What is the iliotibial band? What are the symptoms of iliotibial band syndrome? How can iliotibial band syndrome be treated? Discover the answers to these questions and more in this comprehensive guide.

Understanding the Iliotibial Band

The iliotibial band (IT band or ITB) is a longitudinal fibrous sheath that runs along the lateral thigh and plays a crucial role in lower extremity motion. It spans the lower extremity on its lateral aspect before inserting on Gerdy’s tubercle on the proximal/lateral tibia. Proximally, the ITB receives fascial contributions from the deep fascia of the thigh, gluteus maximus, and tensor fascia lata (TFL).

Anatomy and Structure of the ITB

The detailed anatomy of the ITB, TFL, and their origins, insertions, and variations have been extensively studied in the literature. According to recent research, the proximal IT tract begins as three distinct layers that fuse at the level of the greater trochanter (GT). The TFL has a separate origin from the ilium and merges with the superficial and intermediate IT layers distally. The ITB also receives contributions from the gluteal aponeurotic fascia and the gluteus maximus muscle.

Proximal Anatomy

• The proximal IT tract begins as three distinct layers that fuse at the level of the greater trochanter (GT).
• The TFL has a separate origin from the ilium and merges with the superficial and intermediate IT layers distally.
• The ITB receives contributions from the gluteal aponeurotic fascia and the gluteus maximus muscle.

Distal Anatomy

Proximally to the knee joint, the ITB attaches to the intermuscular septum and supracondylar tubercle of the femur. At the level of the lateral femoral epicondyle, the ITB contributes to lateral knee stability due to its anatomic position and intimate contact with the epicondyle and lateral collateral ligament (LCL).

Functional Anatomy of the ITB

The ITB performs several important functions, both proximally and distally. Proximally, the ITB contributes to hip abduction, extension, and lateral rotation. Distally, the ITB’s function depends on the position of the knee joint, with the ITB playing a role in lateral knee stability and weight transmission.

Iliotibial Band Syndrome (ITBS)

Iliotibial band syndrome (ITBS) is a common overuse injury that manifests as lateral knee pain. It is often seen in athletes, particularly those involved in sports that place a high demand on the lower extremities, such as running, cycling, and skating.

Symptoms of ITBS

The primary symptom of ITBS is lateral knee pain, which can range from a dull ache to a sharp, burning sensation. The pain is typically aggravated by activities that involve repeated flexion and extension of the knee, such as running or cycling. Patients may also experience snapping or popping sensations along the lateral knee.

Causes of ITBS

ITBS is typically caused by repetitive friction and irritation of the ITB as it glides over the lateral femoral epicondyle. This can be exacerbated by factors such as biomechanical abnormalities, muscle imbalances, and excessive training volume or intensity.

Treatment of Iliotibial Band Syndrome

The treatment of ITBS typically involves a combination of conservative measures, including rest, ice, anti-inflammatory medications, and physical therapy. In some cases, more advanced interventions, such as corticosteroid injections or even surgical procedures, may be necessary.

Conservative Treatment

• Rest and activity modification
• Ice and anti-inflammatory medications
• Stretching and strengthening exercises
• Soft tissue mobilization and massage

Surgical Treatment

In cases where conservative treatment fails to provide relief, surgical options may be considered. These include procedures such as ITB lengthening, release, or resection, which aim to reduce the tension and friction on the lateral knee.

Prevention of Iliotibial Band Syndrome

Preventive measures for ITBS include proper training techniques, strengthening of the hip and core musculature, and the use of appropriate footwear and orthotics. Regular stretching and mobility exercises targeting the ITB and surrounding structures can also help reduce the risk of ITBS.

Anatomy, Bony Pelvis and Lower Limb, Iliotibial Band (Tract) – StatPearls

Introduction

The iliotibial band tract or IT band (ITB) is a longitudinal fibrous sheath that runs along the lateral thigh and serves as an important structure involved in lower extremity motion. The ITB is also sometimes known as Maissiat’s band.  The ITB spans the lower extremity on its lateral aspect before inserting on Gerdy’s tubercle on the proximal/lateral tibia. 

Proximally in the thigh, the ITB receives fascial contributions from the deep fascia of the thigh, gluteus maximus, and tensor fascia lata (TFL).[1]  The TFL is the deep investing fascia of the thigh, encompassing the muscles of the hip and lower extremity around this region.[2] Distally, the ITB becomes a distinct soft tissue layer of the lateral knee.[3]

There are multiple clinical conditions that can present secondary to a spectrum of ITB dysfunction and many of these manifest in physical laborers to recreational or high-level professional athletes.   Moreover, these conditions will vary depending on the specific anatomic location of the dysfunction.  For example, proximally based ITB conditions include external snapping hip syndrome, which occurs secondary to ITB friction as these fibers rub (or “snap”) over the greater trochanter of the femur[4]  Distally, ITB pathology most commonly manifests as some form of lateral-based knee pain (commonly ITB syndrome, or ITBS).  Athletes affected are often involved in sports heavily reliant on peak lower extremity function and performers, such as runners, skaters, or cyclists.  

Regardless of the ITB condition, most patients experience complete resolution of symptoms following nonoperative management modalities alone.  However, surgical consideration is a potential option for chronic, recurrent, or recalcitrant cases that continue to persist despite exhausting of all nonoperative management options after several months.

Structure and Function

Origin, insertion, and structure

The detailed anatomic structure of the ITB, TFL, and its origins, insertions, and variations have been debated for decades in the literature.   Huang et al. delineated the proximal anatomy in a recent study from 2013.[5]

Proximal anatomy[5][6]

• The proximal IT tract begins as three distinct layers coursing distally to fuse/coalesce at the level of the greater trochanter (GT)

• TFL 

  • Separate origin of TFL fibers originates off the ilium and in between the superficial and intermediate IT layer origins 

  • Distally, the TFL becomes a tendinous structure as it merges with the superficial and intermediate IT layers

  • Farther distal, the TFL tendinous fibers, including the superficial and intermediate IT layers, fuse as a single confluent structure near the level of the GT

• Gluteal contributions
  • Gluteal aponeurotic fascia:

    • Originates from the posterior iliac crest

    • Courses distally to invest the anterior two-thirds of the gluteus medius 

    • A portion of its fibers merge with the posterior ITB to continue distally while the remaining aponeurotic fibers insert at the gluteal tuberosity on the femur

