58. Iliotibial Band Pain w/ Dr. Rich Willy

Welcome back to episode 58 of the E3 rehab podcast where we bring you the world's experts in rehabilitation, performance and pain. Our mission is simple, empowerment through evidence-based education. I'm Mark Sertica and I'll be joined by my co-host Sam Spinelli. In this episode, we sat down with Dr. Rich Willie to discuss Iliotibial band pain. We hope you enjoy. All right. Do you mind introducing yourself to the listeners? Yeah. Hi. My name is Rich Willie and I'm an associate professor of physical therapy, the school of physical therapy, the University of Montana and Missoula, Montana. Great. Well, Rich, thanks for coming on today. And today we're talking about the Iliotibial band. You have a great blog on the topic that I think was first published on South Coast seminars. And then also a recent paper that you're a co-author on titled the Iliotibial band, a complex structure with versatile functions and the lead author on that is Hutchinson. And that was just this year. So can we start by having you kind of describe what the Iliotibial band is and its role in the day-to-day function and running? Yeah. Thanks for that. Yeah. So we recently published that paper with Laura Hutchinson. She's a PhD student from Australia and she did a really wonderful job. That is an open access paper. So if you want to learn more about what we talk about today, I think that would be a really great resource and perhaps we can make that link available to everybody. But I suspect that that paper that the Laura wrote and led and I contributed to end up being a well-sided resource. And so when you look at the Iliotibial band, it's the structure that if you've ever had IT band syndrome, you probably wonder why you have this structure because you're kind of like, well, I really would just like to cut it off the side of my leg because if you have IT band pain, it's really uncomfortable. It can be this kind of scary injury because it kind of comes out of nowhere. It seems to kind of catch it like a result in pain with very kind of surprising frequency I would say. I would say sometimes you feel like you're doing okay. Then I'll send you and I might just move kind of funny and it'll make you kind of grab the side of your knee. I would say for me, I mean, I'm a runner and I've had my fair share of running injuries. But this is the only running injury that's ever made me sit down on the side of the road and wait for my wife to come pick me up. So it's really hard if you've ever had it and anybody who's listening, who has had it before knows what I'm talking about, can be a very debilitating injury if you can call running injuries debilitating. But I think for runners, I think that they would consider it to be so because it's not an injury that you can run through. And when it gets really exacerbated, you're going to feel not just during running but you're also going to feel it when you're doing other functional activities like descending stairs. And that's actually one of the key diagnostic criteria if you're trying to decide if you have a leotibial band pain versus some other sort of knee injury. So but what it does is that this structure, we used to think of it kind of as this kind of strap structure that went from the ilium, which is the eye to the tibia and in particular, the girdys tubercul, which is on the lateral side of the knee. And then it was just this big long strap and it didn't really connect anything in between. But when we look at the anatomical dissection papers a little bit more closely, we know that it actually has attachments, you know, the whole length of the femur, particularly on the distal aspects, it has some attachments to the lateral retinaculum of your patellar femoral joint. And then when you look at the muscular chart that it attaches to, I think that that's a good thing to go back and review as well because that will kind of give us a good idea of what muscles we need to be loading when we're doing some sort of rehabilitation exercise with this injury. So it's often thought that it attaches to the gluteus medias, but that's actually not true at all. There's has no attachments to the gluteus medias, but what it does has, it has very kind of very robust attachments to the tenser fascia lotto and the anterior lateral aspect to the hip. And then the superior portion, the gluteus maximus muscle. So there's actually two portions, the gluteus maximus. There's a superior and an inferior aspect and the inferior portion inserts directly onto the femur and the superior portion attaches onto the aliotibial band. And then it also, of course, the aliac crest. So yeah, so those are the main anatomical attachments of that structure. And it has a really important role too when you look at it from a functional anatomy standpoint. It basically does two things. It's a massive energy and storage, energy storage and release structure. So you kind of think about it as a tendon. And in fact, when you run, it stores and releases the second most amount of energy behind your Achilles tendon, your Achilles tendon stores about 35 to 40% of the energy and releases it. And the aliotibial band is responsible for storing and releasing about 5 to 8% of the energy of running. So the other thing that it does, too, is that it provides a very robust, I guess, reinforcement against various torques on the lateral aspect of the knee. So it reinforces the lateral collateral ligament or the figular collateral ligament, whichever you want to describe it as, and it also provides some reinforcement against tensile loading on the lateral aspect of the femur. So in fact, if you were to remove your aliotibial band, you would have a lot more tensile loading on the lateral aspect of the femur, and it would dramatically increase your risk of developing a femoral bone stress injury on the lateral aspect of that bone. So it's a really neat structure. It's one that I think most clinicians and perhaps runners kind of see as more of an annoyance, but it's a really vital part of locomotion. And if we didn't have it, we wouldn't run as efficiently. And a lot of other primates actually don't even have this structure. So I think it's something that's distinctly human. And I think it's what helps us run the long distances that we can run. That was a great overview. And in terms of this pain, I guess, first of all, do you have a preferred nomenclature? You know, it is somewhat about diagnosis of exclusion, so what do you prefer calling it? Yeah, I would say we've kind of moved away from this term of Iliotibial band syndrome. You'll still see that, and in fact, in our sports medicine paper, I think we still call it that. I think you're starting to see more of a gravitation more towards this Iliotibial band pain term. And the reason for that is when you kind of take a step back and you look at what actually is a syndrome, you know, a medical syndrome would be something that is a collection of signs and symptoms that typically has an underpinning of some sort of histological evidence for it, a genetic evidence for it or some sort of radiological or imaging sort of evidence for it. When we think kind of more globally as far as like what is a medical syndrome that would kind of classically come to mind. So like, like, Marfan syndrome is a perfect example of that. So there's a there's a genetic component to it. In fact, you're not going to have Marfan syndrome if you don't have that gene down syndrome also as well. When we get toward kind of more musculoskeletal injury type injuries, when we think about from our acetabular impingement syndrome, that is a true syndrome because there is an imaging component that is required to diagnose someone with with F.A.I. With IT band pain or IT band syndrome, there is no imaging. There's no genetic predisposition to IT band pain that we know there we know of and there's no blood test for IT band pain either. So it's very similar to patellar femoral pain and that's the reason why we've moved away from patellar femoral pain syndrome to more just patellar femoral pain. So and to your point, it is a diagnosis of exclusion and luckily, there aren't really a lot of other lateral structures that can result in pain that's similar