Medicine:Iliotibial band syndrome

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Iliotibial band syndrome
Other namesIliotibial band friction syndrome (ITBFS)[1]
Iliotibial band syndrome-en.svg
SpecialtySports medicine, orthopedics

Iliotibial band syndrome (ITBS) is the second most common knee injury, and is caused by inflammation located on the lateral aspect of the knee due to friction between the iliotibial band and the lateral epicondyle of the femur.[2] Pain is felt most commonly on the lateral aspect of the knee and is most intensive at 30 degrees of knee flexion.[2] Risk factors in women include increased hip adduction and knee internal rotation.[2][3] Risk factors seen in men are increased hip internal rotation and knee adduction.[2] ITB syndrome is most associated with long-distance running, cycling, weight-lifting, and with military training.[4][5]

Signs and symptoms

ITBS symptoms range from a stinging sensation just above the knee and outside of the knee (lateral side of the knee) joint, to swelling or thickening of the tissue in the area where the band moves over the femur. The stinging sensation just above the knee joint is felt on the outside of the knee or along the entire length of the iliotibial band. At initial symptom onset pain typically occurs following activity, but as the condition progresses pain is frequently felt during activities and may be present at rest.[6] Pain may also be present above and below the knee, where the ITB attaches to the tibia.[7] Pain is frequently worsened by running up or downhill or by stride lengthening.[8]

Risk Factors

ITBS is associated with various risk factors including training habits, anatomical abnormalities, or muscular imbalances:[9]

Anatomical mechanism

Iliotibial band syndrome is one of the leading causes of lateral knee pain in runners. The iliotibial band is a thick band of fascia composing the tendon of the tensor fascia latae muscle. It is located on the lateral aspect of the knee, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band serves to stabilizing the knee. It has been proposed that during activity such as running and cycling the iliotibial band slides back and forth over the lateral femoral epicondyle, which causes friction and inflammation of the band.[6] It has also been suggested that symptoms are caused by impingement of the iliotibial band in the knee during 30 degree flexion, which is a position common in running and cycling.[11] Additional proposed mechanisms causing the symptoms of ITBS include compression of the fat and soft tissues beneath the iliotibial band, and chronic iliotibial band bursitis.[6]

Diagnosis

Diagnosis of iliotibial band syndrome is primarily based on history and physical exam findings, including tenderness at the lateral femoral epicondyle, where the iliotibial band passes over the bone.[12]

Differential Diagnosis

Other conditions that may present with knee pain similar to ITBS that must be differentiated include a lateral meniscus tear, degerative joint disease, teninopathy of the biceps femoris, stress fracture, patellofemoral pain syndrome, and injury to the lateral collateral ligament.[6]

Exam Maneuvers

There are several physical exam maneuvers used to test iliotibial band function and provoke symptoms diagnostic of ITBS. The Noble test is used to assess for iliotibial band disfuction, in which the examiner extends the patient's knee from the 90 degree position with pain over the lateral femoral epicondyle occurring at 30 degrees of flexion. Additional tests include the Ober test to detect iliotibial band contracture, where the patient lies on their side and the examiner attempts to abduct, extend, and then adduct the leg. A positive test occurs with inability to adduct the leg due to iliotibial band shortening. The Thomas test is used to detect excessive tightness of the iliotibial band. In this test the patient holds the unaffected leg to their chest while the examiner straightens and lowers the other leg to a horizonal position, inability to fully straighten and lower the leg indicates excessive band tightness.[13][14][15]

The iliotibial band may be assessed by MRI in severe cases.

Imaging

Imaging studies are generally not needed for diagnosis of ITBS, as characteristic symptoms and physical exam findings are sufficient for diagnosis. However, in severe or persistent cases MRI may be used to confirm the diagnosis as well as rule out other causes of lateral knee pain. Ultrasonography may also be used to evaluate disease progression by measuring iliotibial band thickness.[6]