  • In addition, the posterior ITB also receives distinct fascial/tendinous contributions from:

    • Superior gluteus maximus

    • Superficial fibers of the inferior gluteus maximus

  • Deep fibers from the inferior gluteus maximus course toward the femur to insert onto the gluteal tuberosity of the linea aspera 

Distal anatomy:

Proximal to the knee joint, the ITB attaches to the intermuscular septum and supracondylar tubercle of the femur.   Proximal to the lateral epicondyle, there is an interposed fat layer between the ITB and the vastus lateralis.[8]   The ITB is more tendinous proximal to the lateral femoral epicondyle, and at the level of the epicondyle, the ITB contributes to lateral knee stability secondary to its anatomic position, intimal contact with the epicondyle, and relative to its location with respect to the lateral collateral ligament (LCL).[9]

Function

Proximal ITB function includes[6]:

Distally, ITB function depends on the position of the knee joint[2]

Embryology

Tendons and ligaments are connective tissue structures that allow for stability and elasticity between bone-muscle and bone-bone interfaces, respectively. Molecular structure high in water and extracellular matrix content provide the durability and elasticity needed for these structures. The mesoderm is the middle layer of the embryologic trilaminar disc of tissue that forms because of gastrulation in a fetus. Surrounded by the endoderm and ectoderm, the mesoderm is the structure giving rise to connective tissue of the human body aside from muscle of the head, which develops from neural crest tissue. The ITB, being a tendinous structure, therefore derives from mesoderm.[10]

Blood Supply and Lymphatics

The ITB, being a tendinous extension of the tensor fascia lata (TFL), shares the same arterial supply:

• Ascending branch of the lateral femoral circumflex artery (LFCA)

• Superior gluteal artery (SGA)

The LFCA traverses the TFL as a single branch from the profundus femoris arterial system usually 6-10 cm distal from the anterior superior iliac spine (ASIS) directly into the muscle belly.

The SGA is the largest branch of the posterior division of the internal iliac artery and exits the greater sciatic foramen where it divides into superficial and deep branches. The latter of which also provides collateral arterial blood supply to the TFL in addition to the gluteus medius and minimus muscles. [11]

Nerves

Analogous to the arterial blood supply, the ITB shares the innervation of the TFL and gluteus maximus via the superior gluteal nerve (SGN) and inferior gluteal nerve (IGN), respectively.

The SGN arises from the ventral rami of nerve roots L4-S1 and originates from the lumbosacral nerve plexus.  Like the SGA, the SGN exits the pelvis via the greater sciatic foramen to innervate the TFL as well as the gluteus minimus and medius (both hip abductors and medial rotators). The IGN is comprised of the ventral rami of L5-S2 and provides innervation of the gluteus maximus muscle.[11]

Muscles

The TFL works in concert with the gluteus medius and minimus to medially rotate and abduct the hip, as well as assist in flexing the hip with the rectus femoris.[12] The distal attachment of the ITB on Gerdy’s tubercle serves as a focal point of lower extremity abduction.[13][14]

The gluteus maximus primarily serves to extend the hip, however, also contributes to hip abduction via the ITB tract. Again, the ITB is an extension of the tendinous insertions of these muscles, and a better understanding of each of their function, will, in turn, improve one’s understanding of the biomechanics of the ITB.[11][15]

Physiologic Variants

This structure has little variation concerning the anatomical location and function. Previous studies have revealed different locations of insertion for the TFL – however, the band itself has been consistent with its insertion onto Gerdy’s tubercle. Anatomical and structural bony abnormalities, whether because of injury or degenerative process, may ultimately affect the physiological function of the ITB depending on the adaptation of the musculoskeletal structures. Further evaluation of the proximal muscular structures may be warranted to determine the clinically significant variations of the ITB tract distally. 

Surgical Considerations

External snapping hip syndrome

In most cases, patients are minimally, if not completely, asymptomatic from the clinical condition.

In the setting of persistent pain despite exhaustion of all nonoperative treatment modalities (therapy, activity modification, injection of corticosteroid), surgical consideration is warranted.  

Surgical techniques for painful external snapping hip syndrome include open versus endoscopic ITB z-plasty and excision of the greater trochanteric bursa.  A successful z-plasty lengthening procedure can have excellent outcomes when performed appropriately (in either the open or endoscopic setting).[16][17][18]

Iliotibial Band Syndrome (ITBS)

Similar to snapping hip syndrome, ITBS most often improves with nonoperative management modalities alone.  In painful, recalcitrant cases, however, several techniques have been described:

• Lateral bursal excision/synovial recess debridement (arthroscopic versus open)

• ITB z-plasty

  • Similar to the aforementioned procedure at the hip, an analogous procedure can be performed distally over the lateral femoral condylar area of irritation

• Elliptical surgical excision

  • An incision is made over the ITB at the lateral distal femur with incision of the posterior ITB at the lateral femoral epicondyle

  • Typically, there is excision of a 2cm x 4cm area of tissue[19]

Clinical Significance

External Snapping Hip Syndrome

External snapping hip syndrome, or externa coxa saltans has the potential to cause chronic pain in the lateral aspect of the hip located over the greater trochanter of the femur. Pathophysiology comprises thickening of the posterior aspect of the ITB or anterior tendon fibers of the gluteus maximus muscle near its insertion. This portion of the band remains posterior to the greater trochanter in hip extension, however, moves anteriorly when flexed, adducted, or internally rotated causing a “snapping” mechanism. This snapping is the tense fascial structure catching on the greater trochanter as it moves in the before mentioned motions.[4] Treatment generally initiates with ITB stretching and physical therapy. NSAID use may be beneficial to reduce inflammation. Surgery is a last resort used for refractory cases.[20]

Iliotibial Band Syndrome (ITBS)

ITB syndrome and contracture is a condition secondary to increased tension throughout the structure most commonly causing symptoms near the distal insertion site. This condition can be seen in individuals with cerebral palsy and polio, however, more commonly in individuals who have increased their physical activity (particular lower extremity performance).

Common presentations are usually runners or cyclists that have increased their mileage during recent training intervals. This condition seems to be secondary to overuse and repetitive motion. However, there are some conflicting thoughts as to the exact mechanism eliciting the pain experienced. Several etiologies have been suggested, including the friction induced by the band catching the lateral epicondyle of the femur, compression of the underlying connective tissue and fat, and chronic inflammation of the ITB bursa. Other predisposing structural risk factors are gait abnormalities (i.e., overpronation), leg length discrepancies, and varus deformity of both knees. Symptoms are also most pronounced when the arc of motion reaches 30-40 degrees of knee flexion and occurs along the lateral aspect of the knee. 

