[Golden Oldie] Assessing and treating ITB pain with Dr Rich Willy

This episode is a REPLAY of one of the most popular Physio Explained episodes we’ve ever released.

In this ITB pain episode with Dr. Rich Willy, we explore:

• What we now know about the causes of ITB pain
• Simple, evidence-based explanations clinicians can use with patients
• How this changes late-stage rehab decisions
• Practical strategies to build knee robustness and reduce reinjury risk in runners

Want to learn more about ITB pain?

🎁 For a limited time, you can get Paul Ingraham’s Complete Guide to ITB Syndrome e-book for FREE when you start a 7-day free trial of Practicals.

👉 Claim this offer here: https://physio.network/promo-willy

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Dr. Richard Willy is an Assistant Professor in the School of Physical Therapy, University of Montana (Missoula, MT, USA). He received his PhD in Biomechanics and Movement Science from the University of Delaware and his master of physical therapy from Ohio University. In addition to his research, Dr. Willy has been a clinician for 18 years specializing in the treatment of the injured runner. 

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Our host is Michael Rizk from Physio Network and iMoveU. 

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Transcript

SPEAKER_00 0:00

Hey everyone, you're about to listen to one of our most popular episodes ever. We're bringing it back because it's still a topic that causes a lot of confusion in practice. And the timing works out really well because right now you can get the complete guide to ITB syndrome ebook by Paul Ingram for free. It's a big one. Over 80 chapters covering diagnosis, treatment, and recovery. All you need to do is start a seven-day free trial of practicals. You'll get access to over 40 expert-led practical video sessions that show exactly how top experts assess and treat specific conditions so you can become a better clinician faster. If you want to grab the offer while it's still available, just hit the link in the show notes, start the free trial, and everything's unlocked straight away. This offer ends soon though, so you do need to act now. All right, let's get into today's episode.

SPEAKER_01 1:03

You know, it's really helpful when we're trying to figure out who might get this injury to actually take a step back and think about why we have an ileotibule band and what loads that structure. And that can also tell us about what types of running might put more stress on this structure and might lead to this relative overload injury that we are starting to think that this injury actually is.

SPEAKER_02 1:25

The evidence on ITV pain has really shifted. Is it a compression, a friction, an irritation, an inflammation? Well, today we had Rich Willie on and he helped us answer all of those questions. Rich is really well published. He's been helping runners for 18 years. He has a wonderful Instagram called the Montana Running Lab. And in this episode, he covered some really wonderful things we can do in the interview and subjective to help connect with our clients a little more and have a more of a VPS lens approach to an ITB pain. But then he went in depth into some biomechanics and how he would structure and progress his rehab for ITB pain. Really wonderful and practical solutions towards the end of this episode. Rich also did a masterclass where he went a lot deeper on this. You can try that for free in the show notes. We will pop the link there for you. If you are enjoying the podcast, if you're loving the guests we're having on, if you're getting value from this podcast, we would love for you to help us out and click the subscribe button. That helps us get in more ears and we would really appreciate it. My name is Michael Risk, and this is Physio Explained. Welcome back, Rich, and thank you for coming on a second time.

SPEAKER_01 2:40

So thank you so much for having me, Michael.

SPEAKER_02 2:42

No worries. Today we're talking about ITB pain, your understanding of that, what's changed in the research. So we might start at the start. Who gets ITB pain and how by your current understanding?

SPEAKER_01 2:54

Yeah, so this has actually changed now that we're starting to get more prospective data. We used to think that females got this injury more so than males, but now we know that up to 75% of all individuals who experience iliotibule band pain are males.

SPEAKER_00 3:08

Yeah.

