Whitney Lowe:
Welcome to the Thinking Practitioner. Hi. This is Whitney Lowe and ABMP is proud to sponsor the Thinking Practitioner Podcast. ABMP membership gives massage therapists and bodyworkers exceptional liability insurance, numerous discounts, and great resources to help you thrive like their ABMP podcast, which is available at abmp.com/podcasts or wherever you happen to listen.
Til Luchau:
Even if you're not a member, you can get free access to Massage and Bodywork Magazine where Whitney and I, Til Luchau, are frequent contributors and special offers for Thinking Practitioner listeners at abmp.com/thinking Hey, Whitney, how are you doing there?
Whitney Lowe:
Very well, sir. How are you doing today?
Til Luchau:
I'm also good. I've been looking forward to our conversation. This is a perennial topic, you could say. This is something that one of those that doesn't seem to go away, even though it's different times some of us wished it would maybe.
Whitney Lowe:
[crosstalk 00:01:11].
Til Luchau:
Speaking for myself but I'm actually looking forward to the topic because I want to get your take on it and I got a couple updated ideas I want to share too. What are we talking about today, Whitney?
Whitney Lowe:
I believe we're talking about the iliotibial band today.
Til Luchau:
Oh, yeah. [crosstalk 00:01:28].
Whitney Lowe:
Fascinating facets of the ITB.
Til Luchau:
It's fascinating facets and there are some controversies around it, I think. What would you say about that? What are those, Whitney?
Whitney Lowe:
Yeah, if you kind of cruise through some of the social media posts, the research literature and the buzz around the ITB, you're likely to come across some significant disagreements and debates around there. There are some controversies around the ITB. There's, for example, I think some of this emanates out of the fact that just comes from palpatory analysis of the fact that we're always taught, as manual therapists, to try to soften tissues all the time. The ITB feels really hard most of the time on people. There's controversies around can we stretch it? Can we make it softer? Can we elongate it with manual therapy? Those are some of the things that we hear a lot about.
Til Luchau:
Yeah. Is it even physically possible, you're asking?
Whitney Lowe:
Yeah, yeah.
Til Luchau:
You're also saying something interesting. You're saying that just because we feel something hard, as manual therapists in our hand, can we soften it or/and I think you're implying, should we?
Whitney Lowe:
Yeah, that's a big question. I mean, for years, I know early on when I was taught a lot of this stuff and I kind of taught some of this early on too is this idea of like, well, we're working on the soft tissues of the body, so they should be soft, right? The reality is, some of them aren't meant to be soft. I fall on the side of the fence that's saying, I think we've been overdoing it with trying to do things to the iliotibial band [crosstalk 00:03:09].
Til Luchau:
You can draw a hardline around that do you?
Whitney Lowe:
Yeah.
Til Luchau:
Softening?
Whitney Lowe:
Mm-hmm (affirmative).
Til Luchau:
But in any case, there's also the fact that for massage therapists, other sorts of manual therapists, for sure, we feel things, "soften with our hands," and people feel better.
Whitney Lowe:
Yeah.
Til Luchau:
It's not really simplistic. Maybe almost unconscious level, we start to assume and I think a lot of our models did or have assumed that just softening it is improving it.
Whitney Lowe:
Yeah, right.
Til Luchau:
That leads to that thing you were talking about, like, if I feel something hard, then it's a problem and I should soften it. Yeah, the controversies are can we and should we?
Whitney Lowe:
Mm-hmm (affirmative). I think the question that comes up that certainly came up for me and we'll explore this in a little bit more detail when we looked at this anatomically, I've sort of wondered years down the road, when we felt changes in that aspect to the lateral thigh when we were working on it. Did we actually even change the iliotibial band or are we changing the vastus lateralis, which goes all the way underneath it and it definitely is a tissue much more responsive to changes in sensation than we might be feeling in the [crosstalk 00:04:14].
Til Luchau:
The vastus lateralus underneath it. The foundation, the muscular foundation we're feeling underneath that. Interesting.
Whitney Lowe:
Yeah.
Til Luchau:
Then, I guess last episode, Robert Schleip, talked about this some. He gave a couple of views on what might be happening when he feels softening. He also described it, interestingly, as a North American social media controversy.
Whitney Lowe:
Yeah, which I thought that was interesting.
Til Luchau:
I had to chuckle. I had to chuckle. I think there's something to that perhaps that certainly is controversial in social media. I think maybe that might extend to our friends in Australia because I know that's been controversial there as well.
Whitney Lowe:
Yeah.
Til Luchau:
But I think probably there are certain subcultures where these questions are more hotly debated than others, perhaps, put it that way.
Whitney Lowe:
Yeah. Yeah, that certainly could be.
Til Luchau:
Okay, we're going to share our views on those controversies, I think, as we go along, is that right? Because I want to-
Whitney Lowe:
Yeah.
Til Luchau:
I want to hear what you think about that.
Whitney Lowe:
Yeah.
Til Luchau:
You want to tell us something about what it is first? What is that iliotibial band?
Whitney Lowe:
Yeah. An interesting thing I noticed, for me, this was really one of those fascinating things that I sort of learned and first saw. The first time I was in a cadaver lab, I was quite astonished and taken aback by how thin the iliotibial band is in a lot of people because the anatomy books, with a number of different things, but the anatomy books can sometimes tend to mislead us a little bit about what things really look like because it always is illustrated as this big thick mass going down the side of the thigh. I was quite surprised how thin it actually is.
Til Luchau:
A discreet band of fibers that has color different than things around it is how it looks in, say, [inaudible 00:05:58] or things like that.
