Iliotibial Band Syndrome; Causes, Symptoms, Diagnosis, Treatment

Iliotibial band syndrome is a common condition that usually presents as pain on the outer side of the knee. The IT Band is a thick band of connective tissue that crosses the hip joint and extends down the outer thigh and attaches just below the outer side of the knee. IT Band syndrome is caused by excessive friction at the distal portion of the IT Band as it rubs over the outside portion of the knee. This is most common in runners and cyclists, but also other sports that involve repetitive knee bending because it leads to inflammation in this area.

The iliotibial band tract or IT band (ITB) is a longitudinal fibrous sheath that runs along the lateral thigh and serves as an important structure involved in lower extremity motion. The ITB is also sometimes known as Maissiat’s band.  The ITB spans the lower extremity on its lateral aspect before inserting on Gerdy’s tubercle on the proximal/lateral tibia.

Proximally in the thigh, the ITB receives fascial contributions from the deep fascia of the thigh, gluteus maximus, and tensor fascia lata (TFL).[rx]  The TEFL is the deep investing fascia of the thigh, encompassing the muscles of the hip and lower extremity around this region.[rx] Distally, the ITB becomes a distinct soft tissue layer of the lateral knee.[rx]

Iliotibial Band Syndrome (ITBS) has commonly been thought of as an overuse injury in runners. The exact etiology of ITBS is not well understood and there is no consensus on how to properly manage it. The purpose of this case series is to present a comprehensive model that utilizes a review of the current literature and the concept of regional interdependence as a foundation for the treatment of ITBS in runners.

Anatomy Of Iliotibial Band Syndrome

Origin, insertion, and structure

The detailed anatomic structure of the ITB, TFL, and its origins, insertions, and variations have been debated for decades in the literature.[rx]

Proximal anatomy[rx][rx]

• TFL 

  • Separate origin of TFL fibers originates off the ilium and in between the superficial and intermediate IT layer origins
  • Distally, the TFL becomes a tendinous structure as it merges with the superficial and intermediate IT layers
  • Farther distal, the TFL tendinous fibers, including the superficial and intermediate IT layers, fuse as a single confluent structure near the level of the GT

• Gluteal contributions

  • Gluteal aponeurotic fascia:

    • Originates from the posterior iliac crest
    • Courses distally to invest the anterior two-thirds of the gluteus medius
    • A portion of its fibers merge with the posterior ITB to continue distally while the remaining aponeurotic fibers insert at the gluteal tuberosity on the femur

  • In addition, the posterior ITB also receives distinct fascial/tendinous contributions from:

    • Superior gluteus maximus
    • Superficial fibers of the inferior gluteus maximus
  • Deep fibers from the inferior gluteus maximus course toward the femur to insert onto the gluteal tuberosity of the linea aspera

Distal anatomy

Proximal to the knee joint, the ITB attaches to the intermuscular septum and supracondylar tubercle of the femur.  Proximal to the lateral epicondyle, there is an interposed fat layer between the ITB and the vastus lateralis.[rx]   The ITB is more tendinous proximal to the lateral femoral epicondyle, and at the level of the epicondyle, the ITB contributes to lateral knee stability secondary to its anatomic position, intimal contact with the epicondyle, and relative to its location with respect to the lateral collateral ligament (LCL).[rx]

Function

Proximal ITB function includes[rx]:

• Hip extension
• Hip abduction
• Lateral hip rotation

Distally, ITB function depends on the position of the knee joint[rx]

• 0 degrees/full extension to 20 to 30 degrees of flexion

  • Active knee extensor >The ITB lies anterior to the lateral femoral epicondyle

• 20 to 30 degrees of flexion to full flexion ROM

  • Active knee flexor >ITB lies posterior relative to the lateral femoral epicondyle

Causes of Iliotibial Band Syndrome

This injury is most often the result of overuse, especially for runners and cyclists. The longer distance you run or cycle, the more likely you are to experience this syndrome. For these two physical activities, bending the knee over and over again can create irritation and swelling of the iliotibial band.

