History
The usual clinical history describes lateral knee pain:
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Pain with activity
Typically, the patient with ITBS presents with an insidious onset of lateral knee pain that is present during running.
Early in the course of the injury, the pain usually resolves after running.
If the athlete continues to run, the pain may progress to being present during walking and between training sessions.
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Pain localized over the lateral femoral epicondyle
The athlete is able to localize the lateral knee pain to approximately 2 cm above the lateral joint line.
Untreated, the pain may eventually radiate to the distal tibia, calf, and up to the lateral thigh.
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Pain while climbing stairs or running downhill
Pain is commonly experienced when the athlete climbs stairs or runs downhill.
Pain may develop with any activity that places the knee in a weight-bearing position at approximately 30º of knee flexion.
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Pain at rest
Pain at rest is usually associated with severe tendinitis, an associated lateral meniscus tear, an associated lateral femoral condyle bruise, or a cartilage injury.
Any time there is pain at rest but no history of acute or repetitive trauma, the practitioner should ask questions to rule out neoplasm, infection, or inflammatory arthropathy.
See also Medscape Drugs & Diseases topics Soft Tissue Knee Injury, Meniscal Tears on MRI, Meniscus Injuries, and Meniscal Injury.
Physical
Physical examination findings in patients with ITBS may include the following:
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Abnormal gait: The athlete may walk with the affected knee extended because this gait pattern avoids motion in which the tendon rubs on the lateral femoral epicondyle.
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Point tenderness is noted upon palpation of the lateral femoral epicondyle, as well as with palpation of a site 2-4 cm above the lateral joint line and at the Gerdy tubercle. Oftentimes, the patient indicates pain with the use of the palm of the entire hand.
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Reproducible pain: Pain may be elicited with knee flexion to 30° when varus stress is applied to the knee.
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The Ober test is used to assess the flexibility of the ITB. To perform this test, the examiner instructs the athlete to lie on the uninjured side. The examiner stabilizes the athlete's pelvis with one hand while controlling the affected limb with the other hand. The examiner abducts and extends the affected hip toward the table. Once the hip is abducted, the examiner adducts the hip. If the hip resists adduction, it is a result of tightness of the ITB (see the image below). [17]
Causes
See the list below:
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Runners
The posterior edge of the ITB impinges against the lateral epicondyle of the femur just after foot strike in the gait cycle. This friction occurs at or slightly below 30 º of knee flexion. Downhill running and running at slower speeds may exacerbate ITBS because the knee tends to be less flexed at foot strike.
Running on hard surfaces and banked surfaces: The injured leg is often the downside leg on a banked or crowned road.
Worn out or improper running shoes
Lower limb and foot misalignment such as valgus or varus alignment of the leg or leg-length discrepancy
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Cyclists
In cycling, the ITB is pulled anteriorly on the pedaling downstroke and posteriorly on the upstroke. The ITB is predisposed to friction, irritation, and microtrauma during this repetitive movement because its posterior fibers adhere closely to the lateral femoral epicondyle.
Cyclists with an external tibia rotation greater than 20 º: Stress is created on the ITB if the athlete's cycling shoe is placed in a straight-ahead position or the toe is in a cleat position.
Cyclists with varus knee alignment or active pronation place a greater stretch on the distal ITB when they ride with internally rotated cleats.
Poorly fitted bicycle saddle: A high-riding saddle causes the cyclist to extend the knee more than 150 º. This exaggerated knee extension causes the distal ITB to abrade across the lateral femoral condyle. Bicycle saddles that are positioned too far back cause the cyclist to reach for the pedal, with a resultant stretch to the ITB.
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All athletes
Improper warm-up and stretching
Increasing the quality and quantity of training sessions too quickly
Lower limb and foot misalignment such as valgus or varus alignment of the leg or leg-length discrepancy
Worn out or improper athletic shoes
On occasion, a contusion to the knee may precipitate ITBS.
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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 that is performed in a side-lying position.
