My secret of TFL stretching from my physiotherapy experience

       

Tensor fascia lata (TFL) muscle
(Ref: https://learnmuscles.com/glossary/tensor-fasciae-latae-tfl/)

      I have taken care of many patients with ITB syndrome (IT band syndrome) for many years who were soccer players, tennis players, runners, cyclists, triathletes, the most. One of my routine treatments was ITB stretching as Ober’s maneuver that I have felt does not satisfy the outcome.  

Ober's stretch
(Ref: https://www.aafp.org/pubs/afp/issues/2005/0415/p1545.html)

Then, I changed stretching to be another TFL (Tensor fascia lata) stretching because I found some factors from TFL related to ITB tightness which was demonstrated in exercise #5. However, I still have not felt stretched enough. Moreover,  the TFL muscle stretching in standing position is difficult to apply to subjects who have unstable knee joints or have leg pain with the weight bearing.  

Exercise #5: Stand TFL stretching: Step target leg backward, then put it behind the fore - leg. Then rotate the hip external rotation as the toe out. Final, shift pelvic forward like over - pressure hip extension.  

Finally, I would like to present one normal stretching that may stretch TFL directly. Due to, TFL is one joint muscle that passes only the hip joint; additionally, IT band stretching is not the way to release IT band tension. Therefore, I focus on stretching only the TFL at the hip joint by reversing all its muscle action. 

“To perform TFL stretch, the main direction consists of hip extension, hip external rotation and hip adduction.” 

4 options to stretch Tensor fascia lata (TFL) muscle

Exercise #1: Single leg stand TFL stretch

Exercise #2: Half kneeling TFL stretch

Exercise #3: Prone TFL stretch

Exercise #4: Supine TFL stretch

Anatomically, TFL muscle is located on the lateral portion of the femur. TFL merged into the IT band, So do gluteus maximus. The fasciae of these two muscles join the iliotibial band just distal to the greater trochanter forming a triangular ‘‘pelvic deltoid”.

TFL originates from the outer lip of the iliac crest, the anterolateral iliac fossa just below the iliac crest, the deep surface of the fascia lata, the iliac tubercle, the lateral aspect of the anterior superior iliac spine and a notch below the anterior superior iliac spine. TFL attaches to two layers of the IT band of the fascia lata and ends usually around the greater trochanter.

The major muscle action of TFL includes three directions that are hip abduction, hip internal rotation, and hip flexion. By mechanical, the gluteus medius and minimus are at a major disadvantage to act as the primary hip abductors, whereas the tensor fasciae latae is at a major advantage to exert the necessary force to counterbalance the force of weight during the full stance phase of the gait cycle. TFL function depends on the position of the hip. It helps the gluteal abductors prevent the Trendelenburg gait and stance so that we can conclude that it is one of the posture muscles. The anterior fibers flex the hip and the posterior fibers abduct and internally rotate the hip. 

Trendelenburg sign (Ref: https://www.pinterest.com/)

Mechanism of TFL shortening happened after hip abductor fatigue. The TFL muscle was in spasm, it is pulling hard on ITB and developing pain at the insertion point on the outside of the knee. Shortening of the TFL and ITB can pose problems in the behavior of walking and running. Additionally, they often develop clinical symptoms such as the iliotibial band syndrome or the patellofemoral syndrome.

Patellofemoral pain syndrome
(Ref: https://www.enzopierromassagetherapy.it/)

IT band syndrome
(Ref: https://www.kaizo-health.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

"However, I would like to recommend strengthening exercise for gluteus maximus and gluteus medius. It is very crucial part of treatment and be able to release IT band tension, afterward".

Reference:

https://www.researchgate.net/publication/337228717_Detailed_Morphological_Study_of_Tensor_Fasia_Lata_TFL_and_its_Clinical_Significance 

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.908.4975&rep=rep1&type=pdf 

https://www.researchgate.net/publication/322583917_Morphometric_properties_of_the_tensor_fascia_lata_muscle_in_human_fetuses 

https://www.ijsr.net/archive/v7i10/ART20191686.pdf 

https://www.koreascience.or.kr/article/JAKO202018436566234.pdf 

To release IT band syndrome by 5 ways foam roll massage

     

Ref: https://www.runwell.net.au/blog/

        Foam roll massage and tennis ball massage is a popular technique of muscle - fascia tension release for prevent and treatment benefits. It is applied to many parts of the body and musculoskeletal impairments including the IT band syndrome. 