Whitney Lowe:
Yeah. That's one of the things that I think leads to the first thing I want to talk about misunderstanding in relation to the iliotibial band or maybe lack of understanding around it is that it isn't really so much a discreet band by itself, but it is actually part of a cylinder of fascia connective tissue that surrounds the entire thigh called the fascia lata. There really is a, you really want to think about it as like maybe one section of the sidewall of this cylinder, which is a lot thicker, but it's part of that whole connective tissue cylinder surrounding the thigh.
Til Luchau:
Like a stocking or like a wrapping of the leg and then the iliotibial band would be the fibrous portion of it.
Whitney Lowe:
Yeah, like that analogy. Maybe you got a stocking and you spray some sticky kind of firm stuff on one side of the stocking and it gets stiffer and stronger than the rest of the soft stocking around there.
Til Luchau:
Nice. Is it fluorescent color, the stuff we're spraying on our stockings?
Whitney Lowe:
Oh yeah, yeah.
Til Luchau:
Okay. It's fine.
Whitney Lowe:
The IT band is also fluorescent. You may not know this, but you can glow it in the dark sometimes.
Til Luchau:
That's why we can see it so well and dissect it. Now, are you familiar with the idea of [crosstalk 00:07:14]?
Whitney Lowe:
Caveat, that is not true for [inaudible 00:07:16].
Til Luchau:
Speak for yourself.
Whitney Lowe:
That's right.
Til Luchau:
Anyway, are you familiar with this idea that the iliotibial band is a T-shaped structure and seen in cross-section?
Whitney Lowe:
No, tell me about that.
Til Luchau:
Well, gosh, I got to pull up the reference and I'll put it in the show notes because I know that this was an actual study.
Whitney Lowe:
Oh, yeah, we're talking about like the anatomical attachments like to the linea aspera down the femur and everything like that [crosstalk 00:07:41].
Til Luchau:
Correct. That's right. That's right.
Whitney Lowe:
Yeah. Tell us about that. Yeah.
Til Luchau:
Well, it's basically, again, we think about it as a stripe painted on the side of our stocking but if you're going to do a cross-section of the femur, you can see that it actually is contiguous with the septum that goes down between the muscles and attaches to the femur, along its whole length. It's not just like a discreet band floating out there on the edge of your thigh is actually a T-shaped structure that's attached to the femur [inaudible 00:08:05].
Whitney Lowe:
Yeah, yeah. Interestingly, a couple other resources that I was reading some stuff on iliotibial band spoke about the upper portion of it acting more tenderness and the lower portion of it acting more ligamentous. For example, as you noted, the connections over to the femur may have a lot more to do with transmission of forces from gluteus maximus and tensor fascia lata to the femur and the upper portion of the thigh and the lower portion of the IT band acting more like a ligament in stabilizing the knee...
Til Luchau:
A new ligament.
Whitney Lowe:
... during [inaudible 00:08:40] activities, which we're going to get into in a little bit but yeah, that's fascinating as well.
Til Luchau:
Yes. Then, I've actually read the opposite where they wonder about, I think you're going to tell us some about pain around the lateral knee that being due to say tendon-like responses in the iliotibial band itself, as well as some other things around it, which I hope you'll tell us about as well.
Whitney Lowe:
Yeah. What else here on an anatomical thing? Generally, in most anatomy books, the distal attachment of the iliotibial band is noted as Gerdy's tubercle on the tibia, Gerdy, G-E-R-D-Y, Gerdy's tubercle on the tibia. Hey, do you know who Gerdy was, by the way?
Til Luchau:
You got me. This is-
Whitney Lowe:
No, you got me. I don't know. I was just curious if you knew.
Til Luchau:
Well, and this is different than what I just said about it being attached to the whole length.
Whitney Lowe:
Yeah.
Til Luchau:
You're saying that it's a classical attachment. You can look up Gerdy's tubercle on the tibia and the distal end of that, obviously, which attaches on across the knee.
Whitney Lowe:
We would consider that as probably one place where a bunch of the lower portions of the IT band attach but as you noted, that's not the only place at all. It's along the whole length of the femur. There's connections into the femur itself, as well as there are fascial connections in with some of the patellar retinaculum. We got to remember, these things aren't just one small discreet location but there's other ways in which those forces are dispersed along the length of that iliotibial band to other adjacent structures there.
Til Luchau:
Things are connected, especially as we start to talk about, I mean, it's interesting the iliotibial band is a fascial structure that has a name. There are fewer of those, perhaps, than muscles. I wonder if we added up the number of named fascial structures and the named muscles have [crosstalk 00:10:28].
Whitney Lowe:
I think it could be far less than the number muscles probably.
Til Luchau:
Yeah. Thank you for confirming my guess around that but that's the problem with naming fascial structures. Of course, they are connective tissue. They connect everything.
Whitney Lowe:
Yeah.
Til Luchau:
It's hard to draw the lines and say, "Okay, here's where this starts and stops."
Whitney Lowe:
Yeah. Hopefully, as we delve deeper into some biomechanical research in the future, we can, one of the things that I've always been fascinated with as we look at all these connections, is having a better understanding of what percentage of load is transmitted to all these different places.
Whitney Lowe:
For example, you talk about Gerdy's tubercle being the main location where the IT band connects, but if you look at some of the biomechanical studies about the function of iliotibial band, they're talking about tensile loads changing with different angles of knee flexion. It's more on the anterior fibers in certain knee positions and more on the posterior fibers in other knee positions.
Til Luchau:
Yes.
Whitney Lowe:
I'm curious to know more about that as we learn more about the function of those connective tissues.
