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Disease/Disorder

Definition

Iliotibial band syndrome (ITBS) is an overuse injury associated with lateral knee pain.1

Etiology

The etiology of ITBS is debated and likely has multiple factors. One theory suggests that repeated friction between the IT Band (ITB) and the lateral epicondyle during knee movement causes inflammation. This contact, called the “impingement zone,” occurs at 30 degrees of knee flexion.2 Other theories include compression of a highly innervated fat pad beneath the ITB or chronic inflammation of a bursa between the ITB and the lateral epicondyle.3 It’s unclear if one theory is the main cause or if it is a combination of these factors.

Epidemiology including risk factors and primary prevention

ITBS is a common knee overuse injury syndrome4,5,6 and is the primary cause of lateral knee pain in long distance runners.2,4,5,6,7,8 It was first described by Renne in 1975 in US Marine Corps soldiers during their basic training.9 ITBS has been reported in men and women equally, however, women may be more susceptible. Female anatomical differences that include increased internal tibial rotation and genu varum can generate weakness of the quadriceps muscle and an increased varus angle of the femur in relation to the knee.10

ITBS is the most common etiology of lateral knee pain in runners and cyclists. It is thought to affect up to 12% of runners and other repetitive motion athletes.11 In cyclists, it is the source for 15% of overuse injuries.12 Participants in basketball, soccer, tennis, hockey, skiing, and weightlifting are also affected. ITBS can be prevented through proper mechanics during activity, particularly avoiding valgus at the knee. Therefore, proper strength and control of the lower limb are important for prevention, as are extrinsic factors such as footwear and bike fit.

Patho-anatomy/physiology

Basic anatomy

The iliotibial band is a collection of fibers that course from its origin at the iliac crest along the lateral thigh to the proximal tibia. The gluteus maximus, gluteus medius, tensor fascia lata, and vastus lateralis connect to the ITB proximally. Distally, the ITB inserts onto the lateral femoral epicondyle and Gerdy’s tubercle. As such, the ITB is a fascial structure that promotes anterolateral stability of the hip and knee in stance and resistance of large varus torques at the knee.12

Patho-anatomy

Pain from ITBS is commonly thought to be due to that repetitive friction between the ITB and the lateral epicondyle during knee flexion and extension. This causes inflammation in the ITB’s contact area, known as the “impingement zone,”. This occurs at 30 degrees of knee flexion, typically at foot strike. However, anatomical studies do not support the existence of this gliding motion across the lateral epicondyle.1 An alternative concept initiated by Fairclough involves compression of a highly vascular fat pad just deep to the ITB, creating inflammation and pain.3 Repeated stress causing chronic inflammation of a fluid-filled ITB bursa located between the ITB and the lateral epicondyle may also be implicated.

Functional mechanics

Not all runners, cyclists, or individuals with repetitive knee movements develop ITBS, indicating that specific biomechanical factors within the kinetic chain, exacerbated by repetition and overuse, can lead to ITBS.13 Research on the running biomechanics of females has identified certain joint postures and positions during the gait cycle that contribute to ITBS development. During the stance phase, individuals with greater knee internal rotation and peak hip adduction are more likely to develop ITBS.7 The internal knee rotation is theorized to stem from an externally rotated femur rather than an excessively internally rotated tibia. This suggests that the increased medial knee rotation in individuals who develop ITBS likely originates from proximal factors, particularly hip muscle imbalances.7 The contribution of foot and ankle mechanics to ITBS is questionable. Some studies note ITBS patients to have reduced ankle eversion and rearfoot pronation,7,14 while others show no difference.15,16

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Pain associated with ITBS tends to be worse with loaded flexion and extension of the knee and improves with rest. Early on, athletic activities are primarily affected. However, left untreated, ITBS may also affect activities of daily living.

Specific secondary or associated conditions and complications

The biomechanical factors associated with ITBS are noted to be similar to those associated with patellofemoral pain syndrome. Particularly in runners, these disorders may be seen concurrently. In addition, uncorrected mechanics may predispose athletes to other injuries up and down the kinetic chain.

Of note, proximal ITB issues may also occur, such as an external snapping hip. This involves snapping of the posterior border of the ITB at the level of the greater trochanter of the hip. As shown in a small study of 7 cases of painful external snapping hip, this can be evaluated dynamically by ultrasound and most often is treated conservatively.17

Essentials of Assessment

History

Patients with ITB endorse lateral knee pain with repetitive loading in a weight bearing position or hip pain across the greater trochanter.The pain is described as sharp or burning, that worsens with athletic activities such as cycling or long distance running. Cyclers may note the pain with “down-pedaling” motion during which the knee extends. Runners may note the pain during heel strike that worsens when traversing hills. Others have reported the knee pain when using the stairs.14,15,18 A thorough history should assess for acute or traumatic onset of ITB pain versus insidious onset. The patient’s history may elicit recent change in training habits such as load, cadence, hills, addition of cross-training, resistance training, or changes in footwear. The patient should be asked about other concurrent or recent musculoskeletal injuries and for any neurologic symptoms.

