AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Iliotibial band syndrome (ITBS) is the result of inflammation and irritation of the distal portion of the iliotibial tendon as it rubs against the lateral femoral condyle, or less commonly, the greater tuberosity. This overuse injury occurs with repetitive flexion and extension of the knee. Inflammation and irritation of the iliotibial band (ITB) also may occur because of a lack of flexibility of the ITB, which can result in an increase in tension on the ITB during the stance phase of running.

Other causes or factors that are believed to predispose an athlete to ITBS include excessive internal tibial rotation, genu varum, and increased pronation of the foot.

Pathophysiology

The ITB is a dense fibrous band of tissue that originates from the anterior superior iliac spine region and extends down the lateral portion of the thigh to the knee. The ITB has insertions on the lateral tibial condyle (ie, the Gerdy tubercle) and the distal portion of the femur. When the knee is extended, the ITB is anterior to the lateral femoral condyle. When the knee is flexed more than 30°, the ITB is posterior to the lateral femoral condyle.

Frequency

United States

ITBS is most common in athletes who participate in long-distance running. Studies have indicated a 4.3-7.5% occurrence rate for ITBS in long-distance runners. ITBS is less common in shorter-distance or sprint-distance runners. The higher rate in long-distance runners is primarily because of the increased stance phase during longer-distance running. ITBS also has been reported in military recruits, cyclists, and tennis players. The frequency of ITBS is also increased in adolescents undergoing the rapid growth phase.

Mortality/Morbidity

No mortality has been associated with ITBS.

Race

No known association exists between race and ITBS.

Sex

ITBS has been reported in men and women equally; however, women may be more susceptible to developing the syndrome because of anatomical differences of the thigh and knee, such as genu varum and increased internal tibial rotation. These anatomical differences result in an increased varus angle of the femur in relation to the knee and weakness of the quadriceps muscle.

Age

ITBS usually is seen in individuals aged 15-50 years, an age range that generally includes active athletes.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The patient typically reports pain at the lateral aspect of the knee; however, in some cases, the presenting symptom is hip pain over the greater trochanter. The pain usually worsens with physical activity such as running or cycling. Pain may be exacerbated by running hills and is most intense at heel-strike. Some patients may also report lateral knee pain when walking up or down stairs. The patient also may report an audible repetitive popping noise in the knee with walking or running.

Physical

The physical examination should include the entire lower extremity to rule out other causes of lateral knee or hip pain. In most cases, point tenderness occurs with palpation of the lateral femoral condyle or lateral tibial condyle, especially when flexing or extending the knee, as the ITB slides across the lateral femoral condyle. Some patients may have tenderness over the greater trochanteric region of the hip.

• Strength testing: Strength testing may reveal knee flexor or extensor weakness or hip abductor weakness.
• Tests: Increased or noticeable tightness of the ITB also may be noted upon examination with the Ober test. A modified Thomas test can be performed to assess flexibility of the hip flexors, hamstrings, and the ITB.

Causes

The injury typically is due to overuse. ITBS is seen most commonly in runners, although other athletes (eg, cyclists, tennis players) also may be affected. The usual mechanism is irritation of the iliotibial tract as it crosses over the lateral femoral condyle and, less commonly, the greater tuberosity. Increased tension or friction of the ITB in this area can result in an increase of irritation or inflammation. Abnormal gait or running biomechanics also have been implicated.

• Cyclists may experience ITBS due to improper positioning on the bike. Excessive internal or medial rotation of bike cleats and a bike seat that is too high are 2 main causes of ITBS among cyclists.
• Long-distance runners have a higher incidence of ITBS than short-distance runners and sprinters. This higher incidence may be due to the change in the biomechanics of running versus sprinting. Long-distance runners tend to have a more prominent and extended heel-strike and stance phase in comparison to sprinters. The ITB is under its greatest tension during the first third of the stance phase.
• Weakness of muscle groups in the kinetic chain may also result in the development of ITBS. Weakness in the hip abductor muscles such as the gluteus medius may result in higher forces on the ITB and the tensor fascia lata.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Muscle strain
Degenerative joint disease
Biceps femoris tendinitis
Popliteus tendinitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory studies are not indicated for the diagnosis of ITBS. However, laboratory tests may help rule out other sources of knee pain, such as rheumatoid arthritis or a septic joint.

