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Iliotibial Band Syndrome
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Contents
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
Epidemiology
- Incidence
- 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
- Iliotibial Band
- Consists of dense fibrous connective tissue
- Proximally, it runs from the Iliac Crest, over Greater Trochanter
- Distally, it runs over the LFE to the Tibia at Gerdys Tubercle
- Tensor Fasciae Latae
- Muscle that originates at the Iliac Crest and inserts into the Iliotibial Band
- Assists in internal rotation of thigh, external rotation of knee
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
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
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

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
- Standard Radiographs Knee
- Typically normal, useful to exclude other etiology
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
- IT Band Corticosteroid Injection
- Gunter et al found benefit when infiltrating in the area where the ITB crosses the LFC[23]
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
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
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
- https://www.sportsmedreview.com/blog/ultrasound-guided-it-band-injection/
References
- ↑ Colson JHC, Armour WJ. Sports injuries and their treatment. London: Stanley Paul & Co., Ltd; 1961.
- ↑ Renne J. The iliotibial band friction syndrome. The Journal of Bone and Joint Surgery 1975;57–A(8):1110–1
- ↑ Ellis, Richard, Wayne Hing, and Duncan Reid. "Iliotibial band friction syndrome—a systematic review." Manual therapy 12.3 (2007): 200-208.
- ↑ McNicol K, Taunton J, Clement D. Iliotibial tract friction syndrome in athletes. Canadian Journal of Applied Sport Science 1981; 6(2):76–80
- ↑ Farrell K, Reisinger K, Tillman M. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. The Knee 2003;10:103–9
- ↑ 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
- ↑ Image courtesy of https://www.physio-pedia.com/, "Iliotibial Tract"
- ↑ 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
- ↑ Kirk K, Kuklo T, Klemme W. Iliotibial band friction syndrome. Orthopedics 2000;23(11):1209–15
- ↑ Fairclough, John, et al. "Is iliotibial band syndrome really a friction syndrome?." Journal of Science and Medicine in Sport 10.2 (2007): 74-76.
- ↑ Fredericson, Michael, et al. "Hip abductor weakness in distance runners with iliotibial band syndrome." Clinical Journal of Sport Medicine 10.3 (2000): 169-175.
- ↑ 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.
- ↑ Nohren, B., I. Davis, and J. Hamill. "Prospective study of the biomechanical factors associated with iliotibial band syndrome." Clin Biomech 22 (2007): 951-956.
- ↑ 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.
- ↑ 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.
- ↑ 16.0 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.
- ↑ 17.0 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.
- ↑ Jiménez Díaz, Fernando, et al. "Ultrasound of iliotibial band syndrome." Journal of ultrasound 23 (2020): 379-385.
- ↑ 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.
- ↑ Lindenberg G, Pinshaw R, Noakes TD. Iliotibial band friction syndrome in runners. Phys Sportsmed 1984; 12(5): 118–30.
- ↑ 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
- ↑ 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
- ↑ 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.
- ↑ 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"
- ↑ McNicol K, Taunton J, Clement D. Iliotibial tract friction syndrome in athletes. Canadian Journal of Applied Sport Science 1981; 6(2):76–80
- ↑ 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.
- ↑ 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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