Til Luchau:
You're talking about knee positions, meaning degree of flexion or extension of the knee?
Whitney Lowe:
Yeah, mm-hmm (affirmative).
Til Luchau:
Okay, because then there's abduction, adduction of the hip too which is thought to change the force that's going through that structure.
Whitney Lowe:
Yup, absolutely, as does knee positions and I think you'll mention a few things about this too, with genu valgum and genu varum, the knock knee or bow legged position. If you imagine, in particular a bow-legged individual, which is referred to as genu varum, that IT band is a bit more bow strong around the outside edge of the thigh and knee in a genu varum position than the bow-legged position. Those static positions, in addition to gait mechanics, can certainly have an effect on ITB force distribution.
Til Luchau:
Well, is it time to bring in a point of view yet?
Whitney Lowe:
Yeah, let's do.
Til Luchau:
What you're saying there is the bow strong idea that if your knock kneed or bow-legged, your iliotibial band will have a different tension to it or have a different contributor there with the idea that if it's tight, it might actually bow your leg sideways and give you like a valgus pattern like a knock kneed pattern, I assumed that, as [inaudible 00:12:47], especially, we were really looking at what didn't lengthen, what was short and how that tensegrity model of that tension and compression force is going to be bouncing out across the joint like the knee.
Til Luchau:
There's something to that, and yet, it has liberated my thinking and helped me drop another level and my understanding, I think, the question that assumption to say that just because a knee is valgus, "Is that iliotibial band tighter?" Then, that dovetails with the question of like should we even stretch it. The other point of view being well, maybe if it's tight, it's because it's helpful for it to be "tight." Maybe it's a spring more than say, a muscle, that's not relaxing.
Whitney Lowe:
In fact, a number of the studies that are looking at iliotibial band function say that it does appear to be playing a very prominent role in knee stability during certain phases of gait, especially in the deceleration phases of the stance, portion of gait.
Til Luchau:
That makes a lot of sense to me.
Whitney Lowe:
Yeah, that seems to reinforce the idea that it's really meant to be tight with tension on it to help in stabilizing the knee in certain activities.
Til Luchau:
This makes sense to me because I was just walking down a steep mountain with a backpack on and stepped around a bush and did a funny little thing and kind of almost went down onto my knees and had to decelerate that forced kneeling thing.
Whitney Lowe:
Yes.
Til Luchau:
That's like right where I felt it, right in the lateral knee thing. It was like helping me stabilize that moment in time.
Whitney Lowe:
I'm curious, after that point, did you continue to have discomfort in that knee as you continue to go downhill?
Til Luchau:
It was sensitized. I kind of walked it off as it were, but I could feel like, okay, that got a little happy, minor strain or a little aggravation in there. No lasting effects at all but it definitely lit it up in my awareness for a little while.
Whitney Lowe:
Yeah. Another interesting hill walking story, ITB friction and we'll talk about this problem a little bit later on here but lateral knee pain with the ITBs, as we noted, is frequently associated with either running or walking activities but especially the deceleration phase going downhill and I was hiking with a friend of mine. We were hiking up South Sister, which is a mountain nearby us about 10,000 feet. It's a pretty good climb up there. We were no longer spring chickens. We were a little bit farther down the road of [crosstalk 00:15:15].
Til Luchau:
... chicken worry for you.
Whitney Lowe:
I'm thinking when this happened, I was probably late mid to late 40s or something like that. My friend was a little bit older than me. Anyway, we hiked up the mountain and on the way down, he began to have just a screaming case of ITB friction syndrome, unilateral knee pain. I had learned this in an Orthopedic Clinic when I was working two years ago, I said to this guy, "Look, I know this is going to sound really weird and you're probably going to tell me I'm a nutcase for doing this and trying to do that but if you want to get down this hill without as much severe knee pain, if you walk backwards, you won't feel that knee pain because it changes the mechanics of the way it loads the IT band and he did walk probably halfway down the rest of this mountain backwards."
Til Luchau:
If it hurts, you win. Did you have him put his backpack on his front?
Whitney Lowe:
Luckily, we were just day hiking.
Til Luchau:
Okay.
Whitney Lowe:
Yeah, he wasn't carrying a load. He wasn't carrying a heavy backpack.
Til Luchau:
That's good. That would totally change the dynamics, wouldn't it?
Whitney Lowe:
Yeah. If you're a person with ITB friction or lateral knee pain from iliotibial band and you're wanting to continue your activities, just turn around and do it backwards. It may change it for you.
Til Luchau:
You know a lot about this ITB friction thing. Do you want to jump into that or anything more you want to tell us about?
Whitney Lowe:
Yeah, I think we kind of covered a lot of the main things that we were focusing on with anatomy. So let's talk about some of those things that how the ITB is frequently involved with certain types of pain complaints. I keep mentioning this thing with ITB friction syndrome, it is a condition that does tend to affect quite a number of people, especially if your runners or doing active work.
Whitney Lowe:
Some of the studies about it indicated anywhere from 12 to 16%. I saw these numbers for the number of people who developed this lateral knee pain from iliotibial band involvement in people who are runners, a pretty common thing. It's often reported as like the second most common running overuse injury.
Til Luchau:
Okay, now I'll just throw in assumption of mine, not based on much. I work here in the Boulder area and we have a lot of athletes, a lot of runners and I somewhere got the idea that it's mileage-dependent, that you get it more frequently in high mileage runners, it's more common, say in marathoners than others and that in my estimation is not that common in anybody else, that seems to be a high mileage runner thing. Is that fit with what you know?
