Thanks to an escalating emphasis on prevention, patient education about vaccinations, screening tests, diet and exercise are taking center stage. And many patients are listening. More people are exercising, and with this comes a potential for exercise-induced orthopedic injuries that previously were a concern limited to athletes and sports enthusiasts.
Starting an exercise program can be a difficult lifestyle modification, so educating patients about how to avoid exercise-induced injuries and helping them recover from them quickly is essential to adherence and continued physical activity. This article focuses on a common knee condition, iliotibial band friction syndrome (ITBFS).
A 29-year-old white woman presents with a history of sudden pain along the lateral aspect of her left knee after running for approximately 15 minutes. She has experienced several episodes of this pain at approximately the same time during her runs. She describes it as a sharp, stabbing pain that worsens with flexion of the knee. The pain is severe enough to prompt her to walk home.
At first the discomfort lasted for 20 to 30 minutes after she finished jogging, and she experienced relief after sitting down, icing her knee and taking 600 mg of ibuprofen. At the time she presented to the clinic, this pain was lasting 2 to 3 days before resolving. She stated that she had recently started running again and was trying to run at least three times a week, increasing her mileage with each run. However, the pain was so severe that she did not believe she could continue to run.
During the physical examination, the patient exhibited pain with extension and flexion of her left knee. A slight decrease in range of motion during left knee flexion and extension was noted. Muscle strength was 5 out of 5. No effusion was noted, nor was increased warmth, erythema or other signs of infection. Marked point tenderness was present just above the lateral femoral epicondyle (LFE), but no tenderness was evident with palpation of any of the muscle groups of her upper or lower leg.
The patient had negative anterior and posterior drawer tests, varus and valgus stress tests, Lachman test and McMurray test. Thus, ligamentous instability did not appear likely.
The history of a patient with ITBFS likely includes a report of extended or excessive activity involving the legs, such as running, cycling or skiing. The number of miles run or cycled per week is helpful in making this diagnosis. The patient typically complains of sharp, stabbing or burning pain just superior to the lateral joint line that may or may not radiate proximally or, in some cases, distally.1-3
Mild to moderate cases of ITBFS often involve painful symptoms that start at a consistent time or distance during physical activity. In more progressive cases, the patient may experience pain while walking or sitting with the knee in flexion.1,4 Activities that require weight bearing while in flexion, such as climbing or descending stairs, often elicit painful responses, and patients often go through daily activities with their knee in extension.2,4
During the physical examination of a patient with lateral knee pain, observe the patient's legs in the standing position for increased varus or valgus alignment. Assess the knee for any swelling or effusion.4 The most reproducible result is point tenderness over the LFE.1,2,4 Two simple tests can assess the tightness and inflammation surrounding the iliotibial band (ITB) and the LFE. The first is a provocative test called the creak test. Have the patient stand with all of his or her weight on the affected knee. A positive result is produced when the patient reports stinging pain over the LFE when the knee begins to approach 30 degrees of flexion.2 The Noble test is another evaluation option. Apply moderate pressure to the LFE while the knee is in 90 degrees of flexion. A positive result is when pain is experienced over the LFE at around 30 degrees of flexion.1,2,4
Etiology of ITBFS
The friction of ITBFS occurs as the ITB moves anterior to the epicondyle in extension and posterior to the epicondyle during flexion.1 Usually the body can repair the soft tissue damage caused by this friction, but ITBFS is an overuse injury that has outpaced the body's ability to heal.2 This is why the syndrome occurs most often occurs in runners, cyclists, weightlifters, snow skiers and military recruits - all of whom are subjected to repetitive use of their legs.1,2
Experts believe that repetitive motion is not the only cause of ITBFS. Specific training errors may exacerbate the problem: sudden increases in mileage, excessive mileage and sudden changes in training surfaces (e.g., from flat to hilly terrains).1,2
The musculoskeletal cause of strain on the ITB is recognized as weakened hip abductors.1-3 This allows greater hip adduction, which allows the knee to be pulled medially. In the process, the ITB is stretched tighter over the lateral epicondyle. The gluteus medius also plays a role in the stabilization of the pelvis and in preventing excessive hip adduction, making gluteus medius weakness a possible contributing factor to ITBFS.1
Workup for ITBFS
ITBFS is a clinical diagnosis based on the patient history and physical exam findings. A history of overuse or improper training combined with a positive creak or Noble test are usually enough to diagnose ITBFS. Imaging can rule out other causes of lateral knee pain if any doubt remains.1,2,4 An x-ray series of the knee can rule out joint space narrowing, stress fractures and patellar maltracking.4 If the possibility of articular damage, meniscal tears or cysts is present, an MRI can rule them out and possibly reveal fluid below the ITB or thickening of the ITB. Either of those findings would point toward a diagnosis of ITBFS.1,2,4
The initial treatment for ITBFS is to reduce or discontinue all physical activity involving the knee until pain is reduced significantly. Oral nonsteroidal anti-inflammatories, ice pack application and corticosteroid injections are other options that can help eliminate local swelling and inflammation.1,2,4 Inflammation reduction is rarely curative, so once the patient's pain and inflammation have subsided, physical therapy is the next component of treatment.
The main goal of physical therapy is to lengthen the IT band and to eliminate any myofascial adhesions, since this decreases the friction over the LFE.1,2,4 To lengthen the IT band, patients should be taught stretching exercises that are aimed at this goal; they have been proven highly effective at lengthening the IT band and relieving IT band tightness.1,4 Myofascial adhesions are best treated using a combination of methods. Soft tissue mobilization can be performed through muscle massage by trained therapists. Also, foam rollers are used by patients to help maintain freedom from any adhesions that were released during soft tissue mobilization.1,4
After the patient has lengthened the IT band and eliminated any myofascial adhesions, the next phase of treatment consists of strengthening the hip abductors and core muscles to help stabilize the pelvis during activity.1,4 Examples are side-lying leg lifts, balanced single-leg stepdowns and pelvic drop exercises.1,5,6
Finally, patient education is important for preventing recurrence of ITBFS. Patients should be made aware of the danger of rapidly increasing their mileage, rapidly changing their exercise terrain, excessive exercise mileage, and the lack of stretching or core muscle strengthening.4
Most cases of ITBFS respond to conservative treatment with a return to normal exercise levels within 6 to 8 weeks. The patient in the case example experienced a complete resolution of symptoms in about 6 weeks, after taking a complete break from exercise and following the prescribed NSAID regimen.
Symptoms may recur if the patient returns to poor training habits. Maintaining a regimen of stretching the IT band and strengthening hip abductor and core muscles helps remove biomechanical factors that can contribute to recurrence.1,2,4 Surgery is not usually recommended unless a patient does not respond to conservative therapy, experiences symptoms for more than 6 months, and other possible causes of pain have been eliminated.4
1. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 2006;16(3):261-268.
2. Kirk KL, et al. Iliotibial band friction syndrome. Orthopedics. 2000;23(11):1209-1217.
3. Ellis R, et al. Iliotibial band friction syndrome--a systematic review. Man Ther. 2007;12(3):200-208.
4. Strauss EJ, et al. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011;19(12):728-736.
5. Snyder KR, et al. Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clin Biomech. 2009;24(1):26-34.
6. Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM R. 2011;3(6):550-561.
Marc Le Duc is a student in the physician assistant program at Georgia Regents University in Augusta, Ga. Kathy H. Dexter is the clinical director of the program. The authors have completed disclosure statements and report no relationships related to this article.