Imaging Studies

• Imaging tests are not necessary to confirm the diagnosis of ITBS. Depending on the findings of the physical examination, the physician may want to obtain radiographs of the knee to rule out other pathology such as a fracture or bone spur. In severe cases, MRI may be helpful in identifying the extent of inflammation of the ITB. Findings on MRI most commonly include thickening of the ITB in the region overlying the lateral femoral condyle and a fluid collection underneath the ITB at this area.

Procedures

• Local injection with corticosteroids may be indicated in patients who do not respond to stretching, physical therapy, and exercise modification. If the patient still does not improve, then tendon-lengthening surgery with excision of the damaged ITB may be required.
• Surgery for the correction of ITBS has typically been an open procedure using a Z-plasty technique, although small prospective studies have used arthroscopy to create a diamond-shaped defect in the ITB (Ilizaliturri, 2006).

Histologic Findings

Histologic changes associated with acute and chronic inflammation of the ITB are observed.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Treatment for ITBS usually is conservative. Conservative treatment consists of (1) relative rest by decreasing the amount of exercise or training, (2) the use of superficial heat and stretching prior to exercise, and (3) the use of ice after the activity. Heat should be applied before and during stretching for at least 5-10 minutes, and ice treatments should be employed with a cold pack applied to the area for 10-15 minutes or an ice massage, which involves rubbing ice over the inflamed region for 3-5 minutes or until the area is numb.

Physical therapy is one of the mainstays of treatment for ITBS, in addition to reducing the amount of inflammation and irritation. The physical therapist can advise the athlete to modifying his/her training program so that faster results are seen with therapy. Running and cycling should be decreased or avoided to prevent further repetitive stress to the ITB. Wearing proper shoes also is very important in individuals with ITBS. Frequently, patients with ITBS demonstrated excessive pronation of their feet. The physical therapist should evaluate the patient's biomechanics during walking and running and should assist him/her in obtaining custom-made orthotics to correct faulty mechanics that may cause the ITBS.

Physical therapy treatment within the acute stage may include modalities such as phonophoresis or iontophoresis in addition to cryotherapy to decrease the inflammation. Since some cases of ITBS are caused by excessive tension on the ITB, physical therapy can help incorporate proper stretching techniques into the patient's exercise routine. These exercises concentrate on increasing flexibility of the ITB and of the gluteus muscles. Other muscles that commonly need attention for flexibility include the hamstrings, quadriceps, gastrocnemius, and soleus muscles.

Soft tissue mobilization and massage techniques may be used to assist with lengthening of the sore ITB. Prior to mobilizing the tissues, the physical therapist may perform an ultrasound treatment over the ITB to increase blood flow to the area and prepare the tissues to be stretched. Massage should generally be performed with the ITB in a lengthened state.

As the patient's symptoms improve, the physical therapy can progress toward strength development and maintenance. The physical therapist should instruct the patient in a home exercise program that continues to improve the strength and endurance of the hip and knee, as well as the back and abdominals. Strengthening of the hip abductors and knee flexors and extensors is an important component of rehabilitation. Once the patient is able to complete all strengthening exercises without discomfort, he or she may gradually return to the previous training regimen.

Occupational Therapy

Occupational therapy usually is not indicated in the treatment of individuals with ITBS.

Surgical Intervention

Reports of surgical intervention exist for recurrent ITBS that has not been responsive to previous conservative treatment. The operation may involve (1) releasing the posterior portion of the ITB, (2) performing an osteotomy of the lateral femoral epicondyle, or (3) performing a bursectomy.

Consultations

Patients with ITBS that is recurrent and difficult to treat may be referred to a sports medicine specialist.

