Iliotibial Band Syndrome

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Contributor Information and Disclosures

Author
Jerold M Stirling, MD Interim Chairman of Pediatrics, Associate Professor of Pediatrics and Orthopedics,
Departments of Pediatrics and Orthopedic Surgery, Loyola University Medical Center
Jerold M Stirling, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)
Pietro Tonino, MD Director of Sports Medicine, Associate Professor of Orthopaedic Surgery, Orthopaedic
Surgery, Loyola University Medical Center
Pietro Tonino, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American College of Sports Medicine, American Medical Association, American Orthopaedic Society
for Sports Medicine, Chicago Medical Society, Illinois State Medical Society, Mid-America Orthopaedic
Association, American College of Occupational and Environmental Medicine
Disclosure: Nothing to disclose.
Timothy D Marsho, DO Pediatrician
Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor
Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine,
Medical Director of Sports Medicine, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family
Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta
Kappa
Disclosure: Nothing to disclose.

Additional Contributors
Leslie Milne, MD Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School
of Medicine
Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine
Disclosure: Nothing to disclose.

OVERVIEW

Background
Iliotibial band (ITB) syndrome (ITBS) is the most common cause of lateral knee pain among athletes. [1, 2, 3, 4, 5,
6]
ITBS develops as a result of inflammation of the bursa surrounding the ITB and usually affects athletes who
are involved in sports that require continuous running or repetitive knee flexion and extension. [1, 2, 3, 7, 8, 9, 10] This
condition is, therefore, most common in long-distance runners and cyclists. ITBS may also be observed in
athletes who participate in volleyball, tennis, soccer, football, skiing, weight lifting, and aerobics. [11]
The image below illustrates active stretching of the ITB.

This illustration demonstrates active stretching of the iliotibial band (ITB). The
athlete stands a comfortable distance from a wall and, with the contralateral knee extended, leans the proximal shoulder
against the wall to stretch the ipsilateral ITB.

See Football Injuries: Slideshow, a Critical Images slideshow, to help diagnose and treat injuries from a football
game that can result in minor to severe complications.
For patient education resources, see the Osteoporosis Center. Also, see patient education articles Knee
Pain, Knee Injury, Tendinitis, and Running.
See also Medscape Drugs & Diseases articles Iliotibial Band Friction Syndromeand Physical Medicine and
Rehabilitation for Iliotibial Band Syndrome.
See also the Medscape CME & Education topic Medical Interventions Effectively Treat Overuse Injuries in Adult
Endurance Athletes.

Epidemiology
Frequency
United States
ITBS is the most common cause of lateral knee pain in runners. Although few studies are available regarding
the incidence of ITBS in athletes, some studies cite this condition with an incidence as high as 12% of all

running-related injuries.[12] Several studies of US Marine Corps recruits undergoing basic training determined the
incidence of ITBS among this group to vary from 5.3 to 22.2%.
International
Data are not available regarding the international incidence of ITBS.

Functional Anatomy
The ITB is the condensation of fascia formed by the tensor fascia lata and the gluteus medius and minimus
muscles. The ITB is a wide, flat structure that originates at the iliac crest and inserts at the Gerdy tubercle on
the lateral aspect of the proximal tibia. This band serves as a ligament between the lateral femoral condyle and
the lateral tibia to stabilize the knee. The ITB assists in the following 4 movements of the lower extremity:

Abducts the hip

Contributes to internal rotation of the hip when the hip is flexed to 30
Assists with knee extension when the knee is in less than 30 of flexion
Assists with knee flexion when the knee is in greater than 30 of flexion
The ITB is not attached to bone as it courses between the Gerdy tubercle and the lateral femoral epicondyle.
This lack of attachment allows it to move anteriorly and posteriorly with knee flexion and extension. Some
authors hypothesize that this movement may cause the ITB to rub against the lateral femoral condyle, causing
inflammation. Other investigators hypothesize that injury of the ITB results from compression of the band
against a layer of innervated fat between the ITB and epicondyle. Furthermore, a potential deep space is
located under the ITB as it crosses the lateral femoral epicondyle and travels to the Gerdy tubercle. This bursa
may become inflamed and cause a clicking sensation as the knee flexes and extends. The inflamed bursa may
add another component to ITB tendinitis.
See also Medscape Drugs & Diseases topics Bursitis and Tendonitis.

