What is the diagnosis and treatment for pain at the lateral aspect of the knee above the joint line near the lateral femoral epicondyle in a runner?

Iliotibial Band Syndrome (ITBS)

This is iliotibial band syndrome (ITBS), the most common cause of lateral knee pain in runners, resulting from repetitive friction of the iliotibial band over the lateral femoral epicondyle at approximately 30 degrees of knee flexion. 1, 2

Clinical Presentation

The pain is characteristically:

• Located directly over the lateral femoral epicondyle, above the joint line 1, 3
• Aggravated by running long distances, excessive striding, and particularly downhill running 3, 4
• Often poorly localized initially but becomes more specific with continued activity 3
• May radiate downward along the iliotibial tract 4
• Can be prevented temporarily by walking with a stiff knee 3

Key Diagnostic Features

On examination, look for:

• Point tenderness directly over the lateral femoral epicondyle 1, 2
• Weakness or inhibition of the lateral gluteal muscles (hip abductors), which is a primary causative factor 1, 2
• Pain reproduction with knee flexion at approximately 30 degrees where maximal impingement occurs 1
• History of overtraining, excessive weekly mileage, or repetitive same-direction track running 1, 2

Treatment Algorithm

Acute Phase (First 1-2 Weeks)

• Activity modification: reduce or temporarily cease running 1, 2
• Ice application through wet towel for 10-minute periods 5
• NSAIDs (oral or topical) for inflammation control 1, 2
• Corticosteroid injection for severe pain or swelling - most patients require 1-2 injections, though some need up to 3 2, 3

Subacute Phase (Weeks 2-4)

Once acute inflammation subsides:

• Stretching exercises for the iliotibial band 1, 2
• Deep transverse friction massage and soft tissue therapy to eliminate myofascial restrictions - this must precede strengthening 5, 1
• Continue relative rest from aggravating activities 5

Recovery Phase (Weeks 4-6)

• Eccentric strengthening exercises emphasizing hip abductor muscles (gluteus medius/minimus) 5, 1
• Focus on triplanar motions and integrated movement patterns 1
• Biomechanical correction with orthotics if excessive foot pronation is present 5

Return to Running Phase

• Begin with faster-paced running rather than slow jogging - biomechanical studies show faster strides are less likely to aggravate ITBS 1
• Start with easy sprints on an every-other-day program 2
• Avoid hill training initially, particularly downhill running 2, 3
• Gradually increase distance and frequency over time 1, 2

Expected Outcomes

Most patients fully recover by 6 weeks with this comprehensive conservative approach 1. In the original series of 100 knees, 30% resolved with single injection and training modification, 21% required two injections, and 8% needed three injections 3. Only 14% required complete rest from running for 4-6 weeks, and surgery was needed in just 5% of refractory cases 3.

Surgical Consideration

Surgery should only be considered after 3-6 months of failed conservative treatment 5, 1. The procedure involves releasing or lengthening the posterior aspect of the ITB at the location of peak tension over the lateral femoral condyle 1, 6.

Critical Pitfalls

• Do not completely immobilize the knee - this causes muscular atrophy and deconditioning 5
• Never inject corticosteroids directly into the ITB substance - only inject around the area of inflammation to avoid tendon rupture 5
• Do not begin strengthening exercises before addressing myofascial restrictions - soft tissue therapy must precede strengthening 1
• Avoid returning to slow jogging pace initially - faster strides create less impingement at 30 degrees of flexion 1