Graston Technique Treatments For Iliotibial Band Syndrome

IT band (Iliotibial band) Friction Syndrome

Iliotibial (IT) Band Syndrome is a common injury among runners and triathletes. Eventually, running's pounding miles overwhelms the tendon on the side of the knee creating dull or sharp stabbing pain. Initially the knee and leg feels tight and becomes increasingly sore. As the injury worsens, the pain increases and eventually stops a runner in his or her tracks.

Anatomy of Iliotibial Band

quadriceps muscle anterior labeled

The IT band is a large sheath of tissue, called an aponeurosis. The tough group of connective tissue fibers runs on the outside of the quadriceps and inserts on the lateral tibia (outside of the knee). The tensor fascia lata and gluteal muscles attach to the top part of it in the upper leg. The tensor fascia lata starts on the front aspect of the pelvis and inserts on the front of the aponeurosis, while the gluteal muscle starts in the back of the pelvis and inserts on the back of IT band. These muscles help stabilize the hip during walking and running. The wide aponeurosis becomes a narrower, rope-like tendon near the knee as it crosses the side of the femoral epicondyle. As the iliotibial band attaches to the tibia, its rope-like structure spreads out to a wide attachment site.

The muscles work to pull and balance on the IT band which keeps the "hip and knee from wobbling side to side." Hip and knee stabilization is very important to running efficiency and speed. When the muscle hip stabilizers fatigue they are unable to contract with enough force to stabilize the lateral movements of the knee through the IT band.

With increased muscle fatigue the knee "wobbles" even more, creating strain on the bottom part of the tendon that attaches to the knee. The bottom part of the IT band tendon absorbs a significant amount of force when running. As the knee wobbles inward, or internally rotates, the strain is increased. As the run continues, the strain on the knee continues to increase with each mile, leading to micro tearing of the tendon and tissue damage. The chronic repetitive stress and accumulation of microtears lead to larger tears, sprains, inflammation, and pain.

Iliotibial band friction syndrome is a condition that keeps people from running or finishing their race. A mild or moderate injury feels stiff and sore at the beginning of the run, but eventually disappears. A few miles later knee stiffness and soreness begins and increases throughout the race with increased tendon damage and inflammation. A dull ache becomes a sharp and stabbing pain. Eventually the body will stop you from continuing to damage the tendon by making the pain unbearable to walk on, let alone run. It becomes very tender to touch the outside of the knee, and every runner can cause sharp pain by rubbing or putting more pressure on the IT band tendon insertion or outside of the knee.

Causes of Runner's Knee

Runners and triathletes often experience iliotibial band friction syndrome with increased training mileage or volume, especially as they near peak training volume. Training plans increase weekly milage and volume throughout the plan. Near the end of training, the ramp up increases the mileage beyond a runner's previous weekly high. The increased training is challenging the muscles, tendons, ligaments, and joints beyond their structural limits.

knee model posterior labeled

Athletes have most commonly felt IT band symptoms when ramping up for their event, such as moving from a 5K to a 10K or from a half marathon to a full marathon. People describe chronic runner's knee symptoms whenever they reach a certain distance on long runs. They come into the clinic trying to prevent the knee pain from developing in this training cycle because they are very concerned it will prevent them from reaching their marathon goal.

Lateral knee pain is more likely to develop on uneven or hard surfaces that place more stress on the knee stabilizers. Rocky trails or hard roads with a side slant require more strength and endurance of the hip and knee stabilizers. The more difficult roads fatigue the muscles and create tearing in the IT band tendon insertion at the knee. A nice, soft, smooth trail is easier to run on and does not challenge the stabilizers like a rocky trail. Running 10 miles on a canal or lake trail is not as demanding on the ankle, knee, and hip stabilizer muscles as six miles on a rocky up-and-down mountain trail. Variations of terrain, rocks, tree roots, inclines, and declines wear out and fatigue the muscles faster, which increases the likelihood of micro tears, sprains, and strains. Likewise, running on a road with a slight curve near the curb keeps the ankle slightly inverted and increases the forces on the lateral knee and IT band. Runners who always run on one side of a road often experience pain on the outside of the knee.

Diagnosing Iliotibial Band Friction Syndrome

Your physician or chiropractor may order x-rays or an MRI to evaluate the knee bone, muscles, tendons, and ligaments. Advanced imaging may be needed if the examination of the knee reveals possible internal cartilage or joint damage. If the exam does not indicate any internal damage, your provider may pursue a trial course of treatment for ITB, and if you do not improve as expected then order the tests.

Differential diagnoses may include patellofemoral pain syndrome, patellar tendinitis, knee meniscus tears, quadriceps tendinitis, bursitis, stress fractures, hip labral tears, and low back injuries. Functional strength testing will be performed to evaluate stabilizer hip and knee strength and endurance, and appropriate strengthening exercises will be given based on weakness.

