What is the recommended management for iliotibial (IT) syndrome?

Management of Iliotibial Band Syndrome

Conservative management with rest, stretching, activity modification, and anti-inflammatory therapy is the first-line treatment for iliotibial band syndrome, with surgical intervention reserved only for refractory cases that fail 3-6 months of conservative therapy.

Initial Conservative Management (First-Line Treatment)

Phase 1: Acute Symptom Control (2-6 weeks)

• Rest or activity modification is essential, requiring cessation or significant reduction of the aggravating activity (typically running or cycling) 1, 2, 3
• NSAIDs should be initiated for pain control and reduction of inflammation at the lateral femoral epicondyle 1, 4
• Ice application to the lateral knee helps reduce acute inflammation 1
• Iliotibial band stretching must be performed consistently as the cornerstone of treatment 1, 2, 3
• Knee immobilizer and crutches may be necessary for severe cases with pain during ambulation 1

Phase 2: Return to Activity

• Progressive stretching program focusing on the iliotibial band should continue throughout recovery 1, 2, 3
• Gluteus medius strengthening is critical to address underlying biomechanical dysfunction 2
• Gradual return to running should progress only to the point of iliotibial band tightness, not pain 1
• Training regimen modification including changes in running surface, distance, and frequency 2, 4
• Footwear assessment and replacement is necessary, as worn-out or poorly cushioned shoes are common contributing factors 4

Corticosteroid Injection

• Corticosteroid injection should be considered if visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 2
• This intervention targets the inflamed bursa beneath the iliotibial band at the lateral femoral epicondyle 2

Expected Outcomes with Conservative Management

• 44% complete cure rate at 8 weeks with conservative management 3
• 91.7% cure rate at 6 months with continued conservative therapy 3
• Most patients respond to conservative treatment when active participation and compliance with activity modification are maintained 2, 3

Surgical Management (Reserved for Refractory Cases)

Indications for Surgery:

• Failure of conservative management after 3-6 months of compliant treatment 2, 3
• Persistent symptoms preventing return to sport despite optimal conservative therapy 5, 3

Surgical Technique:

• Transection of the posterior half of the iliotibial band where it passes over the lateral femoral epicondyle, with optional removal of the underlying bursa 5
• Alternative approaches include excision or release of the pathologic distal portion of the iliotibial band 3

Surgical Outcomes:

• 100% return to sport rate at 7 weeks to 3 months post-operatively in surgical series 3
• 84.4% good to excellent results (48.9% excellent, 35.5% good) in a 45-patient retrospective series 5
• 75.6% of patients would choose surgery again knowing the outcome 5
• Minimal complications, with only minor postoperative infection reported 5

Critical Management Pitfalls

• Premature return to activity before adequate stretching flexibility is achieved leads to recurrence 1, 2
• Failure to address biomechanical factors including gluteus medius weakness and training errors results in persistent symptoms 2
• Inadequate trial of conservative therapy before considering surgery; at least 3-6 months of compliant conservative management should be attempted 2, 3
• Ignoring footwear issues as worn-out or insufficient cushioning is a major contributing factor in runners 4