Iliotibial Band Syndrome

Original Editors - Yves Demol, Aurelie Ackerman 

Lead Editors  

Definition/Description

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.

Iliotibial band friction syndrome (ITBFS) is the most common injury of the lateral knee in runners and has an incidence between 1.6 and 12%. It has even been reported that ITFBS is responsible for 22% of all lower extremity injuries.

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.

Epidemiology /Etiology

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.

Other proposed etiologies for IT band syndrome include compression of the fat and connective tissue that is deep the the IT band, as well as chronic inflammation of the IT band bursa. 

Characteristics/Clinical Presentation

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. This overuse condition is often seen in runner, cyclists, and military recruits. 

Differential Diagnosis

Biceps femoris tendinopathy, degenerative joint disease, lateral collateral ligament sprain, lateral meniscus repair, myofascial pain, patellofemoral stress syndrome, popliteal tendinopathy, referred pain from lumbar spine, stress fractures, and superior tibiofibular joint sprain. 

Diagnostic Procedures

There are different provocative tests:

• Renne test
  
• Noble’s test
  
• Ober’s test
  

Outcome Measures

Lower Extremity Functional Scale (LEFS)

Examination

•  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.

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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.

Medical Management

http://guideline.gov/content.aspx?id=36632&search=band+syndrome+and+knee+disorders

The treatment of ITBFS is usually non-operative, but in some cases in which conservative treatment and physical therapy remain uneffective, it might be necessary to apply surgery.

During surgery, a small piece of the posterior part of the iliotibial band that covers the lateral femoral epicondyle will be resected.[15]

There are also a number of case series [1] reporting resolution of ITBFS from the surgical excision of a bursa, cyst, or portion of a lateral synovial recess.

Physical Therapy Management

The accepted treatment of ITBFS follows the outline common to the treatment for many connective tissue injuries, beginning with treatment of the acute inflammatory response using medication, rest, ice, heat or alternative techniques, progressing through a physical therapy treatment phase and finally surgical intervention, in case the common treatments would not be effective.

1. Treatment of the acute inflammatory response

Research has confirmed that oral nonsteroidal anti-inflammatory drugs (NSAIDs) and/or corticosteroid injections in the bursae or trigger points can be used to reduce the acute inflammatory response and pain. However, NSAIDs alone have not been found to be effective in providing symptom relief. Yet, in conjunction with other nonsurgical modalities and modification of activities, they can be beneficial in the short term for the therapy management.[6][15][17]

Other care in the acute phase should focus on activity limitation or modification, and measures to relieve pain such as ice (cryotherapy) or heat.[1] [15] Some authors[10][11] suggest complete rest from athletic activities for at least 3 weeks; other authors[12][13] 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 and the reproduction of pain during clinical examination. But it is not necessary to stop the athletic activities in the initial stages (grades 1 and 2). It is sufficient to lower the intensity of the trainings, especially the activities that cause pain such as running.
In the more advanced cases (grades 3 and 4) it is requested that the patient does not perform any athletic activity in first 3 to 4 weeks. But it is suggested that the athlete performs other physical training activities, such as e.g. swimming, so that they can keep their functional abilities and also keep in shape.

If no improvement of symptoms occurs and inflammation persists, the following other treatment techniques might be considered:
• ultrasound therapy[15], providing thermal or non-thermal treatment of the injured tissue at a frequency range of 0.75 to 3 MHz (depending on the depth of the soft tissue to be treated)[25]
• muscle stimulation[15]
• iontophoresis or phonophoresis[15], techniques in which medication is administered into the injured tissue through ion distribution driven by an electric field or passed through the skin using ultrasound waves, respectively. 
2. Physical therapy treatment

Once the acute inflammation and pain have subsided, physical therapy can be applied on the ITBFS in the subacute phase. The physiotherapist will determine the best approach suited for each person on an individual basis. The following consecutive phases in physical therapy are important:
• Exercises to stretch the iliotibial band and related structures.
The best exercises to start the physical treatment of ITBFS are passive or static stretching exercises[14]. This will lengthen the iliotibial band and will reduce friction with the lateral epicondyl of the femur. However, not only the iliotibial band needs stretching, but also the glutea. If the lateral gluteal muscles are found to be weak or functioning improperly, this will result in other muscles - including the iliotibial band - to have to compensate, which will cause contraction of the iliotibial band.[17] Furthermore, if the glutea is too short, it will also provoke a rotation of the leg and this will again create an abnormal stress on the iliotibial band, resulting in ITBFS.[21]
The following exercices will stretch and lengthen the iliotibial band, tensor fascia latae, the gluteus medius and the related structures. Fredericson et al. compared the relative effectiveness of 3 common standing stretches for the iliotibial band. This study found that a particular stretch B – with the athlete standing, placing the affected foot adducted and behind the other, and laterally flexing away from the affected side with the arms stretched overhead – created the greatest lengthening of the band.[18]

