Iliotibial band syndrome
- Jonathan Jackson, MD
Jonathan Jackson, MD
- Assistant Professor of Family Medicine
- Uniformed Services University of the Health Sciences
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Iliotibial band syndrome (ITBS) is an overuse injury of the lateral knee that occurs primarily in runners and was first described in 1973 . Pain develops where the iliotibial band (ITB) courses over the lateral femoral epicondyle (LFE), just proximal to the lateral joint line.
This topic will review the epidemiology, risk factors, clinical presentation, and treatment of ITBS. Undifferentiated knee pain and common causes of such pain are discussed separately. (See "Overview of running injuries of the lower extremity" and "Patellofemoral pain" and "Meniscal injury of the knee" and "Anterior cruciate ligament injury" and "Physical examination of the knee".)
Overall rates of iliotibial band syndrome (ITBS) vary from 2 to 25 percent in physically active individuals; the syndrome has not been reported in those who do not exercise [2,3]. ITBS is the second most common cause of knee pain due to overuse after patellofemoral dysfunction [4-6]. The problem is most common in runners, military personnel, and cyclists, but has also been described in Nordic skiers, soccer players, and other athletes [1-3,7,8]. Based upon limited observational studies, ITBS affects approximately 1.6 to 12 percent of runners [2,4-7,9]. The relative incidence among runners has increased over the past three decades for unknown reasons [2,6,9]. Up to 50 percent of cyclists experience knee pain [10,11]. In one observational study of 254 cyclists over six years, 24 percent of the cyclists presenting to a sports medicine clinic for knee pain were diagnosed with ITBS . Competitive cyclists who are frequently pedaling against high resistance may be at higher risk.
The iliotibial band (ITB) is a fibrous band that runs longitudinally along the lateral aspect of the thigh from its origin at the iliac crest to the proximal tibia (figure 1). Proximally, the tensor fascia lata, gluteus maximus, gluteus medius, and vastus lateralis all have connections to the ITB. The ITB has broad attachments to multiple structures at the lateral knee, including the quadriceps-patella-patellar tendon complex, the lateral femoral epicondyle (LFE), and the biceps femoris muscle-tendon-fibula complex. Distally, the ITB courses over the LFE, before inserting at Gerdy’s tubercle at the anterolateral tibia just below the knee joint line (picture 1) [12-14].
BIOMECHANICS AND PATHOPHYSIOLOGY
The iliotibial band (ITB) is thought to assist with knee extension when the knee is near terminal extension, and with knee flexion once the knee is flexed beyond 30 degrees (figure 2) [2,15,16]. The ITB also provides lateral knee stability .
- Staff PH, Nilsson S. Tendoperiostitis in the lateral femoral condyle in long-distance runners. Br J Sports Med 1980; 14:38.
- Orava S. Iliotibial tract friction syndrome in athletes--an uncommon exertion syndrome on the lateral side of the knee. Br J Sports Med 1978; 12:69.
- Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med 1996; 24:375.
- Ellis R, Hing W, Reid D. Iliotibial band friction syndrome--a systematic review. Man Ther 2007; 12:200.
- Pinshaw R, Atlas V, Noakes TD. The nature and response to therapy of 196 consecutive injuries seen at a runners' clinic. S Afr Med J 1984; 65:291.
- Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95.
- Noble CA. Iliotibial band friction syndrome in runners. Am J Sports Med 1980; 8:232.
- Renne JW. The iliotibial band friction syndrome. J Bone Joint Surg Am 1975; 57:1110.
- Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000; 10:169.
- Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. Knee 2003; 10:103.
- Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in cyclists. Am J Sports Med 1993; 21:419.
- Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat 2006; 208:309.
- Falvey EC, Clark RA, Franklyn-Miller A, et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports 2010; 20:580.
- Whiteside LA, Roy ME. Anatomy, function, and surgical access of the iliotibial band in total knee arthroplasty. J Bone Joint Surg Am 2009; 91 Suppl 6:101.
- Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc 1995; 27:951.
- Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg 2011; 19:728.
- Louw M, Deary C. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners - A systematic review of the literature. Phys Ther Sport 2014; 15:64.
- Noble CA. The treatment of iliotibial band friction syndrome. Br J Sports Med 1979; 13:51.
- Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM R 2011; 3:550.
- Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport 2007; 10:74.
- Jelsing EJ, Finnoff JT, Cheville AL, et al. Sonographic evaluation of the iliotibial band at the lateral femoral epicondyle: does the iliotibial band move? J Ultrasound Med 2013; 32:1199.
- Hariri S, Savidge ET, Reinold MM, et al. Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes. Am J Sports Med 2009; 37:1417.
- Jelsing EJ, Finnoff J, Levy B, Smith J. The prevalence of fluid associated with the iliotibial band in asymptomatic recreational runners: an ultrasonographic study. PM R 2013; 5:563.
- Muhle C, Ahn JM, Yeh L, et al. Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology 1999; 212:103.
- Nishimura G, Yamato M, Tamai K, et al. MR findings in iliotibial band syndrome. Skeletal Radiol 1997; 26:533.
- Nemeth WC, Sanders BL. The lateral synovial recess of the knee: anatomy and role in chronic Iliotibial band friction syndrome. Arthroscopy 1996; 12:574.
- Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther 2010; 40:52.
- Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006 prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon) 2007; 22:951.
