Iliotibial Band Friction Iliotibial Band Friction SyndromeSyndrome

What is ITB Friction Syndrome?What is ITB Friction Syndrome?

ITBFS is an inflammatory, non- traumatic, repetitive ITBFS is an inflammatory, non- traumatic, repetitive strain injury to the knee affecting predominantly long strain injury to the knee affecting predominantly long distance runners and cyclists.distance runners and cyclists.

AnatomyAnatomy

The ITB is the condensation of The ITB is the condensation of fascia formed by the tensor fascia formed by the tensor fascia lata and the gluteus fascia lata and the gluteus medius and minimus muscles.medius and minimus muscles.

ITB is a wide, flat structure that ITB is a wide, flat structure that originates at the iliac crest and originates at the iliac crest and inserts at the Gerdy tubercle on inserts at the Gerdy tubercle on the lateral aspect of the the lateral aspect of the proximal tibia.proximal tibia.

The band serves as a ligament The band serves as a ligament between lateral femoral condyle between lateral femoral condyle and lateral tibia to stabilize the and lateral tibia to stabilize the knee. knee.

The ITB is not attached to The ITB is not attached to

bone as it courses between bone as it courses between

the Gerdy Tubercle and thethe Gerdy Tubercle and the

Lateral Femoral epicondyleLateral Femoral epicondyle..

Iliotibial band Iliotibial band moves moves

posteriorposterior to lateralto lateral

epicondyle with knee flexion.epicondyle with knee flexion.

Iliotibial band Iliotibial band moves moves

anterioranterior to lateral femoral to lateral femoral

Epicondyle withEpicondyle with

knee extensionknee extension

EtiologyEtiology

During flexion and extension of the Knee, the iliotibial band During flexion and extension of the Knee, the iliotibial band rubs over the Lateral Femoral condylerubs over the Lateral Femoral condyle

Resulting an irritated Resulting an irritated

and inflamed bursa.and inflamed bursa. Excessive lower leg Excessive lower leg

adduction and medialadduction and medial

rotation of tibia exerts rotation of tibia exerts

more stress over distal more stress over distal

attachment of attachment of iliotibialiliotibial

band.band.

Predisposing FactorsPredisposing Factors

Most common in runners or cyclistsMost common in runners or cyclists Chronic overuse injuryChronic overuse injury Sudden increase in mileage, training errorsSudden increase in mileage, training errors Changes in surfaces (i.e. soft to hard, flat to uneven etc.)Changes in surfaces (i.e. soft to hard, flat to uneven etc.) Overpronation and underpronationOverpronation and underpronation Leg Length discrepancies Leg Length discrepancies Circular and arched track runningCircular and arched track running Weak quadriceps, and abductors, particularly weak gluteus medius Weak quadriceps, and abductors, particularly weak gluteus medius Genu VarumGenu Varum Genu ValgusGenu Valgus Thicker IT bandThicker IT band Lateral Femoral condyle protrusionLateral Femoral condyle protrusion

Risk Factors for ITBFSRisk Factors for ITBFS

Extrinsic risk factors may include :Extrinsic risk factors may include :1.1. Worn out running shoes: Worn out running shoes:

The more worn out the shoe, the more ground The more worn out the shoe, the more ground reactive forces are transferred to the knee.reactive forces are transferred to the knee.

2.2. Training programs that increase mileage or Training programs that increase mileage or incorporate hills inappropriately (10% rule incorporate hills inappropriately (10% rule should be followed).should be followed).

3.3. Running at improper pace. – placing too much Running at improper pace. – placing too much strain on untrained legs may lead to fatigue or strain on untrained legs may lead to fatigue or injuryinjury

4.4. Running on cambered surface or slippery Running on cambered surface or slippery surface.surface.

Intrinsic risk factors may include :Intrinsic risk factors may include :

1.1. Bow legs/Genu varumBow legs/Genu varum

2.2. Rarefoot and forefoot varum – increases the stress over Rarefoot and forefoot varum – increases the stress over lateral ankle and kneelateral ankle and knee

3.3. Pes cavus/high arch. – this foot has limited ability in Pes cavus/high arch. – this foot has limited ability in absorbing ground reactive forces, placing more stress absorbing ground reactive forces, placing more stress on the knee joint on the knee joint

4.4. A prominent lateral femoral epicondyle and tight ITB A prominent lateral femoral epicondyle and tight ITB and TFL. – results in irriration of the bursa between the and TFL. – results in irriration of the bursa between the condyle and ITB due to constant friction rub.condyle and ITB due to constant friction rub.

