Tendinopathy and Iliotibial Band Syndrome:
Understanding Pathology Informs Treatment
Craig R. Denegar, Ph.D., P.T., A.T.,C.Professor and Associate Department Head Director, Doctor of Physical Therapy Program Department of KinesiologyUniversity of [email protected]
Invitation
Address the contemporary use of
one or more therapeutic modalities
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Premise
At the foundation of therapeutic
interventions for musculoskeletal
conditions lies a diagnosis
(medical, functional)
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Purpose
Consider therapeutic interventions from a perspective of new understandings of two relatively common musculoskeletal conditionsHighlight the links between diagnosis from a tissue and biomechanical perspective and treatment recommendations
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Tendinopathy
Tendinosis
or
Tendinitis
Implication of “itis”
Implications of labeling in treatment
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What it is: A closer look at a degenerative process
UltrasonographyFiber disorganization
Hypoechoic islands
Increased fluid volume
Increased diameter
Neovascularization
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Transverse View 5 cm prox insertion
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Ultrasound: Achilles Rupture
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Neovascularization
From: Hoksrud A. et
al. Ultrasound-guided
sclerosis of neovessels
in painful chronic
patellar
tendinopathy: a
randomized
controlled trial. Am J
Sports Med. 2006;
34:1738-46.9EATA 2010
Collagen Organization: H&E
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Signs and Symptoms
Pain
Why is tendinopathy painful?
Stiffness
What does loss of stiffness imply?
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Neovascularization
Not always present
Resolution has been associated with
symptom relief
May be present in asymptomatic
individuals
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What it is not: highlights of the literature
“There is some scientific support in the
literature for the diagnosis of tenosynovitis
and tendinosis as a pathologic entity. Actual
inflammation of tendon tissue consistent with
tendonitis has not been seen clearly in patho-
anatomic studies”Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of
tendonitis: an analysis of the literature. Med Sci Sports Exerc 1999
31:352-3
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What it is not: bottom line
Tendinopathy is not an inflammatory condition based upon contemporary understanding of an acute inflammation > repair process.
PGEs elevated but not neutrophil, macrophage counts
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Treatments suggested for “itis”
Ultrasound & phoresis(how many have used US to treat a tendinopathy?)
NSAIDs
Friction massage
LLLT
Exercise
Superficial heat and cold
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Ultrasound etc.
“Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit for tendinopathy.”
Wilson JJ, Best TM Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005
Why would we treat a non-inflammatory condition with anti-inflammatory medication or suggest we promote resolution of an inflammatory condition with ultrasound, especially in light of the absence of evidence of efficacy?
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Friction massage
No benefit but limited to ECRB and ITB –further investigation needed
Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003528. DOI:10.1002/14651858.CD003528.
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NSAIDs
NSAIDs are recommended for short-term pain relief but have no effect on long-term outcomes.
Wilson JJ, Best TM Common overuse tendon
problems: A review and recommendations for
treatment. Am Fam Physician. 2005
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NSAIDs
“Overall, a short course of NSAIDs appears a reasonable option for the treatment of acute pain associated with tendon overuse, particularly about the shoulder. There is no clear evidence that NSAIDS are effective in the treatment of chronic tendinopathy in the long term.”
Andres BM, Murrell GAC. Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clin Orthop Relat Res. 2008 466: 1539–1554.
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LLLT
Mixed resultsSystematic reviews do not support use of LLLT for tendinopathyResults may be parameter specific
See: Bjordal JM, et al. A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. 2008; 9: 75.
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LLLT
Bottom line – we have much to learn regarding LLLT and the treatment of tendinopathy
Additional data are needed before LLLT with specific treatment parameters (wavelength, dose etc.) can be recommended for general care
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Exercise
Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound.
Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise British Journal of Sports Medicine 2007;41:188-198
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Effective treatment ‐ exercise
Achilles and patellaEvidence of response to progressive eccentric loading
Less benefit with insertional Achilles pathology often including bursitis, Haglund’s deformity
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Effective treatment‐exercise
Evidence of benefit of closed chain incline squat in management of patella tendinopathyPosterior tibialis: preliminary evidence of benefit with brace (FAO)-> orthotic and eccentric loading
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A New Approach
Glyceryl Trinitrate Patches
Evidence of effectiveness – new solution based on a new understanding of tendon pathology ?
Paoloni et al. Topical Glyceryl TrinitrateApplication in the Treatment of Chronic Supraspinatus Tendinopathy:A Randomized, Double-Blinded, Placebo-Controlled Clinical Trial . Am J Sports Med. 2005;33:806–813
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GTN
GTN reduced pain with activity at 12 & 24 wks, reduced night pain at 12 wks, reduced tenderness at 12 wks, decreased pain after the hop test at 24 wks, and increased ankle plantar flexor mean total work compared with the baseline 24 wks. 78% of GTN group were asymptomatic with activities of daily living at six months, compared with 49%) in placebo group. The mean effect size for all outcome measures was 0.14.
Paoloni et al. Topical Glyceryl Trinitrate Treatment of Chronic Noninsertional Achilles Tendinopathy. JBJS (Am) 2004; 86:916-922
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GTN
Kane et al. Topical Glyceryl Trinitrate and NoninsertionalAchilles Tendinopathy: A Clinical and Cellular Investigation. Am J Sports Med. 2008;36:1160-3.
“This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperativetherapy.”
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Concerns with “Recovery”
Resolution of symptoms does not imply structural repairEvidence of repair
Decrease diameterResolution of vascular in-growthImproved fiber organization and resolution of hypoechoic islands
No treatment universally effective –fuller understanding of pathology needed to advance treatment
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Current best practice? EdUReP+
Educate the patient
Unload – active rest, brace as indicated
Glyceryl Trinitrate Patch?
