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. [1] 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. [2, 3, 4]
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. [2, 1]
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Strength testing - Strength testing may reveal knee flexor or extensor weakness or hip abductor weakness.
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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 the images below.
The Thomas test can be used to evaluate restriction in the iliotibial band and hip flexors.
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. [5, 6, 11, 12, 18, 19]
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.
A study by Phinyomark et al found that external rotation of the hip was significantly more pronounced in female runners with ITBS than in healthy female runners and male runners with ITBS, while ankle internal rotation was significantly greater in male runners with ITBS than in healthy male runners. The study included 48 runners with ITBS and 48 healthy controls. [20]
A literature review by Aderem and Louw indicated that in shod female runners with ITBS, peak knee internal rotation and peak trunk ipsilateral flexion are greater during the stance phase of running than they are in healthy runners. [21]
A study by Stickley et al indicated that increased knee-varus angle and maximum knee-adduction moment increase the risk for development of iliotibial band syndrome (ITBS). Vertical stiffness was found to be lower in study patients with ITBS. [22]
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. A literature review by Mucha et al, for example, suggested that a link exists between hip abduction weakness and ITBS in distance runners. [23]
Seijas et al reported evidence that ITBS can develop as a result of hip arthroscopy, with increased postoperative range of motion and local inflammatory changes possibly being factors in this. [24]
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In this 27-year-old female marathon runner with anterolateral pain superior to the joint line, a coronal fast spin-echo T2-weighted magnetic resonance imaging scan with fat suppression demonstrates edema between the iliotibial band and the lateral femoral condyle (arrow). The edema's location is consistent with a clinical diagnosis of iliotibial band syndrome.
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Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.
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Iliotibial band noted prominently along the lateral thigh.
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Lateral hip stabilizers.
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The Thomas test can be used to evaluate restriction in the iliotibial band and hip flexors.
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The Ober test.
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This illustration demonstrates active stretching of the iliotibial band (ITB). The athlete stands a comfortable distance from a wall and, with the contralateral knee extended, leans the proximal shoulder against the wall to stretch the ipsilateral ITB.
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This illustration demonstrates iliotibial band syndrome stretching performed in a side-lying position.
