How to inject corticosteroids (corticosteroid) in a patient with iliotibial (IT) band syndrome?

How to Inject Corticosteroids for Iliotibial Band Syndrome

For IT band syndrome, ultrasound-guided corticosteroid injection should target the space between the iliotibial band and the lateral femoral epicondyle, where bursal inflammation or fluid collection occurs, using strict aseptic technique with the patient positioned supine and the knee flexed at 30 degrees.

Indications for Injection

Corticosteroid injections are indicated when:

• Visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 1
• Symptoms are recurrent or refractory to initial conservative management 2
• The patient has failed rest, stretching, physical therapy, and anti-inflammatory medications 1, 3

Pre-Injection Requirements

Patient Preparation

• Obtain informed consent documenting the nature of the procedure, potential benefits, and risks according to local protocols 4
• Position the patient supine on an examination table with the affected knee flexed at approximately 30 degrees—this is the position where maximum tenderness occurs and optimal access to the inflamed bursa is achieved 5
• Ensure the setting is professional, clean, quiet, private, and well-lit 4

Special Populations

• Diabetic patients must be counseled about transient hyperglycemia risk, particularly days 1-3 post-injection, and advised to monitor glucose levels closely 4
• Pregnant patients can receive local corticosteroid injections as the benefit/risk ratio may be superior to systemic therapy 4
• Patients on anticoagulation or with bleeding disorders can receive injections unless bleeding risk is high 4

Injection Technique

Imaging Guidance

• Ultrasound guidance is strongly recommended to improve accuracy and ensure proper placement between the iliotibial band and lateral femoral epicondyle 4, 2
• Ultrasound findings to identify include soft-tissue edematous swelling or discrete fluid collection suggestive of bursitis between the IT band and lateral femoral epicondyle 2
• While landmark-guided injections can be performed, ultrasound improves accuracy and allows visualization of the target pathology 4

Aseptic Technique (Mandatory)

• Use surgical gloves 4
• Prepare skin with alcohol, iodine disinfectant, or chlorhexidine 4
• Change needles between drawing the medication and injecting into the tissue 4
• Have resuscitation equipment nearby 4

Local Anesthesia

• Offer local anesthetic after explaining pros and cons 4
• Options include topical anesthetic (ethyl chloride spray) or subcutaneous infiltration along the needle path 4
• Warmed local anesthetic (37°C) reduces infiltration pain compared to room temperature 4

Corticosteroid Selection and Dosing

• Methylprednisolone acetate is the most commonly used formulation for soft tissue injections 6, 7
• Alternative options include triamcinolone acetonide 6
• The injection targets the bursal space or area of inflammation between the IT band and lateral femoral epicondyle, not into the band itself 2, 5

Injection Procedure

1. Identify the point of maximal tenderness over the lateral femoral epicondyle with the knee at 30 degrees flexion 5
2. Under ultrasound guidance, advance the needle to the space between the IT band and the lateral epicondyle 2
3. Aspirate if fluid collection is visible to confirm needle placement 4
4. Inject the corticosteroid slowly into the bursal space 5

Post-Injection Care

Immediate Instructions

• Avoid overuse of the injected area for 24 hours following injection 4
• Immobilization is discouraged—gentle range of motion is acceptable 4
• Patients may eat and drink immediately after the procedure 8

Activity Modification

• Continue activity modification and training regimen adjustments 1, 3
• Maintain stretching of the iliotibial band and strengthening of the gluteus medius 1
• Address training irregularities including distance, speed, terrain, surface, and footwear 3

Monitoring and Follow-Up

• Most patients with IT band syndrome respond within days to weeks when injection is combined with activity modification 1, 3
• Symptoms often persist 2-6 months without proper treatment 3
• Re-injection decisions should consider benefits from previous injections, treatment alternatives, and individual factors 4
• A small percentage of patients are refractory to conservative treatment including injections and may require surgical release of the posterior fibers of the IT band 1, 5

Critical Pitfalls to Avoid

• Never inject into an infected site—rule out septic process before injection 7
• Do not inject directly into the IT band itself; target the bursal space beneath it 2
• Avoid repeated injections without addressing underlying biomechanical factors and training errors 1, 3
• Do not use corticosteroids as first-line treatment before attempting conservative measures 1
• Be aware that systemic absorption can occur even with local injection, particularly with larger doses 7