AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Iliotibial band friction syndrome (ITBFS) is a common cause of lateral knee pain, particularly among runners, military personnel, and cyclists. 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.

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.

Problem

ITBFS typically is observed in people who exercise vigorously. The overuse creates stress that the body cannot repair, and soft tissue breakdown occurs. When the knee flexes, the ITB moves posteriorly along the lateral femoral epicondyle. Contact against the condyle is highest between 20° and 30° (average 21°), so when the band is excessively tight or stressed, the ITB rubs more vigorously. The space deep to the ITB is believed to have an adventitial bursal extension from the synovial capsule. This space was coined the lateral synovial recess (LSR). The LSR lies underneath the ITB and acts as an interface between the ITB and the lateral femoral epicondyle.

In runners, friction occurs near or just after foot strike during the contact phase of the gait cycle. Downhill running reduces the knee flexion angle and can aggravate ITBFS, while sprinting and fast running increase the knee flexion angle and are less likely to cause the syndrome.

Frequency

Overall incidence of ITBFS in the general population is not well reported. Depending on which population is examined, the incidence ranges from 1.6-52%. Incidence varies with the target population's type and intensity of activity. For instance, Linenger et al reported that in 12 weeks of Marine basic training, ITBFS was the most common specific injury and accounted for 22.2% of all lower extremity injuries. Runners experience 12% of all running-related overuse injuries from ITBFS.

Etiology

The etiology of ITBFS is multifactorial. Many factors have been postulated, few with overwhelming evidence supporting them.

ITBFS usually is caused by overuse, mostly due to errors in training. Single session errors cause ITBFS as often as repetitive deficiencies. Sudden changes in surface (ie, soft to hard, flat to uneven or decline), speed, distance, shoes, and frequency can break down the body faster than it can heal, causing injury. Other factors frequently reported are the following:

• Limb length discrepancy
• Genu varum
• Overpronation
• Hip adductor weakness
• Myofascial restriction

Studies examining limb length discrepancies provide conflicting conclusions regarding whether a direct correlation exists. Limb length inequalities cause changes in hip abduction during the gait cycle, sacral leveling, and pelvic tilt, which is believed to increase tension on the ITB and tensor fascia lata. However, other studies did not find a direct correlation between limb length inequality and ITBFS. Still, the postulate merits consideration when examining the hip and pelvis.

Genu varum is considered a risk factor due to the increased tension on the ITB as it is stretched more over the lateral femoral epicondyle. This concept is widely accepted, though with little empirical support.

Overpronation is controversial as well. In the running cycle, the lower limb strikes the ground with a rigid supinated foot. As the leg moves forward, the tibia internally rotates over the planted foot, "unlocking" it into a pronated-everted position, which allows for weightbearing. Pronation and internal rotation stress the ITB. Excessive pronation causes quicker tibial internal rotation and increased hip adduction, stressing the ITB over the lateral femoral condyle.

James implicated a combination of genu varum, heel varus, forefoot supination, and compensatory pronation with ITBFS, but further videography studies led to dispute of that claim. Most studies support overpronation as a potential cause.

Hip abductor weakness is an important factor as well. Several studies support this claim. When the foot strikes the ground, the femur adducts against the eccentric load of the abductors (gluteus medius and tensor fascia lata). These muscles move from eccentric to concentric through the support phase and into the propulsive phase of gait. The gluteus medius also externally rotates the hip, while the tensor fascia lata internally rotates.

When the hip abductors are weakened or fatigued, runners have increased adduction and internal rotation at midstance. This generates more valgus force at the knee, which Fredericson postulates as increasing tension and friction on the ITB.

Myofascial restrictions and inflexibility can increase stress in the posterior ITB, particularly with the tensor fascia lata. Tightness in the hip flexors (iliopsoas), extensors (gluteal muscles), and rotators (particularly piriformis) can shift more load to the abductors and adductors. Weaker hip abductors eventually fail under continuous stress.

Pathophysiology

A small recess is formed between the lateral femoral epicondyle and the ITB as it travels along the lateral thigh to the tibial plateau. This space was believed to have a separate bursa lying deep to the band, but studies have revealed it to be synovium that is a lateral extension and invagination of the actual knee joint capsule (lateral synovial recess). Histologic analysis demonstrates inflammation and hyperplasia in the synovium, while MRI studies have demonstrated diffuse signal abnormality below the band and in the synovium but not in the ITB. This suggests that this syndrome is not a tendinopathy. Variance is observed in the congenital thickness of the band, so patients with thicker bands may be predisposed to ITBFS.