Whitney Lowe:
I don't know if that is supported by the literature of how frequently it occurs but that would make sense to me because it does tend to be an overuse injury of repetitive loading on those structures. The longer your mileage is, it would seem the more likely you would be to develop that.
Til Luchau:
People don't get it sitting around listening to podcasts, for example.
Whitney Lowe:
Tend to not do that.
Til Luchau:
Yeah.
Whitney Lowe:
Unless they're in a very awkward chair position and leaning on their lateral knee region and irritation.
Til Luchau:
We should do an episode on podcast injuries or podcast risks.
Whitney Lowe:
Yeah, that be [crosstalk 00:18:20].
Til Luchau:
This one won't be on the list. Let's make sure we cover it today. What else about ITB friction syndrome?
Whitney Lowe:
Yeah, a couple other things here and this kind of goes back to anatomy for just a second. The iliotibial band friction, historically, was somewhat blamed on irritation of a bursa underneath the distal iliotibial band. There was suggesting that there was a bursa that was getting squeezed between the distal iliotibial band and the lateral epicondyle of the femur during repeated flexion and extension movements. During flexion and extension, the iliotibial band would rub back and forth across that greater skinny lateral epicondyle of the femur and the bursa underneath there would become inflamed and irritated.
Whitney Lowe:
A couple of recent anatomical studies have called that into question saying that they in fact did not find a true bursa underneath the distal iliotibial band, but instead found a fat pad under there, which attended to be richly innervated. It was an irritation of that sensitized fat pad that was likely causing some of the lateral knee pain from the activities there.
Til Luchau:
There was a lot about this, say five, six years ago when this was coming out. Does that change the way you approach it at all, Whitney?
Whitney Lowe:
Not really.
Til Luchau:
[crosstalk 00:19:41]?
Whitney Lowe:
My perspective on addressing this is still kind of the same of like, let's see what we can do to reduce the load on there. One of the things that's interesting for understanding some of the more fine points of the biomechanics there is a recognition and understanding of something called the screw home mechanism of the knee. When you move your knee in flexion and extension, it isn't a pure sagittal plane movement of just moving straight forward and back.
Whitney Lowe:
This has to do with the difference in size of the femoral condyles, with the medial condyle of the femur being a little bit larger than the lateral femoral condyle. As a result of that, during the very end of extension, usually about the last 30 degrees of extension, the tibia rotates externally, and it sort of locks into position and we call it the screw home mechanism.
Til Luchau:
External rotation on extension, the two Es. That's how I remember.
Whitney Lowe:
Yes. Again, to clarify that is external rotation of the tibia in relation to the femur, in what we call an open chain position, which means the body is not weightbearing. If you are weightbearing, the reverse will occur, which is essentially, this is a weight bearing position is called the closed-chain position. If you are with your feet on the ground and standing up straight from a bent position, your knees moving into extension but because the foot is firmly on the ground, the tibia won't rotate. Instead, the femur will internally rotate at the very end of that movement.
Til Luchau:
Our terminology is the opposite, the movement is actually the same.
Whitney Lowe:
The movement is the same and the terminology how we reference it is, is somewhat different there. Now, the reason that that's important is during flexion movements of the knee and this is what tends to happen, as you noted, during the downhill portion of that stance, where you're decelerating your body, your knee is moving slightly into flexion, as your knee moves into flexion, the tibia internally or medially rotates and as it does, it pulls Gerdy's tubercle around toward the midline of the body. That increases-
Til Luchau:
You can feel it.
Whitney Lowe:
Yeah.
Til Luchau:
I can feel it my left knee as you describe it.
Whitney Lowe:
Yes.
Til Luchau:
Interesting.
Whitney Lowe:
That increases the tensile load on the entire iliotibial band and then consequently, anything on the lateral side of the knee gets compressed, actually, against the bone in that position because you're sort of pulling those tissues taut across the protruding epicondyle.
Til Luchau:
Stretching and wrapping around those bony prominences.
Whitney Lowe:
Yeah. This is one of the things as the anatomists look at this and the biomechanical specialists looked at this process, it changed at least some people's idea of the primary aspect of this pathology. Also, as you mentioned earlier, these anatomical connections from the iliotibial band to the femur make it less likely that the iliotibial band is rubbing back and forth across the femoral condom because it's firmly anchored down there to the femur along this line.
Whitney Lowe:
There's not as much side-to-side movement across the lateral epicondyles as we might have once thought, but there is a change in compression and relief of compression, compression relief of tension, compression relief of compression during that flexion and extension cycle and that may be what's irritating the underlying fat pad underneath there during those movements. Maybe, there's just a little bit of that rubbing back and forth across just maybe not as much as we originally thought.
Til Luchau:
Well, and I think most, this was a big say, maybe it was a social media, I mean, it's more of a Twitter battle but there was a lot of controversy around this question of is it compression or is it friction? Is that band sliding around, which was the conventional story or is it a compression of the taut band pulling against the bony landmarks?
Whitney Lowe:
Yeah.
Til Luchau:
Most of those discussions that resolved, at least, came to the idea of, well, maybe it's some of both or maybe it doesn't matter, that there's an irritation for sure. There's pain there for sure with probably compression factors and maybe friction factors as well, although less perhaps than conventionally thought. By the way, that did change the way I approached that lateral knee pain there.
Whitney Lowe:
How does that change for you thinking about that?
Til Luchau:
Well, when I was thinking about the bowstring analogy, like let's say that long band as I imagined [inaudible 00:24:16] crossing the knee there and a compression there getting wrapped around the bony prominences, I would logically then want to "lengthen" the band or how would it be less taut pulled against those prominences less acutely.
