INTRODUCTION — Iliotibial band syndrome (ITBS) is an overuse injury of the lateral knee that occurs primarily in runners and was first described in 1973 . Pain develops where the iliotibial band (ITB) courses over the lateral femoral epicondyle (LFE), just proximal to the lateral joint line.
This topic will review the epidemiology, risk factors, clinical presentation, and treatment of ITBS. Undifferentiated knee pain and common causes of such pain are discussed separately. (See "Approach to the adult with knee pain likely of musculoskeletal origin" and "Running injuries of the lower extremities: Risk factors and prevention" and "Patellofemoral pain" and "Meniscal injury of the knee".)
EPIDEMIOLOGY — Overall rates of ITBS vary from 2 to 25 percent in physically active individuals; the syndrome has not been reported in those who do not exercise [2,3]. ITBS is the second most common cause of knee pain due to overuse after patellofemoral dysfunction [4-6]. The problem is most common in runners, military personnel, and cyclists, but has also been described in Nordic skiers, soccer players, and other athletes [1-3,7,8]. Based upon limited observational studies, ITBS affects approximately 1.6 to 12 percent of runners [2,4-7,9]. The relative incidence among runners has increased over the past three decades for unknown reasons [2,6,9]. Up to 50 percent of cyclists experience knee pain [10,11]. In one observational study of 254 cyclists over six years, 24 percent of the cyclists presenting to a sports medicine clinic for knee pain were diagnosed with ITBS . Competitive cyclists who are frequently pedaling against high resistance may be at higher risk.
ANATOMY — The ITB is a fibrous band that runs longitudinally along the lateral aspect of the thigh from its origin at the iliac crest to the proximal tibia (figure 1). Proximally, the tensor fascia lata, gluteus maximus, gluteus medius, and vastus lateralis all have connections to the ITB. The ITB has broad attachments to multiple structures at the lateral knee, including the quadriceps-patella-patellar tendon complex, the lateral femoral epicondyle (LFE), and the biceps femoris muscle-tendon-fibula complex. Distally, the ITB courses over the LFE, before inserting at Gerdy’s tubercle at the anterolateral tibia just below the knee joint line (figure 2 and picture 1) [12-14].
BIOMECHANICS AND PATHOPHYSIOLOGY — The ITB is thought to assist with knee extension when the knee is near terminal extension, and with knee flexion once the knee is flexed beyond 30 degrees (figure 3) [2,15,16]. The ITB also provides lateral knee stability .
ITBS occurs from overuse, not acute trauma. However, the precise source of pain in ITBS and the biomechanical factors most responsible remain unclear . Previously, pain was thought to be due to friction from the ITB moving back and forth (anteriorly and posteriorly) over the lateral femoral epicondyle (LFE) during running (thus, the once common term "iliotibial band friction syndrome") [2,3,18]. However, subsequent studies have shown that the ITB is tethered at the LFE by the epicondylo-patellar ligament and patellar retinaculum, and does not make significant movements in the sagittal plane, making friction an unlikely source of pain [12,13,19-21]. The ITB does appear to have anterior and posterior fibers that are active (respectively) in extension and flexion [12,14].
Some studies describe a sub-tendinous bursa at the LFE [2,22]. However, cadaveric studies, corroborated by MRI and ultrasound investigations, show there is no isolated bursal sac deep to the ITB at the LFE [12,13,23-25]. One histologic study showed there is vascular, innervated adipose tissue deep to the ITB, which may play a role in causing pain . Other studies suggest pain is due to compression of the lateral synovial recess contiguous with the knee joint or to overuse tendinopathy .
Kinematic studies offer insights into elements of gait and training that may contribute to ITBS [17,27,28]. According to a number of biomechanical studies, the ITB is under greatest tension at 30 degrees of knee flexion, suggesting that repeated motion around this knee angle during sport can lead to ITBS in susceptible individuals [3,15,29]. Most runners approach 30 degrees of knee flexion during the early stance phase ("foot strike") . Cyclists maintain the knee in flexion throughout the pedaling revolution, but the knee is at its minimum flexion of approximately 30 degrees at the lowest point in a pedaling revolution ("down-pedal" position) .
The role of foot position and ankle motion during foot strike in ITBS remain unclear. Some studies report that individuals with ITBS have reduced ankle eversion and rearfoot pronation [15,28], while others show no difference [3,30]. In cyclists, in-toeing or genu-varum leads to increased tension over the lateral femoral epicondyle [10,11]. Pedaling in this position may contribute to the development of ITBS.