to IT band pain. But it is really important to kind of roll out all the kind of kind of guilty parties that might might mimic this injury. So when we think about injuries that we really want to be rolling out, I would say patellar femoral pain is a really important one. So you want to make sure that your patient doesn't have that and if you're dealing with runners, it's an important injury to know how to treat both IT band pain as well as patellar femoral pain because of all running related injuries, 50% of all injuries are patellar femoral pain or IT band pain. And so we want to really want to be really, really good at treating both of those and you need to be able to distinguish between the two of them. So patellar femoral pain, let's say distal femoral bone stress injury is going to be a really important one to roll out. And gluteal tendonopathy is an important one because that's an injury that can radiate down the lateral aspect of the thigh and can mimic illiotibial band pain. And let's see here, lateral meniscal lesion is another important injury to roll out as well. So I think those are going to be your main injuries that you want to be rolling out. I mean, runners don't really get lateral collateral ligament sprains. So I would say that that's not a real important injury to be to be rolling out. And, but yeah, I would say that those are your main ones. I think that femoral bone stress injury is a really important injury to make sure that you know how to roll that out. And the reason for that is that it does mimic illiotibial band pain quite closely. And so one of the best clinical tests for that is the fulcrum test. And the full Chrome test is a it has a it has a very high positive or I'm sorry, has a very good negative likelihood ratio, and what that means is it's very, very good at ruling out this injury. So if you if you have a negative Fulcrum test, you can typically feel very confident that your runner does not have a femoral bone stress injury. And of course you should be ruling out or you should be screening for other signs and symptoms of a of a bone stress injury, which should be a recent rapid increase in running my age. And pain at rest and certainly pain at night. So pain when you're someone's lying in bed is always a really classic sign that someone has some sort of of a of a bone stress injury. So so make sure you do that. And I think that's a real important injury to roll out. And I say that because femoral bone stress injuries get missed for for quite a while, they tend to get misdiagnosed for sometimes two to three months before they actually get diagnosed correctly. So so don't ever let that one fall off your radar, particularly if you're dealing with any sort of endurance athlete. So for lateral minuscule lesions, you know, of course, I think as we know the diagnostic testing for for lateral minuscule injuries is not so good. So you want to kind of really start thinking about, you know, kind of a collection of findings, you know, with that one. So typically you're going to have some sort of a memorable event. Not all the time, particularly if you have a degenerative tear. So that's something worth keeping in mind. So look at the person in front of you if they're older athlete. You know, that they may be a little bit more prone to degenerative injuries. But also the things like joint line palpation and coupled with malmicmerious tests. And again, maybe perhaps some sort of mechanical symptom there, I think would be some some good things to consider. So yeah, so I would consider those to be kind of the real big ones. I'm sure I'm probably forgetting one. Oh, and then we did talk about gluteal tendon opathy. I think that's a really important injury to make sure that we're ruling out. And so the best way to do that would be just doing some resisted lateral hip testing. And so targeting the gluteus medius, and so if that results in a reproduction of symptoms, and that's probably more. So what you need to be thinking about rather than aliotibial band pain. So there's no single good test for diagnosing people with aliotibial band pain. So the one that we think of the most often is the noble compression test. And to perform the noble compression test, you find the lateral femoral condyle. You move just proximal to that by about, you know, about a centimeter or so, kind of clamp your hands around that region. And then you take the person's knee through you passively through an arc of motion between 45 degrees to about 10 degrees short of full extension. And you continue to do that as you're kind of compressing the lateral aspects of of the knee. And if it reproduces symptoms, and that will be a positive test. Unfortunately, there's no known positive or negative negative likelihood ratios for that test. And then, you know, basically the reason for that is that there's no real gold standard diagnostic test that we can compare it to. So, and that gets to our next thing and that's that imaging is not helpful in diagnosing aliotibial band pain. It can be with someone who's got a really, I guess, persistent case, you know, you may they may have some some fluid or some adema and that that lateral epicon dial space that might show up on ultrasound. But for the most part, there's no real diagnostic or diagnostic test for that. So, yeah, so those are the kind of special tests. Other things I'd be really looking forward to be pain that is reproduced with, I should say lateral knee pain that is reproduced with with descending steps or do sending a stairs. I think that would be important. I think that some patients would even get pain when they are walking and they they take a big step. So they're trailing leg would be their symptomatic leg. And so, really, anything that's going to be putting that tensor fascia lata on eccentric load is going to reproduce that this person symptoms and you should really start thinking about it to be able to be on pain at that, at that point. Great. And in terms of patho mechanics, you know, initially it was discussed as a friction syndrome. And now maybe it's leaning more towards a compression type issue. Can you touch on that? Yeah, absolutely. So it used to be thought that that this was a, this friction injury and that we had this strap structure, the strap, the tibial band that was going from ear, ilium down to your tibia. And it was, you know, kind of going back and forth or the lateral femoral epicon dial and just causing a lot of friction and it was, you know, irritating, maybe a burst that was between those two structures. But now that we know that that this is a structure that's really bound down really quite well. What, what happens there is that we just kind of get some excessive compression on the lateral aspect of the knee and it's not so much that the compression is excessive. It's just just that the tissue that's underneath the iliotibial band is just not accustomed to this amount of compression or either from a, from a magnitude standpoint, or from a volume standpoint. And this is where the training load error kind of comes in. So, so a runner that has recently ramped up their, their, their gate velocity, sort of like doing a lot of speed work or running downhill in particular, those seem to be things that that kind of really precipitate this injury. Also someone who is suddenly starting to run with a much narrower base of support, maybe even crossing over quite a bit, you see that in trail runners. So if someone's been, say, maybe they've been running on a treadmill, a winner, and then, you know, I live in Montana, all the trails are kind of frozen right now that trails all out and suddenly they start running on a much more narrow surface, like a trail like single track. They're going to run with a narrow basis support and that's going to put a lot of extra various load on the lateral aspect to the knee and that's going to result in some compression on the highly integrated kind of fatty tissue that's just below your, your iliotibial band is just above that lateral femoral condo. So yeah, so we used to think of it as this friction injury and now we've kind of really moved more towards it's more of a compression injury. And there are some other things too that we've kind of thought