Whitney Lowe:
Yeah.
Til Luchau:
If I start to think about it like a local irritation, perhaps, especially with this idea that maybe it's attached along the whole femur, then it becomes more about local tissue response sensitivity and maybe hydration. My work, realizing that the classic work of just say rolling the iliotibial band or even like with a forearm snowplowing down the side of your leg there, maybe there's less of a clear rationale for that than it would be for lifting or skin rolling or even a hydrating idea of opening up the layers there to let fluids perfuse the zone and help resolve any local inflammation in the fat pad there or in the subcutaneous layers and maybe increased tissue hydration, so that there's more slides.
Til Luchau:
Even if there is a friction aspect, maybe that stimulation of hyaluronic acid production with fibro, the fascist sites or something like that, whatever we're doing through either stretching or lifting, maybe that actually increases the tissue glide. There's less of the potential for friction as well as less of that inflammatory reactivity.
Whitney Lowe:
Yeah. It's kind of gets back to us talking about maybe trying to create the ideal environment for optimum function of those tissues. Like you said, making a little bit more capability for some, the necessary level of appropriate slide and glide but still, maybe kind of, at least for me, my perspective is migrating away from this idea that we're doing something to the band and making the band more extensible because if you go back and think about this mechanically, the purpose, the primary functional purpose of the iliotibial band, is to maintain and increase knee stability, which means it has to pull on something firmly to transmit those tensile loads around the knee.
Whitney Lowe:
If something is really extensible, and able to elongate from some forces applied to it, especially those kinds of forces that we might apply with manual therapy, then it's going to be far less efficient at transmitting that tensile load down there to stabilize the knee. It seems like it's really-
Til Luchau:
You don't want a rubber band around your knee. You don't want rubber bands around your knee. You want something firm.
Whitney Lowe:
Yeah, you want cables. Yeah.
Til Luchau:
Cables?
Whitney Lowe:
Yup. It has certainly spawned the profusion of commercial activities with things to do stuff to the iliotibial band, whether that's foam rollers or massage tools, are all kinds of things that people do advocate to try to work this band and soften it up but that's still quite a thing out there. Maybe that is the North American social media phenomenon that Robert Schleip was referring to possibly.
Til Luchau:
Well, yeah, it could be, but, okay. How much should I get into this? I mean, maybe the rationale of lengthening the band isn't really one that I go by in my work but that is a sensitive structure. The higher side of the leg, especially down at that distal end around the fat pad or whatever, highly innervated, highly sensitive, and it's sensitive, in my mind, because it senses. It's our lateral sensor. It's the little thing that tells us what our knee is doing, what our hip is doing, what our whole body is doing and standing, walking, running, et cetera.
Whitney Lowe:
Yeah.
Til Luchau:
There's ways that as a sensor, as a musculoskeletal fascial sensor, I'm really interested in bringing it into the body schema through my work and sensation is one way I do that. Sensation is my paintbrush for the paintings I draw along the clients' brain or the way I recolor their irritated zones of their brain or whatever it is. Sensation is useful as a really sensitive structure. I will work it but again, it's different purpose there, a different idea. I'm not thinking of stretching it like a rubber band, I'm thinking about using its sensitivity to talk to the brain to normalize the brain's reactivity or responsiveness to that.
Whitney Lowe:
Interestingly, along those same lines, one of the studies that I was reading was referencing a very high number of sensory receptor cells in that fat pad underneath the iliotibial band that was reading levels of compression of the band against the knee that's probably doing some things to help monitor the overall tension levels on that.
Whitney Lowe:
I think we touched on this earlier, but I just want to reiterate for everybody thinking about the band really that the monitor that's changing those levels is the tensor fascia lata and gluteus maximus muscles. They're the ones that are giving the main pulling force to the upper level of the band that we can perhaps alter and change that may alter and change the level of tensile load on that band.
Til Luchau:
Okay, yeah, you're saying if we are interested in changing the compression forces there at the knee by reducing the tension on the band, maybe the muscle components, the upper hand are the places to think about?
Whitney Lowe:
Yeah.
Til Luchau:
That fits with my thinking and my approach too for sure.
Whitney Lowe:
Yeah, it seems to me to be the most likely place where we can make an intervention and have some kind of effects in there.
Til Luchau:
In fact, I'm saying that this is a good opportunity. We should mention the handout we're putting together for this episode. One of the things I'm going to put in there for sure is a tensor fascia lata technique with just that idea in mind that we're actually changing the thing that pulls on the band-like structures.
Whitney Lowe:
Yeah.
Til Luchau:
That'd be one of the things I'll put in the handout from my side.
Whitney Lowe:
Yeah. Excellent. I think I've got a couple things I was going to put in there as well. That's certainly, that'll be helpful for elaborating on some of these ideas.
Til Luchau:
Absolutely.
Whitney Lowe:
Yeah.
Til Luchau:
What else do you got, Whitney? What else do you want to talk about?
Whitney Lowe:
Well, a couple other things that I want to mention just briefly, a couple things in particular that mimic iliotibial band pain and are often mistaken for ITB pain that people may jump in and try to do something about that you can have pain in that area. I'm always a big one on trying to distinguish and identify what the primary cause is whenever we can, so that we don't, for example, do something inappropriate or we missed the mark and we're ineffective because we missed what was happening there.
Whitney Lowe:
A couple things I'm just going to highlight here, there is a pretty, well, it was a couple bursa just on the lateral aspect of the hip, the trochanteric bursa in between gluteus medius and the femur as well as gluteus maximus and the femur and those bursa that can become inflamed and irritated and cause lateral hip pain that may be mistaken for iliotibial band pain.