The braking force when running (ie, force of deceleration immediately after foot-strike) appears to be lower in athletes with ITBS. It is thought that braking force is accomplished in large part by eccentric firing of the biceps femoris tendon. If the bicep femoris is delayed or weak, it increases the strain on the ITB .
RISK FACTORS — Intrinsic and extrinsic factors play a potential role in ITBS, and both should be considered during patient evaluation.
Intrinsic — There is conflicting evidence and ongoing debate about the anatomic and biomechanical factors that put an individual at risk for ITBS. Limited evidence suggests that runners with lower extremity alignment problems have a higher incidence of ITBS, as do those with tight ITBs [3,6,9,15,19,28,29,31-33]. Two types of alignment problems are thought to prevail:
●Weak hip abductors lead to increased hip adduction ("knock-knees") and increased internal rotation at the knee. This is thought to place a rotational strain on the distal ITB. Because the distal ITB is tethered from the lateral femoral epicondyle to its insertion on Gerdy’s tubercle, it cannot accommodate this rotational strain [9,17,19,27-29,34-40]. This phenomenon occurs most often in female or novice runners. (See 'Anatomy' above.)
●Runners with increased hip abduction, genu varum ("bow-legs"), or increased ankle supination are thought to develop increased tension of the ITB at the lateral femoral epicondyle [6,7,36,41,42]. In such cases, strain is due to angular rather than rotational forces, as the varus alignment causes increased stretch of the ITB where it crosses the lateral joint line of the knee. This phenomenon is often seen in experienced distance runners.
●Anatomic variations causing greater pressure at the lateral femoral epicondyle were reported in a case-control study . A more prominent lateral femoral epicondyle was noted in 75 patients with ITBS compared with 75 age- and height-matched control patients with medial knee pain and medial meniscus injury.
Additional anatomic factors that may contribute to ITBS include:
●Iliopsoas muscle contracture 
●Gastrocnemius and soleus muscle inflexibility 
●Leg length discrepancy (associated with ITBS in many but not all studies) [3,5,15,19,31,45]
Extrinsic — Preliminary research suggests that the following extrinsic factors predispose to ITBS:
●Running surface with horizontal or vertical gradients [3,7]. A horizontal gradient might involve running on the side of a crowned or cambered road. With vertical gradients, downhill running presents greater risk than uphill running. Some studies question the role of gradients .
●High weekly running mileage (even if this is athlete’s baseline) .
●Running footwear with increased heel height and width, causing increased relative supination .
●Over-striding [18,47]. Excessively long strides cause increased hip flexion and increased strain at lateral knee.
●Excessive running in the same direction on a track .
●Cycling with incorrect pedal position or an improperly fitting bicycle [10,11].
●Sudden increase in mileage or hill workouts in cycling .
●Exercise in cold weather [1,2,7].
Patient presentation — ITBS is an overuse injury of the lateral knee that occurs primarily in runners [16,31,48]. Athletes typically describe the insidious onset of pain localized to where the ITB courses over the lateral femoral epicondyle (LFE). Initially pain occurs only during sport. It is typically sharp or burning and occurs just prior to or during foot-strike when running, or as the knee extends (down-pedal position) when cycling. Over time, the pain can become constant and deep, persisting throughout exercise. Less commonly, pain persists for hours or days after exercise.
In runners, the presentation can vary with experience. Novice runners may develop symptoms within weeks of beginning a program and present soon thereafter. In experienced distance runners, pain may be present for weeks, months, or even years at a milder level or intermittently, but they often do not seek care until the pain becomes limiting.
Physical examination — Key examination findings associated with ITBS include focal tenderness at the distal ITB where it courses over the LFE (picture 2), and a positive Noble compression test, which a number of experts believe is the single best test to confirm ITBS. The Ober test is another maneuver used by some to assess for ITBS.
We perform the Noble compression test with the patient in a lateral decubitus position and the examiner standing behind them (movie 1) [7,18,31]. For examination of a symptomatic right knee, the patient is placed in a left lateral decubitus position for examination. The patient’s hip is slightly flexed and the examined leg should be completely relaxed. The clinician uses their left hand to hold and palpate the right knee. The examiner places their thumb on the posterior border of the ITB just proximal to the LFE, while the fingers support the underside (ie, medial side) of the knee. With their right hand, the examiner holds the patient’s lower shin and passively flexes the knee from 0 to approximately 60 degrees, while the right thumb positioned on the ITB maintains moderate but steady pressure. If the maneuver reproduces the patient’s typical knee pain this is considered a positive test. Pain is typically most pronounced at approximately 30 degrees of knee flexion. The patient is placed in a right lateral decubitus position and all maneuvers are reversed to examine a patient with a symptomatic left knee.