about too that's kind of kind of gravitated along the lines that we have kind of made a start thinking about this thing a little bit more. We used to think that it was related to a very tight iliotibial band. And so the Ober test, I think we all learned that when we're in PT school, I think I'm sure our program still teaches it as well. You know, it used to think that that, you know, if you had a positive Ober whether it's the modified or the kind of the classic version that that you had a tight IT band, however, there's been it was a really nice and well done kind of Eric study that was published in American General Sports Medicine. Just a few years ago, and what they did, they had a series of fresh frozen cadavers and they went in and they systematically kind of snipped different structures. And to see which ones would affect the iliotib or affect this Ober test and what they found was that if you clip your your IT band, it actually doesn't really change your your Ober test whatsoever. So the Ober test doesn't even really test IT band tightness, if you will, what they found was that it tended to relate more toward gluteous media restrictions. So if they once they release that, that that seemed to really, you know, allow your your femur to become more horizontal on that Ober test, and the other big one was joint capsule tightness. So, you know, it seems to be a good good test for seeing how tight someone's joint capsule is, but it's not very good at testing iliotibial band tightness and the other part of it too is you actually kind of want to have a tight iliotibial band. So, this idea that we need to be thinking about this is a, this is a tight IT band that is causing a lot of friction on the lateral aspect to the knee, I think that that's kind of let us down some, I would say probably not the best roads when it comes to developing treatment plans for them. And one of the things when it is what I said is because a tight IT band, again, we kind of go back to the original point of this structure is that it's a very large energy storage and release structure. And so, and I guess the way I think about is is almost like a, like a rubber band or like like a spring, and if you want to store and release a lot of energy and a rubber band, you're probably going to want a stiffer rubber band, not necessarily a looser one. And in fact, there was a really nice lastography study I believe was done in Australia, and they, they use the lastography, which is a very kind of very technical type of ultrasound and what it does is it bounces a ultrasound wave off of an elastic structure and then it measures the velocity that it comes back at the ultrasound head. And by doing that, you can see how stiff a structure is, and as people recovered from illegal to be on pain, their, their IT band actually got stiffer. And so again, this idea that we need to be thinking about it, this is being a tight structure that causes friction, I think that that's actually really what we want to be going toward really want to get we want to improve the tissue qualities of the illegal to be on the way to do that is by is by getting it stiffer. So if you've given us an overview of what the billiotypical band is, what it does discussing patho mechanics, you know, discussing excluding other diagnoses, especially femoral bone stress injuries, you know, kind of honing in on subjective information. So running downhill, increasing volume, you know, intensity, maybe a narrower step with because they're doing trail running. But do we understand why certain people, you know, get this or who gets it and is it only in runners, do we see other populations also get this pain. Yeah, that's a good question. Yeah, I don't think it's an injury that we really understand very well like the actual like what's that so much for this injury. You know, it seems that males get this injury more so than females, so I would say that when you compare that to petal femoral pain, and this is should be something that's factoring into your clinical reasoning when you're trying to side of some. one has, petal femoral pain or ITBN pain, is that females, or I get petal femoral pain at about twice the rate that males do. But that kind of flips around when we look at ITBN pain. So males tend to get ITBN pain about twice the rate that females do. So there's that. There is some data that suggests that people who have more of a virus structure to their lower lambs tend to be a greater likelihood for this injury. I would say that that evidence is not very good. And it kind of fits in with most of what we are kind of starting to see when you kind of look at the data looking at structure and how that relates to injuries. It doesn't really seem to hold water very well. So yeah, I would say that younger runners tend to get this injury more than older runners. So ITBN pain doesn't seem to be something that a fact like the masters runner is much. And it's not so much that they won't ever get it. It's just that other structures are going to get injured on them first before they get a chance to develop the ITBN pain. And for them, they're going to be much more so likely to get things like calf strains or Achilles tendonopathy or to have you. So yeah, if you're treating someone who is who is new to trail running or new to trail running in that season, particularly if they're going to be doing a lot of trail running running downhill, that's going to be someone that I would say that it would be more likely to get this injury. Someone who suddenly starts doing the last speed work, I think that that would be a runner that I would say would be more likely to get it. Experience runners. This is not a runner. This is not an injury that experience runners get. This is new. This is typically a new runner's injury injury. So you're not going to see if you're working with elite athletes, ITBN pain is probably something that you just don't see that much of. They're going to see much more of of tendonopathies and bone stress injuries in that group. But ITBN pain tends to be much more of a recreational runner or maybe an injury that this is an injury that I see a lot in and runners who recently switched from doing something that was very that resulted in a lot of quad hypertrophy. So a cyclist, for instance, for so if a cyclist who is doing a lot of cycling and they develop a lot of quad hypertrophy, if you can kind of imagine that that's going to kind of you know it's going to be putting a lot of extra load on the on your early ITBN and then they start they start running. They're not used to going into a lot of hip extension either and so they don't they have not loaded that aspect of the early ITBN that much either. So yeah so I think that would be those would be the main the main things we from a biomechanical standpoint. There's it seems to be that if you run with a if you cross over a lot so if you're run with a narrow step with me and we've mentioned that earlier so runners who do that you know I I would say that that's that's the main one we used to think that that hip adduction so how much your your thighs kind of angled inward had something to do with that but really that's more of a function of crossing over your your gate and and when you think about like who crosses over a lot it's typically going to be the runner who takes very long strides and what happens then is when you when you take a really long stride you get your foot you know your legs so far out in front of you and then after a while it starts kind of roll it kind of wrapping around the front of your body because you just kind of can't you know you're like you only have so much hip flexion to go through and that's what seems to set people up for for more of a cross over a narrow step with them so and of course the flip side of that would be if you want to reduce that you would just have them increase their their running cadence and I'm guessing that we'll talk about that a little bit here in a bit when we talk about about treatments so but yeah we we don't really understand this injury very well and I think it's um oh you know one of the big things with it is is that it it's an injury that kind of comes and goes while it's a pretty common injury I think a lot of attention