Iliotibial band syndrome is the most common cause of lateral knee pain in runners.
Runners predisposed to this injury are typically in a phase of over-training and often have underlying weakness of the hip abductor muscle. Male runners may exhibit kinematic faults such as increased hip internal rotation and knee varus, and weakness in the external rotator muscles of the hip. Female runners may exhibit increased hip adduction and knee internal rotation, and abnormal iliotibial band strain and strain rate.
In the acute phase, treatment includes activity modification, ice, and non-steroidal anti-inflammatory drugs. Offer a combined local anaesthetic and corticosteroid injection if severe pain or swelling.
During the sub-acute phase, emphasis is on stretching of the iliotibial band and soft-tissue therapy for any myofascial restrictions.
The recovery phase focuses on a series of exercises to improve hip abductor strength and integrated movement patterns. The final return to running phase is begun with an every-other-day programme, starting with easy sprints and avoidance of hill training with a gradual increase in frequency and intensity.
Consider surgery if refractory to conservative treatment.
Iliotibial band syndrome (ITBS) results from repetitive friction of the iliotibial band sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, and remaining tense in both positions. However, some functional anatomists and musculoskeletal radiologists consider ITBS a possible compression syndrome. The soft tissue involved may include the iliotibial band attachment into the lateral epicondyle of the femur, underlying adipose and bursal tissue, and distal ligamentous insertions into Gerdy's tubercle of the tibia.
History and exam
Key diagnostic factors
- sharp or burning pain superior to the lateral joint line
- positive Noble's test
- positive Ober's test
- positive modified Thomas's test
Other diagnostic factors
- reduced hip abductor muscle strength
- genu varum (bow leg)
- hind-foot and fore-foot varum
- pes cavus (high arch)
- prominent lateral femoral epicondyle, tight iliotibial tract and tensor fascia lata
- weak gluteus medius, gluteus maximus, and tensor fascia lata
- tightness and weakness in the quadriceps, iliotibial tract, and lateral retinaculum
- pain on sitting or walking
- local oedema
- pre-existing iliotibial band tightness
- high weekly mileage
- time spent walking or running on a track
- interval training
- muscular weakness of knee extensors, knee flexors, and hip abductors
- leg-length discrepancies
- step width
- downhill running
- lack of running experience
- abrupt increase in running distance or frequency
- long-distance running
- running at an improper pace
- use of worn-out running shoes
- running on a cambered or slippery surface
- knee varus in male runners
- muscular weakness in hip external rotator muscles in male runners
- excessive hip internal rotation in male runners
1st investigations to order
- clinical diagnosis
Investigations to consider
- MRI of knee
pain and inflammation
resolved pain and inflammation
refractory to conservative treatment
Bob Baker, PT, PhD, MBA, OCS
Rehabilitation Services Manager
RLB declares that he has no competing interests.
Jenson C. Mak, PhD, FRACP, FAFRM, FACP, MBBS
University of Sydney
JCM declares that he has no competing interests.
Michael Fredericson, MD, FACSM
Professor of Orthopaedic Surgery
Stanford Medical Center
MF declares that he has no competing interests.
Robert Werner, MD
Chief of Physical Medicine and Rehabilitation
Ann Arbor VA Medical Center
RW has been reimbursed by the University of Michigan for attending several conferences and has been paid an honorarium for speaking at the American Association of Neuromuscular and Electrodiagnostic Medicine national meeting. RW has been paid by the National Institute for Occupational Safety and Health, the American Dental Association, and SmartHealth as a consultant and has received grant funding from the UAW/GM Health and Safety Board (over US$1 million).
- Biceps femoris tendinopathy
- Degenerative joint disease
- Lateral collateral ligament (LCL) sprain
- Practical management of iliotibial band friction syndrome in runners
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