ITB stands for the iliotibial band. It is also known as the iliotibial tract or Maissiat’s band. ITB syndrome (ITBS) is a common injury that causes inflammation and irritation of the iliotibial band. The damage affects the lateral or outer side of the knee as the band runs along the outer side of the leg.

The iliotibial band is a long piece of connective tissue that runs from the hip to the knee and down to the shin bone. The band runs along the outer border of the leg.

It functions to extend, abduct, and rotate the hip. It also caters to a stabilizing act by protecting the outer thigh and moving the side of the knee.

Usually, overuse and repetitive extension and flexion at the knee joint result in damage. In addition, the resultant tightness of the band causes pain and tenderness in the knee while bending. Rarely, the knee pain gets referred to the hip as well.

Iliotibial syndrome often arises as a non-traumatic condition due to overuse. However, the situation is almost always seen in runners.  The underlying weakness of hip abductor muscles predisposes to the state.

Research says that the compression of the local fat tissue contributes to the development of ITB syndrome. An impingement zone is observed at the knee joint or slightly below during the early phase of running in such patients.

During such an impingement, eccentric contraction of the hip muscles (tensor fascia lata muscle and the gluteus maximus) causes the leg to lose pace, generating tension in the iliotibial band and causes pain.  

Anatomy of the iliotibial band

The iliotibial tract is a thick band of fascia or connective tissue from the tensor fascia lata and gluteus maximus muscles. It originates from the iliac crest of the hip bone, runs along the outer side of the thigh, and inserts at the knee onto the lateral tibial plateau (leg bone) at a projection known as Gerdy’s tubercle.

The distal (far-end) portion of the iliotibial tract covers the lateral femoral epicondyle. At this instant, it gives off an expansion to the lateral border of the patella (the bone in front of the knee joint).

The iliotibial band does not attach to any bone while running its course between the Gerdy tubercle and the lateral femoral epicondyle. That is why the band can move posteriorly during flexion and anteriorly during extension of the knee joint.  This may cause friction between the posterior edge of the iliotibial band and the underlying lateral femoral epicondyle resulting in microtrauma and pain.

Cause of iliotibial band syndrome

About 5-14% of the runners suffer from the iliotibial syndrome. It is the most prevalent injury that causes lateral knee pain and accounts for approximately 22% of all lower limb injuries.

Though cyclists and runners are more at risk of developing the syndrome, other movements like repetitive walking up and downstairs, wearing of high heels or sitting for extended hours with bent knees also contribute to the lateral knee pain. Hikers, basketball and soccer players, and weightlifters are also more likely to develop this condition.

Many factors contribute to the development of iliotibial syndrome, the underlying cause of excessive friction of an overly tight IT band against bone.

• Long-distance running especially running on the slightly banked ground
• A sudden increase in activity levels
• Repeated tissue compression
• Muscle weakness of the hip abductors (increased hip internal rotation and knee adduction)
• chronic inflammation of the ITB bursa

Some risk factors that predispose one to ITB syndrome include;

• Any previous injury or preexisting tightness of the iliotibial band
• Weak musculature of the abdomen, hip, and gluteal areas
• Excessive uphill walking or running
• Weakness or lack of flexibility of the lower limb
• Undue sitting for extended hours
• Weak extensors and flexors of the knee
• Weak hip abductors
• Sports as running and cycling
• Degenerative changes due to disease like arthritis
• Congenitally imbalanced leg lengths
• Bowlegs
• Flat feet

Signs and symptoms of iliotibial band syndrome

Lateral knee pain is usually the presenting complaint.

The history of the presenting complaint, lateral knee pain, indicates the involvement of the knee joint in repetitive flexion and extension movements.

The following are the signs and symptoms of ITB syndrome;

• Burning pain at the level of or just below the lateral femoral epicondyle at the outer side of the knee joint
• A sharp painful jolt on the outer aspect of the knee that radiates to the outer thigh or calf when the heel strikes the floor
• Pain worsens on activities like running or climbing downstairs
• An audible snapping sensation upon bending the knee (due to the band flicking over the bone)
• Visible swelling on the outer side of the knee
• Other signs of inflammation like redness and warmth of the affected area may also be present.

Diagnosis of iliotibial band syndrome

Besides the history, some tests on physical examination confirm the diagnosis of ITB syndrome. These include;

• Weakness of hip abductors as shown by a decrease in the force of abduction
• Treadmill test; pain in the lateral side of the knee on running is a positive diagnosis of ITB syndrome.
• The noble compression test; is conducted with the patient in a supine posture with the knee flexed at 90 degrees. The patient is asked to extend the knee, and the doctor applies pressure on the lateral femoral epicondyle. Pain while doing this maneuver is considered positive.
• Ober test; the test is conducted with the patient lying on his side. The injured side faces upwards. The knee is flexed at 90 degrees, and the hip is placed in abduction and extension positions. The thigh remains in line with the trunk. The patient is asked to adduct the thigh, which is not possible due to pain.  

Treatment

The treatment and management of the iliotibial band syndrome include;

1. During the initial phase till pain relief

1. RICER

Rest and modified activity should be employed. In addition, both the frequency and intensity of the aggressive activity should be checked.

If complete abstinence from an activity is not possible, the patient must be taught to modify the physical activity. For example, take up swimming instead of running.

Some doctors may suggest complete rest from athletics and sports for at least three weeks. However, inactivity can last from a week to few months depending upon the severity of the symptoms.

Ice (cryotherapy) or heat therapy and taping can help manage the pain, cater to immobilization and reduce swelling in the initial days.

• Medication

Over-the-counter NSAIDs and corticosteroid injections help manage the pain.

