Iliotibial band syndrome

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iliotibial band syndrome

Iliotibial band syndrome

Iliotibial band syndrome also known as “IT band syndrome” or “iliotibial band friction syndrome“, occurs when the iliotibial band (a portion of the fascia lata), a tendon that runs along the outside of your leg, due to overuse becomes swollen and irritated from rubbing against the bone on the outside (lateral side) of your hip or knee 1, 2, 3, 4, 5, 6. With iliotibial band syndrome you might hear a popping or snapping sound from the outside (lateral side) of your knee. And you might feel the pain on the outside of your knee that worsens with running, cycling, or performing any activity that involves repeated bending and straightening of your knee 7. The pain occurs at the level of the distal iliotibial band, between the lateral femoral epicondyle and its tibial insertion, and is associated with regular physical activity. Initially, the outside of the knee pain is often experienced late in or after completing a sporting activity. As the iliotibial band syndrome progresses, it begins earlier in the course of the activity 6. On physical assessment, tenderness can be observed at the level of the lateral femoral epicondyle 6.

Common causes of IT band syndrome include irritation of the iliotibial band (ITB) after repeatedly rubbing against the bones of the hip or knee and running 8. Iliotibial band syndrome is commonly reported in athletes, such as runners, cyclists, basketball, soccer, or hockey players but may also present in tennis, skiing, and weight lifters 9, 10, 11. Iliotibial band syndrome has been reported as a cause of knee pain in 62% and 38% of female and male runners, respectively 10 and in 24% of cyclists 11.

Iliotibial band syndrome is slightly more common in women than men and seldom occurs in the non-active population. One cross-sectional study demonstrated that the incidence of iliotibial band syndrome was 6.2% in military recruits 12. The U.S. Marine Corps reported running/overuse injuries accounted for 12% of injuries sustained by their personnel 13.

The iliotibial band (ITB) is a portion of the fascia lata. The iliotibial band (ITB) receives contributions from the tensor fascia lata and gluteus maximus muscles in the lateral thigh and terminates distally about the knee, having the main ribbon-shaped insertion into the Gerdy tubercle on the anterior aspect of the lateral tibial condyle (see Figures 1 and 2) 14. The iliotibial band transmits forces from the hip to the knee, acts as a lateral stabilizer of the knee, and also serves an important postural function 15, 16. The iliotibial band functions as a knee extensor when the knee is less than 30 degrees of flexion but becomes a knee flexor after exceeding 30 degrees of flexion. The iliotibial band has been postulated to acquire a more posterior position relative to the lateral femoral epicondyle with increasing degrees of flexion 17.

Iliotibial band syndrome is a clinical diagnosis and rarely requires further studies and imaging. The diagnosis of iliotibial band syndrome is based on clinical assessment, and imaging is mostly performed in recurrent or refractory cases 6. The Ober test is an orthopedic evaluation procedure used to assess for tightness of the tensor fascia latae and iliotibial band (Figure 6) 18. With the patient lying on the side with the unaffected side down and the unaffected hip and knee at a 90-degree angle, the examiner stabilizes the pelvis, then abducts and extends the affected leg until it is aligned with the rest of the patient’s body. The affected leg is lowered into adduction. If the iliotibial band is normal in length and unaffected, the leg will adduct and the patient will not experience pain. If the iliotibial band is tight, the leg will remain in the abducted position and the patient may have lateral knee pain 19, 20, 21. A tight iliotibial band contributes to the excess friction placed on the iliotibial band as it slides over the femoral condyle during flexion and extension of the knee.

Both magnetic resonance imaging (MRI) and ultrasound may be used to confirm the diagnosis 22, 23, 24. As a cost-effective imaging modality that enables visualization of the superficial soft-tissue structures with high resolution, dynamic evaluation, and comparison with the contralateral healthy side, ultrasound is valuable for the assessment of iliotibial band syndrome 25, 26, 27, 28.