Graston Technique is utilized in many professional, Olympic, and collegiate sports therapy programs. Specifically-designed stainless steel instruments have rounded, concave and convex edges. The edges are not sharp. Graston tools are classified under Instrument Assisted Soft Tissue Mobilization (IASTM) and are used to detect and effectively treat soft tissue fibrosis or chronic inflammation. With these instruments the practitioner can scan over and detect areas of fibrotic tissue.

There are six different Graston tools to help break up fascial restrictions or scar tissue that develops after trauma to muscles, ligaments, tendons, or fascia, which is commonly referred to as soft tissue. Scar tissue forms when tissue does not heal correctly, or is under chronic, repetitive stress. Scar tissue is weaker than normal muscle and connective tissue, which is why it becomes chronically sore with activity.

What is Scar Tissue and Fascial Adhesion?

Scar tissue accumulates in the body whenever tissue undergoes excessive stress and strain. Scar tissue is like the body's duct tape; it is meant as a short term patch to help support tissue. However, in some cases the scar tissue is not replaced with normal collagen fibers. Scar tissue is also referred to as fascial adhesions, as it causes restrictions between the body's fascia. Stiffness, loss of normal range of motion and chronic pain develops from patches of fascial adhesions.

tissue progression

The next time a scar tissue patch undergoes stress and strain it becomes aggravated and flares up. This process causes more scar tissue to be added to the outside of the patch and the process repeats itself over and over, leading to larger accumulation of scar tissue patches.

I like to describe scar tissue patches as "onions." Scar tissue ends up growing in layers around the initial injury. Stress to the area aggravates the outside layers and triggers another layer to be formed. The layers further from the center are easier to aggravate than the inside layers, which is why the onion continues to grow in size without causing the inside area to properly repair.

Video: Scar Tissue Treatment with Graston Technique for Muscle Pain

How Graston Technique Improves Treatment

Adding Graston Technique to any treatment decreases overall treatment time. It reduces the need for anti-inflammatory medication and enhances rehabilitation. Many patients with chronic conditions show significant improvement with IASTM. Your provider is trained in how to properly utilize the instrument assisted soft tissue mobilization of either Graston, Gua Sha, and ASTYM. Basic concepts and treatments with IASTM:

GT therapy
  • Reduce the stress and strain to the injured areas.
  • Decrease inflammation.
  • Increase muscle flexibility and strength.
  • Increase blood flow.
  • Break up scar tissue.
  • Promote proper tissue repair.
  • Enhance functional movements.
  • Accelerate fibroblast activity.

Home therapies are recommended to limit further scar tissue formation, encourage proper healing and speed up recovery. Braces and supports may be recommended for specific injuries.

Pulling Fascia Apart to Break Up Scar Tissue

Graston Technique works by stretching the outer layer of the "onion" and breaking it into several pieces. The Graston instruments use shear force to pull the top fascial layer across the bottom fascial layer. This pulling motion breaks up the scar tissue between the layers. The broken scar tissue triggers healing mechanisms to migrate into the tissue and properly repair the muscles and soft tissues.

Ice therapy helps limit additional scar tissue formation, inflammation, and pain. The next office visits breaks up the next layer of scar tissue, working toward the center of the onion. The goal is to get to the center of the onion so the body can fix the original problem.

Many sports therapy chiropractors, physical therapists, doctors, and athletic trainers have been properly trained in how to utilize the Graston tools.

Expectations of Therapy

Graston Technique is not meant to be painful and should be performed at a comfortably tolerable level to break up scar tissue. Being too aggressive with Graston Technique, Active Release Technique, manual therapy, cross friction therapy, or massage therapy causes excessive pain and actually slows the repair process by flooding the area with inflammation.

Treatment usually lasts a few minutes per area or region. As the treatment tool slides across the soft tissue fibrotic areas, the injury may feel "bumpy or sandpaper-like." Redness and mild swelling may develop with treatment, especially after the first few treatments. In some cases, small petechiae or bruises may develop post-treatment. Ice therapy is commonly utilized post-treatment to limit the bruising, pain, and inflammation.

Most people notice a significant difference after 4-6 visits. Severe cases may take a little longer to see significant improvement. Runners, triathletes, and weekend warrior athletes have all benefited from this therapy. Over the course of treatment, most patients notice that less bumpiness, sandpaper, and tenderness is felt around the injury. As the treatment progresses, your healthcare provider will be able to apply more pressure, thereby treating deeper and deeper tissue levels.

Conservative Treatments Combined with Graston Technique

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, or Active Release Technique combined with Graston Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are integrated with therapeutic exercise and flexibility programs.

Soft tissue treatments restore proper muscle function and flexibility; and exercise restore strength, endurance, and neuromuscular control. Neuromuscular control is especially important and often not emphasised in many therapy clinics.

For any joint to work optimally the muscles need to contract and the exact right time. In many chronic injuries the muscles are not "firing" correctly leading to excessive strain on neighboring muscles and tendons. Many chronic rotator cuff injuries are the result of poor neuromuscular control.

