What is the treatment for iliotibial (IT) band tendinitis?

Treatment for Iliotibial Band Tendinitis

Begin with 3-6 months of conservative management including relative rest, eccentric strengthening exercises, ITB stretching, gluteus medius strengthening, and NSAIDs before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest by avoiding activities that worsen lateral knee pain while maintaining some activity to prevent muscle atrophy and deconditioning 1
• Modify training regimens to reduce repetitive knee flexion-extension cycles that irritate the distal ITB 1
• Most patients (approximately 80%) with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 2

Stretching Program (Cornerstone of Treatment)

• ITB stretching should be the primary focus, as it directly addresses the tight fascial band causing lateral knee friction 1
• Perform stretches daily when pain and stiffness are minimal 3
• Begin with a warm shower or superficial moist heat application before stretching 3
• Hold each stretch for 10-30 seconds, breathing normally throughout 3
• Current evidence supports including ITB stretching in early rehabilitation, though its isolated contribution within multimodal treatment remains unclear 4

Strengthening Exercises

• Gluteus medius strengthening is essential to correct biomechanical dysfunction contributing to ITB syndrome 1
• Eccentric strengthening exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers 2
• Progress from basic strengthening to sport-specific exercises as symptoms improve 3

Pain Management

• Oral or topical NSAIDs provide effective short-term pain relief in the acute phase 2, 1
• Topical NSAIDs are preferable due to elimination of gastrointestinal hemorrhage risk 2
• Ice application through a wet towel for 10-minute periods reduces tissue metabolism and blunts inflammatory response 5

Adjunctive Physical Therapy Modalities

• Deep transverse friction massage may reduce pain when combined with other interventions 2, 6
• Ultrasound can be used as an adjunct to evaluate ITB syndrome and follow treatment progress 7

Second-Line Treatment (If No Improvement After Initial Conservative Care)

Corticosteroid Injections

• Consider corticosteroid injections only if visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 1
• Injections may be more effective than oral NSAIDs for acute phase pain relief but do not improve long-term outcomes 5, 6
• Critical pitfall: Avoid direct injection into the ITB substance itself, as this inhibits healing, reduces tensile strength, and may predispose to rupture 5
• Inject around the inflamed bursa or tissue, not into the tendon structure 5

Other Modalities with Limited Evidence

• Phonophoresis has been studied but shows limited evidence of significant benefit 6
• Extracorporeal shock wave therapy appears safe but requires further research and is costly 5

Surgical Management (For Refractory Cases)

Indications for Surgery

• Surgical evaluation is warranted only if pain persists despite 3-6 months of well-managed conservative treatment 2, 1
• A small percentage of patients are refractory to conservative treatment and require surgical intervention 1

Surgical Techniques

• Arthroscopic or open release of the distal ITB 8, 9
• Excision of the pathologic distal portion of the ITB 9
• Bursectomy of the inflamed bursa beneath the ITB 9
• Studies focusing on excision or release show 100% return to sport rates at 7 weeks to 3 months post-surgery 9

Treatment Algorithm

Weeks 1-2:

• Relative rest from aggravating activities 1
• Ice application for acute pain 5
• Begin gentle ITB stretching 1
• Initiate gluteus medius strengthening 1
• NSAIDs for pain control 1

Weeks 2-6:

• Progressive eccentric strengthening exercises 2
• Continue and advance ITB stretching program 1
• Deep transverse friction massage 2
• If visible swelling or pain with ambulation persists >3 days, consider corticosteroid injection 1

Weeks 6-12:

• Sport-specific exercises 3
• Gradual return to running or cycling activities 3
• Maintenance stretching and strengthening program 3

Beyond 3-6 months:

• If symptoms persist despite well-managed conservative care, refer for surgical evaluation 2, 1

Common Pitfalls to Avoid

• Do not inject corticosteroids directly into the ITB substance 5
• Avoid complete immobilization, which leads to muscle atrophy 5
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 2
• Do not neglect gluteus medius strengthening, as proximal hip weakness is a key contributing factor 1
• Avoid returning to full activity too quickly before adequate stretching and strengthening have been achieved 1

Evidence Quality Note

The systematic review by Gunter and Schwellnus (2004) highlights the paucity in both quantity and quality of research regarding conservative treatment of ITBS, with limited evidence suggesting significant benefit from the specific treatments studied 6. However, clinical experience and lower-quality evidence support the multimodal conservative approach outlined above, with most patients responding favorably 1, 9.