DIAGNOSIS AND TREATMENT OF
ILIOTIBIAL BAND FRICTION SYNDROME
Richard T. Herrick, M.D., F.A.A.N.O.S., F.I.C.S., F.A.C.S.M.
Stella Herrick, A.T., C.Ped., O.S.T., O.P.A.
Iliotibial band friction syndrome (ITBFS) is an overuse syndrome resulting from friction between the iliotibial band and the lateral femoral epicondyle (outside the knee) during flexion and extension of the knee.
Repeated knee flexion/extension as occurs in squatting, as well as running, is particularly troublesome forindividuals with iliotibial band tightness. This results in either inflammation of the bursa overlying the lateral femoral epicondyle or direct irritation of the iliotibial band and periosteum.1
If ITBFS is suspected, a test for iliotibial band tightness introduced by Ober in 19366 should be performed. This has been used primarily to examine infants for abduction contractures, but also can determine inflexibility in athletes. A positive Ober's test indicates a good prognosis for treatment with exercises to stretch the iliotibial band.
The ITBFS was first described in 1975.1 Since then there has been increasing interest in it, including diagnostic measures for this cause of lateral knee pain in lifters, weight-training participants,7 and runners.2-5
Signs and Symptoms
The ITBFS usually affects only continuous running and not activities that permit rest between flexion/extension bouts.3 The syndrome is aggravated by smooth, even-paced running,2 excessive striding and, occasionally, squatting, especially maximal lifts.4 It usually results from a training error, primarily excessive distance during a single run or a rapid increase in weekly training.3 Runners who consistently run on the same side of a pitched road develop ITBFS on the down-side leg. Weightlifters and powerlifters, especially those doing several sets of several repetitions (usually greater than 5 x 5), are also prone to develop ITBFS, particularly in they are inflexible and/or increase the weight too rapidly.7 Of course, it also occurs in the "weekend warrior" and those who do any unaccustomed walking.
The presenting symptom is a stinging pain over the lateral femoral epicondyle (outside of area just above the knee) that may radiate down the iliotibial band, even to the tibial (shin bone) attachment. The pain is most intense when the leg comes in contact with the ground during deceleration,2 or at the bottom of a squat. Walking with the knee fully extended will provide relief. Physical examination reveals point tenderness approximately 3 cm proximal to the lateral knee joint line.
Diagnostic Tests
In 1975, Renne1 reproduced the pain of ITBFS by having the patient support all his weight on the effected leg with the knee in 30o to 40o flexion. This maneuver brings the iliotibial band into contact with the prominence of the lateral femoral epicondyle.8
In 1979 Noble3 described the compression test for ITBFS. With the patient supine, the knee is flexed to 90o and pressure is applied to the lateral femoral epicondyle or 1 to 2 cm proximal to it. The knee is gradually extended, and at 30o of flexion the patient with ITBFS will complain of severe pain over the lateral femoral epicondyle that is the same pain he gets when running8 or squatting.7
If the previous diagnostic tests are positive, Ober's test for iliotibial band tightness5 should be performed. The patient lies on his side with the thigh of the unaffected leg next to the table and flexed enough to obliterate any lumbar lordosis. The affected knee is then flexed to a right ankle and the leg is grasped tightly with one hand while the pelvis is stabilized by the other. Then the hip is abducted widely and extended so the thigh is in line with the body to catch the iliotibial band on the greater trochanter, maximizing its excursion. The leg is then brought toward the table in adduction. If any iliotibial band shortening is present, the hip will remain passively abducted in direct proportion to the amount of shortening.
Stretching Exercises
When Ober's test is positive, a lateral sole wedge is usually prescribed and the athlete is started on a series of stretching exercises that are performed daily and before activity. Static positions are held for a count of 20 to 30 and repeated at least twice. Three are specifically designed to stretch the iliotibial band and one stretches both the hand and the hamstrings.
