eMedicine Specialties > Sports Medicine > Lower Limb
Iliotibial Band Syndrome: Treatment & Medication
Updated: Jan 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Modalities to decrease inflammation include ultrasonography, phonophoresis, iontophoresis, and icing. After the acute inflammation has resolved, the patient should begin a stretching program, which should include active stretching of the hamstrings, gluteal musculature, and hip adductors to improve the flexibility of the ITB.
Medical Issues/Complications
The acute phase of treatment focuses on control of inflammation, correction of poor training habits, as well as accommodation made for any anatomic structural variants.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation
- To reduce stress on the knee, ideally, the athlete should avoid participating in the activity that incited the injury. Pragmatically, it is often helpful for the physician to work with the athlete to develop a training program that allows athletes to participate in their sports to the extent that they are not experiencing discomfort.
- Swimming, using only the arms, is a way for athletes to maintain cardiovascular fitness during this period. Once the inflammation is reduced, the athlete's activity level can be gradually increased as he/she moves to the next phase of recovery.
- Inspect the athlete's running shoes for uneven or excessive wear.
- Evaluate and identify anatomic factors that may contribute to ITBS. If a leg-length discrepancy is present, consider prescription of a heel lift. Many runners have a tendency toward foot pronation or supination. If either condition is present, orthotic devices may be helpful.
- Runners should modify their training routine to avoid running on banked surfaces and/or hills or running in the same direction on a track.
- Cyclists
- Often, cyclists who are diagnosed with ITBS have their cleats positioned in internal rotation. This position increases tension on the ITB. To eliminate stress on the ITB, the cleats should be adjusted to reflect the cyclist's anatomic alignment, or the cleats can be externally rotated to reduce stretch on the ITB. If the cyclist is riding with fixed, clipless pedals, a switch to floating pedals is often beneficial.
- Evaluate the cyclist’s saddle or seat position. A saddle that is too high should be adjusted so that 30-35° of flexion is present at the bottom of the pedaling stroke. Consider reducing stress on the ITB by widening the cyclist’s bike stance and by improving both the hip and foot alignment. This correction can be accomplished by placing spacers between the pedal and the crank arm.
Surgical Intervention
Surgical intervention is not indicated for ITBS except in rare cases in which prolonged conservative treatment has failed to either alleviate the patient's symptoms or resolve the ITBS.3,11,12
Before considering surgery, the physician should investigate other possible sources of lateral knee pain. Lateral meniscus tears and chondromalacia can also cause lateral knee pain. Diagnostic arthroscopy should accompany any surgical procedure for ITBS.
Several procedures have been reported to be effective, most of which involve removing a portion of the ITB where it comes into contact with the lateral femoral epicondyle. Z-lengthening of the ITB at the level of the lateral epicondyle has also been proposed.11
Consultations
The following consultants may be of assistance in managing ITBS:
- Primary care sports medicine specialist (pediatrician, family practitioner, or internal medicine specialist with a certificate of added qualification [CAQ] in sports medicine)
- Orthopedic surgeon
- Physiatrist with fellowship training in sports medicine
Other Treatment
- Local corticosteroid injection has been shown to be beneficial in managing acute inflammation for those who do not respond to analgesia and rest.1,3,11,13,14
- Place the patient in a lateral recumbent position with the affected knee flexed to approximately 30 º.
- Direct the injection into the deep space at the point of maximal tenderness just lateral to the lateral femoral condyle.
Recovery Phase
Rehabilitation Program
Physical Therapy
Once the pain of ITBS has resolved and the athlete has achieved adequate ITB flexibility, the patient should begin strengthening exercises. The strengthening program focuses on the proximal hip musculature. Examples of exercises that are used at this stage include side-lying leg lifts, pelvic drops, and step-down exercises.
Medical Issues/Complications
If the preceding management of the injury is not successful, consider a period of total rest (4-6 weeks).
Surgical Intervention
Surgical treatment of ITBS is rarely required because most cases respond to conservative treatment (see Acute Phase, Surgical Intervention, above).
Maintenance Phase
Rehabilitation Program
Physical Therapy
Integrate active ITB stretching and strengthening of the hip musculature into the athlete’s training program.
Medication
NSAIDs are often incorporated into the medical management of overuse injuries such as ITBS because of these agents' analgesic and anti-inflammatory effects. All NSAIDs share a common mechanism of action, inhibition of prostaglandins. Many types of NSAIDs are available for treatment of overuse injuries, but these drugs vary primarily in their onset of effectiveness and duration of action.