Iliotibial band syndrome is mainly managed conservatively and the treatment varies according to the phase of the disease. Fredericson et al. 29 have proposed different treatment strategies according to three disease phases, such as the acute, subacute, and recovery strengthening phases. The path to recovery involves the correction of facilitating factors, such as the weakness of the gluteus medius, the excessive adduction of the hip and internal rotation of the knee, the varus alignment of the knee, and lower limb length discrepancy 30.

In the acute phase of iliotibial band syndrome, treatment is aimed at reducing local inflammation. Rest from physical activities such as running and cycling is a mainstay of treatment. Any activity that requires repeated knee flexion and extension is prohibited 31. During treatment, the patient may swim to maintain cardiovascular fitness. In severe iliotibial band syndrome cases, patients should also avoid any activity involving repetitive flexion or extension of the knee and swim using only their arms and a floating device 30. Concurrent therapies such as ice, ultrasound, and iontophoresis (the area to be treated is placed into water and a weak electrical current is passed through the skin) play additional roles 32. Both oral nonsteroidal anti-inflammatory medications (NSAIDs) and local corticosteroid injections can be used 32. Local corticosteroid injections are considered in severe cases where physical therapies and oral medications fail to relieve symptoms 33, 34, 35. They have been shown to effectively decrease pain in patients with recent onset of iliotibial band syndrome 36. The response to corticosteroid injections helps diagnose iliotibial band syndrome as well 37. The procedure is performed with a sterile and local anesthetic technique. The tip of the needle is placed at the deep surface of the iliotibial band. Fluid aspiration can be performed if a focal fluid collection or bursitis is present. A combination of corticosteroid and anesthetic is injected 38. Up to 2 pain-free weeks are advised before returning to usual activity in a graded progression 30.

Once acute inflammation is under control, stretching exercises can be started. Therefore, in the subacute phase of iliotibial band syndrome, treatment focuses on achieving flexibility in the iliotibial band as a foundation to strength training. Iliotibial band stretching and soft-tissue mobilization aimed at reducing myofascial adhesions are performed 39. Myofascial release with a foam roller has been used to break up adhesions and is an integral part of the rehabilitation process 17. Eliminating myofascial adhesions precedes strengthening and muscle reeducation. For this reason, the recovery strengthening phase focuses on a series of exercises to improve gluteus medius strength. Exercises should be pain-free and include side-lying hip abduction, single-leg activities, pelvic drops, and multiplanar lunges 39.

Most people do not need surgery. But if other treatments do not work, surgery may be recommended. Surgical options include the release of the iliotibial band, iliotibial band bursectomy, and the resection of the lateral synovial recess 40, 41, 42.

Figure 1. Iliotibial band

Iliotibial band

Figure 2. Iliotibial band insertion

Iliotibial band insertion

Figure 3. Iliotibial band syndrome

iliotibial band syndrome

Figure 4. Iliotibial band syndrome ultrasound

Iliotibial band syndrome ultrasound

Footnotes: On longitudinal (a) and axial (b) sonograms, soft-tissue hypoechoic edematous swelling (asterisks) is noted between the iliotibial band (arrowheads) and the lateral femoral epicondyle.

[Source 22 ]

Figure 5. Iliotibial band syndrome ultrasound

Iliotibial band syndrome ultrasound

Footnotes: On longitudinal sonograms in different patients (a, b), bursae (arrows) are noted between the iliotibial band (IT band) and the lateral femoral epicondyle.

[Source 22 ]

Figure 6. Ober’s test

Ober's test

Footnotes: Ober’s test with different contralateral hip flexion (0°, 45°, 90°, and maximal contralateral hip flexion). The patient lies down with the unaffected side down and the unaffected hip and knee at a 90-degree angle. If the iliotibial band is tight, the patient will have difficulty adducting the leg beyond the midline and may experience pain at the lateral knee (arrows).

