Iliotibial Band Syndrome | Diagnosis and Treatment
Danielle R. Steilen, MMS, PA-C
Injury to the tendons of the knee
Iliotibial Band Syndrome, Diagnosis and Treatment
In this article Danielle R. Steilen, MMS, PA-C of Caring Medical and Rehabilitation Services discusses the various challanges with determining a correct diagnosis and treatment plan for Iliotibial Band Syndrome.
- There are a few theories of the etiology of Iliotibial Band Syndrome, but they agree that there is a component of abnormal compression forces between the iliotibial band and the lateral femoral condyle which causes the irritation and inflammation of the tissue.
- Sometimes the typical approach of rest, NSAIDS, and PT are helpful to relieve the pain of ITBS, however these modalities do not address the injured tissue, and therefore the athlete commonly reinjures the ITB.
- When this conservative approach does not work, traditional medicine recommends removing and shaving of the inflamed tissue of the IT band. Of course this will only make the band weaker.
- Prolotherapy, Neurofascial Prolotherapy and Platelet Rich Plasma therapy to the injured IT band will strengthen the tissue, effectively repairing the IT band and allowing the athlete to confidently return to their sport.
What causes Iliotibial Band Syndrome?
Iliotibial Band Syndrome (ITBS) or strain is a common athletic injury to the tendons of the knee. The primary cause is strong exertion of the muscle during sports or training which manifests itself as pain in the outer knee area. ITBS can stop runners in their tracks.
The iliotibial band (ITB) is a thick band of tissue that extends from the lateral thigh down over the knee. It functions to control the amount of hip adduction (movement towards the body trunk) and minimizes the rotational forces experienced at the hip and knee.
Iliotibial band syndrome is an overuse injury, seen frequently in runners, that has typically been described as being caused by friction, as the iliotibial band rubs anteriorly and posteriorly (front and back) over the lateral femoral condyle (the outer knee bone).
A more recent theory appears to be related to increased peak hip adduction and knee internal rotation.1 Both theories rely on an abnormal increase in compression forces between the IT band and the lateral femoral condyle (LFC) to cause irritation and inflammation in the tissue.
Since female runners demonstrate a greater hip adduction and internal rotation angle while running than male counterparts, they are more likely to develop iliotibial band syndrome. Two different studies comparing female distance runners and female recreational runners with ITBS to healthy controls, found that the ITBS group exhibited significantly greater hip adduction and knee internal rotation than the control group. They hypothesized that these combined motions created excessive strain to the ITB as it attempted to decelerate hip adduction and knee internal rotation causing compression of its distal aspect against the lateral femoral condyle.1
Some studies have shown that athletes with ITB syndrome have different running kinematics than those without the problem. “The kinetics and kinematics of the hip, knee and/or ankle/foot appear to be considerably different in runners with ITBS to those without.”2
Some of these studies concentrate on changing the running style, or length of stride to help to alleviate the symptoms of ITBS.1 However, a literature review of many studies concluded, “It appears unlikely that abnormal biomechanics at the foot or tibia is responsible for increasing tension in the ITB.”3
Other proposed contributing factors to the development of ITBS include “a sudden increase in exercise intensity, downhill running, wearing old shoes, always running on the same side of a cambered road, leg length discrepancies, excessive pronation of the foot, a tight IT band and weakness of the gluteus medius muscles.”3
In the most recent research (November 2015) “Female shod runners who went onto developing Iliotibial band syndrome presented with increased peak hip adduction and increased peak knee internal rotation during stance.”4
However, once again there is disagreement in the literature reviews. This time the issue is muscle strength and weakness
“There is currently no evidence to suggest that reduced muscle strength plays a role in the aetiology of ITBS.” And another, “Weakness of hip abductors does not seem to play a role in the etiology of Iliotibial Band Syndrome in runners, since dynamic and static strength measurements did not differ between 10 healthy runners and 10 runners with Iliotibial Band Syndrome, and differences between hip abduction and adduction were the same. Strengthening of hip abductors seems to have little effect on the prevention of Iliotibial Band Syndrome in runners.”5
Symptoms and traditional treatment of iliotibial band syndrome
ITBS symptoms vary from patient to patient and may range from a stinging sensation just above the knee 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 typically felt on the outside of the knee or along the entire length of the IT band. This severe excruciating pain in the lateral knee makes running very difficult. Sometimes there is a grating sound where the iliotibial band rubs over the femur. Pain may not occur immediately during activity, but may intensify over time, or at the end of a run. Pain is most commonly felt when the foot strikes the ground, and pain often persists even after the activity has commenced. Pain may also be present above and below the knee, where the IT band and the tibia attach.
