summary Iliotibial band friction syndrome is a condition characterized by excessive friction between the iliotibial band and the lateral femoral condyle and presents with activity related lateral knee pain. Diagnosis is made clinically with tightness of the IT band (Ober's test) with tenderness over the lateral femoral condyle made worse with a single leg squat. Treatment is nonoperative with rest, NSAIDs and stretching of the iliotibial band, quadriceps and gluteal muscles. Rarely, surgical release of the IT band is indicated in chronic and refractory cases. Epidemiology Incidence comprises 2-15% of all overuse injuries of the knee region Demographics most commonly in runners, cyclists and other athletes undergoing exercises with repetitive knee flexion and extension Risk factors training errors sudden change in training intensity poor shoe support anatomical factors genu recurvatum or genu varum limb length discrepancies excessive foot pronation weak hip abductors tight iliotibial band biomechanical factors disparity between quadriceps and hamstring strength increased landing forces increased angle of knee flexion at heel strike Etiology Pathophysiology mechanism of injury iliotibial band is repetitively shifted forward and backwards across the lateral femoral condyle causing friction, iliotibial band tensioning and inflammation impingement zone = 30 degress of knee flexion pathoanatomy compression and irritation of the underlying connective tissues beneath the iliotibial band may result in cysts or bursitis in the lateral synovial recess may be associated with femoral condyle osseous edema pathologic changes in the iliotibial band are less common Associated conditions patellofemoral syndrome may be due to tightness of ITB medial compartment osteoarthritis reduced medial joint space causes varus knee deformities greater trochanteric pain syndrome alters biomechanics of the ITB Anatomy Iliotibial band origin continuation of tensor fascia lata insertion Gerdy tubercle innervation superior gluteal nerve (L1-3) primary synergistic muscles hip aBDuctors Presentation History endurance athletes presenting with activity related knee pain Symptoms pain predominantly localized over the lateral femoral condyle pain may be exacerbated by changes in running terrain or mileage usually relieved with rest Physical exam inspection may have swelling over iliotibial band foot and knee malalignment palpation localized tenderness over the lateral femoral condyle motion joint crepitus reduced hip and/or knee motion weakness of hip aBDuction pain reproduced with single leg squat provocative tests Ober test detects iliotibial band tightness positioning lateral with symptomatic side up with knee flexed to 90deg hip is brought from flexion and abduction into extension and adduction findings positive if pain, tightness, or clicking over the iliotibial band Radiography Radiographs recommended views AP, lateral views of knee additional views oblique or skyline views findings usually normal may show associated bone pathology medial joint compartment narrowing patellar malalignment fracture MRI indications rule out associated soft-tissue pathology in the same region (e.g., lateral meniscal tear, LCL sprain/tear, etc) with normal radiographs findings may reveal signal changes in the lateral synovial recess, iliotibial band or periosteum Treatment Nonoperative rest, ice, NSAIDs, corticosteroid injections indications initial treatment to reduce pain and swelling modalities ice oral or topical anti-inflammatory medications corticosteroids injection when conservative measures fail physical therapy and training modifications indications mainstay of treatment that follows initial treatment phase aimed at reducing pain and swelling modalities therapy stretching of the iliotibial band, lateral fascia and gluteal muscles deep transverse friction massage strengthening hip aBDuctors proprioception exercises to improve neuromuscular coordination training modifications change shoes every 300-500 miles avoid sudden increases in mileage Operative excision of a cyst, burse or lateral synovial recess indications failed nonoperative management soft-tissue pathology with no signal change in the iliotibial band techniques arthroscopic vs. open outcome may cause chronic synovial fluid effusion and pain elipitical surgical excision of iliotibial band indications failed nonoperative therapy with chronic presentation techniques open technique lateral distal femur incision expose posterior portion of the band over lateral femoral epicondyle incise 2 x4 cm ellipse of band tissue Z plasty of iliotibial band indications only indicated in refractory cases Prognosis 50-90% of patients will improve with 4-8 weeks of non-operative modalities