Iliotibial band syndrome – Sports related knee pain

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Recently you may have received a diagnosis of Iliotibial band syndrome. This causes pain on the outside of the knee just below the joint line. It is caused by strong exertion of the muscle during the sport or during training. It is the explanation for your chronic knee pain that you and your doctor will follow in your treatment guidelines moving forward.

If you do a lot of running your doctor may have called it “runner’s knee,” if you are involved in a sport where you do a lot of jumping your doctor may have said you have “jumper’s knee.” Specifically the iliotibial band rubs anteriorly and posteriorly over the lateral femoral condyle during running. Running, in particular, causes pain to this area located on the lateral (outside) of the knee joint. The symptoms may include severe excruciating pain in the lateral knee which make running very difficult. Sometimes there is a grating sound where the ilitibial band rubs over the femur.

For many people, the conservative care treatments we will outline below will probably be helpful and the athlete or the person with a physically demanding job will have their immediate knee pain reduced. Typically this approach does decrease symptoms and some athletes even get back to running, but generally the conditions continues to recur, why is that? The answer is more simple than complex, the attachment of the iliotibial band to the tibia is weak. So it keeps giving out.

A lot of the people we see are in a chronic situation. Their knee pain is accompanied by ankle instability and hip instability. There is really nothing on their MRIs or ultrasounds to suggest they need surgery but they have pain, focused in the knee, and it is making their hip and ankle joints problems as well. One more factor to consider: Possibly the reverse is happening, their ankle and hip instability are the cause of their knee pain. Finally, eventually, for some of these people, the Achilles tendon has become involved as well as problems in the feet.

Article outline:

• You started experiencing outer knee pain and have been diagnosed with Iliotibial Band Syndrome.
• Conservative care treatments were recommended:
  • Step 1: Anti-inflammatory programs and medications:
  • Step 2: Foam rollers, stretching, and massage
• Like many sports injuries, doctors tend to manage symptoms as opposed to fixing the problem of Iliotibial Band Syndrome.
• Hip and Knee Dynamics – Runners.
  • The hip and knee dynamics that cause pain in runners
• The issue of muscle strength and weakness in Iliotibial band syndrome is still poorly understood and hotly debated in current research.
• Symptoms and traditional treatment of iliotibial band syndrome.
• Difficulty in treating and diagnosing Iliotibial Band Injury.
  • The confusion and the conflicting idea of stretching.
  • Stretching because of stiffness and muscle weakness?
  • Kinesio Taping: Benefits were only seen in half the participants.
  • Prolotherapy for Iliotibial Band Syndrome

You started experiencing outer knee pain

Like most runners, you kind of get used to nagging injuries and you always manage to work your way through them. Injuries do not become “real” injuries for most runners until such time that it becomes too difficult and painful to run. At some point, you decide that you can no longer manage this pain on your own with over-the-counter pain relief medications and ace bandages so you go to a health care provider.

There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone) which causes the irritation and inflammation of the tissue. It is this location that also gives IT Band Syndrome, and it may be easier to understand the name “Runner’s Knee.” There are two distinct problems labeled “runner’s knee.” For problems that relate to Chondromalacia Patella – Patellofemoral Pain Syndrome please see that article.

The iliotibial band is a thick band of tissue that extends from the outer thigh down over the knee. It functions to control the amount of hip adduction and minimize the rotational forces experienced at the hip and knee. 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 friction syndrome.

When you were diagnosed with Iliotibial Band Syndrome what was the first thing you did? Search for remedies online and confirm what your doctor told you. What did you come across?

Step 1: Anti-inflammatory programs and medications:

• RICE
  • The RICE Protocol is Rest, Ice, Compression, and Elevation: For many athletes, a doctor’s recommendation of the RICE protocol for healing their sports-related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism as the components of the therapy are somewhat “anti-circulation.” Soft tissue needs blood pumping into it so it can heal. Rest, Ice, Compression, Elevation do the exact opposite. They send the blood away.
  • Please see our article for why we do not typically recommend RICE or PRICE.
• NSAIDs
  • NSAIDs are also something we would not typically recommend as chronic non-steroidal anti-inflammatory drugs (NSAIDs) usage can make the pain worse in the long-term. We just said soft tissue needs blood to heal. Blood carries inflammatory factors that repair the damage. Inflammation is only bad when it is always there.

Let’s stop here for a second and realize you are probably reading this article because these treatments did not repair your injury. They only made it feel better for a short time.