Some describe performing the Noble test with the patient supine, but we believe this may decrease the accuracy of the test if the patient’s hamstring mobility is limited. Other authors advocate alternative techniques for the Noble test, such as performing the maneuver with the patient standing or striding forward to more closely mimic the closed-chain kinetics of running, but these maneuvers are not widely used. Regardless of the method selected, no objective data are available to quantify the accuracy of the Noble test for ITBS. Nevertheless, we have found the Noble test to be a reasonable predictor of ITBS.
Although it is described as a test for ITBS, the Ober maneuver is not well studied, and we find it of limited use for diagnosing ITBS [32,49]. One cadaveric study found the Ober maneuver does not assess mobility of the ITB, but rather of the gluteus medius/minimus and hip capsule . For those wishing to perform the test, place the patient in a lateral decubitus position with the unaffected leg resting on the examining table with its hip flexed to 90 degrees (picture 3). While standing behind the patient, grasp the top (symptomatic) leg and flex the knee to 90 degrees while extending and slightly abducting the hip. From this position, allow the top knee to adduct passively by gravity, while still supporting the lower leg or ankle. Although the definition of "normal" ITB mobility varies among studies, the test is generally considered normal (ie, no excessive ITB tightness) if the knee drops level to or below the level of the examination table without eliciting symptoms [16,31,32]. If the affected side has less mobility than the unaffected side, and testing elicits pain, decreased ITB mobility may be contributing to ITBS.
In patients suspected of having ITBS, it is important to examine the entire knee joint, paying particular attention to the lateral collateral ligament and the lateral joint line, where focal tenderness suggests meniscal injury. Palpate for a knee effusion and assess the joint for stability. Consider the possibility of pain radiating from the hip or other areas. Of note, patellofemoral pain can occur concomitantly with ITBS (more commonly in novice runners). The knee examination is described in detail separately. (See "Meniscal injury of the knee" and "Patellofemoral pain" and "Physical examination of the knee".)
Other elements of the knee examination of particular importance to the assessment of ITBS include the following:
●Assess ankle mobility. Have the patient sit with their hip flexed to 90 degrees and knee extended, and then assess foot dorsiflexion (picture 4). If the ankle cannot be passively dorsiflexed to at least neutral (ie, foot remains in plantarflexion), the posterior calf muscle complex is restricted. This causes increased knee flexion and ankle pronation, which may contribute to ITBS [27,31].
●Assess hip flexor mobility with the modified Thomas test. Limited hip extension, as demonstrated by a positive test, may contribute to ITBS [16,31,32]. Performance of the Thomas test is described separately. (See "Physical examination of the knee", section on 'Range of motion and muscle flexibility'.)
●Assess hip abductor (specifically gluteus medius) strength [9,34]. Hip abduction weakness is often noted in injured runners and even in strength athletes (eg, rugby forwards and American football linemen), and thus testing should be part of the routine evaluation even in elite athletes. Although there are several ways to evaluate hip abduction, the author prefers the two following tests:
Lateral side-leg raise: Have the patient lay on their side with their knee fully extended and hip at neutral. From this position, the patient abducts their hip about 20 to 30 degrees against manual resistance provided by the examiner (picture 5 and figure 4). Be sure that the movement involves only hip abduction. Other hip movements, such as internal or external hip rotation, enable the patient to recruit other muscles to assist hip abduction . A strength discrepancy between sides or notable weakness compared with other patients represents a strength deficit that may contribute to ITBS.
Single-leg shallow knee bend: Have the patient balance on one leg and perform repeated shallow knee-bends to approximately 20 degrees of flexion (picture 6). If the knee tends to wobble inward (ie, medially), this suggests weak hip abductors. If the patient has general difficulty and excessive trunk movement, this suggests poor balance and weak core musculature. A similar maneuver is the step-down test: The patient stands on a step or platform and slowly steps down to the ground. Watch the knee that remains on the step for any medial movement (indicating weak hip abductors).
