Some years ago, while working in the Anatomy laboratory of University of Melbourne with my colleague Dr Eanna Falvey, we carried out a 3 part study into the anatomy, and strain of the Iliotibial band, including an examination of the Obers Test used to assess its role in lateral knee pain in runners. I summarise the detail of the studies here and link to the original paper.
Cadaveric anatomy
Subjects: 20 adult formalin fixed cadavers were examined (age: 79±12 years, height: 1.66±0.14m, body mass: 69.4±14.9 Kg) with University of Melbourne Human Ethics approval.
Methods: Limb alignment was assessed by measuring Q angle with <13° (male) and <18° (female) confirming a normal configuration. All limbs were fully flexed before positioning in the anatomical position. Deep dissection was performed to investigate the origin of ITB and the relationship to Tensae fascia latae (TFL), the location of the Gluteus Maximus insertion to ITB, the location of the longitudinal attachment of ITB to the linea aspera and the site of attachment of ITB to the lateral femoral condyle (LFC)
Findings: The ITB is in fact an integral part of the fascia of the leg, it is not a discrete structure. In all cases it was connected to the femur at the linea aspera from the greater trochanter by the intermuscular septum, to and including the lateral femoral condyle. We failed to demonstrate a bursae between the LFC and the ITB on a single cadaver. The TFL was completed enveloped in fascia its origins from the fascia latae of the iliac crest TFL inserting directly into ITB, behaving as an elongated tendon of TFL. A substantial portion of Gluteus maximus invests directly into ITB independent to the portion which invests to the greater trochanter. These findings are shown in cadaveric form in Fig.1
Fig 1. Dissected specimens of the iliotibial band on the left leg viewed posteriorly (A) The circumferential nature is demonstrated and the location of ITB. (B) The ITB is a lateral
thickening of the fascia latae rather than a discrete entity.
(C) The fascia latae dissected to reveal the intermuscular septum separating vastus lateralis (VL) from Biceps femoris (BF)
Cadaveric ITB Strain
Subjects: Five un-embalmed fresh-frozen cadavers ( age: 76±10.0 year, height: 1.74±0.008 m, mass: 73.4±18.6 Kg). All cadavers were thawed for 36h at 4° before testing.
Protocol: The cadaver was positioned in the anatomical position. The three tests performed are shown in the diagram below. The hip was maintained in the anatomical position by applying load superior to the greater trochanter on the contralateral limb external loading was applied to the knee by the examiner to force hip adduction using a manual muscle tester at 100N. All stretches were held for 30s, separated by 1 minute intervals. All limbs were treated independently. Detached fascia specimens subjected to controlled loading showed little evidence of plastic deformation.
Methods: Insulated, 10mm, 120Ω foil type microstrain gauges (BCM Sensor technologies, Antwerp, Belgium) were attached to the external surface of the ITB using a gauge specific cryanocylate adhesive (TML, Tokyo, Japan). Data was acquired at 50Hz via a USB based CompactDAQ, The strain acquisition protocol has been published by the authors elsewhere. The sensor was located 8cm proximal to the lateral femoral condyle. The peak strain measured during each test was determined using a custom designed Labview analysis program (National Instruments, Austin Texas)
Data analysis : Multiple Wilcoxon signed rank tests at a significance of P<0.05 were performed for each combination (SPSS, Chicago, Ill USA). The microstrain (me) values [median(IQR)] for OBER [15.4(5.1-23.3)me], HIP [21.1(15.6-44.6)me], and SLR [9.4(5.1-10.7)]. Analysis showed the HIP stretch demonstrated greater strain than the other trials as seen in Fig 3.
Fig 3. Strain measured in the ITB during the three different testing protocols.
*Significant ( p<0.05) increase in strain during the HIP stretch in comparison with the SLR and OBER.
OBER;Obers Test, HIP hip flexion, adduction and external rotation;SLR, straight leg raise
Most of the traditional treatments for ITBS re based on the premise of a bursae between the ITB and the LFC, an ability to stretch the ITB, and the development of friction between the ITB and LFC due to transverse movement. Our findings challenge these anatomical and pathological finding’s. Two common treatments focus on distal ITB and the putative bursae. The effectiveness of these interventions due to the absence of bursae and the low magnitude and disparate strain occurring during stretching.