Clinical

While pain is localized along the lateral knee, it also can include the hip. Pain is worse with downhill running and becomes worse with activity after a pain-free start. Pain may radiate from knee proximally or distally. Most individuals experience pain only during activities; however, individuals may experience pain with walking as the syndrome progresses.

Tenderness is over the lateral knee, with a tender point at the lateral femoral condyle, approximately 1-2 cm proximal to the lateral joint line. Pain can be elicited with active flexion-extension of the knee within the first 30° while the thumb presses over the epicondyle and ITB. Crepitation may be felt.

Restriction in hip adduction indicates tightness in the ITB and tensor fascia lata. In evaluating for ITBFS, also look for restrictions in iliopsoas, rectus femoris, gastrocnemius, and soleus function. Examination usually reveals restriction of hip adduction and weakness of the hip abductors, specifically the gluteus medius.

Myofascial restrictions can mimic ITBFS, and these restrictions can be identified with a careful examination. Trigger points along the vastus lateralis, biceps femoris, and gluteus minimus can refer pain to the lateral knee, while fascial adhesions of the posterior ITB can generate pain as well. Careful palpation of these points can differentiate ITBFS from myofascial trigger points.

The following provocative tests may be helpful:

• Ober test: This test is performed with patient lying on the unaffected side with that hip flexed enough to straighten the lumbar lordosis. The down leg is flexed 90° at the knee, while the operator's hands stabilize the greater trochanter and hold up the ankle. The thigh is abducted passively and extended to catch the ITB over the greater trochanter. The thigh is then adducted passively. If the thigh remains suspended off the table, this indicates a shortened ITB.
• Noble test: Place the patient supine with the knee at approximately 90° flexion and apply firm digital pressure on or around the lateral femoral epicondyle while passively extending the knee. A positive result is pain elicited at approximately 30° of flexion over the lateral femoral epicondyle, similar to what occurs when the patient is active.
• Renee creak test: Place patients on a step stool and have them support all of their weight on the affected leg. The operator's thumb is placed over the lateral femoral condyle and pressure is applied while the patient bends the knee into 30-40° of flexion. Here, the posterior fibers of the ITB are directly over the lateral epicondyle; reproduction of pain with pressure is considered a positive test result for ITBFS. Some literature lists separately the creak test. This is the same as the Renee test, but the operator thumb is not placed on the patient. Pain when the patient bends the knee 30° is considered a positive test result.
• Thomas test: The patient sits on the end of the table and then rolls back into a supine position, holding both knees to the chest but not so that the pelvis has excessive posterior tilt. This flattens the lumbar spine. The patient holds the leg of the asymptomatic hip and slowly lowers the other to the floor. The Thomas test result is considered positive if the patient cannot achieve 90° of knee flexion, a neutral angle of the hip (if the hip hovers above the table), or 15° of hip abduction relative to the pelvis. This test is used to evaluate the iliopsoas, rectus femoris, and tensor fascia lata and/or ITB.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Failure of conservative therapy is an indication for surgery. Conservative therapy includes rest, stretching and strengthening exercises, anti-inflammatory medication, other therapy modalities, and biomechanical correction of limb length discrepancies and pes planus. A minimum trial of 3 months should be given before considering surgery. Even then, surgery is best withheld for highly motivated people who want to return to their sport or activity.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The ITB originates from the outer lip of the anterior iliac crest, anterior border of the ilium, and outer surface of anterior superior iliac spine. The tensor fascia lata originates here also, and its fascia blends with the ITB at the lateroanterior thigh one third of the way distally. The intermuscular septum connects the ITB to the linea aspera femoris until inserting just proximal to the lateral femoral condyle.

From there, it passes in its broad expansion between lateral aspect of patella and biceps femoris to insert into the Gerdy tubercle, off the lateral tibial plateau. This expanse helps the lateral collateral ligament and posterolateral capsule to stabilize the knee.

The primary synergistic muscles are the hip abductors. These muscles are the gluteus medius, gluteus minimus, and upper fibers of the gluteus maximus. Their nerve supply comes from the superior gluteal nerve, which is a branch off of the L4, L5, and S1 nerve roots.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Active infection and coagulopathy are contraindications to surgery.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• Perform basic preoperative laboratory tests, such as CBC count, electrolytes, BUN, creatinine level, and LFTs.

