IBS ruined my spring break :(

[Margaret Snyder]

No not THAT IBS! Iliotibial band syndrome has struck me in my tracks, forcing me to abort my Gila Wilderness loop. This is the scoop I got off Wikipedia. Does anyone else have experience with this knee problem?

Definition

Iliotibial Band Syndrome is one of the leading causes of lateral knee pain in runners. The iliotibial band is a superficial thickening of tissue on the outside of the thigh, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, moving from behind the femur to the front during the gait cycle. The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed, or the band itself may suffer irritation.

[edit] Symptoms

Iliotibial Band Syndrome symptoms range from a stinging sensation just above the knee joint (on the outside of the knee or along the entire length of the iliotibial band) to swelling or thickening of the tissue at the point where the band moves over the femur. The pain may not occur immediately during activity, but may intensify over time, especially as the foot strikes the ground. Pain might persist after activity. Pain may also be present below the knee, where the ITB actually attaches to the tibia.

ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury. It commonly occurs during pregnancy, as the connective tissues loosen and the woman gains weight — each process adding more pressure. ITBS at the hip also commonly affects the elderly. ITBS at the hip is studied less; few treatments are generally known.

[edit] Sports Activities to Avoid while Symptomatic

* Stair stepping
* Dead lifts or squats
* Court sports, such as tennis, basketball, or similar
* Martial arts, such as karate (especially where being bare foot emphasises any symptoms being caused by leg/foot abnormalities)

[edit] Causes of Injury

Iliotibial Band Syndrome is the result of poor training habits, equipment and anatomical abnormalities.

Training habits:

* Running on a banked surface (such as the shoulder of a road or an indoor track) bends the downhill leg slightly inward and causes extreme stretching of the band against the femur
* Inadequate warm-up or cool-down
* Increasing distance too quickly or excessive downhill running
* In cycling, having the feet "toed-in" to an excessive angle
* Running up and down stairs

Abnormalities in leg/feet anatomy:

* High or low arches
* Overpronation of the foot
* The force at the knee when the foot strikes
* Uneven leg length
* Bowlegs or tightness about the iliotibial band.
o Excessive wear on the outside heel edge of a running shoe (compared to the inside) is one common indicator of bowleggedness for runners.

Muscle Imbalance:

* Weak hip abductor muscles

[edit] Treatment

As with any injury or ailment, one should see one's physician, physical therapist, chiropractor or athletic trainer for diagnosis and treatment.

For a runner with acute ITBS, reduce weekly distance training to 50% for 2 weeks, and only run on flat ground. After, in the absence of ITBS pain, slowly begin to build distance again. If ITBS pain remains or is chronic, one should stop running immediately for two weeks (minimum). If the pain and inflammation are still present, another month of rest may be needed. Once the injury begins to improve, resuming activity can be possible, doing low distance, low speed jogging on flat terrain. Also, changing one's route may help counteract re-injury, as running a common route may put increased stress on the iliotibial band of one leg.

To prevent, or cure chronic ITBS there are some essential exercises:

* Strength building of the hip abductors (especially the gluteus medius), which control ITB tightness
* Performing specific stretches; Iliotibial band stretch, stretching the gluteal muscles, and other leg based static stretching

To create a good treatment program, proper assessment of injury severity is critical. Once the injury has been properly assessed, a treatment program (usually consisting of three steps) can be planned. The length of time spent on each phase varies depending on the athlete, the reasons for the initial injury, and the severity of the injury.

[edit] Immediate Treatment

After noticing symptoms, the important task is controlling pain and inflammation. For these symptoms, RICE works well. Stretching is second in importance, to make sure that the iliotibial band does not become taut. Next, examining what may have caused ITBS is important. Issues range from poor training habits to structural abnormalities, but the shoes a runner uses are another consideration. For example, after 500 miles most shoes retain less than 60% of their initial shock absorption capacity, increasing the chance of ITBS injury. Lastly, anti-inflammatories or ultrasound may be helpful to relieve symptoms.