Certain factors can make you more prone to developing Iliotibial Band Friction Syndrome:

• Muscle Tightness – Tightness in the leg muscles and the Iliotibial Band itself increases the friction on the ITB. Visit the knee stretches section for simple tests to see if your muscles are tight
• Muscle Weakness – Weakness in the buttock muscles (glutes) puts more strain on the Iliotibial Band, increasing your chances of developing Iliotibial Band Syndrome
• Flat Feet – If you have flat feet (dropped foot arches) it slightly changes the angle of the leg, putting more friction through the Iliotibial Band
• Excessive long distance or hill running – Overuse can also lead to Iliotibial band syndrome due to repetitive friction. Hill running puts even more tension through the ITB
• Running on a sloped surface –  Lots of running surfaces e.g. roads and running tracks are slightly banked. The foot position on the lower leg causes the Iliotibial band to be stretched
• The sudden increase in activity – Someone who rapidly increases their training is at risk of developing Iliotibial Band Syndrome due to the sudden increase in friction at the knee
• Leg Length Discrepancy – If one leg is slightly shorter than the other it puts more strain on the Iliotibial Band
• Bowlegs – The curved nature of bow legs means there is a larger than normal space between the knees. This puts extra stretch on the Iliotibial Band

Other Causes Include 

• Being in poor physical condition, including a lack of strength and flexibility, especially a tight iliotibial band
• Not warming up before exercising
• Having bowed legs
• Having arthritis of the knee(s)
• Poor training techniques, including sudden changes in the amount, frequency or intensity of workouts, as well as inadequate.
• Poor training techniques
• Large Q angle
• Sacroiliac joint dysfunction
• Genu valgum  ( knock kneed)
• Leg length discrepancies
• Strength imbalances in the hip inductors
• Overpronation

Training habits

• Spending long periods of time/regularly sitting in lotus posture in yoga. Esp beginners forcing the feet onto the top of the thighs
• Consistently running on a horizontally banked surface (such as the shoulder of a road or an indoor track) on which the downhill leg is bent slightly inward, causing extreme stretching of the band against the femur
• Inadequate warm-up or cool-down
• Excessive up-hill and down-hill running
• Positioning the feet “toed-in” to an excessive angle when cycling
• Running up and down stairs
• Hiking long distances
• Rowing
• Breaststroke
• Treading water

Symptoms of Iliotibial Band Syndrome

• Sharp pain – People with IT band syndrome typically experience sharp pain at the outside of the knee joint, either at or just below the rounded end of the thighbone, called the lateral femoral epicondyle, or just femoral condyle.
• Pain when the knee is bent 30 degrees – IT band syndrome pain is usually most noticeable when the knee is bent at about 30 degrees—this is when experts theorize the IT band passes over the femoral condyle.
• Tightness and loss of flexibility – The outside of the thigh feels tight and hip and knee may be less flexible.
• Tenderness – The outside of the knee is tender and pressing against it may cause pain.

Pain when running – IT band syndrome is the second most common injury for runners.

• Running on a decline can be especially irritating for runners.
• A runner typically feels a sharp pain when a foot hits the ground or right afterward.

Pain when cycling –  Cyclists will typically feel the pain come and go during the downward pedal stroke and again during the upward pedal stroke when the knee is bent at 30 degrees.

• Pain, tenderness, swelling, warmth, or redness over the iliotibial band at the outer knee (above the joint); may travel up or down the thigh or leg
• Initially, pain at the beginning of an exercise that lessens once warmed up; eventually, pain throughout the activity, worsening as the activity continues; may cause the athlete to stop in the middle of training or competing
• Pain that is worse when running down hills or stairs, on banked tracks, or next to the curb on the street
• Pain that is felt most when the foot of the affected leg hits the ground
• Possibly, crepitation (a crackling sound) when the tendon or bursa is moved or touched
• Stabbing or stinging pain along the outside of the knee
• A feeling of the ITB “snapping” over the knee as it bends and straightens
• Swelling near the outside of your knee
• Occasionally, tightness and pain at the outside of the hip
• Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to a standing position
• Pain that is worse when running down hills or stairs.
• Pain that is felt most when the foot of the affected leg hits the ground.
• Possibly, a crackling sound when the ITB or bursa is moved or touched.

Differential Diagnosis

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Physical examination

There is usually tenderness on palpation of the iliotibial band (ITB) 2 to 3 cm superior to the lateral joint line. In mild cases, results of an examination may be normal, but in severe cases, there may be local edema or crepitation. Noble’s, Ober’s, and modified Thomas’s tests are used in the diagnosis, but are provocative tests used in the physical examination, and not true diagnostic tests. Noble’s test is often positive.

