Updated: 5/29/2021

Iliotibial Band Friction Syndrome

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  • 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
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