[Source 18 ]

Iliotibial band syndrome causes

Iliotibial band syndrome has several proposed causes, including friction of the iliotibial band against the lateral epicondyle of the femur 43, 44, 45, compression of the fat and connective tissue deep to the iliotibial band 46, and chronic inflammation of an adventitial bursa underneath the iliotibial band 47. The first is linked to iliotibial band rubbing back and forth across the lateral femoral epicondyle during activities involving repetitive knee flexion and extension, thus resulting in friction of the iliotibial band and inflammation of the adjacent soft tissues 45. This proposed cause has been debated over the years, particularly with regard to the direction and extent of the iliotibial band motion. However, an ultrasound study has demonstrated that the iliotibial band moves in an antero-posterior (front-back) direction relative to the lateral femoral epicondyle during knee extension and flexion, thus supporting the central role of friction as an causative factor 48. Other proposed causes, such as fat compression 46 and soft-tissue irritation 49 deep to the iliotibial band, may coexist and explain why pathological changes primarily occur in the soft tissues rather than within the iliotibial band 50. Particularly, chronic irritation can result in an adventitial or secondary bursitis underneath the iliotibial band, where no primary bursa has been consistently identified in cadaveric studies 47.

The predisposing factors associated with iliotibial band syndrome are both extrinsic and physical or intrinsic factors. The extrinsic factors include training errors, such as a rapid increase in mileage and downhill running 51, 52. Particularly, in the latter case, knee flexion is reduced, and iliotibial band friction may be facilitated as this occurs around or slightly below 30° of flexion 52. The main physical or intrinsic factors include bow legs (genu varum where the legs curve outward at the knees while the feet and ankles touch), hip abduction weakness, and lower limb length discrepancy 52, 53. Particularly, bow legs (genu varum where the legs curve outward at the knees while the feet and ankles touch) may favor the development of iliotibial band syndrome by increasing the strain of the iliotibial band during weight-bearing, as seen on sonoelastography in female athletes with genu varum in comparison with normal knee alignment 54.

Other causes of iliotibial band syndrome include 55, 56, 20:

  • Being in poor physical condition
  • Having a tight iliotibial band
  • Poor form with your activities
  • Not warming up before exercising
  • Having bowed legs
  • Changes in activity levels
  • Imbalance of the core muscles
  • Injury to the area like a contusion or bruise.

Iliotibial band syndrome symptoms

Iliotibial band syndrome is a common cause of outside of the knee pain (lateral knee pain) in athletes.

If you have iliotibial band syndrome you may notice:

  • Mild pain on the outside of your knee or hip when you begin to exercise, which goes away as you warm up.
  • Over time, the pain feels worse and doesn’t go away during exercise.
  • Running down hills or sitting for a long time with your knee bent may make pain worse.

The pain occurs at the level of the distal iliotibial band, between the lateral femoral epicondyle and its tibial insertion, and is associated with regular physical activity. Initially, the outside of the knee pain is often experienced late in or after completing a sporting activity. As the iliotibial band syndrome progresses, it begins earlier in the course of the activity 6. On physical assessment, tenderness can be observed at the level of the lateral femoral epicondyle 6.

Iliotibial band syndrome complications

Disease progression is the most common complication of iliotibial band syndrome. As the disease progresses, the patient will experience pain throughout the activities and even at rest. Furthermore, because of iliotibial band attachments to the lateral patella, the progression of the disease may lead to patellofemoral syndrome.