Sport-Specific Biomechanics
In runners, the posterior edge of the ITB impinges against the lateral epicondyle of the femur just after foot
strike in the gait cycle.[7, 8] This friction occurs at or slightly below 30 of knee flexion.[2, 3, 7] Downhill running and
running at slower speeds may exacerbate ITBS as the knee tends to be less flexed at foot strike. [13, 14]
In cyclists, the ITB is pulled anteriorly on the pedaling downstroke and posteriorly on the upstroke. The ITB is
predisposed to friction, irritation, and microtrauma during this repetitive movement because its posterior fibers
adhere closely to the lateral femoral epicondyle.

PRESENTATION

History
The usual clinical history describes lateral knee pain:

o
o
o

o
o

Pain with activity

Typically, the patient with ITBS presents with an insidious onset of lateral knee pain that is
present during running.
Early in the course of the injury, the pain usually resolves after running.
If the athlete continues to run, the pain may progress to being present during walking and
between training sessions.
Pain localized over the lateral femoral epicondyle
The athlete is able to localize the lateral knee pain to approximately 2 cm above the lateral
joint line.
Untreated, the pain may eventually radiate to the distal tibia, calf, and up to the lateral thigh.
Pain while climbing stairs or running downhill
Pain is commonly experienced when the athlete climbs stairs or runs downhill.

Pain may develop with any activity that places the knee in a weight-bearing position at
approximately 30 of knee flexion.

Pain at rest
o
Pain at rest is usually associated with severe tendinitis, an associated lateral meniscus tear,
an associated lateral femoral condyle bruise, or a cartilage injury.
o
Any time there is pain at rest but no history of acute or repetitive trauma, the practitioner
should ask questions to rule out neoplasm, infection, or inflammatory arthropathy.
See also Medscape Drugs & Diseases topics Soft Tissue Knee Injury, Meniscal Tears on MRI, Meniscus
Injuries, and Meniscal Injury.
o

Physical
Physical examination findings in patients with ITBS may include the following:

Abnormal gait: The athlete may walk with the affected knee extended because this gait pattern avoids
motion in which the tendon rubs on the lateral femoral epicondyle.
Point tenderness is noted upon palpation of the lateral femoral epicondyle, as well as with palpation of
a site 2-4 cm above the lateral joint line and at the Gerdy tubercle. Oftentimes, the patient indicates pain with
the use of the palm of the entire hand.
Reproducible pain: Pain may be elicited with knee flexion to 30 when varus stress is applied to the
knee.
The Ober test is used to assess the flexibility of the ITB. To perform this test, the examiner instructs the
athlete to lie on the uninjured side. The examiner stabilizes the athlete's pelvis with one hand while controlling
the affected limb with the other hand. The examiner abducts and extends the affected hip toward the table.
Once the hip is abducted, the examiner adducts the hip. If the hip resists adduction, it is a result of tightness
of the ITB (see the image below).

The Ober test.

Causes
See the list below:

Runners
o
o
o
o

o
o
o

The posterior edge of the ITB impinges against the lateral epicondyle of the femur just after
foot strike in the gait cycle. This friction occurs at or slightly below 30 of knee flexion. Downhill running and
running at slower speeds may exacerbate ITBS because the knee tends to be less flexed at foot strike.
Running on hard surfaces and banked surfaces: The injured leg is often the downside leg on a
banked or crowned road.
Worn out or improper running shoes
Lower limb and foot misalignment such as valgus or varus alignment of the leg or leg-length
discrepancy
Cyclists
In cycling, the ITB is pulled anteriorly on the pedaling downstroke and posteriorly on the
upstroke. The ITB is predisposed to friction, irritation, and microtrauma during this repetitive movement
because its posterior fibers adhere closely to the lateral femoral epicondyle.
Cyclists with an external tibia rotation greater than 20 : Stress is created on the ITB if the
athlete's cycling shoe is placed in a straight-ahead position or the toe is in a cleat position.
Cyclists with varus knee alignment or active pronation place a greater stretch on the distal ITB
when they ride with internally rotated cleats.

o
o
o
o
o

Poorly fitted bicycle saddle: A high-riding saddle causes the cyclist to extend the knee more
than 150 . This exaggerated knee extension causes the distal ITB to abrade across the lateral femoral
condyle. Bicycle saddles that are positioned too far back cause the cyclist to reach for the pedal, with a
resultant stretch to the ITB.
All athletes
Improper warm-up and stretching
Increasing the quality and quantity of training sessions too quickly
Lower limb and foot misalignment such as valgus or varus alignment of the leg or leg-length
discrepancy
Worn out or improper athletic shoes
On occasion, a contusion to the knee may precipitate ITBS.

