ITB: Don’t let one study deter you from work on this area —Art Riggs

This is part of a series of articles discussing the implication of a cadaver study which found that ITB cannot be stretched.

What an interesting subject!  I appreciate and agree with most all the comments of your experts, but after reinforcing some of their statements, I’d like to take a more informal approach to some of the broader issues that we therapists must deal with in interpreting and implementing research studies into our practices and offer a few strategies for work.

Of course I agree with the comments questioning the validity of conclusions about the stretching ability of the ITB from embalmed cadaver studies, and that even if it does not stretch appreciably, that benefits from manual therapy to the ITB can still be achieved and may be due to many other factors such as neuromodulators, trigger points, or release of adhesions.  I particularly liked Joe Muscolino’s caveat against extrapolating manual therapy strategies from isolated studies, along with his pointing out that fibrous tissue has different qualities besides just ability to stretch.  I’ll add my skepticism of jumping to conclusions from purported “evidence-based” research implying that manual therapy to the band is ineffective and that treating ITBS, “…can only (my emphasis) be properly achieved when the biomechanics of hip muscle function are properly addressed.” Such exclusionary and simplistic implications that stretching and manual work on the ITB is not productive would short-change creative analysis and treatment of a complex situation that our clients desire.  I would also suggest a more complex “chicken/egg” feedback loop, where the increased tension and especially pain of ITBS can cause dysfunction of muscles and joints rather than just being a result of their dysfunction.

The narrow conclusions and implications of treatment of the article remind me of other controlled cadaver studies stating that the SI joint is immovable, and quibbling over distinctions between “true” sciatica and apparent “false” sciatica that seems to discount overlap in symptoms and effective treatment.

Of necessity, careful evidence-based research must isolate factors, both of anatomy, symptoms, and treatments.  But inference from the study that defines and limits ITBS symptoms as lateral knee pain and implies that since the ITB can’t be stretched, attempts to lengthen are useless, is an example of the pitfalls of improper inference from isolated facts, especially in brief summaries or abstracts.

Abstracts and capsulized summaries often neglect many important descriptions of the methods and conclusions of the studies. A famous comic quipped, “I used speed-reading for Tolstoy’s War and Peace and it only took 45 minutes!!!…..It was about Russia.”  More studied reading of the studies and comments from other researchers exemplify the importance of more careful reading and consideration of experiments and data.  As a brief example, the measure of stretch was performed only with tension devices placed 8 cm proximal to the lateral condyle of the knee—questionably an accurate measure of the complex activity of movement of the ITB during activity.

What is the ITB?  It is valuable that the authors point out that it is not a discrete anatomical entity but a thickening of the iliotibial tract or fascia latae.  So extrapolating causes and treatment from isolated measurement of the ITB seems “a stretch” of throwing the baby out with the bathwater.  ITBS would seem to be much broader in scope and this exemplifies the importance of semantics when anatomy makes its way into everyday speech by laymen.  We see this in many other popularizations and simplifications of anatomy. For many people the “glutes” seem only to refer to gluteus maximus rather than the complicated weave of all the posterior pelvic muscles.  To the public, the term “abs” refer only to rectus abdominus rather than the complex relationship between the internal and external obliques, and transversus abdominus, as well as deeper abdominal muscles.

Attempting to isolate the ITB from the more accurate complex of the iliotibial tract and muscular and fascial connections that go both distal to the knee and ascend past the pelvis seems misleading.  I think the more functional term “lateral line” used by Ida Rolf, Tom Myers, James Earls and many other structural integrator is much more useful and helpful for planning strategy, and henceforth I will speak to the issues of the term “ITB” with this broader definition.

Pain along the lateral line also seems much more extensive than just lateral knee pain caused from running and other athletic endeavours mentioned in the article; albeit the information that a bursa often does not even exist was very interesting. Many people, including non-athletes report considerable pain on the entire length of the lateral line.  I would suggest that a tight and misaligned lateral line may be associated as both a cause and effect of strain patterns descending to foot balance and plantar fasciitis, and ascending upwards to hip and low back pain and stress patterns.