Treatment

Conservative treatments

While ITBS pain can be acute, the iliotibial band can be treated conservatively with rest, ice, compression and elevation (RICE) to reduce pain and inflammation, followed by stretching.[16] Utilization of corticosteroid injections and the use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) or topical NSAIDs on the painful area are possible treatments for ITB syndrome. Corticosteroid injections have been shown to decrease running pains significantly 7 days after the initial treatment.[17] Similar results can be found with the use of anti-inflammatory medication, analgesic/anti-inflammatory medication, specifically.[17] Physical therapy is an effective treatment modality, with the goal of stretching the iliotibial band, tensor fascia latae, and gluteus medius.[6] Other non-invasive treatments include modalities such as flexibility and strength training, neuromuscular/gait training, manual therapy, training volume reduction, myofascial release, or changes in running shoe.[2][17][3][18]  Muscular training of the gluteus maximus and hip external rotators is stressed highly as those muscles are associated with many of the risk factors of ITBS.[2] For runners specifically, neuromuscular/gait training may be needed for success in muscular training interventions to ensure that those trained muscles are used properly in the mechanics of running.[2] Strength training alone will not result in decrease in pain due to ITBS, however, gait training, on its own can result in running form modification that reduces the prevalence of risk factors.[3]

Surgical treatments

Surgery treatments are utilized if several conservative approaches fail to produce results.[17] 6 months of conservative treatments are generally used before surgical intervention.[3] Surgery typically involves removal of a small piece of the iliotibial band to release excessive tension. Other procedures that have been utilized include resection of the iliotibial band bursa and z-lengthening. In the z-lengthening procedure, two horizontal incisions are made in the band and connected by a vertical incision, forming a z. The resulting sections are reattached together in a lengthened position, increasing the length of the band.[6]

Prognosis

ITBS symptoms typically improve with treatment. An estimated 50-90% of patients have symptom resolution with 4-8 weeks of conservative treatment, while surgical patients also generally have good outcomes.[19] Complications of ITBS include recurrence and exacerbation by return to activity following treatment, as well as possible progression to patellofemoral pain syndrome.[19]

Epidemiology

Occupation

ITBS commonly affects athletes and has been reported in runners, cyclists, rowers, skiers, and triathletes, as well as basketball, soccer, and field hockey players.[6]

Significant association between the diagnosis of ITBS and occupational background of the patients has been thoroughly determined. Occupations that require extensive use of iliotibial band are more susceptible to develop ITBS due to continuum of their iliotibial band repeatedly abrading against lateral epicondyle prominence, thereby inducing inflammatory response. Professional or amateur runners are at high clinical risk of ITBS in which shows particularly greater risk in long-distance. Study suggests ITBS alone makes up 12% of all running-related injuries and 1.6% to 12% of runners are affected by ITBS.[20]

The relationship between ITBS and mortality/morbidity is claimed to be absent. A study showed that coordination variability did not vary significantly between runners with no injury and runners with ITBS.[21] This result elucidates that the runner's ability to coordinate themselves toward direction of their intention (motor coordination) is not, or very minorly affected by the pain of ITBS.[22]

Additionally, military trainee in marine boot camps displayed high incidence rate of ITBS. Varying incidence rate of 5.3–22% in basic training was reported in a case study. A report from the U.S. Marine Corps announces that running/overuse-related injuries accounted for >12% of all injuries.[23]

Studies suggest that there is not a difference in ITBS incidence rate between patients of different race, gender, or age. However, there has been a claim that females are more prone to ITBS due to their anatomical differences in the pelvis and lower extremities. Males with a larger lateral epicondyle prominence may also be more susceptible to ITBS.[24]  Higher incidence rate of ITBS has been reported between the ages of 15 and 50, which generally includes most active athletes.[25]

Other professions that had noticeable association with ITBS include cyclists, heavy weightlifters, et cetera. One observational study discovered 24% of 254 cyclists were diagnosed with ITBS within 6 years.[26] A study provided data that shows more than half (50%) of professional cyclists complain of knee pain.[27] Additional studies have shown that ITBS makes up 15-24% of all overuse injuries in cyclists.[6]

History

ITBS was originally described by Lieutenant Commander James W. Renne in 1975 after observing frequent lateral knee pain in recuits participating in intensive military training. He initially named the syndrome iliotibial band friction syndrome.[28]

