What is the recommended treatment for a 24-year-old female with iliotibial (IT) friction syndrome, mild patella alta, and minor focal superficial chondromalacia patella?

Treatment for IT Band Friction Syndrome, Patella Alta, and Chondromalacia Patella in a 24-Year-Old Female

Begin with conservative management centered on relative rest, eccentric strengthening exercises targeting the hip and knee, NSAIDs for pain control, and address the IT band tightness and patellofemoral tracking issues through specific physical therapy interventions. 1

Initial Conservative Management (First 3-6 Months)

Activity Modification and Rest

• Reduce repetitive loading activities that reproduce pain, particularly running, cycling, stair climbing, and prolonged sitting 1
• Maintain general activity levels to prevent quadriceps atrophy and deconditioning—complete immobilization must be avoided 1, 2
• The goal is relative rest, not complete cessation of activity 1

Pain Management

• NSAIDs (oral or topical) for short-term pain relief during the acute phase to facilitate participation in physical therapy 1
• Topical NSAIDs are preferable as they eliminate gastrointestinal hemorrhage risk while providing equivalent pain relief 1, 2
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief and should be applied repeatedly 1, 2
• NSAIDs do not alter long-term outcomes but facilitate better exercise compliance 1

Core Rehabilitation Program

Eccentric Strengthening Exercises

• Eccentric exercise is the cornerstone of treatment for both patellar tendinopathy and IT band syndrome, reducing symptoms, increasing strength, and promoting tendon healing 1, 2
• Focus on hip-and-knee-targeted exercise therapy given the combination of IT band involvement and patellofemoral pathology 1
• Begin with hip strengthening if knee-loaded exercises are poorly tolerated, then progress to combined hip-knee exercises 1
• Exercise parameters should be modified based on symptom severity and irritability 1

Addressing Patella Alta and Tracking Issues

• Patellar taping assists tracking and provides better patellofemoral stability while reducing mechanical stress 1, 3
• The 2024 British Journal of Sports Medicine guidelines recommend taping when rehabilitation is hindered by elevated symptom severity, irritability, or high fear of movement 1
• Movement retraining should be considered when symptoms are associated with task-specific biomechanics 1

IT Band-Specific Interventions

• Deep transverse friction massage is recommended to reduce pain in both IT band syndrome and patellar pathology 1, 2, 4
• Stretching of the IT band and lateral structures improves mobility and enhances patellar tracking 1, 4
• The modified Ober's test can assess IT band tightness, which has a moderate correlation (r=0.34) with lateral patella displacement 5

Adjunctive Treatments

Orthotics and Bracing

• Prefabricated foot orthoses should be prescribed if the patient responds favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place) 1
• Customize orthoses for comfort by modifying density and geometry 1
• Knee braces with limited range of motion are commonly recommended for patellar instability 6
• Orthotics can correct biomechanical misalignments that contribute to both IT band and patellofemoral symptoms 1

Manual Therapy

• Manual therapy should be considered when rehabilitation is hindered by elevated symptom severity, irritability, or high fear of movement 1
• This provides short-term pain relief to facilitate exercise therapy participation 1

Education

• Education must underpin all interventions, providing rationale for the treatment plan 1
• Build confidence and understanding that pain does not correlate with tissue damage 1
• Develop insight into the recovery journey and expected timeframes (3-6 months for full recovery in approximately 80% of patients) 2, 7
• Promote autonomy and reduce fear of movement 1

Advanced Interventions (If Conservative Management Fails)

Corticosteroid Therapy

• Corticosteroid iontophoresis (not direct injection) is effective for patellar tendon pain and function 1
• Critical pitfall: Never inject corticosteroids directly into tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 2, 7
• Corticosteroid injections may be more effective than NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1

Extracorporeal Shock Wave Therapy

• Safe, noninvasive, and effective for chronic tendinopathies unresponsive to conservative management 1, 7
• Expensive but provides pain relief in carefully selected patients 1

Surgical Considerations

• Surgery is reserved only for patients who fail 3-6 months of well-managed conservative therapy 1, 2, 7
• For IT band syndrome: surgical release of the IT band over the lateral femoral epicondyle 4
• For patellar pathology: arthroscopic or open excision of abnormal tendinous tissue and longitudinal tenotomies 2
• For severe chondromalacia: in adults over 20 years with Grade III-IV changes, patellectomy historically showed 77% satisfactory results, though this is now less commonly performed 8

Critical Pitfalls to Avoid

• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2, 7
• Avoid complete immobilization—this causes muscular atrophy and deconditioning 1, 2
• Avoid multiple corticosteroid injections—they weaken tendon structure despite short-term symptom relief 2
• Do not use cookbook treatment approaches—adapt the rehabilitation program to the patient's specific needs and symptom irritability 1, 3
• If symptoms persist beyond 6 months with appropriate conservative management, revisit assessment findings to ensure interventions align with clinical reasoning 1

Expected Outcomes

• Approximately 80% of patients achieve full recovery within 3-6 months with appropriate conservative treatment 2, 7
• The combination of IT band syndrome, patella alta, and chondromalacia requires addressing both the lateral tracking issues and the underlying biomechanical factors 1, 4