Also, although the lateral line does indeed act like a tendon in contraction of the TFL and gluteus maximus, it is not a tendon and has different cellular composition with properties of collagen and fascia with a capacity to alter its texture in response to manual therapy.   Its role is not simply to exert force on the knee joint like a Newtonian physics pulley. In many ways it acts like a postural muscle to enable standing without muscular contraction, providing lateral stability, and has the important role of dissipating and distributing shock from foot plant.  When stress is applied to the lateral line it actually recoils like a spring to augment muscular contraction from above and increase spring in walking and jumping.

 

Moving Beyond the Study to Applications

Since ITBS is so common, I’d like to move beyond the “science” of an isolated study to discuss some issues for treatment.  Let’s face it… it is very common for clients to come to us seeking manual work with complaints about pain in the lateral line and reporting benefit from manual therapy that go well beyond what would be expected from a placebo effect.  We need to be able to work with this issue with understanding and skill.

Alignment of stress through joints and tissue by minimizing torsional strain is at least as important as simple stretching. Effective therapy should consider global issues of joints, fascia, transmission of shock, and the differences in the structure of individuals. A good structural integration approach should consider among others: varus/valgus knee patterns, internal/external femur rotation, anterior/posterior pelvic tilt and stress from factors in feet in pronation/supination and inversion/eversion.

Addressing ITBS causes and treatments

Manual therapy along the entire lateral line in combination with frequent and consistent home programs is an excellent plan, but it is crucial to recognize that alignment of torsional forces is equally important. A tight and painful lateral line can be reacting to very different body structures and activities since tissue and structure thicken according to strain patterns. Assessment of these patterns is crucial for treatment instead of one-size-fits-all unimaginative strokes.

Shock transmission:  A varus (bowlegged) knee and a high arched foot in impact related activities will send shock up the lateral aspect of the leg causing thickening of the entire area including vastus lateralus. Working with the feet for more balanced foot plant by mobilizing the lateral and medial arches to dissipate shock is often helpful along with attention to the adductors and medial leg for lateral/medial leg balance.

Strain and overwork of the lateral leg due to valgus knees (knock knees) or over-pronation presents a different problem.  This is often a hyper-mobility issue, and soft tissue work would be considerably different from the previous example.  The lateral compartments may be compensating in a productive attempt to provide stability, so stretching the ITB may be counter-productive.  This is not to imply that thoughtful work on the area should be skipped, but the goals would be to increase circulation, free adhesions, work with trigger points and to work with alignment of the knee and hip. Rather than working to lengthen the ITB, cross-fibre work to break down adhesions and promote tissue health and decrease inflammation would be more effective.

Proximal strain patterns:  As the authors note, strain on the ITB is often created from above the knee.  Working with gluteus and TFL as described later can be very beneficial. In addition to lengthening and softening these tight muscles, enabling them to glide over deeper tissues by freeing their anterior and posterior borders with precise compartment separation strokes so they may exert force in a direct line depending upon hip flexion or extension.  Visualize rolling the muscles from side to side in different positions of hip flexion, paying attention to any possible bias for restrictions on each side.

More global issues: Don’t be too muscle specific in treatment; consider broader factors that may influence strain and torsion upon the hip, knee, and feet, including looking at broad fascial strain patterns that may transmit over several body segments. Shoulder carriage, tight lumbar fascia, quadratus lumborum, or hamstrings that are associated with pelvic tilt can significantly improve distribution of strain.

Clarity in intention with touch

The key to softening, lengthening, and aligning fibrous tissues is to grab and stretch the tissue rather than just sliding over it and compressing it. Use lubrication sparingly to enable a good grip and stretch on whatever layer you are working on.  The biggest complaint I hear is from too aggressive and painful work.  Almost always it is a result of two factors:  First, working too fast so tissue does not have enough time to melt and cooperate; this actually can result in a rebound that counters your attempt to promote lasting release.

Second, working too vertically and painfully compresses the ITB and other fibrosed tissue against the femur. This is the same drawback with foam rollers that several others mention. We are trying to elongate and align tissue, not squeeze and compress.  The only force necessary is to slowly sink into whatever level you wish to free, then to grab without sliding and then apply force distally  (rather than proximally since compression from activities “jams” the tissue upwards) at a very oblique angle while also working for alignment.

It is crucial to have clarity on your intention and techniques rather than just performing rote strokes without consideration of the depths of restriction. Different layers should be able to slide over each other. I teach the following examples in detail in classes, but limitations on space prevent that now.  They are not intended as specific directions but as a conceptual way of working.