Clinical examination testing for ITB dysfunction is best elicited utilizing the Ober Test.

To perform the Ober test, have the patient lie on his or her uninvolved side in the lateral decubitus position.   The symptomatic side should be facing upward (i.e., closest to the ceiling).  Next, the examiner passively flexes the knee to about 90 degrees.  The hip is then brought passively into a flexed and abducted position.  Next, the examiner assesses the passive flexibility over the ITB with the hip brought into increasing levels of extension and adduction.  A positive test entails pain, tightness, or clicking over the ITB.

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Figure

Iliotibial band. Image courtesy S Bhimji MD

References

1.

Evans P. The postural function of the iliotibial tract. Ann R Coll Surg Engl. 1979 Jul;61(4):271-80. [PMC free article: PMC2492187] [PubMed: 475270]

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Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011 Dec;19(12):728-36. [PubMed: 22134205]

3.

Chahla J, Murray IR, Robinson J, Lagae K, Margheritini F, Fritsch B, Leyes M, Barenius B, Pujol N, Engebretsen L, Lind M, Cohen M, Maestu R, Getgood A, Ferrer G, Villascusa S, Uchida S, Levy BA, Von Bormann R, Brown C, Menetrey J, Hantes M, Lording T, Samuelsson K, Frosch KH, Monllau JC, Parker D, LaPrade RF, Gelber PE. Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2019 Aug;27(8):2520-2529. [PubMed: 30478468]

4.

Musick SR, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 22, 2023. Snapping Hip Syndrome. [PubMed: 28846235]

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Huang BK, Campos JC, Michael Peschka PG, Pretterklieber ML, Skaf AY, Chung CB, Pathria MN. Injury of the gluteal aponeurotic fascia and proximal iliotibial band: anatomy, pathologic conditions, and MR imaging. Radiographics. 2013 Sep-Oct;33(5):1437-52. [PubMed: 24025934]

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Flato R, Passanante GJ, Skalski MR, Patel DB, White EA, Matcuk GR. The iliotibial tract: imaging, anatomy, injuries, and other pathology. Skeletal Radiol. 2017 May;46(5):605-622. [PubMed: 28238018]

7.

Gold M, Munjal A, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 25, 2022. Anatomy, Bony Pelvis and Lower Limb, Hip Joint. [PubMed: 29262200]

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Biondi NL, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2022. Anatomy, Bony Pelvis and Lower Limb: Vastus Lateralis Muscle. [PubMed: 30335342]

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Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309-16. [PMC free article: PMC2100245] [PubMed: 16533314]

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Tozer S, Duprez D. Tendon and ligament: development, repair and disease. Birth Defects Res C Embryo Today. 2005 Sep;75(3):226-36. [PubMed: 16187327]

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Trammell AP, Nahian A, Pilson H. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2022. Anatomy, Bony Pelvis and Lower Limb: Tensor Fasciae Latae Muscle. [PubMed: 29763045]

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Bordoni B, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 8, 2023. Anatomy, Bony Pelvis and Lower Limb: Thigh Quadriceps Muscle. [PubMed: 30020706]

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Ramage JL, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 29, 2022. Anatomy, Bony Pelvis and Lower Limb: Medial Thigh Muscles. [PubMed: 30521196]

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Attum B, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 17, 2022. Anatomy, Bony Pelvis and Lower Limb: Thigh Muscles. [PubMed: 29494052]

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Bordoni B, Mahabadi N, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 18, 2022. Anatomy, Fascia. [PubMed: 29630284]

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Sayed-Noor AS, Pedersen E, Sjödèn GO. A new surgical method for treating patients with refractory external snapping hip: Pedersen-Noor operation. J Surg Orthop Adv. 2012 Fall;21(3):132-5. [PubMed: 23199940]

17.

Provencher MT, Hofmeister EP, Muldoon MP. The surgical treatment of external coxa saltans (the snapping hip) by Z-plasty of the iliotibial band. Am J Sports Med. 2004 Mar;32(2):470-6. [PubMed: 14977676]

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Ilizaliturri VM, Martinez-Escalante FA, Chaidez PA, Camacho-Galindo J. Endoscopic iliotibial band release for external snapping hip syndrome. Arthroscopy. 2006 May;22(5):505-10. [PubMed: 16651159]

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Walbron P, Jacquot A, Geoffroy JM, Sirveaux F, Molé D. Iliotibial band friction syndrome: An original technique of digastric release of the iliotibial band from Gerdy’s tubercle. Orthop Traumatol Surg Res. 2018 Dec;104(8):1209-1213. [PubMed: 30341031]

20.

Pierce TP, Kurowicki J, Issa K, Festa A, Scillia AJ, McInerney VK. External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review. Hip Int. 2018 Sep;28(5):468-472. [PubMed: 29902932]

Disclosure: Scott Hyland declares no relevant financial relationships with ineligible companies.

Disclosure: Steven Graefe declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.

Iliotibial Band Friction Syndrome – StatPearls

Andrew Hadeed; David C. Tapscott.

Author Information and Affiliations

Last Update: May 23, 2023.

Continuing Education Activity

Iliotibial band syndrome is a common cause of lateral knee pain in athletes. Iliotibial band syndrome is often successfully treated with nonoperative management, although surgical intervention is sometimes warranted. This activity reviews the evaluation and management of iliotibial band syndrome and highlights the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the etiology of iliotibial band syndrome.

• Describe how to evaluate iliotibial band syndrome.

• Outline the treatment and management options available for iliotibial band syndrome.

• Explain the importance of improving care coordination amongst interprofessional team members to improve outcomes for patients affected by iliotibial band syndrome.

Access free multiple choice questions on this topic.

Introduction

Knee pain has been reported to limit mobility and impair quality of life in 25% of adults.[1] Iliotibial band syndrome (ITBS) is one of the many different causes of lateral knee pain. It was first seen in US Marine Corps recruits during their training in 1975 and has been diagnosed frequently in long-distance runners, cyclists, skiers, and participants of hockey, basketball, and soccer since then. These activities all depend on rapid and prolonged cycling of the knee through flexion and extension. This article will discuss how this cycling can cause the syndrome, as well as, discuss evaluation and treatment modalities. 