A third part of this study, not reported here examined the movement of the musculo- tendinous junction of tensae fascia latae during a maximal voluntary contraction in athletes. This demonstrates that the ITB stretches minimally in a MVC ( 0.2% increase in length), the cadaveric strain work demonstrates in the absence of muscle tone the stretches exert little influence on the length of ITB. This supports the tensioning role of Gluteus Maximus and Tensae fascia latae
The findings of these studies reported here highlight the limited role lengthening of the fascial component (ITB) has in lengthening the TFL/ITB complex which may instead result from a decrease in stiffness of the muscular components.
So we can see that endlessly foam rolling the ITB can not only irritate the fat pad but compresses Vastus lateralis. Focussed soft tissue release should be directed at TFL and Gluteus Medius which act as a direct tensioning to the fascia but no role in the 'release' of the fascial band itself, which is adherent via a fascial investment to the femur along its length.
Source: Scand J Med Sci Sports. 2010 Aug;20(4):580-7. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options
Article 2: Found @ http://www.premax.com.au/blog/massage-versus-foam-roller-for-the-itb
The Iliotibial Band (ITB) has a poor reputation in sports and sports medicine. A tight ITB is often associated with sports injuries and problems such as iliotibial band friction syndrome and anterior knee pain. The ITB is however connective tissue. It doesn’t contract, or relax, and you can’t directly strengthen or lengthen it. So why do people feel better after foam rolling or massage to the area? And should you indeed be foam rolling the ITB at all?
The ITB is often thought to be a singular discrete structure, running from the Iliac crest (side of the pelvis), TFL and gluteus maximus muscles, down to attach to the lateral condyle of the tibia bone (lateral side of the knee). The ITB is actually a thickening of the Fascia Lata; stocking-like connective tissue that surrounds the entire upper leg. The ITB is also anchored to the femur (thigh bone) via the intermuscular septum (tissue between the lateral quads and hamstrings). Dr Andy Franklin Miller described this anatomy in more detail in a recent Linkedin post.
Picture: Iliotibial band anatomy
I hope I didn’t lose too many people with the anatomy lesson, however I feel that it’s important to understand the ITB is a passive structure that is influenced by the many muscles around the region – the TFL and glut max muscles that attach to it proximally, and the quadriceps and hamstrings that can pull and tug on the fascia lata which in turn can create stress and tension on the ITB. Weakness and/or asymmetry in any or all of these muscles, particularly combined with repetition (running and cycling) can contribute to problems with the ITB.
Typically, sports people and health practitioners will say that the ITB is “tight” and needs to be “released”. Massage, foam rolling, and dry needling are the most common forms of treatment/management for a “tight ITB” and all these treatments in my experience can work to an extent. But it can be hit and miss.
The reason these treatments can work is not by loosening or releasing the ITB; remember the ITB is connective tissue that can’t really lengthen (0.2% max). The treatments work by reducing tone in the adjacent muscles that contribute to ITB tension – the quads, hamstrings, TFL and gluteals. Muscles are being released (a better term is relaxed), and the most important of all these is the TFL.
A cliché I like to use often is “weak muscles get tight”, so the primary issue is usually a strength deficit, sometimes biomechanical, sometimes overuse, sometimes a combination, rarely flexibility.
The last point I’d like to make is that generally, connective tissue doesn’t like to be compressed. Think of having your Achilles tendon pinched for a few minutes, or kneeling on a hard surface for a while (patellar tendon). Foam rolling is a compression activity, and whilst it may help release tone and tension in the muscles, it can and does cause irritation of the ITB. I’ve had plenty of patients complain that they feel worse, not better when they foam roller the lower part of their ITB – just above the knee. There’s also a bursa in the area, and bursae don’t like being compressed either.
For all the reasons mentioned, I’d encourage sports people and health practitioners to stop heavy compressive treatments of the ITB, rather focus on relaxing muscles - especially the TFL and gluteals. Foam rolling these muscles is tricky and usually painful, so in my opinion, massage therapy is the choice modality for the TFL and gluteals, and in turn the best manual treatment to combat problems of the ITB.
References
- Falvey, E.C., Clark, R.A., Franklyn‐Miller, A., Bryant, A.L., Briggs, C. and McCrory, P.R., 2010. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian journal of medicine & science in sports, 20(4), pp.580-587.
About Randall Cooper
Randall is an experienced sports physio who consults at the Olympic Park Sports Medicine Centre in Melbourne, and is a fellow of the Australian College of Physiotherapists.