[edit] Short Term Treatment

If the pain and inflammation do not subside, all painful activity should stop while continuing immediate treatment. A regular stretching regimen is important. A video analysis of running movements may provide insight into problematic running mechanics. To retain fitness, a number of options will work at this stage, as long as they do not promote pain. Altering these exercises will minimize overtraining:

* Swimming, though abstain from the breaststroke as it may aggravate symptoms
o Optionally, wearing a life jacket, one may run in the pool (depth allowing)
* Cycling, though with care, as it may aggravate symptoms
* Speed walking, especially straight-legged to discourage pain
* Cross-country skiing
* Yoga, or similar low-impact aerobics

At this stage, steroid injections may be helpful, though some risks are involved.

[edit] Long Term Treatment

The last phase is only started once pain and inflammation are gone. Often, this phase involves returning to a normal state, even competitive sports. Though, at least these criteria must be satisfied:

* The injured knee has regained full range of motion without pain
* The injured knee has regained normal strength compared to the uninjured knee
* Cardiovascular endurance has normalized

Most importantly, one must ensure that old symptoms do not recur. Thus, any pain or inflammation must be treated cautiously, especially if the ITBS was serious and involved a lengthy downtime. The return process must be gradual and treated with extreme care, structurally specific stretching during this time is essential and must be done extensively, before and after activity. Returning to activity should be done while correcting, or significantly reducing, any factors that were thought to have caused ITBS. If no factors are identified and corrected, the chance of the re-injury is much higher.

Rarely, and only in extreme cases, surgery is used to correct the injury. Typically, unless one is still suffering from symptoms in 6-12 months, surgery is not performed. It involves the release-excision of the iliotibial band, performed after an arthroscopic evaluation of the knee, which rules out other causes for the symptoms. Only patients unwilling to adapt their exercise because of this injury undergo surgery; it should only be performed after all other treatments have failed.

[edit] Rehabilitation

[edit] After the Pain is Gone

* Continue stretching, as well as strengthening of the leg muscles.
* The patient should start running only after treatment.
o Restart running with small distances, building slowly.
o If the patient feels pain, he or she should stop.

[edit] Some Rehabilitation Options

* Deep-tissue massage, Active Release Technique ("ART") or Rolfing may help break up scar tissue that forms.[citation needed]
* Non-steroidal anti-inflammatory drugs (aka NSAIDs), in high doses for a period of weeks, can help reduce inflammation but should not be used as a long term solution.
* Strengthening exercises for the quadriceps femoris and gluteus medius muscles can help support the leg, thus lessening the load on the ITB.
* Glucosamine Sulfate and Chondroitin Sulfate may help.

[edit] Example Physical Therapy Regimen

For successful rehabilitation, it is essential to restore the flexibility of the iliotibial band, and the strength and flexibility of the muscles which act upon it. Stretching the band is a complicated task; before the band can stretch, the hip flexors must stretch.

To prepare for ITB stretching, one may heat the lateral thigh with hydrocollator packs for a period of time, typically twenty minutes. This is followed by ultrasonic heating (1.5-2.0 watts/cm²) to the length of the ITB tract for 5-7 minutes. After one stabilizes the pelvis while another person (qualified therapist) stretches the leg to maximally tolerated adduction. This may be repeated using three 1-minute stretches. Cryotherapy of the painful and inflamed tissue for ten minutes in the stretched position is also effective. (Gose, 1989)[2]

[Greg Mihalik]

What are your symptoms?
Who diagnosed you?
What did they suggest?
What have your tried?

[Margaret Snyder]

I haven't yet been to the doctor, but the army medic I was hiking with suggested this was my problem. On downhills I was getting a sharp pain on the outside of my left knee. On uphills it didn't hurt. Then my right knee hurt over the right side of my kneecap from compensating for my left leg. Thank god for trekking poles! I stopped hiking Monday and the pain started to subside yesterday. But now my calves are cramped from hobbling along those last 4 miles Monday and then driving for 4 hours Tuesday. I've been stretching my calves today and am trying to get to a doctor this afternoon.