has been paid much more so to patelle femoral pain IT band pain it it typically actually has a pretty good natural history so it it kind of you know it kind of will go away it seems to be self limiting so it does seem to go away and not in everybody I know for there are some people that it does seem to stick around with whereas patelle femoral pain is an injury that once you get patelle femoral pain where you've really it's going to be the injury that you're probably going to be dealing with for the for the next several years on again off again yeah so there's a lot of considerations here and maybe you can give us your systematic approach right because you talked about maybe there's a component of load management with you know the higher speed running maybe there's a component of activity modifications with downhill or trail running there's you know altering cadence there's strength training so yeah can you talk to us about your systematic approach to to rehab yeah I mean what I would but kind of when I whenever I look at these runners and once I've decided that they have earlier tubule band pain the first thing that I want to make sure that I can do is try to keep them as active as possible so we look at how can we keep this person running you know if possible and that's always the goal without shutting that person down and so for a lot of runners you you you are able to do that and so if you think about the types of running that do load the illegal tubule band and then you just basically do the opposite of that so you think about okay well you don't want to be doing speed work and you don't be doing downhill running and so you kind of flip that around and so maybe do some uphill uphill running and so treadmill is the best place to do that on treadmill is also a really good place to be doing a lot of running because you everybody kind of naturally shortens their step length by about 3% and so and that's kind of across the board and so that's going to reduce you know one's likelihood that they're going to be running with a very narrow step with as well so some some slight uphill treadmill running works great and I usually have people running on a treadmill about 5% grade and in the meanwhile so that's going to kind of help kind of calm it down if they can't do that we'll just do very fast uphill walking on a treadmill and the reason why we want to do it on a treadmill and a lot of people are like oh I don't really don't want to get on a treadmill but it's certainly a lot better than not running at all and the other reason why running on a treadmill is nice is because as I mentioned earlier this is an injury that once it gets kind of flared up we'll kind of stop you in your tracks and you don't have to worry about wondering when your wife is going to remember that you went out for a run so she can come pick you up you know so you can just step off a treadmill if it gets if it gets flared up so so anyway so uphill treadmill walking if you can't do running I would say bump that and climb up to 10% and work on doing you know 30 40 minutes of uphill walking and that'll help maintain your conditioning and it keeps you loading your lower limbs and that's really important because as we know and I think really a great way to kind of think about this injury is just think about it as a tendonopathy and if you do that you'll do really well with them so we know that tendonopathy's absolute rest is absolutely contraindicated in the same thing with with this injury so and if you've ever had this injury before you know that if you just stop doing stuff stop running or that hurts and I'm going to let it kind of calm down and once you start running again this injury will typically just come back and in particular if you're continue to do the same training load errors which would be too much downhill running too much speed work so so yeah so that's kind of how we we do some offloading of the runner we we start off by instrumented relative offloading then at the same time this would be what we would consider to be in the in the pain dominant stage and so then at this point we start doing some loading and we do a lot of open chain hip abduction strengthening and hip extension strengthening so we work on kind of loading the TFL the glute max and start doing some some open chain exercises I think like the bridging type exercises work well or hip thrusters if your patient can tolerate them I also do I think most people know the Thomas test and if you don't you're lying on your back and you've got your opposite limb kind of tucked up against your chest and you work on kind of pushing your thigh you're involved thigh down against the table and you work on flexing your involved knee back as much as you can and so that's kind of an exercise that we'll do we'll do that kind of periodically throughout the day until their things start to calm down and the way you kind of know when you're ready to kind of progress into this kind of more of a low dominant stage is when when that patient wakes up and they can go down stairs without pain they don't feel it when they're going down steps when they can take a big step when they're walking and they also don't feel any symptoms that's a good sign to start now it's time to start really working on getting more and more load on that person and so so for me what I do in this stage and I you know I try to get them into this this kind of low dominant stage as quickly as possible you know for me I don't I mean I try to get them try to go with as much weight as they can tolerate and so we really start loading them up you know you know again it's very much like a like a tendon-opathy type approach we know that heavy slow resistance training is going to be what we want to do and again when we go back and look at that alastography paper we saw that a stiffer a killi's our stiffer IT band is one that is is what we see in people who recover from this injury and we also see the same thing and a killi's tendon-opathy and we know that heavy loading is what you really want to be doing if you want to be increasing the stiffness of any sort of structure so for this injury what we'll do to load it I really like doing split squats and some people would call that the Bulgarian split squat and rather than putting the involved limb in the front you put the involved limb in the back so it's the trailing leg and you want to have a a surface that is that is high enough that when you lower yourself down you're thinking about eccentricly lowering yourself with your trailing leg the leg that is propped up on whatever surface is behind you so a treatment table or a chair or or what have you? And you think about really kind of eccentrically lowering you down, try to shift as much weight on the back limb as possible. Most people when they do a Bulgarian split squat, they have a tendency to kind of lean forward with their trunk. And what that does is that shifts a lot of load onto the stance legs, hip extensors. But instead when you're treating the ITB and what you want to do is you want to kind of think about standing much more upright and maybe even leaning back just a little bit when you do that, that lowering down phase. So we'll do that. I tend to start off with three sets of 15. And then we very rapidly progress with our weight. And so we're getting down to four sets of six repetitions. And for me, I do three second repetitions, so three seconds on the way down and three seconds on the way up. We're only doing that three times per week again, because we're lifting pretty heavy. We want to make sure that these structures have a chance to recover and adapt to the progressive loading and we're applying to it. So that's kind of what we'll do from a heavy load standpoint. Well, so switch the limbs in that Bulgarian split squat position. And then in this case, now we do want to be loading the gluteus maximus. So we've got our involved leg in the front. And it's our stance leg. And in this case, we do want to lean forward. And so again, we'll be using a lot of heavy weight there as well. So we'll be doing those. I think a lot of other hip strengthening exercise to be great. Again, hip thrusters are really great at this phase. If you can progress to doing them