• Noble’s test – Physician applies pressure over the lateral femoral epicondyle while extending the knee from 90° of flexion.  Pain occurs when the knee is flexed at around 30°.
• The force of hip abduction – The force of hip abductors can be decreased. These muscles should thus be tested.
• Treadmill test – This test is described in several studies as a valid, effective, and sensitive method of evaluating the effects of treatments for running-related pain and is used to measure the amount of pain that subjects experience during normal running. If this includes pain to the lateral side of the knee, the test is considered positive.
• Noble compression test – This test starts in supine posture and knee flexion of 90 degrees. As the patient extends the knee the assessor applies pressure to the lateral femoral epicondyle. If this induces pain over the lateral femoral epicondyle near 30-40 degrees of flexion, the test is considered positive. A goniometer is used to ensure the correct angle of the knee joint.
• Ober’s test – The patient lies down with the unaffected side down and the unaffected hip and knee at a 90° angle. If the ITB is tight, adducting the leg beyond the midline is difficult and the patient may experience pain at the lateral knee. Normal tightness is when the leg can be passively stretched to a position horizontal but not completely addicted to a table. Moderate tightness is when the leg can be passively adducted to horizontal at best. If the leg cannot be passively adducted to horizontal, this is maximal tightness.
• Modified Thomas’s test – The patient sits on the end of an examining table, rolls back to a supine position, and holds both knees to the chest. The patient holds the knee on the asymptomatic side close to the chest, keeping the hips on the table, and avoiding excessive posterior tilt. The examiner then slowly lowers the affected limb towards the floor. The test is positive if the angle of the femur is below horizontal.
• MRI or ultrasound – may be requested if there is doubt about the diagnosis from the physical examination.The result may be normal, or show cystic changes (ultrasound) or poorly defined signal intensity (MRI) changes under the ITB.
• MRI of the hip without contrast – may be indicated if initial knee x-rays are non-diagnostic (demonstrate normal findings or a joint effusion), or show osteochondral injuries (fracture/osteochondritis dissecans or a loose body), avascular necrosis, or internal derangement (e.g., Segond’s fracture, deep lateral femoral notch sign)

Treatments Iliotibial Band Syndrome

Whether using a foam roller or not, patients can benefit from making changes in their stretching and exercise routines.

• Rest – People with IT band syndrome may need to cut back on the intensity, duration and frequency of activity that leads to IT band pain (for example, reduce running or cycling mileage). People with moderate to severe IT band pain may need to take time off from their sport. It can be frustrating and difficult for active people to cut back on their training schedules; however, rest is necessary for the injury to heal.
• Warm-up – Five to 10 minutes of gentle exercise and stretching can literally increase the body’s temperature, helping muscles become more elastic and responsive and reducing the chance of IT band syndrome or other injuries.
• Change footwear – Switching out shoes and/or getting orthotic inserts can alter a person’s biomechanics and reduce the risk of IT band pain.
• Massage – Much like the foam roller exercise, massage may help relieve tension and improve blood flow in the IT band, thereby reducing pain.
• Stretching – A doctor may recommend stretching or yoga to promote flexible muscles and other soft tissue.
• Change running biomechanics – Runners may consider shortening their stride⁶ and running on soft, flat surfaces, such as tracks and even, grassy trails.
• Change cycling biomechanics – Cyclists may consider adjusting saddle position and pedal clips. Even a small adjustment can alter the biomechanics of their pedaling and reduce IT band pain.
• Ultrasound – Efforts to heal the IT band and reduce pain may get a small boost from ultrasound and electrical muscle stimulation.⁷
• Iontophoresis – Doctors and physical therapists occasionally recommend iontophoresis, which uses a mild electrical current to administer an anti-inflammatory medicine (e.g. dexamethasone) through healthy skin and into the sore area. This treatment may be appropriate for people who can’t tolerate injections or want to avoid injections.

Medication

• Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your painful area. Steroids make inflammation go down. The corticosteroid will provide prolonged anti-inflammatory protection by inhibiting the inflammatory mediators. Patients will most likely be symptom-free within days to weeks without treatment.[rx]
• Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
• Muscle Relaxants – These medications provide relief from spinal muscle spasms.
• Neuropathic Agents: Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids  – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• The lidocaine – will help by providing immediate relief from the pain by blocking the sodium channels in the surrounding tissue, inhibiting the transmission of the pain signal
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.

