Iliotibial Band Syndrome
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Keywords : knee, iliotibial, Iliotibial band syndrome, therapy , treatment
Consulted databases : Pubmed, Pedro and the medical library of the VUB
An iliotibial friction syndrome is most frequently seen in military personnel, cyclists, runners or other athletes submitted to repetitive motion of the knee. This repetitive motion is responsible for excessive friction between the lateral epicondyle and the iliotibial tract. It is considered as an overuse injury and is often concomitant with underlying weakness of hip abductor muscles. Pain appears in the region of the lateral femur epicondyle or a bit inferior to it. During a physical examination we see an important tenderness of the lateral aspect of the knee. This tenderness is found superior to the joint line and inferior to the lateral femoral epicondyle.
Clinically Relevant Anatomy
The iliotibial tract has its origin on the lateral border of the iliac crest. It is composed of dense fibrous connective tissue that appears from the M. tensor fasciae latae, the gluteal fascia and M. gluteus maximus. It descends vertically at the lateral aspect of the thigh, between the layers of the superficial fascia, and inserts on Gerdy’s tubercle and the lateral proximal aspect of the fibular head.Moreover the ilitibial tract becomes denser in its distal portion and gives an expansion to the lateral border of the patella. In this distal portion, the iliotibial tract covers the lateral femoral epicondyle, The iliotibial tract is stretched by M. gluteus maximus and M. tensor fasciae latae, both inserting on the proximal part of the tract.
When the knee is positioned in extension the iliotibial band lies anterior to the lateral femoral epicondyle ; but when the knee is in 30° flexion the band will lie behind the lateral femoral epicondyle.
Friction at the level of the knee takes place at the instant near footstrike, mainly in the foot contact phase at or slightly below 30° flexion. The exact location of the friction is, between the posterior edge of the iliotibial band and the underlying lateral femoral epicondyle.
Because of the mobility of the knee, activities with many repetitive flexions and extensions of the knee can cause the iliotibial band to rub the lateral femoral epicondyle. This can produce irritation and eventually an inflammatory reaction of the iliotibial band.
In many instances the anamnesis will already provide an excellent basis for suspicion of this syndrome. As mentioned above, repetitive activities involving knee flexion-extension are usually reported, as is a burning pain at the level of (or just underneath) the lateral femoral epicondyle. The diagnosis in patients with this syndrome is based on different symptoms. Among the characteristics, we find an exercise-related tenderness over the lateral femoral epycondyle. The patients experience, on regular basis, an acute, burning pain when pressure is applied on the epycondyle with the knee in flexion and in extension. Sign of inflammation due to the friction between tract and the lateral epicondyle during extension and flexion of the knee can also be found. There is pain on the lateral aspect of the knee during running, increasing in intensity while running down hill. Pain is also exacerbated when running a long distance.
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There are different provocative tests:
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- Force of hip abduction:
The force of hip abductors can be decreased. These muscles should thus be tested.
- Noble compression test:
This test starts in supine posture and a knee flexion of 90 degrees. As the patient extends the knee the assessor applies pressure to the lateral femoral epicondyle. If this induces pain over the lateral femoral epicondyle near 30 degrees of flexion, the test is considered positive.
- Ober test:
The patient is lying on his side with the injured extremity facing upwards. The knee is flexed at 90 degrees and the hip in abduction and extension, the thigh is maintained in line with the trunk. The patient is invited to adduct the thigh as far as possible. The test is positive if the patient cannot adduct farther than the examination table. A positive Ober test indicates a short / tense ilio-tibial band or tensor fasciae latae, which is frequently related to the friction syndrome. (demo)
Both the Noble compression test and the Ober test can be use to examine a patient with a suspicion of Iliotibial friction syndrome. The result will be more obvious when we combine the two into one special test. For this, the position of the Ober test is adopted and compression is applied on the lateral epicondyle during passive knee extension and flexion. Moving the knee can produce more strain on the injured structures and can help to reproduce the symptoms of the patient if the combination does not . Medial patellar glide can also increase the symptoms (by tending the patellar expansion of the iliotibial band) and can reveal the precise localization while lateral glides reduces them. An internal rotation of the tibia when the knee is moved from flexion to extension can also produce the symptoms. A combination of the Nobel and Ober tests with an unloaded knee or in a weight bearing position can also be done the reproduce the symptoms. 
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Physical Therapy Management
The treatment of the iliotibial band friction syndrome is usually non-operative, but in some cases it is necessary to apply surgery.
The following steps are part of the Non-Operative Treatment:
- Short-term cessation or modification of the athletic activities
- Performing iliotibial band stretching exercises
- Applying an ice massage on the painful area
- Taking of analgesics/nonsteroidal anti-inflammatory drugs
- Correction of predisposing factors, such as training errors, running shoes, underground, malalignment of the lower extremity, …
Some authors suggest complete rest from athletic activities for at least 3 weeks; other authors suggest that it is best to rest a period from 1 week to 2 months, but this rest period depends on the severity of the condition.