To some degree, all NSAIDs share a common side effect of irritation of the gastrointestinal (GI) tract. Patients who take NSAIDs may experience symptoms of flatulence, abdominal cramping, and diarrhea. The more serious GI side effects include esophageal reflux, gastritis, acid reflux, peptic disease, and ulcer formation. NSAIDs as a group may also produce renal side effects (interstitial nephritis, vasomotor nephropathy), dermatologic reactions (rashes), and central nervous system (CNS) symptoms (eg, headache, dizziness, mood change, confusion), but these are much less common than GI side effects.
The ideal NSAID for treatment of an overuse injury is one that combines several properties. The drug should act quickly, have good penetration into synovial tissues, and produce few or no side effects. Unfortunately, no NSAID exists that fulfills all these criteria. The following list indicates only a few of the NSAIDs that are commonly prescribed for overuse injuries.
See also the following on eMedicine:
Overuse Injury
Toxicity, Nonsteroidal Anti-inflammatory Agents
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Naproxen (Naprelan, Naprosyn, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
250, 375, or 500 mg PO bid qam and hs recommended initially; not to exceed 1.25 g/d
Pediatric
10 mg/kg/d PO divided bid
Use of NSAIDs in patients who are receiving ACE inhibitors may potentiate renal disease states; may decrease the effectiveness of anticoagulants, coumarin, heparin, or thrombolytic agents; naproxen, like other NSAIDs, has been shown to reverse the effects of antihypertensives; may cause hypoprothrombinemia in patients using cefamandole, cefoperazone, cefotetan, plicamycin, or valproic acid; has been shown to increase the steady state concentration of lithium by decreasing the renal clearance
Documented hypersensitivity; history of angioedema, urticaria, bronchospastic reactivity, and nasal polyps
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
1200-3200 mg PO divided tid/qid
Pediatric
30-40 mg/kg PO divided tid/qid
Bleeding has been reported in patients receiving coumarin-type anticoagulants; if given with aspirin, a net decrease in anti-inflammatory effects has been noted; ibuprofen may enhance the toxicity of methotrexate if given concomitantly; ibuprofen may also decrease the natriuretic effects of furosemide and thiazides in some patients; closely monitor patients who are using lithium for toxicity as ibuprofen has been shown to increase the plasma levels of lithium.
Documented hypersensitivity; patients with the syndrome of nasal polyps, angioedema, and bronchospastic reactivity to aspirin
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Ibuprofen should be used with caution in patients with a history of hypertension or cardiac decompensation because its use has been associated with fluid retention and edema; patients taking ibuprofen should report any signs or symptoms of GI ulceration or bleeding, blurred vision, or other eye symptoms, skin rash, weight gain, or edema to their physicians.
Diclofenac (Cataflam, Voltaren)
Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA.
One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment.
Rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.
The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. Has relatively low risk for bleeding GI ulcers. Available in extended-relief dosage of 75 mg or 100 mg (Voltaren SR) am or hs.
Adult
50 mg PO tid or 2 tab 75 mg PO am or hs
Pediatric
Not established
Closely monitor patients who use warfarin-type anticoagulants because interactions have been demonstrated for many of the NSAIDs; concomitant use of diclofenac and aspirin is not recommended because such a combination may decrease the anti-inflammatory effect; may increase plasma digoxin, methotrexate, and cyclosporine levels; carefully monitor patients who are using lithium for signs of toxicity because diclofenac has been shown to increase the plasma concentration of lithium; diclofenac sodium may alter the response of patients to insulin and oral hypoglycemic agents; may inhibit the activity of diuretics and result in hyperkalemia in those patients using potassium-sparing diuretics
Documented hypersensitivity; history of angioedema, urticaria, bronchospastic reactivity, and nasal polyps; not recommended for use in the presence of blood dyscrasias or a clinical history of bone marrow depression; caution in patients with hepatic porphyria, may cause an acute attack
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Serious GI toxicity such as bleeding, ulceration, and perforation can occur at any time with or without warning in patients who are chronically treated with NSAIDs; diclofenac, along with other NSAIDs, may cause fluid retention and edema, therefore, it should be used with caution in those patients with a history of hypertension and/or fluid retention; history of porphyria
More on Iliotibial Band Syndrome |
| Overview: Iliotibial Band Syndrome |
| Differential Diagnoses & Workup: Iliotibial Band Syndrome |
 Treatment & Medication: Iliotibial Band Syndrome |
| Follow-up: Iliotibial Band Syndrome |
| Multimedia: Iliotibial Band Syndrome |
| References |
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References
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Further Reading
Keywords
iliotibial band tendonitis/tendinitis, iliotibial band friction syndrome, ITB syndrome, ITBS
