Conditions & Treatments - Iliotibial Band Syndrome (Runner's Knee)

 

The iliotibial tract or band (ITB) is a dense band of connective tissue that originates from the outer lip of the anterior iliac crest, the anterior border of the ilium, and the outer surface of the anterior superior iliac spine and inserts at the lateral tibial condyle at Gerdy's tubercle (1). Distally, the IT band is responsible for providing lateral support to the knee (1). Proximally, the IT band serves as the insertion site for the tensor fascia lata and gluteus maximus muscles (2). The IT band helps flex, abduct, and internally rotate the hip (1).

Pathology/Etiology
Iliotibial band syndrome (ITBS) is the most common running injury of the lateral knee and is a "non-traumatic overuse injury caused by repeated flexion and extension of the knee that causes irritation in the structures around the knee" (3). Researchers have described an "impingement zone" at approximately 30 degrees of knee flexion (3). When the knee passes through this "impingement zone" during running, eccentric contractions of the gluteus maximus and tensor fascia lata generate tension in the IT band, compressing the IT band against the lateral femoral epicondyle (3). This compression may contribute to irritation of the posterior fibers of the IT band, as well as inflammation of the periosteum of the lateral femoral epicondyle (4).


Mixed evidence exists regarding whether or not hip abduction strength plays a role in the development of ITBS. A study by Fredericson et al. compared hip abductor torque between the injured and uninjured side of runners with and without ITBS (3). Researchers found that the hip abduction torque was significantly lower on the injured side in collegiate and club long distance runners with ITBS than in runners without ITBS (3). However, a study by Grau et al. concluded that no difference exists between hip abduction strength of runners with ITBS and hip abduction strength of runners without ITBS, as measured by the concentric endurance quotient of the hip abductors/adductors at 30 degrees/sec. More research is needed to determine whether or not hip abduction strength contributes to ITBS.

Clinical Examination
Subjectively, patients with ITBS may report lateral knee pain that is worse when running, cycling, or ascending/descending stairs (3). Patients may describe training errors, including rapid commencement of a running program, sudden hill exposure, a single severe training session, a rapid increase in training volume, and footwear/surface issues (3).


Objectively, the Noble compression test may reproduce symptoms, and flexibility of the IT band should be assessed via the Ober test (3). Hip muscle strength should be evaluated via appropriate manual muscle tests, or if available, via surface EMG or dynamometry (3). A functional test, perhaps a 6" or 8" box forward tap down, can be utilized to offer insight into muscle substitutions (3). Special tests or imaging may be needed to rule out a lateral meniscus tear, a discoid lateral meniscus, popliteus tendonitis, or lateral patellofemoral pain syndrome (1).

Treatment
Fredericson and Wolf created a treatment protocol for ITBS that consists of three phases: acute, subacute, and recovery strengthening. During the acute phase of ITBS, early use of anti-inflammatory medications, soft-tissue mobilization, and stretching are advised (2). A systematic review concluded that both corticosteroid injections and NSAIDs were moderately supported when used within the first 14 days following injury (4). During the subacute phase of ITBS, iliotibial band stretching and soft tissue mobilization to reduce myofascial adhesions should be utilized (2). During the recovery strengthening phase, exercises should focus on strengthening the glute muscles, particularly the gluteus medius (2). As measured by EMG, the gluteus medius averaged 61% of a maximal voluntary isometric contraction during lateral band walks, 64% of a maximal voluntary isometric contraction during a single limb squat, and 81% of a maximal voluntary isometric contraction during side lying hip abduction (2). When treating patients with ITBS, Baker et al. recommend including at least one IT band stretch, side lying hip abduction, pelvic drops, and an appropriately challenging progression of closed-chain exercises (2).

 

Last revised: May 21, 2014
by Michelle Kornder, DPT

 

References
1) Wheeless' Textbook of Orthopaedics. Tensor Fascia Lata/Iliotibial band. Available at: http://www.wheelessonline.com/ortho/tensor_fascia_lata_iliotibial_band. Accessibility verified May 14, 2014.
2) Baker RL, Souza RB, Fredericson M. Iliotibial Band Syndrome: Soft Tissue and Biomechanical Factors in Evaluation and Treatment. PM&R. 2011;3(6):550-561. Available from University of Wisconsin Madison, Madison, WI. Accessed May 14, 2014.
3) van der Worp MP, van der Horst N, de Wijer A, Backx FJG, Nijhuis-van der Sanden MWG. Iliotibial Band Syndrome in Runners: A Systematic Review. Sports Med. 2012;42(11):969-992. Available from University of Wisconsin Madison, Madison, WI. Accessed May 14, 2014.
4) Ellis R, Hing W, Reid D. Iliotibial band friction syndrome-A systematic review. Manual Therapy. 2007;12:200-208. Available from University of Wisconsin Madison, Madison, WI. Accessed May 14, 2014.

 

Iliotibial Band Syndrome (Runner's Knee) Treatment Options for a PT

Ice Packs/Ice Massage

Postural Training/Functional Training

ROM/Stretching (see videos 26, 27 & Z4 for hip/groin/knee)

Strengthening  

Myofascial Release/Soft Tissue Mobilization 

 

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