You're standing in the middle of a crowded gym struggling to finish your 3000th repetition of a small squat motion. The smooth round bar feels like a razor sharp edge because four times your body weight is resting on your shoulders. You think "just one more rep" as you knees struggle through the fifteen degrees of motion.
Sound outrageous? Think you could do it? Well, just try running 3 miles and your body will experience the same degree of force. In one mile of running, the foot hits the ground over 1000 times and with each strike sends a shock up the leg equal to nearly four times body weight force. Every joint, muscle and tendon in your lower body and spine kicks in to share the load. But as the run stretches on, the load sharing begins to shift as muscles tire, joint surfaces compress and tendons stretch.
Over 21,000 people are diagnosed with Iliotibial Band (IT Band) Syndrome each year. The explanation for the burning pain found on the lower and outside of the knee is that the IT Band rubs on the end of the femur. The rubbing creates friction which irritates the soft tissue creating an inflammatory reaction and pain soon follows. The conventional wisdom is the IT Band is too tight. The tightness causes the friction so the solution is to stretch. By making the IT Band looser, there will be less friction or so the thinking goes.
But what is friction anyway? Friction occurs when two surfaces come in close contact and develop resistance as one element moves over the other. The IT Band is in close contact with the end of the femur and even has some padding between it and the femur in the form of a bursa. The function of the bursa is to reduce friction. This implies that the IT Band is normally very close to the femur and in fact rubs on it whenever the knee moves. So, rubbing is not the problem. It's actually an increase in pressure.
Does the increase in pressure (which increases the friction) result from an IT Band that is too tight? Does the length of the structure influence the pressure on the lower end and side of the femur? If the IT Band is too tight, does it actually move closer to the femur? If so, how? If I attach a rope to each end of a stiff rod and slowly tighten the rope, the rope will at first move closer to the rod but as I continue tightening the rope, the movement is less and less. The tighter it gets, the less it moves. The reason is that the tightening occurs in a straight line not in a curved line. The rubbing comes from the femur moving underneath the IT Band and is not related to the relative tautness of the IT Band. It is from the femur sliding against the bursa for too long. The femur is rotating inward too much as the foot hits the ground and the weight moves over the leg. The combination of the weight of the body with a rapid inward rotation of the femur step after step sets the stage for an angry IT Band.
So what is the solution? Well, first we have to know what the problem is before we can solve it. In this running case, the IT Band Syndrome is the result of excessive pressure. In runners with IT Band Syndrome, the gluteus medius is often quite weak and the IT Band is often tight (Quick Solutions for Iliotibial Band Syndrome Michael Fredericson, MD; Marc Guillet, PT, ATC; Len DeBenedictis, MS, CMT THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 2 - FEBRUARY 2000). Because of the notion that the IT Band tightness causes the friction, stretching is usually suggested. But stretching the IT Band is first of all virtually impossible (more on that in another View) due to its size and thickness and secondly does not address the rotation of the femur. The IT Band is an internal rotator of the hip while the gluteus medius is an external rotator. The gluteus medius decelerates the inward rotation of the femur as the foot hits the ground. To reduce the pressure of the IT Band on the femur, this muscle (along with the muscles of the rotator cuff of the hip) must do its job. As the gluteus medius slows the rotation effectively countering the rotation produced by the IT Band, the "rubbing" decreases as does the pressure. Remember, it’s not just the friction that is the problem; it is the magnitude of it. The solution is to then retrain the external rotators of the hip to do their job.
Next week, I'll explain how to test the hip rotators in a weight bearing position along with suggestions of how to retrain the muscles. These two pieces of information will make dramatic changes in your clients and reduce frustration with the stubborn IT Band.
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