Iliotibial Band Friction Syndrome Treatment & Management


Background

Iliotibial band (ITB) friction syndrome (ITBFS) is a common cause of lateral knee pain, particularly among runners, military personnel, and cyclists. [12Biomechanical and training factors play a large role in the development of ITBFS, but its exact etiology is somewhat elusive. [34]

With the increasing understanding of human biokinetics, health professionals are able to spot flaws in training, environment, and biomechanics quickly and avert significant disability with ITBFS. Biomechanical screenings can be used to identify predisposing factors and correct them before symptoms ever develop. Aggressive intervention, particularly with athletes and industrial workers, can resolve the problem before it becomes disabling.

Conservative therapy is successful in most persons with ITBFS. When conservative therapy does not resolve the pain, surgery may be indicated. Conservative therapy should be employed for 3 months before surgery, but most patients for whom surgery is necessary have had symptoms for more than 9 months.

Surgery is rarely indicated. When surgical treatment is called for, the most common procedure for ITBFS is resection of the posterior portion of the ITB and, if desired, the adventitial bursa deep to the band. Surgery is performed with the knee held in 30° of flexion and consists of a limited resection of a small triangular or elliptical piece of the posterior part of the ITB covering the lateral femoral epicondyle. The bursa may be removed in certain cases as well. Arthroscopic techniques are being employed more frequently.

For patient education resources, see the Osteoporosis Center, as well as Knee Pain and Knee Injury.

Anatomy

The ITB originates from the outer lip of the anterior iliac crest, the anterior border of the ilium, and the outer surface of the anterior superior iliac spine. The tensor fasciae latae (TFL) originates here also, and its fascia blends with the ITB at the lateroanterior thigh one third of the way distally. (See the image below.)

Lateral hip stabilizers. Lateral hip stabilizers.

The intermuscular septum connects the ITB to the linea aspera femoris until inserting just proximal to the lateral femoral condyle. From there, it passes in its broad expansion between the lateral aspect of patella and the biceps femoris to insert into the Gerdy tubercle, off the lateral tibial plateau. This expanse helps the lateral collateral ligament and posterolateral capsule to stabilize the knee.

The primary synergistic muscles are the hip abductors. These muscles are the gluteus medius, the gluteus minimus, and the upper fibers of the gluteus maximus. Their nerve supply comes from the superior gluteal nerve, which is a branch off of the L4, L5, and S1 nerve roots. [5]

Pathophysiology

ITBFS typically is observed in people who exercise vigorously. The overuse creates stress that the body cannot repair, and soft-tissue breakdown occurs. [6When the knee flexes, the ITB moves posteriorly along the lateral femoral epicondyle. Contact against the condyle is highest between 20° and 30° (average, 21°); thus, when the band is excessively tight or stressed, the ITB rubs more vigorously.

A small recess is formed between the lateral femoral epicondyle and the ITB as it travels along the lateral thigh to the tibial plateau. This space was believed to have a separate bursa lying deep to the band, but studies revealed it to be synovium that is a lateral extension and invagination of the actual knee joint capsule (lateral synovial recess [LSR]). The LSR lies underneath the ITB and acts as an interface between the ITB and the lateral femoral epicondyle.

Histologic analysis demonstrates inflammation and hyperplasia in the synovium, whereas magnetic resonance imaging (MRI) studies have demonstrated diffuse signal abnormality below the band and in the synovium but not in the ITB. This suggests that this syndrome is not a tendinopathy. Variance is observed in the congenital thickness of the band; patients with thicker bands may be predisposed to ITBFS.

In runners, friction occurs near or just after foot strike during the contact phase of the gait cycle. Downhill running reduces the knee flexion angle and can aggravate ITBFS, whereas sprinting and fast running increase the knee flexion angle and are less likely to cause the syndrome. [278910The friction point at the lateral epicondyle prominence is illustrated in the image below.

Illustration of the friction point at the lateral Illustration of the friction point at the lateral epicondyle prominence. Note the shift in position of the iliotibial band from anterior to posterior as the knee moves into flexion, drawing the iliotibial band across the prominence.

