Iliotibial Band Friction Syndrome Treatment & Management

Updated: Aug 06, 2018
  • Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Conservative therapy for iliotibial band (ITB) friction syndrome (ITBFS) includes the following:

  • Rest
  • Stretching and strengthening exercises
  • Anti-inflammatory medication
  • Other therapeutic modalities
  • Biomechanical correction of limb-length discrepancies and pes planus

Failure of conservative therapy is an indication for surgery. Conservative therapy should be tried for a minimum of 3 months, and all other factors related to ITBFS should be thoroughly addressed before surgery is considered. Even then, surgery is best limited to highly motivated people who want to return to their sport or activity.

Active infection and coagulopathy are contraindications for surgery.

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Medical Therapy

The basic principles of treatment include control of inflammation, modification of activity, and correction of underlying problems. [15] An aggressive treatment program is as follows.

Acute phase

Medical therapy consists of nonsteroidal anti-inflammatory drugs (NSAIDs) 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 should be considered. Examine recent changes in training, such as duration and intensity of exercise. Curtail activity to a level at which pain is not generated.

Ice may be applied to the region of inflammation near the lateral femoral condyle, but for no longer than 15 minutes. Ice compresses or cold packs can be used for 20 minutes.

Use hydrocortisone or a similar topical steroid preparation with ultrasound (phonophoresis) or electrical stimulation (iontophoresis) for control of inflammation.

Subacute phase

Begin stretching exercises after inflammation subsides. Restoration of proper range of motion (ROM) in the hip flexors (iliopsoas, quadriceps), hip extensors (gluteus maximus, hamstrings), hip abductors (gluteus medius, tensor fasciae latae [TFL]), and, most important, hip adductors is crucial for restoring overall hip function.

Myofascial therapy should focus on treating trigger points and loosening restrictions along the ITB. Target areas include over the lateral femoral condyle and greater trochanter.

Manipulative therapy can be effective in treating areas of restriction and repairing the biomechanical flaws that led to ITBFS. Muscle energy techniques can be safely applied to the TFL, hip flexors, and piriformis to restore ROM 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 TFL 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) not only can 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. The patient should start with easy sprints on even surfaces, no more than every other day at first, and then 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.

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Surgical Therapy

The typical surgical treatment is an open procedure used to resect a small triangular portion of the posterior ITB over the lateral femoral epicondyle. Studies demonstrated positive results with the knee flexed at 30° during the procedure. [24, 25, 26]

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.

However, arthroscopic procedures are becoming more commonly used in ITBFS, specifically for resecting tissue in the lateral synovial recess and separating the band from the lateral condyle. [27, 28, 29] Arthroscopy limits the amount of bleeding, and the incidence of hematoma formation can be reduced.

The procedure requires no special equipment other than what is common and appropriate for knee arthroscopy. The patient can be positioned with the operative leg in a leg holder hanging off the end of the bed, or using a lateral post while supported by the bed. Resection of the synovial tissue in the lateral recess and gutter is typically accomplished with a shaver blade. (See the image below.)

Resection of lateral synovial fold through arthros Resection of lateral synovial fold through arthroscopic knee procedure. Courtesy of Elsevier, Inc (Cowden CH 3rd, Barber FA. Arthroscopic treatment of iliotibial band syndrome. Arthrosc Tech. Feb 2014;3(1):e57-60).

Surgical correction of anatomic variants leading to ITBFS, such as severe genu valgum, must be considered carefully and with the entire well-being of the patient in mind. [30]

Inoue et al described a minimally invasive approach to ITBFS that involved lengthening the central part of the ITB by splitting it into a superficial and a deep layer and maintaining the anterior and posterior fibers immediately above the lateral epicondyle. [31]  They found that this procedure removed the cause of ITBFS and was associated with a reduction in inflammation. Patients were able to return to competition within 6 weeks without any degradation of performance.

Operative details

The patient is restricted to taking nothing by mouth at least 8 hours before the procedure. If an ITB resection is being performed through an arthroscopic procedure, 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.

With the knee in 30° of flexion, a longitudinal incision is made centered over the lateral epicondyle. The posterior portion of the 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.

To confirm adequate release of the ITB, the knee is then moved through the full ROM. The wound is then irrigated and closed.

Excision of an elliptical section of the ITB also has been described.

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Postoperative Care

Some controversy exists regarding postoperative immobilization. Martens et al [32] advocated splinting the knee in extension for 1 week postoperatively, followed by a gradual return to activity. In a study by Holmes et al, [33] a soft dressing was applied and bicycling was allowed on postoperative day 3. In this study, nine of 21 patients developed a small seroma near the lateral incision, which subsequently resolved with rest and icing.

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Complications

Potential complications include the following:

  • Recurrent swelling in the lateral synovial recess (LSR)
  • Persistent bleeding
  • Bisection of the ITB
  • Infection
  • Seroma
  • Recurrent pain
  • Impingement
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