Iliotibial band syndrome

Associate Editor-In-Chief:

Overview
Iliotibial Band Syndrome (ITBS or ITBFS, for Iliotibial Band Friction Syndrome) is a common thigh injury generally associated with running. Additionally it can also be caused by biking, hiking or weight-lifting (especially squats).

Definition
Iliotibial Band Syndrome is one of the leading causes of lateral knee pain in runners. The iliotibial band is a superficial thickening of tissue on the outside of the thigh, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, moving from behind the femur to the front during the gait cycle. The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed, or the band itself may suffer irritation.

Symptoms
Iliotibial Band Syndrome symptoms range from a stinging sensation just above the knee joint (on the outside of the knee or along the entire length of the iliotibial band) to swelling or thickening of the tissue at the point where the band moves over the femur. The pain may not occur immediately during activity, but may intensify over time, especially as the foot strikes the ground. Pain might persist after activity. Pain may also be present below the knee, where the ITB actually attaches to the tibia.

ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury. It commonly occurs during pregnancy, as the connective tissues loosen and the woman gains weight -- each process adding more pressure. ITBS at the hip also commonly affects the elderly. ITBS at the hip is studied less; few treatments are generally known.

Sports Activities to Avoid while Symptomatic

 * Running, especially hills and on arched surfaces (such as roads and tracks)
 * Stair Stepping
 * Dead lifts or Squats
 * Court sports, such as tennis, basketball, or similar
 * Martial arts, such as Karate (especially where being bare foot emphasises any symptoms being caused by leg/foot abnormalities)

Causes of Injury
Iliotibial Band Syndrome is the result of poor training habits, equipment and anatomical abnormalities.

Training habits: Abnormalities in leg/feet anatomy:
 * Running on a banked surface (such as the shoulder of a road or an indoor track) bends the downhill leg slightly inward and causes extreme stretching of the band against the femur
 * Inadequate warm-up or cool-down
 * Increasing distance too quickly or excessive downhill running
 * In cycling, having the feet "toed-in" to an excessive angle
 * Running up and down stairs
 * High or low arches
 * Overpronation of the foot
 * The force at the knee when the foot strikes
 * Uneven leg length
 * Bowlegs or tightness about the iliotibial band.
 * Excessive wear on the outside heel edge of a running shoe (compared to the inside) is one common indicator of bowleggedness for runners.

Muscle Imbalance:
 * Weak hip abductor muscles

Treatment
As with any injury or ailment, one should see one's physician, physical therapist or athletic trainer for diagnosis and treatment.

For a runner with acute ITBS, reduce weekly distance training to 50% for 2 weeks, and only run on flat ground. After, in the absence of ITBS pain, slowly begin to build distance again. If ITBS pain remains or is chronic, one should stop running immediately for two weeks (minimum). If the pain and inflammation are still present, another month of rest may be needed. Once the injury begins to improve, resuming activity can be possible, doing low distance, low speed jogging on flat terrain. Also, changing one's route may help counteract re-injury, as running a common route may put increased stress on the iliotibial band of one leg.

To prevent, or cure chronic ITBS there are some essential exercises:
 * Strength building of the proximal hip musculature for controlling ITB tightness; especially the straight leg raising motion and hip adduction
 * Performing specific stretches; Iliotibial band stretch, stretching the gluteal muscles, and other leg based static stretching

To create a good treatment program, proper assessment of injury severity is critical. Once the injury has been properly assessed, a treatment program (usually consisting of three steps) can be planned. The length of time spent on each phase varies depending on the athlete, the reasons for the initial injury, and the severity of the injury.

Immediate Treatment
After noticing symptoms, the important task is controlling pain and inflammation. For these symptoms, RICE works well. Stretching is second in importance, to make sure that the iliotibial band does not become taut. Next, examining what may have caused ITBS is important. Issues range from poor training habits to structural abnormalities, but the shoes a runner uses are another consideration. For example, after 500 miles most shoes retain less than 60% of their initial shock absorption capacity, increasing the chance of ITBS injury. Lastly, anti-inflammatories or ultrasound may be helpful to relieve symptoms.

Short Term Treatment
If the pain and inflammation do not subside, all painful activity should stop while continuing immediate treatment. A regular stretching regimen is important. A video analysis of running movements may provide insight into problematic running mechanics. To retain fitness, a number of options will work at this stage, as long as they do not promote pain. Altering these exercises will minimize overtraining:
 * Swimming, though abstain from the breaststroke as it may aggravate symptoms
 * Optionally, wearing a life jacket, one may run in the pool (depth allowing)
 * Cycling, though with care, as it may aggravate symptoms
 * Speed walking, especially straight-legged to discourage pain
 * Cross-country skiing
 * Yoga, or similar low-impact aerobics

At this stage, Steroid injections may be helpful, though some risks are involved.

Long Term Treatment
The last phase is only started once pain and inflammation are gone. Often, this phase involves returning to a normal state, even competitive sports. Though, at least these criteria must be satisfied:
 * The injured knee has regained full range of motion without pain
 * The injured knee has regained normal strength compared to the uninjured knee
 * Cardiovascular endurance has normalized

Most importantly, one must ensure that old symptoms do not recur. Thus, any pain or inflammation must be treated cautiously, especially if the ITBS was serious and involved a lengthy downtime. The return process must be gradual and treated with extreme care, structurally specific stretching during this time is essential and must be done extensively, before and after activity. Returning to activity should be done while correcting, or significantly reducing, any factors that were thought to have caused ITBS. If no factors are identified and corrected, the chance of the re-injury is much higher.

Rarely, and only in extreme cases, surgery is used to correct the injury. Typically, unless one is still suffering from symptoms in 6-12 months, surgery is not performed. It involves the release-excision of the iliotibial band, performed after an arthroscopic evaluation of the knee, which rules out other causes for the symptoms. Only patients unwilling to adapt their exercise because of this injury undergo surgery; it should only be performed after all other treatments have failed.

After the Pain is Gone

 * Continue stretching, as well as strengthening of the leg muscles.
 * The patient should start running only after treatment.
 * Restart running with small distances, building slowly.
 * If the patient feels pain, he or she should stop.
 * Even better, the patient should try to stop running before the pain starts.

Some Rehabilitation Options

 * Deep-tissue massage or Rolfing may help break up scar tissue that forms.
 * Non-steroidal anti-inflammatory drugs (aka NSAIDs), in high doses for a period of weeks, can help reduce the inflammation.
 * Strengthening exercises for the quadriceps femoris and gluteus medius muscles can help support the leg, thus lessening the load on the ITB.
 * Glucosamine Sulfate and Chondroitin Sulfate may help.

Example Physical Therapy Regimen
For successful rehabilitation, it is essential to restore the flexibility of the iliotibial band, and the strength and flexibility of the muscles which act upon it. Stretching the band is a complicated task; before the band can stretch, the hip flexors must stretch.

To prepare for ITB stretching, one may heat the lateral thigh with hydrocollator packs for a period of time, typically twenty minutes. This is followed by ultrasonic heating (1.5-2.0 watts/cm²) to the length of the ITB tract for 5-7 minutes. After one stabilizes the pelvis while another person (qualified therapist) stretches the leg to maximally tolerated adduction. This may be repeated using three 1-minute stretches. Cryotherapy of the painful and inflamed tissue for ten minutes in the stretched position is also effective. (Gose, 1989)

External References and Links

 * Sports Medicine Tent: ITB
 * A Runner's Guide to Illiotibial Band Syndrome (ITBS)
 * Illiotibial Band Syndrome (ITBS)
 * Iliotibial Band Friction Syndrome