Etiology

The etiology of ITBFS is multifactorial. Many causative factors have been postulated, few with overwhelming evidence supporting them.

ITBFS usually is caused by overuse, which is mostly due to errors in training. Single-session errors cause ITBFS as often as repetitive deficiencies. Sudden changes in surface (ie, from soft to hard or from flat to uneven or a decline), speed, distance, shoes, and frequency can break down the body faster than it can heal, causing injury. Other factors frequently reported are the following:

  • Limb-length discrepancy
  • Genu varum
  • Overpronation
  • Hip abductor weakness
  • Myofascial restriction

Studies examining limb-length discrepancies provide conflicting conclusions regarding whether a direct correlation exists. Limb-length inequalities cause changes in hip abduction during the gait cycle, sacral leveling, and pelvic tilt, which is believed to increase tension on the ITB and the TFL. However, other studies did not find a direct correlation between limb-length inequality and ITBFS. Still, the postulate merits consideration in examination of the hip and pelvis. [1112]

However, most limb-length discrepancies are not actual anatomic variations but physiologic changes related to malalignment of the pelvis. For example, a superior shear of the left or right innominate (ilium) in relation to the sacrum would cause the leg on the ipsilateral side to migrate in the superior direction as well, thus creating a shorter leg in comparison to the right. Attempts to correct this difference with a heel lift would only reinforce the dysfunction in the pelvis.

Genu varum is considered a risk factor because of increased tension on the ITB as it is stretched more over the lateral femoral epicondyle. This concept is widely accepted, though with little empiric support.

Overpronation is controversial as well. In the running cycle, the lower limb strikes the ground with a rigid supinated foot. As the leg moves forward, the tibia internally rotates over the planted foot, "unlocking" it into a pronated-everted position, which allows for weightbearing. Pronation and internal rotation stress the ITB. Excessive pronation causes quicker tibial internal rotation and increased hip adduction, stressing the ITB over the lateral femoral condyle.

James implicated a combination of genu varum, heel varus, forefoot supination, and compensatory pronation with ITBFS, but further videography studies led to dispute of that claim. Most studies support overpronation as a potential cause. [8]

Hip abductor weakness is an important factor as well. [1314When the foot strikes the ground, the femur adducts against the eccentric load of the abductors (gluteus medius and TFL). These muscles move from eccentric to concentric through the support phase and into the propulsive phase of gait. The gluteus medius also externally rotates the hip, while the tensor fasciae latae internally rotates.

When the hip abductors are weakened or fatigued, runners have increased adduction and internal rotation at midstance. This generates more valgus force at the knee, which Fredericson postulates as increasing tension and friction on the ITB. [1315Hip abductor weakness is often seen with core instability or malalignment and greater trochanteric bursitis. [16]

Myofascial restrictions and inflexibility can increase stress in the posterior ITB, particularly with the TFL. Tightness in the hip flexors (iliopsoas), extensors (gluteal muscles), and rotators (particularly piriformis) can shift more load to the abductors and adductors. Weaker hip abductors eventually fail under continuous stress.

In rare cases, ITBFS can be related to surgical changes to the knee from other pathology, such as anterior cruciate ligament tears. [17]

Epidemiology

The overall incidence of ITBFS in the general population is not well reported. Depending on which population is examined, the incidence is in the range of 1.6-52%. It varies with the target population's type and intensity of activity. For instance, Linenger et al reported that in 12 weeks of Marine basic training, ITBFS was the most common specific injury and accounted for 22.2% of all lower-extremity injuries. [18Runners experience 12% of all running-related overuse injuries from ITBFS.

Prognosis

Most patients with ITBFS recover with conservative therapy and enjoy good prognoses. One study in 1992 documented 19 athletes with ITBFS, all of whom were treated successfully without surgery. Those for whom surgery is eventually performed are patients who are motivated to return to a specific activity in which ITBFS limits or prohibits their participation.

Those who require surgery often do well. Surgical release of the ITB is typically successful in eliminating pain. Athletes are able to return to their normal activities with a rehabilitation program in 3-7 weeks. Nemeth et al described 17 cases of ITBFS recalcitrant to conservative therapy, of whom 11 had excellent results from surgical treatment at 2-year follow-up. [19Firer reported 94% excellent or good results in 64 runners surgically treated after failure of conservative therapy. 