●Assess running gait. Watch the patient as they run towards you. Look for excessive movement of the knee medially during the stance phase (foot in contact with ground). Determine whether the patient’s knees migrate to or over the midline from either dynamic genu valgum or rapid medial horizontal motion. These biomechanical flaws are common in novice runners. Excessive genu varum (bow-legs) is typical of the advanced runner with ITBS.
DIAGNOSTIC IMAGING — Radiographic imaging is rarely needed to confirm ITBS and is obtained most often to look for other pathology in patients with persistent symptoms.
●Plain radiographs rarely show any abnormalities in cases of isolated ITBS. On rare occasion one may identify a prominent lateral femoral epicondyle [2,8,46].
●Ultrasound evaluation may show iITB thickening at the lateral femoral epicondyle (LFE) (image 1) [23,51,52]. Fluid around the distal ITB can be a non-specific finding, as suggested by a study of ultrasound imaging in 20 asymptomatic runners that reported fluid around the ITB in all patients . However, a focal, unilateral fluid collection around a symptomatic distal ITB raises concern for ITBS.
●MRI findings associated with ITBS may include ITB thickening and nonspecific abnormalities in the signal intensity between the ITB and LFE (image 2) [3,16,24,25,53]. MRI should only be used if the ITBS diagnosis is unclear and to evaluate potential surgical issues (eg, displaced lateral meniscal tear) due to cost.
DIAGNOSIS — ITBS is diagnosed clinically based upon a suggestive history and characteristic examination findings. Athletes typically describe an insidious onset of pain localized at the lateral femoral epicondyle (LFE). Initially the pain occurs only with prolonged activity (eg, distance run) but over time becomes more severe and begins sooner. Pain is typically sharp and occurs during foot-strike with running or as the knee extends (down-pedal position) during cycling. Localized tenderness at the LFE and a positive Noble Test are the most useful examination findings. (See 'Clinical features' above.)
Although generally unnecessary, injection of a local anesthetic where the ITB passes over the LFE can be performed to assist diagnosis. Following the injection, the patient attempts a brief trial of running (or the inciting sport), and resolution of their typical pain confirms the diagnosis. Imaging is used primarily when ITBS is unlikely and a specific cause for lateral knee pain cannot be identified. (See 'Chronic phase' below and 'Diagnostic imaging' above.)
INDICATIONS FOR ORTHOPEDIC REFERRAL — ITBS is an overuse condition; there are no absolute indications for urgent or emergent surgical consultation. Conservative treatment should be attempted for many months prior to considering surgery . Surgical release of part of the ITB is seldom needed for treatment. For difficult cases, in which pain persists despite long-term physical therapy performed by a compliant patient using an appropriate program, clinicians can refer patients to a surgeon with experience performing procedures to relieve ITBS. The surgeon can advise the patient about possible approaches to surgery.
Relative indications for surgery include:
●Persistent, activity-limiting pain despite diligent participation in a well-designed conservative treatment program
●Pain persisting for over six months after initiating conservative treatment
Several surgical treatments have been used, but no randomized controlled trials have been performed and thus their relative effectiveness remains unknown.
DIFFERENTIAL DIAGNOSIS — Patients with ITBS complain of focal lateral knee pain. Other potential diagnoses in patients with lateral knee symptomatology include the following, listed in order of decreasing likelihood, along with important features to differentiate them from ITBS:
●Patellofemoral pain (PFP): An athlete can develop PFP and ITBS simultaneously. Although the onset of both is gradual and progressive, PFP causes anterior knee pain, (although pain from PFP can radiate to the medial and lateral knee). Tenderness at the ITB over the lateral femoral epicondyle (LFE), and the absence of tenderness at the patellofemoral joint helps to distinguish ITBS from PFP. (See "Patellofemoral pain".)
●Lateral meniscal injury (typically post-traumatic but may be insidious): Palpation of lateral knee can clarify the diagnosis, as ITBS tenderness is focal at the LFE, while tenderness from a lateral meniscal tear is found at the joint line inferior to the location of ITB tenderness. Specialized testing for each further helps to clarify the diagnosis. Tests that compress the meniscus (eg, Thessaly test) are often positive with meniscal tears but not with ITBS, while the Noble test is often positive with ITBS but not with meniscal injury. (See "Meniscal injury of the knee" and 'Physical examination' above.)