Iliotibial band syndrome diagnosis

Your doctor will examine your knee and move your leg in different positions to see if your iliotibial band (ITB) is tight. Usually, iliotibial band syndrome can be diagnosed from your description of the symptoms and physical examination 6. Patients with iliotibial band syndrome often demonstrate tenderness on palpation of the lateral knee approximately 2 cm above the joint line. Tenderness frequently is worse when the patient is in a standing position and the knee is flexed to 30 degrees. At this angle, the iliotibial band slides over the femoral condyle and is at maximal stress, thus reproducing the patient’s symptoms.1,6 Swelling may be noted at the distal iliotibial band and thorough palpation of the affected limb may reveal multiple trigger points in the vastus lateralis, gluteus medius, and biceps femoris. Palpation of these trigger points may cause referred pain to the lateral aspect of the affected knee. Strength of the lower extremity should be assessed with particular emphasis on examining the knee extensors, knee flexors, and hip abductors. Weakness in these muscle groups has been associated with the development of iliotibial band syndrome 56, 20, 57

The Ober’s test can be used to assess tightness of the iliotibial band 18. With the patient lying on the side with the unaffected side down and the unaffected hip and knee at a 90-degree angle, the examiner stabilizes the pelvis, then abducts and extends the affected leg until it is aligned with the rest of the patient’s body. The affected leg is lowered into adduction. If the iliotibial band is normal in length and unaffected, the leg will adduct and the patient will not experience pain. If the iliotibial band is tight, the leg will remain in the abducted position and the patient may have lateral knee pain 19, 20, 21. A tight iliotibial band contributes to the excess friction placed on the iliotibial band as it slides over the femoral condyle during flexion and extension of the knee.

If imaging tests are needed, they may include any of the following:

  • X-rays
  • Ultrasound
  • Magnetic resonance imaging (MRI)

Imaging, including ultrasound, is reserved for recurrent or refractory cases and requires correlation with clinical information 6. Radiographic imaging of the knee is useful for ruling out other pathology that could be causing lateral knee pain such as osteoarthritis, fracture, or patella malalignment. Iliotibial band syndrome in the absence of other pathology will appear normal on plain radiograph of the knee. If the diagnosis is still unclear after the history and physical, magnetic resonance imaging (MRI) of the knee may confirm the diagnosis if it demonstrates hyperintensities at the lateral femoral epicondyle with a thickened distal iliotibial band and often detects a fluid collection deep to the iliotibial band in the same region 58. Additionally, ultrasound is a low cost and low-risk modality that may show abnormal distal IT band thickening 17.

Ultrasound findings of iliotibial band syndrome include soft-tissue edematous swelling and discrete fluid collection, suggestive of adventitial bursitis, between the iliotibial band and the lateral femoral epicondyle 59, 60. The thickening of the iliotibial band has been reported inconsistently 61, 62 and researchers have questioned whether this finding occurs only in chronic cases 62. Cortical irregularity of the adjacent femoral epicondyle can also be observed 63. A common pitfall is the normal lateral recess of the knee joint as fluid is associated with the iliotibial band in a large number of asymptomatic runners, deep or anterior to it 64. The lateral recess extends adjacent to the lateral femoral condyle, deep to the iliotibial band 49 and should not be mistaken for an adventitial bursitis. Continuity of the recess with the joint can be demonstrated with ultrasound 65.

Iliotibial band syndrome differential diagnosis

The following lists the most common causes of lateral knee pain:

  • Stress fracture of the lateral tibial plateau
  • Lateral meniscus tear
  • Lateral compartment of the knee osteoarthritis
  • Lateral collateral ligament strain
  • Biceps femoris tendinopathy
  • Radiation from hip pathology
  • Patellofemoral syndrome
  • Popliteal tendinopathy

Iliotibial band syndrome treatment

Iliotibial band syndrome is mainly managed conservatively and the treatment varies according to the phase of the disease. Fredericson et al. 29 have proposed different treatment strategies according to three disease phases, such as the acute, subacute, and recovery strengthening phases. The path to recovery involves the correction of facilitating factors, such as the weakness of the gluteus medius, the excessive adduction of the hip and internal rotation of the knee, the varus alignment of the knee, and lower limb length discrepancy 30.

