Iliotibial Band Friction Syndrome Clinical Presentation

Updated: May 18, 2022
  • Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Thomas M DeBerardino, MD  more...
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Pain is localized along the lateral knee, but it also can include the hip. The pain is worse with downhill running and becomes worse with activity after a pain-free start. It may radiate from the knee proximally or distally. Most individuals experience pain only during activities; however, individuals may experience pain with walking as the syndrome progresses.


Physical Examination

Tenderness is over the lateral knee, with a tender point at the lateral femoral condyle, approximately 1-2 cm proximal to the lateral joint line. Pain can be elicited with active flexion-extension of the knee within the first 30° while the thumb presses over the epicondyle and the iliotibial band (ITB). Crepitation may be felt.

Restriction in hip adduction indicates tightness in the ITB and the tensor fasciae latae (TFL). In evaluating for ITB friction syndrome (ITBFS), it is important also to look for restrictions in iliopsoas, rectus femoris, gastrocnemius, and soleus function. Examination usually reveals restriction of hip adduction and weakness of the hip abductors, specifically the gluteus medius.

Myofascial restrictions can mimic ITBFS, and these restrictions can be identified with a careful examination. Trigger points along the vastus lateralis, biceps femoris, and gluteus minimus can refer pain to the lateral knee; fascial adhesions of the posterior ITB can generate pain as well. Careful palpation of these points can differentiate ITBFS from myofascial trigger points.

The following provocative tests may be helpful:

  • Ober test
  • Noble test
  • Renee (creak) test
  • Thomas test

The Ober test is performed with patient lying on the unaffected side with that hip flexed enough to straighten the lumbar lordosis. The down leg is flexed 90° at the knee, while the operator's hands stabilize the greater trochanter and hold up the ankle. The thigh is abducted passively and extended to catch the ITB over the greater trochanter. The thigh is then adducted passively. If the thigh remains suspended off the table, this indicates a shortened ITB. (See the image below.)

Iliotibial band noted prominently along the latera Iliotibial band noted prominently along the lateral thigh.

For the Noble test, the patient is placed supine with the knee at approximately 90° flexion, and firm digital pressure is applied on or around the lateral femoral epicondyle while the knee is passively extended. A positive result is pain elicited at approximately 30° of flexion over the lateral femoral epicondyle, similar to what occurs when the patient is active.

In the Renee test, patients are placed on a step stool and directed to support all of their weight on the affected leg. The operator's thumb is placed over the lateral femoral condyle, and pressure is applied while the patient bends the knee into 30-40° of flexion. Here, the posterior fibers of the ITB are directly over the lateral epicondyle (see the image below). Reproduction of pain with pressure is considered a positive test result for ITBFS. 

Iliotibial band at the lateral femoral epicondyle, Iliotibial band at the lateral femoral epicondyle, with the posterior fibers denoted.

Some literature lists the creak test separately; this is the same as the Renee test, except that the operator's thumb is not placed on the patient. Pain when the patient bends the knee 30° is considered a positive test result.

In the Thomas test, the patient sits on the end of the table and then rolls back into a supine position, holding both knees to the chest but not so that the pelvis has excessive posterior tilt (see the image below). This flattens the lumbar spine. The patient holds the leg of the asymptomatic hip and slowly lowers the other to the floor. The test result is considered positive if the patient cannot achieve 90° of knee flexion, a neutral angle of the hip (if the hip hovers above the table), or 15° of hip abduction relative to the pelvis. This test is used to evaluate the iliopsoas, the rectus femoris, and the TFL or ITB.

The Thomas test can be used to evaluate restrictio The Thomas test can be used to evaluate restriction in the iliotibial band, hip flexors, and rectus femoris.