History

Pain is localized along the lateral knee, but it also can include the hip. The pain is worse with downhill running and becomes worse with activity after a pain-free start. It may radiate from the knee proximally or distally. Most individuals experience pain only during activities; however, individuals may experience pain with walking as the syndrome progresses.

Physical Examination

Tenderness is over the lateral knee, with a tender point at the lateral femoral condyle, approximately 1-2 cm proximal to the lateral joint line. Pain can be elicited with active flexion-extension of the knee within the first 30° while the thumb presses over the epicondyle and the iliotibial band (ITB). Crepitation may be felt.

Restriction in hip adduction indicates tightness in the ITB and the tensor fasciae latae (TFL). In evaluating for ITB friction syndrome (ITBFS), also look for restrictions in iliopsoas, rectus femoris, gastrocnemius, and soleus function. Examination usually reveals restriction of hip adduction and weakness of the hip abductors, specifically the gluteus medius.

Myofascial restrictions can mimic ITBFS, and these restrictions can be identified with a careful examination. Trigger points along the vastus lateralis, biceps femoris, and gluteus minimus can refer pain to the lateral knee; fascial adhesions of the posterior ITB can generate pain as well. Careful palpation of these points can differentiate ITBFS from myofascial trigger points.

The following provocative tests may be helpful:

  • Ober test
  • Noble test
  • Renee (creak) test
  • Thomas test

The Ober test is performed with patient lying on the unaffected side with that hip flexed enough to straighten the lumbar lordosis. The down leg is flexed 90° at the knee, while the operator's hands stabilize the greater trochanter and hold up the ankle. The thigh is abducted passively and extended to catch the ITB over the greater trochanter. The thigh is then adducted passively. If the thigh remains suspended off the table, this indicates a shortened ITB. (See the image below.)

Iliotibial band noted prominently along the lateraIliotibial band noted prominently along the lateral thigh.

For the Noble test, place the patient supine with the knee at approximately 90° flexion and apply firm digital pressure on or around the lateral femoral epicondyle while passively extending the knee. A positive result is pain elicited at approximately 30° of flexion over the lateral femoral epicondyle, similar to what occurs when the patient is active.

In the Renee test, patients are placed on a step stool and directed to support all of their weight on the affected leg. The operator's thumb is placed over the lateral femoral condyle, and pressure is applied while the patient bends the knee into 30-40° of flexion. Here, the posterior fibers of the ITB are directly over the lateral epicondyle (see the image below). Reproduction of pain with pressure is considered a positive test result for ITBFS. 

Iliotibial band at the lateral femoral epicondyle,Iliotibial band at the lateral femoral epicondyle, with the posterior fibers denoted.

Some literature lists the creak test separately; this is the same as the Renee test, except that the operator's thumb is not placed on the patient. Pain when the patient bends the knee 30° is considered a positive test result.

In the Thomas test, the patient sits on the end of the table and then rolls back into a supine position, holding both knees to the chest but not so that the pelvis has excessive posterior tilt (see the image below). This flattens the lumbar spine. The patient holds the leg of the asymptomatic hip and slowly lowers the other to the floor. The test result is considered positive if the patient cannot achieve 90° of knee flexion, a neutral angle of the hip (if the hip hovers above the table), or 15° of hip abduction relative to the pelvis. This test is used to evaluate the iliopsoas, the rectus femoris, and the TFL or ITB.

The Thomas test can be used to evaluate restrictioThe Thomas test can be used to evaluate restriction in the iliotibial band, hip flexors, and rectus femoris.

Laboratory Studies

Basic preoperative laboratory tests are indicated, including the following:

  • Complete blood count (CBC)
  • Electrolytes
  • Blood urea nitrogen (BUN)
  • Creatinine level
  • Liver function tests (LFTs)

Imaging Studies

In patients with iliotibial band (ITB) friction syndrome (ITBFS), a complete history and physical examination should provide enough information that imaging beyond radiography is typically not necessary. If the diagnosis is unclear or conservative treatment fails, then magnetic resonance imaging (MRI) and ultrasonography (US) should be considered.