DDX

Differential Diagnoses

Lateral Collateral Knee Ligament Injury

Background

Lateral collateral ligament (LCL) injuries result from a varus force across the knee. A contact injury,
such as a direct blow to the medial side of the knee, or a noncontact injury, such as a hyperextension
stress, may result in a varus force across the knee injuring the LCL. In terms of functionality, the LCL
has often been grouped with the popliteofibular ligament and the popliteus tendon as the posterolateral
corner (PLC).
See the figure below.

The medial and lateral collateral

ligaments of the knee. Courtesy of Randale Sechrest, MD, CEO, Medical Multimedia Group

WORK-UP
Laboratory Studies
No specific laboratory tests are required in the workup of ITBS.

Imaging Studies

Initially, radiographic studies are not indicated if the working diagnosis is completely consistent with ITBS.
Radiographs are almost always negative. If the patient's history and physical are not consistent with the
diagnosis of ITBS or the patient's response to treatment is unsatisfactory, radiographs are required. In some
patients, the practitioner may elect to obtain radiographs on the first visit or before the athlete resumes
competition.

TREATMENT

Acute Phase
Rehabilitation Program
Physical Therapy
Modalities to decrease inflammation include ultrasonography, phonophoresis, iontophoresis, and icing. After the
acute inflammation has resolved, the patient should begin a stretching program, which should include active
stretching of the hamstrings, gluteal musculature, and hip adductors to improve the flexibility of the ITB. (See
images below.)

This illustration demonstrates active stretching of the iliotibial band (ITB). The
athlete stands a comfortable distance from a wall and, with the contralateral knee extended, leans the proximal shoulder
against the wall to stretch the ipsilateral ITB.

This illustration demonstrates iliotibial band

syndrome stretching that is performed in a side-lying position.

Medical Issues/Complications
The acute phase of treatment focuses on control of inflammation, correction of poor training habits, as well as
accommodation made for any anatomic structural variants.

Nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation

To reduce stress on the knee, ideally, the athlete should avoid participating in the activity that incited
the injury. Pragmatically, it is often helpful for the physician to work with the athlete to develop a training
program that allows athletes to participate in their sports to the extent that they are not experiencing
discomfort.
o
Swimming, using only the arms, is a way for athletes to maintain cardiovascular fitness during
this period. Once the inflammation is reduced, the athlete's activity level can be gradually increased as
he/she moves to the next phase of recovery.
o
Runners

Inspect the athlete's running shoes for uneven or excessive wear.

Evaluate and identify anatomic factors that may contribute to ITBS. If a leg-length
discrepancy is present, consider prescription of a heel lift. Many runners have a tendency toward foot
pronation or supination. If either condition is present, orthotic devices may be helpful.

Runners should modify their training routine to avoid running on banked surfaces
and/or hills or running in the same direction on a track.
o
Cyclists

Often, cyclists who are diagnosed with ITBS have their cleats positioned in internal
rotation. This position increases tension on the ITB. To eliminate stress on the ITB, the cleats should be
adjusted to reflect the cyclist's anatomic alignment, or the cleats can be externally rotated to reduce
stretch on the ITB. If the cyclist is riding with fixed, clipless pedals, a switch to floating pedals is often
beneficial.

Evaluate the cyclists saddle or seat position. A saddle that is too high should be
adjusted so that 30-35 of flexion is present at the bottom of the pedaling stroke. Consider reducing stress
on the ITB by widening the cyclists bike stance and by improving both the hip and foot alignment. This
correction can be accomplished by placing spacers between the pedal and the crank arm.

Surgical Intervention
Surgical intervention is not indicated for ITBS except in rare cases in which prolonged conservative treatment
has failed to either alleviate the patient's symptoms or resolve the ITBS. [3, 12, 15]
Before considering surgery, the physician should investigate other possible sources of lateral knee pain. Lateral
meniscus tears and chondromalacia can also cause lateral knee pain. Diagnostic arthroscopy should
accompany any surgical procedure for ITBS.

