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Iliotibial Band Friction Syndrome

Runner's knee is frequently responsible for lateral knee pain in highly active individuals. Prevalence, diagnosis, management, and preventing recurrence of this common athletic injury.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.

History/Pathogenesis

Iliotibial band friction syndrome (ITBFS) is an overuse injury associated with repetitive knee flexion that is frequently responsible for lateral knee pain in highly active individuals. It most commonly results from an abrupt shift in training intensity. Pain has been reported to radiate both superior and inferior to the knee, as well as present at the hip.

Overuse of the iliotibial band (ITB) is thought to produce friction, inflammation, and eventually physiologically irreparable damage that leads to the deterioration of soft tissue. The traditional model of ITBFS proposes that the ITB moves posteriorly over the lateral femoral condyle with flexion of the knee, with the highest contact occurring at an average of 21 degrees. Intensity of this contact can be exacerbated by severe tightness or strain of the ITB resulting from continual knee movement and prolonged activity.

Although the precise etiology of ITBFS is somewhat speculative, its development and progression can be largely explained by analyzing the biomechanical influences, as well as various aspects associated with training habits.1-4

Image: iStock (cheshiirecat)Iliotibial band friction is the most common cause of lateral knee pain among runners and athletes, accounting for 10% to 12% of all running-related injuries.

Prevalence/Epidemiology

ITBFS is reportedly the most common cause of lateral knee pain among runners and athletes. Known as "runner's knee," the inury has been reported to account for 10% to 12% of all running-related injuries.2,5,6

Signs/Symptoms

  • Lateral knee pain made worse by running and repetitive activities, lateral knee pain when ascending and descending stairs, occasional “popping,” with stiff-legged walking in advanced cases

High Risk Activities for ITBFS

  • Running (especially distance and cross country), cycling, rowing, soccer, volleyball, basketball, football, and skiing.

Related Conditions and Risk Factors

  • Post-operative ACL patients 
  • Patients with osteoarthritis
  • Congenital ITB thickness (there is a possible positive correlation)
  • ITB tightness may be correlated with patellofemoral syndrome and/or tensor fascia latae dysfunction.2,7-10

 

Physical Exam 

Clinicians should look for:

  • Tenderness over the lateral femoral epicondyle, with tightening of the iliotibial band (ITB), with essentially normal intra-articular findings noted
  • Specific tenderness to lateral femoral condyle and distal ITB
  • Possible leg length discrepancy
  • Increased subtalar joint pronation
  • Sacroiliac joint dysfunction
  • Increased Q angle
  • Positive Ober’s test
  • Hip weakness (particularly gluteus medius)
  • Poor neuro-muscular control during single leg activities (squat and/or step down)
  • Check footwear and appropriateness for foot type.

Diagnostic Tests

  • If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing

Differential Diagnoses

  • Lateral meniscal/collateral ligament injury
  • Patellofemoral syndrome
  • Occult lesion
  • Stress fracture.

 

Acute Treatment

Common first-line approaches include:

  • Relative restA
  • Analgesia through appropriate doses of NSAIDs with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant (eg, Gebauer’s Spray & Stretch)
  • Electrical stimulation (eg, RS Medical Sequential Stimulator)

 

Long-Term Treatment/Rehab

Long-term treatment may include the following: stretching (regional muscles including ITB); regional myofascial restriction release (including ITB); manual connective tissue manipulation (trigger points in ITB, any restricted component(s) of the affected leg); hip abductor strengthening, as well as neuromuscular control training through progressively complex multidimensional movement patterns.

Corrective exercise for the hip musculature (emphasis on gluteus medius), manual therapy (to break up fibrotic adhesions, scar tissue, and trigger points), stretching (hip flexors, hamstrings, calves, and ITB), self-myofascial release techniques, and orthotic intervention (if deemed appropriate).11-18

For patients who have unresolved pain and do not respond to conservative treatment for three months, surgical intervention may be recommended.

Regenerative medicine techniques, such as platelet-rich plasma and stem cell injection options, are now on the forefront of research and for potential treatments for chronic overuse musculoskeletal/sports injuries. They should be considered on a case-by-case setting for these ITBFS.1,2,19,20

Prevention

To prevent occurrence, as well as recurrence of the injury, advise the patient to make gradual transitions in training intensity, allowing the body to adapt to the next level before progressing.

For runners, it’s a good idea to encourage alternate running on different sides of the road or changing direction on the track.

 

Practical Takeaways 

  • ITBFS is reportedly the most common cause of lateral knee pain among runners and athletes, reported to account for 10% to 12% of all running-related injuries.
  • ITBFS is an injury seen predominantly from running (especially distance and cross country), cycling, rowing, soccer, volleyball, basketball, football, and skiing.
  • Signs of ITBFS include lateral knee pain made worse by running and repetitive activities, lateral knee pain when ascending and descending stairs, occasional “popping,” with stiff-legged walking in advanced cases.
  • Acute treatment includes relative rest; analgesia through appropriate doses of NSAIDs and with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation.
  • Long-term treatment/rehab includes stretching (regional muscles including ITB), regional myofascial restriction release (including ITB), manual connective tissue manipulation (trigger points in ITB, any restricted component[s] of the affected leg), and hip abductor strengthening.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
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Elbow Pain – Medial and Lateral Epicondylitis
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