• TENS

TENS alleviates the pain by sending a gentle tingling sensation with the help of very low-intensity electrical signals. The therapy is also believed to stimulate the release of endorphins, the body's natural painkillers.

The electrodes may be placed around the outer knee area or higher up towards the hip. You can use two or four pads. Common locations for pad placement in knee pain include the sides, the back, or the front of the knee.

• Surgery

Surgical management of ITB syndrome is recommended only if conservative treatment fails to bring relief. Surgery includes removing a small piece of the posterior part of the iliotibial band covering the lateral femoral epicondyle.  

• After few weeks, when the injury has healed.

1. Massage

Massage therapy in acute cases while the inflammation ensues in the knee is contraindicated. However, after the pain and swelling have resolved, massaging the thigh muscles can relax the hip and thigh muscles.

Myofascial massage helps relieve the compression around the iliotibial band. The surrounding hamstring and quads are released effectively, thereby allowing the iliotibial band to move freely. The trigger points in the thigh muscles are affectively addressed with this technique.

The use of a foam roller on the tight muscles is helpful, especially in self-massage techniques. In addition, it helps to perform stretching exercises at home, caters to deep transversal friction and self-myofascial release.

• Therapeutic ultrasound

Ultrasound therapy that utilizes thermal or non-thermal treatment of the injured tissue is an effective remedy to speed up healing and recovery.  

Some newer techniques that involve introducing analgesic or anti-inflammatory drugs into the injured tissues via electric field (iontophoresis) or passed through the skin via ultrasound (phonophoresis) are being employed, for example, iontophoresis with dexamethasone speed healing.

Phonophoresis enhance the absorption of topically applied analgesics and anti-inflammatory agents via the therapeutic application of ultrasound.

• Radial shock wave therapy

Another treatment strategy is radial shockwave therapy. It has proven effective as a rehabilitation remedy for runners with iliotibial band syndrome.

The treatment uses energy that is generated when a hand-held projectile is accelerated by pressurized air. The energy created is transferred via a metal applicator through the ultrasound gel into the skin. The shockwave disperses outwardly into the tissue to be treated.

The therapy is suggested to stimulate the healing of soft tissue and inhibit pain receptors. Thus, the treatment increases cytokine diffusion across blood vessel walls into the painful area and promotes the healing and recovery process.

The therapy is also believed to increase vascularization and improve the local blood supply of the injured area, thereby contributing to healing.

• Active rehabilitation

Physical therapy is a must for iliotibial band syndrome, whether to supplement the conservative therapy or as a preventive measure for any recurrences.

The best exercises to start to depend upon the causative factor and the severity of the condition.

A physical therapist makes sure to understand the type of aggressive forces that caused the syndrome in the first place.

Here are some stretching and strengthening exercises that help iliotibial band syndrome;

Standing IT band stretch

• Stand and keep your feet shoulder-width apart.
• Cross your right leg in front of your left.
• Make sure to plant both your feet firmly on the ground.
• Now move your right side of the body as far as possible.
• You should be able to feel a stretch in your outer knee and hip.
• Reach your left arm over your head to increase the stretch.
• Hold the stretch for about 30 seconds.
• Repeat this stretch three times by switching sides and taking the left leg in front of the right.

Standing forward bend variation.

• Stand and cross over your right ankle in front of your left.
• Keep your knees slightly bent, bend your body forwards, and try reaching your feet. You may turn as far as you are comfortable.
• While bending forwards, press both of your legs into each other. This will add more resistance.
• Hold the position for about a minute.
• Switch sides and do the same with the left leg crossed over. Then do the opposite side.
• Repeat sets as per your convenience.

Wide-legged standing forward bend

• Stand and keep your feet at a distance wider than your shoulders.
• Bend your knees slightly.
• Turn in your toes.
• Now make a move at the hip joint and hinge forwards, dropping your hands down to reach the ground or as far as possible.
• You can try to take support from a chair or table if the hands do not reach the ground.
• Now try to reach the outer edges of your feet; first, the right, then left. You should be able to feel the stretch along the outer side of your legs.
• Hold the position when you touch the feet for about ten to fifteen seconds. 
• Repeat on each side two to three times.

Hip hikes

• Stand on a step or a footstep.
• When you are steady, let your one leg hang off the edge of the footstep while you support your body on the other leg.
• Keep your hips and shoulders squared and straight.
• Now drop your hanging leg down to the floor without touching it.
• Make sure to keep your leg on the footstep straight.
• Bring the dropped leg up and down again.
• Do at least fifteen reps.
• Switch sides and do the same with the other leg.
• Perform at least two steps on each side.

Focus on pulling from your hip and waist rather than lifting your leg with your knee or from your foot.

Heel drops

• Stand on footstep and steady yourself.
• Now stand on one leg and extend the other one forwards as if taking a step.
• Move your leg in a stride but do not touch the floor.
• Squat a little before bringing your forward leg back to starting position.
• Keep your other leg slightly bent for support.
• Do not bend your hips during this move.
• Repeat at least ten times on one side before switching legs and doing the same with the other.

Prevention of iliotibial syndrome

Some preventive tips to safeguard against ITB syndrome include;

1. Adopt an appropriate and suitable form.
2. Do not exert yourself.
3. Warm-up your body and cool it down while exercising. Stretching at the end of the exercise is essential.
4. Keep doing regular strengthening and stretching of your body.
5. Avoid training mistakes like;
6. Straining and stressing your body
7. Not taking enough rests between workouts
8. Wearing improper gear like shoes
9. Selecting wrong surfaces for training
10. Increasing training levels too quickly