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Denver T. Stanfield, MD



ILIOTIBIAL BAND FRICTION SYNDROME

Iliotibial Band Friction Syndrome (ITBFS) is a relatively common overuse syndrome. It is caused by friction between the Iliotibial (I-T) band and the lateral femoral condyle of the knee. It is often seen during running and other activities that involve repeated flePxion and extension of the knee. (Figures 1 and 2)

 
Figure 1. Relationship of the I T band to the lateral femoral epicondyle with the knee in full extension. Note that the I T band lies anterior to the lateral femoral epicondyle.   Figure 2. Relationship of the l-T band to the lateral femoral epicondyle with the knee in 60 of tlexion. Note that the l-T band is now posterior to the lateral femoral epicondyle.



Several years ago I became involved in the initial description and study of the injury while working at the Marine Corps Officer Candidate School in Quantico, Virginia. This work, along with the anatomic description of the mechanism of the injury, was published in December, 1975. Since that initial study, we have learned much more about the etiology and the treatment of ITBFS.

The majority of cases are found in distance runners. Other activities which have been reported to cause ITBFS are downhill skiing, circuit training, weight lifting, jumping sports, and cycling. The most frequently cited etiological factor is ITBFS is training errors, with increased mileage being the most frequent offender along with a high volume of speed training, downhill running, and overstriding on flats as possible contributing factors. Hyperpronation of the foot will cause increased lower extremity rotation and therefore theoretically increases the susceptibility to ITBFS, although only 20% of patients diagnosed with ITBFS have been found to have a pronated foot. Symptoms have also been identified in runners who fail to repair a worn outer sole or are running in shoes which need replaced. Running consistently on the same side of a crowned road has been noted to result in ITBFS on the downside leg. Flexibility is another factor which needs to be considered. Tightness of the I-T band is a common etiological factor. This tightness results in increased friction at the sight of the lateral femoral condyle.

The discomfort of ITBFS felt during running usually occurs at a fixed distance. The condition is also aggravated while ascending and descending stairs. It is seldom aggravated by walking, squatting, jumping, or sprinting. The reason sprinting does not cause pain may be explained by the observation that a sprinter makes ground contact in approximately 35 degrees of knee flexion and does not extend beyond that angle. Since friction (and therefore pain) occurs at 30 degrees of flexion, sprinting does not irritate the inflamed I-T band.

The diagnosis of ITBFS is usually made by localizing tenderness to the lateral femoral condyle and ruling out other causes of lateral knee pain. The diagnosis can be confirmed by a compression test. In this test the knee is flexed to 90 degrees and pressure is applied to the lateral femoral condyle of the knee. The knee is then gradually extended. At 30 degrees of flexion there will be significant discomfort in the area of the I-T band which is the same pain as identified during running.

Perhaps the most effective treatment for ITBFS is total cessation of running, but this is quite often unacceptable. A reasonable compromise would be the reduction of distance combined with various therapeutic modalities, anti-inflammatory agents, and the use of ice after activity. Considering that training errors often cause ITBFS, some changes in training may be necessary. Among these are decreased mileage, change in terrain with a reduction in the number of hills, as well as a decrease in speed work. Decreasing strike length may also help. In addition, I recommend inspection of your shoe's outer sole with particular attention to the lateral heel. Shoes should not have greater than 300-400 miles and shoe pairs should be rotated during the week.

Probably the most important area of treatment to be addressed is flexibility. I have found that all patients with ITBFS have I-T band tightness. Once the I-T band has tightened or contracted, this injury cannot be resolved and you will not be able to return to normal activity with regaining proper flexibility. The other above mentioned treatments will make you feel better but stretching is the only thing which will now resolve the problem. Many treatment methods will probably be used in combination, but religious performance of a stretching program is of central importance for improvement. Attached are several stretching exercises which can be used to increase flexibility of the lateral hip, thigh, and knee structures. Remember that a short regular stretching program should be incorporated in your routine warm-up and cooldown even after your recovery to prevent reinjury.


ILIOTIBIAL BAND STRETCHING PROGRAM

Start with the all important quadriceps stretch. The flexibility of these large four muscles will relieve stress on the iliotibial band.

Pull heel toward buttock until a stretch is felt in front of thigh.
Tuck foot near groin with opposite leg straight. Reach down until a stretch is felt in back of thigh.


Next work on the large posterior hamstring muscles. Use both tile seated and standing hamstring stretch.

Place foot on stool. Slowly lean forward rwaching down shin until a stretch is felt in back of thigh.