• Myofacial treatment.
A next step in the physical therapy is to address myofacial restrictions. Frequently, soft tissue treatment through massage and triggerpoint therapy of the affected area by the physiotherapist decreases the pain and definitively treats the condition. The use of a foam roller on the tight muscles could also be beneficial.[17]
The patient can also perform exercises using a foam roller at home to create deep transversal friction, self myofascial release (massage) and stretching of the muscles. A possible exercise is to lie on the side with the foam roller positioned perpendicular to the bottom leg, just below the hipbone. The upper leg should be positioned in front for balance. Using the hands for support, roll from the top of the outer thigh down to just above the knee, straightening the front leg during the movement. Pause over any spots where the tissue feels especially tight or knotted, and hold for at least 10 seconds. Reverse the motion, rolling from the knee back up to the hip.

• Exercises to strengthen the abductor muscles and stabilize the hip.
A next important phase in the physical treatment of the ITBFS is to perform exercises to strengthen the muscles in the affected area. Since ITBFS is often associated with hip abductor weakness, strengthening and stabilizing of the hip will be beneficial in the treatment of ITBFS.[23]
Some examples of useful exercises: Hip hikes to strengthen the gluteus medius help stabilize the hip. Stand on the edge of a step with the majority of the body weight on the unaffected side. Lower the hip of the involved hip and bring it back to neutral. Repeat the exercise: first 2 sets of 10 repeats, lateron 3 sets of 15 repeats.[26] Another example is the side-lying hip abduction exercise with the back against a wall and the leg held at approximately 30° of hip abduction with slight hip external rotation and neutral hip extension. This exercise can be made more stenuous by placing a 1-metre-long band between the ankles.[23]
• Hip/knee coördination and running/cycling style modification through the increase of neuromuscular control of gait.[1][17]
Going to the next phase of physical therapy, the physiotherapists will give training and instructions on multidimensional movement patterns, eccentric muscle contractions and integrated movement patterns. The main goal is to work with combinations of running, jumping, agility and balance exercises and that all with a clear emphasis on using the proper technique.
Cyclist are also at risk for ITBFS if they tencto pedal with their toes turned in, which can cause abnormal stretching of the iliotibial band at the knee, so being aware of correct pedaling technique may minimize the risk of developing symptoms.[17]

These sorts of exercises need a strictly defined position so that they can be performed correctly. Follow the clear instructions and advice from a physiotherapist. 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. [14]

Maintenance and prevention

When returning to regular activity, it is important to keep performing maintenance and prevention exercises, in order to prevent reoccurrence of the ITBFS.

The first way of preventing reoccurrence is by stretching of the iliotibial band and related structures on a regular basis. Performing the same exercises as described in the section 'Physical therapy treatment' can be useful to prevent shortening of the iliotibial band after starting to sport again, e.g. the various kinds of standing stretches.

The second way to prevent ITBFS from reoccurring is to continuously strengthen the abductor muscles of the lower extremities, since patients with ITBFS were often noted to have weakened abductors of the affected leg compared to the other leg, or in comparison with a control group who did not suffer from ITBFS.[1][17][19][20][23] The focus should be mainly on the M. tensor fascia latae and the glutea.[19][20][21][23] This strengthening of abductors and glutea can be achieved in various ways. Some exercises are already described in the section 'Physical therapy treatment'. This can be expanded with the following exercises: one leg squat, steps-up, frontal plane lunges and side lunges.[17][24]

It is also important to slowly build up the training intensity in order to prevent reoccurrence of ITBFS.[19] Avoid training factors such as a rapid increase in weekly mileage and excessive running in the same direction on a track.[17]

Using the right material is crucial in the prevention of ITBFS.
For runners it is important to use the correct running shoes.[22] In case of doubt, seek specialist advice. Running shoes should also be replaced regularly. Worn shoes absorb less shock which may lead to an increased incidence of iliotibial band pain. In case of daily running, it could also be considered alternating between two pairs of shoes to allow 24 hours for the shoe's shock absorbing cushion to return to its optimal form before running in them again.
Cyclists should make sure to use bicycles of proper fit. It is also suggested to lower the seat beyond the typical height, as this will reduce the stretching of the gluteus maximus and iliotibial band and thus allowing for less knee extension and stress on the iliotibial band. Adjustment of the cleat position could also be beneficial.[17]
The use of orthotics could be considered, especially when runners experience unwarranted calcaneal eversion and tibia internal rotation or in case of an anatomical leg length deficiency. For cyclists, orthotics could be useful to prevent excessive tibial rotation and foot hyperpronation.[17]

