eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Iliotibial Band Syndrome

Author: John M Martinez, MD, Medical Director, Primary Care Sports Medicine, Coastal Sports and Wellness Medical Center
Coauthor(s): Kenneth Honsik, MD, Consulting Staff, Department of Primary Care Sports Medicine, Kaiser Permanente; Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Contributor Information and Disclosures

Updated: Apr 17, 2009

Introduction

Background

Iliotibial band syndrome (ITBS) is the result of inflammation and irritation of the distal portion of the iliotibial tendon as it rubs against the lateral femoral condyle, or less commonly, the greater tuberosity. This overuse injury occurs with repetitive flexion and extension of the knee. Inflammation and irritation of the iliotibial band (ITB) also may occur because of a lack of flexibility of the ITB, which can result in an increase in tension on the ITB during the stance phase of running. (See image below and Image 1.)

Pathophysiology

The iliotibial band (ITB) is a dense fibrous band of tissue that originates from the anterior superior iliac spine region and extends down the lateral portion of the thigh to the knee. The ITB has insertions on the lateral tibial condyle (ie, the Gerdy tubercle) and the distal portion of the femur. When the knee is extended, the ITB is anterior to the lateral femoral condyle. When the knee is flexed more than 30º, the ITB is posterior to the lateral femoral condyle. (See images below and Images 2, 3, 4.)

Frequency

United States

Iliotibial band syndrome (ITBS) is most common in athletes who participate in long-distance running. Studies have indicated a 4.3-7.5% occurrence rate for ITBS in long-distance runners. ITBS is less common in shorter-distance or sprint-distance runners. The higher rate in long-distance runners is primarily because of the increased stance phase during longer-distance running. ITBS also has been reported in military recruits, cyclists, and tennis players. The frequency of ITBS is also increased in adolescents undergoing the rapid growth phase.^1,2,3,4

Mortality/Morbidity

No mortality has been associated with iliotibial band syndrome.

Race

No known association exists between race and iliotibial band syndrome.

Sex

Iliotibial band syndrome has been reported in men and women equally; however, women may be more susceptible to developing the syndrome because of anatomical differences of the thigh and knee, such as genu varum and increased internal tibial rotation. These anatomical differences result in weakness of the quadriceps muscle and an increased varus angle of the femur in relation to the knee.

Age

Iliotibial band syndrome usually is seen in individuals aged 15-50 years, an age range that generally includes active athletes.

Clinical

History

The patient with iliotibial band syndrome typically reports pain at the lateral aspect of the knee; however, in some cases, the presenting symptom is hip pain over the greater trochanter. The pain usually worsens with physical activity, such as running or cycling. Pain may be exacerbated by running hills and is most intense at heel-strike. Some patients may also report lateral knee pain when walking up or down stairs. The patient also may report an audible, repetitive popping noise in the knee with walking or running.⁵

Physical

The physical examination should include the entire lower extremity to rule out other causes of lateral knee or hip pain. In most cases, point tenderness occurs with palpation of the lateral femoral condyle or lateral tibial condyle, especially when flexing or extending the knee, as the iliotibial band (ITB) slides across the lateral femoral condyle. Some patients may have tenderness over the greater trochanteric region of the hip.⁵

• Strength testing - Strength testing may reveal knee flexor or extensor weakness or hip abductor weakness.
• Tests - Increased or noticeable tightness of the ITB also may be noted upon examination with the Ober test. A modified Thomas test can be performed to assess flexibility of the hip flexors, hamstrings, and ITB. (See images below and Images 5, 6.)

Causes

Iliotibial band syndrome (ITBS) typically is due to overuse. The injury is seen most commonly in runners, although other athletes (eg, cyclists, tennis players) also may be affected. The usual mechanism is irritation of the iliotibial tract as it crosses over the lateral femoral condyle and, less commonly, the greater tuberosity. Increased tension or friction of the ITB in this area can result in an increase of irritation or inflammation. Abnormal gait or running biomechanics also have been implicated.^1,2,3,4,6

• Cyclists may experience ITBS due to improper positioning on their bike. Excessive internal or medial rotation of bike cleats and a bike seat that is too high are 2 main causes of ITBS among cyclists.
• Long-distance runners have a higher incidence of ITBS than do short-distance runners and sprinters. This higher incidence may be due to the change in the biomechanics of running versus sprinting. Long-distance runners tend to have a more prominent and extended heel-strike and stance phase in comparison with sprinters. The ITB is under its greatest tension during the first third of the stance phase.
• Weakness of muscle groups in the kinetic chain may also result in the development of ITBS. Weakness in the hip abductor muscles, such as the gluteus medius, may result in higher forces on the ITB and the tensor fascia lata.

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