eMedicine Specialties > Orthopedic Surgery > Knee

Iliotibial Band Friction Syndrome: Treatment

Author: Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Coauthor(s): Cynthia Kooima, MD, Staff Physician, Department of Orthopedic Surgery, Henry Ford Hospital; Terrence Lock, MD, Senior Consulting Surgeon, Department of Orthopedic Surgery, Henry Ford Hospital
Contributor Information and Disclosures

Updated: Jan 8, 2009

Treatment

Medical Therapy

The basic principles of treatment include control of inflammation, modification of activity, and correction of underlying problems.¹² An aggressive treatment program is as follows:

Acute phase

• Medical therapy: Medical therapy consists of nonsteroidal anti-inflammatory drugs with adjunctive physical therapy. These drugs reduce the inflammation in the soft tissue. Analgesics, such as acetaminophen or codeine preparations, can be used in persons with functional disability. Injection of corticosteroid can be used when conservative attempts to control inflammation fail or swelling persists for more than 3 days.
• Activity modification: Examine recent changes in training, such as duration and intensity of exercise. Curtail activity to a level at which pain is not generated.
• Local ice massage: Apply to the region of inflammation near lateral femoral condyle for no longer than 15 minutes. Ice compresses or cold packs can be used for 20 minutes.
• Phonophoresis and/or iontophoresis: Use hydrocortisone or a similar topical steroid preparation with ultrasound (phonophoresis) or electrical stimulation (iontophoresis) for control of inflammation.

Subacute phase

• Stretching exercises: Begin after inflammation subsides. Restoring proper range of motion in the hip flexors (iliopsoas and quadriceps), hip extensors (gluteus maximus, hamstrings), hip abductors (gluteus medius, tensor fascia lata), and, most importantly, the hip adductors is crucial to restoring overall hip function.
• Myofascial therapy: Direct treatment on trigger points and loosen restrictions along the iliotibial band (ITB). Target areas include over the lateral femoral condyle and greater trochanter.
• Manipulative therapy: Effective in treating areas of restriction and repairing the biomechanical flaws that led to the iliotibial band friction syndrome (ITBFS). Muscle energy techniques can be safely applied to the tensor fascia lata, hip flexors, and piriformis muscles to restore ranges of motion in hip adduction, extension, and internal rotation. Attention should be paid to lumbosacroiliac mechanics to ensure resolution of any dysfunction there. Anterior or posterior rotational innominate (iliac) dysfunctions affect the origin of the tensor fascia lata and can delay recovery if left untreated. Other specific areas to address with manipulation include the T12-L1 vertebral segments (origin of the iliopsoas) and the fibular head (partial insertion point of the ITB). In fact, fibular head dysfunction (either anterior or posterior rotation) cannot only contribute to ITBFS but can mimic it as well.

Recovery phase

Progressive strengthening exercises are started to restore muscle strength lost from inhibition and disuse. Exercises include side-lying leg lifts, pelvic drops, and step-down exercises.

Return to running

The angle of the knee during faster-paced running is beyond the friction point of ITBFS, so the patient should start with easy sprints on even surfaces, no more than every other day at first. The patient may gradually increase distance and frequency according to tolerance. Time to return to sports depends on the initial severity. Patients who return must first perform all strength exercises and stretches without pain. Most people return to their sport or running within 4-6 weeks.

Surgical Therapy

Surgery is used to resect a small triangular portion of the posterior iliotibial band (ITB) over the lateral femoral epicondyle. Studies demonstrated positive results with the knee flexed at 30° during the procedure.^17,18,19

A resection of the underlying synovial tissue can also be performed, but some question exists as to whether it should be resected. Resection can cause chronic synovial fluid effusion in the recess and hematoma formation. Several studies state that tissue resection deep to the ITB is optional but not typically recommended.

Preoperative Details

The patient is restricted to taking nothing by mouth at least 8 hours before the procedure. Iliotibial band (ITB) resections also can be performed through an arthroscopic procedure, and the patient is prepared for surgery similar to that for any such procedure. Otherwise, a tourniquet is applied to provide adequate hemostasis. Anesthesia can be achieved by general or epidural administration. The affected leg is positioned so that the lateral femoral condylar region is exposed.

Intraoperative Details

With the knee in 30° of flexion, a longitudinal incision is made centered over the lateral epicondyle. The posterior portion of the iliotibial band (ITB) is then exposed. The knee is flexed and extended to identify the portion of the ITB that is impinging on the lateral epicondyle. A triangular piece of the ITB is then resected. The base of the triangle is approximately 2 cm and centered over the posterior fibers of the ITB. The height of the triangle is roughly 1.5 cm. The knee is then moved through the full range of motion to confirm adequate release of the ITB. The wound is then irrigated and closed. Excision of an elliptical section of the ITB also has been described.

Postoperative Details

Some controversy exists regarding postoperative immobilization. Martens et al²⁰ advocated splinting the knee in extension for 1 week postoperatively followed by a gradual return to activity. In a study by Holmes et al,²¹ a soft dressing was applied and bicycling was allowed on postoperative day 3. In this study, 9 of 21 patients developed a small seroma near the lateral incision, which subsequently resolved with rest and icing.

Follow-up

Surgical release of the iliotibial band (ITB) is typically successful in eliminating pain. Athletes are able to return to their normal activities with a rehabilitation program in 3-7 weeks.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center; Arthritis Center; and Bone Health Center. Also, see eMedicine's patient education articles Knee Pain and Knee Injury.

Complications

Potential complications include recurrent swelling in the lateral synovial recess, persistent bleeding, bisection of the iliotibial band (ITB), infection, seroma, recurrent pain, and impingement.

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