Iliotibial Band Syndrome

Introduction

The Iliotibial band (or IT band) is an extension of fibrous fascia that extends from the top of the plevis, down the side of the leg, and attaches to the lateral aspect of the knee. The IT band is involved in flexion and extension of the knee, and as a result, is a key player in activities such as running, cycling, weight-lifting (especially squats), and hiking.

It is commonly injured in runners. Especially those that have increased distance recently or amount of training. The IT band rubs against the tibia during knee flexion and extension, and thus becomes inflammed after repetitive movements. Pre-disposing factors include old shoes, and excessive heel wear, running in the same direction on a pitched surface, leg-length discrepancy, and lack of stretching (or warm up before stretching).

Signs and symptoms of IT Band Syndrome Include:

1. A sharp pain over the lateral femoral condyle posteriorly
2. Pain that starts half-way through a run
3. Hypertonic muscles and trigger points found in tensor fascia lata, quadriceps, and hamstrings
4. Weak hip abductors
5. Increasing pain on running or walking when the foot strikes the ground

Treatment:

Activites that aggravate the condition should be curtailed or avoided completely. If actively inflammed the RICE method of treatment should be in the fore-front (Rest, Ice, Compression, Elevation).

In the long term, orthotics can be prescribed to help improve the mechanics of the feet and to reduce stresses on the knee joint. Soft-tissue therapy, aimed at the aggravated muscles, including the IT band, can help with any residual tightness exhibited. Proper stretching should be done for the IT band, including a proper warm up before any activity or stretching is done. Shockwave treatments and/or laser can help with the healing process. A rehab program will address muscle weakenss in the hip abductors (gluteal muscles), as well as strengthening the quadriceps and hamstrings.

The following is a good stretch for the IT band. But make sure the tissue is warm before proceeding to do so. A hot towel placed on the tissue can help warm it up, or you can also do something like 20 jumping jacks, to help warm up the tissue.

1)Stand upright
2)Cross the involved leg BEHIND the opposite leg
3)Lean to the uninvolved side until a stretch is felt across the affected iliotibial band
4)Hold for 30 seconds
5)Repeat X 5

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Ankle Sprains Demystified

Typical mechanism of an inversion-type sprain of the ankle is stepping on an uneven surface (i.e. another foot). Ankle sprains are, by far, the most common sports injury. The good news is that most will almost inevitably heal within 4-6 weeks, and most show modest improvement within 2 weeks. Most commonly, ankles are sprained as a result of sudden movements such as twisting. All it takes is one awkward step, an uneven surface, or jumping and landing on another foot, that can set a barrage of symptoms into motion. It is common in sports such as basketball and volleyball when the players comes down from a jump and lands on another player’s foot. The pain results from injury to the ligaments of the foot. These ligaments are responsible for helping the joints and bones of the foot and ankle maintain stability and to prevent excessive movements. There are two main categories of ankle sprains.

1. Inversion Ankle Sprains

If you were to bet on the type of sprain, put your money on this one. Almost 90% of ankle sprains are inversion sprains. Pain is on the outside of the ankle and there is usually no pain inside of the ankle joint. There is also limited and painful dorsiflexion. The main ligament involved is known as the anterior talofibular ligament (ATFL).

2. Eversion Ankle Sprains

The other type of sprained ankle is called an eversion injury, where the foot is twisted outwards. When this occurs, the inner ligament, called the deltoid ligament, is stretched too far. Patients will have pain on the inner side of the ankle. The deltoid ligament is one of the strongest in the body, and often a fracture is present if this ligament is torn.

Commom Symptoms of Ankle Injury

There are 3 different grades of sprains, which have to do with the amount of damage to the ligaments.

Grade I: Grade I ankle sprains cause minor stretching of the ligament. The symptoms tend to be limited to pain and swelling. Dorsiflexion of the ankle is also painful. Generally tendons of the calf muscles become irriated, and should be addressed. Sometimes the joints of the ankle can also become immobile and locked.