Several procedures have been reported to be effective, most of which involve removing a portion of the ITB
where it comes into contact with the lateral femoral epicondyle. Z-lengthening of the ITB at the level of the
lateral epicondyle has also been proposed. [12]

Consultations
The following consultants may be of assistance in managing ITBS:

Primary care sports medicine specialist (pediatrician, family practitioner, or internal medicine specialist
with a certificate of added qualification [CAQ] in sports medicine)
Orthopedic surgeon
Physiatrist with fellowship training in sports medicine

Other Treatment
See the list below:

Local corticosteroid injection has been shown to be beneficial in managing acute inflammation for
those who do not respond to analgesia and rest. [1, 3, 12, 16, 17]
o
Place the patient in a lateral recumbent position with the affected knee flexed to approximately
30 .
o
Direct the injection into the deep space at the point of maximal tenderness just lateral to the
lateral femoral condyle.

Recovery Phase
Rehabilitation Program
Physical Therapy
Once the pain of ITBS has resolved and the athlete has achieved adequate ITB flexibility, the patient should
begin strengthening exercises. The strengthening program focuses on the proximal hip musculature. Examples
of exercises that are used at this stage include side-lying leg lifts, pelvic drops, and step-down exercises.

Medical Issues/Complications
If the preceding management of the injury is not successful, consider a period of total rest (4-6 weeks).

Surgical Intervention
Surgical treatment of ITBS is rarely required because most cases respond to conservative treatment (see Acute
Phase, Surgical Intervention, above).

Maintenance Phase
Rehabilitation Program
Physical Therapy
Integrate active ITB stretching and strengthening of the hip musculature into the athletes training program.

MEDICATION

Medication Summary
NSAIDs are often incorporated into the medical management of overuse injuries such as ITBS because of
these agents' analgesic and anti-inflammatory effects. All NSAIDs share a common mechanism of action,
inhibition of prostaglandins. Many types of NSAIDs are available for treatment of overuse injuries, but these
drugs vary primarily in their onset of effectiveness and duration of action.
To some degree, all NSAIDs share a common side effect of irritation of the gastrointestinal (GI) tract. Patients
who take NSAIDs may experience symptoms of flatulence, abdominal cramping, and diarrhea. The more

serious GI side effects include esophageal reflux, gastritis, acid reflux, peptic disease, and ulcer formation.
NSAIDs as a group may also produce renal side effects (interstitial nephritis, vasomotor nephropathy),
dermatologic reactions (rashes), and central nervous system (CNS) symptoms (eg, headache, dizziness, mood
change, confusion), but these are much less common than GI side effects.
The ideal NSAID for treatment of an overuse injury is one that combines several properties. The drug should
act quickly, have good penetration into synovial tissues, and produce few or no side effects. Unfortunately, no
NSAID exists that fulfills all these criteria. The following list indicates only a few of the NSAIDs that are
commonly prescribed for overuse injuries.
See also Medscape Drugs & Diseases topics Overuse Injury and Nonsteroidal Anti-inflammatory Agent Toxicity.

Nonsteroidal anti-inflammatory drugs

Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents
is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms
may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity,
neutrophil aggregation, and various cell-membrane functions.
View full drug information

Naproxen (Naprelan, Naprosyn, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of
cyclooxygenase, which results in a decrease of prostaglandin synthesis.
View full drug information

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis.
View full drug information

Diclofenac (Cataflam, Voltaren)

Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an
empirical formula of C14 H10 Cl2 NO2 NA.
One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in
pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of
prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of
treatment.
Rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.
The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac
potassium. Has relatively low risk for bleeding GI ulcers. Available in extended-relief dosage of 75 mg or 100
mg (Voltaren SR) am or hs.

FOLLOW-UP

Return to Play

An athlete can return to full activity when pain has resolved, and he/she has achieved normal flexibility of the
ITB. To prevent recurrence of the injury, the athlete should have regained full muscle strength of the proximal
hip and knee musculature.

Complications
If the injury has not been fully rehabilitated before the athlete returns to play, ITBS can become a chronic
condition.

Prevention
The athlete should integrate active stretching of the ITB and maintenance of strength of the proximal hip
musculature into his/her training program. Athletes should be aware of aspects of their training programs that
may provoke ITBS (eg, overtraining, running on banked roads) and should make appropriate alterations. By
working with their physicians, trainers, physical therapists, or coaches, athletes should identify and correct
problems with their equipment (eg, bicycle seats that are too high, worn-out athletic shoes).