Physical examination

Exam findings associated with ITBS include:

  • Tenderness at the lateral epicondyle of the femur (LFE)
  • Tenderness along the ITB
  • Tenderness along the greater trochanter of the hip
  • Positive Noble compression test
  • Positive Renne test
  • Positive Ober test

The Noble compression test, the Renne test, and the Ober test are provocative maneuvers commonly associated with ITBS.19 There are no official studies to indicate the validity of these tests.20

  • Noble compression test – Position the patient supine or side-lying with the affected side facing the ceiling. Grip above the ankle and flex the knee back and forth from 0-90° while applying gentle pressure on the LFE. The test is positive if pain is elicited at LFE or palpable crepitus is present.
  • Renne test – Position patient in a neutral stance. Ask the patient to stand on the affected leg only, bringing the knee to 30-40 degrees of flexion. The test is positive if there is pain at the LFE.
  • Ober test – Position the patient side-lying in the lateral decubitus position with the affected side facing the ceiling. Standing behind the patient, fixate the pelvis with one hand, then use the other hand to grasp the affected leg to passively abduct at the hip and bring it to slight extension. While supporting the leg, passively lower it to the table. The test is positive if the affected leg stays in the air and does not lower to the table.

Manual muscle testing of the gluteus maximus and gluteus medius should be performed, as well as testing of hip external rotation. There should be no lateral joint line tenderness at the knee, and no sign of intra-articular disorders.

Functional assessment

The examiner should look for muscle substitutions compensating for weakness in the gluteus medius or gluteus maximus. This includes reliance on other hip musculature, including TFL, hip flexors, and/or hamstrings. Common functional tests are the step-down test and the single-leg squat. Signs of gluteal weakness include internal rotation of the weight-bearing femur, hip adduction, and contralateral hip drop.12

Laboratory studies

Labs are not commonly included in the assessment of chronic exertional ITBS.  Acute pain with any suspicion of infection can be investigated with labs such as CBC, ESR, and CRP.

Imaging

Radiographic imaging is not required to confirm ITBS. If obtained, it is generally to rule out other pathologies in patients with persistent symptoms.

Magnetic resonance imaging (MRI) can show thickening of the ITB over the lateral femoral epicondyle.  Due to cost concerns, MRI should only be used if the definitive ITBS diagnosis is confounded by a potential surgical issue such as a displaced lateral meniscal tear.21

Ultrasound can evaluate ITB anatomy as well and has added advantages of ability to perform a dynamic exam, and ability to assess for hypervascularity of the fat pad deep to the ITB. Soft-tissue edematous swelling or discrete fluid collection suggestive of bursitis between the ITB and the LFE may be seen. Thickening of the ITB has been inconsistently reported.22 Ultrasound studies find fluid at the ITB to be pervasive in both symptomatic and asymptomatic individuals. Such fluid should therefore be interpreted with caution as a sign of ITBS. This fluid likely emanates from the knee joint, representing a synovial fold of the lateral synovial recess.16,23,24

Supplemental assessment tools

Sport-specific functional tasks may be evaluated. Video gait or cycling analysis may be useful in athletes to detect biomechanical abnormalities during athletic performance. Footwear and bike fit should be assessed.

Early predictions of outcomes

Severity and duration of symptoms at presentation may predict the course of recovery. More severe symptoms predicting a longer course may include pain at rest or with activities of daily living. The Noble compression test is thought to be a reasonable predictor of ITBS.25

Environmental

Training errors, including rapid changes in mileage, pace, speed work, or hills contribute to overuse injuries (including ITBS), as rapid increases do not allow adaptation to increased levels of stress.

Running footwear with increased heel height and width which causes relative supination, over-striding, and exercise in cold weather also contribute to the ITBS.25 Running shoes should be fitted to an individual’s foot type and should be replaced at regular intervals.

Bike fit can be adjusted to decrease time in the impingement zone.

Social role and social support system

Social support during recovery for an athlete includes the physician, physical therapist, athletic trainer, coach, teammates, and family.

It is important for an athlete to maintain any improvements initiated to prevent recurrence of ITBS.25 A strong support system will help enable the patient to adhere to new adjustments.