Grade II: Grade II ankle sprains are more severe and involve partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. Patients usually have pain with walking, but can take a few steps.

Grade III: Grade III ankle sprains are complete tears of the ligaments. The ankle is usually quite painful, and walking can be difficult. Patients may complain of instability, or a giving-way sensation in the ankle joint.

Pain and swelling are the most common symptoms of an ankle sprain. Patients often notice bruising over the area of injury. This bruising will move down the foot towards the toes in the days after the ankle sprain--the reason for this is gravity pulling the blood downwards in the foot.

Do I need to see the doctor if I have an ankle sprain?

If you do have significant symptoms following a sprained ankle, you should seek medical attention. Signs that should raise concern include:

• Inability to walk on the ankle, for 4 steps or more
• Significant swelling
• Symptoms that do not improve quickly or persist beyond a few days
• Pain in the foot or above the ankle
• Sometimes an x-ray is needed to differentiate between a sprained ankle and a fracture. While moderate pain and swelling are common symptoms following a simple sprained ankle, symptoms such as inability to place weight on the leg, numbness of the toes, or pain that is difficult to manage should raise concern. If you think you may have done more than sustained a sprained ankle, you should seek medical attention.

What is the treatment of a sprained ankle?

Treatment of sprained ankles is important because returning to normal activities in a timely manner is important for most patients. Early treatment of a ankle sprain is the "RICE" method of treatment. If you are unsure of the severity of your ankle sprain, talk to your doctor before beginning any treatment or rehab. The following is an explanation of the RICE method of treatment for ankle sprains:

Rest:

The first 24-48 hours after the injury is considered a critical treatment period and activities need to be modified. Gradually put as much weight on the involved ankle as tolerated and discontinue crutch use when you can walk with a normal gait (with minimal to no pain or limp).

Ice:

For the first 48 hours post-injury, ice pack and elevate the ankle sprain 10 minutes at a time every 20 minutes or so, for 3-4 hours. The ice pack can be a bag of frozen vegetables, allowing you to be able to re-use the bag. Do NOT ice a ankle sprain for more than 15 minutes at a time! You will not be helping heal the ankle sprain any faster, and you can cause damage to the tissues!

Compression:

Use compression when elevating the ankle sprain in early treatment. Using an Ace or tensor bandage, wrap the ankle from the toes all the way up to the top of the calf muscle, overlapping the elastic wrap by one-half of the width of the wrap. The wrap should be snug, but not cutting off circulation to the foot and ankle. So, if your foot becomes cold, blue, or falls asleep, re-wrap!

IMPORTANT NOTE: Please remove footwear. I've witnessed people instructing shoes to be kept on during an acute ankle injury because 'it prevents swelling'. This is FALSE and shoes should be removed. If the ankle swells too much with the shoe on, it could cut off circulation and make your life more difficult. And furthermore, you need more direct contact to the area in order to ice it.

Elevate:

Keep your ankle sprain higher than your heart as often as possible. Elevate at night by placing books under the foot of your mattresses--just stand up slowly in the morning. Later, treatments involve addressing the muscle and joint issues with soft tissue treatments and an active rehabilitation program, focussing on proprioception. Laser is a modality which can help patients deal with pain and promote faster healing of the injured ligaments. Mobilizations and adjustments of the ankle joint can help promote tissue healing and create optimal mobility within the ankle complex, should mobility be compromised as a result of injury.

Ankle Braces:

One of the best pieces of experience that I can share has to do with ankle braces. They are an excellent way to compress and protect the ankle after an injury, but more importantly, can be used to help prevent you from rolling over on your ankle in the first place. I would suggest anyone who is involved in any sort of sport whereby ankle injuries are common, to invest in a pair of ankle braces. They are very much worth the effort and can save you a lot of trouble in the end.

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References:

Wolfe, MW, et al. "Management of Ankle Sprains" Am Fam Physician 2001;63:93-104.

Osborne MD, Rizzo TD "Prevention and treatment of ankle sprain in athletes" Sports Med. 2003;33(15):1145-50.