Step 2: Foam rollers, stretching, and massage

Foam rollers, stretching exercises, and massage are effective pain relief methods for many people. But they are not fixing the problem of a damaged ligament or frayed tendon. They are fixing the problem of a spasming muscle. The muscle is in spasm because you have damaged ligaments in your joints causing instability and this is damaging the tendon muscles.

Let’s explain.

Ligaments are the strong connective tissue that holds bones to bones. The most famous of these ligaments is the ACL or the anterior cruciate ligament which help hold the thigh and shin bones together.  The knee contains many ligaments including the Lateral Collateral Ligament or LCL, and the Medial Collateral Ligament or MCL. For knee instability to occur you do not need a complete rupture or tear of these knee ligaments, you only need for them to be stretched out or made weak by their loss of elasticity. How do these ligaments lose elasticity? Wear and tear damage.

For many people with knee instability, it is thought that by strengthening the muscles you can strengthen the knee. In part, this can be true if there is no tendon damage. The tendons hold the muscle to the bone. Any weakness or damage to the tendon will reduce the resistance load that any muscle needs to grow and strengthen.

Researchers from Southern Illinois University wrote in the December 2020 update STAT Peals at the National Library of Medicine (1)

“Knee pain has been reported to limit mobility and impair quality of life in 25% of adults. 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.”

So the problem is friction, overuse, and subsequent knee instability causing pain.

Usually managed conservatively, there is a lack of scientific evidence supporting the (conservative) treatment recommendations of ITB Syndrome

A March 2022 paper (16) in the journal Physical therapy in sport discusses conservative care treatments for Iliotibial band syndrome and whether or not the majority of them work. This is what they write: “Usually managed conservatively, there is a lack of scientific evidence supporting the (conservative) treatment recommendations, and high symptom recurrence rates cast doubt on their causal effectiveness.” The researchers point out that Iliotibial band syndrome symptoms may be made worse by anatomical predisposition (abnormalities in the tendon attachments), joint malalignments, aberrant (not usual or unnatural) activation of inserting muscles as well as excessive ITB stiffness. The researchers also suggest “Hip abductor strengthening may correct excessive hip adduction but also increase ITB strain. Intermittent stretching interventions are unlikely to change the ITB’s length or mechanical properties. Running retraining is a promising yet understudied intervention.”

Like many sports injuries, doctors tend to manage symptoms as opposed to fixing the problem of Iliotibial Band Syndrome

In the video below Ross Hauser MD explains that we see many patients at our center with problems of “Runner’s Knee,” or “Iliotibial Band Syndrome.” We typically see these people after they have tried many treatments with little to no success.

Hip and Knee Dynamics – Runners

Typically we will have someone contact our office and go through the very recognizable problems of hip and knee pain that seem to be confusing their doctors. Let’s point out again that many people with IT Band Syndrome get great results, it is the people who don’t are the people we usually see.

Here is an example of what these people tell us:

My doctor sent me to physical therapy. He was hopeful that we could really pinpoint what was causing my issues with PT. Unfortunately, the physical therapist could not. She told me that there was nothing obvious in my hip and knee pain except for the fact that it was obvious I had knee and hip pain. My hip and knee hurt just the same I had a lot of pain going through a range of motion during the PT sessions. Eventually, the physical therapist and doctor agreed that I must have a hip labrum tear and IT band syndrome. I was told to rest more and that we would start PT again in three months. I have been active all my life, I love to run. Three months of rest does not seem to be something that would help me as I have already rested and I am tired of resting, I am looking for something more to get me running again.

The hip and knee dynamics that cause pain in runners

As mentioned above and confirmed by 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 (the knee hip complex rotating inwards) than control groups.  This was demonstrated in a 2015 study (2). The theory is that these combined motions created excessive strain to the ITB as it attempted to decelerate hip adduction and knee internal rotation causing compression and the ITBS lowest connection points to the bottom of the femur/thigh bone.

Supporting this is acase history from the Cleveland Clinic Rehabilitation and Sports Therapy suggesting that problems of Iliotibial band syndrome were connected to the dynamic between increased hip rotation and knee internal rotation. (3)

Dutch researchers also supported this idea of rotation by suggesting that female runners demonstrate a greater internal rotation angle while running than male counterparts, which is why they are more likely to develop iliotibial band syndrome. (4)

Bringing these paper more current, a September 2020 paper (16) published in the journal Physical therapy in sport which tested the theory that Iliotibial Band Syndrome (ITBS) is caused by excessive iliotibial band (ITB) tension, caused by hip abductor and external rotator weakness. To put the theory to the test the researchers took 14 recreational runners with ITBS and 14 healthy controls of both sexes. They had physical therapy applied for six weeks to see if the treatment had any impact on ITB stiffness. In this study, one of the measuring tools used was ultrasound shear wave elastography which could show stiffness or elasticity in the tendon).

