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The Iliotibial Band, Father Figures and What the Heck Is Sports Medicine Anyway?

Op-Med is a collection of original articles contributed by Doximity members.
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If you are a serious runner you probably know about iliotibial band friction syndrome (ITB) already. It’s a very common topic in running magazines and websites. If you’re not, or you don’t read running magazines, you might be about to think “oh yeah…I’ve had that!” ITB is a sharp pain that pops up in the outer part of your knee midway into a run. It’s more intense while your weight is on that side. Sometimes it nags for a couple of miles then goes away. Sometimes it stays. It usually doesn’t stop you. But it’s mysterious — it can go away by itself for months and then come back when you’re doing the same run, at the same speed, in the same shoes. It can be pretty bad — it might leave you limping for a day after the run. ITB is the reason why a fair number of runners give up the sport.

I’ve operated on a few dozen cases of ITB at this point, and a good bit of the mystery remains. Although you only do surgery when it’s really bad (and hasn’t gotten better with running modifications, physical therapy and injections), nothing about that painful iliotibial band looks different from a normal one; it’s not thicker, or tighter or more inflamed. Yet the surgery works — quickly and reliably. One thing I can tell you about ITB is that in all of my training I never heard of it. I never saw a case. No one taught me about it, and it wasn’t in the books I studied for exams. I first learned about ITB because I had it.

Dr. Ruben (pseudonym) was a very famous orthopedic surgeon. He was, perhaps, the most famous one of us in the world at the point this story begins, thirty years ago, when I flew down to visit with him. I was only a couple of years out of training, and had been taken on as an assistant clinical professor by the orthopedics program in which I had done my residency. Two of the guys in the years below me, who had been my residents, left our program and were now doing year-long fellowships with Dr. Ruben. I liked them a lot, and when they called and told me that Dr. Ruben was a great guy, that he was doing a lot of the things I was interested in, and that I should come down and spend some time with him in the operating room, I said sure. After a night on their couch I arrived at the amazing operating rooms of the most famous man in my field.

So much has been written about him and his practice that all I’m going to say is that after spending just a day with him, supervising six surgeries at once, (about 25 total for the day!), then going to his own PT clinic that was cluttered with huge NFL and NBA pros and their high-heeled girlfriends, then flying down to a D1 football school clinic with him, in his own plane, I was thoroughly honored to be learning from him. I was also, although 30 years his junior, quite exhausted. And then there we were, at the end of this enormous day, just the two of us in his big white van parked at a McDonald’s.

He was a hell of a nice guy, this Dr. Reuben. We had a lot of colleagues in common and we both liked sailing. We got along. So I felt comfortable asking him a personal question.

“…It’s this pain that I get about a mile and a half into a run, right here,” (pointing to the outside of my knee).

“You know, Scott, I get that myself, and I would love to know what it is.”

Now that was pretty surprising; this doc had been treating elite track athletes for decades — but somehow his not knowing made me really want to go figure it out. Not as easy in those pre-Googling days, but I got back to our medical library and pored through a bunch of dusty volumes to find something that fit what I was feeling. And there it was. “Iliotibial Band Friction Syndrome” had been described in a journal article published when I was in high school.

Why didn’t Dr. Reuben know about it? Maybe high-level runners didn’t get it, or they just sucked it up and ran through. More likely he was just too famous for people to be seeing him for things so minor. Dr. Reuben operated on nearly every patient he saw, and most ITB patients didn’t need surgery.

Why had I never learned about it? I had trained at big, urban medical centers where they tended to treat “big” problems. And I had trained in orthopedic surgery — which then meant broken bones, congenital deformities, joint replacements. Not quirky pains that runners get. ITB is usually a naggy little pain that only hurts when you run and usually gets better with physical therapy, some new shoes or if you stop running — and that was the advice that most docs would have given to anyone with my complaint back then. There certainly are lots of aches and pains that get better with rest. But what happens after the rest, when you go back to running and it hurts again? What if you really want to run?

Enter “sports medicine.” This ill-defined area of medical practice has, as far as I have been able to tell, one special rule: telling your patient to stop doing their sport is not an option. If you intend to be practicing “sports” medicine (as opposed to the regular kind), “no running” is a prescription of last-resort.

The way orthopedics has evolved over the last 50 years, docs like me who do a lot of arthroscopic surgery are usually said to be practicing sports medicine. There are reasons for this. Patients often recover (and therefore get back to their sports) from arthroscopic operations faster than from ones done through big cuts. Orthopedists tend to like watching and playing sports themselves. And most importantly, patients like upbeat, “sporty” reasons for making a doctor’s appointment a lot more than the downbeat, “sickly” ones. So, put “sports medicine” on your shingle, and you see more patients. Which, after coming back from Dr. Reuben’s, I did. And thus, I found myself in my exam room, soon after, with Nick, the marathon cardiologist.

An incredibly nice guy, Nick had stopped running because of this pain on the outside of his knee that came on after a few miles and got worse and worse ‘til he couldn’t stand it. He had seen three orthopedists at his Ivy-league medical center without help. Therapy, running mods, new shoes — no dice. I went over his story and examined him. A completely normal knee except for one thing: he was tender in just the right place for it to be ITB — where my knee hurt. So I gave him an injection of cortisone and local anesthetic right there — numbing up only that spot. Then I sent him off on a run. With just that nickel-sized spot numb, it was his first pain-free run in many months. Our exhilaration at making this new diagnosis was short-lived though. The steroid only lasted about two weeks. Nick, and the pain, came back. It was pretty clear that he was going to need an operation. So I hunted around the journals and called colleagues. There were a few papers on it by then, and the consensus favored “pie-crusting” the band — making lots of 3–4 mm cuts in it to allow it to lengthen but not losing all of its pull — which, everyone figured, was needed for normal running.

Well, I was taking bows for about nine months after that pie-crusting operation. Nick was just born to run and he was running again, to his heart’s content. He was grateful. This was sports medicine!

And then the damn thing came back.

It’s hard to fail at anything, but to fail to help a fellow doctor — with a problem I thought I had sussed out, a problem that affected me as well as my sports medicine godfather, a problem that, in some minor, private way, I had “discovered” in my own knee — was a hard failure to live with. It got under my skin. I went over everything I knew about the iliotibial band. I remembered that we used to use it for a graft when I was an intern. I had “harvested” quite a few of them for a plastic surgeon I worked under in Boston. It must not have bothered them too much to have the band totally removed. I also remembered that the muscle that pulls on the ITB (the Tensor Fascia Lata) was frequently affected by polio. And I knew one orthopedist who knew a lot about polio.

My dad trained in orthopedics before the Salk vaccine, in a Montreal hospital where children with polio came from all over Canada for surgery. Polio paralyzed that muscle and it shrank, leaving the IT band so tight that you had to cut it just to get their knees together. I laid out Nick’s case to my father — ending with “how were they after you cut the IT band?”

“We cut it all the time — didn’t bother them a bit — just go back and cut the whole thing, forget that namby-pamby sports medicine stuff,” was his answer.

And I had my answer for Nick. I laid it all out for him. He agreed, and we went back to the OR. He was perfect — the pain never came back after this operation. And that’s the only operation I’ve done for ITB since.

Is this the way to go about learning new surgical procedures? I learned about ITB because I was lucky enough to have known Dr. Reuben and my father. And to have had a cardiologist as my first patient with it. And, as I wince along that last half mile home, a case of it myself. It makes patients uncomfortable but they all need to remember that every teaching doctor, every good doctor, in fact, is still a learning doctor.

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