The iliotibial band (ITB) is the distal fascial continuation of the tensor fascia lata, gluteus medius, and gluteal maximus. It traverses superficial to the vastus lateralis and inserts on the Gerdy tubercle of the lateral tibial plateau and partially to the supracondylar ridge of the lateral femur.[2] There is also an anterior extension called the iliopatella band that connects the lateral patella and prevents medial translation of the patella. The ITB functions as a knee extensor when the knee is less than 30 degrees of flexion but becomes a knee flexor after exceeding 30 degrees of flexion. The ITB has been postulated to acquire a more posterior position relative to the lateral femoral epicondyle with increasing degrees of flexion.[3]

Etiology

The etiology of ITBS is controversial and likely multifactorial. One theory advocates that repetitive friction of the ITB and the lateral epicondyle during flexion and extension lead to inflammation of the contact area of the ITB. Contact between the ITB and lateral epicondyle occurs at 30 of flexion, which is the degree of knee flexion at foot strike.[4] This contact area has the name of the “impingement zone.” However, anatomical studies have not supported this gliding motion across the lateral epicondyle. Histologic examinations of cadaveric specimens show a highly innervated fat pad that is deep to the distal ITB. Compression of this fat pad is implicated to be the source of the lateral knee pain.[5] Furthermore, another theory includes chronic inflammation of a fluid-filled ITB bursa located between the ITB and lateral epicondyle. It is not clear at this time if one theory is most causative of the syndrome or if it is multifactorial. 

Modifiable risk factors include running on a tilted surface, hill running, errors in training technique, and abrupt changes in training intensity. Anatomical factors such as internal tibial torsion, hip abductor weakness, excessive foot pronation, and medial compartment arthritis leading to genu varum can increase the tension of the ITB and can perpetuate the pathology.[6] ITBS correlates with greater trochanteric pain syndrome because of the altered biomechanics of the hip and tension of the proximal fascial complex. Also, the patellofemoral syndrome is commonly seen in these patients because of the tension through the iliopatellar band.

Epidemiology

ITBS is the most common etiology of lateral knee pain in runners and cyclists but may also present in athletes participating in tennis, soccer, skiing, and weight lifting. The incidence ranges from 1.6% to 12% in runners and other repetitive motion athletes. [3] It is slightly more common in women than men and seldom occurs in the non-active population. One cross-sectional study demonstrated that the incidence of ITBS was 6.2% in military recruits.[7] The U.S. Marine Corps reported running/overuse injuries accounted for 12% of injuries sustained by their personnel.[8]

History and Physical

Iliotibial band syndrome is a clinical diagnosis and rarely requires further studies and imaging. The clinician must be vigilant about mechanical symptoms, changes in activity level, mileage of long-distance activity, and condition of training shoes. The patient often presents with lateral knee pain localized to the area between the Gerdy tubercle and the lateral epicondyle. The history is commonly consistent with a recent change in prolonged aerobic activities and rarely in the setting of an acute injury. The pain initially will occur at the completion of the activity but may be present at the beginning of the activity and even at rest with later disease progression. Furthermore, the pain is often worse with running on a cambered surface, and also hills or longer strides may increase symptoms as deeper knee flexion at foot strike and leads to more time in the “impingement zone.”[3]

The first step is a physical examination of the knee. Coronal and sagittal plane knee misalignments such as genu varum, genu valgum, recurvatum, and procurvatum are worth noting as this can increase tension on the ITB. Knee effusion or ligamentous laxities are not commonly part of the presentation with isolated ITBS. Palpation of the distal ITB can be painful, and the clinician may feel crepitus with range of motion. Special tests for ITBS include the Noble and Ober tests. To perform the Noble test, the clinician first palpates the lateral femoral epicondyle and then extends the knee from 90 degrees of flexion to 0 degrees of extension. Reproducible pain at 30 of flexion is a positive test. The Ober test involves placing the patient in the lateral recumbent position with the knees flexed to 90. The clinician stands behind the patient and abducts and extends the affected hip while supporting the knee. A positive test is indicated by restriction and pain to the lateral knee while the clinician adducts the hip in this extended position.[9]

Evaluation

Radiographic imaging of the knee is useful for ruling out other pathology that could be causing lateral knee pain such as osteoarthritis, fracture, or patella malalignment. ITBS in the absence of other pathology will appear normal on plain radiograph of the knee. If the diagnosis is still unclear after the history and physical, magnetic resonance imaging (MRI) of the knee may confirm the diagnosis if it demonstrates hyperintensities at the lateral epicondyle with a thickened distal ITB. Additionally, ultrasound is a low cost and low-risk modality that may show abnormal distal ITB thickening.[3]

Treatment / Management

The first-line treatment for the vast majority of patients with ITBS is nonoperative management. The patient should be advised to refrain from the inciting activity until the pain has resolved. Intermittent cryotherapy can help with acute flares. A gradual return to activity can commence as soon as the patient is pain-free with activity and palpation. Physical therapy focused on stretching of the ITB and abduction strengthening can be very effective at lengthening the ITB and reducing tension. Furthermore, manual therapy such as myofascial release with a foam roller has been used to break up adhesions and is an integral part of the rehabilitation process.[3] The physical therapist should also focus on teaching proper ergonomics and posture while performing inciting activities.

Non-steroidal anti-inflammatories can help with diminishing the inflammation. Likewise, corticosteroid injections can be therapeutic, as well as diagnostic for ITBS by providing immediate and prolonged pain relief.[10] Shoe modification, foot orthosis, and sport-specific technique training can help prevent ITBS from returning in some cases. Most patients will have complete symptom relief and able to return to activity within 6 to 8 weeks with nonoperative management alone.

The recommended progression back to activity starts with a week of running on alternating days on a flat surface. The following weeks are focused on fast-paced running daily and avoid downhill running. After 3 to 4 weeks, the patient can gradually increase the distance and frequency. Introducing hills and cambered surfaces should only take place if there is no pain or symptoms on a flat surface. If the patient relapses, then they will need to start their activity progression over again and may require a period of rest beforehand.

