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Iliotibial Band Syndrome

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Other Names

  • IT Band Syndrome
  • ITBS
  • Iliotibial Band Syndrome (ITBS)
  • Iliotibial Band Friction Syndrome (ITBFS)

Background

  • This page refers to overuse injuries of the Iliotibial Band (ITB), most commonly termed iliotibial band syndrome (ITBS)

History

  • First described by Colson and Armour[1]
  • Later in more detail by Renne in 1975[2]

Epidemiology

  • Incidence
    • Ranges from 1.6% to 52% depending on the population referenced[3]
    • Among runners, incidence is estimated to be 1.6% to 14% and is the most common injury of the lateral knee[4]
    • Among cyclists, the incidence is 15-24%[5]
    • Among military recruits, incidence ranges from 1% to 5.3%[6]
  • Second most common cause of knee pain after patellofemoral pain syndrome
  • Note estimates of true incidence are challenging, many studies simply list knee injuries and not specifically ITBS

Introduction

Illustration of the iliotibial tract and associated structures[7]
  • General
    • Atraumatic, overuse syndrome caused by friction or rubbing of the ITB over the lateral femoral epicondyle (LFE).
    • Weakness of hip abductors is now recognized as a major contributor to development of ITBS
    • Commonly seen in running, cycling due to repeated flexion and extension of the knee
    • During eccentric contraction of the knee, Tensor Fasciae Latae & Gluteus Maximus cause deceleration, increasing tension in ITB

Etiology

  • Impingement Zone[8]
    • During knee flexion, the ITB gets compressed against the LFE
    • Occurs at approximately 30° of knee flexion during foot-strike and early stance phase
    • After 30°, the ITB passes over and posterior to the LFE
  • Inflammation
    • With repetition, this leads to ITB inflammation as well as inflammation of the tissue/bursa between the ITB and LFE
    • Inflamed structures include lateral synovial recess, posterior fibers of ITB, periosteum of LFE[9]
  • Compression
    • Growing theory that symptoms are not caused by friction but compression of fatty tissue, nerve endings[10]
  • Weakness of hip abductors
    • Now recognized as a major contributor to the development of ITBS
    • Weak hip abductors lead to increased hip adduction, genu valgum and internal rotation which increase tension on IT band
    • Overtraining, failure to develop hip abductor muscle endurance contributes to the disease[11]
  • Gait contributions[12]
    • During foot strike, knee is in 30 degrees of flexion
    • Repeated flexion can lead to IT band strain
    • Kinematic malalignment of the ankle knee and hip may contribute

Anatomy


Risk Factors

  • Sports
    • Running
    • Cycling
  • Occupations
    • Military recruits
  • Extrinsic Risk Factors[13]
    • Downhill running
    • High running mileage, especially a sudden increase
    • Too much time spent running in the same direction on the track
    • Uneven running style
    • Improper shoe/ bicycle fit
    • Running on a track or banked surface
    • Cold weather running
  • Intrinsic Risk Factors
    • Increased hip adduction[14]
    • Internal rotation of the knee
    • Femur external rotation
    • Prior IT band tightness
    • Muscle weakness of the Hip Abductors[15]
    • Younger age in men[16]
    • Leg length discrepancy > 0.5 cm[16]
    • Over striding or taking short steps

Differential Diagnosis

Differential Diagnosis Lateral Knee Pain

Differential Diagnosis Knee Pain


Clinical Features

  • History
    • Sharp, burning lateral knee pain
    • Typically unilateral
    • May see radiation of symptoms along the length of the ITB
    • Popping sensation sometimes noted over the lateral aspect of the knee with activity.
    • Pain is often experienced at a predictable distance, duration into a workout. Not present immediately upon beginning.
    • Pain usually subsides after activity cessation.
    • Pain worsened with downhill running, lengthening of stride, ascending/descending stairs, sitting for prolonged periods with knee flexed.[17]
    • There is no sensation of instability
  • Physical Exam
    • Classically, tenderness is appreciated at 2 cm above the lateral joint line with possible swelling
    • Crepitus or popping may be palpated upon 30 degrees of knee flexion
    • Joint effusion is unlikely to be present and will suggest a distinct intra-articular cause
    • Evaluate for muscle strength differences and leg length discrepancy as these can contribute to ITBS
  • Special Tests
    • Nobles Test: Pain elicited when the ITB is pressed against the lateral femoral condyle ranging from 0-90° flexion
    • Obers Test: Patient lays in lateral decubitus position, affected leg up and allowed to adduct against gravity
    • Renne Test: Patient standing, hand placed on lateral femoral condyle, patient squats slowly to 60-90° of flexion

