Ilio-tibial band (ITB) syndrome

Written by Carolina Vaccari


What is Iliotibial band syndrome?

Iliotibial band syndrome is one of the most common causes of lateral knee pain, which is usually the result of a non-traumatic overuse injury. Iliotibial band syndrome pain is commonly associated with tenderness on palpation of the lateral femoral epicondyle, that is located to the external aspect of the knee. It seems to be caused by a compression of the inferior (bottom) part of the iliotibial band itself.

The iliotibial band is a thick fibrous band of connective tissue that runs to the outside of the thigh from the iliac crest on the pelvis to the knee. It originates from the muscles tensor fascia latae and gluteus maximus and it inserts at the lateral tibial area (outisde of the knee joint). It does not have any bony attachments, this allows the IT band to move freely, and be possibly pinched when the knee goes from movements of flexion and extension.

What are the signs of Iliotibial band syndrome?

The main presentation of ITB syndrome is a sharp pain to the external area of the knee, that can radiate to the outer area of the thigh or the calf. A tenderness to the lateral knee is frequently detected and the patient can experience an acute burning feeling if pressure is applied to the area. Pain is usually worsened by activities involving knee flexion and extension. Running or going down stairs usually exacerbates the pain.

What are the common causes of Iliotibial band syndrome?

The cause of ITB syndrome is usually multifactorial even though the repetitive compression of the ITB tissue seems to be the main reason for its onset. In fact, ITB syndrome is often triggered by repetitively bending the knee during physical activities, such as running, climbing and cycling. Sudden increases of physical activities involving the knee, as well as muscular weakness of the hip abductors can also be considered as risk factors for ITB syndrome. Hip abductor weakness can increase hip internal rotation and knee adduction and consequently incdrease the stress at the ITB insertion point.

How is Iliotibial band syndrome diagnosed?

A detailed physical examination, combined with taking a medical history of the patient about the onset of the pain, is usually an excellent tool for diagnosing ITB syndrome. However, in some instances the GP might prescribe an X-ray or an MRI to rule out any other conditions that can cause knee pain in the same area.

What are the treatment options for Iliotibial band syndrome?

There are many different treatment options with regards to ITB syndrome.

The first precaution to take in order to not aggravate the symptoms when there is an acute inflammation of the ITB is to decrease the activity provoking the pain (e.g. running). Active resting should be promoted. This means the patient should avoid activities that overload the knee but remain active, practicing activities which are less stressful for the knee (e.g. swimming).

Icing the involved area may help to decrease the inflammation and then consequently the pressure on the knee. General stretching of the thigh (not just the iliotibial band) might also help to manage the pain.

If the inflammation does not decrease some treatment techniques, such as ultrasound therapy, radial shockwave therapy, muscle stimulation or iontophoresis might be suggested to have some local benefits and reduce the inflammation. Among all of these, radial shockwave therapy seems to be the most recommended because it inhibits nociceptors and promotes soft tissue healing.

Overall, it is recommended to manage the ITB syndrome with an Osteopath or a Physiotherapist. They will work with you to find the causative factors and reduce any postural compensation that overloads the knee. They may:

  • Prescribe you specific exercises tailored to you and your posture. This will usually involve, stretching and strengthening the thigh muscles in order to stabilize the hip and release the overload on to the IT band.
  • Work on your running mechanics. Taking part in a running assessment/analysis helps to outline compensations and habits that maybe the trigger cause of the ITB inflammation. Correcting your running patterns will help you to recover faster and help with injury prevention.
  • Use hands-on treatment involving myofascial release techniques to release the tension on the ITB and the other muscles which have adapted as a compensatory mechanism.

In rare cases, when prolonged conservative management has not been effective in alleviating the pain, surgery might be indicated. However, is must be noted that surgery is not considered as a first form of intervention for managing ITB syndrome.

How long does Iliotibial band syndrome last?

When treated, ITB syndrome can take from a few weeks to months to completely heal. The more you rest the faster you recover. However, it is important to work on the causative factors otherwise there might be a risk of relapse as soon as you go back to your normal routine.

Can Iliotibial band syndrome be prevented?

Not all causes of ITB syndrome can be prevented. However there are a few things that you can do to keep your knee joints healthy:

  • Maintaining flexibility and strength in the lower back, hips, knee and thigh muscles.
  • Daily hamstring, quadriceps and glutes stretching are highly recommended, especially if you routinely do activities that can overload the ITB, such as running.

What are the best exercises for Iliotibial band syndrome*?

Muscles which stabilise the hips seem to have a key role in avoiding overloading the ITB. In particular, glute or hip abductor weakness can contribute to the onset of ITB syndrome. In light of this, the following exercises might be very effecting in ITB syndrome management and treatment:

  • Side-lying hip abduction. Lie down on the floor on your side resting your head on your arm. Hips and shoulders should be aligned vertically to the floor and your head should be aligned with the spine. Raise the top leg off the lower leg while keeping the knee extended and the foot in a neutral position. Lift the leg up until the hip starts tilting upwards or until you feel tension developing to the lower back or to the oblique muscle. Then gradually return to the neutral position. Repeat it 10 times, then switch legs.
  • Single-leg wall squat. Start by positioning yourself with the back flat against the wall. Walk the feet a few steps forwards, keeping your back against the wall. Legs should be overall straight, with the knee slightly bent, and the feet hip-width apart and parallel. Lift the right leg and extend it in front of you, while bending the left knee and squatting down until the left thigh is parallel to the floor. Keep the right leg lifted and extended during the execution of the exercise, as well as the back pressing backwards to the wall. Pause for 3 second and then come back to the starting position. Repeat for 10 times, then switch legs.
  • Single-leg deadlift. Start standing with your feet hip-width apart and parallel. Hold a weight, kettlebell or barbell in your hands in front of you. Lean forward with your chest and shift the weight to one leg, while you start extending the other one straight behind you. Lift the back leg while you move your upper body forward until you form a ‘T’ shape. Arms remain straight down, holding the weight. Keep this position for 5 second, then gradually come back to the neutral position. Repeat 10 times for each leg.

*It is recommended to get the go ahead from your osteopath, physiotherapist or GP before trying out any of these exercises.

It is important to remember that a specific individualised plan based on a physical assessment with a professional therapist might be more effective on finding the causative factors and addressing the needs for your body and symptoms.

Do I need to see my GP for Iliotibial band syndrome?

Iliotibial syndrome is not an emergency that needs urgent GP intervention. You might try first to rest, carry out some self care adise (e.g. icing, stretching) and exercises. If improvements are not witnessed, your GP might suggest a referral for some physical therapy to better address the syndrome and manage the biomechanical abnormalities that might still persist.

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