●Popliteus tendinopathy: The popliteus tendon origin is located just anterior and inferior to the proximal attachment of the lateral collateral ligament (LCL). Repeated downhill running is the most common cause of injury. Typically, patients complain of increasing posterolateral knee pain when attempting to prevent acceleration while running downhill. The condition is distinguished from ITBS primarily by the history and the location of tenderness, just anterior and inferior to the LCL (the ITB is nontender). (See "Approach to the adult with knee pain likely of musculoskeletal origin", section on 'Conditions causing lateral and posterior knee pain'.)
●Lateral hamstring (biceps femoris) insertional tendinopathy: Although the onset of pain associated with hamstring tendinopathy is gradual, tenderness is present at the tendon insertion on the fibular head, not at the LFE, as occurs with ITBS. (See "Hamstring muscle and tendon injuries".)
●Lateral compartment knee osteoarthritis (OA): Knee OA is associated with morning joint stiffness, tenderness that typically localizes to the lateral joint line, not the LFE, and characteristic radiographic findings. (See "Clinical manifestations and diagnosis of osteoarthritis".)
●Lateral collateral ligament (LCL) injury: An LCL injury is caused by acute trauma, typically a varus stress to the knee, causing pain when the LCL is stretched and focal tenderness directly over the ligament; ITBS develops gradually without acute trauma and the LCL is nontender. The IT Band may be acutely injured concomitantly with an LCL injury . (See "Lateral collateral ligament injury and related posterolateral corner injuries of the knee".)
●Fibular head subluxation (tenderness would be at fibular head, not LFE).
●Uncommon causes for lateral knee pain include sensory nerve entrapment (eg, common peroneal nerve), tumor, and psychosomatic pain.
TREATMENT — There is little high quality evidence to inform the treatment of ITBS; the approach described here is based primarily upon case series, expert opinion, and our clinical experience [33,55]. One major limitation in the current understanding of ITBS is uncertainty about whether pain stems primarily from tendon injury or inflammation deep to the ITB. Our treatment scheme is organized by phases based in large part upon the duration of symptoms [19,31,46].
Acute phase: Symptom control — Treatment for patients whose initial presentation occurs within a few days to a week or so after the onset of symptoms consists of the following steps. This treatment continues for one to two weeks.
●Rest from any activities that reproduce symptoms.
●Apply ice to the symptomatic area (lateral aspect of knee) for 10 to 15 minutes per hour, several times per day. Avoid cold injury by using ice massage (massaging area of ITB with small amount of ice—avoiding constant prolonged contact of ice with skin).
●Use oral anti-inflammatories (NSAIDs) and other oral analgesics (eg, acetaminophen) to control pain . Although there are no studies of topical NSAIDs in the treatment of ITBS, the author believes they may be helpful in this phase (particularly for those who cannot take oral NSAIDs). (See "NSAIDs: Therapeutic use and variability of response in adults".)
Subacute phase: Correct strength and mobility deficits — The subacute phase of treatment begins one to several weeks after the onset of symptoms and may continue for many months, although patients may continue to perform some treatments begun during this phase for years to prevent recurrence. The focus of the subacute phase is to correct strength and mobility problems. To ensure that improvements are genuine, objective assessments of strength and flexibility should be performed regularly (eg, every three to four weeks) during this phase. To maintain fitness, athletes may perform exercises (eg, swimming, or for runners cycling using a lower crank resistance) other than the inciting activity during this phase, provided these do not cause pain. Remain cautious about any exercise that involves repeatedly placing the affected knee in 30 degrees of flexion. Since some runners experience their ITB symptoms only at specific training paces, we often allow runners with mild to moderate symptoms to continue to train at a level that does not reproduce pain. This is only recommended if the patient can run without a limp, as determined by direct observation during their office evaluation. We use a similar approach with cyclists (ie, permitting reduced training provided it does not cause symptoms).
Key facets of this phase include the following:
●Address strength deficits and discrepancies: This can be done through formal physical therapy or with a home exercise program under the supervision of a knowledgeable clinician. Several standard exercises are described in the accompanying table and photographs (table 1 and picture 7 and figure 5 and figure 6 and figure 7). Novice runners and other athletes with hip abduction weakness or genu valgum ("knock knees") benefit from exercises focused specifically on correcting these deficits [9,31]. Hip abduction weakness is common, even among elite runners and otherwise strong athletes.
●Address mobility deficits: The focus of mobility work is to improve any limitations in the flexibility of the ITB and related muscles identified during the physical examination. Several standard exercises are described in the accompanying table and photographs (table 2 and figure 8 and picture 8). Advanced runners with genu varum benefit from programs to improve ITB mobility [2,9,19,44,46,57]. In addition, we recommend incorporating exercises to correct any calf or iliopsoas inflexibility.
