Iliotibialband Syndrome

 

What is Iliotibial band syndrome?

Iliotibial band (ITB) is a thickened band of tissue that runs along the outer side of thigh from the pelvis to the shinbone (just below the knee joint). It helps to transmit forces from the hip to the knee and acts a stabiliser of the outer side of knee, playing an important role in postural control.

With bending and straightening of the knee this band moves over the lower outer end of thigh bone and sometimes repeated motion can cause the ITB to irritate the surrounding tissues. This is addressed as iliotibial band syndrome (ITBS) or IT syndrome. It manifests as pain along the outer side of knee after repetitive motion. Although anyone can develop this condition, it occurs more frequently in athletes and those participating in activities involving frequent knee bending and straightening.

Key points about iliotibial band syndrome

• Iliotibial band syndrome causes pain on the outer side of the knee
• This condition can affect anyone, although is more common in athletes especially runners
• Most people recover with rest, simple painkillers and physical therapy
• Early ultrasound guided injections can be helpful in reliving symptoms and promoting early return to routine activities
• Identifying of the underlying cause is important for preventing reoccurrences

What are the symptoms of ITBS?

Common presenting features include:

• Sharp, stinging, aching or needle-like pain on the outer side of the knee
• This occurs at the same distance, late in or sometimes even after completing a sporting activity. As the condition progresses pain begins earlier in the course of the activity or can even affect the ability to walk or sit with knees bent. 
• Pain tends to be worse every time the heel strikes the ground. Activities such as running downhill, cycling or stairs can make it worse
• Snapping or popping sound from the knee, sometimes associated with swelling
• Pain may radiate upward towards the outer side of the thigh /hip or downwards towards the leg

ITBS is uncommon in the inactive population. It is seen more frequently in

• Long distance runners- incidence ranges from 1.6% – 12%
• Cyclists – accounting for 15–24% of overuse injuries in cyclists
• Athletes participating in hiking, hockey, basketball, tennis, weightlifting, soccer, jumping activities, rowing and skiing
• Military recruits – incidence between 1% to 5.3%
• Those who squat repeatedly

What causes ITBS?

The exact cause of iliotibial band syndrome is not clear and there may be multiple factors contributing to its development. Most popular belief is that this is an overuse injury resulting from friction from the movement of the iliotibial band over the lower outer edge of the thigh bone, as during repeated bending and straightening of the leg. Most contact between the ITB and lower end of thigh bone occurs when the knee is bent (flexed) at 30 degrees, which is the angle at which the foot strikes the ground and hence the maximal pain at this time. Other theories attribute the condition to the abnormal compression of the tissues beneath ITB or to the inflammation in the small fluid-filled sac (bursa) bone and tendons in the area.

A combination of issues may contribute to its development including

• Poor training factors like running on uneven of hilly terrain, abrupt changes in training intensity, running with worn out shoes
• Poor strength and flexibility of muscles such as having weak hip muscles, tight IT band. The hip muscles play an important role in the gait and their weakness places increased strain on ITB
• Other mechanical imbalances such as unequal leg length, arthritis of the inner side of knee or bowed legs. Imbalances may also involve low back and pelvis (abnormal pelvis tilt). These situations can cause the iliotibial band to become excessively tight thus enhancing friction.

ITBS occurs more commonly in association with certain other conditions such as outer hip pain (greater trochanteric pain syndrome/ trochanteric bursitis) and pain along the kneecap (patellofemoral syndrome).

How is this condition diagnosed?

Iliotibial band syndrome can be diagnosed on the basis of history and examination findings. There is often history of recent change in level of activities with the typical symptoms as explained previously. Tenderness on the outer side of knee just above the joint and other special clinical tests can help in the diagnosis. Investigations such as the MRI or ultrasound scans can help confirm the diagnosis and rule out other conditions with similar presentation.

Ultrasound scan has the advantage of being a rapid, low cost, widely available, in clinic investigation which can demonstrate swelling, fluid collection, bursitis and thickening of the ITB. It has the advantage of being able to compare with the other side and carrying out a dynamic assessment (assessment with leg movement). MRI may show thickening, tearing of ITB or swelling above / below the ITB.

What are the treatment options for ITBS?

Optimal management of these patients requires a multidisciplinary team approach with the pain specialists and physiotherapists playing the key role.

Acute phase treatment

During this phase the aim is to relieve pain and limit the inflammatory response. This requires activity limitation or modification and refraining from provoking activities such as running. General principles of management during this phase are

• Refrain from the inciting activity for up to 6 weeks or until the pain has resolved. Activities such as yoga, swimming, walking which do not provoke pain can be continued.
• Rest, ice, compression and elevation (RICE)
• Simple painkillers and anti-inflammatory medications
• Ultrasound guided Injections
• Physiotherapy

Ultrasound guided steroid Injections

Local injections are considered in severe cases where physical therapy and oral medications fail to provide adequate relief. Local injection can help in confirming the diagnosis, providing prolonged pain relief and facilitating early return to routine physical activities, especially when used early in the disease. Ultrasound guidance throughout the procedure is valuable in improving accuracy and reducing complications. Any fluid collection, if present, can be removed at the same time. Post injection activities can be increased in a graded fashion once the patient has been pain free for two weeks.

Subacute phase- Gradual Stretching

Once inflammation is under control exercises focussing on stretching and improving flexibility can be started. This lays the foundation for subsequent strength training. Any contributory factors such as footwear, posture, sports specific technique training etc should be addressed.

Restarting activities

Most patients are able to return to activity within 6 to 8 weeks. ITBS however can have a fluctuating course and may relapse during the treatment or return to activity phase. Stretching of the iliotibial band, gluteus muscles and strengthening of the low back, hips, knees, and leg muscles is frequently recommended as part of the treatment plan to prevent reoccurrences. Improving strength around the hip helps to reduce the forces on the IT band.

Identifying and addressing the underlying causes of the problem is important. It may involve analysis of gait, leg length, pelvic tilt, and that of muscle strength, balance and flexibility.

Surgical intervention is reserved for refractory cases not responding to the above-mentioned measures for more than 6 months. Options include ITB release, ITB lengthening, removal of bursa (ITB bursectomy), and arthroscopic ITB debridement.

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