Professional issues

Safely returning an athlete to practice and competition requires excellent communication between the patient, treating providers (physician, physical therapist, athletic trainer), and coaching staff. Returning an athlete to play too soon may result in re-injury, and ultimately more time away from competitive sport.

In the event an athlete experiences recurrence of the pain, treatment should be focused on interventions that were initially successful. Training volume should be gradual until full activity is tolerated. It is important to note that all potential underlying factors are adequately assessed.25

Rehabilitation Management and Treatments

Available or current treatment guidelines

While there are no standardized treatment guidelines for treatment of ITBS, most patients improve with non-surgical care focused on treating inflammation and addressing contributing biomechanical factors. Mass General Sports Medicine created a three phased rehabilitation protocol outlining rehabilitation goals, therapy interventions and progression criteria.23

Phase 1: Acute Inflammatory Phase

  • Occurs within 2-7 days after symptom onset. Apply the treatment plan for 1-2 weeks. 
    Goal: Reduce inflammation and minimize pain while restoring lower extremity mobility and range of motion. Avoid activities with repetitive knee flexion-extension that reproduce symptoms such as descending stairs, prolonged sitting, running and cycling.
  • Therapeutic interventions such as soft tissue mobilization, taping, dry needling, joint mobilization can be used for pain reduction and increase mobility.
  • Exercise program including minimal resistance stationary bike or walking program, minimal loading strengthening exercises, upper leg and perihip muscle stretches.
  • Patients may progress to next phase once full knee motion restored, along with appropriate quadricep contraction and full weight bearing tolerance

Phase 2: Subacute Reparative Phase

Occurs 2-4 weeks after symptoms onset
Goal: To progress towards closed-chain weight bearing activities tolerance while maintaining full ROM. 

  • Phase 1 interventions continued as needed
  • Weightbearing strengthening program with extension-based loading emphasis and balancing exercises
  • Progression to next phase determined by tolerance to weightbearing activities, maintenance of ROM, and muscle length normalization

Phase 3: Late/Remodeling Phase

Goal: Focusing on achieving muscle strength, proper movement mechanics and full tolerance to closed chained knee flexion loading exercises

  • Exercises should be pain free with avoidance of post-exercise inflammation
  • Weightbearing strengthening program with flexion-base loading exercises.
  • Initiate return to running program. 
  • Progression to discharge or return to sport determined by the patient’s ability to self-manage symptoms and injury recurrence prevention.

At different disease stages

For the acute phase, steroid injections in ITBS where the ITB crosses the LFE have been studied. A 2004 trial of steroid vs. placebo injection in 45 runners with ITBS revealed a significant difference in pain with running in the first two weeks after injection.24 No formal studies have thoroughly assessed topical NSAIDs for pain control however it may prove helpful for those who cannot tolerate oral NSAIDs.26 An RCT using 3 treatments of radial shockwave therapy at weekly intervals highlighted reduction in pain, however, with no significant difference to manual therapy.27

As inflammation and pain begin to subside during the subacute phase, treatment and therapies focus on flexibility, biomechanic correction, and introduction to weightbearing exercises. In a 2002 study of 5 male elite-level distance runners, the most effective stretch was performed with the ipsilateral leg extended and adducted behind the other leg. The subject raises the arms overhead and then laterally bends toward the contralateral side.28

In the recovery phase, the goal of strengthening is improved neuromuscular control. Certain strength patterns have been associated with abnormal hip mechanics in ITBS. Hip flexion and internal rotation is increased in individuals with a tight and strong TFL, along with a relatively weak gluteus maximus and gluteus medius. This may result in a Trendelenburg sign and subsequent poor control of the lower limb during stance, increasing stress at the ITB.12 In a controlled case series study of 24 distance runners with ITBS, Fredericson confirmed hip abductor strength deficits. He also showed resolution of symptoms in 90% of individuals after a six-week strengthening program focusing on the gluteus medius. Improved control of hip adduction and knee varus was noted as well.29

An article by Baker includes specific exercise recommendations based on electromyography (EMG) studies for recruitment of appropriate gluteal muscles. The exercises include an ITB stretch, resisted gluteal strengthening, and functional closed chain exercises.12 Pelvic drops, step downs, single leg squats can all improve motor control of the lower limbs. Strengthening of the posterior gluteus medius and of the gluteus maximus are emphasized.30

Biomechanics can also be addressed in cyclists, where bike fit is important, avoiding toeing-in and the 30-degree flexion impingement zone.

Surgery can be effective in refractory cases of ITBS. In an uncontrolled study of 36 athletes with a resistant ITBS, an arthroscopic technique has been shown to have good outcome and offers the opportunity to treat intra-articular pathology of the knee concurrently.31 At least six months of conservative care is recommended prior to surgery.