in single leg, I think you're doing a great job. And other ones would be single leg sit to stance where you've got like your hands behind your back. And this would be for someone who maybe doesn't have access to like some heavy dumbbells. They can do this exercise with the backpack where they're just kind of working on going sit to stand out of a chair from that on their involved leg. But anyway, I think all of us have-- I think knowing the people that are probably interested in the content that you guys put out, I think are well versed in progressive resistive exercises. And I'm sure it's kind of got their favorite exercises when it comes to loading the hip extensors and that sensor fascialata. But that's what we end up doing. Once a patient starts getting down to like the really heavy phase of this rehab, like four sets of six reps, at this point, remember we want to kind of always kind of go back to, OK, what is the Iliotib you'll be undue? And it stores and releases energy. And so just like with Achilles tendonopathy, we're starting to learn with that injury that there needs to be an energy storage and release phase. So there needs to be some plyometrics to help bridge the gap between going from heavy slow resistance training to doing more dynamic activities such as running or what have you. And so for us, we'll start doing some plyometrics. And because we want to be loading the structure, the best way to load it is if you're doing lateral hopping. Because it's going to be a structure that's going to be really resisting various loads on the ladder aspect of the knee. And so I'll do like some lateral skaters starting off without any resistance. And then we'll add in an elastic band or a cable column with a belt on our person. If you don't have that, you can have them hop up onto a step and hop back down laterally. So doing up and down, up and down with the involved leg on the, I guess, your downhill leg, if you will. So at that stage, when she started doing some plyometrics, that's going to be a really good time that you can really start getting them off the treadmill, lowering down the incline, getting this person running outside again, and kind of slowly transitioning them into the activities that tends to stress the structure a little bit more. So I think that as they're going along, you can start adding back control running. You can start adding in some hill work. But what you don't want to do is add those two things in on the same day. So you want to be doing hill work on maybe something that's very flat and even. So sidewalks, for instance, if you're going to be running trails, I would say keep them very flat. And then eventually, once that person is kind of mastering those activities without having an exacerbation of symptoms, then you can start doing trail running on, on hilly trails. And at that point, I would say that your, your runner has, has recovered. And you can kind of think about it too. Same thing with speed work as well. You want to kind of gradually start easing that activity in as well. So yeah, so I know we're mostly talking about runners and earlier you asked about what other athletes get this, and I forgot to answer that question. So I'll go ahead and hit it now. Cyclists are another group that we see this injury in a lot. And we're coming up on the spring. And so a lot of cyclists maybe have not been riding as much over the winter. And so they'll do the same thing. They'll start riding a lot and going outside in a lot of times in the winter. You know, when you cyclist, and I'm a cyclist, I do a lot of mountain biking. People tend to monkey with their positions a lot over the winter. And when we think about the types of mechanics that might affect this injury, that might lead to this and cyclists would be a cyclist that has their seat too high, and their seat too far back. So those are two things to kind of think about. And then the other thing too would be if you have a person who is locking, using shoes, like cleats that lock into their pedals, if those are too narrow. So this is called the cue factor on pedals. If their feet are too close together, that's going to basically narrow that step with, if you will. And that'll increase compression, a ladder aspect to the knee. So the reason why I bring that up too is not just from another athlete who might get this injury, but also if you're athlete during that initial phase of that kind of pain, the pain dominant phase, that they can't tolerate being on a treadmill. What you can do is you can do stationery cycling for your conditioning. And the way to do that would be to lower the seat and slide the seat forward on the rails. And that's going to be a great way that you're going to reduce load on the other two wheel band. And you're going to be able to still do a lot of very hard work out like bike intervals or something like that on a stationary bike. And not worry about getting or exacerbating this injury. Yeah, and I mentioned the blog earlier. So if people want a visual for some of this stuff, you have some nice graphics, kind of outlining that pain dominant phase where you're modifying aggravating activities, maintaining conditioning. And then going into that load dominant phase, like you mentioned, heavy slow resistance to work on those peak loads, plyometrics to work on that energy storage and release. And then the return to running for cumulative loads. I know you are. I think you are a proponent of, you know, strength training or resistance training in general for runners. When somebody does return to their normal level of function, no longer have symptoms, do you, you know, suggest that they continue with this type of approach in terms of some of the plyometrics and heavy slow resistance. If so, is it at a reduced frequency, reduced volume? Is it just a more general program rather than specific to the, you know, IT band? Yeah, I mean, I think when you look at that's a good question. I think, yeah, I would say without risk of sounding like, I have a hammer and everything looks like a nail. I do. I tend to recommend heavy resistance training for all runners. And I just think that when you think about the fact that running alone doesn't seem to be enough of a stimulus to increase the desirable tissue qualities that we want to see in bone. But we want to see in tendon and that we want to see in an articular cartilage. So it seems to be helpful to a certain degree, but after a certain point, it's not going to be any more helpful than just running more. And we know that when we look at tendon stiffness, and again, we want to kind of think about this structure as a tendon, you know, we know that running alone, it does not seem to be enough to really result in kind of a rapid increase in stiffness. And so when you do think about what does, it's that heavy resistance training. And so for me, I do tend to recommend heavy resistance training for our runners. In particular, like one of the athlete groups that I see a lot are collegiate and high school runners and they get a lot of bone stress injuries. And so there's no better way than heavy resistance training and plyometrics to improve bone health in that population. Aside from all the other energy availability issues that we can also, we also need to be considering about that group as well. So yeah, I'm a big fan of Bulgarian split squats and runners. I think it's a really great exercise. I think the way to kind of think about strength training is that particularly if you're in the off season or in your base season is that you get the same bang that you would out of doing a lot of running, but you get it with many, many, many fewer repetitions with heavy strength training. So the accumulation of wear and tear that you're gonna get in the weight room is much less than what you would if you're going out and you're running high volume. So the way to kind of think about that would be that if you're in the off season, you can be doing a lot of heavy strength training now and that's gonna prepare you for the end season training loads that you're gonna be doing if you're ramping up for a marathon or a half marathon or what have you. And so I just think that, I think that's just a really important part of any runners