Radiography

This study is used to rule out fractures, osteophytes, or osteochondrotic lesions. Alignment and soft-tissue swelling may be evaluated also. Radiographic findings usually are unremarkable in ITBFS.

Magnetic resonance imaging

MRI [212223 can be an effective means of excluding other pathology (eg, lateral meniscus tear, lateral collateral ligament sprain, patellofemoral subluxation, chondromalacia patellae, biceps or popliteus tendinitis, meniscal cysts, and osteochondritis dissecans). It can reveal diffuse signal deep to the ITB in the recess just proximal to the lateral femoral condyle. Reactive signal in the periosteum of the condyle and thickening of the ITB can be observed as well, but no pathology typically is observed in the knee joint.

The stage of development of ITBFS may impact the findings seen on MRI. Acute cases may have an ill-defined signal abnormality beneath the ITB; progression of the syndrome can be associated with increasing signal changes superficial to the ITB, whereas the chronic stage can be associated with bursal fluid and ITB thickening.

Ultrasonography

US is useful in evaluating cystic masses and fluid in the lateral synovial recess (LSR). It is effective in revealing the dynamic motion of the ITB through knee flexion and extension, thus allowing visualization of the impingement.

Procedures

Lidocaine can be injected for diagnostic purposes if a localized source of pain is suspected.

Histologic Findings

Tissue from the LSR demonstrates hyperplasia and inflammation. ITB tissue may exhibit tendinosis.



Approach Considerations

Conservative therapy for iliotibial band (ITB) friction syndrome (ITBFS) includes the following:

  • Rest
  • Stretching and strengthening exercises
  • Anti-inflammatory medication
  • Other therapeutic modalities
  • Biomechanical correction of limb-length discrepancies and pes planus

Failure of conservative therapy is an indication for surgery. Conservative therapy should be tried for a minimum of 3 months, and all other factors related to ITBFS should be thoroughly addressed before surgery is considered. Even then, surgery is best limited to highly motivated people who want to return to their sport or activity.

Active infection and coagulopathy are contraindications for surgery.

Medical Therapy

The basic principles of treatment include control of inflammation, modification of activity, and correction of underlying problems. [15An aggressive treatment program is as follows.

Acute phase

Medical therapy consists of nonsteroidal anti-inflammatory drugs (NSAIDs) with adjunctive physical therapy. These drugs reduce the inflammation in the soft tissue. Analgesics, such as acetaminophen or codeine preparations, can be used in persons with functional disability. Injection of corticosteroid can be used when conservative attempts to control inflammation fail or swelling persists for more than 3 days.

Activity modification should be considered. Examine recent changes in training, such as duration and intensity of exercise. Curtail activity to a level at which pain is not generated.

Ice may be applied to the region of inflammation near the lateral femoral condyle, but for no longer than 15 minutes. Ice compresses or cold packs can be used for 20 minutes.

Use hydrocortisone or a similar topical steroid preparation with ultrasound (phonophoresis) or electrical stimulation (iontophoresis) for control of inflammation.

Subacute phase

Begin stretching exercises after inflammation subsides. Restoration of proper range of motion (ROM) in the hip flexors (iliopsoas, quadriceps), hip extensors (gluteus maximus, hamstrings), hip abductors (gluteus medius, tensor fasciae latae [TFL]), and, most important, hip adductors is crucial for restoring overall hip function.

Myofascial therapy should focus on treating trigger points and loosening restrictions along the ITB. Target areas include over the lateral femoral condyle and greater trochanter.

Manipulative therapy can be effective in treating areas of restriction and repairing the biomechanical flaws that led to ITBFS. Muscle energy techniques can be safely applied to the TFL, hip flexors, and piriformis to restore ROM in hip adduction, extension, and internal rotation. Attention should be paid to lumbosacroiliac mechanics to ensure resolution of any dysfunction there. Anterior or posterior rotational innominate (iliac) dysfunctions affect the origin of the TFL and can delay recovery if left untreated.

