Iliotibial Band Syndrome

Overuse syndrome causing lateral knee pain, from compression of richly innervated fat and connective tissue deep to the distal iliotibial band against the lateral femoral epicondyle, at about 30 degrees of knee flexion. The older friction theory is not supported by current evidence.

• It is the commonest cause of lateral knee pain in runners, with an incidence of about 5 to 14% of running injuries, and is also common in cyclists, hikers, rowers, and military recruits.
• Risk factors: sudden increase in training volume, downhill or banked running, long distance running, weak hip abductors, excessive hip adduction and knee internal rotation during stance, narrow step width, high mileage, worn shoes, and in cyclists a saddle that is too high or too far back.
• It affects men and women equally, but female runners have more hip adduction.
• Prognosis is good: most athletes return to sport in 4 to 8 weeks with load modification and strengthening, and about 80% recover without surgery.

• Sharp or burning pain over the lateral femoral epicondyle, 2 to 3 cm proximal to the lateral joint line, starting at a consistent distance or time into a run, worsening on downhill running and stairs, and settling with rest. In severe cases, pain occurs on walking.
• Examination: tenderness over the lateral epicondyle, a positive Noble compression test (pain at about 30 degrees of knee flexion with thumb pressure on the epicondyle as the knee is extended from 90 degrees), tight iliotibial band on Ober test, and hip abductor weakness. Swelling is minimal, and a crepitus may be felt. Knee range, ligaments and menisci are normal.
• Differential diagnosis: lateral meniscal tear (joint line tenderness, locking), lateral collateral ligament injury, popliteus tendinopathy, biceps femoris tendinopathy, lateral patellar compression, common peroneal neuropathy, stress fracture of the lateral femoral condyle or tibia, osteoarthritis, osteochondral lesion, and referred hip or lumbar pain.
• Red flags: locking, giving way, large effusion, night pain, trauma, and fever.
• Complications: chronic pain, prolonged time away from sport, and compensatory injury.

• Clinical. Ask about mileage, surface, shoes, bike set up and recent changes. Assess running gait, hip abductor strength (single leg squat, side lying abduction), leg length and foot mechanics.
• Imaging is not needed initially. Ultrasound can show thickening of the band and fluid. MRI shows fluid and thickening deep to the band and excludes meniscal, ligament and bone injury, and is used when the diagnosis is uncertain or symptoms persist beyond 6 to 8 weeks.
• X-ray if stress fracture or arthritis is suspected.

• Relative rest and load management: reduce running volume and avoid the provoking pattern (downhill, banked surfaces, running to the pain point). Cross train with swimming, pool running or cycling at lower saddle height, as long as it is pain free.
• Analgesia and anti-inflammatory treatment: ice for 10 to 15 minutes after activity, paracetamol 1 g orally 6 hourly, ibuprofen 400 mg 8 hourly with food for 5 to 7 days if no contraindication, or topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily.
• Rehabilitation (the main treatment), for 6 to 12 weeks:
  • Hip abductor and gluteal strengthening: side lying hip abduction, clam shells with a band, side planks, single leg bridges, step downs and single leg squats with control of knee alignment, 3 sets of 10 to 15, 3 to 4 times weekly.
  • Core stability and hip external rotator work.
  • Iliotibial band and tensor fasciae latae flexibility, foam rolling to the lateral thigh (symptomatic effect only).
• Running retraining: increase cadence by 5 to 10% (shorter steps), widen step width, shorten stride, avoid heel first overstriding, and replace worn shoes. Gradual return to running: begin with walk run intervals on flat ground and increase weekly by about 10%, once pain free for walking and stairs.
• Corticosteroid injection for refractory pain: methylprednisolone acetate 20 to 40 mg with lidocaine 1% 2 to 3 mL into the tender area deep to the band near the lateral epicondyle, under ultrasound guidance. It provides relief in a majority for several weeks and helps rehabilitation. Limit to 1 to 2 injections.
• Surgery for failure after 6 months of rehabilitation (rare, below 5%): release, Z-lengthening or excision of the posterior band segment and bursa, with a return to sport in 3 to 6 months.
• Cyclists: lower the saddle (knee flexion about 30 to 35 degrees at the bottom of the stroke), move the saddle forward, and avoid toe in cleat position.
• Special groups:
  • Adolescents: manage load carefully and check for growth related and physeal causes.
  • Pregnancy: physiotherapy, strengthening, and paracetamol. Avoid NSAIDs after 20 weeks.
  • Diabetes: monitor glucose for 3 to 5 days after injection.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 2 to 3 weeks and again at 6 weeks. Refer to sports medicine or orthopaedics for no improvement by 6 to 8 weeks, mechanical symptoms, or diagnostic doubt.