Surgical intervention is only for refractory cases despite nonoperative management for more than 6 months. There are several surgical options including percutaneous or open ITB release, ITB lengthening with a Z-plasty, open ITB bursectomy, and arthroscopic ITB debridement. Furthermore, there are several different techniques described for the open ITB release including resecting a triangular portion of the distal posterior ITB band, resecting the 2 cm x 4 cm portion overlying the lateral femoral epicondyle, and also making a V-shaped incision in the ITB. [9][11][12] All of the different techniques have demonstrated success, but there are limited comparative studies to demonstrate superiority. ITB bursectomy is the indicated option with the symptomatology of ITBS but no enhancement of the ITB on MRI. The procedure consists of excising the underlying ITB bursa but leaving the ITB completely intact. One study demonstrated that the majority of patients who undergo open bursectomy are overall completely or mostly satisfied with the results.[13] Minimal invasive techniques have been described to resect the lateral synovial recess that connects the ITB to the lateral femur and innervated synovial fat. Michels et al. described this arthroscopic technique and showed a 97% good to excellent result with all patients returned to full activity.[14]

Differential Diagnosis

The following lists the most common causes of lateral knee pain:

• Stress fracture of the lateral tibial plateau

• Lateral meniscus tear

• Lateral compartment of the knee osteoarthritis

• Lateral collateral ligament strain

• Biceps femoris tendinopathy

• Radiation from hip pathology

• Patellofemoral syndrome

• Popliteal tendinopathy

Prognosis

Roughly 50% to 90% of patients will improve with 4 to 8 weeks of non-operative modalities. Likewise, all surgical modalities have reported good to excellent results.[9][12] ITBS typically follows a fluctuating course and may relapse at any point in the treatment progression or return to activity.

Complications

Disease progression is the most common complication of ITBS. As the disease progresses, the patient will experience pain throughout the activities and even at rest. Furthermore, because of its attachments to the lateral patella, the progression of the disease may lead to patellofemoral syndrome.

Deterrence and Patient Education

Patient education and adherence to the treatment plan is the key to treating this disorder. Running at faster paces and on a flat ground have been shown to limit the time in the so-called “impingement zone” between the lateral femoral epicondyle and ITB. Furthermore, patients must change their shoes regularly to prevent uneven wear of the soles.[3] Patients may also benefit from a personal trainer or physical therapist to improve their sport-specific biomechanics. It is crucial that the patient is aware that the ITBS can sometimes relapse after returning to activities, and they should restart the nonoperative treatment progression.

Enhancing Healthcare Team Outcomes

Successful treatment of ITBS is only possible through an interprofessional approach. Patients with ITBS often present initially to their primary care clinician and nonoperative treatment can be started at that time before seeing an orthopedic surgeon. Physical therapy is imperative to strengthening the abductors, loosening the ITB tension, and teaching proper biomechanics during the activity. The sport-specific trainers must also be knowledgeable on how to prevent or minimize activities that are at high risk for developing this syndrome. Open communication with the patient, physical therapist, and treating clinician is imperative to limit progression or relapse of the disease.

To summarize, ITBS requires an interprofessional team approach, including clinicians, specialists, physical therapists, specialty-trained nurses, and occasionally pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]

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Figure

ITB friction syndrome. Image courtesy Dr Chaigasame MD

References

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Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med. 2011 Dec 06;155(11):725-32. [PMC free article: PMC3408027] [PubMed: 22147711]

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Falvey EC, Clark RA, Franklyn-Miller A, Bryant AL, Briggs C, McCrory PR. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010 Aug;20(4):580-7. [PubMed: 19706004]

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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 Feb;40(2):52-8. [PubMed: 20118523]

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Disclosure: Andrew Hadeed declares no relevant financial relationships with ineligible companies.

Disclosure: David Tapscott declares no relevant financial relationships with ineligible companies.

Running Injury Guide: iliotibial tract syndrome

The Injury Guide is not a guide to self-treatment. Its task is only to help you figure out what could cause the injury, what are its main signs, and what is useful to do for prevention. Only a doctor can accurately determine the problem and prescribe treatment, and not an article on the Internet.

Contents:

• Anatomy of the knee joint
• Symptoms of iliotibial tract syndrome
• Causes
• Treatment
• Prophylaxis
• How to get back to running

In the previous publication, we already wrote about the “runner’s knee” – one of the most common injuries among runners. It mentioned the most common cause of runner’s knee, patellofemoral pain syndrome (PFPS).

Today we will consider the iliotibial band syndrome (ITBS), which can also cause pain in the knees.

Anatomy of the knee joint

To better understand what will be discussed, pay attention to the anatomical features of the structure of the knee joint described in the previous article.

The iliotibial tract is a dense tendon that runs from the iliac crest down the outside of the thigh and through the knee joint, joining the outside of the patella on its way to the outer edge of the tibia. This tendon crosses the hip and knee joints, passing near the lateral condyle, and also communicates with the biceps femoris and patella.

Work of the iliotibial tract and adjacent muscles provides movement and stabilization of the knee joint during planting of the foot on the ground. This also prevents excessive inward rotation of the leg when turning the hip to the side.

Iliotibial tract syndrome

Iliotibial tract syndrome (TITS) is a running injury caused by inflammation of part of the iliotibial tract, resulting in pain on the outside-side of the knee. In some cases, pain may be localized at the top or tibial tract.

The pain itself in the syndrome appears as a result of excessive friction of the lower part of the ilio-tibial tract against the external epicondyle of the thigh.

The prevalence of SPBT is 7–14% among the total number of running injuries and is predominantly typical for marathon runners.

But this injury also affects hockey players, football players, cyclists, skiers – representatives of sports with a fairly high load on the knee joints.

It is not only athletes who suffer from this syndrome. People far from sports, leading an inactive way of life and, as a result, having underdeveloped leg muscles and insufficiently elastic fascia, are also at risk.

In general, despite the rather severe pain in the knee area, SPBT responds well to conservative treatment, which involves reducing training loads, using alternative loads, as well as special exercises to strengthen the iliotibial tract.

Main symptoms

The most characteristic symptom of PTSD is severe pain outside the knee.

Typically, the iliotibial tract begins to hurt 3-4 minutes after starting a run. At first, a slight stiffness on the outside of the knee joint may be felt, which quickly turns into sharp pain. Pain sensations can significantly increase on descents, and in case of chronic injury, pain can persist even at rest.

