Iliotibial Band Syndrome: Evaluation and Management PDF

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Review Article Iliotibial Band Syndrome: Evaluation and Management Abstract Eric J. Strauss, MD Iliotibial band syndrome is a common overuse injury typically seen Suezie Kim, MD in runners, cyclists, and military recruits. Affected patients report lateral knee pain associated with repetitive motion ...

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Review Article

Iliotibial Band Syndrome: Evaluation and Management Abstract Eric J. Strauss, MD Suezie Kim, MD Jacob G. Calcei Daniel Park, PT, DPT

Iliotibial band syndrome is a common overuse injury typically seen in runners, cyclists, and military recruits. Affected patients report lateral knee pain associated with repetitive motion activities. The diagnosis is usually made based on a characteristic history and physical examination, with imaging studies reserved for cases of recalcitrant disease to rule out other pathologic entities. Several etiologies have been proposed for iliotibial band syndrome, including friction of the iliotibial band against the lateral femoral epicondyle, compression of the fat and connective tissue deep to the iliotibial band, and chronic inflammation of the iliotibial band bursa. The mainstay of treatment is nonsurgical; however, in persistent or chronic cases, surgical management is indicated.

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From the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases (Dr. Strauss and Dr. Kim), New York University School of Medicine (Mr. Calcei), and Sports PT (Mr. Park), New York, NY. Dr. Strauss or an immediate family member has received nonincome support (such as equipment or services), commercially derived honoraria, or other nonresearch–related funding (such as paid travel) from Mitek. None of the following authors or any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Kim, Mr. Calcei, and Mr. Park. J Am Acad Orthop Surg 2011;19: 728-736 Copyright 2011 by the American Academy of Orthopaedic Surgeons.

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liotibial band syndrome (ITBS) is a common cause of lateral knee pain in the active, athletic population. First described by Renne1 in 1975 as a condition affecting US Marine Corps recruits undergoing rigorous endurance training, the diagnosis of ITBS has increased with the growing popularity of recreational distance running and cycling. Epidemiologic studies have identified ITBS as the most common cause of lateral knee symptoms in runners, with a reported incidence ranging from 1.6% to 12%.2-9 Among cyclists, ITBS accounts for 15% to 24% of all overuse injuries in similar observational investigations.3,10,11 Lateral symptoms attributed to ITBS have also been reported in competitive rowers, skiers, and athletes participating in soccer, basketball, triathlons, and field hockey.2,12-14 The etiology of ITBS is a subject of debate. Theories include friction of the iliotibial band (ITB) against the lateral femoral epicondyle during repetitive flexion and extension activities, compression of the fat and connective tissue deep to the ITB, and

chronic inflammation of the ITB bursa. The diagnosis is typically made based on a characteristic patient history and physical examination, including specific tests designed to assess the ITB for tightness and contracture and to reproduce the patient’s lateral symptoms. A thorough understanding of the local anatomy and biomechanics associated with ITBS can assist the managing orthopaedic surgeon in making the correct diagnosis and in formulating an appropriate treatment plan.

Relevant Anatomy The ITB or iliotibial tract is a lateral thickening of the fascia latae of the thigh.15 The ITB is formed proximally at the level of the greater trochanter as a coalescence of the fascial investments of the tensor fascia latae and the gluteus maximus and gluteus medius muscles16 (Figure 1). Anatomic studies have demonstrated that the ITB is a dense fibrous connective tissue that passes distally

Journal of the American Academy of Orthopaedic Surgeons

Eric J. Strauss, MD, et al

Figure 1

Figure 2

Illustration of the iliotibial band (ITB). The ITB is formed proximally at the level of the greater trochanter as a coalescence of the fascial investments of the tensor fascia latae and the gluteus maximus and gluteus medius muscles and extends distally to insert on the Gerdy tubercle.

along the thigh.15 Proximal to the knee joint, the ITB has attachments to the intermuscular septum and the supracondylar tubercle of the femur; it continues distally to insert on the Gerdy tubercle at the anterolateral aspect of the proximal tibia.16,17 It is separated from the lateral cortex of the femur, proximal to the lateral epicondyle, by a layer of fat that extends to the vastus lateralis muscle.16 At the level of the lateral femoral condyle, contact between the ITB and the underlying epicondyle and origin of the lateral collateral ligament is present, helping provide lateral stability to the knee joint.16 The function of the ITB depends on the position of the knee. With the knee in full extension to 20° to 30°of flexion, the ITB lies anterior to the lateral femoral epicondyle and serves as an active knee extensor.18 At 20° to 30° of flexion, the ITB assumes a posterior position relative to the lateral femoral epicondyle and becomes an active knee flexor18 (Figure 2). December 2011, Vol 19, No 12

