Iliotibial band syndrome is a painful, usually self-limiting cause of knee and hip pain in endurance athletes. It was initially described in 1975 amongst US Marine Corps undergoing rigorous, intensive endurance training, usually a combination of long distance running and cycling1. It is one of the most common causes of knee pain in athletes, particularly cyclists, with an incidence ranging from 15-24%2. Fortunately, the condition usually resolves with stretching and physiotherapy over a six to eight week period2.  Patients generally present with pain to the outside of their knee that is usually present after a training session. As the condition worsens, the pain may also be present at the start of the session, then present at rest. The pain can radiate down the leg to the ankle or even appear as vague ankle pain.

 

The iliotibial band (ITB) is a thick strip of fascia, or an ‘envelope’, that runs down the side of the leg, from the outside of the hip to the outside of the knee. Multiple muscles insert into it, including the gluteus maximus and gluteus medius (or ‘butt muscles’). It is one of the few anatomical structures in the leg that cross both the hip and the knee, which is why it is prone to irritating both joints. The ITB is separated from the knee by a layer of fat that extends underneath the quadriceps muscle. This layer of fat can become irritated with constant rubbing of the ITB over the knee.

 

The function of the ITB varies with different positions of the knee. Between a straight leg and bending the knee to approx 20deg, the ITB acts to extend the leg. Between approx 20deg and a fully bent knee, it acts to flex the knee. This is part of the reason why knee pain is such a common presentation of friction underneath the ITB.  If this band becomes overly tight, usually due to overuse, it can rub on the bony and soft tissue structures around the outside of the knee joint and cause inflammation and subsequent pain.

 

The ITB is a relatively tense structure that has an important role in stabilising the pelvis, especially when the knee is bent. Try it on yourself – when standing, bend forward and feel just the outside of the knee. There is a thick band that tightens up as you straighten the knee. The more weight you put on the knee, the tighter the band. A group of Melbourne-based sports physicians analysed the gait of long distance runners, and found that the ITB was likely to rub on the outside of the knee when the knee was bent approximately 30degrees3.  Therefore, runners that participate in large amounts of hill training, particularly downhill running, are more likely to develop ITB irritation syndrome than runners who train mostly on the flat. A sudden change in terrain or route, such as running on holidays, may exacerbate existing ITB irritation or initiate an episode of symptoms.

In patients with ‘bendy knees’ (varus knees), there is increased stress along the side of the knee, which can increase ITB irritation symptoms4. Even though this condition is more common in males, it is fifteen times more common than ‘knock knees’ (valgus knees) and therefore its prevalence amongst females is still quite high5. In addition, ITB irritation is associated with over-pronation, or rolling in, of the ankle and foot4. Females are more likely to have knock-knees and rolling out of the foot, but over correction of these conditions, such as the use of aggressive orthotics, can contribute to ITB irritation symptoms. Weak hip abductors are also a major cause of ITB irritation syndrome4. This is because the abductor muscles, mainly the ‘butt muscles’ also act to stabilise the pelvis. Without their strong action, the main support of the pelvis is by the ITB, which tightens painfully under the strain. Women generally have weaker abductors than men and are thus slightly more prone to ITB syndrome.

Before making a diagnosis of ITB syndrome, it is important to eliminate other, more sinister, causes of knee pain. A meniscus (or cartilage) tear can present as severe knee pain that may warrant surgical treatment. Stress fractures, early osteoarthritis, patellofemoral joint pain (look out for an article coming up soon) or damage to ligaments may also present as knee pain that need different treatment modalities to ITB syndrome. It is important to be reviewed by an experienced musculoskeletal physiotherapist who will be able to appropriately diagnose and treat the knee pain and refer on to another medical practitioner if necessary. Generally, only a plain x-ray of the knee is required to eliminate osteoarthritis or tumour as a cause of the pain.