In my physiotherapy clinic experience with IT band syndrome patients, I have used this technique many times that roll on the IT band directly as the standard management. The outcomes demonstrated both effectiveness and ineffectiveness. Finally, I found a way to massage with the foam that I always recommend to patients who are with IT band syndrome. 

Ref: https://physioworks.com.au/pain-injury/knee-pain/itb-friction-syndrome/

I have seen muscle spasm not only at mid IT band but also above knee cap, rear hip joint, calf muscles. 

5 ways to do roll massage in IT band syndrome

Exercise #1: IT band: lying on the side to roll.

Exercise #2: Gluteus maximus: it is necessary to bend hip joint with half - prone in front.

Exercise #3: Tensor Fascia Lata: prone on the ball to roll.

Exercise #4: Biceps femoris: lying on the side with half - supine.

Exercise #5: Vastus lateralis: lying on the side with half - prone.

I would like to introduce all muscles anatomy  which I have recommended to do foam roll; include,

    (1) The IT band

    IT band is a strong thick wide tendinous band located on the lateral thigh. IT band origin is insertion attachment of gluteus maximus (Gmax) and Tensor Fascia Latae (TFL) that extend their part into the IT band directly. The mass of the IT band descended along the lateral thigh to the knee joint that covers the vastus lateralis muscle. The IT band has 2 primary attachments, including the lateral epicondyle and the Gerdy tubercle. 

Ref: https://www.mygcphysio.com.au/

The first iliotibial band attachment is into the distal femur at the upper edge of the lateral epicondyle. The histologic makeup is consistent with tendon and has a layer of adipose tissue underneath the iliotibial band attachment area. The adipose tissue contains pacinian corpuscles, is highly vascular, and may be “the site of the inflammation” that causes pain during compression.

The second attachment of the iliotibial band is the insertion into the Gerdy tubercle of the tibia and serves as a ligament in structure and function. The Gerdy tubercle attachment is tensed during tibia internal rotation as the knee flexes during the weight-acceptance phase of gait. Internal tibial rotation explains the occasional connection between toeing in and iliotibial band “strain”

Moreover, there are many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

About this muscle, I have seen trigger points at mid IT band and 2 - 5 cm. above knee joint the most. 

(2) Gluteus maximus (Gmax)

We can see Gmax at the rear hip which is the biggest muscle that is why origin attachment of Gmax covered large area; include, posterior ilium, posterior layer of thoracolumbar fascia, posterior superior iliac spine (PSIS), posterior gluteal line, posteroinferior sacrum, coccyx, sacrotuberous ligament, and over on gluteal fascia. It is used for support and bumpers while sitting in our daily lives. Gmax has two distinct portions that consist of inserts into the IT band and the inferior portion inserts into the femur. The Gmax pulls posteriorly on the IT band and femur to extend the hip.    

According to its insertion, there is thickening and stiff soft tissue behind the greater trochanter. 

     (3)Tensor Fascia Lata (TFL)

Origin of TFL started on anterolateral of an iliac crest that is approximately 15 - 76 millimeters wide. TFL has many origin attachments; include, the lateral aspect of the anterior superior iliac spine (ASIS). The iliac tubercle, a notch located below the superior spine of the ilium, the anterolateral iliac fossa that is slightly below the crest, and the deep surface of the fascia lata of the thigh. 

Insertion of TFL has been recorded in many locations. There are disputes , for example, on greater trochanter or around there, to the middle layer of the IT band. So, It is not clear whether such tendinous tissue belongs to the fascia lata, or is the muscle’s own tendon. However, the TFL pulls anterosuperiorly on the ITB to flex the hip generally.

I have found tightness, stiffness, and trigger points on this muscle often that related IT band tension progressively.  

Ref: https://www.pinterest.com/pin/

   

(4) Biceps femoris

Biceps femoris is a member of the hamstring muscle which is located on the lateral side of the posterior thigh. They consist of long head and short head that short head originated medial to the linea aspera of the distal femur and descended distally and laterally. 