Several techniques are used to improve mobility including classic stretches, assisted stretches, and rollers. A biomechanical study of five male distance runners reported that the "arms over head" stretch caused the greatest stretching of the ITB . While several small observational studies support the notion that ITB mobility can be improved [21,58], other studies have refuted that the ITB can be stretched and suggest that treatment be focused on improving the strength, mobility, and suppleness of the proximal muscles, such as the tensor fascia lata, that attach to the ITB . However, there is no evidence that ITB stretching is harmful and we usually recommend it as part of a treatment program.
A simple device called a (foam) roller or bolster is commonly recommended and is thought to help break up adhesions that restrict ITB motion (figure 9), although there is little evidence to support this technique .
A single study of deep transverse friction massage did not show benefit in ITBS [59,60]. The author does not recommend this technique for ITBS, but others do.
Although a distinction is made between strength deficits, which are most common in novice runners, and mobility deficits, which are most common in elite runners, overlapping problems occur in many runners, and many athletes will benefit from elements of the rehabilitation program designed for each issue.
●Correct leg length discrepancy with an insole lift: Debate continues about whether heel or full-length foot lifts are most effective [45,61,62]. Based on expert opinion and clinical experience, the author typically uses a heel lift to correct approximately 50 percent of the difference in length . A 50 percent correction is used because most athletes have adapted to the leg length inequality over a lifetime, and a 100 percent correction might overcompensate creating additional problems. If the athlete’s symptoms improve but do not resolve with a 50 percent correction, the clinician can try gradually introducing additional corrections up to 100 percent. Three to four weeks may be needed for the patient to note improvement. If no improvement occurs by this time, or if pain increases at any point, remove the heel lift.
No studies were identified on the use of foot orthoses for treating ITBS. We have had moderate success using custom-molded semi-rigid orthotics for ITBS. Before using a custom orthotic, runners with excess supination can try a lateral heel wedge, while runners with pes planus (flat feet) or weak hip abductors can try a prefabricated arch support, which may help to decrease excess hip adduction during the stance phase of running. Clinicians who rely on orthotics risk addressing the symptom and not the underlying cause of the problem, and we suggest they be used only after mobility and strength deficits are addressed.
Although supporting evidence is scant, some sports medicine physicians use a compression knee sleeve to help treat ITBS. The risk of wearing such a sleeve is low and some patients report speedier recovery and less soreness when they use one .
Chronic phase — For athletes who do not improve with subacute phase treatment, and for those who present after months or years of symptoms, alternative treatments may be used in addition to the therapies described above . Some of the following treatments are more effective for tissue inflammation deep to the ITB (eg, glucocorticoid injection), while others are typically used for tendinopathy. It remains unclear whether the pathophysiology underlying ITB is comparable to that seen in chronic tendinopathy. If an injection is performed, it can be landmark based or ultrasound guided (image 3) .
●Glucocorticoid injection: Limited evidence suggests that glucocorticoid injection provides some short-term relief of pain caused by ITBS, although long-term benefit is unlikely . Such injections have been used for over forty years and there appear to be few adverse outcomes [1-3,7,31]. A single case of IT band rupture after repeated injection has been reported . In our experience, approximately 25 percent of ITBS patients have complete resolution of symptoms, 50 percent derive benefit for a few weeks, and 25 percent gain no benefit. We recommend glucocorticoid injection for patients who have been compliant with 6 to 12 weeks of acute and subacute treatment as described above, but who continue to have significant pain.
Glucocorticoid injection may also be used in well-trained athletes who develop symptoms shortly prior to an important race or event. Prior to any such injection, the clinician and athlete must thoroughly discuss the important potential risks and benefits. These include the risk that competing may exacerbate the underlying injury and prolong the time required for treatment and healing. The use of glucocorticoid injection in the treatment of tendinopathy and other musculoskeletal disorders is reviewed separately. (See "Overview of the management of overuse (persistent) tendinopathy", section on 'Glucocorticoids' and "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?".)
The following therapies have been used to treat chronic tendinopathy and are discussed in detail separately. Their use in the treatment of ITBS is controversial, in part because the underlying pathophysiology of ITBS remains unclear, but they are used on rare occasions, particularly in patients wishing to avoid surgery but whose symptoms are recalcitrant to the interventions described above. The author favors percutaneous needle tenotomy, while the section editor favors topical nitroglycerin.