program. I think that just like all things you should, you should periodize that a bit. I think in the winter you should be in the off season and based season you should be strength training more frequently. And then once you get into the heavy part of your training load on your season like you're ramping up for a marathon, I think that's gonna be a really great time to just draw back to just doing like once a week of strength training because you're really gonna be kind of more in that maintenance phase. But yeah, I think from a plyometrics standpoint too, you know, we look at the two things that seem to improve tendon stiffness the best, it's gonna be heavy resistance training and plyometrics. They tend to. effect different parts of the muscle and the tendon. And so like a heavy resistance training for if you're thinking about the Achilles tendon seems to increase stiffness of the actual tendon itself, plyometrics seems to have more in effect at that muscular tendon is junction. And so I think doing them both makes a lot of sense. I think saying I'm just going to I'm just I really like to imply metrics more than than heavy strength training. I think that's great. At least you're doing something, but I think you really probably should be doing both of them. So and you know, I say that after I was at the weight room this morning and I didn't do any plyometrics, I should probably listen to my own advice, but yeah, but I mean, I think like I think it's I think it's hard. And I think writing up a program for an athlete, I think is really important. So they have so they have something to follow. And when you think about plyometrics, you know, the soleus and the planar flexors, so your gastrocnemius are really responsible. It's really really amazing set of muscles when you think about running because they're responsible not just for vertical vertical movement of your center mass, but they also are one of the main contributors to your propulsive force also. And so thinking about working that that muscle group and in both directions, both vertically and then doing some some horizontal hopping. And then also for your your lateral your post lateral hip muscles. So we would kind of get into these the muscles that we're talking about today. So TFL and gluteus maximus, I think doing some resisted lateral hopping is going to be the way to go for this to be working on on those structures. So if I were to break things down to say, okay, well, just do like the bare bones kind of plyometric program, I would be doing doing those two activities or those three, I guess, so forward hopping, vertical hopping, and then lateral resisted hopping. You bring up the gastrocnemius and we had Jason Torion not too long ago and his joke was, you know, for power lifters, it's squat bench deadlift for runners, it's squat calf raised deadlift, you know, some some variations of those. So you're hitting all the all the major muscle groups. I think one thing that we we didn't touch on yet is kind of gate analysis, running retraining. How does that factor in to the management or treatment of IT venthing? Yeah, you know, I used to, for me, it's been it's been a bit of an evolution and I suspect anybody, anybody who's spent a lot of time, you know, doing some rehab, they'll look back or probably treated maybe 10 years ago and like, oh, wow, treat a lot differently now. And it wasn't like, it wasn't really deliberate, it just been, it's just kind of evolved that way. But it used to be that I would say that if you had any injury and you came to see me, you probably got some form of gate retraining along the way. I would say that now, I would say that's probably less than one out of five runners, probably get some sort of of of of gate retraining. I still do a gate analysis on all runners. And that's no different than if I were if I were treating a swimmer, I would want to see, I would want to see how they're swimming and they say they've got shoulder pain. And if I'm treating and you know, when I first came out of PT school, I got my start in occupational health. And so I did a lot of like job site analyses and worked with injured workers. And so with them, you know, I saw them as occupational athletes. And I would want to see how they would lift something. I really want to and particularly if they're having it, they're doing it very repetitively. So running is no different. I'm still going to want to do a gate analysis on those folks. For that, the main gate that I'm looking for is if they're doing this kind of narrow basis support of this crossover gate. And the way to do that is, you know, you should have some sort of high speed camera. And of course, if you have a smartphone, you know, they all have some sort of high speed function. Me, I have a I have a Casio that I use here. And I import the the video into another program so we can analyze them. But I think everybody's kind of got their own kind of video analysis program that they're using. But what I'm looking for is I will take, you know, find L5 S1, and I'll drop a vertical line straight down. And first of all, kind of go frame by frame until I get that person in mid stance. And at that point, the forces are the greatest on the IT band. They're the greatest on the Patelli Federal joint. They're the greatest on your Achilles tendon. And so at that point, I'm going to, you know, I'm going to drop that vertical line straight down and then from L5 S1. And I'm looking to see where it bisects the ankle joint center. And if I see that the ankle joint center is medial to that vertical line. So basically, medial to L5 S1. That's kind of, it's our operational definition of someone who is running with a crossover gate pattern. And so from there, I'll try to figure out why they're doing it. And so they're then I'll kind of pivot around to the side. And I'll take a look at their, their gate, I'm basically looking at their stride length. And almost without fail, when you see that kind of that crossover running mechanic, it's because they're over striding. And the typical signs of that would be someone who has their, I see their lower leg is less than vertical. So it's maybe inclined out in front of them quite a bit. And that's, that's a good sign that that someone is, is, is over striding. When it comes to gate retraining, I used to get really involved with, when I, I did my dissertation and we used like a full length mirror. We were working on female runners who had Patelli Federal pain and we were working on their alignment. And I was telling them all kinds of crazy cues, like I was like, okay, I want you to squeeze your glutes and push your knees out. And these are runners, these are female runners who had Patelli Federal pain, who also had that proximal mechanism. I think we all learned in physical therapy school of, of higher hip adduction. And that's just a small segment of people who have, who have Patelli Federal pain. And I would say the same thing too, when it comes to Ilya, to be able to be on pain, don't assume that your athlete has a narrow step with, you need to do that, that gate analysis. We shouldn't be just like stabbing in the dark. But I've kind of, I've kind of moved away from being like more involved on what we were doing, and particularly from a queuing standpoint, because when I was working on my dissertation, I would give them very scripted cues because we were doing a study. And then for the last half dozen runners, I remember I started asking them, okay, I'd be like, well, listen, I'm, I'm telling you to do these things. I mean, these are the cues I'm, and I'd be like, well, what are you actually thinking about? And without fail, every single one of them told me they weren't doing what, they weren't thinking about what I told them to do. They were all kind of coming up with, with their own, with their own cues. So, so we, I've really kind of backed off a lot, and I've made it a lot simpler. And so for us, what we use is, we use a garment or some other running watch, like a sento, whatever the runner is coming in with. And then we get the watch set up to it so it can give real-time feedback on running cadence. And if you have a, if you have a running watch that counts your steps, it surely has an ability to