This is what the researchers found: “No statistical differences in ITB tension between legs as well as between patients suffering from ITBS and healthy controls were detected. Results showed significant strength deficits in hip abduction, adduction as well as external and internal rotation. Following six weeks of physiotherapy, hip muscle strength (all directions but abduction), pain and lower extremity function were significantly improved. ITB stiffness, however, was found to be increased compared to baseline measurements.” These findings also called into question conservative care options. “Shear wave elastography data suggest that ITB tension is not increased in the affected legs of runners with ITBS compared to the healthy leg or a physical active control group, respectively. Current approaches to the conservative management of ITBS appear ineffective in lowering ITB tone Tendon tightness). ”

As with the friction theory, the hip-knee rotation dynamic involves the tendons and irritation and inflammation in the tissue.

The issue of muscle strength and weakness in Iliotibial band syndrome is still poorly understood and hotly debated in current research

In January 2022 doctors at the University of Queensland and the University of Montana wrote in the journal Sports Medicine (14) that the mechanical behavior of the iliotibial band structure is still poorly understood and hotly debated in current literature.  . . (Doctors) currently lack a comprehensive understanding of the healthy behavior of the ITB, and this is necessary prior to further investigating the etiology of pathologies like Iliotibial band syndrome. . . The complexity of understanding the mechanical function of the Iliotibial band is due, in part, to the presence of its two in-series muscles: gluteus maximus and tensor fascia latae. At present, we lack a fundamental understanding of how gluteus maximus and tensor fascia latae transmit force through the Iliotibial band and what mechanical role the Iliotibial band plays for movements like walking or running. While there is a range of proposed Iliotibial band syndrome treatment strategies, robust evidence for effective treatments is still lacking. Interventions that directly target the running biomechanics suspected to increase either Iliotibial band strain or compression of lateral knee structures may have promise. . . ”

Some studies concentrate on changing the running style, or length of stride to help to alleviate the symptoms of ITBS. However, a literature review of many studies conducted by the University of Brighton in the United Kingdom concluded:

• “It appears unlikely that abnormal biomechanics at the foot or tibia is responsible for increasing tension in the ITB.”
• “There is currently no evidence to suggest that reduced muscle strength plays a role in the etiology of ITBS.”(5)
• 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.”(6)

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 crunching or 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 patient has stopped running.
• Pain may also be present above and below the knee, where the IT band and the tibia attach.

As we alluded to above and in the medical journal Arthroscopic Therapies doctors write, “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.”(7) These are procedures that cut the IT Band to “release” tension. “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.”

Difficulty in treating and diagnosing Iliotibial Band Injury

A March 2022 paper in the journal Physical therapy in sport (14) questioned the current traditional and conservative treatment options for Iliotibial band syndrome. They write: “Iliotibial band syndrome (ITBS) is presumably caused by excessive tension in the iliotibial band (ITB) leading to compression and inflammation of tissues lying beneath it. Usually managed conservatively, there is a lack of scientific evidence supporting the treatment recommendations, and high symptom recurrence rates cast doubt on their causal effectiveness. . . .  Hip abductor strengthening may correct excessive hip adduction but also increase iliotibial band strain. Intermittent stretching interventions are unlikely to change the ITB’s length or mechanical properties. Running retraining is a promising yet understudied intervention.”

University researchers in the Netherlands, publishing in the journal Sports Medicine (8) suggest to treat IT Band injury, doctors need to know what its causes are and to be able to diagnose it. “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 etiology, diagnosis, and treatment of this injury. . . The methodological quality of research into the management of Iliotibial Band Syndrome in runners is poor and the results are highly conflicting.”

Doctors at the University of California Irvine also wrote of the problems of unresolved iliotibial band syndrome misdiagnosis. They suggest that when orthotic devices failed to deliver favorable results in IT Band Syndrome, it may be suggesting a different diagnosis – potentially popliteal tendinitis or lateral meniscus tear.[9]  It is important that the runner has a physical examination and discusses with the doctor a detailed history to reach an accurate diagnosis.

The confusion and the conflicting idea of stretching

Many people find stretching will help alleviate and reduce their pain related to IT Band syndrome. Too much of a good thing may be a problem. This section is also not focused solely on you doing particular stretching exercises. Stretching also occurs during the IT Bands’ normal job and range of motion as being a primary stabilizer for the hip and knee.

