Thomas Michaud, DC, is widely respected for his lower extremity expertise. To update his textbook, Foot Orthoses and Other Forms of Conservative Foot Care, * Dr. Michaud pored over the post-1997 literature. He found good studies that contradict some current assumptions about iliotibial band friction syndrome--contradictions important enough for a doctor of chiropractic to consider while formulating a treatment plan.
Dr. Michaud's private practice is in Newton, Massachusetts.
The Sagittal Plane Theory
Classically, says Dr. Michaud, doctors have thought that iliotibial band friction syndrome (ITBFS) was caused by a backward/forward "snapping" motion in the band that led to inflammation and pain. "The belief was that the iliotibial band (ITB) was in front of the lateral epicondyle when a runner's knee was straight. And when the knee reached the angle of 28 degrees, the ITB would transition over the lateral epicondyle. By bending the leg, the runner's ITB would displace backward, causing the band to snap over the epicondyle, irritating an underlying bursa--that was the widely accepted sagittal plane theory." But, he says, "they've discovered that it's invalid. The band does not move forward and backward, and there is no evidence that the bursa is involved in any way. New research confirms the ITB doesn't snap back and forth. It pushes in toward the femur as the tensor fasciae latae (TFL) and gluteus maximus contract. The snapping back and forth is an illusion created by the alternating tension generated first in the front and then in the back of the band. (See Figure 1) It turns out that when your foot first hits the ground, the anterior--the forward aspect of the band--shoots out. And later, as the knee flexes, the back aspect shoots out. This makes it look like the band is sliding forward and backward." But it's doing nothing of the sort, he says. "It's just pushing in." (See Figure 1.)
ITB and Fascia
Equally surprising is how much a part of each other the ITB and the fascial system are. "The latest theories are focusing on the fact that the ITB is not an isolated band," says Dr. Michaud. "Instead, it's a thickening of a fascia that surrounds the entire thigh. It's not just a surface band, either. It wraps deeply under the outer quadriceps to stabilize the entire femur." (1)
Dr. Michaud says that providers have long thought that the ITB bypassed the femur and attached only to the tibia. "But what imaging studies have shown is that before the ITB attaches to the tibia, it produces a fibrous anchor that goes deep into the side of the lower femur. (1) This fibrous anchor blends not just into the periosteum around the bone; it also blends completely around the entire femur to stabilize the structure (See Figure 2.) This extensive fascial support keeps the femur from bending, which may play a role in preventing stress fractures in the femur while running." Researchers, he says, "are comparing the femoral insertion of the ITB to the Achilles tendon because of...