Til Luchau:
Especially if you scrimped on your camping pad from REI and you got a tooth in a pad and you're sleeping on your side on the ground.
Whitney Lowe:
You're a side sleeper. That sounds like something from experience there that you have.
Til Luchau:
Absolutely. Well, here in Colorado, I mean, I can't, there's been more than a few people and it tends to be age related. Those of us as the years go by getting more sensitive in sleeping on our sides, on hard surfaces, that side of the hip seems to get more easily irritated from that, just the direct pressure there probably on those bursal structures that you're talking about.
Whitney Lowe:
Right. That would be one, hopefully, we would pick a lot of that up in the history of something doing some kind of activity would cause pain and discomfort out there. There's also some of the trigger point referral patterns from especially gluteal muscles, hip and gluteal muscles that may also refer down to the lateral aspect of the thigh and be mistaken for kind of aching kinds of pain along the iliotibial band region themselves.
Whitney Lowe:
Sometimes I used to do this very early on before I learned a little bit more about the anatomy and mechanics there, just trying to go in and work all those areas where the pain was being felt. That was just probably irritating some of the IT band because it's really, it's sensitive all along its whole length there, too much pressure from [crosstalk 00:32:29].
Til Luchau:
This is important. You're saying that sometimes somebody could feel pain of let's say, their lateral thigh, iliotibial band and by working it, you could irritate it or make it worse and maybe that pain is a referral pattern, you're saying, from gluteal structures?
Whitney Lowe:
Yeah. Right. You could kind of sensitize some of the neural receptors in that area from working something and especially if you kind of take this attitude like, well, yeah, it's going to hurt good now, but we'll work this stuff out and we'll soften it up later on when that may not necessarily be occurring in there.
Til Luchau:
Which is also an unhelpful assumption if there is any kind of inflammatory reactivity going on too. There is some add fat pad irritation or other sorts of things happening there or strain, of tissue strain. Again, it might feel really "good" because it's giving some strong sensation there in a moment but the question is, what happens later? Does that help resolve or does it keep it irritated, which by the way, I got to stick this in, sorry, this is one of the objections say to foam rolling or one of the concerns about foam rolling, for one mechanical plausibility was questioned, can you lengthen... If your goal was to try to lengthen the iliotibial band, can you do it with a roller or even if your goal is to differentiate it can you do with a roller?
Til Luchau:
I mean, per Greg Lehman's analogy of lengthening, sorry, how do you say, lengthen the iliotibial band is like trying to fillet a chicken with a rolling pin.
Whitney Lowe:
I like that.
Til Luchau:
Probably not. You're probably not lengthening or differentiating it. You're mashing it with a roller and in my view, maybe that's okay except that if you just keep doing it and you keep irritating it, you keep something sensitized because it feels really intense and it has that kind of satisfying experience in the moment then that could be, you could be keeping yourself in that situation, self-perpetuating pain.
Whitney Lowe:
Right. The other one I want to call attention to and this is one that I sort of only a few years back became aware of as a prominent problem and actually had this issue myself and was kind of surprised to find the similarity and relevance.
Whitney Lowe:
This is compression of the lateral femoral cutaneous nerve, which is a moderately small sensory nerve that goes across the top part of the iliac or the anterior aspect of the iliac crest underneath the inguinal ligament and then supplies the skin over the lateral thigh, so directly over the iliotibial band and it's pretty common to have compression of that lateral femoral cutaneous nerve from tight jeans, tight belts or occupational like a policeman wearing a heavy belt with gun holsters and all that kind of stuff and you can compress that lateral femoral cutaneous nerve and get this dull, constant aching pain over the lateral thigh region.
Whitney Lowe:
Then, you try to go in and work that area and that's not going to get results because that's not where the problem is occurring. The problem is occurring with compression right across the anterior aspect of the hip near the inguinal ligament.
Til Luchau:
You're talking about right at the ASIS and below.
Whitney Lowe:
Yeah.
Til Luchau:
Fascinating.
Whitney Lowe:
Yeah.
Til Luchau:
Cool. Stuff we'd wear could be a fracture as well.
Whitney Lowe:
Yeah. Actually, I found this getting irritated for me from some jeans that were relatively tight and I was sitting a lot cross legged in these relatively tight fitting jeans. That's what was squeezing my lateral femoral cutaneous nerve. I went through a period of saying, "I'm going to just instead of wearing my jeans around all the time, I'll wear like sweatpants that are really loose," and then do some gentle, easy kind of myofascial or dermal neuro modulating type of skin drag techniques over the top of that lateral femoral cutaneous nerve to try to settle it down, try to make it a little bit more mobile and decrease the compressive loading across that area. You'll find that to be like the thing that worked after years and years of trying to poke in on my TFL and work on trigger points around the area and found nothing really working with addressing other strategies for soft tissue involvement there.
Til Luchau:
Beautiful. This skin drag was in the areas of sensitivity or were you tracing the nerve anatomy or how will you [crosstalk 00:36:48]?
Whitney Lowe:
No, it was following the nerve anatomy because the area of sensitivity was lateral thigh and down the thigh and where I was working is right across the anterior thigh region, not at all where the pain was but where the nerve is most likely to be getting compressed there as it's passing under the inguinal ligament across the anterior hip region.
Til Luchau:
That skin drag, I assume, was really light? You weren't particularly being-
Whitney Lowe:
Yes, very light, just [crosstalk 00:37:10].
Til Luchau:
Using a rolling pin or no?
