How to treat weakness and pain in the left knee with IT (Iliotibial) band syndrome 2 years after bilateral total knee replacement surgery?

Management of Weakness, Pain, and IT Band Syndrome 2 Years Post-Bilateral TKA

Initial Diagnostic Approach

Begin with plain radiographs of the left knee to evaluate for aseptic loosening, osteolysis, component malposition, or periprosthetic fracture—these are the most common causes of late pain after TKA. 1, 2

Key Clinical Assessment Points

• Characterize the pain pattern precisely: Pain on weight-bearing suggests aseptic loosening or component wear, while night pain or pain at rest raises concern for infection 2, 3
• Assess for infection signs: Warmth, erythema, fever, or systemic symptoms warrant immediate infection workup via joint aspiration, as periprosthetic infection is the most serious complication requiring urgent management 2
• Evaluate for instability: At 2 years post-TKA, aseptic loosening is a leading cause of late-stage failure and often coexists with instability and osteolysis 1

Diagnostic Imaging Algorithm

First-Line Imaging

• Obtain weight-bearing radiographs of the left knee to assess component positioning, alignment, progressive lucencies >2mm, and osteolysis 1, 2

Advanced Imaging Based on Radiographic Findings

If radiographs suggest aseptic loosening or osteolysis:

• CT knee without IV contrast (rated 8/9 for appropriateness) is the preferred modality for quantifying osteolysis and assessing the bone-implant interface 1
• MRI without contrast (rated 6/9) may be considered as an alternative for evaluating surrounding soft tissues 1

If component rotation or malposition is suspected:

• CT scan without IV contrast (rated 9/9) is the imaging modality of choice 4

If infection cannot be excluded clinically:

• Proceed to joint aspiration for cell count, culture, and sensitivity after reviewing radiographs 2

Management of IT Band Syndrome Post-TKA

Conservative Treatment (First-Line for 3 Months)

IT band syndrome after TKA requires active patient participation with activity modification and structured physical therapy. 5, 6

• Stretching of the iliotibial band is the cornerstone of conservative management 5
• Strengthening of the gluteus medius to address biomechanical contributors 5
• Activity modification: Reduce repetitive flexion-extension activities that aggravate symptoms 5, 7
• NSAIDs as first-line pain management for inflammation control 3

Corticosteroid Injection Indication

• Consider corticosteroid injection if visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 5
• Ultrasound can guide injection and confirm ITB enthesopathy (rated 7/9 for appropriateness for soft tissue evaluation) 4, 8

Surgical Management

If conservative treatment fails after 3 months, selective open release of the ITB should be performed. 6, 9

Specific Surgical Considerations Post-TKA:

• Evaluate for mechanical obstruction under the ITB: Extruded cement at the lateral femoral component, sharp-edged bearing components, or lateral osteophytes can cause ITB friction syndrome after TKA 9
• Excision of the obstruction completely relieves symptoms when mechanical irritation is the cause 9
• Selective ITB release is effective when no mechanical obstruction is identified 6

Management of Weakness

Quadriceps weakness >20% deficit predicts significant strength deficits until 2 years post-ACLR, and similar principles apply to post-TKA rehabilitation. 1

• Measure quadriceps and hamstring strength bilaterally to quantify the deficit 1
• Isometric quadriceps exercises should be performed when they provoke no pain 1
• Electrostimulation in combination with conventional rehabilitation may improve muscle strength for up to 2 months, though long-term functional benefit is inconclusive 1
• Continue structured rehabilitation for 9-12 months depending on functional goals 1

Critical Pitfalls to Avoid

• Do not dismiss lateral knee pain as simple IT band syndrome without ruling out aseptic loosening: At 2 years post-TKA, aseptic loosening is a major cause of late failure and can present with lateral-sided pain 1
• Do not obtain bone scans routinely: Positive bone scans occur in 12.5% of asymptomatic knees at 2 years post-TKA, making interpretation difficult 1
• Do not delay surgical referral: If conservative IT band treatment fails after 3 months or if radiographs show concerning findings, refer back to the orthopedic surgeon 4, 2, 6

Follow-Up Recommendations

• Annual weight-bearing radiographs are recommended for detecting subclinical wear and osteolysis 4, 2
• Reassess at 3 months if conservative IT band management is pursued; surgical intervention should be considered if symptoms persist 6