Illustrations demonstrating how the function of the iliotibial band (ITB) depends on the position of the knee. A, With the knee in extension, the ITB lies anterior to the lateral femoral epicondyle and serves as an active knee extensor. B, At 20° to 30° of flexion, the ITB assumes a posterior position relative to the lateral femoral epicondyle and becomes an active knee flexor.

Proposed Etiology of Iliotibial Band Syndrome In the classic description of ITBS, repetitive knee flexion and extension cause a friction-type syndrome secondary to cyclic anterior-posterior motion of the ITB over the lateral femoral epicondyle.2,11,14,19-24 Supporters of the friction explanation report that this repetitive motion leads to inflammation of the distal ITB directly over the lateral femoral condyle. In an effort to explain the high incidence of symptomatic ITBS in distance runners, Orchard et al19 proposed that the condition arises from the ITB sliding through an “im-

pingement zone” in the knee. This impingement zone occurs near 30° of flexion, approximating the angle of the knee at the time of foot strike or the early stance phase of running, which may explain why persons with ITBS experience the most pain immediately following foot strike.25 Runners who run uphill, downhill, and at slower paces tend to decrease their angle of knee flexion at foot strike, thereby spending more time in the impingement zone and, thus, experiencing worse ITBS symptoms.19 Compared with runners, Farrell et al10 found that cyclists spend 50% less time in the impingement zone and experience a reduction in force

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Iliotibial Band Syndrome: Evaluation and Management

of 17% to 19% while in this zone, which may explain the lower prevalence of ITBS in this population. Recent anatomic and radiologic studies have questioned the validity of the friction cause of ITBS. In a functional anatomy and radiology study using cadaver knees and patients both with and without ITBS, Fairclough et al15 reported that the anatomic constraints of the ITB prevent the possibility of cyclic anteriorposterior motion and rubbing over the lateral femoral epicondyle. Based on their results, the authors report that changing tension of the anterior and posterior fibers of the distal ITB creates an illusion of gliding over the epicondyle. Histologic examination of the tissue between the ITB and the lateral aspect of the femur identified highly vascularized and innervated adipose tissue, leading Fairclough et al15,26 to conclude that ITBS is more likely a “fascia lata compression syndrome” than a repetitive friction issue. Inflammation of the bursa and tendon over the lateral epicondyle has been postulated as a third potential etiology of ITBS. Cadaver dissections by Ekman et al27 demonstrated a potential fluid-filled space that they referred to as an ITB bursa. This potential space between the ITB and the lateral femoral epicondyle was consistent with high signal intensity seen on the MRI scans of patients who presented clinically with ITBS. Proponents of the inflamed bursa theory of ITBS commonly cite the positive outcomes of surgical bursectomy of the sub-ITB space as supporting evidence.28

Risk Factors Associated With Iliotibial Band Syndrome Observational studies and retrospective clinical reviews of patients with

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ITBS have identified several risk factors that can affect the ITB and may contribute to the development of symptoms.6,7,29 Training errors, including rapid changes in training routine, hill running, excessive striding, and increased mileage are commonly cited contributing factors.20,21 The surface of activity can also contribute to the development of ITBS in runners: running on surfaces with excessive camber can put excess strain on the lateral aspect of the knee. Downhill running tends to be worse because of the decrease in knee flexion that is present at the time of foot strike, thus increasing the forces experienced by the knee within the Orchard impingement zone.19,21 Anatomic factors that contribute to increased resting tension of the ITB and lateral knee strain include excessive genu varum, excessive internal tibial torsion, foot pronation, hip abductor weakness, and paralytic disorders.20,21,25,30 Noehren 24 et al performed a biomechanical study to evaluate the anatomic variations and kinematics between female runners with ITBS and an asymptomatic control group. The authors found that increased hip adduction and knee internal rotation were associated with the presence of ITBS. Fredericson et al7 compared hip abductor strength between 24 distance runners with ITBS and 30 asymptomatic controls. These authors found that runners with ITBS had statistically significantly weaker hip abductors on the affected side compared with the unaffected side and compared with the asymptomatic controls. Grau et al31 used threedimensional kinematics to evaluate 18 runners with symptomatic ITBS compared with 18 healthy control subjects. The greatest biomechanical difference found was in the hip. Contrary to the results of Noehren et al,24 Grau et al31 reported less hip

adduction in the ITBS group. They also noted a difference in hip frontal range of motion, maximum hip velocity, and maximum knee velocity.

