Iliotibial band syndrome (ITBS) is an overuse injury associated with lateral knee pain 1.
The etiology of ITBS involves repetitive knee flexion and extension, resulting in inflammation at the lateral knee between the ITB and the lateral femoral epicondyle. Compression of the ITB at the femoral epicondyle is greatest at 20-30 degrees of knee flexion, termed the impingement zone. Biomechanical and frictional factors are thought to play a role 2.
Epidemiology including risk factors and primary prevention
ITBS is the second most common knee overuse injury behind patellofemoral syndrome 3,4,5 and is the primary cause of lateral knee pain in long distance runners 2,3,4,5,6,7. It was first described by Renne in 1975 in US Marine Corps soldiers during their basic training 8. 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 9.
The incidence of ITBS among runners has increased over the past 30 years for reasons that are not fully understood 5, 10. In cyclists, it is the source for 15% of overuse injuries 11. Participants in basketball, soccer, and hockey are also affected. These sporting activities involve prolonged cycling of the knee through flexion and extension. 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.
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 11.
Pain from ITBS is commonly thought to be due to inflammation at the lateral femoral epicondyle. A long-held theory of the source of inflammation is related to anterior-posterior friction of the ITB over the lateral femoral epicondyle (LFE) during flexion and extension of the knee. This is referred to as ITB friction syndrome 6. Anterior posterior motion of the ITB over the lateral femoral epicondyle was shown in a 2013 ultrasound study of 20 runners aged 18-40 years by Jelsing, supporting this theory 12. An alternative concept initiated by Fairclough involves compression, by the ITB, of a highly vascular fat pad just deep to the ITB, creating inflammation and pain 13. Other studies show that the ITB is tethered at the LFE by both the epicondylo-patellar ligament and patellar retinaculum. Tethering restricts movement in the sagittal plane, making friction an unlikely source of pain 12,13,14,15.
The concept of the knee internally rotating during flexion has implications for the biomechanics of ITBS. Consequently, ITBS has been associated with biomechanical abnormalities in the coronal plane, particularly at the hip, which controls orientation of the lower limb during stance. In a study of female runners, ITBS has been associated with greater peak hip adduction, and with greater peak knee internal rotation angle. The contribution of foot and ankle mechanics to ITBS is questionable. Some studies note ITBS patients to have reduced ankle eversion and rearfoot pronation 16,17, while others show no difference 6,18.
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 also are proximal ITB issues, also referred to 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 19 and most often is treated conservatively.
Essentials of Assessment
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 6, 13, 16. 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.
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 20. There are no official studies to indicate the validity of these tests 21.
- 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.
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 11.
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.
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 22.
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 23. 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 18,24,25.
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 26.
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 26. 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 26. A strong support system will help enable the patient to adhere to new adjustments.
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 26.
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. A table of recommendations for phases of rehabilitation were published by Fredericson and Wolf and is summarized below from that article .
Occurs within 2-7 days after symptom onset. Apply the treatment plan for 1-2 weeks.
Goal: Reduce inflammation of the ITB at the lateral femoral epicondyle.
- Avoid activities with repetitive knee flexion-extension that reproduce symptoms such as running and cycling.
- Recommend swimming using only their arms and a pool buoy to remain active.
- Apply an ice pack to the painful area for 10 min/hour, several times per day.
- Oral NSAIDs and Tylenol for pain control. The efficacy of topical NSAIDs has not been formally studied 27.
- Corticosteroid injection, if no response to the above methods.
- Up to 2 pain-free weeks before return to running or cycling in a graded progression.
Occurs more than 1 week after symptom onset.
Goal: Achieve flexibility in the ITB as a foundation to engaging in the recovery strength training phase, without pain.
- ITB stretching.
- Soft tissue mobilization to reduce myofascial adhesions, such as the use of a foam roller.
Recovery – strengthening phase
Goal: Strengthen the gluteus medius muscle, including multiplanar closed chain exercises.
- Exercises should be pain free.
- Repetitions and sets of exercises are 8-15 repetitions and 2-3 sets.
- Recommend hip abduction strengthening exercises of side lying hip abduction, single leg activities, pelvic drops, and multiplanar lunges.
Return to running phase (for runners)
Goal: Graded return to activity taking place over 3-4 weeks
- Achieved when open chain and closed chain exercises are performed without pain
- Recommend running every other day and avoiding hill training
- Increase frequency and intensity as tolerated
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 25. No formal studies have thoroughly assessed topical NSAIDs for pain control however it may prove helpful for those who cannot tolerate oral NSAIDs 27. An RCT using 3 treatments of radial shockwave therapy at weekly intervals highlighted reduction in pain, however, with no significant difference to manual therapy 28.
In the subacute phase, as inflammation and pain begin to subside, making flexibility and corrections in biomechanics is the primary focus. 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 29.
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 11. 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 30.
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 11. 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 14.
Mechanics 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.
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 11.
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
Cutting edge 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. 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.
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.
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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
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