SPEAKER_01 3:09

It's actually the second most common injury that runners experience behind only patellophemoral pain. So it is important to keep in mind too that females tend to get patelephemoral pain far more frequently than males do. So that can be a really helpful diagnostic criteria to think about when you're trying to do some clinical reasoning to decide if your patient has iliotibial band pain or patellophemoral pain, because we know males tend to get ITB and pain more than females do. We used to think that things like tightness of the iliotibial band, foot over pronation, whatever that might mean, or leg length discrepancies cause this injury, but evidence is now clearly suggesting that that is not the case. So it's it's typically an injury that is much more commonly seen in new runners, particularly those who ramp up the running volume quite quickly. So the new runner who is running a relatively high amount of volume, that's going to be the typically that runner who's going to be getting this injury. In contrast, more experienced runners or elite runners, they rarely get iliotibial band pain. And so again, our clinical reasoning should have us thinking that if we have an elite runner or a more experienced runner who's coming in who's got pain in this region, we should be probably thinking about some other injuries, such as a distal femoral bone stress injury, which is quite a bit more serious than iliotibule band pain. The other part of it too is that you know it's really helpful when we're trying to figure out who might get this injury to actually take a step back and think about why we have an iliotibule band and what loads that structure. And that can also tell us about what types of running might put more stress on this structure and might lead to this relative overload injury that we are starting to think that this injury actually is. First off, the ileotibial band is actually a distinctly human structure, which is really cool. So no other animal or mammals or animals have an iliotibule band. We actually aren't even born with one. And when we are born and we start, we become upright and we start walking, we start loading that side of our knee, the lateral side of our knee, and we develop an ileotabial band. But the reason why we have it is that it's this massive energy storage and release structure. And we use it a lot when we're sprinting, when we're running downhill. It also stabilizes the knee in the frontal plane. So it restricts various loads on the knee. So those frontal plane type of loads. So the type of runners that we see this with are particularly in trail runners. So actually, this is the number one injury that trail runners get, and that's because they tend to run downhill a lot. They might be running downhill quite quickly. Yeah. And they're also running on single track, and because of that, they're running with a narrow step width. And what that does is that increases frontal plane loads on the knee.

SPEAKER_02 5:38

I've got so many notes already. This needs more than 15 minutes. You start with the the females greater than males. Did it used to be that we thought that and there's being new research? And what changed in that research that revealed that?

SPEAKER_01 5:51

Yeah, it's it it was that we were, you know, I think that the data have switched from being retrospective data. So we were looking at people who actually had ileotibial pain versus we went back and other researchers have started doing these much larger prospective studies, meaning we looked at a lot of runners before they had an injury and then followed them over the course of time and to see what types of injuries they got. And that's a higher grade level of evidence to do a prospective type design. And using those types of designs with much larger sample sizes is now becoming apparent that males tend to get iliotibial band pain much more so than females do.

SPEAKER_02 6:28

Okay, that's good to know. And and then off of that, you spoke a little bit about over-pronation and valgus, which sometimes we thought because females do tend to display particularly the valgus, that could be one of the reasons. So if we canceled that out, when we think about the BPS model in general, do we still consider biomechanics for this? So if a runner comes in with ITB pain and they do display a big valgus and they do display a big pronation, is it meaning that there's no weight in that now? Or there is some weight, but it's just very minimized.

SPEAKER_01 6:59

So that's that's like another big change, too. We used to think this is a very biomechanically driven injury. We think now that it has much more so to do with like really rapid increases in training loads. And so when someone comes in, it is important to take a look at their running biomechanics. But yeah, I mean, if someone's pronating a lot, we probably shouldn't be paying that much attention to it. That's probably just an anomaly that has nothing to do with this injury. And rather than the knee diving in like a knee valgus, it's actually the opposite direction, which is knee verus. So a knee that kind of bows outward. Those types of forces are the ones that kind of, if you can kind of think about stretching this iliotibule band around that lateral knee, that's what's going to tend to cause this injury more. So but you know, that's a structure that's really hard to change. You really can't change that mechanic very well at all. So for me, it's not it's not a biomechanic that I pay a lot of attention to. So the main biomechanic that we tend to see with people who have ileotibule band pain are are runners who tend to take really big, very long steps.

SPEAKER_02 7:54

Yeah.

SPEAKER_01 7:54

And so this over striding type running biomechanic will put a lot of extra strain on the ileo tubial band. And so that's the main one that we're really looking for when we're doing a running gate analysis with this group.

SPEAKER_02 8:07

I like that. And you're taking me to this next place where if we imagine a knee virus and the ITB, if I inverted, commas stretching around that curve. Was there some change in the research whether this was a friction syndrome, an inflammation syndrome, or a could you touch on that a little bit?

