ITB: Empirical evidence is the reality—Robert Baker

First, I want to say – great questions and comments. It really is confusing when you have such well-done studies like Falvey et al. that present good information that the ITB stretches minimally in cadavers.

My response is that the clinician gets to choose what works and what does not work. The empirical evidence is the reality. If you use a foam roller and use soft tissue techniques, both the patient and you will know what works. Perhaps the first challenge is helping clients discriminate change in the short and medium term, with a long term strategy. Both the foam roller and hands on techniques will likely move Substance P and other neuro-modulators so a short term pain reduction may be present. Now if pain is a factor in increased tone in soft tissue, then perhaps the overall tone of the entire region may reduce. It may also be true that kinematics improve, and muscle activation changes as pain is reduced. So, the treatment session includes questions about pain reduction, and perhaps observations of gait, step down at 6 inches (15 cm) and maybe other functional tasks. So this clinical assessment of pain and function and duration of change are key areas to understand empirical outcome.

From the research perspective, there is evidence that ITB length does occur with stretching1.

I have never seen a research project that tested foam roller. However the physiological concept is moving neuro-modulators, and traditional tack and stretch soft tissue methods that we use with our hands and instruments. In the literature, I think expert opinion favours hands-on techniques2. Conceptually, one soft tissue deficit is the bow string effect of the vastus lateral and biceps femoris that I referenced in my review paper. In this case you are trying to normalize the interface between the adjacent soft tissues to reduce that stress among those structures. Another conceptual approach is to look at the overall tone of the soft tissue including the gluteus maximus and TFL to ITB connects. This is based in part on the recent work of Carolyn Eng and colleagues3 looking at the ITB as an energy absorbing structure in swing phase and delivers energy back in stance phase. So in effect, you are normalizing the tone of the ITB as a musculoskeletal structure interacting with the biceps femoris, vastus lateralis, and perhaps other muscles that affect running stride.

The point that I am suggesting is that the ITB functions as more than a physical constraint to the lateral knee and femur. It likely has a proprioceptive role, and may even contribute energy to help running economy. The role of soft tissue mobilization may be to promote better tone among the related muscles, and reduce pain caused by neuromodulators, trigger points and perhaps adhesions to nearby muscles. If you are looking at improved kinematics by better muscle performance, then the issue of a length change in the ITB is more an academic debate than a primary focus. The soft tissue work readies the muscles to work within their capacity in a pain reduced and overall healthier environment.

Muscle contractions and joint kinematics are the factors to treat. So your body work is trying to assist in muscle performance: well timed, appropriate duration and well balanced. The soft tissue work aims at normalizing muscle tone to improve muscle performance: eccentric and isometric muscle activation from lumbar core through the hip. Reducing pain, trigger points, tension, all normalize muscle tone and muscle readiness. Promoting the lumbar core length tension relationships may be a factor as well, but this is not fully researched.

Your empirical assessment should consider more than simply pain or ITB length, as an improvement is better lowering of the body with fewer trunk, pelvic and knee deviations. Unfortunately, the root factor may be non-visible – strain rate issues. So we have to use kinematic and muscle activation to gauge strain rate. Hamill et al. 4 found significant strain rate issues but not significant strain issues. So you can have a kinetic factor (strain rate) without necessarily a change in length factor. So the question of whether or not the ITB lengthens is not the only consideration, and may be a secondary consideration.

I will close by suggesting that a person cannot be at their best if stressed and irritated, and pulled and pushed while trying to perform. The same is likely true for the ITB. My suggestion is that the ITB works with muscles that cannot perform well in a painful, irritated, push and pull environments. Our techniques should aim to create relaxed muscle tone and hospitable environments where muscle performance is easier for the entire run and entire day.

The foam roller can be gentle or aggressive, so the actual method for the foam roller is based on your goal. If you simply want to move neuromodulators and ease tone, tweak that method so the ITB is nurtured at its own pace. If you want to separate adhesions between neighbouring muscles, perhaps you modify the technique to stretch and isolate those structures as appropriate to any other stretching technique.  Creative use of therapeutic balls may be even better. Your clinical empirical evidence seems appropriate to use when assessing these approaches.

References

  1. Fredericson M, White JJ, Macmahon JM, et al. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil 2002;5:589-92.
  2. Fredericson M, Guillet M, Debenedictis L. Innovative solutions for iliotibial band syndrome. Phys Sports Med 2000;2:53-68. doi: 10.3810/psm.2000.02.693.
  3. Eng CM, Arnold AS, Lieberman DE, et al. The capacity of the human iliotibial band to store elastic energy during running. J Biomech 2015;12:3341-8. doi: 10.1016/j.jbiomech.2015.06.017.
  4. Hamill J, Miller R, Noehren B, et al. A prospective study of iliotibial band strain in runners. Clin Biomech (Bristol, Avon) 2008;8:1018-25.

Robert Baker is a Doctoral Candidate in Orthopedic and Sports Science at Rocky Mountain University of Health Professions, Provo, UT. His dissertation is on: Comparison of hip muscle electromyography and 3D kinematics in runners with iliotibial band syndrome.  He is the President of Emeryville Sports Physical Therapy in Emeryville, CA. He specialised in sports and orthopedic practice with a blended manual therapy and exercise approach. 

Read also