How to prevent and treat Iliotibial Band Syndrome
This article summarises our latest understanding of Iliotibial Band Syndrome and current wisdom on the best ways of treating and avoiding this painful and disabling condition.
Iliotibial Band Syndrome is one of the most common injuries sustained by runners, and one that we encounter regularly at Perfect Balance Clinic. It is also a common injury amongst cyclists and hikers. An overuse injury, its primary causes relate to training errors such as failing to allow adequate time for recovery and biomechanical problems that relate to how the joints and muscles of the leg and pelvis control running motion.
Although runners will have suffered from this painful condition for as long as people have been running, the condition was not specially recognised until it was described by Renne (1975) as a pain felt on the lateral knee associated with activities such as running and cycling with the cause being inflammation and irritation of the lateral synovial recess and continued irritation of the posterior fibres of the IT band (Fredericson et. al., 2002).
It is likely that with this kind of repetitive soft tissue irritation there is insufficient time for the body to repair the tissues, which can result in additional irritation and injury, extending the injury zone and increasing the risk of irritation (Levin, 2003). In most cases ITBS responds well to rest and conservative treatments with success rates as high as 94% (McNicol et. al., 1981).
Despite the considerable research that has been carried out on ITBS, there remain doubts over its precise causes, and while most sufferers recover with adequate rest, there is no miracle cure. However, even if you fail to respond to rest and other conservative treatments, there is still good reason to remain optimistic. Various surgical procedures are available, some of which are minimally invasive, and in most cases, they are highly effective.
If you are experiencing the symptoms of ITBS, you have been diagnosed with the condition, or you just want to learn more about it so that you can reduce your chances of sustaining this painful injury, this article and ebook should help you. Although we have tried to keep it reasonably simple, parts of it are inevitably a little technical as we have based much of it on original medical and academic research. In all instances where we have done so, we provide references to our source material. The rest is based on our own experience along with what we believe to be common sense.
What is Iliotibial Band Syndrome?
Iliotibial Band Syndrome (IBTS) is one of the more common overuse injuries. It affects from 7 to 14% of runners (McKean et. al., 2006; Taunton JE et. al., 2002) and is responsible for decreasing performance in cyclists, football players, rowers, and other athletes.
The precise causes of IBTS are not fully understood. It used to be thought (Orchard et. al., 1996) that it was the result of friction between the iliotibial band and the lateral femoral condyle (a projection on the lower extremity of the femur) when the knee is flexed by thirty degrees, leading to inflammation and pain. However, anatomical studies (Fairclough et al 2006, 2007) indicate that this is an illusion and that the ITB does not slide across the bone. Instead, it exerts a compressive force on the joint when the fascia tightens.
Ferber et al (2010) identified decreased iliotibial band and iliopsoas extensibility in recreational athletes. The authors also reported a lack of inflammatory response and no bursa were found where the iliotibial band inserts. Fairclough et al (2006, 2007) postulate that the iliotibial band is not transferring loads properly and that friction is not responsible for the pain.
Another possible contributory cause is an abnormal movement of the lower extremity. Studies of the hip, knee, and ankle kinematics in runners have produced conflicting results including:
Increased hip internal rotation and adduction range of motion upon contact (Noehren et al 2007)
Increased hip adduction at initial contact and maximal hip adduction (Grau et al, 2008)
Runners with ITBS land with less knee flexion upon initial contact on the involved limb than uninjured runners (Orchard et al 2006)
Runners with ITBS have greater peak hip adduction, peak knee internal rotation and femoral external rotation moments and remained more adducted during stance (Noehren et al 2007) No difference was found in knee flexion and rearfoot eversion (Noehren et al 2007)
Muscle weakness in the hip abductors may also be a contributing factor, though again conflicting results have been published. While Grau et al (2008) found no difference between controls and subjects with IBS, Fredericson et. al. (2000) found that hip abductor torque was lower in subjects with IBS.
Because of these inconclusive findings, the optimal treatment for ITBS sufferers remains unknown.
Typical early-stage treatments involve anti-inflammatory medications, however current evidence suggests that inflammation in the area is not the cause, thus the use of anti-inflammatories is questionable. That said, however, most of our patients find they do help a little.
Physical therapy is often recommended including static stretching, strengthening, manual therapy, and neuromuscular reeducation. The importance of proper shoe wear and training schedules has been addressed by Pinshaw et. al. (1984). Deep friction massage is often used but there is little evidence of its effectiveness. Various surgical procedures have been used in chronic cases, including resection of the lateral synovial recess. We look at these in detail later.