Other Treatment

Local injections with corticosteroids may be indicated for symptoms that do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs), relative rest, stretching, and physical therapy.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Category: Cyclo-oxygenase-2 inhibitors

COX-2 inhibitors are a new class of nonsteroidal anti-inflammatories that report a lower incidence of GI side effects such as gastritis and ulcers. COX-2 inhibitors may be indicated in patients who require anti-inflammatory medications but have a history of gastric ulcers.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• The patient should continue physical therapy until symptoms improve or he/she can continue the exercises independently. See Physical Therapy for treatment recommendations.

In/Out Patient Meds

• The patient with ITBS is treated as an outpatient with medications including NSAIDs or corticosteroid injections, as discussed above (see Medication).

Transfer

• Transfer of care (referral) is warranted if the patient's symptoms do not improve with conservative management.

Deterrence

• The key to preventing ITBS is having a well-balanced approach to training. Runners need to limit their uphill/downhill training and try to run on level surfaces as much as possible. When training on a track, it is important to alternate the direction of running from clockwise to counterclockwise regularly to avoid repetitive stress to one leg. Preventative stretching of the ITB and gluteals also is important. Individuals with known subtalar joint hyperpronation may occasionally avoid developing ITBS by wearing proper shoes and orthotics to correct faulty biomechanics.

Complications

• Complications can include continued pain and an inability to maintain a training program. Some patients may demonstrate significant biomechanical abnormalities of the lower extremity as they attempt to compensate for the pain due to ITBS.

Prognosis

• Prognosis for ITBS is very good with the appropriate treatment.

Patient Education

• Education is important in preventing recurrence.
• Education should focus on instructing the patient in proper stretching techniques, as well as educating patients about the use of ice and NSAIDs for minor irritation or inflammation of the ITB.
• More importantly, the patient should learn to recognize symptoms that indicate when training volume should be decreased and when training surfaces should be changed.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Misdiagnosing a more severe knee condition, such as femoral rhabdomyosarcoma, as ITBS results in subsequent delay of appropriate treatment.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Adams WB. Treatment options in overuse injuries of the knee: patellofemoral syndrome, iliotibial band syndrome, and degenerative meniscal tears. Curr Sports Med Rep. Oct 2004;3(5):256-60.
• Biundo JJ Jr, Irwin RW, Umpierre E. Sports and other soft tissue injuries, tendinitis, bursitis, and occupation-related syndromes. Curr Opin Rheumatol. Mar 2001;13(2):146-9. [Medline].
• Brosseau L, Casimiro L, Milne S. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002;CD003528. [Medline].
• Faraj AA, Moulton A, Sirivastava VM. Snapping iliotibial band. Report of ten cases and review of the literature. Acta Orthop Belg. Feb 2001;67(1):19-23. [Medline].
• Fredericson M, Cookingham CL, Chaudhari AM. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. Jul 2000;10(3):169-75. [Medline].
• Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. May 2006;16(3):261-8.
• Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35(5):451-9.
• Garrick JG, Webb DR. Sports Injuries. Diagnosis and Management. Philadelphia, Pa: WB Saunders; 1999.
• Ilizaliturri VM, Martinez-Escalante FA, Chaidez PA, Camacho-Galindo J. Endoscopic iliotibial band release for external snapping hip syndrome. Arthroscopy. May 2006;22(5):505-10.
• Jones RL. The injured or painful knee and its evaluation. In: Clinics in Family Medicine. 1999 Dec:209.
• Kendal FP, et al. Muscles: Function and Testing. 4th ed. Baltimore, Md: Williams & Wilkins; 1993.
• Khaund R, Flynn SH. Iliotibial band syndrome: a common source of knee pain. Am Fam Physician. Apr 15 2005;71(8):1545-50. [Medline]. [Full Text].
• Noble CA. The treatment of iliotibial band friction syndrome. Br J Sports Med. Jun 1979;13(2):51-4. [Medline].
• Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band syndrome in distance runners. Sports Med. Nov-Dec 1985;2(6):447-51. [Medline].

Article Last Updated: Dec 6, 2006