Introduction

Iliotibial band syndrome is on of the most common causes of lateral knee pain in runners. It is considered a non-traumatic overuse injury in which typically, the distal area of the iliotibial tract becomes inflamed and tender. Much rarely, tenderness may occur at the proximal area of the iliotibial tract.

Epidemiology

  • Incidence: 200.00 cases per 100,000 person-years
  • Peak incidence: 30-40 years
  • Sex ratio: 1:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

The aetiology behind iliotibial band syndrome is considered multifactorial. The main risk factors associated with iliotibial band syndrome include: hip adductor weakness, a sudden increase in exercise (especially long distance running) and compression of the fat and connective tissue that is deep the the iliotibial band. Running specifically on slightly banked ground increases the risk of injury as the subtle drop of the outside of the foot repeatedly stretches the iliotibial band.

The main pathogenesis of iliotibial band syndrome is as follows:
  • Repeated friction of the iliotibial band over the lateral femoral epicondyle, in addition to repeated flexion and extension of the knee during running may cause this area to become irritated.
  • If this persists, an inflammatory reaction of the iliotibial band can occur.
    • This inflammation then leads to the pain and discomfort associated with iliotibial band syndrome.

Clinical features

The characteristic symptom of iliotibial band syndrome is discomfort/pain (100% of the time).
  • Usually located at lateral aspect of the knee, particularly when weight bearing.
  • The pain may be exacerbated by activity e.g. running or when walking downstairs.
  • The pain may persist/worsen after the activity.
  • The pain, typically a burning sensation, may also radiate into the lateral thigh or calf.

On examination, there may be swelling at the lateral aspect of the knee.

Ober's and Noble's tests are provocation tests for iliotibial tract syndrome.
  • Ober's test
    • The patient lies on their unaffected side, with the knee in 30 degrees of flexion. The clinician then extends and adducts the hip. If knee extension occurs, iliotibial tightness is confirmed.
  • Noble's test
    • Direct pressure is applied over the lateral femoral epicondyle with knee in 30 degrees of flexion. Flexing and extending the knee causes pain +/- palpable 'snapping' in a positive test.

These test may be combined and performed simultaneously.

Investigations

Diagnosis is based on the clinical picture (both the history and examination findings), including tenderness at the lateral femoral epicondyle, where the iliotibial band passes over the bone.

Scanning is only indicated if symptoms persist following 6 months of physiotherapy.

Scans used include:
  • MRI
  • Ultrasound

Differential diagnosis

Differential diagnoses for lateral knee pain include:
  • Lateral meniscal/cartilage injury
    • More likely to occur from a traumatic injury or a sudden twisting injury. However this may also occur gradually through wear and tear of the cartilage.
    • Meniscal tears more classically associated with 'locking' or 'catching' of the knee on flexion/extension.
  • Patellofemoral joint syndrome
    • Similarly to iliotibial band syndrome, patellofemoral joint syndrome commonly affect runners and is considered an overuse injury.
    • In contrast to iliotibial band syndrome, patellofemoral joint syndrome causes anterior knee pain as opposed to lateral pain. Pain may also be triggered after a period of inactivity e.g. a flight.
  • Biceps femoris tendinopathy
    • An overuse injury to the biceps femoris tendon. May occur with proximal at the buttock or distally at the lateral aspect of the knee.
    • Pain is aggravated when kicking the leg backwards during running.
  • Stress fractures
    • Common injuries that begin with repetitive and excessive stress on the bone. Most commonly present with site specific pain.
    • Can be assessed if suspected by the hop test - single leg hopping that produces severe localised pain.
  • Lateral compartment arthritis
    • Osteoarthritis of the lateral compartment of the knee joint. Associated with increasing age and a much more chronic timescale than iliotibial band syndrome.

Management

Management options in iliotibial band syndrome include: conservative, medical and surgical. Most commonly, a conservative approach in the form of physiotherapy is sufficient. This may be aided with medical analgesia and NSAIDs. The need for surgical intervention is rare. No formal guidelines exist at present for the treatment of iliotibial band syndrome.

  • Physiotherapy
    • The first and main line of treatment
    • Focuses on correcting biomechanical errors, reducing the tightness of the iliotibial band with stretching and strengthening of hip abductors.
    • Initially, activity modification should be assessed training programmes altered if appropriate to decrease the training intensity and increase rest periods. Non-traumatic training such as swimming should be promoted to maintain conditioning.
    • Some authors suggest complete rest for a time period ranging from 1 - 3 weeks, however at present there are no formal guidelines on this.
    • Stretching and trigger point techniques may be used to break down inflamed areas and lengthen the muscle.
    • Iliotibial band syndrome may be associated with weak hip adductors, therefore a targeted exercise regime to build hip adductor strength may be implemented.
    • Patient gait may be assessed and modified for optimisation.
    • Ultrasound therapy and muscle stimulation may be considered.

  • Medical management
    • Corticosteroid injections and NSAIDs may be useful if no progress is being made following 8 weeks of physiotherapy. Injections are given at the level of the lateral femoral epicondyle.

  • Surgical management
    • Rare, only considered if symptoms persist for over 6-months. If considered, it may involve distal release of the iliotibial band, removal of inflamed tissue, or lengthening of the iliotibial band.