What is it?
Iliotibial band (ITB) syndrome is described as an irritation of the tissues near the distal attachment of the iliotibial band at the outside of the knee. This overuse syndrome is particularly common in runners and cyclists.
The best explanation for ITB syndrome is the compression of a highly innervated fat pad between the iliotibial band and the epicondyle on the outside of the knee that is compressed when the band is tight.
ITB syndrome is common in populations exposed to knee flexion and extension, especially while in a single leg stance. This problem is most often found in runners, where it compromises almost ¼ of all lower extremity injuries. ITB syndrome affects up to 12% of all runners. The condition is also frequently seen in cycling, weight lifting, skiing, soccer, and basketball.
Risk factors for the development of ITB syndrome include TFL hypertonicity, high mileage running, running on a circular track, and weakness of the knee extensors, flexors, or hip abductors. Weak or fatigued hip abductors allow for excessive adduction of the thigh and internal rotation of the knee during the stance phase of walking. This leads to compressive irritation to the tissues under the ITB with increased tension.
Clinical Presentation
The typical presentation for ITB syndrome is a runner or cyclist complaining of “sharp” or “burning” pain just superior to the lateral joint line of the knee. Pain may radiate slightly proximally or distally. Less severe presentations may report pain only during activity, but as the condition worsens, symptoms become more persistent. Clinicians will palpate over the lateral femoral epicondyle and it will reveal tenderness.
Diagnosis
Plain film imaging is generally not required or beneficial for the diagnosis of iliotibial band syndrome. MRI may be useful to rule out alternate diagnoses, or in patients who do not respond to a trial of conservative care.
Management
Conservative care has been shown to help ITB syndrome patients. Forty-four percent of patients treated conservatively report complete resolution at two months and 92% report resolution at six months. Conservative management includes modalities, activity modification, stretching and hip abductor strengthening.
Incorporating deep tissue massage or myofascial release prior to stretching may enhance flexibility gains. The use of foam rollers may help promote recovery. Dry needling may improve outcomes as well. IASTM over the iliotibial band, particularly the distal component, may provide additional benefits. Identification and resolution of joint restrictions is appropriate for the lumbar, sacroiliac, and lower extremity.
Perhaps the single most important aspect of treatment includes strengthening the hip abductors and external rotators. The vast majority of patients who incorporate hip abductor strengthening into their ITB rehab will experience symptom resolution within six weeks.
Activity modification may require lower duration of exercise rather than pace. Runners should minimize downhill running and avoid running on a banked surface like an indoor track. Running on a small circular track causes the inner leg’s ITB to work harder to prevent it from swinging medially. Athletes should avoid running on wet or icy surfaces as this requires more muscle activation for stabilization. Athletes should also consider new training shoes, particularly if the current shoes have in excess of 300 miles or show signs of wear on the lateral heel.
Treatment of recalcitrant cases may include corticosteroid injections, which have demonstrated benefit in treating ITB syndrome. Surgical consultation may be considered for refractory patients who fail more than six months of conservative care.