5. 5. Weak gluteus medius, gluteus maximus and TFLWeak gluteus medius, gluteus maximus and TFL

On the side of gluteus medius weakness pelvic hiking On the side of gluteus medius weakness pelvic hiking occurs which results in trendelenberg gait and also results occurs which results in trendelenberg gait and also results in stretching of ITB causes lateral knee pain. in stretching of ITB causes lateral knee pain.

66. Tightness in the quadriceps, ITB and lateral retinaculum. Tightness in the quadriceps, ITB and lateral retinaculum

This leads to lateral tracking of patella more during This leads to lateral tracking of patella more during initial knee extension thus limiting the medial glide initial knee extension thus limiting the medial glide of patella, leading to increased stress on the lateral of patella, leading to increased stress on the lateral stabilizing structures of the knee joint.stabilizing structures of the knee joint.

Aggravating FactorsAggravating Factors

Any movement that causes excessive Any movement that causes excessive

friction of the IT band over the lateral femoral condylefriction of the IT band over the lateral femoral condyle

Running down hillsRunning down hills Lengthening strideLengthening stride Sitting for long period of time with Knee in flexed Sitting for long period of time with Knee in flexed

positionposition

Clinical PresentationClinical Presentation

Point tenderness on the lateral femoral epicondyle Point tenderness on the lateral femoral epicondyle approximately 1-2 cm above the lateral joint line.approximately 1-2 cm above the lateral joint line.

Pain elicited Pain elicited with active flexion-extension of the knee with active flexion-extension of the knee within the first 30° within the first 30°

Pain may radiate from knee proximally or distally. Pain may radiate from knee proximally or distally. Abnormal Gait – patient may walk with affected knee Abnormal Gait – patient may walk with affected knee

extended.extended. Injury progression not unlike that of tendonitis Injury progression not unlike that of tendonitis

1º Pain only after exercise1º Pain only after exercise 2º Pain during and after exercise2º Pain during and after exercise 3º Pain affecting Activity of daily Living.3º Pain affecting Activity of daily Living.

On ExaminationOn Examination

InspectionInspection Localized edema, if Localized edema, if

anyany

PalpationPalpation Tenderness over Tenderness over

Lateral femoral Lateral femoral

condyle and distal condyle and distal attachment of ITB atattachment of ITB at

lateral tibial tuberclelateral tibial tubercle Snapping, crepitus over Snapping, crepitus over

Lateral femoral condyleLateral femoral condyle

On Examination (contd.)On Examination (contd.)

RANGE OF MOTION AND STRENGTHRANGE OF MOTION AND STRENGTH

Full ROM with pain at last 20-30Full ROM with pain at last 20-30º of extensionº of extension If there is a decrease in ROM, most likely fromIf there is a decrease in ROM, most likely from

patient apprehension (pain)patient apprehension (pain)

StrengthStrength: Weak hip abductors (gluteus medius): Weak hip abductors (gluteus medius)

Weak hip adductors and flexorsWeak hip adductors and flexors

Special TestsSpecial Tests

Ober’s TestOber’s Test Patient lies on side, unaffected side down Patient lies on side, unaffected side down Flex unaffected hip and knee to 90 degrees Flex unaffected hip and knee to 90 degrees Abduct and extend affected leg and hipAbduct and extend affected leg and hip Adduct affected kneeAdduct affected knee

Ober’s Test PositionOber’s Test Position

Positive sign: leg remains abducted.Positive sign: leg remains abducted. Indication: IT band tightness Indication: IT band tightness

•Negative TestNegative Test: : Thigh drop to adducted Thigh drop to adducted position position

