Physical Medicine and Rehabilitation for Iliotibial Band Syndrome

Updated: Apr 27, 2020
  • Author: John M Martinez, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Overview

Practice Essentials

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 the image below.) Treatment for ITBS usually is conservative.

In this 27-year-old female marathon runner with an 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.

Other causes or factors that are believed to predispose an athlete to ITBS include excessive internal tibial rotation, genu varum, and increased pronation of the foot.

Signs and symptoms of iliotibial band syndrome (ITBS)

The patient with iliotibial band syndrome (ITBS) 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]

Workup in iliotibial band syndrome (ITBS)

In severe cases, magnetic resonance imaging (MRI) may be helpful in identifying the extent of inflammation of the iliotibial band (ITB). Findings on MRI most commonly include thickening of the ITB in the region overlying the lateral femoral condyle and fluid collection underneath the ITB at this area.

Management

Treatment for iliotibial band syndrome (ITBS) usually is conservative. Conservative treatment consists of (1) relative rest by decreasing the amount of exercise or training, (2) the use of superficial heat and stretching prior to exercise, and (3) the use of ice after the activity.

Physical therapy is one of the mainstays of treatment for ITBS, in addition to reducing the amount of inflammation and irritation. [5, 6, 2]

Physical therapy treatment in the acute stage may include modalities such as phonophoresis or iontophoresis in addition to cryotherapy to decrease the inflammation. Since some cases of ITBS are caused by excessive tension on the ITB, physical therapy can help to incorporate proper stretching techniques into the patient's exercise routine. Soft-tissue mobilization and massage techniques may be used to assist with lengthening of the sore ITB. As the patient's symptoms improve, the physical therapy can progress toward strength development and maintenance.

Reports of surgical intervention exist for recurrent ITBS that has not been responsive to previous conservative treatment. The operation may involve (1) releasing the posterior portion of the ITB, (2) performing an osteotomy of the lateral femoral epicondyle, or (3) performing a bursectomy. [7, 8]

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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. [9] See the images below.

Iliotibial band at the lateral femoral condyle, wi Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.
Iliotibial band noted prominently along the latera Iliotibial band noted prominently along the lateral thigh.
Lateral hip stabilizers. Lateral hip stabilizers.
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Epidemiology

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. [5, 6, 10, 11]

International

A study of a Central European population by Benca et al found that iliotibial band friction syndrome was one of the five most common runners’ injuries (12.3%), second only to patellofemoral pain syndrome (13.4%) and equal to patellar tendinopathy. [12]

Mortality/Morbidity

No mortality has been associated with iliotibial band syndrome. A study by Hafer et al indicated that coordination variability in runners is not affected by ITBS-associated pain. The investigators found that at the start and end of a run, coordination variability did not differ between uninjured runners and runners with ITBS. [13]

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. [14, 15]

A study by Kim et al found that during weight-bearing, strain on the iliotibial band (ITB) is particularly high in women with genu varum knee alignment. [16]

Age

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

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