Evaluation of Walking and Running Gait

The two legs function as a system for movement. Injuries in one area area of the system are commonly associated with poor joint stabilization in the foot, knee, or hip. This leads to poor alignment and excessive forces being placed onto muscles and tendons. Knee injuries and Iliotibial band friction syndrome is common in runners because of weakness and poor stabilization of the leg and hip muscles. These runners have a combination of muscle weakness, poor coordination, and altered gait mechanics.

Leg sprains and strains usually cause injuries in multiple areas in the leg, one spot usually just hurts more than the others. Many people develop back or knee pain because of dysfunction in walking or running gaits. Overcompensating to protect an injury or weakness eventually overwhelms the compensating muscles and tendons leading to pain.

Many knee injuries are direction related to weakness in gluteus medius and hip stabilizers; which causes excessive internal rotation of the knee while walking or running. A lack of hip stability increases the impact forces that travel up the leg and into the knee joints. Dysfunction in the vastus medialis and vastus lateralis muscles of the quadriceps further increase the internal rotation. If the foot over pronates, the knee absorbs additional strain on the stabilizing muscles, tendons, and ligaments.

Treatments for foot pain often involve neuromuscular stabilizing exercises for the hip, knee, ankle, and foot; along with enhancing leg and hip strength and endurance.

Proprioception exercises quickly accelerate healing and help prevent future leg compensation injuries.

Medical Treatments

NSAIDs are often prescribed for the initial acute injury stages. In severe cases that involve multiple joint regions, muscle relaxers or oral steroids can be given. Trigger point injections, botox, or steroid injections can be treatment options. Prolotherapy or Platelet Rich Plasma (PRP) Injection therapy can enhance healing, especially with internal joint injuries or difficult tendon injuries. Pain management is not usually required unless stronger medications or advanced joint injections are required for treatment.

MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. NCV testing may be utilized in cases that also involve muscle, sensory, or reflex loss.

Lumbar disc bulges and herniations onto the spinal cord or nerve root produce different symptoms and location of symptoms. Pain radiating in the foot is one symptom; along with numbness, weakness, fatigue, loss of sensation, or reduced reflexes. Your chiropractor, physical therapist, occupational therapist, or physician will evaluate your condition and make a proper diagnosis and treatment recommendations. Ask them any questions you might have about your injury.

Many people do have arthritis or degenerative changes in their back, hip, knee, or foot joints. Arthritis does not mean you will always have pain in the joints. Degenerative arthritis means the structural integrity of the bones have changed which alters its gliding, sliding, and hinging motions. The more severe the arthritic changes the easier it becomes to aggravate the joint and produce pain.

Likewise joints may take longer to heal when joints they have significant joint cartilage and bone degeneration. Osteoarthritis and rheumatoid arthritis will also slow healing and recovery time. However, arthritis does not mean a joint will always be painful. People with severe arthritis can eventually be pain free. In fact many times incorrectly blame their arthritis as the source of their pain when it is actually coming from injured tendons.

This is especially common in knee pain, where people believe their daily dull and sharp pain is osteoarthritis or meniscus tears when much of the pain is coming from chronic knee tendonitis in the small tendons that insert around the knee joint and patella bone.

Graston Technique is especially effective at stimulating and enhancing tendon repair and eliminating chronic tendon pain.

Low level laser therapy is another treatment option for enhancing muscle and tendon healing. Class IV cold lasers stimulate the fibroblasts or healing cells to "work faster." Specific frequencies can also decrease inflammation in the soft tissues and inside of the joints. Combining low level laser therapy with Graston Technique enhances soft tissue healing and repair.

Graston Technique Enhances Treatment and Recovery

The lower extremity works as a comprehensive unit so you can rung, walk, squat, bend, or turn. You appreciate your legs when many basic and repetitive tasks at home, work, or the gym become impossible because of pain. Injuries to one area of the musculature often indicate that additional damage has been incurred by other muscles.

Many therapeutic exercises can help restore proper strength and endurance to the hip and leg muscles. Isometric exercises are often the initial treatment exercises. Followed by single plane rubber band exercises for flexion, extension, adduction, abduction, and rotational movements. Dynamic exercises involving stability ball, BOSU, Foam, and vibrational exercises enhance propioception and neuromuscular control. The more unstable of the surface the more effort and stabilization is required of all the lower extremity muscles.

Our Chandler Chiropractic and Physical Therapy Clinic treats patients with a variety of muscle, tendon, joint, and ligament injuries. The clinic provides treatment for runners, tri-athletes, and weekend warriors in addition to common headache, neck, and back patients traditionally seen in Chiropractic, Physical Therapy, Massage Therapy clinics. We work with all ages and abilities of the residents in Phoenix, Tempe, Gilbert, Mesa, and Chandler AZ.