Patient Evaluation The patient history and clinical examination are the most effective means of making the diagnosis of ITBS and determining the severity of the condition. On initial presentation, patients with ITBS report pain localizing to the lateral aspect of the knee. Patients typically localize the pain to the region of the distal ITB between the lateral femoral condyle and its insertion on the Gerdy tubercle. Early in the disease process, symptom onset usually occurs at the completion of a repetitive flexionextension exercise. As the condition worsens, pain is often experienced earlier in the athletic activity and may begin to be present at rest. Pertinent questions in the patient history include mileage run or cycled per week, condition of the person’s running shoes, the presence or absence of swelling and mechanical symptoms, and aggravating/relieving factors. Characteristically, patients report an increase in symptom frequency and intensity when running outside, when running down hills, and with attempts at lengthening their stride.29 A complete knee examination is imperative in identifying ITBS and ruling out other pathologies present within the differential diagnosis of lateral knee pain (Table 1). Standing lower extremity alignment must be evaluated; the examiner should look for increased varus or valgus alignment at the knee. The knee should be examined for evidence of an effusion or soft-tissue swelling. ITBS patients often have tenderness over the distal ITB at the level of the lateral femoral epicondyle, a location approximately

Journal of the American Academy of Orthopaedic Surgeons

Eric J. Strauss, MD, et al

Table 1

Figure 3

Differential Diagnosis of Lateral Knee Pain Lateral meniscal tear Lateral compartment degenerative joint disease Biceps femoris tendinopathy Stress fracture Patellofemoral syndrome Lateral collateral ligament pathology

3 cm proximal to the knee joint. In his initial evaluation of the condition, Renne1 described a “creak” sound, similar to rubbing your fingers on a wet balloon, and Noble20 described the sound like “wet leather” while palpating the lateral femoral epicondyle throughout knee flexion and extension. Knee range of motion should be assessed, and a complete ligamentous examination should be performed. Three provocative tests are commonly used in the assessment of ITBS and ITB function. The Noble test is performed with the patient lying supine; beginning with the affected knee flexed at 90°, the leg is extended with direct pressure over the lateral femoral epicondyle, with reproducible pain near 30° of knee flexion.28 The Ober test can be used to assess ITB contracture and tightness. With the patient lying on his or her side with the unaffected leg down and bent at 90°, the examiner stabilizes the pelvis, then abducts and extends the affected leg, followed by an attempt by the examiner to adduct the leg. The Ober test is positive if the examiner cannot adduct the affected leg from this position.11,21 The Thomas test is used to determine the tightness of the iliopsoas muscle, rectus femoris muscle, and ITB. The patient is instructed to lie supine at the edge of the examination table with both knees held to the chest. While the examiner stabiDecember 2011, Vol 19, No 12

Coronal (A) and axial (B) T2-weighted magnetic resonance images of a 27year-old female distance runner demonstrating increased signal medial to the iliotibial band (arrow) in the region of the lateral femoral epicondyle.

lizes the pelvis, the patient holds the unaffected leg to the chest, and the affected leg is extended and lowered. A positive test results if the patient cannot completely extend and lower the affected leg to horizontal.32 Although not routinely required, radiographic imaging can be used to supplement the physical examination. Routine radiographs of the knee, including AP, lateral, and sunrise views, can be used as a diagnostic adjunct to rule out other possible causes of lateral knee pain, such as lateral joint space narrowing from degenerative disease, patellar maltracking, and stress fractures. However, in a study comparing the radiographs of 16 knees with ITBS symptoms and 16 age- and sexmatched unaffected knees, no difference in radiographic findings was reported.1 In cases of refractory ITBS, MRI can be used as a diagnostic tool. Ekman et al27 described a case series of 7 patients with a clinical diagnosis of ITBS compared with 10 age- and sex-matched unaffected knees. These authors reported the presence of a high-intensity signal, representing a fluid-filled collection, over the lateral

epicondyle deep to the ITB, as well as a marked thickening of the distal ITB (Figure 3). MRI can also be useful in ruling out other potential causes of lateral knee pain, including articular cartilage injuries, meniscal tears, and cysts. Ultrasonography may help in the management of ITBS. Gyaran et al33 performed a study to measure ITB thickness with ultrasonography. They recommended the use of ultrasonography in following up patients with the diagnosis of ITBS because of the low cost and availability of this modality compared with MRI.