A number of special tests are used to diagnose STDs, such as the Auber test or the Nobel test. However, in order to exclude other possible pathologies of the knee joint (rupture of the lateral meniscus, stretching of the lateral collateral ligament, patelofemoral pain syndrome, etc.), as well as for a more accurate diagnosis of the state of the tissues adjacent to the area of ​​inflammation, magnetic resonance imaging (MRI) is often additionally prescribed .

Causes

As in the case of patellofemoral pain syndrome, the reasons for the appearance and development of SPBT in some athletes and the absence in others remain poorly understood.

A number of MRI studies have shown that SPBT causes thickening of the distal part of the iliotibial tract due to chronic inflammation that arises from its constant friction against the epicondyle of the femur. In many cases, there was also a significant narrowing of the gap between the iliotibial tract and the knee joint compared to healthy athletes, as well as filling it with inflammatory fluid.

Some studies show a significant impact on the development of SPBT of incorrect running biomechanics in connection with overtraining. But, at the same time, many runners with similar disabilities may not have the syndrome at all.

Factors that increase the risk of developing SPBT:

• large running volumes, a sharp increase in mileage
• a lot of running on hilly terrain (especially downhills)
• underdeveloped muscles: glutes, quadriceps, extensors, flexors, hip abductors
• defects in the structure of the foot, flat feet
• ill-fitting sneakers
• incorrect running biomechanics/technique, including stride width
• poor-quality warm-up before a run.

Treatment

As with patellofemoral pain syndrome, PTSD can usually be successfully treated at home. But in any case, you should contact an orthopedist-traumatologist or a physiotherapist. This will allow you to competently plan a rehabilitation program and gradually bring the work of the knee back to normal.

The most popular and successful approach to rehabilitation for SPBT described in the scientific literature is the Frederickson method (2005).

Acute phase

The main task at this stage is to eliminate all unnecessary load on the injured leg in order to provide it with rest.

To reduce pain and swelling, you can use cold compresses by applying an ice pack (frozen vegetables), always through a cloth (!) for 20–30 minutes, 2–3 times throughout the day.

Non-steroidal anti-inflammatory drugs (aspirin, ibuprofen, etc.) are often used for severe pain. But first, be sure to consult with your doctor.

Ultrasound techniques, including phonopheresis (delivering anti-inflammatory drugs through the skin into inflamed tissue using ultrasound) and iontophoresis (electricity is used instead of ultrasound), can be used as an adjunct to help reduce irritation in the soft tissues surrounding the knee.

You can additionally fix the knee joint with an elastic bandage, providing it with external support.

Conservative method

After the inflammation is relieved and the acute phase is over, a “conservative method” is used to treat SPBT, which consists of a set of physical therapy exercises, massage, stretching, strengthening the leg muscles with a gradual return to jogging. It is equally important to eliminate the risk factors that lead to injury.

Depending on the degree of “neglect” of SPBT, active training is stopped for 5-6 weeks completely or replaced with alternative ones that give a minimum load on the problem area (for example, swimming or orbitrek).

Physical therapy exercises consist of complexes that include stretching and strengthening different muscle groups of the injured leg.

Note that the iliotibial tract itself is quite stiff, so stretching it has not been shown to be effective for either treating or preventing SPBT.

Then they move on to workouts with no impact (orbitrek, bicycle) and, finally, to light running workouts on a flat, non-hard surface.

To reduce friction between the iliotibial tract and the epicondyle of the knee joint, a knee orthosis (compression bandage) can be used initially. Kinesiology taping can also be used.

It should be noted that wearing an orthosis and kinesio taping are complementary methods of treatment that reduce pain, and their effectiveness in the long term has not yet been proven.

To speed up the rehabilitation process in SPBT, it is recommended to use a deep massage of the adjacent tissues: every day for professional athletes and 2-3 times a week for amateurs.

Alternatively a massage roll can be used. Please note that you should not roll the injured area or the otibial tract – this will only aggravate the syndrome. At the same time, rolling out the fascia above and below the injured area, as well as rolling out the glutes, piriformis, adductors, quadriceps, will definitely give a positive result, since by relieving excess tension from these muscles, we will balance the work of the tract.

Surgical treatment of SPBT is rarely used, only in severe cases.

Prevention

A range of approaches are used to prevent STDs, from controlling your training schedule and gradually increasing your training load, to strengthening your thigh muscles and more. May help:

• regular exercise and gradual increase in intensity
• optimization of running technique
• suitable sports shoes
• high-quality warm-up before the main workout
• strengthening of the thigh muscles, as well as the muscles of the stabilizers of the movement of the knee joint.

Exercise

To prevent the syndrome, it is necessary to strengthen the quadriceps and gluteal muscles with the help of exercises.

Lateral leg raises

Starting position: lying on the side, legs together, injured leg on top; the lower hand can be placed under the head.

Brace your leg muscles and lift your straight leg to a 45 degree angle.

Hold the leg in this position for a few seconds, then slowly lower it without touching the healthy leg.

Do 20 reps, switch legs. Do 2-3 sets per day.

External rotation of the thigh

Starting position: lying on the side, legs bent at the knees at an angle of 90 degrees, bend the hips at an angle of about 60 degrees to the body.

Keeping your heels together and your pelvis pressed to the ground, raise your top knee as high as you can, hold for a second or two, then lower it.

Repeat 10-15 times per side for 2-3 sets.

Over time, small weights can be used to increase the effect of exercises 1 and 2.

Single Leg Squats

Starting position: standing straight, feet shoulder-width apart, arms down.

We transfer the weight of the body to the right leg, the knee is slightly bent. We straighten the left leg and bring it forward, tearing it off the floor. We move the pelvis back and begin to descend into a squat without lifting the heels of the working leg from the floor. Stretch your arms in front of you as a counterweight. Keeping balance, you need to go as low as possible, trying to touch the heel with your buttocks. Without helping yourself with your left foot, return to the starting position.

If you find it difficult to balance while squatting on one leg at first, you can use a wall or a chair as an additional support, holding on with your hands.
Repeat 3-10 times on one leg for 2-3 sets.

Monster walk

Starting position: feet shoulder-width apart, rubber band on hips or shins.

Step left with your left foot, then step left with your right foot. Take a step to the right with your right foot, pull up your left leg – take a step to the right with your left foot. Repeat the movement in the opposite direction (to the right).

The exercise can be done until muscle fatigue appears or a little longer. The lower the rubber band, the more difficult the exercise will be.