Coronal view of knee MRI consistent with IT Band syndrome. Seen is thickening of the IT band with signal changes, surrounding superficial edema
Longitudinal (a) and axial (b) ultrasound demonstrates soft-tissue hypoechoic edematous swelling (asterisks) between the iliotibial band (arrowheads) and the lateral femoral epicondyle[18]

Evaluation

  • Note: Imaging is not typically needed as this is a clinical diagnosis

Radiographs

MRI

  • General
    • Typically normal
    • Not needed to confirm diagnosis, may be used to exclude other pathology
  • Potential findings
    • Ill-defined signal abnormality within the fatty soft tissues interposed between the ITB and bone
    • Soft tissues lateral to the lateral femoral condyle show low T1, high on T2 signal
    • Chronically, can see thickening of the IT band, increased T2 signal intensity

Ultrasound

  • Can be useful to view the dynamic motion of the IT band in flexion and extension
  • May be preferred imaging modality in suspected IT band syndrome[19]

Classification

Lindenberg Classification

  • Classified by severity of symptoms[20]
  • Grade I: pain comes on after running, but does not restrict distance or speed
  • Grade II: pain comes on during running, but does not restrict distance or speed
  • Grade III: pain comes on during running and restricts distance or speed
  • Grade IV: pain is so severe that it prevents running

Management

Nonoperative

  • Activity modification
    • Period of rest from exacerbating activity
    • Can be challenging in athletes who are motivated to continue exercising
  • Analgesia including
  • Ice Therapy
  • Physical Therapy
    • Emphasis on hip abduction and pelvic strengthening
    • Stretching, foam rolling are popular (paucity of ebidence to support, however)
  • Running shoes
    • Pinshaw showed that changing running shoes, shoe inserts and adjusting training methods was effective[21]
  • Running activity changes which can help
    • Decreasing mileage
    • Altering the course
    • Cross-training
  • Therapeutic Ultrasound
    • Fredericson et al showed benefit when combined with NSAIDS, PT program[22]
  • Massage Therapy
  • Not well studied
    • Dry Needling
    • Kinesiology Taping
    • IT Band Straps
    • Orthobiologics

Procedures

Operative

  • Indications
    • No relief after exhaustive conservative management.
  • Technique
    • All interventions aim to reduce compression of the ITB in this area. [17]
    • Resection of a portion of the ITB
    • ITB lengthening
    • Bursectomy

Rehab and Return to Play

Rehabilitation

  • Primary emphasis is on strengthening hip abductors

Return to Play/Work

  • After a 2-6 week rest period, may gradually return to activity.
    • Mileage should increase slowly, only when athlete is pain free
  • Running
    • Begin on level ground and gradually progress towards more distance, resistance, elevation.
    • Sprinting as opposed to longer, slower runs helps to avoid ITB friction.
    • Running on an incline treadmill or uphill may decrease symptoms[24]
  • Crosstraining
    • Can attempt earlier return to activity with non-weight bearing activity such as swimming.
    • Include activities which do not repetitively place the knee in 30 degrees of flexion
    • Prevent future injury with appropriate warm-up and stretching. [17]

Prognosis and Complications

Prognosis

  • Conservative therapy
    • Success rates reported as high as 94%[25]
  • Surgical
    • Hariri found all patients were able to return to pre-injury activity levels, reported less pain within 20 months of bursectomy[26]
    • Michels evaluated arthroscopic resection of lateral synovial recess and found excellent (80%) or good (17.1%) results[27]