“Conservative management including rest from activity, equipment modification, oral nonsteroidal anti-inflammatory drug (NSAID) use, and physical therapy is the mainstay of treatment initially, refractory cases do exist. Surgical options include percutaneous release, open release, ITB Z-lengthening, and an arthroscopic technique.”6 “Assuming the inflammation in the tissue connecting the ITB band to the lateral femoral epicondyle is the culprit of ITB pain, this tissue can be removed with an arthroscopic shaver.”5 Interestingly, these research surgeons are ready to perform a more “conservative surgery” by removing and shaving off tissue on an assumption!!!
As noted above, the typical mainstream ITBS treatment options are anti-inflammatories, rest, orthotics and stretching of the iliotibial band. Massage may also be prescribed. Typically this approach decreases symptoms and some athletes even get back to running, but generally the condition continues to recur, because the attachment of the iliotibial band to the tibia is injured, and therefore will continue to give out.
What athletes want are muscles, ligaments and tendons that are strong and the proper length (and not removed!). Clearly if a muscle is tight, especially compared to the ‘non-injured’ side, then it needs to be stretched. However, having the athlete rest and then giving anti-inflammatory medications and cortisone shots to areas like the iliotibial band inhibits healing and causes further harm.They may give initial pain relief but in the end the athlete’s tissue is weaker and the injury keeps recurring or never goes away. Prolotherapy strengthens and repairs the soft tissue injury, relieving the pain and allowing the athlete to return to sport.
Difficulty in treating and diagnosing Iliotibial Band Injury
“The popularity of running is still growing and, as participation increases, the incidence of running-related injuries will also rise. Iliotibial band syndrome is the most common injury of the lateral [outer] side of the knee in runners, with an incidence estimated to be between 5% and 14%. In order to facilitate the evidence-based management of Iliotibial band syndrome in runners, more needs to be learned about the aetiology, diagnosis and treatment of this injury.”2
Researchers publishing in the journal “Sports Medicine,” found what we’ve noted above, a confusing and conflicting set of medical reviews that basically said, “The methodological quality of research into the management of Iliotibial Band Syndrome in runners is poor and the results are highly conflicting.”
One of the problems with unresolved iliotibial band syndrome is misdiagnosis. This was pointed out in research when orthotic devices failed to deliver favorable results, suggesting a different diagnosis – potentially popliteal tendinitis or lateral meniscus tear.6 It is important that the runner has a physical examination and discusses with the doctor a detailed history to reach an accurate diagnosis.
Prolotherapy for Iliotibial Band Syndrome
Since the iliotibial band goes from the hip area across the knee area, it traverses two joints. If either of these two joints is weakened or has ligament laxity, the tibia and/or femur will move excessively. This will put extra stress on the iliotibial band. In runners with iliotibial band syndrome, Prolotherapy would be recommended into and around their knees and hips. If the hip is evaluated and considered stable, then an athlete with iliotibial band syndrome will get Prolotherapy to the area on the tibia where the iliotibial band attaches. If there are other parts of the iliotibial band that are tender on the athlete besides the attachments, then these areas are treated with the components of Comprehensive Prolotherapy, including Neurofascial Prolotherapy, and/or Platelet Rich Plasma to increase healing to the area. Typically 3-6 visits of Prolotherapy are needed. The treatments can be done weekly, if necessary. Generally after two treatments the athlete starts working out again.
The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. For the athlete with chronic lateral knee pain, an evaluation by a Prolotherapist is warranted. We have treated many cases of iliotibial band syndrome in athletes (mostly runners) successfully with Prolotherapy.
1. Allen DJ. Treatment of distal iliotibial band syndrome in a long distance runner with gait re-training emphasizing step rate manipulation. Int J Sports Phys Ther. 2014; 9(2): 222–231.
2. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012; 42(11):969-92. doi: 10.2165/11635400-000000000-00000.
3. Louw M, Deary C. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners: A systematic review of the literature. Physical Therapy in Sport. 2013; 1-12.
4. Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskelet Disord. 2015 Nov 16;16(1):356. doi: 10.1186/s12891-015-0808-7.
5. Grau S , Krauss I, Maiwald C, Best R, Horstmann T. Hip abductor weakness is not the cause for iliotibial band syndrome. Int J Sports Med. 2008; 29(7): 579-583. DOI: 10.1055/s-2007-989323
6. Cowden CH. Barber FA. Arthroscopic treatment of iliotibial band syndrome. Arthrosc Tech. 2014; 3(1): e57–e60. doi: 10.1016/j.eats.2013.08.015
7. Pettitt R, Dolski A. Corrective neuromuscular approach to the treatment of iliotibial band friction syndrome: a case report. J Athl Train. 2000; 35(1):96-9.