give real-time feedback on your running cadence. Usually it's just buried down in the menu, and you have to kind of dig around and probably have to do some Google searching to find your instruction manual so you can see how you can look at your running cadence in real-time. And what we do is we have them increase their running cadence by about 5% over their preferred. And we want to be a little bit careful because we're going to be doing our gate analysis on a treadmill. And as I mentioned earlier, everybody tends to shorten their step length by about 3%, which means their running cadence is also going to go up by 3%. So if you, if you tell someone on, if you look at someone and they're running and see like 100, 75 steps, or 170 steps per a minute, and they're doing that on a treadmill, and you ask them to increase their running cadence by 10%. Don't forget that they're probably going to be running a 3% slower cadence over ground. And so it's going to be a huge change for them. They're going to be doing all their gate retraining over ground. So we tend to only do about 5% over their preferred treadmill running cadence when we ask them to queue it. As far as the gate retraining goes, what we do is we just have them look at their watch when they want. And that's from a motor learning standpoint, it's called self-controlled feedback because it's motor, you know, it's motor learning and they always have to come up with something about my phone there. It has to come up with a very technical term for it. But really what that means is they, they just look at their watch when they're, when they're motivated to do so. And that's important because we know that a learner is not going to learn a new movement skill or learn anything new unless they're highly motivated to do so. And so we only do that for eight runs. And then after that, we start weaning them off the looking at their cadence. Because at that point, they need to start internalizing it. They need to start thinking about their own internal cues on what it, what it feels like when they're hitting the higher cadence. And then, and then at that point, we just, we don't really worry about it too much because this is not it. This doesn't need to be a permanent change in their running gate. It only needs to be a temporary thing. Something that would they can do in the initial stages of getting back to their full running volume to reduce the overall loading. And then at that point, if they start drifting back to their old cadence, it's fine. It's, it's no big deal. We don't, we don't get too excited about that. Rich, I imagine you have a pretty consistent and reliable process for your gate analysis for clinicians who are going to do this on their own. Do they need to be a certain distance from the subject? Does the, you know, camera have to be at a certain height relative to the subject? Yeah, you know, I think, I think if anybody were to watch me do a gate analysis, I think they would probably be really, I don't know, underwhelmed, I guess is a good way to put it. I tend not to get too technical about it because whenever I see patients, I'm under the same constraints that everybody else is when the big ones time. And so at the same time, I need to make sure that it's, that it's effective and I get to see what I need to see. And when, you know, whenever someone's running on a treadmill, the stride to stride variability is, is really quite low, which means that if you just get a half a dozen to a dozen stance phases, you know that they're going to be very, very similar. So I tend to take very short snippets of, of video. As far as positioning goes, I tend to just stand behind the person. I make sure that the, my camera or my phone whatever I'm using is at the same level of the subject that I want to be videotaping. So for instance, if I'm interested in their hip mechanics, I make sure that my camera is at the same level as their hip. If I'm looking at their foot and ankle mechanics, I make sure that I get that camera right down to the level of their feet so I can look at how that foot is interacting with the ground or their shoe is interacting with the ground. Yeah, you need to be very, very careful about, you know, looking at things off plain, where you're looking, for instance, your videotaping the feet, but you're standing up above the person and looking down. You're never going to get, you're going to get what's called perspective error. And so that part is important. I do tend to, it's not really on purpose, but I guess I probably would do it anyway, but it is somewhat standardized in the distance they get away from the athlete because I just go far enough away that I can fit their whole body into the image or the actual, if I'm looking at their foot, so they can get their whole foot during the whole stance phase in our view. But do I have marks on the ground? No, do I use a tripod? I don't do that either. I just, yeah, I just record on high speed and then imported into Kenovia, which is the free software that we end up using. And then that's it. I tend not to make it too technical. And I mean, keep that, keep in mind that I have a, we have a three-dimensional motion analysis laboratory. We have an instrument at treadmill, which has force plates built into it. We have measured, we have, we have wearable devices that can measure impact forces. We can model patellar femoral joint contact forces. We can measure muscle for our model, muscle forces and all that stuff. But we don't do any of that stuff for clinical patients. I don't think you need to get to that level of precision. I think it's very questionable on what that would do for, you know, do for a clinician or even the runner. I think it'd be very overwhelming. And the same thing, too, when we're looking at, when we do gate analysis, I don't measure angles on runners either. I just do what's more like a qualitative analysis. So what we described earlier on how that, that foot is crossing over a midline. That's a perfect example. That I'm not measuring centimeters, or I'm not measuring hip-adduction degrees or anything like that. And for, you know, two reasons. One, that it's overwhelming for the runner. It takes too much time. And I think that the third reason I guess are three reasons is that I really question my day-to-day reliability and my ability to do that with a, with a handheld camera. And so I think I'm not, I want to make sure that I'm not fooling myself with thinking that I'm more precise than I really am. Yeah, it's great to hear your perspective because I think often the impression is that more data is, is better. You touched on the Obers test, but are there any other myths or misconceptions related to the diagnosis or management of IT band pain that you want to talk about? Yeah, let's see here. So the Obers test is, is a big one. So I think that, you know, if you're doing the Obers test, I think it's probably maybe time to move away from that and save your time to do some other things. It's not telling you probably what you think it is. And then as far as from a treatment standpoint, when you think about, and again, we don't stretching the IT band is not something that is probably, when we think about that we want to have a stiffer IT band, it's probably not necessarily justified. So I would probably lay off on the, on the stretches of that structure. Unless you're thinking about them as like just like an early loading exercise, you really want to kind of progress more towards heavy resistance training with that, with that individual. The other thing too that you'll see a lot is foam rolling or aggressive soft tissue work on them. And I've seen this and my former institution. We weren't seeing a lot of the collegiate athletes, but I could always see them walking across campus because they have bruises on the sides of their thighs. And or other areas where they were getting like aggressive instrument and soft tissue work. And I really, I don't know, this is one thing I kind of feel a little bit strongly about. I don't really feel like that has a has a place in practice. I think that doing aggressive soft tissue work. Again, this is a compression injury. So doesn't make any sense to continue compressing this highly innovative