Iliotibial Band Syndrome
Knee conditions normally involve disease or injury that can disturb the normal functioning of the joint. This can result in knee pain, weakness, instability, and limited movement. With longer life expectancy and greater activity levels, joint replacement is being performed in greater numbers on patients thanks to new advances in artificial joint technology provided by the orthopedic surgeons at Peninsula Bone & Joint Clinic.
This joint is formed by two or more bones that are connected by thick bands of tissue called ligaments.
The knee is the largest joint in the body and is made up of three main parts:
- The lower end of the thigh bone, or femur.
- The upper end of the shin bone, or tibia.
- The kneecap, or patella.
At some time in life, you may experience knee pain. Iliotibial band syndrome is a common knee injury that usually presents as lateral knee pain caused by inflammation of the distal portion of the iliotibial band; occasionally, however, the iliotibial band becomes inflamed at its proximal origin and causes referred hip pain.
The iliotibial band is a thick band of fascia that is formed proximally by the confluence of fascia from hip flexors, extensors, and abductors. The band originates at the lateral iliac crest and extends distally to the patella, tibia, and biceps femurs tendon.
Iliotibial band syndrome occurs frequently in runners or cyclists, and is caused by a combination of overuse and biomechanical factors. The syndrome can cause significant morbidity; however, most patients respond to a conservative treatment approach that involves stretching and altering training regimens.
Cause
Iliotibial band syndrome is caused by excessive friction of the distal iliotibial band as it slides over the lateral femoral epicondyle during repetitive flexion and extension of the knee resulting in friction and potential irritation.
In patients with iliotibial band syndrome, magnetic resonance imaging (MRI) studies have shown that the distal iliotibial band becomes thickened and that the potential space deep to the iliotibial band over the femoral epicondyle becomes inflamed and filled with fluid.
Despite a clear pathophysiology, it is unclear why this syndrome does not affect all athletes. Few studies have shown any direct relationship between biomechanical factors and the development of iliotibial band syndrome.
Excessive pronation causing tibial internal rotation and increased stress in the iliotibial band was believed to be a factor in the development of iliotibial band syndrome; however, the literature does not support this theory.
Some observational studies have identified potential risk factors for the development of iliotibial band syndrome, including the following: preexisting iliotibial band tightness; high weekly mileage; time spent walking or running on a track; interval training; and muscular weakness of knee extensors, knee flexors, and hip abductors.
Hip abductor weakness seems to contribute to the development of iliotibial band syndrome. Strengthening of the hip abductors has led to symptom improvement.
Symptoms
The primary initial complaint in patients with iliotibial band syndrome is diffuse pain over the lateral aspect of the knee.
These patients frequently are unable to indicate one specific area of tenderness, but tend to use the palm of the hand to indicate pain over the entire lateral aspect of the knee. With time and continued activity, the initial lateral achiness progresses into a more painful, sharp, and localized discomfort over the lateral femoral epicondyle and/or the lateral tibial tubercle.
Typically, the pain begins after the completion of a run or several minutes into a run; however, as the iliotibial band becomes increasingly irritated, the symptoms typically begin earlier in an exercise session and can even occur when the person is at rest.
Patients often note that the pain is aggravated while running down hills, lengthening their stride, or sitting for long periods of time with the knee in the flexed position.
Diagnosis
Physical Examination & Patient History
During your first visit, your doctor will talk to you about your symptoms and medical history. During the physical examination, your doctor will check all the structures of your injury, and compare them to your non-injured anatomy. Most injuries can be diagnosed with a thorough physical examination.
Imaging Tests
Imaging Tests Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they will not show any injury, x-rays can show whether the injury is associated with a broken bone.
Magnetic resonance imaging (MRI) scan. If your injury requires an MRI, this study is utilized to create a better image of soft tissues injuries. However, an MRI may not be required for your particular injury circumstance and will be ordered based on a thorough examination by your Peninsula Bone & Joint Clinic Orthopedic physician.
Treatment Options
Non-Surgical
Treatment requires:
- activity modification
- massage
- stretching and strengthening of the affected limb
The goal is to minimize the friction of the iliotibial band as it slides over the femoral condyle.
The patient may be referred to a physical therapist who is trained in treating iliotibial band syndrome.
Most runners with low mileage respond to a regimen of anti-inflammatory medicines and stretching; however, competitive or high-mileage runners may need a more comprehensive treatment program.
The initial goal of treatment should be to alleviate inflammation by using ice and anti-inflammatory medications.
Patient education and activity modification are crucial to successful treatment.
Any activity that requires repeated knee flexion and extension is prohibited.
During treatment, the patient may swim to maintain cardiovascular fitness. If visible swelling or pain with ambulation persists for more than three days after initiating treatment, a local corticosteroid injection should be considered.
Corticosteroid injection for iliotibial band syndrome. Gerdy’s tubercle and the femoral condyle are marked as landmarks. With the patient in a supine or side-lying position, the needle is inserted at the point of maximum tenderness over the femoral condyle.
As the acute inflammation diminishes, the patient should begin a stretching regimen that focuses on the iliotibial band as well as the hip flexors and plantar flexors. The common iliotibial band stretches have been evaluated for their effectiveness in stretching the band. Although this study demonstrates the effectiveness of stretching the iliotibial band, participants in the study did not have iliotibial band syndrome and studies have not demonstrated that stretching hastens recovery from the syndrome.
Stretches of the right iliotibial band.
Once the patient can perform stretching without pain, a strengthening program should be initiated. Strength training should be an integral part of any runner’s regimen; however, for patients with iliotibial band syndrome particular emphasis needs to be placed on the gluteus medius muscle.
Running should be resumed only after the patient is able to perform all of the strength exercises without pain. The return to running should be gradual, starting at an easy pace on a level surface. If the patient is able to tolerate this type of running without pain, mileage can be increased slowly. For the first week, patients should run only every other day, starting with easy sprints on a level surface. Most patients improve within three to six weeks if they are compliant with their stretching and activity limitations.
Surgical
For patients who do not respond to conservative treatment, surgery should be considered. The most common approach is to release the posterior 2 cm of the iliotibial band where it passes over the lateral epicondyle of the femur.
Conservative Treatment Options
Treatment Highlights
