Updated: 10/6/2016

Iliotibial Band Friction Syndrome

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Introduction
  • A condition characterized by excessive friction between the iliotibial band and the lateral femoral condyle
  • 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
  • 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
  • Prognosis
    • 50-90% of patients will improve with 4-8 weeks of non-operative modalities
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 initital 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
 

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