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Iliotibial Band Friction Syndrome

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Ovid: 5-Minute Sports Medicine Consult, The


Iliotibial Band Friction Syndrome
Natasha Harrison
Rahul Kapur
Basics
Description
  • Iliotibial band friction syndrome (ITBS or ITBFS) is an overuse tendonitis that occurs from compression of the iliotibial band (ITB) against the lateral femoral epicondyle.
  • Pain is especially sharp after foot strike in the gait cycle, usually at ∼30 degrees of knee flexion.
  • Synonym(s): Iliotibial band tendonitis
Epidemiology
  • Incidence as high as 12% of all running-related overuse injuries
  • Second to patellofemoral syndrome as the most common running injury
Risk Factors
  • Training factors: Higher weekly mileage, downhill running, disproportionate running on a track in the same direction
  • Increased peak hip adduction (possibly owing to significant weakness of the hip abductors of one limb as compared with the other) and increased knee internal rotation with running (1)
Etiology
  • The iliotibial band is composed of dense fibrous connective tissue that originates off the iliac crest. Its course runs inferiorly, passing over the lateral femoral epicondyle prior to insertion distally on the tibia at Gerdy's tubercle.
  • The iliotibial band is compressed against the lateral femoral epicondyle with knee flexion, with the greatest compression at 30 degrees of knee flexion.
  • Etiology is unclear, but it appears that the repetitive compression leads to inflammation of the band as well as inflammation of the connective tissue and fat pad between the band and the epicondyle (2).
Diagnosis
History
  • Lateral knee sharp pain or burning
  • Pain is not present when the patient starts exercising but begins at a predictable time or distance within the workout.
  • Symptoms that subside shortly after the workout but return with the next workout
  • Pain worse with downhill running, stride lengthening, or sitting for long periods of time with a flexed knee
  • Involvement in sports that require continuous running or repetitive knee flexion (ie, bicycling)
Physical Exam
  • Lateral knee pain made worse with running (3)[C]
  • Pain with ascending and descending stairs
  • Stiff-legged walking in advanced cases
  • Extensive musculoskeletal exam with particular attention to the lower extremities: With a patient with ITBS, the clinician may notice local tenderness and swelling, as well as crepitation, snapping, or pitting edema over the distal ITB where it passes over the lateral femoral epicondyle, and there may be pain or paresthesia along the length of the band (3)[C].
  • Perform Obers' test: Position the patient on the unaffected side with the involved knee in 90 degrees of flexion. The leg is abducted at the hip, and the examiner then grasps the ankle, allowing the knee to return to an adducted position. A person with ITBFS remains abducted owing to a contracture of the ITB.
  • Perform Noble's compression test: With the patient on his or her side with the affected knee up and flexed at 90 degrees, apply pressure on the ITB at the lateral femoral epicondyle and extend the knee. A positive test occurs when pain occurs as the knee approaches 30 degrees of flexion.
  • Evaluate for excessive ankle pronation and causes of it, including evaluation for tight gastrocnemius or soleus muscles, pes planus, or femoral or tibial torsion. Excessive ankle pronation increases knee flexion.
  • Evaluate for muscle imbalances, especially pelvic and core musculature.
  • Exclude lumbar spine pathology.
  • Feet and footwear should be evaluated closely. Footwear can give clues to the pronation pattern.
  • Evaluate iliac crests and leg length. Discrepancies of leg length can cause tightening of the ITB.
Diagnostic Tests & Interpretation
Imaging
  • Generally not needed except to rule out other disease processes
  • Consider a standing anteroposterior (AP) view of pelvis (in adult) to assess leg-length discrepancy if clinically indicated.
Differential Diagnosis
  • Patellofemoral syndrome
  • Degenerative joint disease
  • Lateral meniscal damage or pathology
  • Lateral collateral ligament sprain
  • Superior tibiofibular joint sprain
  • Popliteal or biceps femoris tendinitis
  • Peroneal nerve injury
  • Gout and other metabolic arthritides
  • Referred pain

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Treatment
  • Rest or modification of activities may be sufficient, but often all potentially exacerbating activities, notably running and cycling, must be avoided (3)[C].
  • Appropriate doses of NSAIDs along with modalities including ice, phonophoresis, and iontophoresis (3)[C]
  • Address muscle imbalances as necessary, specifically pelvic and core musculature.
  • Address pronation as well as other comorbidities (eg, patellofemoral dysfunction, leg-length discrepancy) if present.
  • Relative rest is very important, but no forms of immobilization are used.
Additional Treatment
Additional Therapies
  • Steroid injections can be considered after appropriate interventions are used. Research has shown steroid injections to be especially useful if given within 2 wks of the development of ITBS (4)[B].
  • Rehabilitation should involve an aggressive stretching and strengthening program targeting the ITB and the muscles attached, with goals to restore range of motion and improve flexibility while increasing strength.
Surgery/Other Procedures
  • Only after exhaustive nonoperative therapy
  • Often involves resection of a portion of the ITB, lengthening of the ITB, or resection of the connective tissue and fat between the ITB and the lateral femoral epicondyle (5)[B]
  • All toward a goal of reducing the compression of the ITB on the lateral femoral epicondyle
Ongoing Care
Follow-Up Recommendations
If no improvement is seen after extensive therapy and training modification, then referral to an orthopedic surgeon is warranted.
References
1. Noehren B, Davis I, Hamill J. ASB Clinical Biomechanics Award Winner 2006 Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon). 2007.
2. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006;208:309–316.
3. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35:451–459.
4. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. Br J Sports Med. 2004;38:269–272; discussion 272.
5. Michels F, Jambou S, Allard M, et al. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc. 2008.
Codes
ICD9
728.89 Other disorders of muscle, ligament, and fascia
Clinical Pearls
  • An attempt to return too early with pain can result in significant delay. Activity can be resumed when symptoms have improved nearly 100% or have resolved. Earlier return can be accomplished using non-weight-bearing activities such as swimming or running in the deep end of a pool. Return should be gradual with gentle buildup on level ground progressing in distance/resistance and elevation.
  • Most patients recover in about 6 wks and are able to resume full activity at that time.
  • To prevent ITBFS, maintain flexibility with adequate warm-up periods and stretching before and after exercise.


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