What is the treatment for a patient with iliotibial (IT) band syndrome presenting with knee pain and tenderness on the lateral aspect of the knee, exacerbated by passive flexion?

Treatment of Iliotibial Band Syndrome

The primary treatment for IT band syndrome is activity modification with complete cessation of running until pain-free, combined with IT band stretching, hip abductor strengthening (particularly gluteus medius), and corticosteroid injection if pain persists beyond 3 days despite conservative measures. 1

Immediate Management

Activity Modification

• Stop running immediately and avoid all activities that reproduce the lateral knee pain 1, 2
• The patient should not attempt to "run through" the pain, as this will perpetuate the inflammatory cycle and delay recovery 1
• Substitute with non-impact activities (swimming, cycling at low resistance) that do not provoke symptoms 1

Initial Conservative Treatment

Stretching Protocol:

• IT band stretching is the cornerstone of conservative management and must be performed consistently 1, 2
• Stretch the IT band by crossing the affected leg behind the unaffected leg and leaning away from the affected side 1
• Hold stretches for 30 seconds, repeat 3-4 times, perform 3-5 times daily 1

Hip Abductor Strengthening:

• Gluteus medius strengthening is essential to correct excessive hip adduction during running 1, 3
• Side-lying hip abduction exercises, clamshells, and single-leg stance exercises should be prescribed 3
• Caution: While hip abductor strengthening corrects aberrant mechanics, it may paradoxically increase IT band strain initially, so progression should be gradual 4

Pharmacologic and Injection Therapy

Corticosteroid Injection:

• Inject corticosteroid at the point of maximal tenderness over the lateral femoral epicondyle if visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 1, 2
• This addresses the local inflammation and can provide significant relief 2
• The injection site should be at the lateral epicondyle where the IT band crosses during knee flexion at approximately 30 degrees 2

NSAIDs:

• Oral or topical NSAIDs can be used to manage inflammation and pain during the acute phase 1
• These are adjunctive to mechanical interventions, not primary treatment 1

Addressing Contributing Factors

Training Modifications:

• Evaluate and correct training errors including excessive mileage increases (should not exceed 10% per week), inadequate rest days, and running on cambered surfaces 1, 3
• Running downhill or on banked tracks places increased stress on the IT band and should be avoided during recovery 1

Footwear Assessment:

• Worn-out running shoes with inadequate lateral support contribute to IT band syndrome 3
• Replace shoes every 300-500 miles 3
• Consider evaluation for excessive foot pronation which may require orthotics 3

Regional Interdependence:

• Assess and address lumbar spine and hip mobility restrictions, as these can contribute to altered running mechanics 3
• Evaluate for leg length discrepancy which may predispose to IT band syndrome 3

Return to Running Protocol

• Do not resume running until the patient can perform daily activities and walk without pain 1, 2
• Begin with walk-run intervals on flat, even surfaces 1
• Gradually increase running duration by no more than 10% per week 3
• Continue IT band stretching and hip strengthening throughout return to activity 1

Surgical Intervention

Indications for Surgery:

• Surgical release of the posterior fibers of the IT band should be considered only after failure of at least 6 months of comprehensive conservative treatment 2, 5
• Surgery is rarely needed, with only approximately 4% of patients (9 of 221 in one series) requiring operative intervention 2
• Surgical options include release of the posterior IT band fibers or excision of the inflamed bursa beneath the IT band 5

Common Pitfalls to Avoid

• Premature return to running: This is the most common cause of recurrence and chronicity 1
• Inadequate stretching compliance: Intermittent or inconsistent stretching is unlikely to provide benefit 4, 1
• Ignoring training errors: Failing to address the underlying biomechanical and training factors leads to symptom recurrence 1, 3
• Overreliance on passive treatments: Corticosteroid injections without addressing mechanical factors and training modifications will result in recurrence 1