MYTH BUSTIN the Iliotibial band By Mora OMalley December 4,
2014 MGH Institute of Health Professions Spaulding Framingham
Slide 2
True or False? 1. ITBS is the result of bursitis 2. ITBS is
caused by excessive friction at the knee 3. Injections may help 4.
You can stretch the ITB 5. Fixing muscle imbalances can help with
ITB alignment
Slide 3
Definition of Iliotibial Band Syndrome 1-2 A non-traumatic
overuse injury caused by friction/rubbing over the lateral femoral
epicondyle with repeated flexion and extension of the knee. -
AAOS
Slide 4
Why it matters 2,4,7,10 ITBS 2 nd most common cause of knee
pain after PFPS Up to 12% of runners 2-25% in active people 22% in
military recruits 24% of cyclists o 50% of cyclists have knee pain
issues
Slide 5
Impingement Zone 2 Occurs at 30 knee flexion Foot strike and
early stance phase Eccentric contraction of TFL & Glute Max for
deceleration = tension through ITB
Slide 6
Risk Factors: Intrinsic 4,7,10 Abnormal LE alignment Genu varus
knee IR Leg length discrepancy Abnormal foot biomechanics
supination Weak hip abductors Tight gastroc/soleus Tight hip
flexors Limited evidence to support any of these.
Slide 7
Risk Factors: Extrinsic 7 Sudden in running mileage or hill
workouts in cycling Includes excessive mileage in a single workout
High weekly running mileage Running footwear with heel height and
width Over-striding Excessive running in same direction on a track
or cambered sidewalk Excessive running vertical gradients: downhill
> uphill Cycling with improperly fitting bicycle Exercise in
cold weather Preliminary evidence on these.
Slide 8
What if it isnt ITBS? 6-7,11 Patellofemoral Pain Syndrome
Lateral meniscal tear Popliteus tendinitis Lateral hamstrings
tendinopathy Contracture in post-polio & cerebral palsy Other:
LCL injury, OA, tumor, psychosomatic pain, common peroneal sensory
nerve entrapment
Slide 9
True or False? 1. ITBS is the result of bursitis 2. ITBS is
caused by excessive friction at the knee 3. Injections may help 4.
You can stretch the ITB 5. Fixing muscle imbalances can help with
ITB alignment
Slide 10
Muscle Attachments: TFL & Glute max Function: Knee
extension near terminal extension Max compression @ 30 knee flexion
Lateral knee stability Anatomy 3,7-8,11
Slide 11
ITB Bursa in Netter 7-8
Slide 12
Fairclough J et al. The functional anatomy of the ITB during
flexion and extension of the knee: implications for understanding
ITBS. J. Anat. 2006 What do the cadavers have to say?
Slide 13
Re-evaluating ITB Anatomy 3 No bursa under ITB Highly
vascularized and innervated fat pad present at many tendon &
ligament entheses Pacinian corpuscles = subject to compression MR
signals & edema in fat pad Conclusion: more likely enthesopathy
Fairclough J et al. The functional anatomy of the iliotibial band
during flexion and extension of the knee: implications for
understanding iliotibial band syndrome. J. Anat. 2006
Slide 14
True or False? 1. ITBS is the result of bursitis T F 2. ITBS is
caused by excessive friction at the knee 3. Injections may help 4.
You can stretch the ITB 5. Fixing muscle imbalances can help with
ITB alignment
Slide 15
Re-evaluating ITB Anatomy 3 Unlikely to roll forward &
backward due to attachments Intermuscular septum/linea aspera
Fascia lata Can move more medial/lateral = compression Fairclough J
et al. The functional anatomy of the iliotibial band during flexion
and extension of the knee: implications for understanding
iliotibial band syndrome. J. Anat. 2006
ITB in an Elite Track Athlete Lig = ligamentous ITB Ten =
tendinous ITB A = anterior ITB fibers P = posterior ITB fibers
Slide 19
True or False? 1. ITBS is the result of bursitis T F 2. ITBS is
caused by excessive friction at the knee T F 3. Injections may help
4. You can stretch the ITB 5. Fixing muscle imbalances can help
with ITB alignment
Slide 20
Number of Treatments 7 Rest Cross training R-I-C-E Stretching
ITB Stretching hip abductors Strengthening hip abductors Podiatric
assessment Massage NSAIDS Injected corticosteroids
Slide 21
Lack of Evidence 2 2007 Systematic Review 4 RCTs looking at:
Corticosteroid injection QS = 9 NSAIDs QS = 8 Deep friction massage
QS = 7 Phonophoresis versus immobilization QS=7 o Limited internal
validity Ellis R, Hing W, Reid D. Iliotibial band friction syndrome
a systematic review. Manual Therapy. August 2007.
Slide 22
Phonophoresis vs Immobilization 2 Navy diving students ITBS for
15-17 days 2 groups: Knee immobilization Phonophoresis with 10%
hydrocortisone Phonophoresis RESULTS: Recovered in
Deep Transverse Friction Massage (DTFM) 2 20 subjects with ITBS
for >14 days Intervention group: 10 minutes of DTFM RESULTS:
Pain significantly in both groups without a significant difference
DTFM does not alter outcomes Schwellnus et al. 1992
Slide 24
NSAIDs 2 3 groups Placebo control group NSAIDs only NSAIDs with
analgesic (codeine) Results Significant pain in all groups
NSAIDs/Analgesic group = only group with significantly running pain
at day 3 o running pain and running time/distance Schwellnus et al.
1991