The first component of the short head was a proximal muscular attachment to the anterior and medial side of the tendon of the long head. Other significant insertions included an attachment of the capsular arm to the posterolateral joint capsule,  the attachment of the capsuloosseous layer to the iliotibial tract (biceps-capsuloosseous iliotibial tract confluens),  a lateral aponeurosis, two tendinous attachments-the direct arm,  the anterior arm, and capsular attachment in the interval between the tendon of the lateral head of the gastrocnemius. Perhaps, insertion anatomy caused patients with IT band syndrome to feel tense calf muscle. 

My own opinion, it is not clear between biceps femoris tightness or posterior fiber of IT band stiffness. 

Ref: https://anatomy.app/encyclopedia/biceps-femoris

     

(5) Vastus lateralis (VL)

VL is a member of quadriceps composed structurally of four distinct muscles; include, the rectus femoris, vastus lateralis, vastus medialis and vastus intermedius. The vastus lateralis is considered the largest part of the quadriceps femoris to form thick, wide and fusiform appearance is intimately attached to the vastus intermedius in its middle third. 

          The origin of the vastus lateralis is on the greater trochanter, lateral lip of linea aspera femoris and the lateral intermuscular septum and its insertion at the base patellar ligament using the patella and tibial tuberosity.

Vastus lateralis muscle has presented two parts; include, long and oblique parts. The oblique portion arises from the linea aspera of the femur and lateral intermuscular septum, a more fibrous expansion of the iliotibial tract by inserting the tendon itself, which is directed inferior and lateral to the vastus lateralis muscle over this by joining the superolateral border of the patella tendon to form a single, often attached to the joint capsule. The distal fibers of the vastus lateralis oblique were presented in interdigitated lateral retinaculum, which is formed from the expansions of tendinous insertions of the vastus lateralis muscle, inserted in the tibia and patella which, in turn, reinforces the anterolateral region of knee, and iliotibial tract. Morphologically, the vastus lateralis oblique is divided into: a distal surface and a spiral proximal portion with deep longitudinal fibers in the femoral shaft below the belly of the vastus lateralis muscle along, mingling with the vastus intermedius. 

Ref: https://learnmuscles.com/glossary/vastus-lateralis/

The vastus lateralis longus has its origin in the femoral trochanter and lateral lip of linea aspera of the femur, as found in the anatomical literature. showing extensive superficial aponeurosis in more than two thirds of the proximal surface and a deep aponeurosis in the distal  1/3 separating it from the vastus lateralis obliquus.  Its insertion is on the superolateral border of the patella by the patellar ligament by means of union with the tendon of vastus lateralis oblique, forming a single tendon. 

Therefore, the extensive lateral oblique is clouded by the IT band giving rise to the lateral retinaculum and completely covering the vastus lateralis oblique.

Bridging kneeout to strength glut
(Ref: https://www.skimble.com/)

Finally, I would like to recommend you to make rolling massage combine strengthening glut muscles that is very important and stretching that follow on https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-6-optionals-tfl-itb.html 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://link.springer.com/content/pdf/10.1007/s40279-021-01634-3.pdf 

https://www.scielo.br/j/rbme/a/htP9y5rrfQdkGFLDkZPQF6r/?lang=en&format=pdf

http://www.jms.periodikos.com.br/article/587cb49f7f8c9d0d058b47a1/pdf/jms-28-4-587cb49f7f8c9d0d058b47a1.pdf 

https://www.researchgate.net/publication/14561312_The_Biceps_Femoris_Muscle_Complex_at_the_Knee/link/5421e5de0cf2a39f4af766e9/download 

https://www.researchgate.net/publication/51823221_A_review_of_the_anatomy_of_the_hip_abductor_muscles_gluteus_medius_gluteus_minimus_and_tensor_fascia_lata 

Physiotherapy with 6 optionals TFL & ITB stretching in iliotibial band syndrome

 

Ref: https://www.knee-pain-explained.com/lateral-knee-pain.html

    Some of my patients who are with knee pain include lateral pain, fore - knee cap pain, and medial pain. Lateral thigh evaluation is one of my routine standard physical assessments. I have found some patients with iliotibial band syndrome or iliotibial friction band syndrome (ITBS).

