Tendinopathy and Iliotibial Band Syndrome: Understanding Pathology - - PowerPoint PPT Presentation

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 Kinesiology University of Connecticut craig.denegar@ uconn.edu

Invitation

Address the contemporary use of

• ne 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 conditions

Highlight the links between diagnosis

from a tissue and biomechanical perspective and treatment recommendations

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Tendinopathy

Tendinosis

• r

Tendinitis Implication of “itis” Implications of labeling in treatment

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What it is: A closer look at a degenerative process

Ultrasonography

Fiber 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 S ports Med. 2006; 34:1738-46.

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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 , S hea B, Tugwell P , Wells GA. Deep transverse friction massage for treating tendinitis.

Cochrane Dat abase of S yst emat ic 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 results Systematic reviews do not support use

• f LLLT for tendinopathy

Results may be parameter specific

S

ee: Bj ordal 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

• utcomes 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 Brit ish Journal of S port s Medicine 2007;41:188-198

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Effective treatment ‐ exercise

Achilles and patella

Evidence 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 tendinopathy

Posterior 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

• f tendon pathology ?

Paoloni et al. Topical Glyceryl Trinitrate

Application in the Treatment of Chronic S upraspinatus Tendinopathy:A Randomized, Double-Blinded, Placebo-Controlled Clinical Trial . Am J S ports 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%

• f 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

• f Chronic Noninsertional Achilles Tendinopathy. JBJS

(Am) 2004; 86:916-922

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GTN

Kane et al. Topical Glyceryl Trinitrate and Noninsertional

Achilles Tendinopathy: A Clinical and Cellular

• Investigation. Am J S

ports Med. 2008;36:1160-3.

“This study has failed to support the clinical benefit

• f 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 nonoperative therapy.”

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Concerns with “Recovery”

Resolution of symptoms does not imply

structural repair

Evidence of repair

Decrease diameter Resolution of vascular in-growth Improved fiber organization and resolution

• f 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

• f 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

• f knee flexion, the ITB is

posterior to the lateral femoral epicondyle

http:/ / emedicine.medscape.com/ article/ 307850-overview

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From PT Corner

What is a possible cause of iliotibial

band 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/

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Iliotibial band syndrome

The continual rubbing of the band over

the lateral femoral epicondyle, combined with the repeated flexion and extension

• f 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.sportsinj uryclinic.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. S keletal 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

• nly 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 vs immobilization, 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 TFL Tender along course of palpatably

tight ITB

Palpation, long-sit suggestive of

right anterior innominate rotation, T-L junction hypomobility

Antecedents?

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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 tenderness

Resume 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 condyle associated with ITB friction syndrome is not associated with friction but rather fat pad entrapment

Tensioning of the ITB is due to proximal

muscle / joint dysfunction

Treatment 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 decisions

A 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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