Coordination of care

Treatment of an athlete with ITBS must involve communication between any affected individuals, including the patient, physical therapist, trainer, and coach.

Patient & family education

As ITBS is an overuse injury, the patient must be educated on training-related issues. These may include mileage, hills, footwear, cycling equipment, and others specific to the affected individual. Gait coaching may be appropriate.

Emerging/unique interventions

A successful outcome in ITBS is pain-free return to play. Athletes treated for ITBS may resume sports when they can perform exercises in proper form without pain. They should also exhibit pain-free range of motion (ROM), full strength, normal Noble testing, and have no ITB tenderness. Exercise should be resumed gradually on a flat surface.12

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

An understanding of lower limb biomechanics, so the practitioner may treat the root cause of ITBS, rather than localized symptoms, is important for full recovery. Mechanics are influenced by training habits, so a thorough training history is essential. A biomechanical physical exam should be performed, addressing the complete kinetic chain, including the core as well as proximal and distal control of the lower limb.

Cutting Edge/Emerging and Unique Concepts and Practice

The newest anatomical information in ITBS involves the presence of fluid at the ITB, not from an inflamed bursa, but from the knee joint itself.32,33

The following treatments for ITBS are controversial. They are primarily used in the treatment of chronic tendinopathy but are used on rare occasions for ITBS refractory to conventional treatment methods. Primary patient population is those wishing to avoid surgery but whose symptoms do not respond to the standard of care treatment.34 No controlled studies are available for these treatments for ITBS:

  • Percutaneous needle tenotomy: Dry needling through pathologic tissue to create microtears that promote healing, sometimes in coordination with injection of a glucocorticoid or biologic.
  • Biologic injection: Injection of autologous blood products, which can include PRP or whole blood into the ITB.
  • Prolotherapy: Injection of irritants into the ITB or surrounding tendons to promote a healing response.
  • Topical nitroglycerin (Glyceryl Trinitrate): Nitroglycerin is a potent dilatator of the blood vessels and can potentially initiate tendon remodeling and promote healing.

Combination injection of hyaluronate and botulinum toxin have given satisfactory relief in runners despite being injected where the ITB crosses the LFE 35. However, this was an uncontrolled study where the participants were also treated with standard care of rest, ice, compression, elevation, and stretching.

ITB Z-lengthening procedure has shown good clinical results and return to pre-activity levels in a retrospective study evaluating the long-term results for chronic ITBS in a consecutive series of 8 patients 36, 37.

A novel minimally invasive surgical approach using ultrasound guidance for distal ITB release showed promising clinical results in patients’ ability to return to sporting activities as well as knee-related symptoms and function.38

Gaps in the Evidence-Based Knowledge

Although physical exam is the gold standard for diagnosis, there are no standards for interpretation of MRI or ultrasound imaging in ITBS.

In addition, more research is needed in the subset of patients who have biomechanical abnormalities distal to the knee contributing to ITBS.

