Iliotibial band syndrome is a common source of knee pain. The most common symptom is 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 crosses the hip joint and extends distally to insert on the patella, tibia, and biceps femoris tendon.
Iliotibial Band Syndrome (ITBS) is one of the most common overuse injuries among runners. Iliotibial band syndrome can cause significant morbidity and lead to cessation of exercise. Although iliotibial band syndrome is easily diagnosed clinically, it can be extremely challenging to treat. Most patients respond to conservative treatment involving stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens. Corticosteroid injections should be considered if visible swelling or pain with ambulation persists for more than a few days after initiating treatment. A small percentage of patients are refractory to conservative treatment and may require surgical release of the iliotibial band.
Iliotibial band syndrome occurs frequently in runners or cyclists, and is caused by a combination of overuse and biomechanical factors.In some athletes, repetitive flexion and extension of the knee causes the distal iliotibial band to become irritated and inflamed resulting in diffuse lateral knee pain. Iliotibial band syndrome can cause significant morbidity and lead to cessation of exercise. Although iliotibial band syndrome is easily diagnosed clinically, it can be extremely challenging to treat.
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 femoris tendon. The iliotibial band bursa lies between the iliotibial band and the lateral condyle of the femur.
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.
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 is based on the history and physical examination. If the diagnosis is in doubt or other joint pathology is suspected, MRI can aid in the diagnosis. In patients with iliotibial band syndrome, MRI shows a thickened iliotibial band over the lateral femoral epicondyle and often detects a fluid collection deep to the iliotibial band in the same region.
Patients demonstrate tenderness on palpation of the lateral knee just above the joint line. Tenderness frequently is worse when the patient is in a standing position and the knee is flexed to 30 degrees. At this angle, the iliotibial band slides over the femoral condyle and is at maximal stress, thus reproducing the patient’s symptoms.1,6 Swelling may be noted at the distal iliotibial band and thorough palpation of the affected limb may reveal multiple trigger points in the vastus lateralis, gluteus medius, and biceps femoris. Palpation of these trigger points may cause referred pain to the lateral aspect of the affected knee. Strength of the lower extremity should be assessed with particular emphasis on examining the knee extensors, knee flexors, and hip abductors. Weakness in these muscle groups has been associated with the development of iliotibial band syndrome.
The patient lies down with the unaffected side down and the unaffected hip and knee at a 90-degree angle. If the iliotibial band is tight, the patient will have difficulty adducting the leg beyond the midline and may experience pain at the lateral knee.
Treatment requires activity modification, massage, and 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. Patient should 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.
Ice and anti-inflammatory medications may help in alleviating inflammation. 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.
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. 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.
Iliotibial band injection should be considered in patients who do not respond to conservative management. The injection involves infiltration of local anaesthetic and steroid in the lateral femoral condyle area deep to the iliotibial tract to target the bursa. The injection is usually performed under ultrasound guidance, which allows visualization of surrounding structures.
Pulsed radio frequency treatment may be effective in patients who get short term benefit from injection of local anaesthetic and steroid.
Platelet-rich plasma (PRP) is a concentrate of platelets derived from the patient’s own blood and is known to contain a high content of growth factors that have the potential to enhance the healing process of the tendon. A blood sample is taken and centrifuged to extract the plasma content, and the blood is then re-injected in to the iliotibial band bursa.
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