- Miller RH, Lowry JL, Meardon SA, Gillette JC. Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Gait Posture 2007; 26:407.
- Grau S, Krauss I, Maiwald C, et al. Kinematic classification of iliotibial band syndrome in runners. Scand J Med Sci Sports 2011; 21:184.
- Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med 2005; 35:451.
- Ferber R, Kendall KD, McElroy L. Normative and critical criteria for iliotibial band and iliopsoas muscle flexibility. J Athl Train 2010; 45:344.
- van der Worp MP, van der Horst N, de Wijer A, et al. Iliotibial band syndrome in runners: a systematic review. Sports Med 2012; 42:969.
- Beers A, Ryan M, Kasubuchi Z, et al. Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiother Can 2008; 60:180.
- MacMahon JM, Chaudhari AM, Andriacchi TP. Biomechanical injury predictors for marathon runners: striding towards iliotibial band syndrome injury prevention. ISBS-Conference Proceedings Archive 2000, Vol. 1, No. 1. https://ojs.ub.uni-konstanz.de/cpa/article/view/2485 (Accessed on June 06, 2013).
- Grau S, Krauss I, Maiwald C, et al. Hip abductor weakness is not the cause for iliotibial band syndrome. Int J Sports Med 2008; 29:579.
- Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskelet Disord 2015; 16:356.
- Noehren B, Schmitz A, Hempel R, et al. Assessment of strength, flexibility, and running mechanics in men with iliotibial band syndrome. J Orthop Sports Phys Ther 2014; 44:217.
- Jenkins J, Beazell J. Flexibility for runners. Clin Sports Med 2010; 29:365.
- Brady RJ, Dean JB, Skinner TM, Gross MT. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther 2003; 33:221.
- Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med 2006; 16:261.
- Barton CJ, Bonanno DR, Carr J, et al. Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. Br J Sports Med 2016; 50:513.
- Lavine R. Iliotibial band friction syndrome. Curr Rev Musculoskelet Med 2010; 3:18.
- Gajdosik RL, Sandler MM, Marr HL. Influence of knee positions and gender on the Ober test for length of the iliotibial band. Clin Biomech (Bristol, Avon) 2003; 18:77.
- Willett GM, Keim SA, Shostrom VK, Lomneth CS. An Anatomic Investigation of the Ober Test. Am J Sports Med 2016; 44:696.
- Bonaldi VM, Chhem RK, Drolet R, et al. Iliotibial band friction syndrome: sonographic findings. J Ultrasound Med 1998; 17:257.
- De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures. Skeletal Radiol 2014; 43:1025.
- Mansour R, Yoong P, McKean D, Teh JL. The iliotibial band in acute knee trauma: patterns of injury on MR imaging. Skeletal Radiol 2014; 43:1369.
- Baker RL, Fredericson M. Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Phys Med Rehabil Clin N Am 2016; 27:53.
- Schwellnus MP, Theunissen L, Noakes TD, Reinach SG. Anti-inflammatory and combined anti-inflammatory/analgesic medication in the early management of iliotibial band friction syndrome. A clinical trial. S Afr Med J 1991; 79:602.
- Fredericson M, White JJ, Macmahon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil 2002; 83:589.
- Wang HK, Ting-Fang Shih T, Lin KH, Wang TG. Real-time morphologic changes of the iliotibial band during therapeutic stretching; an ultrasonographic study. Man Ther 2008; 13:334.
- Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev 2002; :CD003528.
- Schwellnus M, Mackintosh L, Mee J. Deep transverse frictions in the treatment of iliotibial band friction syndrome in athletes: a clinical trial. Physiotherapy 1992; 78:564.
- Gurney B. Leg length discrepancy. Gait Posture 2002; 15:195.
- McCaw ST, Bates BT. Biomechanical implications of mild leg length inequality. Br J Sports Med 1991; 25:10.
- Hill J, Howatson G, van Someren K, et al. Compression garments and recovery from exercise-induced muscle damage: a meta-analysis. Br J Sports Med 2014; 48:1340.
- Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. Br J Sports Med 2004; 38:269.
- Pandit SR, Solomon DJ, Gross DJ, et al. Isolated iliotibial band rupture after corticosteroid injection as a cause of subjective instability and knee pain in a military special warfare trainee. Mil Med 2014; 179:e469.
- Wanich T, Hodgkins C, Columbier JA, et al. Cycling injuries of the lower extremity. J Am Acad Orthop Surg 2007; 15:748.
- Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomech 2012; 11:464.
- Hein T, Schmeltzpfenning T, Krauss I, et al. Using the variability of continuous relative phase as a measure to discriminate between healthy and injured runners. Hum Mov Sci 2012; 31:683.
- Heiderscheit BC, Chumanov ES, Michalski MP, et al. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc 2011; 43:296.
- BIOMECHANICS AND PATHOPHYSIOLOGY
- RISK FACTORS
- CLINICAL FEATURES
- Patient presentation
- Physical examination
- DIAGNOSTIC IMAGING
- INDICATIONS FOR ORTHOPEDIC REFERRAL
- DIFFERENTIAL DIAGNOSIS
- Acute phase: Symptom control
- Subacute phase: Correct strength and mobility deficits
- Chronic phase
- Adaptation phase: Return to sport
- FOLLOW-UP CARE
- SUMMARY AND RECOMMENDATIONS