How to return to running

Since the appearance of SPBT is influenced by several factors (running technique, thigh muscle strength, shoes, etc. ), how soon you can resume running training depends on the elimination of the causes of the syndrome, as well as on progress in strengthening the thigh muscles.

In any case, at the initial stage, it is necessary to refrain from running loads for several days (sometimes weeks) until the inflammation on the outside of the knee joint subsides.

Once the initial inflammation has subsided, you can start working on strengthening the thigh muscles and gradually add running loads.

Complete recovery can occur after a month of daily practice. Moreover, during this period it is already possible to run: the main thing is that the runs are relatively short and do not again lead to irritation of the ilio-tibial tract. Sometimes full recovery may take longer.

Improve your technique, keep fit with alternative workouts, keep strengthening your muscles, and you’ll soon be able to enjoy running again.

Photographed by Dima Kovalenko, coach Dilyara Bukatar showed the exercises.

Other injuries:

• Inflammation of the periosteum (shin splint)
• Chondromalacia and runner’s knee
• Achilles tendinitis
• Plantar fasciitis

More To Read About Injuries:

• The 7 Most Common Running Injuries (Infographic)
• Where do running injuries come from?
• Popular questions and answers about running injuries
• How to deal with stress when you have a running injury

Iliotibial tract syndrome – Physiotherapist

Iliotibial tract syndrome (TIT) iliotibial band syndrome is a common knee injury that is usually accompanied by pain and/or tenderness on palpation of the lateral surface of the knee, above the joint line, and below the lateral epicondyle of the femur [1]. It is considered a non-traumatic overuse injury often seen in runners and is often accompanied by weakness of the hip abductors [2][3]. The current theory is that this condition is probably caused by compression of innervated local adipose tissue [4]. Research has described a “zone of impingement” occurring at or just below 30° of knee flexion during kicking and early running. During the impingement period of the running cycle, the eccentric contraction of the tensor fascia lata and gluteus maximus causes the leg to slow down, creating tension (compression) in the iliotibial tract [5].

Contents

Clinically significant anatomy

The iliotibial tract is a thick band of fascia that runs along the lateral side of the thigh from the iliac crest and inserts at the knee [6]. It is composed of dense fibrous connective tissue that emerges from the tensor fascia lata and the gluteus maximus. It descends along the lateral surface of the thigh, between the layers of superficial fascia, and inserts on the lateral plateau of the tibia in a projection known as Gerdy’s tubercle [2]. In its distal part, the ilio-tibial tract covers the lateral epicondyle of the femur and expands to the lateral border of the patella. While the iliotitibial tract has no bony attachments because it runs between the tubercle of Hardy and the lateral epicondyle of the femur, this lack of attachment allows it to move back and forth with knee flexion and extension.

Histological and anatomical examination of the iliotibial tract on the lateral epicondyle of the thigh, gluteus maximus and tensor fascia lata suggest a mechanosensory role acting proximally on the anterolateral part of the knee. This mechanosensory role may influence the interpretation of the function of the ligaments and tendons of the PBT from the femur to the lateral epicondyle of the femur.

Epidemiology / etiology

STD is one of the most common injuries in runners associated with lateral knee pain, with an estimated incidence of 5% to 14% [7]. Further studies show that SPBT is responsible for approximately 22% of all lower extremity injuries [1].

The etiology of STDs is often multifactorial. Long-distance running is a common cause of SPBT, especially when running on slightly sloping ground, as a small drop on the outside of the foot stretches the SPBT, increasing the risk of injury, and a sudden increase in activity levels can also lead to SPBT. Although repetitive tissue compression leading to irritation is best supported by recent data, there are a number of other hypotheses regarding the development of this condition.

When the knee is in extension, the iliotibial tract lies anterior to the lateral epicondyle of the thigh. When the knee is in 30° flexion, the tract moves posteriorly to the lateral epicondyle of the femur. It is hypothesized that friction may therefore occur between the posterior margin of the iliotibial tract and the underlying lateral epicondyle of the femur.

Muscle weakness of the hip abductors can also be associated with iliotibial tract syndrome because it causes increased internal rotation of the hip and adduction of the knee. This has been considered a major problem for athletes with iliotibial tract syndrome [6][8]. Another proposed etiology is chronic inflammation of the PBT bursa [9].

Characteristics / clinical presentation

In many cases, subjective assessment already provides an excellent basis for suspecting this syndrome. Activities that require repetitive flexion-extension of the knee, as well as burning pain at or just below the lateral epicondyle of the thigh, are commonly reported. Diagnosis in patients with this syndrome is based on various symptoms [10].

The main symptom of PBT is a sharp pain on the outside of the knee, especially when the heel hits the floor, which may radiate to the outside of the thigh or calf [11]. The pain is usually aggravated by running or going down stairs. There may be an audible clicking sensation as the knee flexes due to the tract sliding over the bony protuberance. There may also be some swelling on the outside of the knee.

Among the characteristics is exercise-related pain over the lateral epicondyle of the femur [10]. The patient may regularly experience acute burning pain when pressing on the lateral epicondyle of the thigh during flexion and extension of the knee [3]. Signs of inflammation may also be detected [1][10]. During running, there is pain in the lateral part of the knee, which worsens when descending a hill or going down stairs, and the pain usually worsens when running long distances [12].

The first well-documented cases of STDs were conducted by Lieutenant Commander James Renne, an officer in the Medical Corps, who documented 16 cases of STDs out of 1,000 recruits. Onset most often occurred in the lateral part of the knee after 2 miles of running or walking more than 10 miles. Walking with an outstretched knee relieved the symptoms. All patients had focal tenderness over the lateral femoral epicondyle at 300 flexions, and 5 patients had unusual palpation described as “rubbing a finger on a wet balloon” [13].

The prevalence of SPBT in women is estimated to be 16% to 50% and in men 50% to 81% [7].

Differential diagnosis

• Biceps tendinopathy
• Degenerative joint disease
• Injury to the lateral collateral ligament (LCL)
• Dysfunction or injury of the meniscus
• Myofascial pain
• Patellofemoral stress syndrome
• Popliteal tendinopathy
• radiating pain in the lumbar spine, stress fractures and sprains of the upper tibiofibular joint [14].
• Osteochondritis dissecans of the knee
• Overuse injury
• Peroneal mononeuropathy
• Acetabular bursitis [15].

