W125: Advanced Therapeutic Exercises and Ultrasound-

Guided Procedures for Iliotibial Band Syndrome

John Vasudevan, MD1*

Michael Fredericson, MD2

Robert Baker, PT, OCS3

Yin-Ting Chen, MD4

Eugene Roh, MD2

Michael Khadavi, MD2

Jacob Sellon, MD5

1. Department of Physical Medicine & Rehabilitation, University of Pennsylvania, Philadelphia, PA.

2. Division of PM&R, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.

3. Emeryville Sports Physical Therapy, Emeryville, CA.

4. Department of Orthopaedics & Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD.

5. Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN.

*Course Director

Iliotibial Band Syndrome:Not just what…but why

John Vasudevan, MDPM&R Sports Medicine

Assistant Professor, University of Pennsylvania

November 2014

Objectives1. Define the anatomy and

pathophysiology of iliotibial band

syndrome (ITBS)

2. Learn the pearls of exam and

treatment, and their supporting

evidence

3. Understand common contributing

factors

ITBS: The What

• 2nd most common cause of knee pain in runners

• Lateral knee pain, insidious, progressive

– Worse with hills, slower running speed

– Initially predictable at certain point of run, but then

progresses

• Cause: friction of ITB against lateral femoral condyle

– Or (less likely) distal insertional pain at Gerdy’s tubercle

– “Impingement zone” at ~20-30° knee flexion

– Inflammation of IT bursa…if it exists

ITB Anatomy

• Definition: lateral thickening of the fascia

lata in the thigh, dense fibrous tissue

– Has superficial and deep layers, enclosing tensor

fascia latae prior to anchoring at iliac crest

– Receives majority of gluteus maximus tendon

– Superficial and deep layers, enclosing tensor

fasciae

TFL/ITB Anatomy

• Origin: Iliac crest just posterior to the anterior

iliac spine

• Insertion: lateral femoral condyle, lateral

retinaculum of knee, lateral patella, and

Gerdy’s tubercle on lateral tibial plateau

• Innervation: superior gluteal, L4, L5, S1

• Action: hip flexion, abduction, internal rotation

IT Bursa?

• Anatomic Findings:

– ITB is firmly anchored to lateral femoral condyle

– More medial-lateral translation rather than anterior-

posterior

– No bursa identified, but fibers integrated in fat pad

between ITB and lateral femoral condyle

• Conclusion: Pain may be from compression of

fat, not sliding over bursa

Fairclough 2006; Falvey 2010

IT Band & “Bursa”

Fredericson 2011; Fairclough 2006

IT “Bursa” arising from lateral recess of knee joint

Jelsing 2013

ITBS: The Why

• Anatomic

– Static: leg length discrepancy, genu varum, pes

planus

– Dynamic: Tight TFL/ITB, weak hip abductors, tight

heel cords, excess femoral/tibial internal rotation

• Training Considerations

– Cambered surfaces

– Downhill running

Strauss 2013; *Fredericson 2005

ITBS: The What Else

• Lateral meniscal tear

• Lateral compartment degenerative joint

disease

• Biceps femoris tendinopathy

• Stress fracture

• Patellofemoral syndrome

• Lateral collateral ligament sprain/tear

ITBS: Keys to Exam

• Palpate over LFC and Gerdy’s tubercle

• Ober Test

• Noble Compression Test

• Assess other contributing factors:

– Hip abductor weakness (single-leg squat)

– Heel cord tightness

ITBS: Treatment

• NSAIDs beneficial with PT*

• Steroid injection^ (US-guidance?)

• Physical Therapy

– Transverse friction massage (no clear evidence)**; lateral

retinacular release, medial patellar mobilization

– Gluteal strengthening

– The super-fun FOAM ROLLER!

• Surgical options (release, lengthening, resection of

“bursa”)* Schwellnus 1991; **Schwellnus 1992; ^Gunter 2004; Ellis 2007; Strauss

2013

Gaps in the Evidence

• No clear evidence to support:

– Stretching the ITB (role of TFL in ITB “lengthening”)

– Strengthening the Gluteus Medius

– Trigger Point Therapy

• BUT we suggest that strengthening will fail if myofascial restrictions

persist

• Limited Evidence to support:

– NSAIDs and corticosteroid for short-term relief

• No study comparing US-guided to landmark-guided

– Surgical treatment options (debridement, resection)

ITBS: Treatment

Strauss 2013

Conclusions

1. While evidence-base is limited or conflicting,

outcomes with conservative treatment are

very encouraging

2. Consider distal AND proximal factors

3. Don’t just ask what, but why and what else

to optimize results and prevent recurrence

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Thank you!