●Percutaneous needle tenotomy: This treatment (also called microtenotomy or dry needling) involves percutaneous passage of a needle multiple times through pathologic tissue to stimulate healing. The technique is sometimes combined with injection of a glucocorticoid or biologic. The technique should only be performed by clinicians trained in the procedure. (See "Overview of the management of overuse (persistent) tendinopathy", section on 'Autologous blood and platelet-rich plasma injection'.)
●Biologic injection: This treatment involves injection of autologous blood products (whole blood or platelet-rich plasma obtained by centrifugation) into (or deep to) the ITB. There are no controlled studies of this treatment for ITBS.
●Prolotherapy: Prolotherapy is the injection of irritants into or adjacent to tendons with the goal of inciting a healing response. This technique has not been the subject of controlled studies in ITBS. (See "Overview of the management of overuse (persistent) tendinopathy", section on 'Prolotherapy'.)
●Topical nitroglycerin (Glyceryl Trinitrate): Nitroglycerin is a vasodilator thought by some to promote tendon remodeling and healing. No controlled studies have assessed the effectiveness of nitroglycerin for ITBS. (See "Overview of the management of overuse (persistent) tendinopathy", section on 'Topical nitroglycerin (glyceryl trinitrate)'.)
●Extracorporeal shockwave therapy: A meta-analysis of 19 randomized trials of medium to high quality reported benefit for soft tissue injury around the knee, including ITBS .
Adaptation phase: Return to sport — Once lateral knee pain during daily activities has resolved, patients can resume a gradual return to activity under the supervision of a knowledgeable clinician. Based upon limited evidence and our clinical experience, we suggest the following approach :
●Begin running or cycling at 50 percent of the pre-injury weekly distance or time. Avoid hills for two or more weeks initially [11,68].
●Continue beneficial interventions that were instituted in previous phases of treatment (eg, specific strengthening exercises). We suggest that icing and stretching be done immediately after exercise. Icing (preferably ice massage) should be done after stretching.
●Each week, increase the volume of exercise (time or distance) by 10 to 20 percent of the weekly total until pre-injury volumes are achieved.
●For athletes who develop mild pain during rehabilitation training (0 to 3 out of a maximum of 10), and for runners that can run without gait alterations due to pain, we suggest continuing with a gradual return to sport. If pain is ≥4 out of 10, we suggest a modest reduction in training and waiting at least an additional week before increasing the training volume. Patients who have had a more chronic problem with ITBS, or who seem to develop pain quickly as mileage accumulates, may have to increase their training volume more gradually.
●Some runners can decrease their symptoms by increasing their pace. ITBS is closely associated with a knee flexion angle of 30 degrees at foot strike. Running at a faster pace increases the knee flexion angle at foot strike, generally keeping it out of the 30 degree range .
●Avoid cambered roads and running downhill .
●For runners who in-toe, increase the "width" of the gait: Using a wider gait may reduce symptoms. In theory, the wider stance decreases varus stress across the distal ITB. This should only be used if a runner’s foot crosses the midline (the theoretical line that transects the runner’s torso in the frontal plane). Runners can assess this for themselves by running centered over a straight line on a track and watching where their feet land .
●Some data suggest that runners with decreased gait-to-gait variability (ie, fewer changes in biomechanics from stride to stride) may have an increased risk of injury. However, studies specifically of ITBS are conflicting. It may be that excessive gait-to-gait variability also leads to problems, and that there is a middle-ground at which injury is least likely [29,70]. We suggest including some off-pavement (grass or flat trail) training for running athletes as this may result in a decrease in repetitive stress and an increase in stride-to-stride variability. However, the non-pavement surface must be flat, not sloped.
●There is an increasing consensus that shortening the stride length, increasing the stride rate, and (for those with heavy foot strike) softening the landing may decrease general running injury rates without decreasing speed [47,55,71]. We concur with this approach. The effect of minimalist shoes and bare foot running on ITBS remains to be determined.
Cycling-specific suggestions [10,11,68]:
●Decrease saddle height: For most cyclists, the knee flexion angle at the end of down-pedaling (crank angle of 160 to 180 degrees) is approximately 30 degrees, which is the angle most closely associated with ITBS. Lowering the saddle height increases flexion of the knee during down-pedaling, moving the knee away from 30 degrees (picture 9). A saddle that is too far aft (or back) can produce the same consequences and should be moved forward (picture 10).