Reload – eccentric training
Prevent – training errors, too rapid of a return to sport
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A new tale: complaint of lateral knee pain
Active graduate student in good health
Pain on lateral aspect of right knee 10d
Insidious onset
Unable to run more than 1½ miles
before onset of disabling pain
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Physical examination of right knee
Full motion
No effusion
No laxity
Exquisitely tender over lateral
femoral condyle
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Diagnosis?
If you hear hoof beats think
of horses!!
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Nothing tricky
Athlete evaluated as experiencing
Iliotibial Band Friction Syndrome
What is it?
How is the condition best treated?
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Iliotibial Band Friction Syndrome
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Varying opinions on the etiology of the injury
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Biomechanics
With knee extension, the ITB is anterior to the
lateral femoral epicondyle
With greater than 30 degrees
of knee flexion, the ITB is
posterior to the lateral
femoral epicondylehttp://emedicine.medscape.com/article/307850-overview
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From PT Corner
What is a possible cause of iliotibialband friction syndrome?Overuse may cause shortening of the ITB. The knee goes from flexion to extension and excessive pressure from the ITB causes friction over the lateral femoral epicondyle. This repeated motion produces inflammation of the underlying structures and causes pain.
http://www.nismat.org/ptcor/itb_stretch/37EATA 2010
Iliotibial band syndrome
The continual rubbing of the band over
the lateral femoral epicondyle, combined
with the repeated flexion and extension
of the knee during running may cause the
area to become inflamed.
http://en.wikipedia.org/wiki/Iliotibial_band_syndrome
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Sports Injury Clinic
Runners Knee (Iliotibial band
syndrome)
http://www.sportsinjuryclinic.net/cybertherapist/front
/knee/irunnersknee.html syndrome)
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E‐medicine from Web MD
When the knee flexes, the ITB moves posteriorly along the lateral femoral epicondyle. Contact against the condyle is highest between 20° and 30° (average 21°), so when the band is excessively tight or stressed, the ITB rubs more vigorously. The space deep to the ITB is believed to have an adventitial bursal extension from the synovial capsule.
http://emedicine.medscape.com/article/1250716-overview
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Treatment??
Stretching
Ultrasound
Transverse friction
Etc.
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Second thoughts ?
Does the fascia become tight ?(or is there evidence that it can be substantially stretched?)The fascia is well anchored to the femur and does not rub on the femoral condyle!
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The functional anatomy of the iliotibial
band during flexion and extension of
the knee: implications for
understanding iliotibial band syndrome.
Fairclough et al, J Anat. 2006
Mar;208(3):309-16
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“the ITB is simply a thickened, lateral
part of the fascia lata. It completely
surrounds the thigh, is anchored to the
femoral shaft by the lateral
intermuscular septum and is continuous
with the patellar retinacula”
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“Furthermore, we have shown that the ITB is firmly attached to the distal femur by strong, obliquely orientated, fibrous strands that can be regarded as tendon entheses. Thus, the ITB is unlikely to roll forwards and backwards during flexion and extension of the knee, but could move slightly in a medial–lateral direction.”
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“The impression of a rolling movement
is likely to be an illusion created by a
sequential shifting of tensile load within
the ITB. Its fibres are tensioned in
sequence from anterior to posterior as
the knee flexes.”
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If the band does not roll across the
lateral femoral condyle what would
explain this commonly experienced and
widely recognized problem?
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Is Iliotibial band syndrome really a
friction syndrome? Fairclough et al
J Sci Med Sport. 2007 Apr;10(2):74-6
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“Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle.”
*bursitis cannot be ruled out but …….
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MR findings in iliotibial band syndrome.
Nishimura et al. Skeletal Radiol (1997)
26:533-537
“The MR finding suggested soft tissue
inflammation and/or edema rather than
focal fluid collection in a bursae”
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“Our view is that ITB syndrome is
related to impaired function of the hip
musculature and that its resolution can
only be properly achieved when the
biomechanics of hip muscle function are
properly addressed.”
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Treatment
Iliotibial band friction syndrome – A
systematic review. Ellis, Hing, Reid. Man
Ther. 2007 Aug;12(3):200-8
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Reviewed 4 reports investigating NSAIDs, deep friction massage, phonophoresis vsimmobilization, and corticosteroid injection
Outcome data confounded by other interventions (ice, stretching, rest)
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This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.
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Back to our patient
Very hypertonic over TFLTender along course of palpatably tight ITBPalpation, long-sit suggestive of right anterior innominate rotation, T-L junction hypomobilityAntecedents?
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Treatment
Mobilization of T-L jct, instruction in right knee to chest muscle energy and hip flexor muscle stretching 2-3 times each day. Initial treatment reduced TFL hypertonus and ITB tendernessResume activity as tolerated
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Outcome
Able to resume running without
limitation within 5 days
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Additional considerations
Runners – distance, surface, level of
fitness, heel strike angle
Cyclists – saddle height, cleat peddle
interface, distance
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Key points
Anatomical and MRI investigations suggest that pain over the lateral femoral condyleassociated with ITB friction syndrome is not associated with friction but rather fat pad entrapmentTensioning of the ITB is due to proximal muscle / joint dysfunctionTreatment should be directed at identifying and then treating the mechanical sources of ITB tensioning
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Bottom line
Understanding of the pathoetiology is essential to treatment decisionsA multimodal approach (injection, manual therapy, therapeutic exercise) may yield optimal (early return to full sport participation) treatment results
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Future directions
Value of local interventions
(corticosteroid injection, etc)
warrants investigation in light of a
revised view of the pain generator
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Questions and Discussion
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Thank you !!
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