SPEAKER_01 8:26

Yeah, exactly. So we used to think that this was this this friction injury, and that what was happening was that this this IT band was the strap structure that came down the lateral aspect of the knee. And as we flexed our knee, it would kind of flip back and forth across the lateral femoral condyle. And of course, then people thought, like, well, the tighter that that structure is, the more it's going to be kind of the friction is going to be greater as it's moving back and forth across that lateral femoral condyle. But what we've kind of seen lately is that we were now starting to think of it much more as this as this compression type injury. So back in that friction type model, what people were doing a lot was a lot of really aggressive stretching, perhaps a lot of aggressive soft tissue work. And again, I mentioned earlier, we used to think that a tight iliotibial band was related to this injury, but now we know that that's not necessarily the uh the case. And in fact, when we're looking at like this large energy storage and release structure, we actually kind of want to have a tight iliotibual band. So this idea that we want to have a looser iliotibual band is probably going to defeat the purpose of this structure. So we've really moved away from this idea that it's this iliotibial band tightness and it's much more something that's along the lines of compression. And we think that as the knee flexes, and if you haven't been running a lot and you suddenly ramp up your running, or you start doing some of those other types of running that I mentioned earlier, like very fast running, downhill running, and so forth, what that's going to do is that's going to increase compression on the lateral aspect of the knee in a manner that occurs too quickly for the knee to adapt to it. And we start getting irritation of the these highly innervated structures that are underneath the iliotibule band. That's, and that's kind of thought to be the source of no sooception and this type of injury. So we really have moved away from this friction injury and have moved much more so to this kind of compression type mechanism. And I think because of that, we need to make some changes in the way that we're treating this injury as well.

SPEAKER_00 10:13

So a quick pause here. If you want to get better at assessing and treating ITB pain, right now you can get the complete guide to ITB syndrome ebook by Paul Ingram for free. You'll get it when you start a seven-day free trial of practicals, which also gives you access to over 40 expert-led practical video sessions. The link is in the show notes. Start the free trial now to unlock everything, but hurry, as this offer won't be around for very long. All right, back to the episode.

SPEAKER_02 10:44

That was a really beautiful way that you explained that, Rich, in words that were not no sebic and very different to the biomedical model. So I definitely encourage people to listen to that back because I would feel completely comfortable saying 90% of what you just said to a patient, right? That was a really beautiful way to describe it that shifts a patient away from a structural narrative. So yeah, that that was real nice. Thank you for that. And you just touched on treatment. So how has your has your treatment shifted a little? You mentioned if there was an overstride, that might be something you look at. But what else are you looking at there?

SPEAKER_01 11:18

Yeah, well, again, you know, back when you think about the old model, this friction, we used to think that we needed to do a lot of soft tissue work or stretching, or you know, a lot of people were going to do a lot of foam rolling. But if you think about it, again, I mentioned that it was this, it's now thought to be this compression injury. So it doesn't really make a lot of sense to add even more compression to that structure because that's just going to increase irritability. Yeah. So we've really moved away from doing soft tissue work and compressive, like foam rolling and so forth. And instead, what we've moved to doing is kind of really lean into the actual purpose of the ileotibule band and try to enhance that capacity and get it prepared for the demands of running. And so I mentioned earlier that it's this massive energy storage and release structure, and it's supposed to resist lateral loads on the knee. And so we really want to start aiming toward that in the certainly in the latter half of our of our rehab. But the first thing we want to do is try to reduce the overall irritability of the structure and reduce pain for the patient. And the way to do that is focusing on loading above and below the knee. So a lot of hip abductor strengthening, perhaps some calf strengthening as well, and just do some gentle range of motion for that iliotibule band just to keep that or this person's knee moving. We also want to make sure that this person continues to move a lot. So I like to have people do a lot of uphill treadmill walking. And the reason why we like doing uphill treadmill walking is because we're not running downhill. And because of doing that, the loads on the iliotibule band are actually quite low when you're going uphill. And you also tend to take a wider base of support, which is going to reduce those frontal plane loads also. And so you can keep your patient very active. And so I tend to have like use a treadmill, I do five to 10% of an uphill grade and get them walking pretty fast so they can maintain their overall capacity and maintain their aerobic conditioning as well. So we start off with that. And then from when you know, once this patient is able to do some things, some important functional things, such as going downstairs without experiencing pain, that's our sign that this structure is kind of relaxed a little bit and chilled out a little bit. And now we can start putting some heavier loading on that area. And so for me, what we tend to do is we tend to do a lot of split squats, and we start off without using any weight. And then from there, what we'll do is we'll start adding more and more weight onto this individual so that they're doing some heavy split squats. Basically, what we're doing, we're treating it like a tendinopathy. And that's the way, that's the best way to think about this because it's it basically is a tendon. And so we want to work on improving the capacity of that. And just like Achilles tendopathy, which is going to respond the best to heavy slow resistance training in the iliotibule band is going to also. So the more we can do that, the better. One of the things that's a little bit different, and when we're doing our split squat, it's not the front leg that we want to be loading, it's the back leg. So the leg that we have up on a table or a chair. And we're going to be using that iliotibial band and the associated musculature. So the tensor fasciata and the gluteus maximus to kind of slowly lower us down. So we put a lot of pressure through the top of our foot as we're doing the split squat and kind of leaning backward just a little bit. And that's going to put a lot of load on that structure. So that's kind of that heavy loading part. And then eventually from there, once that person is able to tolerate some heavy loads, we're going to want to start adding in some plymetrics so we can then get, you know, restore that full capacity and doing the energy storage and release that we know that is being asked of the iliotibial band when someone is running.