Other specific areas to address with manipulation include the T12-L1 vertebral segments (origin of the iliopsoas) and the fibular head (partial insertion point of the ITB). In fact, fibular head dysfunction (either anterior or posterior rotation) not only can contribute to ITBFS but can mimic it as well.

Recovery phase

Progressive strengthening exercises are started to restore muscle strength lost from inhibition and disuse. Exercises include side-lying leg lifts, pelvic drops, and step-down exercises.

Return to running

The angle of the knee during faster-paced running is beyond the friction point of ITBFS. The patient should start with easy sprints on even surfaces, no more than every other day at first, and then may gradually increase distance and frequency according to tolerance. Time to return to sports depends on the initial severity. Patients who return must first perform all strength exercises and stretches without pain. Most people return to their sport or running within 4-6 weeks.

Surgical Therapy

The typical surgical treatment is an open procedure used to resect a small triangular portion of the posterior ITB over the lateral femoral epicondyle. Studies demonstrated positive results with the knee flexed at 30° during the procedure. [242526]

A resection of the underlying synovial tissue can also be performed, but some question exists as to whether it should be resected. Resection can cause chronic synovial fluid effusion in the recess and hematoma formation.

However, arthroscopic procedures are becoming more commonly used in ITBFS, specifically for resecting tissue in the lateral synovial recess and separating the band from the lateral condyle. [272829Arthroscopy limits the amount of bleeding, and the incidence of hematoma formation can be reduced.

The procedure requires no special equipment other than what is common and appropriate for knee arthroscopy. The patient can be positioned with the operative leg in a leg holder hanging off the end of the bed, or using a lateral post while supported by the bed. Resection of the synovial tissue in the lateral recess and gutter is typically accomplished with a shaver blade. (See the image below.)

Resection of lateral synovial fold through arthrosResection of lateral synovial fold through arthroscopic knee procedure. Courtesy of Elsevier, Inc (Cowden CH 3rd, Barber FA. Arthroscopic treatment of iliotibial band syndrome. Arthrosc Tech. Feb 2014;3(1):e57-60).

Surgical correction of anatomic variants leading to ITBFS, such as severe genu valgum, must be considered carefully and with the entire well-being of the patient in mind. [30]

Inoue et al described a minimally invasive approach to ITBFS that involved lengthening the central part of the ITB by splitting it into a superficial and a deep layer and maintaining the anterior and posterior fibers immediately above the lateral epicondyle. [31 They found that this procedure removed the cause of ITBFS and was associated with a reduction in inflammation. Patients were able to return to competition within 6 weeks without any degradation of performance.

Operative details

The patient is restricted to taking nothing by mouth at least 8 hours before the procedure. If an ITB resection is being performed through an arthroscopic procedure, the patient is prepared for surgery similar to that for any such procedure. Otherwise, a tourniquet is applied to provide adequate hemostasis. Anesthesia can be achieved by general or epidural administration. The affected leg is positioned so that the lateral femoral condylar region is exposed.

With the knee in 30° of flexion, a longitudinal incision is made centered over the lateral epicondyle. The posterior portion of the ITB is then exposed. The knee is flexed and extended to identify the portion of the ITB that is impinging on the lateral epicondyle. A triangular piece of the ITB is then resected. The base of the triangle is approximately 2 cm and centered over the posterior fibers of the ITB. The height of the triangle is roughly 1.5 cm.

To confirm adequate release of the ITB, the knee is then moved through the full ROM. The wound is then irrigated and closed.

Excision of an elliptical section of the ITB also has been described.

Postoperative Care

Some controversy exists regarding postoperative immobilization. Martens et al [32advocated splinting the knee in extension for 1 week postoperatively, followed by a gradual return to activity. In a study by Holmes et al, [33a soft dressing was applied and bicycling was allowed on postoperative day 3. In this study, nine of 21 patients developed a small seroma near the lateral incision, which subsequently resolved with rest and icing.

Complications

Potential complications include the following:

  • Recurrent swelling in the lateral synovial recess (LSR)
  • Persistent bleeding
  • Bisection of the ITB
  • Infection
  • Seroma
  • Recurrent pain
  • Impingement


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