Prognosis
The prognosis for ITBS is excellent if the athlete maintains ITB flexibility and corrects the intrinsic factors that
lead to this injury. The athlete must also avoid the extrinsic factors that provoke ITBS.

Education
Provide the athlete with educational materials that describe ITBS and its management. An individualized,
written training program must be developed for each athlete through collaboration with the athlete and a
physician, physical therapist, or athletic trainer.

References
1.

Ellis R, Hing W, Reid D. Iliotibial band friction syndrome--a systematic review. Man Ther. 2007 Aug.
12(3):200-8. [Medline].

2.

Fairclough J, Hayashi K, Toumi H, 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 Mar.
208(3):309-16. [Medline].

3.

Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med.
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Drez's Orthopaedic Sports Medicine. 2nd ed. Philadelphia, Pa: Saunders; 2003. 1871-2.

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Physical Medicine and Rehabilitation. Philadelphia, Pa: Hanley & Belfus; 2002. 328-33.

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Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in cyclists. Am J Sports Med. 1993 MayJun. 21(3):419-24. [Medline].

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syndrome in runners: a systematic review. Sports Med. 2012 Nov 1. 42(11):969-92. [Medline].

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Richards DP, Alan Barber F, Troop RL. Iliotibial band Z-lengthening. Arthroscopy. 2003 Mar. 19(3):3269.[Medline].

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Foch E, Milner CE. Frontal Plane Running Biomechanics in Female Runners with Previous Iliotibial
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Diagnosing and Treating Iliotibial Band Syndrome: A Video

Demonstration
Michael J. Conlon
Disclosures|May 24, 2010
Medscape Orthopedics 2010 WebMD, LLC

Cite this article: Michael J. Conlon. Diagnosing and Treating Iliotibial Band Syndrome: A
Video Demonstration. Medscape. May 24, 2010.

Michael Conlon: My name is Michael Conlon. I'm a physical therapist for Finish
Line Physical Therapy. Today we're going to talk about iliotibial (IT) band syndrome.
Patients will often complain of lateral knee pain. It's important to differentiate
between IT band syndrome and patellofemoral syndrome, which is a tracking
problem of the kneecap.
One of the key tests that we're going to do is the Noble compression test. The pain
is typically isolated over the lateral epicondyle of the femur. You will place your hand
just above, on the IT band, above the condyle, and move the knee from 90 flexion
into a fully extended position. This will often replicate the complaint that the patient
has of lateral knee pain.
Patients with patellofemoral syndrome will often complain of global pain around the
kneecap. They'll complain of pain walking down the stairs, running downhill if they're
a runner, and with prolonged sitting. IT band syndrome is typically felt with prolonged
walking or running.
During the interview phase, patients will often state that they don't want to flex their
knee, causing increased pain on the lateral side of the knee, and that they'll want to
walk or run with the knees in full extension.
In addition to the Noble compression test, it's also important to test the flexibility of
the IT band as well as the hip flexor. I'll have the patient come down to the end, roll
onto the back, bring that knee all the way up so that you have [it] maximally flexed
and [you're looking at the] opposite hip. You'll be looking at 2 things: the flexibility of
the hip flexor, as well as the flexibility of the IT band. A positive test for the hip flexor
would demonstrate increased flexion in the hip where the knee is above the
horizontal. A positive test for the IT band would be that the knee is pulled up and out
to the side, indicating that the IT band is inflexible.
Finally, to confirm the diagnosis, it's always important to palpate along the distal
aspect of the IT band.

Next I'd like to show you a couple of exercises that you could have your patient do at
home.
The first exercise we're going to use for the IT band is the roller. We're going to start
in the outside part of the IT band, distal towards the knee. Gently and gradually,
rolling 2 inches up toward the hip, 1 inch back, continue to roll until you reach the hip
area. This should be done for about 1 or 2 minutes, repeating on both the outside
part of the quadriceps as well as the central portion.
The next exercise we're going to use for the IT band is an IT band stretch. Start by
having the patient maximally flex their hip, and then slowly abduct the thigh across
the midline. We are going to hold the stretch for about 20-30 seconds, and we're
going to repeat 1-2 times. You can gradually increase the stretch as tolerated.