But it is not necessary that in the initial stages( grades 1 and 2) you have to stop the athletic activities. It is sufficient to lower the intensity of the trainings, especially the activities that causes pain such as running.
In the more advanced cases ( grades 3 and 4) it is requested that the patient don’t perform any athletic activity in first 3 to 4 weeks. But it suggested that the athlete performs other physical training activities, so that they can keep their functional abilities and also that they are still in shape.
The best exercises for the treatment of iliotibial band friction syndrome are passive or static stretching exercises. These sort of exercises need a strictly defined position so that they can be performed correctly. The exercises should be performed slowly until that the patient feels the sensation of stretching. But the prolonged stretching that may causes pain, will decrease the possibility of longer maintenance of the stretching, it also increases the possibility of the muscle contraction that is triggered by a reflex, and it may eventually cause damage to these muscles.
On the other hand, keeping the stretching at the “initial” point will enable a complete relaxation of these muscles and the maintenance of the position for a longer period of time. The patient should keep the stretching at the point of the initial stretching for 15s , and then should he increase the time gradually to a maximum of 25s .
Both in treatment and prevention of the iliotibial band friction syndrome, it is essential to identify and correct the influences that are playing a role in the iliotibial band friction syndrome.
The most common influences are:
- Excessive and/or prolonged pronation of the foot during running
- Errors in the training
- Excessive tightness of the iliotibial band
- Running surfaces
- Genu varum
Some authors, also recommend that the administration of steroids combined with local anesthetic is a way to treat the pain. This should not be considered as the last resort, but as a way to treat the pain in the non-operative treatment program .
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Renne, J.W. The iliotibial band friction syndrome. J. Bone Joint Surg., 1975; 57A: 1110-1111. 2B
Staff, P.H. and Nilsson, S. tendoperiostitis in the lateral femoral condyle in long-distance runners. Br. J. Sports Med., 1980; 14:38-40. 2B
Orava, S. Iliotibial tract friction syndrome in athletes – an uncommon exertion syndrome on the lateral side of the knee. Br. J. Sports Med., 1978; 12: 69-73. 2B
Noble, C.A. The treatment of iliotibial band friction syndrome. Br. J. Sports Med., 1979;13: 51-54 2B
Literature: Secundary Resources
M Béuima M., Bojanic I.. Overuse injuries of the musculoskeletal system. CRC press, 2004, p 222 – 228
Williams C., Harris M., D Stanish W., J Micheli L.. Oxford textbook of Sportsmedicine. Buller and Tonner ltd, Great Britain, 2000, p 686-687
C Reid D.. Sports injuries assessment and rehabilitation. Churchill Livingstone USA, 1992, p 424-428
Bahr R., Maehlum S., Clincal guide to sports injuries, Human Kinetics, Hong Kong, 2004, p 348 – 349
Clinical Bottom Line
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Recent Related Research (from Pubmed)
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- ↑ 1.0 1.1 1.2 1.3 1.4 Lavine R. Iliotibial band friction syndrome; Current Reviews in Musculoskeletal Medicine (2010) :18–22
- ↑ 2.0 2.1 2.2 2.3 Michael D. Clinical Testing for Extra-Articular Lateral Knee Pain. A Modification and Combination of Traditional Tests; North American Journal of Sports Physical Therapy (2008) 3: 107–109.
- ↑ 3.0 3.1 3.2 3.3 3.4 Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome; Journal of Anatomy (2006) 208, 309-316
- ↑ 4.0 4.1 Sobotta J, Putz R, Pabst R, Putz R, van Lennep MJ. Atlas van de menselijke anatomie. (2006) Bohn Stafleu Van Loghum.
- ↑ Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome; Journal of Anatomy (2006) 208, 309-316
- ↑ Wong M. Pocket Orthopaedics, Evidence-Based. (2009) Jones and Bartlett Publishers.
- ↑ Gajdosik RL, Sandler MM, Marr HL. Influence of knee positions and gender on the Ober test for length of the iliotibial band; Clin Biomech (Bristol, Avon). 2003 Jan;18(1):77-9
- ↑ Renne, J.W. The iliotibial band friction syndrome. J. Bone Joint Surg., 1975; 57A: 1110-1111.
- ↑ Staff, P.H. and Nilsson, S. tendoperiostitis in the lateral femoral condyle in long-distance runners. Br. J. Sports Med., 1980; 14:38-40.
- ↑ Orava, S. Iliotibial tract friction syndrome in athletes – an uncommon exertion syndrome on the lateral side of the knee. Br. J. Sports Med., 1978; 12: 69-73.
- ↑ 11.0 11.1 Noble, C.A. The treatment of iliotibial band friction syndrome. Br. J. Sports Med., 1979;13: 51-54.
- ↑ 12.0 12.1 12.2 M Pecina M., Bojanic I.. Overuse injuries of the musculoskeletal system. CRC press, 2004, p 222 – 228