Sports Medicine
Sports Injury Prevention & Rehabilitation

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Iliotibial Band Syndrome

(Also known as ITB Syndrome, Iliotibial Band Friction Syndrome, Iliotibial Syndrome, ITBFS, Runner's Knee)
What is Iliotibial band syndrome?
Iliotibial band syndrome is a condition that commonly presents in runners and typically causes pain at the outer aspect of the knee where the iliotibial band (ITB) crosses the knee joint. Iliotibial band syndrome describes a condition whereby the iliotibial band rubs against a bony prominence at the outer aspect of the knee and typically causes inflammation and damage to local tissue.
The iliotibial band is a long band of connective tissue than runs down the outer aspect of the thigh. It originates from two muscles on the outer aspect of the hip (the tensor fascia latae (TFL) and gluteus maximus) and runs down past the knee to attach into the lower leg bone (tibia). As the ITB crosses the knee, it overlies a bony prominence known as the femoral epicondyle. As the knee bends and straightens the ITB flicks over this bony prominence which places friction on the ITB and local soft tissue. If this friction becomes excessive or too repetitive (such as during excessive running) the ITB or local tissue can become damaged or inflamed resulting in pain. When this occurs the condition is known as Iliotibial band syndrome.

Signs and symptoms of Iliotibial band syndrome
Patients with iliotibial band syndrome usually experience pain at the outer aspect of the knee. Patients usually experience an ache that may increase to a sharper pain with activity. Pain is typically experienced during activities that bend or straighten the knee particularly whilst weight bearing. Pain may be worse first thing in the morning or following activity (once the body has cooled down). This may be associated with knee stiffness and can sometimes cause the patient to limp.
Activities that frequently aggravate symptoms include running (particularly longer runs, downhill running or running on cambered surfaces), walking (particularly up and down stairs or hills), squatting, or jumping. Patients with iliotibial band syndrome typically experience pain when firmly touching the outer aspect of the knee (femoral epicondyle). In more severe cases, swelling may be present at the outer aspect of the knee along with an associated grinding sound when bending or straightening the knee. Occasionally, patients may also experience episodes of the knee giving way or collapsing due to pain.

Diagnosis of Iliotibial band syndrome
A thorough subjective and objective examination from a therapist is usually sufficient to diagnose Iliotibial band syndrome. Investigations such as an ultrasound or MRI may be used to assist with diagnosis.

Treatment for Iliotibial band syndrome
Most cases of Iliotibial band syndrome settle well with appropriate therapy. This requires careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition, with subsequent correction of these factors.
  • The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free. Activities which place large amounts of stress through the ITB should be minimized, these include: running, squatting, jumping, and going up and down stairs. Exercising into pain must also be avoided. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
  • Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with this condition is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times.
  • Patients with Iliotibial band syndrome will usually benefit from following RICE. RICE is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This involves resting from aggravating activities, regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
  • Patients with this condition should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. One of the key components of rehabilitation is pain-free stretching of the ITB along with pain-free strengthening of the vastus medialis obliquus muscle (VMO). This is often in combination with core stability, pelvic and gluteal strengthening exercises to improve the control of the knee with weight-bearing activities. The treating therapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Contributing factors to the development of Iliotibial band syndrome
There are several factors which can predispose patients to developing Iliotibial band syndrome. These need to be assessed and corrected with direction from a therapist. Some of these factors include:
  • excessively tight ITB
  • muscle tightness (particularly TFL, gluteus maximus, or vastus lateralis)
  • excessive or inappropriate training or activity
  • abnormal biomechanics
  • excessive pronation (i.e. flat feet)
  • poor pelvic or core stability
  • muscle strength imbalances
  • muscle weakness (especially the VMO and gluteal muscles)
  • tightness in specific joints (hip, knee or ankle)
  • inappropriate footwear or surfaces
  • poor running technique

Therapy for Iliotibial band syndrome
Therapy treatment for Iliotibial band syndrome is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
  • soft tissue massage (particularly to the ITB)
  • mobilization
  • dry needling
  • electrotherapy (e.g. ultrasound)
  • ice or heat treatment
  • progressive exercises to improve flexibility, strength and balance
  • activity modification advice
  • biomechanical correction
  • anti-inflammatory advice
  • clinical Pilates and core stability exercises
  • footwear advice

Other intervention for Iliotibial band syndrome

Despite appropriate therapy management, some patients with Iliotibial band syndrome do not improve. When this occurs the treating therapist or doctor can advise on the best course of management. This may include further investigations such as an ultrasound or MRI scan, pharmaceutical intervention, a corticosteroid injection, or a referral to an orthopaedic specialist who will advise on any procedures that may be appropriate to improve the condition. Surgery to release the ITB may sometimes be considered in severe cases where patients have failed to improve through conservative means. A review with a podiatrist may also be indicated for the prescription of orthotics to correct any foot posture abnormalities.