Iliotibial Band Syndrome Symptoms
The most common symptom of ITBS is pain on the lateral side of the knee. Often this begins with a stinging sensation that might feel like needle pricks. If this is ignored, the pain will gradually increase in severity so that your knee hurts each time your heel hits the ground. The pain can increase in severity to such an extent that it becomes disabling. Usually, the pain is more severe when running or walking downhill and when climbing downstairs.
Sometimes the pain is accompanied by visible swelling where the IT band crosses the femoral epicondyle or where it attaches to the tibia below the knee. The pain may radiate up the IT band along the thigh and as far as the hip. Some runners experience a kind of snapping or popping feeling in the knee. We recommend that you seek help as soon as you suspect you might have ITBS or you are experiencing any other kind of knee pain.
Diagnosis of Iliotibial Band Syndrome
Although diagnosing iliotibial band syndrome is not particularly difficult, some practitioners may confuse it with other knee problems. Unsurprisingly, physical therapists who are more exposed to ITBS sufferers tend to be significantly better at identifying it than general medical practitioners.
Sometimes the condition is miss-diagnosed as a sprain, but usually, sprains are immediate traumatic injuries and should not be confused with ITBS. Mostly, if you are active and experience non-traumatic lateral knee pain, the chances are it is ITBS.
ITBS usually occurs when you undertake an unfamiliar exertion when running, walking, or hiking, possibly the first major exercise following a resting period. Although the onset can be sudden, it is almost always associated with unusual leg exercises. Another indicator is that it hurts more when going downhill or downstairs than when ascending. If the pain is more severe when ascending than when descending it is unlikely to be ITBS.
Physical examination may include palpation of the painful area to identify tenderness and swelling over the femoral epicondyle. You might also be checked for any discrepancy in your leg length, muscle imbalance, and tightness in your legs and back. If there is any doubt, then a complete examination of your lower back, legs, hip, and ankles may be carried out to detect any possible other causes of knee pain.
MRI Scan
While not usually required, an MRI scan can confirm the condition, particularly if you are uncertain of the cause of your knee pain. At the least, it can confirm that there is no underlying problem such as a tumour or cyst.
Confusion between ITBS and Patellofemoral Pain Syndrome
Patellofemoral pain syndrome (PFPS) is another injury that is common amongst runners and it is also characterised by knee pain which can range from mild to severe. The pain originates from the point of contact of the back of the patella and the femur.
While the pain resulting from ITBS is felt on the side of the knee, PFPS pain is felt at the front of the knee. In practice, however, ITBS and PFPS can both produce atypical symptoms and the pain can spread from its epicentre to other regions. Thus, there can be confusion over whether the condition is ITBS or PFPS. However, it is likely to be ITBS if:
The pain epicentre is to the side of the knee
There is a spot on the side of the knee that is sensitive to pressure while applying pressure to the kneecap is not particularly painful Pain is worse while descending
The pain came on quite quickly
It doesn’t hurt to bend the knee
It is likely to be PFPS if:
The pain epicentre is under the kneecap
It is uncomfortable to apply pressure to the kneecap but it isn’t painful pressing the side of the knee.
Pain is worse while ascending
Bending the knee is painful
The pain came on slowly perhaps over days or longer
Other common misdiagnosis errors
In addition to possible misdiagnosis of PFPS as ITBS, there are also some other common misdiagnoses. Some examples of these are:
Hip pain
As the IB band connects to the hip via the fasciae latae and gluteus maximus muscles, the hip may well be involved in ITBS. However, hip pain alone is not an indication of ITBS. You might experience hip pain in conjunction with knee pain, but the two should not be confused.
Intra-articular problems
Problems that occur inside the knee joint can sometimes be confused with ITBS. For instance, it is not unusual for people with ITBS to also have meniscal tears, in fact, 18% of them do (Muhle et. al., 1999), but meniscal tears are common and often asymptomatic. There is no evidence that meniscal tears mimic the symptoms of ITBS, but then there is no evidence that they don’t, so an MRI scan might be advised.
Misaligned kneecap
It is possible that a tight iliotibial band can lead to patellar misalignment, but there is no real evidence that this is the case. Neither is there evidence that ITBS is the result of a tight iliotibial band. Poor patella tracking is not evidence of ITBS even though some specialists think otherwise.
Popliteus syndrome
The popliteus muscle is located behind the knee and runs from the lateral side of the femur to the medial side of the tibia below the gastrocnemius (calf muscle). It serves to unlock the knee after the heel touches the ground when walking or running. It is also important when descending. Popliteus syndrome is a painful condition common in runners. It is a tendonitis and treatable with anti-inflammatory drugs, massage, and stretching. Unfortunately, on occasion, it is misdiagnosed as ITBS.