Whitney Lowe:
No, just using fingertips and contacting the skin and pressing down in an inferior direction, just with the kind of off press and hold for a few minutes, let go and then do some gentle movement, just try to do that frequently. That, in combination, with decreasing the aggravating loads on there.
Til Luchau:
Was there any immediate sensory response on your part as your own client? I mean, could you feel it when you had it or you're using your knowledge of anatomy to mobilize those layers and you felt that later?
Whitney Lowe:
I would say both of those things that were true. What I felt when I worked it is like, just this kind of sense of like, that feels good. That just feels like it's just a little bit less irritable when I do that. It's just a sensation of feeling like that's the direction that those things want to be slightly moved or encouraged. There was definitely a sense of interoceptive sense there like, this feels good. This feels right. Yeah.
Til Luchau:
That's great. Then, you could go back to meditating with your tight jeans on?
Whitney Lowe:
Exactly, yeah.
Til Luchau:
[crosstalk 00:38:18] that's why monks wear robes.
Whitney Lowe:
But then I would be-
Til Luchau:
That's why monks wear robes. That's why monks wear robes, Whitney.
Whitney Lowe:
That's right. Yes. They know about LFCN entrapment.
Til Luchau:
Right. It's a good thing I took off my tight jeans and my gun belt before I sat down today because we've been sitting here for a while. I would be having that going on if I hadn't.
Whitney Lowe:
That's right. Yeah. You got a couple other injury things too, that you were mentioning that might be also related here. What else we got there?
Til Luchau:
Yeah, it's just worth bearing in mind the reasons, I kind of went through and brainstorm the reasons that I might go work this region of the body on a client. Injuries, as you mentioned, is one. There's people that will fall on their side or have a scraping injury or a blow that can sometimes tear, literally tear, that fascia lata, the wrapping that that band is a part of. You'll feel like lumps and things like that on other tissue that can be really sensitized for a long time.
Whitney Lowe:
Yeah.
Til Luchau:
I often found that I can help that sensitivity with direct, we're thinking of glide and again, changing the brain's reaction to that sensation there. I use it, again, this hearkens back to my background as a [inaudible 00:39:30], I use it for reduced lateral shift to the hips. Let's say, and we go into this a lot in one of our workshops in particular, let's say someone takes a step and they shift their shoulders over that standing foot as opposed to their hips. You could either be ... This is the chapter I wrote for Erik Dalton's book too. You can either be Marilyn Monroe and shift your hips over that standing foot or you can be John Wayne and shift your shoulders over there.
Whitney Lowe:
Oh, interesting.
Til Luchau:
Yeah. John Wayne isn't lengthening his iliotibial band. He isn't allowing it to lengthen. That's all Marilyn is doing. She's just getting really long there. There is that continuum that I'm looking for, that ability to shift some of your weight over the standing foot that I will work that side of the body. It comes from that thinking of, we're going to help it lengthen and yet my rationale for that has changed. I'm thinking, "Okay, the brain is allowing that structure or that line or that part of the body to adapt and to allow the shift more than like, say, making it more rubber band-ish, making the body more willing to shift in that direction."
Whitney Lowe:
Yeah. Let me pose a question to you because of your specialization and working in sort of myofascial perspectives here, there is a pretty strong anatomical connection we found in fascial connective tissue between the opposite side thoracolumbar fascia and gluteus maximus on the opposite side. When we think about the gluteus maximus transmitting a lot of tensile load into the iliotibial band, would it make sense to then focus, let's say, a person whose left iliotibial band is bothering them, would it make sense to include addressing thoracolumbar fascia on the right side of the body because of the connectivity across those sides there?
Til Luchau:
I can see the rationale. I think, in my style, I tend to be more empirical than theoretical, rather than mapping out the line of where it would connect. I tend to follow my immediate perceptions and especially the clients' reports, what changes as we work along it, but certainly, if I wasn't getting the results I wanted, I might pull on some different theoretical models to think, okay, where else farther up the body might this be connecting?
Til Luchau:
After you've crossed a couple of joints, it's almost like, in my mind, it's less about lines and more about branching connections because everything is so interconnected that it's a little hard for me to predict, like down the leg like, say, where exactly in the back this might be connected to? I will find places all the time. I think those connections happen but it's less predictable and it's just as likely say that it's the same side as the opposite side or that it's around the front or who knows what it is.
Whitney Lowe:
Yeah. I think you mentioned this to me once before or possibly in one of our earlier discussions to the idea of these sort of connections and all these different places, you have a pretty significant degree of force dissipation anytime that there's something that branches off from that connection that some of that pulling is in distributed or dispersed to other adjacent tissues around there. There may not be as strong of a transmission all the way from one distal location or distant location to those particular tissues there.
Til Luchau:
Yeah. Maybe not as strong and certainly not as specific.
Whitney Lowe:
Yeah.
Til Luchau:
I mean, there's definitely exceptions. You'll find like there's all those amazing stories about he worked my knee and my jaw was suddenly free. There are those does that really happen but the mechanism is sometimes maybe up for debate and maybe not always replicable. Now, I'm going to go work everybody's knee and [inaudible 00:43:14] a tight jaw. I don't know. [inaudibleWhitney Lowe:00:43:15].
We tend to, I know me in the way I look at things and a lot of other people will probably tend to default to looking at biomechanical explanations for something like that and those things have frequently perplexed me in trying to figure out what on Earth is occurring that and then maybe it's something as bizarre even as, we had that episode, I can't remember which number it was when we talked about the homunculus and the relationship of the brain's patterns of the body and maybe it's just a homunculus relationship in there as opposed to a direct causal effect mechanical thing in there.
