What is the iliotibial (IT) band and how is iliotibial band syndrome treated?

Iliotibial Band Syndrome: Diagnosis and Treatment

Iliotibial band syndrome (ITBS) is best treated with a combination of activity modification, stretching, strengthening of the gluteal muscles, and addressing biomechanical factors, with most patients responding to conservative management within 6 weeks.

What is the Iliotibial Band?

The iliotibial band (ITB) is a thick band of fascia that:

• Extends from the hip to the lateral knee
• Is not a discrete structure but a thickened part of the fascia lata that envelops the thigh 1
• Crosses the hip joint and extends distally to insert on the patella, tibia, and biceps femoris tendon 2
• Is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur by fibrous bands 1

Iliotibial Band Syndrome

Definition and Mechanism

ITBS is the most common cause of lateral knee pain in runners 3. Traditionally viewed as a friction syndrome, recent evidence suggests it may be a compression syndrome of the highly vascularized and innervated fat and connective tissue between the ITB and lateral femoral epicondyle 1.

Common Causes

• Repetitive knee flexion and extension during activities like running
• Biomechanical factors:
  • Weakness or inhibition of lateral gluteal muscles 3
  • Poor pelvic stabilization during running
  • Excessive running in the same direction on a track
  • Downhill running
  • Greater-than-normal weekly mileage 3
  • Worn-out shoes with insufficient cushioning 4

Symptoms

• Lateral knee pain, typically at approximately 30 degrees of knee flexion 3
• Pain may be sharp initially and then become diffuse around the lateral knee
• Symptoms often worsen with continued activity

Treatment Approach

Immediate Management

1. Activity modification:

   • Reduce or temporarily cease aggravating activities 3, 2
   • When returning to running, faster-paced running is less likely to aggravate ITBS than slower jogging 3

2. Reduce inflammation:

   • Apply ice through a wet towel for 10-minute periods 5
   • Consider nonsteroidal anti-inflammatory medications 3, 2

Physical Therapy Interventions

1. Stretching:

   • Begin stretching exercises once acute inflammation is controlled 3
   • Focus on stretching the iliotibial band
   • Note: Research shows varying effectiveness of different stretching protocols 6

2. Myofascial release:

   • Address myofascial restrictions before strengthening 3
   • Focus on the TFL/ITB complex

3. Strengthening exercises:

   • Emphasize gluteus medius strengthening 3, 2
   • Include eccentric muscle contractions
   • Incorporate triplanar motions and integrated movement patterns 3
   • Include hip and knee strengthening exercises 5

4. Biomechanical correction:

   • Evaluate and correct running form
   • Consider footwear modifications 4
   • Address any underlying biomechanical issues

Advanced Interventions

1. Corticosteroid injections:

   • Consider if visible swelling or pain with ambulation persists for more than three days after initiating treatment 2
   • May be helpful in severe cases 3

2. Surgical intervention:

   • Rarely required - only for refractory cases 3, 2
   • Most common procedure is releasing or lengthening the posterior aspect of the ITB at the location of peak tension over the lateral femoral condyle 3

Return to Activity

• Gradual return to activity once pain-free
• Begin with faster-paced running rather than slow jogging 3
• Gradually increase distance and frequency
• Continue maintenance exercises, particularly gluteal strengthening
• Consider shoe replacement if worn out 4

Common Pitfalls to Avoid

1. Focusing only on stretching: While stretching is important, addressing gluteal weakness is equally crucial 3, 2

2. Returning to activity too soon: Complete resolution of symptoms before full return to previous activity levels is essential

3. Neglecting biomechanical factors: Shoe wear, running technique, and training patterns all contribute to ITBS 4

4. Overreliance on passive treatments: Active participation in rehabilitation is necessary for successful outcomes 2

5. Misunderstanding the anatomy: The ITB is not a discrete structure that moves freely over the lateral femoral epicondyle but is connected to the femur by fibrous bands 1

Most patients with ITBS will fully recover with conservative management within approximately 6 weeks when following a comprehensive treatment approach 3.