SPEAKER_02 14:34

As well as the beautiful explanation, that's a really high-level clinical but practical things that people can do in their rehab. And I'm not sure many young physios would take an ITB patient to that end of rehab. I think the pain tends to subside, they get back to running. And you mentioned this that a lot of runners tend to have this irritating for a long time or it gets better and then comes back. Do you have any other views on that on why runners struggle? I'm guessing it's probably because they're potentially not doing rehab to that level.

SPEAKER_01 15:04

Yeah, I think so. I think I think people, like with a lot of muscoskeletal injuries, tend to treat the pain. And one of the easiest ways that people will kind of get after that would be like to completely offload the structure. And then by doing that, you lose capacity. And then things are starting to feel pretty good. And the runners like, oh, I think I'm over this injury. And then they'll go back to running and then they just get this injury again and they kind of get stuck in this kind of injury, de stress, lose capacity, try to start running again, re-injury kind of cycle. And then they just can't kind of get out of that because they kind of, you know, if you if you go back to the very beginning, this is probably a training load error. And these runners, they will tend to continue to make those same errors. So patient education is really important. And it's you know, a big part of that, I think, is keeping this runner as active as possible. And again, that's where I think that uphill treadmill walking can be super, super helpful. So they can still feel like they're getting a workout, maintaining their overall aerobic capacity. At the same time, they're not losing overall capacity as well.

SPEAKER_02 16:03

I love it. So, two quick questions that that I'll leave with is when you do change someone's running technique, you might mention that they are crossing the midline or close to the midline. Do you do that as a temporary measure to get them through that initial decrease of load and volume? And when do you make it permanent?

SPEAKER_01 16:21

Yeah, that's a super question. So we used to think that we needed to make some do some sort of gate retraining and we needed to change the way that a runner ran permanently. But now what we think of, we think of gate retraining almost like an adjunct, such as like like patelephemoral taping or something like that. And so it's just a temporary measure just to get this person kind of over the hump. And once they get back to running, then they can start to fade back to their old running style. And it's not going to be a big issue for them. So, you know, for us, we keep it super simple. We just typically just do an increase in running cadence because when you do that, it does two things. It shortens their stride length, but it also increases their step width. So we we don't tend to really spend a lot of time on queuing directly someone to run with a wider basis support.

SPEAKER_02 17:04

Yeah, that's a great pearl with cadence. A lot of those small errors or biomechanical issues can be resolved. The last question I had, Rich, was you touched on that we used to release the ITB, right? How would you explain that to a physiotherapist or a young grad who that still seems helpful? Why is that helpful or why does it appear that that seems to work in adverted commoners when we do a bit of an ITB release or a TFL release or a trigger point? Why do patients get up and they do a squat and it feels easier or they walk easier? How might you describe that to someone?

SPEAKER_01 17:39

Yeah, I mean, what that is, that's a very noxious stimulus for that person. And their central nervous system is receiving this very noxious stimulus and it's saying, whoa, that's really strong and it's gonna reduce their overall sensitivity. And so you kind of get this desensitization that's gonna last for maybe just a few minutes, maybe an hour, and then they're able to do a little bit more. So it kind of is like this temporary fix that doesn't really have any permanent, you know, it's not gonna stick around. But the other thing that that also does the same thing is heavy strength training. We know that that desensitizes tissue and it actually improves tissue capacity. So that's why we want to go with that because it's not going to increase the irritability in the long term, which is what a lot of soft tissue work will probably do for this injury.

SPEAKER_02 18:22

I love it. Thank you so much, Rich. That was a really killer episode. Could you direct people if they wanted to find out more about you or read more about this stuff?

SPEAKER_01 18:31

Yeah, you know, I you know, I think for me, the best place to reach out is at our Instagram handle, which is Montana Running Lab. And so I recommend everybody give us a follow, and they'll see lots of hopefully good educational materials that we put up pretty regularly.

SPEAKER_02 18:44

Thank you so much for your time today, Rich, and thank you for episode number two with us. Oh, excellent. Thank you so much for having me.