Til Luchau:
That's a narrative that works for me. That seems to explain a whole lot. Whatever narrative gets you through the night or whatever it is that helps you do your work and get the results you want.
Whitney Lowe:
Right. Just don't build a system around it for everybody that you think is going to fit to everybody and create the homuncula technique or something like that.
Til Luchau:
Oh, boy, I hadn't even think of that. Maybe I should have done that before you told me not to. Too bad.
Whitney Lowe:
That's right.
Til Luchau:
I won't.
Whitney Lowe:
Yup. Our secret. I'm sure nobody else heard that.
Til Luchau:
Yeah. Right. Sure. I think I-
Whitney Lowe:
All right, what else you got there?
Til Luchau:
No, I think I covered it. How, where and what end do I work with iliotibial band, basically, is that lateral hip shift, which is essentially femoral adduction but it's like kind of hip shift over the foot. Lateral knee pain, that's my go-to is that side of the leg there and maybe the hip. Those things you said could be mistaken for iliotibial band syndrome. I will still work that region not assuming I got the mechanism but more like I'm looking for a doorway into that complex. Is there something here I can find that shifts the client's experience with less sensitivity.
Whitney Lowe:
Yeah. I think that just sheds additional light on our kind of holistic perspective of looking at the body and just saying, we're not just going to deal with these individual pieces here, but want to look at the overall person's experience of the intervention that we make and how does that change their feeling on what's going on in the body as well.
Til Luchau:
That's a good summary. I like it.
Whitney Lowe:
Yeah. Okay.
Til Luchau:
Well, I'm going to put my three or so techniques into the handout. We're going to get some cool stuff from you. Anything else you want to say in wrapping it up there, Whitney?
Whitney Lowe:
I think that's kind of a good dive into some interesting dilemmas and things to ponder and think about with the iliotibial band. I think, we're still learning a lot about it, its function, how it works, and how we can intervene with things here but there's some good things to chew on, I think, with what we've gotten into today.
Til Luchau:
No, I appreciate it some of the details that you help fill in, in my map as well. It's fun to talk to you as always. We mentioned the handout, I should have done a commercial sooner for our upcoming leg, knee and foot principles online class that starts early September.
Whitney Lowe:
All right.
Til Luchau:
The first orientation. Yeah, our first orientation is October, sorry, September 8th but you can start anytime up to September 15th or so and get the whole course or it'll be available later by recording, but really, invite the listeners here to come join us in that course because we get to go through, in detail, our set of advanced myofascial techniques for the leg, knee, and foot. It's a hybrid, live and slash online format. It's all done online, but it's a hybrid of recorded and live real time input with small faculty groups and lots of interaction as well.
Whitney Lowe:
Great. People can ask you questions and things like that in the midst of the presentation thing?
Til Luchau:
That's right. In fact, that's been the richest part of it is the in depth discussions we have time to get into in this format while going in for a weekend workshop, we would get through the material and give people great techniques but now we're really finding we can unfold the principles or the ideas behind the work here. Yeah.
Whitney Lowe:
That's one of the things that I love about that environment into is the flexibility of time limitations, you can also, because you're not just limited to the 16 hours of the two days that you're together in many of these kinds of situations. You can come back and ponder things and bring up other questions or things that come up.
Til Luchau:
That's right.
Whitney Lowe:
We hope to see some of these pandemic-inspired hybrid models and experimental educational models that people have been working with for a while, hopefully expand some of our methods of doing educational things. That's one of the things that's exciting to me of what's coming down the pike.
Til Luchau:
Yeah, me too. Me too. I hope you join us in September. I should also mention our closing sponsor. This is Handspring Publishing, who helped me published the book I wanted to write. Even though I had offers from a large media conglomerate, I chose them and they are run by four great people who love these great books about our field and I'm still glad to this day, many years later, to choose them because their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness.
Whitney Lowe:
Handspring's Move to Learn webinars are free 45-minute broadcasts, featuring their authors, including one with you, Til. Head on over to their website at handspringpublishing.com to check those out and be sure to use the code TTP@checkout for your discount. We thank Handspring once again for their sponsorship of the podcast.
Whitney Lowe:
Thanks to all of our other sponsors as well. You can stop by our sites for show notes, transcripts, like Til mentioned, we have a handout on this particular episode here and any other extras over there. You can get links to that from my site @academyofclinicalmassage.com. Til, where can people find links to that from you?
Til Luchau:
Advancedtrainings.com, advanced-trainings.com. I actually found that it works even with this advanced trainings, no dash, it goes to the same place.
Whitney Lowe:
Oh, cool.
Til Luchau:
Yeah, if you got questions or things you'd like to hear about, just email us both at info@thethinkingpractitioner.com or look for us on social media. Just my name, Til Luchau. What's yours, Whitney?
Whitney Lowe:
You can find me also on social under my name at Whitney Lowe as well and you can follow us on Spotify, rate us on Apple podcast and if you do drop a review over there, that does help other people find the show. We really do appreciate that. We want to say thank you to all of our listeners and people who've been hanging out with us listening to our discussion. Hope you're getting some good things from that. You can find us at those locations and then also wherever else you happen to be listening and do share that and tell a friend and of course, as always, if you are unable to find it in any of those locations, you can aim your underwater sonar dish at the South Pacific and you'll hear us emanating from the deep recesses of the Mariana Trench as well.
Til Luchau:
We get like email from everywhere. That's amazing.
Whitney Lowe:
Yeah. Uh-huh (affirmative). It's great. Thanks for listening, everybody. We will see you again in a couple weeks and dive into some other interesting things to chew on at that time.