Once the diagnosis of ITB syndrome has been made, non-operative treatment is the first line of therapy. A good physiotherapist will be able to identify what is causing the ITB to become tight and rub on the knee. Generally, some degree of rest should be involved to let the soft tissues settle. This also makes it easier for the athlete to identify the cause of the syndrome when they resume activities again – such as running downhill, running on concrete or sudden increase in mileage on the bike.

It has been suggested that lowering the bike seat and raising handlebars may help reduce the symptoms of ITB syndrome in cyclists6. I would recommend seeing an experienced bike-fitting specialist who should work in combination with a physiotherapist to identify deficiencies in the bike set up. These deficiencies can lead to increased pressure for the athlete to stabilise their pelvis on the bike and thus over-utilising their ITB. In combination with a review of the athlete’s bike set-up, an intensive stretching and rehabilitation program should be undertaken. ‘Ironing out’ the ITB using a foam roller can be painful, but very useful in stretching it. Importantly, strengthening of the ‘butt muscles’ is vital to restabilise the pelvis and re-train the athlete into using these muscles when running and cycling. This can be done in combination with other stretches and re-education about running technique incorporating a stronger drive from the buttock.

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As discussed in my previous article, non-steroidal anti-inflammatories (NSAID’s) such as neurofen or voltaren can be useful in settling the immediate acute inflammatory response. However, they should be use sparingly and the athlete needs to be mindful of side effects. Gastrointestinal disruption during training is an unfortunate side effect of NSAID use and can make a course of treatment intolerable. There is some evidence to suggest that steroid injections directly into the site of irritation can be useful4, but this should be done only after an intensive rehabilitation program has been undertake.

Only an athlete that has failed non-operative treatment for a period greater than six months is referred to an orthopaedic surgeon. Unfortunately, the operations available for ITB syndrome are limited and have poor results. Because operative intervention is so rare, there is limited information on the long-term follow up of these procedures7. Described operations include an open surgical release where an incision is made over the knee and the band is partially cut to lengthen it out. This procedure can also be done with small cameras. The soft tissue underneath the band that is irritated can be removed with varying results8. A recent innovation is the use of small arthroscopic cameras to remove ‘synovial folds’ or soft tissue folds on the outside of the knee joint9. This has had good results in a very small series of patients, and needs further long-term assessment to prove its efficacy.

ITB irritation syndrome is usually self limiting, provided the athlete follows a stretching and rehabilitation program. There are minimal long-term consequences of the condition and athletes only rarely require surgical intervention. Minor adjustments in running technique or riding position can result in significant ability for the athlete to tolerate greater training loads.

 

References

  1. Renne JW: The iliotibial band friction syndrome. J Bone Joint Surg Am 1975; 57(8):1110-1111.
  2. Lavine R: Iliotibial band friction syndrome. Curr Rev Musculoskelet Med 2010;3(1-4):18-22
  3. Orchard JW, Fricker PA, Abud AT,Mason BR: Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med 1996;24(3):375-379.
  4. Eric J. Strauss, Suezie Kim, Jacob G. Calcei, and Daniel Park. Iliotibial Band Syndrome: Evaluation and Management. J Am Acad Orthop Surg December 2011 ; 19:728-736.
  5. R.W. Parkinson and V.Bhalaik. The valgus and varus knee. Current Orthopaedics (2001) 15, 413
  6. Tony Wanich, MD, Christopher Hodgkins, MD, Jean-Allain Columbier, MD, Erika Muraski, MSPT, MBA, John G. Kennedy, MD. Cycling Injuries of the Lower Extremity. J Am Acad Orthop Surg 2007;15:748-756
  7. Michels F, Jambou S, Allard M, Bousquet V, Colombet P, de Lavigne C: An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc 2009;17(3): 233-236.
  8. Fredericson M, Wolf C: Iliotibial band syndrome in runners: Innovations in treatment. Sports Med 2005;35(5):451-459.
  9. Michels F, Jambou S, Allard M, Bousquet V, Colombet P, de Lavigne C: An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc 2009;17(3): 233-236.

About The Author

Stef Hanson. Chief.

Chief and founder of WITSUP

Serious about what I do, but don’t take myself too seriously

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