Iliotibial Band Syndrome

Iliotibial Band Syndrome (ITB Syndrome) is a common overuse injury affecting the lateral, or outside, part of the knee. It is common in people who run recreationally and competitively, and can be present across the spectrum of sports, from athletics, AFL and soccer, to basketball, netball and hockey. A non-traumatic overuse injury, ITB syndrome is often concomitant with underlying weakness of the hip abductor muscles, which results in altered lower limb biomechanics and compression of tissue on the outside of the knee during the foot strike and early stance phase of running.

A little bit of anatomy

The iliotibial band (ITB) is a thick, tough, durable band of connective tissue that runs along the outside of the thigh, from the pelvis to just below the knee joint. An extension of the tensor fascia latae and gluteus maximus muscles, the ITB is comprised of collagen fibers that provide stability to the knee and hip joints during movement. It is named in reference to its origin and insertion points – it originates from the iliac crest of the pelvis and inserts into the lateral condyle of the tibia just below the knee.

Nerd fact: The ITB inserts into the tibia at Gerdy’s tubercle, a smooth facet of bone named after the French surgeon

Pierre Nicolas Gerdy (1797-1856). The common peroneal nerve runs just behind it which, if damaged, results in foot drop.

During the foot strike and early stance phase of the running cycle, the gluteal muscles contract eccentrically to decelerate the leg, resulting in tension in the ITB and compression across the lateral knee joint. Under abnormal conditions, and with repetition, this activity can inflame and irritate the underlying adipose (fatty) tissue between Gerdy's tubercle and the lateral femoral epicondyle, resulting in pain, discomfort and restriction in activity.

Who gets it?

ITB syndrome is most seen in persons undertaking high repetition lower limb loading activities – think runners, cyclists, and people training for sports that require these motions.

It is estimated to affect up to 14% of people who run regularly and is more prevalent in males (50-81%) than females (16-50%).

The causes of ITB syndrome are multifactorial and include both intrinsic factors such as hip and foot biomechanics, hip muscle weakness and muscle imbalances, and extrinsic factors including running load, running surface, and footwear. In most (but not all) cases, these factors have been present for a prolonged period with the development of lateral knee pain the key driver for seeking advice and treatment. 

Diagnosing ITB Syndrome

ITB Syndrome can be diagnosed clinically by a physiotherapist. The presenting signs and symptoms and history of pain and activity are often suggestive of ITB syndrome, which can be confirmed with a battery of physical tests. In the presence of ITB syndrome, palpation over the lateral aspect of the knee while performing loaded knee flexion will often reveal crepitus and/or pain. Restricted hip joint range of motion and gluteal weakness are common findings, while foot examination may reveal contributing biomechanical issues.

It is important to consider and rule out several other possible diagnoses to ensure the correct course of management is taken. These include injury to the lateral collateral ligament, lateral meniscus injury, osteoarthritis, and referred pain from the lumbar spine to name a few.

Radiological investigations are generally not indicated for a diagnosis of ITB syndrome. In the presence of more complex history or in recalcitrant cases, X-ray, MRI and/or ultrasound may be useful to confirm the diagnosis and plan future management.

Treatment

The mainstay of treatment for ITB syndrome involves client-centered physiotherapy. Effective treatment involves a combination of load management, manual therapy, and strengthening and stretching to reduce pain, improve joint range of motion, and correct biomechanical issues.

The early phase of treatment for ITB syndrome can be frustrating as physical activity loads are adjusted to a threshold below pain. It is important that this is titrated appropriately to avoid unnecessary deconditioning.

The aim is to find a level and type of activity that can be undertaken that maintains fitness without provoking pain,

and implementing a progressive exercise program off this baseline.

During the early phase, soft tissue techniques, dry needling, and manual therapy are useful to reduce pain, release tightness in surrounding muscles and fascia, and improve hip joint mobility. Early strengthening is critical to address muscle weakness and imbalances. Individual assessment and feedback on running biomechanics and sport-specific movement patterns form an important component of the recovery from ITB syndrome.

As symptoms improve, strength and endurance-based exercises can be progressed, and a gradual return to sport managed. Load progression must be done gradually, with close attention paid to the presence of lateral knee pain and biomechanical changes when fatigued. Failure to manage and address these will ultimately result in recurrence of symptoms and delayed return to sport.

Other interventions that may be helpful include foam rolling, kinesiology taping, and the prescription of orthotics. Over the counter non-steroidal anti-inflammatory drugs (NSAIDs) may be recommended by a doctor or pharmacist for short-term pain relief.

Will a steroid injection help? What about surgery?

Studies investigating the effectiveness of cortisone (steroid) injections for ITB syndrome have not found superior long-term outcomes when compared to physiotherapy. While steroid therapy can be effective at reducing pain in the short-term, cortisone has been found to be detrimental to the structure of tendon tissue and increase the risk of degenerative rupture. While this risk can be managed, cortisone therapy is generally only recommended in cases where persistent pain is hampering rehabilitation progression and impacting health-related quality of life.

Open and arthroscopic surgery has been shown to be effective for returning athletes to sport in 81-100% of cases studied. While previously considered a 2^nd line treatment option, given the challenges that can present managing some cases conservatively, there is a strong argument that, for some individuals, early surgery followed by physiotherapy-led rehabilitation may reduce time lost from sport participation. We recommend discussing this with your physiotherapist and referral to an orthopaedic surgeon where indicated.  

How long does it take to recover?

ITB syndrome has a good prognosis, particularly if it is identified early and appropriate client-centered treatment initiated promptly. While most cases resolve within 6 – 12 weeks, the length of time to return to sport is dependent on the duration and severity of symptoms on initial presentation, complexity of factors contributing to the development of symptoms, and individual response to early phases of management. Some cases can take many months to resolve, while occasionally symptoms persist for years.

Commitment to therapy and diligence with exercises, combined with close adherence to prescribed

load and pain management strategies, are crucial for a successful outcome.

Take home Advice

Iliotibial band syndrome is a common injury that predominantly affects runners and running based athletes, characterized by pain on the outside of the knee. The best initial course of treatment involves physiotherapy-led load management, manual therapy, lower-limb stretching, and hip strengthening exercises. Surgery followed by physiotherapy may be indicated, particularly with more severe and/or prolonged symptoms. Early intervention and diligence with physiotherapy are crucial for a successful outcome. With appropriate client-centered treatment, most people can expect to return to sport within 6-12 weeks.

Are you getting knee pain when you run? Feel tight through your ITB? Give us a call.

At Movement for Life Physiotherapy, we can assess your ITB, diagnose what's causing ITB syndrome, and provide you with a comprehensive treatment plan to help get you back to the things you love doing sooner.

Give us a call now or click on BOOK AN APPOINTMENT to book online.

References:

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