Longer-Term Treatment of Iliotibial Band Syndrome

Long-term treatment aims to address the cause of the Iliotibial Band Syndrome and may include

• Strengthening Exercises –  Strengthening the glutes, quads, and hamstrings improves how the hip and knee function which reduces the friction on the Iliotibial Band. Visit the knee strengthening section for exercises that will help
• Stretching Exercises – Stretching the quads, hamstrings, and ITB also helps reduce the friction at the knee. Visit the stretches section to see if tight muscles are likely contributing to your Iliotibial Band Syndrome
• Knee Straps – Wearing a brace that straps around the top of the knee direct forces away from the Iliotibial band so can be very helpful to reduce irritation when running. Visit the knee transaction to see what your options are
• Taping – Taping can also be used to reduce the forces going through the ITB – see you physical therapist/ sports injury specialist for more information
• Massage – Deep tissue massage to the Iliotibial Band can reduce tightness, but it can be quite painful
• Injections – If other treatments have failed, a cortisone injection can be given to help reduce pain and inflammation. However, it should always be accompanied by strengthening and stretching exercises to ensure the problem doesn’t return
• Orthotics – Special insoles can be worn in your shoes to correct poor foot positions such as flat feet. See an orthopedist for a full assessment and advice

How is Iliotibial Band Friction Syndrome Treated?

As described by Fredericson and others, the accepted treatment of iliotibial band friction syndrome follows the outline common to the treatment for many connective tissue injuries, beginning with treatment of the acute inflammatory response and progressing through a corrective treatment phase and ultimately to a return to regular activity [rx].

Exercise for Iliotibial Band Syndrome

Side Leg Raaise

Lie on your right side with both legs straight. Slowly raise your left leg about 45 degrees, then lower. Repeat on both sides. To make this move more challenging, use an exercise band around your ankles to increase resistance. Reps: 20–30 on each side

Clam Shell

Lie on your right side with your knees bent at a 90-degree angle to your torso. Keeping your feet together, use your glutes to slowly open and close your legs like a clamshell. Keep the motion controlled, and don’t allow your pelvis to rock throughout the movement. Use an exercise band just above your knees to increase resistance. Reps: 20–30 on each side

Hip Thrust

Lie on your back with your arms at your sides, knees bent and your feet on the floor. Pushing your heels into the ground, use your glutes to raise your pelvis up until your body forms a straight line from your knees to your shoulders. Lower slowly, then repeat. For a more advanced version, raise one leg into the air and perform the same exercise with each leg individually. Reps: 20–30 on each side

Side Hip Bridge

Lie on your side with your feet elevated 1–2 feet off the ground on a stable surface. Lift your torso using your hip muscles while keeping your spine stable, then lower slowly. Reps: 10–30 on each side

Side Shuffle

Stand with your legs about hip-width apart with an exercise band around your ankles. Take 10 steps to the right, then 10 back to the left. This is one set. The exercise band should remain tight enough to provide resistance throughout the entire movement. Reps: 3–5 sets

Pistol Squat

Stand on your right leg with your left knee raised out in front of you. Slowly lower yourself, balancing on your right leg and allowing your left leg to straighten out in front of you. Try to lower yourself until your quad is just about parallel with the floor, then slowly come back up. Reps: 5–15 per leg

Hip Hike

Stand on your right foot. Start with your pelvis in a neutral position, and then drop the left side so it is several inches below the right side of your pelvic bone. Use your right hip muscle to lift your left side back to its neutral position. Reps: 10–30 on each side

Surgery 

• This is extremely rare and is only considered if all other treatments have failed. It is done arthroscopically (keyhole surgery) and aims to break down any scarring in the tissues and if necessary lengthen the Iliotibial band to reduce the friction at the knee.
• Surgery is often reserved for refractory cases that have failed other avenues of conservative management. However, in the athletic population, return to sport is a common concern, and multiple, long absences from the sport due to trials of various conservative treatment approaches are often not ideal.
• There are differing viewpoints as to when surgical treatment should be implemented. Martens et al. suggest that conservative treatments should be maintained for an average of 9 months before consideration of surgical intervention [rx]. Others have based their decision for surgical intervention on the observation that at 30 degrees flexion, the posterior fibers of the ITB are tighter against the lateral femoral epicondyle than are the more anterior fibers, in which case a surgical release in the posterior fibers is needed to correct the problem [rx, rx].
• Bursectomy has also been explored as a surgical treatment option for ITBS. In a recent study, a single surgeon performed 11 open iliotibial band bursectomies on 11 patients (7 M, 4 W). Each patient presented with persistent (>6 months) symptoms despite conservative treatment, with an average age at onset of 29 (24–41) years [rx]. After a minimum of 20-month followup, all patients were able to return to their preinjury Tegner activity levels, and all reported less pain (11-point visual analogue scale score decreased by 6 points) [18]. Nine of the 11 patients said that knowing what they know now they would have the surgery performed again for the same problem. This population, however, was a mix of athletic and the general population, and the study did not separate out the results of each population.

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