Rehabilitation Program
Physical Therapy
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. Heat should be applied before and during stretching for at least 5-10 minutes, and ice treatments should be employed using a cold pack applied to the area for 10-15 minutes or using an ice massage, which involves rubbing ice over the inflamed region for 3-5 minutes or until the area is numb. [27]
Physical therapy is one of the mainstays of treatment for ITBS, in addition to reducing the amount of inflammation and irritation. [5, 6, 2] The physical therapist can advise the athlete about ways to modify his/her training program so that faster results are seen with therapy. Running and cycling should be decreased or avoided to prevent further repetitive stress to the ITB. Wearing proper shoes also is very important in individuals with ITBS. Frequently, patients with ITBS demonstrate excessive pronation of their feet. The physical therapist should evaluate the patient's biomechanics during walking and running and should assist him/her in obtaining custom-made orthotics to correct faulty mechanics that may be causing the ITBS.
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. These exercises concentrate on increasing flexibility of the ITB and of the gluteus muscles. Other muscles that commonly need attention for flexibility include the hamstrings, quadriceps, gastrocnemius, and soleus. See the images below.
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.
This illustration demonstrates iliotibial band syndrome stretching performed in a side-lying position.
However, a randomized, controlled trial by Pepper et al indicated that short-term iliotibial band (ITB) stiffness is not impacted in healthy individuals by a single session of stretching or foam rolling and that the effectiveness of these exercises in reducing ITB compression may be limited. Although hip adduction passive range of motion did change after these interventions, the improvement was only by 0.8° and occurred in the control group as well, suggesting a measurement error rather than clinical relevance. [28]
Soft-tissue mobilization and massage techniques may be used to assist with lengthening of the sore ITB. Prior to mobilizing the tissues, the physical therapist may perform an ultrasonographic treatment over the ITB to increase blood flow to the area and prepare the tissues to be stretched. Massage should generally be performed with the ITB in a lengthened state.
As the patient's symptoms improve, the physical therapy can progress toward strength development and maintenance. The physical therapist should instruct the patient in a home exercise program that continues to improve the strength and endurance of the hip and knee, as well as the back and abdominals. Strengthening of the hip abductors and knee flexors and extensors is an important component of rehabilitation. Once the patient is able to complete all strengthening exercises without discomfort, he/she may gradually return to the previous training regimen.
A study by Noehren et al suggested that in men with ITBS, treatment that addresses hip and knee neuromuscular control may be particularly beneficial. Examining differences between 17 men with ITBS and 17 healthy controls, the investigators found that, although ITB length was somewhat reduced in males with ITBS and hip external rotators were somewhat weaker, the largest differences occurred in internal rotation of the hip and adduction of the knee, both of which were significantly greater in the ITBS subjects. [29]
Occupational Therapy
Occupational therapy usually is not indicated in the treatment of individuals with iliotibial band syndrome.
Surgical Intervention
Reports of surgical intervention exist for recurrent iliotibial band syndrome (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]
A Belgian study investigated the effectiveness of arthroscopic treatment for ITBS, specifically, resection of the lateral synovial recess, in 33 patients. [26] The authors reported that all of the patients returned to sports after 3 months. At follow-up (a mean period of 2 years and 4 months), good to excellent results were found in 32 of the patients, and a fair result in 1 of them.
Consultations
Patients with iliotibial band syndrome that is recurrent and difficult to treat may be referred to a sports medicine specialist.
Other Treatment
Local injections with corticosteroids may be indicated for symptoms of iliotibial band syndrome that do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs), relative rest, stretching, and physical therapy. [2]
A randomized, controlled trial by Weckström and Söderström found that in runners with ITBS, pain decrease in those treated with radial extracorporeal shockwave therapy (11 patients) was not significantly different from that in runners treated with manual therapy (13 patients), at 4- and 8-week follow-up. The patients underwent an exercise rehabilitation program concurrently with one or the other therapy. [30]
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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.