See also

References

  1. ↑ Ellis, R; Hing, W; Reid, D (August 2007). "Iliotibial band friction syndrome—A systematic review". Manual Therapy 12 (3): 200–8. doi:10.1016/j.math.2006.08.004. PMID 17208506. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Baker, Rober L.; Fredericson, Michael (2016). "ClinicalKey". https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1047965115000650?scrollTo=#hl0000423. 
  3. ↑ 3.0 3.1 3.2 3.3 Neal, Bradley (2016). "Iliotibial Band Syndrome: A Narrative Review". Co-Kinetic Journal 67: 16–20. 
  4. ↑ Iliotibial Band Syndrome: Background, Epidemiology, Functional Anatomy. 2019-11-10. https://emedicine.medscape.com/article/91129-overview#a6. 
  5. ↑ Hadeed, Andrew; Tapscott, David C. (2019), "Iliotibial Band Friction Syndrome", StatPearls (StatPearls Publishing), PMID 31194342, http://www.ncbi.nlm.nih.gov/books/NBK542185/, retrieved 2019-11-17 
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Strauss, Eric J.; Kim, Suezie; Calcei, Jacob G.; Park, Daniel (December 2011). "Iliotibial Band Syndrome: Evaluation and Management:" (in en). American Academy of Orthopaedic Surgeon 19 (12): 728–736. doi:10.5435/00124635-201112000-00003. ISSN 1067-151X. http://journals.lww.com/00124635-201112000-00003. 
  7. ↑ "Iliotibial band syndrome - aftercare: MedlinePlus Medical Encyclopedia" (in en). https://medlineplus.gov/ency/patientinstructions/000683.htm. 
  8. ↑ Khaund, Razib; Flynn, Sharon H. (2005-04-15). "Iliotibial band syndrome: a common source of knee pain". American Family Physician 71 (8): 1545–1550. ISSN 0002-838X. PMID 15864895. https://pubmed.ncbi.nlm.nih.gov/15864895. 
  9. ↑ "Iliotibial Band Syndrome Specialist Clinic | Singapore Sports and Orthopaedic Clinic - Neurosurgeon" (in en-US). https://www.boneclinic.com.sg/orthopaedic-conditions/hip-pain/iliotibial-band-syndrome-itbs/. 
  10. ↑ Farrell, Kevin C.; Reisinger, Kim D.; Tillman, Mark D. (March 2003). "Force and repetition in cycling: possible implications for iliotibial band friction syndrome". The Knee 10 (1): 103–109. doi:10.1016/S0968-0160(02)00090-X. PMID 12649036. 
  11. ↑ Fairclough, John; Hayashi, Koji; Toumi, Hechmi; Lyons, Kathleen; Bydder, Graeme; Phillips, Nicola; Best, Thomas M; Benjamin, Mike (March 2006). "The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome". Journal of Anatomy 208 (3): 309–316. doi:10.1111/j.1469-7580.2006.00531.x. ISSN 0021-8782. PMID 16533314. 
  12. ↑ Flynn, Sharon H.; Khaund, Razib (2005-04-15). "Iliotibial Band Syndrome: A Common Source of Knee Pain". American Family Physician 71 (8): 1545–1550. PMID 15864895. https://www.aafp.org/afp/2005/0415/p1545.html. 
  13. ↑ Hariri, Sanaz; Savidge, Edgar T.; Reinold, Michael M.; Zachazewski, James; Gill, Thomas J. (July 2009). "Treatment of Recalcitrant Iliotibial Band Friction Syndrome with Open Iliotibial Band Bursectomy: Indications, Technique, and Clinical Outcomes" (in en). The American Journal of Sports Medicine 37 (7): 1417–1424. doi:10.1177/0363546509332039. ISSN 0363-5465. http://journals.sagepub.com/doi/10.1177/0363546509332039. 
  14. ↑ Fredericson, Michael; Weir, Adam (May 2006). "Practical Management of Iliotibial Band Friction Syndrome in Runners". Clinical Journal of Sport Medicine 16 (3): 261–268. doi:10.1097/00042752-200605000-00013. ISSN 1050-642X. http://dx.doi.org/10.1097/00042752-200605000-00013. 
  15. ↑ West, R; Irrgang, J (2009). "Overuse injuries of the lower extremity". Orthopaedic Knowledge Update: Sports Medicine 4. 