adipose tissue that is just below the IT band. It doesn't make sense to continue doing that. And because it won't make it better, this is not something that you're trying to reduce adhesions or stiffness or anything like that. So it doesn't, it doesn't really make sense. And if you're if you're listening, you're like, well, you know, I've had IT band pain before. And when I do do some foam rolling, it does feel better. And that's, I totally believe you. And there's a really logical reason for that. And that's that when you're using a foam roller, it's a very noxious stimulus. And your central nervous system is like, wow, that really, really hurts. And so it lowers the gain. And it reduces your overall sensitivity. And so you kind of have this kind of central desensitization. And so you can tolerate, you don't, you don't, you lose some sensitivity there. And that seems to be very transient. However, it only lasts for maybe an hour. And it most up to 24 hours when you do get some sort of aggressive soft tissue work. So it's not really breaking up any sort of adhesions or scar tissue or anything like that. When you talk about like lengthening the IT band, it is a very stout structure. It's not something that we can really lengthen with our, by doing some manual therapy with it. And we really need to kind of treat it the what it's, what it's designed in atomically and biomechanically to do, which is tolerate very, very high loads. It's designed to resist various forces and is designed to energy to store energy and release it. And if you think about that from your rehab standpoint, it's very progressively add those things back in. And then add in the cumulative nature of running or cycling or whatever other activity that you need to get back to, you will do very well with your athletes. And any other final takeaways regarding IT band pain or just runners in general? Oh, yeah, let's see. I think I would say that I think the most important thing to do is know that running is really, really important to a runner. And they call themselves a runner. They don't call themselves a person who runs. And so when they can't run, they really lose a sense of self, no different than a soccer player who's had an ACL injury who can't play soccer for that season. It's a really traumatic process for them. And I think understanding the fact that this person wants to get back to running quickly is going to be really important in that you, you as a rehab specialist are there to help kind of design that return to run program in a very logical manner because this is going to be a person who wants to get back to the way they were before. Get back to their sense of self. And they're going to often rush back into training because your rehab program doing that progressive loading that we described is going to is going to do what it needs to do. It's going to, it's very much going to help them out. But one of the things that I've found over the last three to five years is that the more I focus on that return to run process, the better my runners tend to do. And the biggest part of that is being very objective in that return to run process. And for that, you know, put, keep the reins kind of tight on them and use a very time-based return to run program. And I just don't like, look, this is an injury that maybe you've been dealing with for three months. And if you, you know, do you want to get over this or you want to keep dealing with this the rest of the season? And if they want to get over it and they always roll, yeah, of course, I want to get over this. Then I'm like, well, I need you to kind of agree to doing this program. And no matter how good you're feeling, do not skip steps in this return to run program. That's very, very important. And that's where the treadmill comes in that when their session's over, they step off the treadmill. They're not like, oh, you know, I think I'm just going to run a couple extra blocks. They can step off. And if they want to get more of an exercise or more of a workout, they can go do some cross-training. And then the other side of it too is that being very objective, I use an app on, on, I have all my athletes install it on their phone. It's a free app. It's called interval timer. It's, it's fully free. You get all kinds of spam ads with it. You can pay for the ad-free version. But I really like it because I can sit there and I can program in their entire return to run program into the device. I can say week one day one and all stuff. If I want to go ahead and do that, but normally I just have them do that. And that keeps them on task and it keeps them from, from, from skipping steps, which is where when people have recurrences of this injury, that's typically how that happens. Yeah, I'm not a runner, but I can definitely appreciate the importance of that self identity. Rich, what projects do you have in the works right now? Oh, yeah, I see. So, yeah, I work with runners and we do, we do, you know, spend a lot of time on biomechanics, but we also look at, you know, pain, we're starting to get into some more pain science when it comes to pitile femoral pain. More, more so recently, like I, one of the things I've done throughout my entire career is I've done a lot of work with tactical athletes. And that's where I get my, my research funding is from the Department of Defense. And so we just wrapped up a department of defense grant. And we were looking at, you know, sex differences in lower limb loading when carrying heavy load carriage. And we're looking at predictors of that. And so like who can, like what are predictors is someone who can carry loads very well with minimal, or with lower knee loads. And you know, for that, we'll have some papers out soon, but, you know, consistently what we find is that aerobic conditioning seems to be really important for them. So if you're, if you work with tactical athletes, you probably already know that the number one predicting factor, for a predictive factor, if someone's going to get a bone stress injuries, if they have poor aerobic fitness. And then the other big one we find is quadricep and solely a strength. I'm sure Jason Toria will be happy to hear that. But those, those three things, if you want to have a more durable tactical athlete, those are going to be some places to really spend a lot of time and energy. So Yeah, so that's kind of what we're doing and we're starting to move into more and more looking at returning to load carriage after someone's had a traumatic knee injury because that's one of the main injuries that people get during either deployment or recreational activities when they're enlisted or during basic combat training and we need to make sure that we can work on doing what we can to make sure that these people can go back to deployment or service and do so in a seamless manner and not worry about or reduce their risk of having a re-endery or knee-auster arthritis within the next three to five years, which is typically we see much more so in tactical athletes. They tend to develop knee-o-a after a traumatic knee injury a lot faster than a recreational athlete would. And if people want to learn more about you or from you, where can they go? Yeah, I would say the best thing to do is to false on on Instagram. So our Instagram handle is Montana Running Lab. I'm on Twitter Twitter. It's our Willie 2003 or they can reach out to me and at the University of Montana and my email address is [email protected]. And yeah, those are the best ways to follow us. I would say our Instagram page is kind of where we're starting to put more and more energy into there as long as I can remember to post somewhat regularly. I think you guys do a way better than job than I do, but I think that's a really great place to interact with everybody. Awesome. Well, Rich, thank you so much for your time today. Yeah, thank you. Thanks for having me on. It's been a real pleasure. Thank you so much for listening. Please, if you enjoyed the episode, consider leaving us a five-star review. And thanks to Dr. Rich Willie for joining us today. I'll link his social media, blog and paper in the show notes. You can also check out our content at e3rehab.com. This episode was produced by Matt Hunter. Peace.