References

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  2. Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8.
  3. Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport. 2007 Apr;10(2):74-6; discussion 77-8. 
  4. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome–a systematic review. Man Ther 2007; 12:200.
  5. Pinshaw R, Atlas V, Noakes TD. The nature and response to therapy of 196 consecutive injuries seen at a runners’ clinic. S Afr Med J 1984; 65:291.
  6. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95.
  7. 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;22(9):951-956.
  8. Orchard JW, Fricker PA, Abud, AT, Mason BR. Biomechanics of iliotibial band frictionsyndrome in runners. Am J Sports Med. 1996;24:375-379.
  9. Renne J. The iliotibial band friction syndrome. J Bone Joint Surg. 1975; 57-A: 1110-1111.
  10. Foch E, Reinbolt JA, Zhang S, Fitzhugh EC, Milner CE. Associations between iliotibial band injury status and running biomechanics in women. Gait Posture. 2015 Feb. 41 (2):706-10. [Medline].
  11. Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011 Dec;19(12):728-36.
  12. Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM&R. 2011;3(6):550-561.
  13. Ceyssens L, Vanelderen R, Barton C, Malliaras P, Dingenen B. Biomechanical Risk Factors Associated with Running-Related Injuries: A Systematic Review. Sports Medicine. 2019;49(7):1095-1115.
  14. Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc 1995; 27:951.
  15. Orchard JW, Fricker PA, Abud, AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996;24:375-379.
  16. De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures. Skeletal Radiol. 2014; 43:1025.
  17. Choi YS, Lee SM, Song BY, Paik SH, Yoon YK. Dynamic sonography of external snapping hip syndrome. J Ultrasound Med. 2002;21:753-758.
  18. 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(3):309-316.
  19. Malanga GA, Nadler SF. Musculoskeletal Physical Examination: an Evidence-Based Approach. Philadelphia, PA: Elsevier; 2006:253-254.
  20.  Knee Orthopaedic Test – A Strategic Approach to Assessing the Knee; University of Western States, College of Chiropractic, Clinic Protocol; Renne; Page No.34; Adopted 12/12. (accessed on 21.03.21 from Knee_Orthopedic_Tests.pdf)
  21. Flato R, Passanante GJ, Skalski MR, et al. The iliotibial tract: imaging, anatomy, injuries, and other pathology. Skeletal Radiol 2017; 46:605.
  22. Jiménez Díaz F, Gitto S, Sconfienza LM, Draghi F. Ultrasound of iliotibial band syndrome. J Ultrasound. 2020 Sep;23(3):379-385. doi: 10.1007/s40477-020-00478-3. Epub 2020 Jun 8
  23. Sports Medicine Physical Therapy Rehabilitation Protocols. Massachusetts General Hospital. https://www.massgeneral.org/orthopaedics/sports-medicine/physical-therapy/sports-rehab-protocols. (Accessed on 7.3.2024)
  24. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomized controlled trial. Br J Sports Med. 2004;38(3):269-272.
  25.  Iliotibial band syndrome Jonathan Jackson, Karl Fields, Jonathan Grayzel March 2021
  26. Schwellnus MP, Theunissen L, Noakes TD, Reinach SG. Anti-inflammatory and combined anti-inflammatory/analgesic medication in the early management of iliotibial band friction syndrome. A clinical trial. S Afr Med J 1991; 79:602.
  27. Conservative Rehabilitation Treatments of Iliotibial Band Syndrome: A Systematic Review Miccio S, Berardi A., Tofani M.,Galeoto G. Muscle Ligaments and Tendons Journal volume 11 issue 01 pages 29 March 2021
  28. Fredericson M,White JJ, Macmahon JM, et al. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil 2002;3:269-72.
  29. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestereicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med. 2000;10:169-175.
  30. Baker RL, Fredericson M. Iliotibial band syndrome in runners: biomechanical implications and exercise inventions. Phys Med Rehabil Clin N Am. 2016;27:53-77.
  31. Michels F, Jambou S, Allard M, Bousquet V, Colombet P, de Lavigne C. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc. 2009;17(3):233-236.
  32. Jelsing EJ, Finoff J, Levy B, Smith J. The prevalence of fluid associated with the iliotibial band in asymptomatic recreational runners: an ultrasonographic study. PMR. 2013;5(7):563-7.
  33. Jelsing EJ, Maida E, Finnoff JT, Smith J. The source of fluid deep to the iliotibial band: documentation of a potential intra-articular source. PMR. 2014;6(2):134-8.
  34. Baltes TPA, Zwiers R, Wiegerinck JI, van Dijk CN. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25:1817.
  35. An innovative treatment modality for acute ilio-tibial band syndrome in runners: local hyaluronate + botulinum toxin in a prospective cohort of 45 athletes Petrella R., Decruze A. and Decaria J. Annals of the Rheumatic Diseases volume 76 issue Suppl 2 pages 1002 June 2017
  36. Distal Iliotibial Band Z-lengthening for Iliotibial Band Syndrome Dart S.E., Hyde Z., Gwathmey W., Werner, B.C., Video Journal of Sports Medicine volume 1 issue 2 pages 263502542199713 March 2021
  37. Barber, FA, Boothby, MH, Troop, RL. Z-plasty lengthening for iliotibial band friction syndrome. J Knee Surg. 2007;20(4):281-284.
  38. Villanueva M, Iborra Á, Sanz-Ruiz P, Noriega C. Ultrasound-guided release for iliotibial band syndrome: A novel ultraminimally invasive surgical procedure. Knee. 2021;30:9-17. doi:10.1016/j.knee.2021.02.021

Original Version of the Topic

Heather D. Fullerton, MD. Iliotibial band syndrome. 12/28/2012

Previous Revision(s) of the Topic

Heather D. Fullerton, MD. Iliotibial band syndrome. 9/13/2016

Laurentiu Dinescu, MD, Vivek Mukherjee, MD, Alec Guerzon, MD, Joshua Simons, MD. Iliotibial Band Syndrome. 5/4/2021

Author Disclosures

Sara Flores, MD
Nothing to Disclose

Brandon Kalasho, DO
Nothing to Disclose

Michael Hernandez Jr, MD
Nothing to Disclose