In the acute phase of iliotibial band syndrome, treatment is aimed at reducing local inflammation. Rest from physical activities such as running and cycling is a mainstay of treatment. Any activity that requires repeated knee flexion and extension is prohibited. During treatment, the patient may swim to maintain cardiovascular fitness. In severe iliotibial band syndrome cases, patients should also avoid any activity involving repetitive flexion or extension of the knee and swim using only their arms and a floating device 30. Concurrent therapies such as ice, ultrasound, and iontophoresis (the area to be treated is placed into water and a weak electrical current is passed through the skin) play additional roles 32. Both oral nonsteroidal anti-inflammatory medications (NSAIDs) and local corticosteroid injections can be used 32. Local corticosteroid injections are considered in severe cases where physical therapies and oral medications fail to relieve symptoms 33, 34, 35. They have been shown to effectively decrease pain in patients with recent onset of iliotibial band syndrome 36. The response to corticosteroid injections helps diagnose iliotibial band syndrome as well 37. The procedure is performed with a sterile and local anesthetic technique. The tip of the needle is placed at the deep surface of the iliotibial band. Fluid aspiration can be performed if a focal fluid collection or bursitis is present. A combination of corticosteroid and anesthetic is injected 38. Up to 2 pain-free weeks are advised before returning to usual activity in a graded progression 30.

Once acute inflammation is under control, stretching exercises can be started. Therefore, in the subacute phase of iliotibial band syndrome, treatment focuses on achieving flexibility in the iliotibial band as a foundation to strength training. Iliotibial band stretching and soft-tissue mobilization aimed at reducing myofascial adhesions are performed 39. Myofascial release with a foam roller has been used to break up adhesions and is an integral part of the rehabilitation process 17. Eliminating myofascial adhesions precedes strengthening and muscle reeducation. For this reason, the recovery strengthening phase focuses on a series of exercises to improve gluteus medius strength. Exercises should be pain-free and include side-lying hip abduction, single-leg activities, pelvic drops, and multiplanar lunges 39.

Most people do not need surgery. But if other treatments do not work, surgery may be recommended. Surgical options include the release of the iliotibial band, iliotibial band bursectomy, and the resection of the lateral synovial recess 40, 41, 42.

Iliotibial band pain relief

At home, follow these measures to help reduce your pain and swelling:

  • Apply ice to the painful area for 15 minutes every 2 to 3 hours. Do not apply ice directly to your skin. Wrap the ice in a clean cloth first.
  • Apply mild heat before stretching or doing strengthening exercises.
  • Take pain medicine if you need to. For pain, you can use ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), or acetaminophen (Tylenol). You can buy these pain medicines at the store.

Talk with your doctor before using any pain medicines if you have heart disease, high blood pressure, kidney disease, or have had stomach ulcers or internal bleeding in the past. Do not take more than the amount recommended on the bottle or by your doctor.

Iliotibial band syndrome physical therapy

Your physical therapist may give you exercises to do to help stretch your iliotibial band and strengthen your leg muscles. Before and after activity:

  • Use a heating pad on your knee to warm the area up. Make sure the pad’s setting is on low or medium.
  • Ice your knee and take pain medicine after activity if you feel pain.

The best way for the tendons to heal is to stick to a care plan. The more you rest and practice physical therapy, the quicker and better your injury will heal.

Iliotibial band syndrome activity

Try running or cycling shorter distances than you usually do. If you still have pain, avoid these activities completely. You may need to do other exercises that do not irritate your iliotibial band, such as swimming.

The recommended progression back to activity starts with a week of running on alternating days on a flat surface. The following weeks are focused on fast-paced running daily and avoid downhill running. After 3 to 4 weeks, the patient can gradually increase the distance and frequency. Introducing hills and cambered surfaces should only take place if there is no pain or symptoms on a flat surface. If the patient relapses, then they will need to start their activity progression over again and may require a period of rest beforehand.

Try wearing a knee sleeve to keep the bursa and iliotibial band warm while you exercise.