My patients with ITBS are distance runners, cyclists, and triathlon, the most. Recently, I found it in an ice hockey player. They have trigger points, high - tension, and tightness on the IT band that stretch IT band uses for prevention and treatment of ITBS. 

6 Optionals of IT band stretching 

Exercise #1: Stand stretch TFL & IT band

Exercise #2: Chop stretch TFL & IT band

Exercise #3: Half cross sitting stretch TFL & IT band

Exercise #4: Half kneeing stretch TFL & IT band

Exercise #5: Side lying stretch TFL & IT band (easy)

Exercise #6: Side lying stretch TFL & IT band (advance)

Anatomically, the IT band is a thick tendinous big band that locates on the lateral thigh. It is a continuation of the tendinous portion of the tensor fascia lata (TFL) muscle with some contributions from the lateral gluteal muscles. The IT band has many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

IT band anatomy picture that has origin near hip joint
and many insertions end around knee joint; ITB: IT band
(Ref: https://www.researchgate.net/figure/The-iliotibial-band-and-site-of-injury-at-lateral-epicondyle-of-the-femur_fig1_51211560)

The site of injury is near the insertion at the lateral epicondyle. Majority of the injury mechanism is repetitive friction and compression of the IT band against the lateral epicondyle. IT band sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, and remaining tense in both positions. Repetitive irritation can lead to chronic inflammation, especially beneath the posterior fibers of the ITB, which are thought to be tighter against the lateral femoral epicondyle than the anterior fibers. The critical friction angle of the knee occurs at or at slightly less than 30 degrees of knee flexion which is called  ‘‘impingement zone’’ that associates during walking, running, and cycling. 

Triathlon consists of swimming - biking - running 
Ref: https://www.drjimtaylor.com/

The intrinsic factors consist of leg - length discrepancies that the longer one is more risky, and biomechanics that are very strongly related to muscle performance include strength, endurance, flexibility, and segmental coordination. Strength of  the gluteus medius and gluteus maximus muscles is important to control hip adduction and knee varus and valgus because strength deficits in the hip abductors are believed to play a role in the development of ITBS. 

Extrinsic factors are related to training methods as well as running shoes or cycle fit. Several training factors have been related to ITBS, including excessive running in the same direction on a track, downhill running, a lack of running experience, abrupt increase in running distance or frequency, and running long distances. 

Downhill running
(Ref: https://www.runpacers.org/pasadena/downhill-race-training/)

According to a subjective examination in my physiotherapy clinic, I have heard patients' stories, for example, change speed running immediately, increase distance immediately, not enough recovery, etc. For objective examination some patients never know the cause of pain, for example, weakness of hip abductor muscles, improper running shoes, etc. 

One case came to see me with fore - knee pain who just bought popular and expensive running shoes. She is mid foot strike pattern and her shoes have a narrow outsole at mid and heel section. I informed her of two options; include, change the strike pattern to forefoot strike pattern, or change to new shoes which are wide mid and heel section outsole.    

Clinical present with complaints of a sharp or burning pain roughly 2 cm superior to the lateral joint line. The pain may radiate proximally or distally. There usually is tenderness on palpation of the ITB 2 to 3 cm above to the lateral joint line. There may be local edema or crepitation. The pain always makes it difficult to go up - down stairs, bend knee, and sports performance drop.  

Ober's test use for IT band tightness assessment
(Ref: http://corebalancetherapy.com/wp-content/uploads/2013/09/Iliotibial-Band-Syndrome-review-PMR-2011.pdf)

Michael and Adam (2006) classified ITBS recovery into 4 phases including acure, subacute, recovery - strengthening phase, and Return - to - running phase. Stretching exercises are suggested to start after acute inflammation subsides that mean they should start in the subacute phase. 

The way to stretch is simple: stretch to the point where “tightness without pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 repetitions in one muscle as demonstrated in the video. Stretching exercise is one of the important management parts of ITBS. However, gluteus medius and gluteus maximus strength is very crucial management part for prevention and treatment, as well. 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://www.researchgate.net/publication/7004336_Practical_Management_of_Iliotibial_Band_Friction_Syndrome_in_Runners/link/5665d83208ae192bbf927368/download