Nonsurgical Management Nonsurgical management is the mainstay of treatment of symptomatic ITBS.2 As with most orthopaedic conditions, activity modification can improve the pain associated with this syndrome. Rest from the inciting activity, such as running or cycling, until pain has resolved, followed by a gradual return to activity as tolerated, may help to avoid symptom recurrence. Equipment modification, such as altering cleat position or

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Iliotibial Band Syndrome: Evaluation and Management

Figure 4

Clinical photographs demonstrating iliotibial band (ITB)–specific stretching regimen (A through C) and the Ober stretch (D) designed to lengthen the ITB.

Figure 5

Clinical photograph demonstrating the Graston soft-tissue mobilization technique for iliotibial band lengthening.

lowering the bicycle seat and raising the handlebars in cycling, may also decrease pain and allow for a return to activity.23 Oral nonsteroidal anti-inflammatory drugs (NSAIDs) and/or corticosteroid injections can be used to reduce the acute inflammatory response. NSAIDs alone have not been found to be effective in providing symptom relief; however, several studies have shown that NSAIDs, in conjunction with other nonsurgical modalities, can be beneficial.3 Local corticosteroid injections can relieve

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pain as well as aid in the diagnosis of ITBS. In a randomized controlled trial of 18 individuals with clinical ITBS, Gunter and Schwellnus34 reported statistically significantly better pain relief in the experimental group (1 mL 1% lidocaine plus 1 mL methylprednisolone) compared with control subjects (2 mL 1% lidocaine) by the second week postinjection. Physical therapy is an important component of the nonsurgical management of ITBS. Typical regimens consist of specific stretching exercises focused on the ITB, tensor fascia latae, and gluteus medius (Figure 4). In a biomechanical study that examined the effectiveness of three different ITB-specific stretches in five elite distance runners, Fredericson et al35 demonstrated that all three stretching methods lead to statistically significant lengthening of the ITB relative to baseline measurements. Manual therapy that consists of softtissue and medial patella mobilizations may also contribute to lengthening the ITB. Graston and active release soft-tissue mobilization techniques have been gaining popularity, but research on these treatments is limited (Figure 5). Additionally, the patient can use a foam roller as a myofascial release tool to break up soft-tissue adhesions

in the ITB (Figure 6). Once the patient is capable of performing the stretching regimen without pain, strengthening is added to the rehabilitation program.2 Attention is paid to proximal strengthening of the hip abductors (gluteus medius) and the core muscles to stabilize the pelvis to prevent excessive adduction of the hip. Modalities such as cryotherapy may also be incorporated into the physical therapy program in an effort to reduce the inflammatory component of the condition. Increasing neuromuscular control can also be a goal of physical therapy through several multidimensional movement patterns, eccentric muscle contractions, and integrated movement patterns.32,36 Education about proper running form and running progression are important in getting patients back to their goals. Biomechanical studies have shown that faster-paced running is less likely to aggravate the ITB; faster strides are initially recommended over slow jogging.36 Foot orthoses are also a potential nonsurgical intervention for ITBS.21 Although no specific evidence supports the use of orthoses, theoretically, an orthosis used to raise the heel in runners may decrease the flexion angle of the knee at foot strike and may decrease symptoms.19

Journal of the American Academy of Orthopaedic Surgeons

Eric J. Strauss, MD, et al

Figure 6

Clinical photograph demonstrating how a foam roller is used for selfstretching of the iliotibial band.

A systematic review performed by Ellis et al3 to evaluate the nonsurgical management of ITBS included four randomized trials that used NSAIDs, deep-tissue massage, phonophoresis, immobilization, and corticosteroid injections. The authors concluded that limited evidence exists to support nonsurgical management; however, the studies were heterogenous and of insufficient quality. Despite the lack of evidence supporti...