Imaging Studies

• A complete history and physical examination should provide enough information that imaging beyond radiography is typically not necessary. If the diagnosis is unclear or conservative treatment fails, then MRI and ultrasonography should be considered.
• Radiography: This study is used to rule out fractures, osteophytes, or osteochondrotic lesions. Alignment and soft tissue swelling may be evaluated also. Radiographic findings usually are unremarkable in ITBFS.
• MRI
• • MRI can be used to effectively exclude other pathology, such as lateral meniscus tear, lateral collateral ligament sprain, patellofemoral subluxation, chondromalacia patellae, biceps or popliteus tendinitis, meniscal cysts, and osteochondritis dissecans.
  • MRI can reveal diffuse signal deep to the ITB in the recess just proximal to the lateral femoral condyle. Reactive signal in the periosteum of the condyle and thickening of the ITB can be observed as well, but no pathology typically is observed in the knee joint.
  • The stage of development of ITBFS may impact the findings seen on MRI. Acute cases may have an ill-defined signal abnormality beneath the ITB; progression of the syndrome can be associated with increasing signal changes superficial to the ITB, while the chronic stage can be associated with bursal fluid and ITB thickening.
• Ultrasonography
• • Ultrasonography is useful in evaluating cystic masses and fluid in the LSR.
  • It is effective in revealing the dynamic motion of the ITB through knee flexion and extension, thus allowing visualization of the impingement.

Diagnostic Procedures

• Lidocaine can be injected for diagnostic purposes if a localized source of pain is suspected.

Histologic Findings

Tissue from the lateral synovial recess demonstrates hyperplasia and inflammation. ITB tissue may exhibit tendinosis.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

The basic principles of treatment include control of inflammation, modification of activity, and correction of underlying problems. An aggressive treatment program is as follows:

Acute phase

• Medical therapy: Medical therapy consists of nonsteroidal anti-inflammatory drugs with adjunctive physical therapy. These drugs reduce the inflammation in the soft tissue. Analgesics, such as acetaminophen or codeine preparations, can be used in persons with functional disability. Injection of corticosteroid can be used when conservative attempts to control inflammation fail or swelling persists for more than 3 days.
• Activity modification: Examine recent changes in training, such as duration and intensity of exercise. Curtail activity to a level at which pain is not generated.
• Local ice massage: Apply to the region of inflammation near lateral femoral condyle for no longer than 15 minutes. Ice compresses or cold packs can be used for 20 minutes.
• Phonophoresis and/or iontophoresis: Use hydrocortisone or a similar topical steroid preparation with ultrasound (phonophoresis) or electrical stimulation (iontophoresis) for control of inflammation.

Subacute phase

• Stretching exercises: Begin after inflammation subsides. Restoring proper range of motion in the hip flexors (iliopsoas and quadriceps), hip extensors (gluteus maximus, hamstrings), hip abductors (gluteus medius, tensor fascia lata), and, most importantly, the hip adductors is crucial to restoring overall hip function.
• Myofascial therapy: Direct treatment on trigger points and loosen restrictions along the ITB. Target areas include over the lateral femoral condyle and greater trochanter.
• Manipulative therapy: Effective in treating areas of restriction and repairing the biomechanical flaws that led to the ITBFS. Muscle energy techniques can be safely applied to the tensor fascia lata, hip flexors, and piriformis muscles to restore ranges of motion in hip adduction, extension, and internal rotation. Attention should be paid to lumbosacroiliac mechanics to ensure resolution of any dysfunction there. Anterior or posterior rotational innominate (iliac) dysfunctions affect the origin of the tensor fascia lata and can delay recovery if left untreated. Other specific areas to address with manipulation include the T12-L1 vertebral segments (origin of the iliopsoas) and the fibular head (partial insertion point of the ITB). In fact, fibular head dysfunction (either anterior or posterior rotation) cannot only contribute to ITBFS but can mimic it as well.

Recovery phase

Progressive strengthening exercises are started to restore muscle strength lost from inhibition and disuse. Exercises include side-lying leg lifts, pelvic drops, and step-down exercises.

Return to running

The angle of the knee during faster-paced running is beyond the friction point of ITBFS, so the patient should start with easy sprints on even surfaces, no more than every other day at first. The patient may gradually increase distance and frequency according to tolerance. Time to return to sports depends on the initial severity. Patients who return must first perform all strength exercises and stretches without pain. Most people return to their sport or running within 4-6 weeks.

Surgical therapy

Surgery is used to resect a small triangular portion of the posterior ITB over the lateral femoral epicondyle. Studies demonstrated positive results with the knee flexed at 30° during the procedure.

A resection of the underlying synovial tissue can also be performed, but some question exists as to whether it should be resected. Resection can cause chronic synovial fluid effusion in the recess and hematoma formation. Several studies state that tissue resection deep to the ITB is optional but not typically recommended.