Free, align, and lengthen superficial fascia before addressing deeper layers , so it can slide over the fascia lata and consider fascial restrictions above and below the area of lateral pain.  Work with broad and soft touch using fingers or palms of the hand to feel the superficial fascia glide over the facia latae. This can be done in neutral positioning, but adding stretch to the entire complex can be accomplished by adducting the leg across the midline.  Examples here demonstrate the supine position and a more aggressive stretch having the client in side-lying assisted by gravity with the leg extended and hanging off the table.

After working superficial fascia, sink to the next layer and very slowly “iron” the entire fascia latae by grabbing and sliding with it for length and direction, feeling for wrinkles and thickening and waiting for the tissue to melt. Pin and stretch strokes are an effective strategy using a soft forearm or fists.  Rather than just working in a neutral position, lengthening the lateral line by body positioning when working is also very helpful add stretch.

 

Free and clarify anterior and posterior borders of the ITB  by “compartment separation” strokes. Notice if the band seems restricted on one side more than the other and clarify the boundaries with precise strokes .

Free large groups of muscles and fascia to slide over deep layers, including the femur.  Free the lateral line to slide over the deeper vastus lateralus and then roll the whole quadriceps group and lateral compartment around the femur, paying attention to whether if presents a bias to move medially or laterally and working to help it pull in a straight line from the hip to the knee. Grab the entire complex to slide and rotate over deeper tissues and, in turn, visualize sliding all layers to roll around the femur where they seem “stuck” to the bone. (Figure 6).

 

Soften and elongate the muscles that attach to the ITB, but pay particular attention to freeing them from adjacent or deeper restrictions.   Perform muscle separation strokes along anterior and posterior border of the TFL which may be exerting torsion from adhesions along the anterior or posterior border.  “Roll” the muscle using precise pressure with a fist or knuckles so it can work freely in different degrees of hip flexion and extension. Also work along the borders of the gluteus maximus, especially at fibrous build up at its lower attachment and to free it to slide easily from adhesion to the deeper rotators .

Home Exercise

ITBS needs frequent incremental work; it seems unrealistic to create beneficial change by treating every week or two. Trying to make up for lost time between treatments can result in over-aggressive treatment that can increase symptoms. A home program is essential. As others mention, I’m not a big fan of the foam roller although it certainly seems to be popular. So it may be a worthwhile approach for some people, although I think other options are more effective and humane.  One limitation with the foam roller is that it is difficult to work in tangential directions (the ball that Bob Baker mentions can solve this and also allows for different levels of inflation to not be painful.) Foam rollers present an all-or-none situation by having all of one’s weight on the roller which is often too intense for a painful ITB, and can also require a fair amount of strength in the shoulder girdle to move the body and maintain a side-plank yoga posture and create back strain.  Too aggressive and perpendicular manual work using excess lubrication that prevents grabbing tissue has the same drawback.

The biggest drawback to the roller is that it only compresses tissue (picture a tire rolling over soft ground and leaving an imprint) rather than the all-important stretching and alignment that are beneficial. For this reason I recommend using a stick of some sort that allows for different directional vectors, variation in pressure, access to adjacent tissue such as lateral hamstrings or quadriceps, and especially, the ability to grab and stretch tissue approximating manual work rather than just compressing.

In the following example, the client is using a Theracane which allows for pinpoint pressure to trigger points from the hip down the entire leg and of course anywhere else on the body. It is also useful to create balance with the adductors while comfortably sitting in a chair.  Almost all clients I show this technique to feel it is far more effective and easy to tolerate than foam rollers.

  

Good luck!  And don’t let one study deter you from work on this area.  Clients want and appreciate work whether for ITBS or just to ease strain and tension.  Properly performed manual work on the lateral line not only is helpful for treatment of ITBS, but feels worthwhile and actually pleasant to most everyone.

 

Art Riggs is a certified advanced Rolfer who has been practicing and teaching in the San Francisco Bay area and internationally for over more than 20 years. His graduate studies were in exercise physiology at the University of California in Berkeley. He is the author of Deep Tissue Massage: A Visual Guide to Techniques, now in a second edition and translated into five languages, and the seven volume companion DVD set.  He just  released  a new “Deep Tissue Massage-A Full Body Integrated Approach”  DVD set.

 

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