surfaces, excessive pronation, and hip abductor weakness (7). The purpose of this article is to review some of the underlying causes of ITBS and furthermore provide the rehabilitation and strength and conditioning specialist with stretching and strengthening techniques to help prevent and rehabilitate iliotibial band (ITB) pathology.
The tensor fascia latae begins on the proximal iliac crest and connects with the posterior gluteus maximus to form the ITB (8). The ITB is a thick band of fibrous tissue that runs from the lateral hip to the lateral knee and can become irritated due to friction when the band crosses over the lateral femoral condyle (12), mainly during 30° of flexion (5). More specifically, the ITB is a long collagenous structure that runs from the proximal iliac crest to the distal insertion on the lateral proximal tibia (known as Gerdy's tubercle) (8), the lateral border of the patella (3,11), and the lateral retinaculum of the patella (5). The ITB functions to abduct the leg and to stabilize the pelvis during a single-leg stance. It also acts as a lateral hip stabilizer (7) to counter the adduction and internal rotation at the knee with eccentric loading (1). Both the gluteus medius and the tensor fascia latae are hip abductors; however, the gluteus medius externally rotates the hip, whereas the tensor fascia latae internally rotates the hip (7). The tensor fascia latae also works as a hip flexor (14).
CAUSES OF ITBS
Muscle imbalances are one of the leading causes for ITB tightness and ITBS. This imbalance is caused because the quadriceps and hamstrings contract so frequently during running that the gluteus medius becomes weak (13). Because running occurs primarily in the sagittal plane, the muscles that work in the frontal plane (hip abductors) are not strengthened during a normal running activity (6). This leads to a muscle weakness seen within the hip abductors primarily the gluteus medius in runners (7). The gluteus medius has to exert a force 3 times the body weight in order to counteract movement of the pelvis to maintain alignment (9).
Movement of the ITB over the femoral condyle is another leading cause of ITBS. As the knee extends and flexes, the ITB moves anteriorly and posteriorly over the lateral femoral condyle. The constant flexion and extension required for running can cause irritation to the ITB as it continually slides over the lateral femoral condyle. Researchers have reported the absence of a bursa at the site where the ITB crosses over the lateral femoral condyle (11) and have found a highly vascular fat layer (4). Miller et al. (10) found that individuals with ITBS had an increase in knee flexion, which was highly correlated with impingement of the ITB during heel strike. During running, the femur adducts compared with the pelvis during foot contact. At this point, the gluteus medius and tensor fascia latae are working eccentrically, then work concentrically during the support phase. Athletes with weak gluteus medius muscles are more likely to adduct and internally rotate during midstance of the running gait (7). Furthermore, because of the distal attachment site on the lateral femoral condyle, weak hip abductors create more valgus force on the ITB. The valgus force increases the friction between the ITB and the lateral femoral condyle (7).
To alleviate ITBS in athletes, the strength and conditioning specialist should focus on gluteus medius strengthening and lengthening of the ITB. Strengthening exercises include hip hikes, clams, step downs, lateral monster walks, and 45° elastic band exercises that focus on gluteus medius strengthening as well as proprioception and limiting valgus forces at the knee as seen in Figures 1-3. Along with strengthening, it is critical to lengthen the ITB by performing different variations of stretches as seen in Table 1.
STRENGTHENING EXERCISE DESCRIPTIONS
Hip hikes work to strengthen the gluteus medius to help stabilize the hip in the proper position. Have the athlete stand on the edge of a box 4-6 inches in height with the majority of body weight on the unaffected side. The athlete will lower the involved hip and then bring it back to neutral. Begin with 2 sets of 10 reps and progress to 3 sets of 15 reps.
Place the athlete in a side-lying position with knees flexed to 90°. The athlete will then abduct and adduct the hip (acting like a clam opening and closing). Begin with 2 sets of 15 repetitions and increase to 3 sets of 20 repetitions. More resistance can be added by attaching an elastic band to the lateral portion of the knees.
The main purpose of this exercise is to work to maintain all motions within the sagittal plane and limit valgus forces at the involved knee. Have the athlete stand on a step about 6 inches in height. Have the athlete step down with the uninvolved knee while keeping the involved knee over the second toe. Begin with 2 sets of 10 reps and progress to 3 sets of 15 reps.
LATERAL MONSTER WALKS
Attach an elastic band around lateral portion of both ankles. Flex knees and hips and proceed to side step. Ensure that both knees and hips are remaining flexed and not extending as the gluteus complex becomes fatigued. Begin with 2 sets of 10-15 yd (Figure 1).
ELASTIC BAND (45° ANGLE)
Maintaining the elastic band around the ankles, begin to extend the involved leg at a 45° angle (half way between pure hip abduction and hip extension). Begin with 2 sets of 15 repetitions and progress to 3 sets of 15 repetitions (Figure 2).
By incorporating these exercises, the rehabilitation and strength and conditioning specialist can play an active role in decreasing the likelihood of their athletes developing ITBS. Furthermore, these exercises can quickly assist in rehabilitating injured athletes. These exercises can also be implemented with relative ease and with inexpensive equipment.
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