Iliotibial Band Syndrome (ITBS)

ITBS

Iliotibial band syndrome is a common overuse injury which causes lateral knee pain among runners, cyclists and endurance athletes.

The ITB is a taut band of connective tissue which attaches superiorly into the fascia of the TFL and Gluteus maximus muscle. It travels down the lateral leg attaching into the linea aspera of the femur. At the knee it attaches to the lateral femoral condyle (LFC), Lateral femoral epicondyle, Gerdy’s tubercle of the tibia and the head of the fibula.

Crossing both the hip and knee joint, the ITB is very important in hip and knee flexion actions.

Repetitive friction over the lateral femoral epicondlyle was thought to be the likely cause of pain. Another theory posed ,was inflammation or irritation of an underlying bursa. Cadaver studies however, show no presence of a bursa. Anatomically the ITB’s attachment at the knee renders the repetitive friction theory in doubt. A more plausible theory is due to compression of a highly innervated fat pad between the ITB and the LFC.

Presentation

ITBS usually presents as lateral knee pain with an insidious nature. There is no history of trauma. Athletes can begin their run only to feel pain by about 1-2 mile into the run. The pain increases as intensity/duration increases.

ITBS is a frustrating injury for an athlete to develop. It leaves athletes with a period of unloading much like the early stages of a tendinopathy. Contributing factors to the development of ITBS seem to be, excessive increase in mileage, intensity, hill repeats, running on cambered roads, running the same direction round a track, and running down hill.

Treatment

I have seen a variety of ways to stretch the ITB in an attempt to “loosen it out”. The ITB is a “taut band”. Its supposed to be tight! Trying to stretch it won’t affect its length. A study by Fredericson et al (2010),  showed a minimal ability of the ITB to lengthen. Most likely what people are stretching is the TFL muscle up at the hip. Possibly reducing tension in the gluteus maximus and TFL will have a knock on effect on the ITB, and reduce compression at the knee. Hip strengthening has also been posed as a treatment for ITBS. However, there is no clear evidence that weak hip muscles have a role in ITBS. Despite the lack of quality evidence for these modes of treatment, they may be beneficial.

Alternative/adjuncts to the above modalities include running modification and neural re-education.

Conclusion

In summary, there is a lack of good quality evidence in the treatment of ITBS. In my opinion, I would reduce the athlete’s running time to non painful levels/period of time. This way they unload the structures to an acceptable level and hence reduce the compression at the knee. This doesn’t trigger the pain alarm in our brain and lets the brain know we are comfortable at this level (neural re-education). A slow gradual increase in running would then be applied but only under the pain alarm. Addressing any muscle weakness throughout the body would also be addressed.