Iliotibial band syndrome (ITBS) is the result of inflammation and irritation of the distal portion of the iliotibial tendon as it rubs against the lateral femoral condyle, or less commonly, the greater tuberosity. This occurs with repetitive flexion and extension of the knee. Inflammation and irritation of the iliotibial band also may occur because of a lack of flexibility of the ITB, which can result in an increase in tension on the ITB during the stance phase of running.
ITBS is particularly common in runners and cyclists, though it also occurs in weightlifters, skiers and soccer players. Other causes or factors that are believed to predispose an athlete to ITBS include excessive internal tibial rotation, genu varum, and increased pronation of the foot. The incidence is reported to be as high as 12% of all running-related, overuse injuries.
Anatomy: Iliotibial band is considered to be a continuation of the tendinous portion of the tensor fascia lata muscle and is indirectly attached to parts of the gluteus medius, gluteus maximus, and the vastus lateralis muscles. The intermuscular septum connects the ITB to the linea aspera femoris until just proximal to the lateral epicondyle of the femur. Distally, the ITB spans out and inserts on the lateral border of the patella, the lateral patellar retinaculum, and Gerdy's tubercle of the tibia.
Function: The ITB assists the tensor fascia lata as it abducts the thigh or, more precisely, controls and decelerates adduction of the thigh. The ITB may also act as an anterolateral stabilizer of the knee. The ITB moves anterior to the epicondyle as the knee extends and slides posteriorly as the knee flexes, remaining tense in both positions.
History: The main symptom of ITBS is sharp pain or burning on the lateral aspect of the knee or sometimes around the greater trochanter. Runners often note that they start out running pain free but develop symptoms after a reproducible time or distance. Early on, symptoms subside shortly after a run, but return with the next run. If ITBS progresses, pain can persist even during walking, particularly when the patient ascends or descends stairs. The patient also may report an audible, repetitive popping noise in the knee with walking or running.
Physical Examination: The knee examination is typically negative except for local tenderness and, occasionally, swelling over the distal ITB where the band moves over the lateral femoral condyle. No tenderness is noted at the lateral joint line, popliteal tendon, lateral collateral ligament, or anterior lateral fat pad. Occasionally, pain or paresthesia extends along the length of the band. Crepitation, snapping, or mild pitting edema can occur over the affected area. Pain may be elicited by having the patient lie on his or her side with the affected knee up and flexed 90°, and applying pressure to the ITB over the lateral femoral condyle while straightening the knee. The test is positive if pain occurs as the knee approaches 30° of flexion, the position in which the tensed ITB rubs directly over the lateral femoral condyle. Strength testing may reveal knee flexor or extensor weakness or hip abductor weakness.
Differential Diagnosis: The differential diagnosis of ITB syndrome includes – hamstrings strain, medial and lateral collateral ligament injury, meniscal injuries, osteoarthritis, patellofemoral syndrome and trochanteric bursitis, superior tibiofibular joint sprain, popliteal or biceps femoris tendinitis, common peroneal nerve
injury, and referred pain from the lumbar spine.
Management: In the acute phase, rest and ice are used alongwith NSAIDs to counter inflammation. Once the acute phase is over, the following management strategies can be used –
1. Stretching
2. Contract relax
3. Soft-tissue mobilization
4. Massage techniques
5. Trigger point release (as per the results of physical exam)
6. Strengthening specially gluteus medius
Most patients fully recover by 6 weeks. As a general rule, patients can return to running once they can perform all strength exercises without pain.
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