Iliotibial Band Syndrome

Iliotibial band (ITB) syndrome (ITBS) is the most common cause of lateral knee pain among athletes.[1, 2, 3, 4, 5, 6] ITBS develops as a result of inflammation of the bursa surrounding the ITB and usually affects athletes who are involved in sports that require continuous running or repetitive knee flexion and extension.[1, 2, 3, 7, 8, 9, 10] This condition is, therefore, most common in long-distance runners and cyclists. ITBS may also be observed in athletes who participate in volleyball, tennis, soccer, football, skiing, weight lifting, and aerobics.[11]

The image below illustrates active stretching of the ITB.

See Football Injuries: Slideshow, a Critical Images slideshow, to help diagnose and treat injuries from a football game that can result in minor to severe complications.

For patient education resources, see the Osteoporosis Center. Also, see patient education articles Knee Pain, Knee Injury, Tendinitis, and Running.

See also Medscape Drugs & Diseases articles Iliotibial Band Friction Syndrome and Physical Medicine and Rehabilitation for Iliotibial Band Syndrome.

See also the Medscape CME & Education topic Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes.

Frequency

United States

ITBS is the most common cause of lateral knee pain in runners. Although few studies are available regarding the incidence of ITBS in athletes, some studies cite this condition with an incidence as high as 12% of all running-related injuries.[12] Several studies of US Marine Corps recruits undergoing basic training determined the incidence of ITBS among this group to vary from 5.3 to 22.2%.

International

Data are not available regarding the international incidence of ITBS.

The ITB is the condensation of fascia formed by the tensor fascia lata and the gluteus medius and minimus muscles. The ITB is a wide, flat structure that originates at the iliac crest and inserts at the Gerdy tubercle on the lateral aspect of the proximal tibia. This band serves as a ligament between the lateral femoral condyle and the lateral tibia to stabilize the knee. The ITB assists in the following 4 movements of the lower extremity:

• Abducts the hip

• Contributes to internal rotation of the hip when the hip is flexed to 30°

• Assists with knee extension when the knee is in less than 30° of flexion

• Assists with knee flexion when the knee is in greater than 30° of flexion

The ITB is not attached to bone as it courses between the Gerdy tubercle and the lateral femoral epicondyle. This lack of attachment allows it to move anteriorly and posteriorly with knee flexion and extension. Some authors hypothesize that this movement may cause the ITB to rub against the lateral femoral condyle, causing inflammation. Other investigators hypothesize that injury of the ITB results from compression of the band against a layer of innervated fat between the ITB and epicondyle. Furthermore, a potential deep space is located under the ITB as it crosses the lateral femoral epicondyle and travels to the Gerdy tubercle. This bursa may become inflamed and cause a clicking sensation as the knee flexes and extends. The inflamed bursa may add another component to ITB tendinitis.

See also Medscape Drugs & Diseases topics Bursitis and Tendonitis.

In runners, the posterior edge of the ITB impinges against the lateral epicondyle of the femur just after foot strike in the gait cycle.[7, 8, 13, 14] This friction occurs at or slightly below 30 º of knee flexion.[2, 3, 7] Downhill running and running at slower speeds may exacerbate ITBS as the knee tends to be less flexed at foot strike.[15, 16]

In cyclists, 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.

The usual clinical history describes lateral knee pain:

• 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.

• 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.

• 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.

• 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 examination findings in patients with ITBS may include the following:

• 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.

• 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.

• Reproducible pain: Pain may be elicited with knee flexion to 30° when varus stress is applied to the knee.

• 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]

  The Ober test.

See the list below:

• 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

• 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.

• 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.

No specific laboratory tests are required in the workup of ITBS.

Initially, radiographic studies are not indicated if the working diagnosis is completely consistent with ITBS. Radiographs are almost always negative. If the patient's history and physical are not consistent with the diagnosis of ITBS or the patient's response to treatment is unsatisfactory, radiographs are required. In some patients, the practitioner may elect to obtain radiographs on the first visit or before the athlete resumes competition.

Rehabilitation Program

Physical Therapy

Modalities to decrease inflammation include ultrasonography, phonophoresis, iontophoresis, and icing. After the acute inflammation has resolved, the patient should begin a stretching program, which should include active stretching of the hamstrings, gluteal musculature, and hip adductors to improve the flexibility of the ITB. (See images below.)[18]

Medical Issues/Complications

The acute phase of treatment focuses on control of inflammation, correction of poor training habits, as well as accommodation made for any anatomic structural variants.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation

• To reduce stress on the knee, ideally, the athlete should avoid participating in the activity that incited the injury. Pragmatically, it is often helpful for the physician to work with the athlete to develop a training program that allows athletes to participate in their sports to the extent that they are not experiencing discomfort.

  • Swimming, using only the arms, is a way for athletes to maintain cardiovascular fitness during this period. Once the inflammation is reduced, the athlete's activity level can be gradually increased as he/she moves to the next phase of recovery.

  • Runners

    • Inspect the athlete's running shoes for uneven or excessive wear.

    • Evaluate and identify anatomic factors that may contribute to ITBS. If a leg-length discrepancy is present, consider prescription of a heel lift. Many runners have a tendency toward foot pronation or supination. If either condition is present, orthotic devices may be helpful.

    • Runners should modify their training routine to avoid running on banked surfaces and/or hills or running in the same direction on a track.