Exercise 1. The athlete lies on his/her side with his/her back a few inches from a table edge. The thigh of the unaffected leg is next to the table and in sufficient hip flexion to obliterate any lumbar lordosis. The affected knee is held in full extension and the leg is extended at the hip so that it hangs over the table. Gravity then passively adducts the leg as far as possible, thereby stretching the iliotibial band. This exercise has the disadvantage of possibly requiring assistance to stabilize the pelvis once the leg crosses the midline.
In contrast, the following two exercises are done while standing and do not require assistance, because weight bearing stabilizes the pelvis.
Exercise 2. The athlete stands with both knees in full extension and extends and adducts the affected leg as far as possible. The trunk is then flexed laterally as far as possible toward the unaffected side, which isolates and stretches the iliotibial band.
Exercise 3. The athlete stands with both knees in full extension and extends and adducts the affected leg so that the affected knee rests in the popliteal fossa of the unaffected leg. The athlete then rotates at the waist away from the affected side and bends as far as possible, attempting to touch the heel of the affected leg. This position is maintained for ten counts and repeated three or four times. This exercise stretches both the iliotibial band and hamstrings.
Exercise 4. The athlete lies on the affected side with the knees and hips extended and in a straight line with the trunk. He/she then pushes up to a resting position on the hip of the affected side, placing his/her hand directly under the shoulder and bearing weight on the extended arm and hand. Hip extension must be maintained to maximize the excursion of the iliotibial band. The athlete should be careful not to substitute lateral flexion of the trunk for adduction of the hip in this exercise. It may be necessary to place the opposite foot on the floor to stabilize the pelvis.
Discussion and Conclusion
Once the iliotibial band has been implicated as a cause of lateral knee pain, stretching the band and the tensor fasciae latae has been shown to be an effective means of alleviating symptoms and preventing their recurrence. Active in abduction of the thigh, the band can be stretched through adduction, either with the pelvis stabilized and the hip extended and adducted or with the thigh stabilized and the pelvis rotated laterally.
Recovery may be enhanced by utilizing non-steroidal anti-inflammatory drugs (NSAID's), ice massage, liniments, massage therapy, chiropractic treatment, and/or various physical therapy modalities such as iontophoresis, phonophoresis, electrical stimulation, TENS units, H-wave, acuscope, interferential therapy or even corticosteroid injections. Rarely is surgery ever indicated.
SIMPLE ITB STRETCHES
1. Sitting on floor with legs crossed at the ankles, keep your back straight and gently lean forward from the hips. Hold for 5 seconds. Repeat 5 times. Reverse the leg which is on top and repeat.
2. Stand perpendicular to a wall. With the inner leg straight and the other leg crossed over keep body straight and lean hips into wall.
REFERENCES
1. Renne, J.W.: The iliotibial band friction syndrome. J. Bone Joint Surg. (Am.) 57:1110-1111, December 1975.
2. Craver, S.: Iliotibial tract friction syndrome in athletes. Br. J. Sports Med. 12:69-73, 1978.
3. Noble, C.A.: The treatment of iliotibial band friction syndrome. Br. J. Sports Med. 13:51-54, June 1979.
4. Noble, C.A.: Iliotibial band friction syndrome in runners. Am. J. Sports Med. 8:232-235, July- August 1980.
5. Sutker, A.N., Jackson, D.W., and Pagliano, J.W.: Iliotibial band syndrome in distance runners. Phys. Sportsmed. 9:69-73, October 1981.
6. Ober, F.R.: The role of the iliotibial band and fascia lata as a factor in the causation of low back disabilities and sciata. J. Bone Joint Surg. 18A, 1936.
7. Herrick, R.T., Stone, M., and Herrick, S.: Knee injuries of strength-power athletes. Iron Sport 1:41-43, 1987.
8. Noble, H.B., Hajek, M.R., and Porter, M.: Diagnosis and Treatment of Iliotibial Band Tightness in Runners. The Physician and Sportsmedicine 10(4):67-68, 71-72, 74, 1982.
Back To: Patient_Education