Nobles TestNobles Test

Patient supine, Knee flexed to 90Patient supine, Knee flexed to 90ºº Apply firm digital pressure to lateral femoral condyle Apply firm digital pressure to lateral femoral condyle

while passively extending Kneewhile passively extending Knee Positive sign: Pain (typically around 20-30º flexion)Positive sign: Pain (typically around 20-30º flexion) Indication:Indication:

Iliotibial bandIliotibial band

Friction Friction

SyndromeSyndrome

Renee creak testRenee creak test

Similar to Nobles Test:Similar to Nobles Test: Patient stands on affect limb on step stoolPatient stands on affect limb on step stool Place finger over lateral Femoral condylePlace finger over lateral Femoral condyle Patient bends Knee into 30-40Patient bends Knee into 30-40º flexº flex Positive sign: PainPositive sign: Pain Indication: ITBFSIndication: ITBFS

Thomas testThomas test

Patient in supine. Ask patient to bringPatient in supine. Ask patient to bring

unaffected knee to chest.unaffected knee to chest. Lower the affected limbLower the affected limb Positive sign: If affected limb abducts as leg flexed to chestPositive sign: If affected limb abducts as leg flexed to chest Indication: Tight IT bandIndication: Tight IT band

Differential DiagnosesDifferential Diagnoses

Hamstring StrainHamstring StrainOsteoarthritis Osteoarthritis of hip and knee jointof hip and knee jointLateral Collateral Ligament InjuryLateral Collateral Ligament InjuryOveruse InjuryOveruse InjuryMeniscal InjuryMeniscal InjuryPatellofemoral SyndromePatellofemoral SyndromeMyofascial PainMyofascial Pain

Trochanteric bursitisTrochanteric bursitis

Management-Acute PhaseManagement-Acute Phase

Activity ModificationsActivity Modifications

If edemaIf edema NSAIDSNSAIDS Ice massage,Ice massage, Phonophoresis, Phonophoresis, Iontophoresis, Iontophoresis, UltrasoundUltrasound

Nonsteroidal anti-inflammatory Nonsteroidal anti-inflammatory drugsdrugs

Have analgesic, anti-inflammatory, and Have analgesic, anti-inflammatory, and antipyretic activities. antipyretic activities.

Their mechanism of action is not known, but Their mechanism of action is not known, but they may inhibit prostaglandin synthesis. they may inhibit prostaglandin synthesis. Other mechanisms may exist as well such as Other mechanisms may exist as well such as neutrophil aggregation, and various cell neutrophil aggregation, and various cell membrane functions.membrane functions.

Corticosteroid injectionCorticosteroid injection

Local corticosteroid injection has been shown Local corticosteroid injection has been shown to be beneficial in managing acute to be beneficial in managing acute inflammation for those who do not respond to inflammation for those who do not respond to analgesia and restanalgesia and rest

PositionPosition: Place the patient in a lateral recumbent : Place the patient in a lateral recumbent position with the affected knee flexed position with the affected knee flexed to approximately 30 º.to approximately 30 º.

Direct the injection into the deep space at the Direct the injection into the deep space at the point of maximal tenderness just lateral to the point of maximal tenderness just lateral to the lateral femoral condyle.lateral femoral condyle.

Subacute PhaseSubacute Phase

StretchingStretching Hip AbductorHip Abductor- Iliotibial Band- Iliotibial Band

Hip AdductorsHip Adductors

Hip FlexorsHip Flexors

Myofascial ReleaseMyofascial Release: Using foam roller: Using foam roller

Recovery Phase Recovery Phase

Progressive strengthening exercises Progressive strengthening exercises Single leg squatsSingle leg squats Hip abduction (GLUTEUS MEDIUS), adduction, Hip abduction (GLUTEUS MEDIUS), adduction,

flexion.flexion.

Easy sprints (during faster running, ITB is flexed Easy sprints (during faster running, ITB is flexed beyond the angles that cause friction/irriation)beyond the angles that cause friction/irriation)

Shorten running strideShorten running stride Gradual increase in distance and frequencyGradual increase in distance and frequency

Alternative TreatmentsAlternative Treatments

IT band strapIT band strap Arch tappingArch tapping OrthoticsOrthotics Motion-control shoesMotion-control shoes

If treatment unsuccessful, If treatment unsuccessful,

surgery is an option surgery is an option