●Decrease in-toeing: In-toeing increases the distance from the LFE to Gerdy’s tubercle, thereby increasing the tension across the distal ITB. Adjusting the pedal or cleat so both feet are maintained in a neutral or slightly "out-toeing" position reduces this tension.
●Increase distance from crank to foot: Moving cleats to the medial aspect of cycling shoes, or placing spacers on the crank-arm bolt of both pedals, increases the distance between feet during cycling. This wider stance may decrease varus alignment, thereby decreasing the strain across the ITB.
●Correct for leg length discrepancies: We suggest adding shims to the cleat on the shorter leg to adjust for 50 percent of the difference. In cycling, it is usually the shorter leg that is at risk for ITBS .
In the majority of published studies, most athletes diagnosed with ITBS (whether treatment was brief or prolonged) were able to return to full athletics within six to eight weeks once their symptoms began to improve [1-3,9,31,46]. Protracted cases may require three to six months to heal. If symptoms persist despite appropriate treatment, or if limiting symptoms have been present for over six months, surgical treatment may be considered. (See 'Indications for orthopedic referral' above.)
FOLLOW-UP CARE — Once predisposing biomechanical, strength, and mobility problems have been addressed, it is important that athletes maintain these improvements to avoid a recurrence of ITBS. This is true regardless of whether improvements were due to strengthening the hip abductors, stretching the ITB, or adjusting running stride.
If an athlete experiences a recurrence of pain, treatment should emphasize those interventions that were successful initially. When such patients return to their sport, their initial training volume should be half of what they began the adaptation phase with the first time (ie, 25 percent of preinjury level), and the progression back to full activity should be more gradual (eg, 5 to 10 percent increases per week). Clinicians should be certain that all potential underlying factors are adequately assessed. (See 'Risk factors' above.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Knee pain".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Iliotibial band syndrome (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition, epidemiology, and pathophysiology – Iliotibial band syndrome (ITBS) is an overuse injury of the lateral knee that occurs primarily in runners, cyclists, and military personnel. Pain develops where the iliotibial band (ITB) courses over the lateral femoral epicondyle (LFE) just proximal to the lateral knee joint line. ITBS appears to be associated with repeated knee flexion to or through a 30-degree angle. (See 'Epidemiology' above and 'Anatomy' above and 'Biomechanics and pathophysiology' above.)
●Risk factors – Two categories of lower extremity malalignment are associated with ITBS: weak hip abductors leading to increased hip adduction (common among novice and female runners) and increased hip abduction, genu varum, or increased foot supination (common among experienced distance runners). Other anatomic risk factors include a tight ITB, tight hip flexors, and limited ankle plantarflexion. Extrinsic risk factors include running on angled surfaces, excessive training, poor running footwear, and a bicycle with incorrect pedal position or poor fit. (See 'Risk factors' above.)
●Clinical features and examination – Athletes with ITBS typically describe the insidious onset of pain localized to where the ITB courses over the LFE. Initially, pain occurs only during sport. It is typically sharp or burning and occurs just prior to or during foot strike when running, or as the knee extends (down-pedal position) when cycling. Over time, the pain can become constant and deep, persisting throughout exercise. Key examination findings associated with ITBS include focal tenderness at the distal ITB where it courses over the LFE and a positive Noble compression test. It is important to examine the entire knee joint to exclude other causes of pain. (See 'Clinical features' above.)
●Diagnosis and diagnostic imaging – ITBS is diagnosed clinically based upon a suggestive history and characteristic examination findings. Radiographic imaging is rarely needed and is obtained most often to look for other pathology in patients with persistent symptoms. (See 'Diagnosis' above and 'Diagnostic imaging' above.)
●Differential diagnosis – The differential diagnosis includes patellofemoral pain, lateral meniscal injury, injury of the lateral hamstring near its insertion, popliteus tendinopathy, and lateral collateral ligament injury. (See 'Differential diagnosis' above.)
●Management – Acute treatment includes rest, application of ice, and analgesics. During the subacute phase, deficits in muscle strength and mobility are corrected with appropriate exercises. Patients return to sport along a graded schedule. Specific recommendations for the rehabilitation of runners and cyclists are provided in the text. In recalcitrant cases, interventions similar to those used in chronic overuse tendinopathy may be used, although evidence is limited. (See 'Treatment' above.)
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