Furthermore, also the surface on which athletes exercise plays an important role in the prevention of ITBFS. The probability to develop ITBFS will increase when repeatedly running downhill. This will result in the iliotibial band coming in the impingment zone because it will increase friction between the iliotibial band and the lateral femoral epicondyle due to decreased knee flexion at foot strike.[17][19] Also banked surfaces should be avoided.[15]
 
Athletes should perform selfmonitoring. Runners and cyclists should monitor themselves for reoccurence of symptoms during training. While doing so, they can gradually increase distance and frequency if no adverse symptoms occur.[17]

Finally, athletes should be educated about ITBFS in order to increase awareness of the syndrome, so that they can recognize possible symptoms in a very early stage and improve their sporting experiences.

Key Research

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Resources

Primary resources

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

Due to the variety of potential causes of IT band syndrome, it is important for the clinician to consider areas that may be contributing to abnormal body mechanics.  Especially with knee conditions, the joints above (hip) and below (ankle/foot) should be assessed to determine if they are contributing to the problem. 

Recent Related Research (from Pubmed)

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References

1. ↑ 1.0 1.1 1.2 1.3 1.4 Lavine R. Iliotibial band friction syndrome; Current Reviews in Musculoskeletal Medicine (2010) :18–22
Level of evidence: 5
2. ↑ 2.0 2.1 2.2 2.3 Rosenthal M.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. ↑ 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 begin_of_the_skype_highlighting Vrij (2006) 208 end_of_the_skype_highlighting, 309-316
4. ↑ 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.
5. ↑ 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 begin_of_the_skype_highlighting Vrij (2006) 208 end_of_the_skype_highlighting, 309-316
6. ↑ 6.0 6.1 Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. Journal of the American Academy of Orthopedic Conditions. 2011;19(12):728-36.
7. ↑ Wong M. Pocket Orthopaedics, Evidence-Based. (2009) Jones and Bartlett Publishers.
8. ↑ Khaund R, Flynn SH. Iliotibial band syndrome: a common source of knee pain. American Family Physician. 2005;71(8):1545-1550.
9. ↑ 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
10. ↑ Renne, J.W. The iliotibial band friction syndrome. J. Bone Joint Surg., 1975; 57A: 1110-1111.
11. ↑ Staff, P.H. and Nilsson, S. tendoperiostitis in the lateral femoral condyle in long-distance runners. Br. J. Sports Med., 1980; 14:38-40.
12. ↑ 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.
13. ↑ 13.0 13.1 Noble, C.A. The treatment of iliotibial band friction syndrome. Br. J. Sports Med., 1979;13: 51-54.
14. ↑ 14.0 14.1 14.2 M Pecina M., Bojanic I.. Overuse injuries of the musculoskeletal system. CRC press, 2004, p 222 – 228
15. Pedowitz, R.N.; Use of osteopathic manipulative treatment for iliotibial band friction syndrome; J Am Osteopath Assoc , 2005, vol. 105 no. 12: 563-567
Level of evidence: 5
16. van der Worp, M.P.; iliotibial band syndrome in runners: a systematic review; Sports Med., 2012, 42(11) 969-992
Level of evidence: 3A
17. Saikia, S.; Etiology, treatment, and prevention of ITB syndrome: a literature review; Topics in Integrative Health Care, 2013, Vol. 4(3).
Level of evidence: 3A
18. Fredericson, M.; Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches; Archives of physical medicine and rehabilitation, 2002, vol. 83(5): 589-592
Level of evidence: 3B
19. Gunter P.; Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial; Br J Sports Med 2004;38:269–272.
Level of evidence: 3B
20. Reiman M.P.;Hip Function’s Influence on Knee Dysfunction: A Proximal Link to a Distal Problem; Journal of Sport Rehabilitation, 2009
Level of evidence: 4
21. Krista Simon; Iliotibial Band Syndrome; Nysportsmed
Level of evidence: 5
22. Cheung R.T.H.; Influence of different footwear on force of landing during running. Phys Ther, 2008 May, 88(5): 620-628
Level of evidence: 3B
23. Beers A.; Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiother Can.;2008, 60(2): 180-188
Level of evidence: 1B
24. Starkey C.; Athletic training and sports medicine: An integrated approach; Burlington, MA : Jones & Bartlett Learning; 2013: 167-169
Level of evidence: 3A
25. Speed C.A.; Therapeutic ultrasound in soft tissue lesions, British Society for Rheumatology, 2001
Level of evidence: 2A
26. Lininger M.R.; Iliotibial band syndrome in the athletic population: strengthening and rehabilitation exercises. Strength and Conditioning Journal, 2009 Jun, 31(3):43-46
Level of evidence: 2B