  • Cyclists

    • Often, cyclists who are diagnosed with ITBS have their cleats positioned in internal rotation. This position increases tension on the ITB. To eliminate stress on the ITB, the cleats should be adjusted to reflect the cyclist's anatomic alignment, or the cleats can be externally rotated to reduce stretch on the ITB. If the cyclist is riding with fixed, clipless pedals, a switch to floating pedals is often beneficial.

    • Evaluate the cyclist’s saddle or seat position. A saddle that is too high should be adjusted so that 30-35° of flexion is present at the bottom of the pedaling stroke. Consider reducing stress on the ITB by widening the cyclist’s bike stance and by improving both the hip and foot alignment. This correction can be accomplished by placing spacers between the pedal and the crank arm.

Surgical Intervention

Surgical intervention is not indicated for ITBS except in rare cases in which prolonged conservative treatment has failed to either alleviate the patient's symptoms or resolve the ITBS.[3, 12, 19]

Before considering surgery, the physician should investigate other possible sources of lateral knee pain. Lateral meniscus tears and chondromalacia can also cause lateral knee pain. Diagnostic arthroscopy should accompany any surgical procedure for ITBS.

Several procedures have been reported to be effective, most of which involve removing a portion of the ITB where it comes into contact with the lateral femoral epicondyle. Z-lengthening of the ITB at the level of the lateral epicondyle has also been proposed.[12]

Consultations

The following consultants may be of assistance in managing ITBS:

• Primary care sports medicine specialist (pediatrician, family practitioner, or internal medicine specialist with a certificate of added qualification [CAQ] in sports medicine)

• Orthopedic surgeon

• Physiatrist with fellowship training in sports medicine

Other Treatment

See the list below:

• Local corticosteroid injection has been shown to be beneficial in managing acute inflammation for those who do not respond to analgesia and rest.[1, 3, 12, 20, 21]

  • Place the patient in a lateral recumbent position with the affected knee flexed to approximately 30 º.

  • Direct the injection into the deep space at the point of maximal tenderness just lateral to the lateral femoral condyle.

Rehabilitation Program

Physical Therapy

Once the pain of ITBS has resolved and the athlete has achieved adequate ITB flexibility, the patient should begin strengthening exercises. The strengthening program focuses on the proximal hip musculature. Examples of exercises that are used at this stage include side-lying leg lifts, pelvic drops, and step-down exercises.

Medical Issues/Complications

If the preceding management of the injury is not successful, consider a period of total rest (4-6 weeks).

Surgical Intervention

Surgical treatment of ITBS is rarely required because most cases respond to conservative treatment (see Acute Phase, Surgical Intervention, above).

Rehabilitation Program

Physical Therapy

Integrate active ITB stretching and strengthening of the hip musculature into the athlete’s training program.

NSAIDs are often incorporated into the medical management of overuse injuries such as ITBS because of these agents' analgesic and anti-inflammatory effects. All NSAIDs share a common mechanism of action, inhibition of prostaglandins. Many types of NSAIDs are available for treatment of overuse injuries, but these drugs vary primarily in their onset of effectiveness and duration of action.

To some degree, all NSAIDs share a common side effect of irritation of the gastrointestinal (GI) tract. Patients who take NSAIDs may experience symptoms of flatulence, abdominal cramping, and diarrhea. The more serious GI side effects include esophageal reflux, gastritis, acid reflux, peptic disease, and ulcer formation. NSAIDs as a group may also produce renal side effects (interstitial nephritis, vasomotor nephropathy), dermatologic reactions (rashes), and central nervous system (CNS) symptoms (eg, headache, dizziness, mood change, confusion), but these are much less common than GI side effects.

The ideal NSAID for treatment of an overuse injury is one that combines several properties. The drug should act quickly, have good penetration into synovial tissues, and produce few or no side effects. Unfortunately, no NSAID exists that fulfills all these criteria. The following list indicates only a few of the NSAIDs that are commonly prescribed for overuse injuries.

See also Medscape Drugs & Diseases topics Overuse Injury and Nonsteroidal Anti-inflammatory Agent Toxicity.

Class Summary

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Naproxen (Naprelan, Naprosyn, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Diclofenac (Cataflam, Voltaren)

Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA.

One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment.

Rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.

The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. Has relatively low risk for bleeding GI ulcers. Available in extended-relief dosage of 75 mg or 100 mg (Voltaren SR) am or hs.

An athlete can return to full activity when pain has resolved, and he/she has achieved normal flexibility of the ITB. To prevent recurrence of the injury, the athlete should have regained full muscle strength of the proximal hip and knee musculature.

If the injury has not been fully rehabilitated before the athlete returns to play, ITBS can become a chronic condition.

The athlete should integrate active stretching of the ITB and maintenance of strength of the proximal hip musculature into his/her training program. Athletes should be aware of aspects of their training programs that may provoke ITBS (eg, overtraining, running on banked roads) and should make appropriate alterations.[22] By working with their physicians, trainers, physical therapists, or coaches, athletes should identify and correct problems with their equipment (eg, bicycle seats that are too high, worn-out athletic shoes).

The prognosis for ITBS is excellent if the athlete maintains ITB flexibility and corrects the intrinsic factors that lead to this injury. The athlete must also avoid the extrinsic factors that provoke ITBS.

Provide the athlete with educational materials that describe ITBS and its management. An individualized, written training program must be developed for each athlete through collaboration with the athlete and a physician, physical therapist, or athletic trainer.