Your doctor may recommend a physical therapist to work with your specific injury so you can return to normal activity as soon as possible.

Your physical therapist may recommend ways to change how you exercise to prevent problems. Exercises are aimed at strengthening your core and hip muscles. It will also focus on stretching your tissue to allow less irritation. You may also be fitted for arch supports (orthotics) to wear in your shoes.

Once you can do stretching and strengthening exercises without pain, you can gradually begin running or cycling again. Slowly build up distance and speed.

Iliotibial band syndrome stretching

As the acute inflammation diminishes, you should begin a stretching regimen that focuses on the iliotibial band as well as the hip flexors and plantar flexors 44. The common iliotibial band stretches (Figure 7) have been evaluated for their effectiveness in stretching the iliotibial band 66. The stretch shown in Figure 7C was consistently the most effective in increasing the length of the iliotibial band in a study of elite distance runners 66. Although a study demonstrates the effectiveness of stretching the iliotibial band, participants in the study did not have iliotibial band syndrome and studies have not demonstrated that stretching hastens recovery from iliotibial band syndrome 44.

Once you can perform stretching without pain, a strengthening program should be initiated. Strength training should be an integral part of any runner’s regimen; however, for patients with iliotibial band syndrome particular emphasis needs to be placed on the gluteus medius muscle 20. A strengthening exercise geared toward the gluteus medius is shown in Figure 8.

Running should be resumed only after you are able to perform all of the strength exercises without pain. The return to running should be gradual, starting at an easy pace on a level surface. If you’re able to tolerate this type of running without pain, mileage can be increased slowly. For the first week, you should run only every other day, starting with easy sprints on a level surface. Most patients improve within three to six weeks if they are compliant with their stretching and activity limitations 19.

Figure 7. Iliotibial band syndrome stretching

Iliotibial band syndrome stretching

Footnote: Stretches of the right iliotibial band

[Source 44 ]

Figure 8. Exercise for strengthening gluteus medius muscle

Exercise for strengthening gluteus medius muscle

Footnotes: Exercise for strengthening of the right gluteus medius muscle in a weight-bearing position. (A) The patient stands on a platform and lowers the left leg toward the ground slowly. (B) Through contraction of the right gluteus medius, the patient then elevates the leg, returning the pelvis to a level position.

[Source 44 ]

Iliotibial band syndrome surgery

Surgical intervention for iliotibial band syndrome is only for refractory cases despite nonoperative management for more than 6 months 1. There are several surgical options including percutaneous or open iliotibial band release, iliotibial band lengthening with a Z-plasty, open iliotibial band bursectomy, and arthroscopic iliotibial band debridement. Furthermore, there are several different techniques described for the open iliotibial band release including resecting a triangular portion of the distal posterior iliotibial band, resecting the 2 cm x 4 cm portion overlying the lateral femoral epicondyle, and also making a V-shaped incision in the iliotibial band 67, 68, 69. All of the different surgical techniques have demonstrated success, but there are limited comparative studies to demonstrate superiority. Iliotibial band bursectomy is the indicated option with the symptomatology of iliotibial band syndrome but no enhancement of the iliotibial band on MRI. The procedure consists of excising the underlying iliotibial band bursa but leaving the iliotibial band completely intact. One study demonstrated that the majority of patients who undergo open bursectomy are overall completely or mostly satisfied with the results 70. Minimal invasive techniques have been described to resect the lateral synovial recess that connects the iliotibial band to the lateral femur and innervated synovial fat. Michels et al. 71 described this arthroscopic technique and showed a 97% good to excellent result with all patients returned to full activity.

Iliotibial band syndrome prognosis

Roughly 50% to 90% of iliotibial band syndrome patients will improve with 4 to 8 weeks of nonoperative management 1. Iliotibial band syndrome typically follows a fluctuating course and may relapse at any point in the treatment progression or return to activity. All surgical modalities have reported good to excellent results 67, 69.

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