Complications

  • Delayed return to sport
    • Recovery can be delayed if the athlete attempts to return to activity early despite persistent pain. [17]

See Also

Internal

External


References

  1. Colson JHC, Armour WJ. Sports injuries and their treatment. London: Stanley Paul & Co., Ltd; 1961.
  2. Renne J. The iliotibial band friction syndrome. The Journal of Bone and Joint Surgery 1975;57–A(8):1110–1
  3. Ellis, Richard, Wayne Hing, and Duncan Reid. "Iliotibial band friction syndrome—a systematic review." Manual therapy 12.3 (2007): 200-208.
  4. McNicol K, Taunton J, Clement D. Iliotibial tract friction syndrome in athletes. Canadian Journal of Applied Sport Science 1981; 6(2):76–80
  5. Farrell K, Reisinger K, Tillman M. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. The Knee 2003;10:103–9
  6. Almeida S, Williams K, Shaffer R, Brodine S. Epidemiological patterns of musculoskeletal injuries and physical training. Medicine and Science in Sports and Exercise 1999;31(8):1176–82
  7. Image courtesy of https://www.physio-pedia.com/, "Iliotibial Tract"
  8. Orchard J, Fricker P, Abud A, Mason B. Biomechanics of iliotibial band friction syndrome in runners. American Journal of Sports Medicine 1996;24(3):375–9
  9. Kirk K, Kuklo T, Klemme W. Iliotibial band friction syndrome. Orthopedics 2000;23(11):1209–15
  10. Fairclough, John, et al. "Is iliotibial band syndrome really a friction syndrome?." Journal of Science and Medicine in Sport 10.2 (2007): 74-76.
  11. Fredericson, Michael, et al. "Hip abductor weakness in distance runners with iliotibial band syndrome." Clinical Journal of Sport Medicine 10.3 (2000): 169-175.
  12. Louw, Maryke, and Clare Deary. "The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners–A systematic review of the literature." Physical Therapy in sport 15.1 (2014): 64-75.
  13. Nohren, B., I. Davis, and J. Hamill. "Prospective study of the biomechanical factors associated with iliotibial band syndrome." Clin Biomech 22 (2007): 951-956.
  14. 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 2007; 22 (9): 951–6.
  15. Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000; 10(3): 169–75.
  16. 16.0 16.1 Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36(2): 95–101.
  17. 17.0 17.1 17.2 17.3 Harrison N. et al. Iliotibial Band Friction Syndrome. In: Bracker M. et al. eds. The 5-Minute Sports Medicine Consult; 2011.
  18. Jiménez Díaz, Fernando, et al. "Ultrasound of iliotibial band syndrome." Journal of ultrasound 23 (2020): 379-385.
  19. De Maeseneer, Michel, et al. "Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures." Skeletal radiology 43 (2014): 1025-1039.
  20. Lindenberg G, Pinshaw R, Noakes TD. Iliotibial band friction syndrome in runners. Phys Sportsmed 1984; 12(5): 118–30.
  21. 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(8): 291–8
  22. Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000; 10(3): 169–75
  23. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. Br J Sports Med 2004; 38(3): 269–72.
  24. Willy R. Mythbusting iliotibial band with Dr Rich Willy - "It is not friction". British Journal of Sports Medicine Blog, 9 Aug 2019. https://soundcloud.com/bmjpodcasts/mythbusting-iliotibial-band-itb-pain-with-dr-rich-willy-pt-phd-its-not-friction-393. Accessed 21 Aug 2019"
  25. McNicol K, Taunton J, Clement D. Iliotibial tract friction syndrome in athletes. Canadian Journal of Applied Sport Science 1981; 6(2):76–80
  26. Hariri S, Savidge ET, Reinold MM, et al. Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes. Am J Sports Med 2009; 37(7): 1417–24.
  27. Michels F, Jambou S, Allard M, et al. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc 2009; 17(3): 233–6
Created by:
John Kiel on 4 July 2019 04:57:19
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Last edited:
17 March 2023 16:46:20
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