Diagnostic procedures

Various provocative tests are available:

• Renne test
• Noble test
• Auber test

Examination

• Hip abduction force:

Hip abductor strength may be reduced. Therefore, these muscles should be tested [10].

• Treadmill test:

This test has been described in several studies as a valid, effective and sensitive method for evaluating the effects of treatment for pain associated with running and is used to measure the amount of pain subjects experience during normal running. If this includes pain in the lateral part of the knee, the test is considered positive [16].

• Noble compression test:

This test begins with the supine position and knee flexion to 90 degrees. As the patient extends the knee, the examiner applies pressure to the lateral epicondyle of the femur. If this causes pain over the lateral epicondyle of the femur at 30-40 degrees of flexion, the test is considered positive [3]. A goniometer is used to ensure the correct angle of the knee joint [16].

• Aubert test:

The patient lies on his side, the injured limb is turned upwards. The knee is bent at 90 degrees, and the hip is kept in line with the body during abduction and extension. The patient is asked to abduct the hip as far as possible. The test is considered positive if the patient cannot abduct further than the edge of the couch. A positive Auber test indicates a short/tight iliotibial tract or tensor fascia lata, which is often associated with friction syndrome [1][17].

Both the Noble compression test and the Aubert test can be used to evaluate a patient with suspected iliotibial tract syndrome. The result will be more obvious if you combine them into one special test. To do this, the Auber test position is taken and compression is applied to the lateral epicondyle during passive knee extension and flexion. Moving the knee can cause more stress on damaged structures and can help reproduce the patient’s symptoms if the combination does not. Medial sliding of the patella can also increase symptoms and may pinpoint the exact location, while lateral sliding reduces them. Internal rotation of the tibia, as the knee moves from flexion to extension, can also cause symptoms. A combination of Noble and Auber tests with an unloaded knee or in a leg-supported position can also be performed to reproduce symptoms [3].

Treatment

Treatment of an acute inflammatory response

Changing activity to prevent further worsening of a patient’s symptoms should be the first area to be addressed in treatment. Encouraging a period of active rest or significantly reducing the intensity of aggravated actions would be a good starting point. Patients should be encouraged to participate in other physical activities, such as swimming, that do not aggravate their symptoms, in order to keep fit. It is important to work with the patient to find a level of activity that allows him to feel confident in his ability to rehabilitate and have a clear understanding of why this reduction in load is necessary, as well as to train within the pain-free range [4]. Some authors [1][3] suggest a complete rest from sports for at least 3 weeks; other authors [2] suggest that it is best to rest from 1 week to 2 months, but this rest period is highly dependent on the characteristics of the clinical case of each person.

Other methods that may provide pain relief include ice (cryotherapy) or heat [1][9], taping and stretching according to objective results.

If symptoms do not improve and inflammation persists, the following treatments may be considered: processed soft tissue) [18]

Iontophoresis or phonophoresis [9], methods in which a drug is injected into damaged tissue by means of an electric field driven distribution of ions, or passed through the skin using ultrasonic waves, respectively. Iontophoresis with dexamethasone may be useful as an anti-inflammatory agent [6].

Phonophoresis has been used in an attempt to enhance the absorption of topical analgesics and anti-inflammatory drugs through the therapeutic application of ultrasound. One study evaluated the efficacy of two treatments for PTSD: phonophoresis using ultrasound to transfer 10% hydrocortisone into the subcutaneous tissues and immobilize the knee; the result suggests that phonophoresis is a better treatment than knee immobilization alone [19].

An alternative treatment strategy is radial shock wave therapy. RSWT is considered safe because it results in few side effects, including worsening of symptoms over a short period of time, reversible local swelling, redness, and hematoma. It is believed that RSWT stimulates soft tissue healing and suppresses nociceptors. Thus, it increases the diffusion of cytokines through the vascular walls into the painful area and stimulates the tendon healing response. Shockwaves also shrink unmyelinated sensory nerve fibers and significantly reduce calcitonin-related peptide and substance-P release. Finally, shock wave treatment can stimulate neovascularization at the tendon-bone junction, thereby promoting healing.

Shock wave therapy uses the energy generated when a projectile in the tip is accelerated by compressed air and hits a 15 mm metal applicator. The energy is then transferred from the applicator through the ultrasonic gel to the skin, where the shock wave dissipates radially in the treated tissue.

Radial shock wave therapy has been shown to be indeed effective as a rehabilitation program for runners with iliotibial tract syndrome [16].

Physiotherapy

Treatment of SPBT is usually non-surgical and physiotherapy should be considered the first and best line of treatment.

• Exercises to stretch the iliotibial tract are no longer considered a well-founded approach to treatment. The best exercises to start with will depend on the causative factors obtained through subjective and objective evaluation. If the lateral gluteal muscles are found to be weak or not functioning properly, this will lead to compensatory muscle adaptations that can lead to excessive contraction of the iliotibial tract [12]. If the gluteal bands are too short, external rotation of the leg can occur and create abnormal tension in the iliotibial tract [20][7].
• Myofacial treatment may be effective in reducing pain in the acute phase, when pain and inflammation are felt at the site of attachment. Trigger points in the biceps femoris, vastus lateralis, gluteus maximus, and tensor fascia lata will be treated with myofascial treatment [6].
• The use of a foam roller on tense muscles may also be helpful [12]. The patient can also do foam roller exercises at home to create deep lateral friction, self-myofascial relaxation (massage), and muscle stretch. A possible exercise is to lie on your side with a foam roll perpendicular to your lower leg, just below your pelvic bone. The top leg should be in front for balance. Using your hands for support, roll up and down the roller [21].
• Exercises to strengthen the abductors and stabilize the hip may be helpful when clinically indicated. Since SPBT can often be associated with weakness of the abductor femur, strengthening and stabilizing the hip will be beneficial in the treatment of SPBT [2]. Some examples of useful exercises: Stand on the edge of a step with most of your body weight on the unaffected side. Lower the hip of the involved leg and return it to a neutral position [10]. Another example is the hip abduction exercise in the supine position, with the back pressed against the wall and the leg held at about a 30° angle to hip abduction with slight external hip rotation and neutral hip extension. This exercise can be made more strenuous by placing a 1 meter long band between the ankles [2].

Other exercises that are recommended, given the relationship of weight loss on one leg and neuromuscular control, are the “one-leg down step”, “one-leg squat” and “one-leg raise” [17].