  16. ↑ Barber, F. Alan; Sutker, Allan N. (August 1992). "Iliotibial Band Syndrome". Sports Medicine 14 (2): 144–148. doi:10.2165/00007256-199214020-00005. PMID 1509227. 
  17. ↑ 17.0 17.1 17.2 17.3 Beals, Corey; Flanigan, David (2013). "A Review of Treatments for Iliotibial Band Syndrome in the Athletic Population". Journal of Sports Medicine 2013: 367169. doi:10.1155/2013/367169. ISSN 2356-7651. PMID 26464876. 
  18. ↑ Weckström, Kristoffer; Söderström, Johan (2016). "Radial extracorporeal shockwave therapy compared with manual therapy in runners with iliotibial band syndrome". Journal of Back and Musculoskeletal Rehabilitation 29 (1): 161–170. doi:10.3233/BMR-150612. PMID 26406193. 
  19. ↑ 19.0 19.1 Hadeed, Andrew; Tapscott, David C. (2023), "Iliotibial Band Friction Syndrome", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 31194342, http://www.ncbi.nlm.nih.gov/books/NBK542185/, retrieved 2023-11-06 
  20. ↑ Richards, David P.; Alan Barber, F.; Troop, Randal L. (March 2003). "Iliotibial band Z-lengthening". Arthroscopy: The Journal of Arthroscopic & Related Surgery 19 (3): 326–329. doi:10.1053/jars.2003.50081. ISSN 0749-8063. PMID 12627161. 
  21. ↑ Hafer, Jocelyn F.; Brown, Allison M.; Boyer, Katherine A. (August 2017). "Exertion and pain do not alter coordination variability in runners with iliotibial band syndrome". Clinical Biomechanics 47: 73–78. doi:10.1016/j.clinbiomech.2017.06.006. ISSN 0268-0033. PMID 28618309. 
  22. ↑ Physical Medicine and Rehabilitation for Iliotibial Band Syndrome: Practice Essentials, Pathophysiology, Epidemiology. 2022-04-04. https://emedicine.medscape.com/article/307850-overview. 
  23. ↑ Jensen, Andrew E; Laird, Melissa; Jameson, Jason T; Kelly, Karen R (2019-03-01). "Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training". Military Medicine 184 (Supplement_1): 511–520. doi:10.1093/milmed/usy387. ISSN 0026-4075. PMID 30901397. 
  24. ↑ Everhart, Joshua S.; Kirven, James C.; Higgins, John; Hair, Andrew; Chaudhari, Ajit A.M.W.; Flanigan, David C. (August 2019). "The relationship between lateral epicondyle morphology and iliotibial band friction syndrome: A matched case–control study" (in en). The Knee 26 (6): 1198–1203. doi:10.1016/j.knee.2019.07.015. PMID 31439366. 
  25. ↑ Physical Medicine and Rehabilitation for Iliotibial Band Syndrome: Practice Essentials, Pathophysiology, Epidemiology. 2022-04-04. https://emedicine.medscape.com/article/307850-overview. 
  26. ↑ Farrell, Kevin C.; Reisinger, Kim D.; Tillman, Mark D. (March 2003). "Force and repetition in cycling: possible implications for iliotibial band friction syndrome". The Knee 10 (1): 103–109. doi:10.1016/s0968-0160(02)00090-x. ISSN 0968-0160. PMID 12649036. 
  27. ↑ Holmes, James C.; Pruitt, Andrew L.; Whalen, Nina J. (May 1993). "Iliotibial band syndrome in cyclists". The American Journal of Sports Medicine 21 (3): 419–424. doi:10.1177/036354659302100316. ISSN 0363-5465. PMID 8166785. 
  28. ↑ Renne, James (December 1975). "The Iliotibial Band Friction Syndrome". The Journal of Bone & Joint Surgery. https://pubmed.ncbi.nlm.nih.gov/1201997/. 

Further reading

van der Worp, Maarten P.; van der Horst, Nick; de Wijer, Anton; Backx, Frank J. G.; Nijhuis-van der Sanden, Maria W. G. (23 December 2012). "Iliotibial Band Syndrome in Runners". Sports Medicine 42 (11): 969–992. doi:10.1007/BF03262306. 

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