Iliotibial band syndrome
Iliotibial band syndrome (ITBS or ITBFS, for iliotibial band friction syndrome) is a common injury to the knee, generally associated withrunning, cycling, hiking or weight-lifting (especially squats).
Iliotibial band friction syndrome (ITBFS) is a common cause of lateral knee pain, particularly among runners, military personnel, and cyclists.[1, 2] It is considered an overuse syndrome that usually is treated successfully with a conservative approach. Biomechanical and training factors play a large role in the development of ITBFS, but its exact etiology is somewhat elusive.[3, 4]
Conservative therapy is successful in most persons with ITBFS. When conservative therapy does not resolve the pain, surgery may be indicated. Conservative therapy should be employed for 3 months before surgery, but most patients for whom surgery is necessary have had symptoms for more than 9 months.
Surgery is rarely indicated, but the most common procedure for ITBFS is resection of the posterior portion of the iliotibial band (ITB) and, if desired, the adventitial bursa deep to the band. Surgery is performed with the knee held in 30° of flexion and consists of a limited resection of a small triangular or elliptical piece of the posterior part of the ITB covering the lateral femoral epicondyle. The bursa may be removed in certain cases as well.
Iliotibial band syndrome is one of the leading causes of lateral knee pain in runners. The iliotibial band is a thick band of fascia on the lateral aspect of the knee, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, as it moves from behind the femur to the front of the femur during activity. The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed.
ITBS symptoms range from a stinging sensation just above the knee joint, to swelling or thickening of the tissue in the area where the band moves over the femur. The stinging sensation just above the knee joint is felt on the outside of the knee or along the entire length of the iliotibial band. Pain may not occur immediately during activity, but may intensify over time. Pain is most commonly felt when the foot strikes the ground, and pain might persist after activity. Pain may also be present above and below the knee, where the ITB attaches to the tibia.
ITBS can result from one or more of the following: training habits, anatomical abnormalities, or muscular imbalances:
Consistently running on a banked surface, which causes the downhill leg to bend slightly inward, causing extreme stretching of the band against the femur (such as the shoulder of a road or anindoor track)
Inadequate warm-up or cool-down
Excessive up-hill and down-hill running
Positioning the feet "toed-in" to an excessive angle when cycling
Running up and down stairs
Hiking long distances
Egg Beater (Water Polo)
Abnormalities in leg/feet anatomy:
Weak hip abductor muscles
Weak/non-firing multifidus muscle
Treatment requires activity modification, massage, and stretching and strengthening of the affected limb. The goal is to minimize the friction of the iliotibial band as it slides over the femoral condyle. The patient may be referred to a physical therapist who is trained in treating iliotibial band syndrome. Most runners with low mileage respond to a regimen of anti-inflammatory medicines and stretching; however, competitive or high-mileage runners may need a more comprehensive treatment program.
The initial goal of treatment should be to alleviate inflammation by using ice and anti-inflammatory medications. Patient education and activity modification are crucial to successful treatment. Any activity that requires repeated knee flexion and extension is prohibited. During treatment, the patient may swim to maintain cardiovascular fitness. If visible swelling or pain with ambulation persists for more than three days after initiating treatment, a local corticosteroid injection should be considered6(Figure 3).
Corticosteroid injection for iliotibial band syndrome. Gerdy's tubercle and the femoral condyle are marked as landmarks. With the patient in a supine or side-lying position, the needle is inserted at the point of maximum tenderness over the femoral condyle.
As the acute inflammation diminishes, the patient should begin a stretching regimen that focuses on the iliotibial band as well as the hip flexors and plantar flexors. The common iliotibial band stretches(Figure 4) have been evaluated for their effectiveness in stretching the band. The stretch shown inFigure 4C was consistently the most effective in increasing the length of the iliotibial band in a study9of elite distance runners. Although this study9 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 the syndrome.
Stretches of the right iliotibial band
Once the patient 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.6 A strengthening exercise geared toward the gluteus medius is shown in Figure 5.
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.
Running should be resumed only after the patient is 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 the patient is able to tolerate this type of running without pain, mileage can be increased slowly. For the first week, patients 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.1
For patients who do not respond to conservative treatment, surgery should be considered. The most common approach is to release the posterior 2 cm of the iliotibial band where it passes over the lateral epicondyle of the femur. In a retrospective study10 of 45 patients who underwent surgical release of their iliotibial band, 84 percent of the patients reported that their surgery results were good to excellent.
RAZIB KHAUND, M.D., is clinical assistant professor of medicine in the Department of Orthopedic and Internal Medicine at Brown University School of Medicine, Providence, R.I., a physician in internal medicine at the Hughston Clinic in Columbus, Georgia, and a sports medicine specialist at the New England Center for Athletes in Providence. Dr. Khaund received his medical degree from New Jersey Medical University, Newark. He completed a fellowship in sports medicine at the Hughston Clinic.
SHARON H. FLYNN, M.D., is a hospitalist at the Oregon Medical Group/Hospital Service, Eugene, Ore., and has a special interest in sports medicine. She received her medical degree from George Washington University Medical Center, Washington, D.C., and completed a residency in internal medicine at Rhode Island Hospital/Brown University School of Medicine.
Address correspondence to Sharon H. Flynn, M.D., Oregon Medical Group/Hospital Service, 1200 Hilyard St., Suite S-140, Eugene, OR 97401 (e-mail: firstname.lastname@example.org). Reprints are not available from the authors.
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
Fredericson M, White JJ, Macmahon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83:589–92.
Fredericson M, Guillet M, DeBenedictis L. Quick solutions for iliotibial band syndrome. Phys Sportsmed. 2000;28:53–68.
Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996;24:375–9.
Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10:169–75.
Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc. 1988;20:501–5.
Messier SP, Edwards DG, Martin DF, Lowery RB, Cannon DW, James MK, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc. 1995;27:951–60.
Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95–101.
Ekman EF, Pope T, Martin DF, Curl WW. Magnetic resonance imaging of iliotibial band syndrome.Am J Sports Med. 1994;22:851–4.
Panni AS, Biedert RM, Maffulli N, Tartarone M, Romanini E. Overuse injuries of the extensor mechanism in athletes. Clin Sports Med. 2002;21:483–98.
Drogset JO, Rossvoll I, Grontvedt T. Surgical treatment of iliotibial band friction syndrome. A retrospective study of 45 patients. Scand J Med Sci Sports. 1999;9:296–8.
Lang RA, Cuthbertson RA, Dunn AR (1992). "TNFα, IL-1α and bFGF are Implicated in the Complex Disease of GM-CSF Transgenic Mice". Growth Factors 6 (2): 131–8.doi:10.3109/08977199209011016. PMID 1586489.