A May 2020 study (10) published in the International Journal of Sports Physical Therapy examined the role and the ability of the iliotibial band to stretch and whether stretching should be offered as a possible treatment.

What these researchers were looking at was the IT Band in isolation, its ability to withstand stretching load, and when it is overstretched causing injury.

Learning points:

• The IT Band can withstand substantial tensile forces (stretching).
• The stiffness of the IT Band can present stretching problems. The IT Band resists stretching for fear that the stretching may injury it.
  • Understand what is happening in some people. The IT Band is becoming problematic because it is being overstretched as a result of hip and knee instability. The IT Band recognizes stretching as a symptom of its problem. When the IT Band recognizes that it is being stretched, it then tries to protect itself by becoming stiff and tense. Over time the IT Band will mutate its tendon fibers to become less flexible in response to its desire not to be stretched. The goal of therapy and exercise is to reverse this thinking and get the IT Band to produce fibers that are more responsive to stretching.

Stretching guidelines offered

Here is how the researchers of this paper concluded their study:

“Current study findings and conclusions caution the clinician from expecting permanent IT Band tissue extensibility changes when using clinical IT Band stretching. (In other words stretching may not make the problem go away and clinicians should not have an over-expectation that stretching will solve the patient’s problem.)

Future research should examine the effects of longer stretch holding times, increased repetitions, and patients’ compliance with stretching protocols before conclusions are drawn regarding the utility of IT Band stretching for clinical outcomes.

Additionally, other factors should be considered with respect to IT Band stretching in Iliotibial Band Syndrome patients that include the influence of stretching on:

(1) biomechanical response of neighboring muscles or fascia, along with the hip joint capsule itself (is the stretching harming the problematic hip?)

(2) local immunologic responses; (swelling and edema)

(3) tissue metabolic reactions; (is the stretching causing a beneficial breakdown of tissue to make way for new tissue or is the stretching just breaking down tissue without repair taking place)

(4) subsequent neuro-motor-control modifications in the hip complex. (Is the stretching making the hip worse)

Kinesio Taping: Benefits were only seen in half the participants.

An October 2021 paper in the medical journal Gait Posture (12) University of Central Lancashire in the United Kingdom and  Mahidol University in Thailand aimed to explore the immediate effects of Kinesio Taping on lower limb kinematics, joint moments, and muscle activity, as well as perceived comfort, knee joint stability, and running performance in healthy runners. This was to help assess whether Kinesio Taping application would help runners with Iliotibial band friction syndrome.

Here is how the study was conducted. There were 20 participants.

• Twenty healthy participants ran at a self-selected pace along a 20-meter runway under three conditions;
  • No Kinesio Tape
  • Kinesio Tape with tension (KTT),
  • and Kinesio tape without tension (KTNT).
  • Comparisons of peak hip, knee angles and moments, and EMG were analyzed during the stance phase of running.

Results:

• Results suggest that changes in running biomechanics previously associated with Iliotibial band syndrome can be improved with the application of Kinesio tape, with the greatest effect seen with the application of Kinesio tape with tension. Perceived improvements were seen in comfort, stability, and running performance, however, these benefits were only seen in half the participants.

Iliotibial band syndrome surgery

An August 2022 paper from orthopedic surgeons in Chile published in the journal Arthroscopy techniques (15) compared multiple surgical techniques for patients who did not respond to conservative care treatments for their iliotibial band syndrome. The surgeries included: “posterior triangular resection of the iliotibial band, elliptical resection, transverse sectioning of the posterior half,  multiple punctures of the band, or the mesh technique,  isolated bursectomy, digastric release from Gerdy’s tubercle, and the Z-plasty lengthening technique. Despite the broad range of surgical procedures, the Z-plasty lengthening and bursectomy technique appears as an attractive procedure that combines the treatment of 2 of the most accepted pathophysiologic mechanisms. On the one hand, it lengthens the ITB, decreasing the friction between the band and the lateral epicondyle. On the other hand, removing the inflammatory tissue, especially the bursae, reduces pain and inflammation.”

Prolotherapy for Iliotibial Band Syndrome

Ross Hauser, MD and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida with chronic tight hip flexors, snapping hip, and other instability-related conditions.

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 too much. This will put extra stress on the iliotibial band.

• Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.
• Prolotherapy to the ligaments and the attachments can rebuild and strengthen the soft tissue and provide beneficial outcomes to treat Iliotibial Band Syndrome by also addressing problems in the hip, knee, ankle, and foot.

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.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your knee problems and knee instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References:

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This article was updated March 18, 2022

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.