[Ryan Luke]

Margaret,

If you have access to an athletic trainer, they are always a great resource. This problem is extremely common in athletes (I speak from experience).

I don't know how you would go about locating an athletic trainer in the private sector–I am a Ph.D student in Kinesiology, so I have always had easy access to athletic trainers in the past.

Hope this helps.

[Margaret Snyder]

I have an appointment with a sports medicine doctor this afternoon. I'm a grad student, so I have free health care on campus, thankfully.

[Greg Mihalik]

The typical drill is NSAIDs, ice therapy, and perhaps curtailing activities. Control the inflammation, encourage blood flow, give it a rest.

Then, stretch the ITB.

Watch a PT glide back and forth on a firm 6" foam roller to stretch the ITB. It is excruciating. If you don't see it you won't believe it is possible.

Eventually you'll get past the 10 second mark to a 15 second stretch. In a week you'll be up to a minute, three times. It works. You just have to do it. Every day. Forever.

Oh yea… do the other side too.

The good news is that this is usually easy to fix.
And way better here and now than 15 miles in.

[Mike W]

…

[Anonymous]

Margaret,

This is obviously serious since it caused you to cancel a trip you have prepared for with extensive planning. Why mess around with self-diagnosis. Ask for a referral to an orthopedic surgeon who has a knee and ankle fellowship on his C.V. and does nothing but knees from dawn till dusk. I would stay away from physical therapists, sports medicine practitioners and anyone else but someone with the above credentials and a reputation for respect in his medical community. Let him make the diagnosis and recommend the proper treatment.

[Margaret Snyder]

I wish I could, John. My student health insurance only allows me to go to campus medical services. Luckily I go to the University of Arizona, which has an excellent health center and hospital. I saw 2 docs this afternoon and the consensus was IBS in my left knee and PPS (patellofemoral pain syndrome) in the right. I have a plethora of stretches to do now to help strengthen both knees.

Interestingly, the PPS comes from under use of the inner quad. When we hike mostly the outer quad is used so the inner quad's connection to the kneecap is prone to inflammation and irritation.

Hopefully, the stretches and exercises will prevent a recurrence of this injury. I'll continue to use them in my normal exercise routines. I'm planning to PCT it next year and want to get in tip top hiking shape this year.

[Greg Mihalik]

"Interestingly, the PPS comes from under use of the inner quad. When we hike mostly the outer quad is used so the inner quad's connection to the kneecap is prone to inflammation and irritation."

Maybe…. but PPS is typically the result of the patella tracking to the outside of the femoral groove (the patella femoral interface – see above), from a lateralis that is overpowering the medialis.

The medialis is quite happy to slack off and not contibute to balancing the patella's path. And when there is inflammation anywhere in the knee it typically just quits. It doesn't play well with others.

Hence the specific exercises to get it involved once again. Cyclists develop massive(balancing) medialii through lots and lots of strength work for just this reason.

Beware of the orthopedic surgeon who suggests a "lateral release" – surgically severing the lateralis from the patella so the medialis "can do its job". Run (limp) away as fast as you can.

You should see results in about a week. If not, find someone else who is performance oriented.

[Margaret Snyder]

Just wanted to say thanks for all who suggested exercises and such to me when my knees gave out. They're feeling much better and I was able t walk 2mi continuously with no pain yesterday! The best exercise IMHO has been the 1/4 wall squat where you squeeze a ball between your knees to strengthen the inner quad. When I started I could barely do 30sec now I'm up to almost 5 min!

thank you thank you thank you

[Jay Wilkerson]

Lunges on a half-ball- really will increase your strength and range of motion. See a personal trainer and talk to him/her about knees. I have played two professional sports and have rehabed both my knees over the years. Lunges on a half ball have done wonders for me. Highly recomened.

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