44 D . C . P R O D U C T S R E V I E W

Orthotics

IliotibialBand

Syndrome &Orthotics

By: William M. Austin, DC, CCSP, CCRD

Aching and soreness on the outside of the knee and lower

thigh is frequently reported by our more active patients. This

is often mentioned as a secondary or “offhand” area of pain,

but can develop into a chronically disabling problem. Iliotib-

ial band syndrome (ITBS) is the most common cause of lateral knee pain in

runners and walkers, with an incidence as high as 12% of all running-relat-

ed overuse injuries.1

ITBS results from recurrent friction of the iliotibial band (ITB) sliding

over the lateral femoral epicondyle. This problem can progress to become

a sharp, burning pain at the lateral knee that persists after just a small

amount of walking. While recognition of iliotibial band syndrome isn’t

difficult, treating the condition can be a challenge because underlying

biomechanical imbalances often contribute to the patient’s persisting pain

and disability. A comprehensive postural and biomechanical evaluation is

usually necessary for a complete recovery and return to all recreational

activities.

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Orthotics

Anatomy and FunctionThe iliotibial band is the continuation of the

tendinous portion of the tensor fascia lata muscle.It also attaches indirectly to parts of the gluteusmedius, gluteus maximus, and the vastus lateralismuscles. An intermuscular septum connects theITB to the linea aspera femoris until just proximalto the lateral epicondyle of the femur. Distally,the ITB spreads out and inserts on the lateral bor-der of the patella, the lateral patellar retinaculum,and Gerdy’s tubercle of the tibia. The ITB is onlyfree from bony attachment between the superioraspect of the lateral femoral epicondyle andGerdy’s tubercle.2

Controlled Adduction at Heel StrikeThe ITB assists the tensor fascia lata as it

abducts the thigh or, more precisely,controls and decelerates adductionof the thigh as the foot is planted.As such, it contributes to the biome-chanical stability of the pelvis onthe leg, as well as acting as ananterolateral stabilizer of the knee.During knee extension, the ITBmoves anteriorly, and then it slidesposteriorly as the knee flexes,remaining tense in both positions.

A study of runners with ITBsymptoms found that the posterioredge of the band was impinging against the later-al epicondyle just after foot strike in the gaitcycle.3 The friction first occurred at less than 30°of knee flexion. Recurrent rubbing can produceirritation and chronic low-grade inflammation,especially beneath the posterior fibers of the ITB,which are thought to be tighter against the lateralfemoral condyle than the anterior fibers.

“Osis”, not “Itis”We now know that the lateral knee pain that

develops in ITB syndrome is due to a “tendinosis”condition. It is not due to inflammation, but anunderlying degeneration of collagen tissues inresponse to mechanical overuse. There is a loss ofcollagen continuity and an increase in groundsubstance and cellularity, which is due to fibrob-lasts and myofibroblasts, but not inflammatorycells.4 This is the reason that anti-inflammatorystrategies (such as NSAIDS drugs and corticos-teroid injections) are not indicated for these condi-tions, and actually may interfere with completerepair.5

Treatment of ITB SyndromeInitially, a reduction in stressful activities is nec-

essary to allow the body to catch up with healing.This means limiting all aggravating sport andwork activities for a few weeks to a month. Run-ning and any other potentially exacerbating activ-ity such as cycling should be avoided to reducethe repetitive mechanical stress at the lateralfemoral condyle. Contract-relax exercises tolengthen shortened iliopsoas, rectus femoris, andgastrocnemius-soleus muscles are performedthree times daily in three bouts of a 7-second sub-maximal contraction, followed by a 15-secondstretch (contract-relax procedure).

Particular attention is given to increasing thelength of the ITB. If necessary, gait and treadmillrunning analyses can be used to screen for

dynamic muscle imbalance or weakness con-tributing to the injury. Chiropractic adjustmentsfor biomechanical imbalances and restrictions inthe lumbopelvic region are usually necessary.

Long-term ControlJames observed that runners with ITBS often

demonstrate excessive pronation at heel strike.6

Others have noted that leg-length discrepanciescontribute to ITBS.7 This can be secondary to atrue anatomic discrepancy or environmentallyinduced by training on crowned roads. Studieshave demonstrated a significant decrease in tibialinternal rotation8 and on pronation velocity9 whenusing orthotics, which can help to control theposition of the knee and absorb some of the jointstress at heel strike.

For the long-term, most patients with ITBS willneed stabilizing, custom-made orthotics in orderto control underlying biomechanical faults. Themost common problem seen is excessive prona-tion, which causes a variety of symptoms, but

For The Long-Term, MostPatients With ITBS Will Need

Stabilizing, Custom-MadeOrthotics In Order To Control

Underlying Biomechanical Faults.

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Orthotics

responds well to the use of flexible or semi-flexi-ble orthotics.10 In some cases, an added heel liftwill be needed to compensate for anatomical leglength discrepancy.

References1. Clement DB, Taunton JE, Smart GW et al. A sur-vey of overuse running injuries. Phys Sportsmed1981; 9:47-58.2. Terry GC, Hughston JC, Norwood LA. Theanatomy of the iliopatellar band and the iliotibialtract. Am J Sports Med 1986; 14:39-45.3. Orchard JW, Fricker PA, Abud AT et al. Biome-chanics of iliotibial band friction syndrome in run-ners. Am J Sports Med 1996; 24:375-379.4. Khan KM, Cook JL, Bonar F et al. Histopatholo-gy of common tendinopathies: update and impli-cations for clinical management. Sports Med 1999;27:393-408.5. Almekinders LC, Temple JD. Etiology, diagno-sis, and treatment of tendonitis: an analysis of theliterature. Med Sci Sports Exerc 1998; 30:1183-1190.6. James SL. Running injuries to the knee. J AmAcad Orthop Surg 1995; 3:309-318.

7. Schwellnus MP. Lower limb biomechanics inrunners with the iliotibial band friction syndrome.Med Sci Sports Exerc 1993; 25:S68.8. Nawoczenski DA, Cook TM, Saltzman CL. Theeffect of foot orthotics on three-dimensional kine-matics of the leg and rearfoot during running. JOrthop Sports Phys Ther 1995; 21:317-327.9. Eng JJ, Pierrynowski MR. The effect of softorthotics on three-dimensional lower limb kine-matics during walking and running. Phys Ther1994; 74:836-844.10. Gross ML, Davlin LB, Evanski PM. Effective-ness of orthotic shoe inserts in the long-distancerunner. Am J Sports Med 1991; 19:409-412.

About the Author

An enthusiastic speaker, Dr. William Austin provides anenergetic approach to learning. He draws from over 38years of healthcare experience, which includes AthleticTraining, Chiropractic, and Chiropractic Research. Hehas developed two successful practices. He is a 1986 grad-uate of Logan College of Chiropractic, and is currentlyDirector of Professional Education at Foot Levelers, Inc. ofRoanoke, VA.

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