Iliotibial Band Syndrome

Knee conditions normally involve disease or injury that can disturb the normal functioning of the joint. This can result in knee pain, weakness, instability, and limited movement. With longer life expectancy and greater activity levels, joint replacement is being performed in greater numbers on patients thanks to new advances in artificial joint technology provided by the orthopedic surgeons at Great Lakes Orthopedics & Joint.

This joint is formed by two or more bones that are connected by thick bands of tissue called ligaments.

The knee is the largest joint in the body and is made up of three main parts:

• The lower end of the thigh bone, or femur.
• The upper end of the shin bone, or tibia.
• The kneecap, or patella.

At some time in life, you may experience knee pain. Iliotibial band syndrome is a common knee injury that usually presents as lateral knee pain caused by inflammation of the distal portion of the iliotibial band; occasionally, however, the iliotibial band becomes inflamed at its proximal origin and causes referred hip pain. The iliotibial band is a thick band of fascia that is formed proximally by the confluence of fascia from hip flexors, extensors, and abductors. The band originates at the lateral iliac crest and extends distally to the patella, tibia, and biceps femurs tendon.

Iliotibial band syndrome occurs frequently in runners or cyclists, and is caused by a combination of overuse and biomechanical factors. The syndrome can cause significant morbidity; however, most patients respond to a conservative treatment approach that involves stretching and altering training regimens.

Cause

Iliotibial band syndrome is caused by excessive friction of the distal iliotibial band as it slides over the lateral femoral epicondyle during repetitive flexion and extension of the knee resulting in friction and potential irritation.

In patients with iliotibial band syndrome, magnetic resonance imaging (MRI) studies have shown that the distal iliotibial band becomes thickened and that the potential space deep to the iliotibial band over the femoral epicondyle becomes inflamed and filled with fluid.

Despite a clear pathophysiology, it is unclear why this syndrome does not affect all athletes. Few studies have shown any direct relationship between biomechanical factors and the development of iliotibial band syndrome.

Excessive pronation causing tibial internal rotation and increased stress in the iliotibial band was believed to be a factor in the development of iliotibial band syndrome; however, the literature does not support this theory.

Some observational studies have identified potential risk factors for the development of iliotibial band syndrome, including the following: preexisting iliotibial band tightness; high weekly mileage; time spent walking or running on a track; interval training; and muscular weakness of knee extensors, knee flexors, and hip abductors.

Hip abductor weakness seems to contribute to the development of iliotibial band syndrome. Strengthening of the hip abductors has led to symptom improvement.

Symptoms

The primary initial complaint in patients with iliotibial band syndrome is diffuse pain over the lateral aspect of the knee.

These patients frequently are unable to indicate one specific area of tenderness, but tend to use the palm of the hand to indicate pain over the entire lateral aspect of the knee. With time and continued activity, the initial lateral achiness progresses into a more painful, sharp, and localized discomfort over the lateral femoral epicondyle and/or the lateral tibial tubercle.

Typically, the pain begins after the completion of a run or several minutes into a run; however, as the iliotibial band becomes increasingly irritated, the symptoms typically begin earlier in an exercise session and can even occur when the person is at rest.

Patients often note that the pain is aggravated while running down hills, lengthening their stride, or sitting for long periods of time with the knee in the flexed position.

Diagnosis

Patients with iliotibial band syndrome often demonstrate tenderness on palpation of the lateral knee approximately 2 cm above the joint line.

Tenderness frequently is worse when the patient is in a standing position and the knee is flexed to 30 degrees. At this angle, the iliotibial band slides over the femoral condyle and is at maximal stress, thus reproducing the patient’s symptoms.

Swelling may be noted at the distal iliotibial band and thorough palpation of the affected limb may reveal multiple trigger points in the vastus lateralis, gluteus medius, and biceps femoris. Palpation of these trigger points may cause referred pain to the lateral aspect of the affected knee.

Strength of the lower extremity should be assessed with particular emphasis on examining the knee extensors, knee flexors, and hip abductors. Weakness in these muscle groups has been associated with the development of iliotibial band syndrome.

The Ober’s test can be used to assess tightness of the iliotibial band.

With the patient lying on the side with the unaffected side down and the unaffected hip and knee at a 90-degree angle, the examiner stabilizes the pelvis, then abducts and extends the affected leg until it is aligned with the rest of the patient’s body. The affected leg is lowered into adduction. If the iliotibial band is normal in length and unaffected, the leg will adduct and the patient will not experience pain. If the iliotibial band is tight, the leg will remain in the abducted position and the patient may have lateral knee pain.

A tight iliotibial band contributes to the excess friction placed on the iliotibial band as it slides over the femoral condyle during flexion and extension of the knee.

A clinical diagnosis is based on the history and physical examination. If the diagnosis is in doubt or other joint pathology is suspected, MRI can aid in the diagnosis and provide additional information about patients considered for surgery.

In patients with iliotibial band syndrome, MRI shows a thickened iliotibial band over the lateral femoral epicondyle and often detects a fluid collection deep to the iliotibial band in the same region.