Preoperative details

The patient is restricted to taking nothing by mouth at least 8 hours before the procedure. ITB resections also can be performed through an arthroscopic procedure, and the patient is prepared for surgery similar to that for any such procedure. Otherwise, a tourniquet is applied to provide adequate hemostasis. Anesthesia can be achieved by general or epidural administration. The affected leg is positioned so that the lateral femoral condylar region is exposed.

Intraoperative details

With the knee in 30° of flexion, a longitudinal incision is made centered over the lateral epicondyle. The posterior portion of the ITB is then exposed. The knee is flexed and extended to identify the portion of the ITB that is impinging on the lateral epicondyle. A triangular piece of the ITB is then resected. The base of the triangle is approximately 2 cm and centered over the posterior fibers of the ITB. The height of the triangle is roughly 1.5 cm. The knee is then moved through the full range of motion to confirm adequate release of the ITB. The wound is then irrigated and closed. Excision of an elliptical section of the ITB also has been described.

Postoperative details

Some controversy exists regarding postoperative immobilization. Martens et al advocated splinting the knee in extension for 1 week postoperatively followed by a gradual return to activity. In a study by Holmes et al, a soft dressing was applied and bicycling was allowed on postoperative day 3. In this study, 9 of 21 patients developed a small seroma near the lateral incision, which subsequently resolved with rest and icing.

Follow-up

Surgical release of the ITB is typically successful in eliminating pain. Athletes are able to return to their normal activities with a rehabilitation program in 3-7 weeks.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center; Arthritis Center; and Bone Health Center. Also, see eMedicine's patient education articles Knee Pain and Knee Injury.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Potential complications include recurrent swelling in the lateral synovial recess, persistent bleeding, bisection of the ITB, infection, seroma, recurrent pain, and impingement.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Most patients with ITBFS recover with conservative therapy and enjoy good prognoses. One study in 1992 documented 19 athletes with ITBFS, and all were treated successfully without surgery. Those for whom surgery is eventually performed are patients who are motivated to return to a specific activity in which ITBFS limits or prohibits their participation.

Those who require surgery often do well. Nemeth described 17 cases of ITBFS recalcitrant to conservative therapy, and 11 had excellent results from surgical treatment at 2-year follow-up. Firer reported 94% excellent or good results in 64 runners surgically treated after failure of conservative therapy.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

With the increasing understanding of human biokinetics, health professionals are able to spot flaws in training, environment, and biomechanics quickly and avert significant disability with ITBFS. Biomechanical screenings can be used to identify predisposing factors and correct them before symptoms ever develop. Aggressive intervention, particularly with athletes and industrial workers, can resolve the problem before it becomes disabling.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  Illustration of the friction point at the lateral epicondyle prominence. Note the shift in position of the iliotibial band from anterior to posterior as the knee moves into flexion, drawing the iliotibial band across the prominence.
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Media file 2:  Lateral hip stabilizers.
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Media file 3:  Iliotibial band noted prominently along the lateral thigh.
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Media file 4:  Iliotibial band at the lateral femoral epicondyle, with the posterior fibers denoted.
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Media file 5:  The Thomas test can be used to evaluate restriction in the iliotibial band, hip flexors, and rectus femoris.
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Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

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• Firer P. Results of surgical management for iliotibial band friction syndrome. Clin J Sport Med. 1992;2:247-50.
• Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. Jul 2000;10(3):169-75. [Medline].
• Fredericson MF, Guillet M, DeBenedictis L. Quick solutions for iliotibial band syndrome. Phys Sports Med. 2000;28(2):53-68.
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• Krivickas LS. Anatomical factors associated with overuse sports injuries. Sports Med. Aug 1997;24(2):132-46. [Medline].
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• Linenger JM, Christensen CP. Is iliotibial band syndrome overlooked?. Phys Sports Med. 1992;20:98-108.
• Martens M, Libbrecht P, Burssens A. Surgical treatment of the iliotibial band friction syndrome. Am J Sports Med. Sep-Oct 1989;17(5):651-4. [Medline].
• Muhle C, Ahn JM, Yeh L, et al. Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology. Jul 1999;212(1):103-10. [Medline].
• Murphy BJ, Hechtman KS, Uribe JW, et al. Iliotibial band friction syndrome: MR imaging findings. Radiology. Nov 1992;185(2):569-71. [Medline].
• Nemeth WC, Sanders BL. The lateral synovial recess of the knee: anatomy and role in chronic Iliotibial band friction syndrome. Arthroscopy. Oct 1996;12(5):574-80. [Medline].
• Noble CA. Iliotibial band friction syndrome in runners. Am J Sports Med. Jul-Aug 1980;8(4):232-4. [Medline].
• Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. May-Jun 1996;24(3):375-9. [Medline].

Article Last Updated: Jun 1, 2005