Muscle performance factors and altered loading mechanics have been linked to a variety of
lower extremity musculoskeletal disorders. In this article, biomechanical risk factors asso-
ciated with iliotibial band syndrome (ITBS) are described, and a strategy for incorporating
these factors into the clinical evaluation of and treatment for that disorder is presented.
Abnormal movement patterns in runners and cyclists with ITBS are discussed, and the
pathophysiological characteristics of this syndrome are considered in light of prior and
current studies in anatomy. Differential diagnoses and the use of imaging, medications, and
injections in the treatment of ITBS are reviewed. The roles of hip muscle strength,
kinematics, and kinetics are detailed, and the assessment and treatment of muscle perfor-
mance factors are discussed, with emphasis on identifying and treating movement dysfunc-
tion. Various stages of rehabilitation, including strengthening progressions to reduce
soft-tissue injury, are described in detail. ITBS is an extremely common orthopedic condi-
tion that presents with consistent dysfunctional patterns in muscle performance and
movement deviation. Through careful assessment of lower quarter function, the clinician
can properly identify individuals and initiate treatment.
PM R 2011;3:550-561
INTRODUCTION
Iliotibial band syndrome (ITBS) is the leading cause of lateral knee pain in runners and
accounts for 15% of overuse injuries in cyclists [1-5]. While balancing the need to promote
fitness and the associated risks of repetitive-motion injuries such as ITBS, physicians and
other rehabilitation professionals have searched for methods of identifying contributing
factors for overuse injuries as well as treatments that restore function and enable patients to
maintain their exercise activities.
The first detailed case on ITBS was published by Renne [6] in 1975. The subjects studied
were military recruits whose running and training activities had increased rapidly. Hall-
marks of ITBS were pain on weight bearing at 30° of knee flexion and the exacerbation of
pain after having run more than 2 miles or having hiked more than 10 miles.
Lateral knee pain at the femoral epicondyle is a key finding in patients with ITBS [6-8]. R.L.B. Emeryville Sports Physical Therapy,
Noble [9] analyzed 100 patients with ITBS and developed the Noble compression test, in 2322 Powell Street, Emeryville, CA 94608.
Address correspondence to R.L.B; e-mail:
which compression over the lateral epicondyle of the femur at 30° of knee flexion elicits pain rb415@comcast.net
reproduction. This test is now commonly used to diagnose ITBS. Orchard et al [10] Disclosure: nothing to disclose
described ITBS in runners as an impingement zone related to the time period just after heel R.B.S. Department of Physical Therapy and
strike as the knee approaches 30° of flexion. The investigators described this as the Rehabilitation Science, Department of Radiol-
deceleration phase, which suggests that impingement occurs during eccentric loading of the ogy and Biomedical Imaging, University of
California, San Francisco, CA
iliotibial band during the weight-acceptance phase of running. Disclosure: nothing to disclose
Figure 2. (A) Normal alignment. (B) Trendelenburg sign. (C) Compensated Trendelenburg sign. Reprinted with permission of the
Sports and Orthopedic Sections of the American Physical Therapy Association and Chris Powers, PhD, PT. Powers C. The influence
of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42-49 [27].
inspection, the investigators noted that the subjects with anterior superior iliac spine to medial malleolus, reported
ITBS landed in greater hip adduction and knee internal in 10%. McNicol et al [26] also reported on 52 cases of ITBS
rotation. Noehren et al [22] and Ferber et al [21] support the in runners, including 34 men and 18 women with ITBS. The
theory of frontal and transverse plane factors in female run- investigators reported that 55% had mild-to-severe knee
ners, specifically, excessive hip adduction and knee internal varus, and 8% had mild knee valgus. These studies suggest
rotation. Further study is needed to explain why these run- that clinical management of ITBS may involve training meth-
ners exhibited greater hip adduction, knee internal rotation, ods to control frontal plane dynamics at the knee, in addition
and femoral external rotation. In addition, male runners need to assessing and treating transverse plane issues.
further assessment in similar research models. Weight-bear- One way to theoretically visualize the relationship be-
ing magnetic resonance imaging and dual fluoroscopic imag- tween the hip and knee frontal plane relationships involves
ing may be useful to further assess femoral rotation in male the use of ground reaction force diagrams. During normal
and female runners with and without ITBS, specifically single-limb stance as described by Powers [27], the ground
aimed at evaluating the role of transverse plane contributing reaction force vector may pass medial to the knee joint and
factors of the hip [23-25]. produce a varus torque at the knee (Figure 2A). However,
Hamill et al [12] modeled iliotibial band strain rate with with excessive hip adduction during a single-limb stance and
software for interactive musculoskeletal modeling (SIMM Trendelenburg sign, the ground reaction force vector may
4.0; Motion Analysis Corporation, Santa Rosa, CA). This pass more medial, with a larger perpendicular distance to the
prospective study of female runners compared iliotibial band knee joint (Figure 2B). The result is an increased varus torque
strain (calculated as the change in length during running at the knee, along with an elongated lateral hip musculature,
divided by the resting length), strain rate (calculated as the both of which place increased stress on the iliotibial band
change in strain divided by the change in time), and duration [27,28]. The third possible disturbance at the knee is a valgus
of impingement in 17 patients with ITBS and 17 age-matched stress and ground reaction force vector lateral to the knee,
controls. The entire stance was measured, with a focus on combined with an increased hip adduction, a compensated
touch-down and peak knee flexion. Although strain was Trendelenburg sign (Figure 2C).
increased versus that in the control, only strain rate was Abnormal mechanics at the foot and the tibia may play a
statistically significant between the groups. The investigators role in the development of ITBS given the anatomic connec-
suggested that strain rate is a factor in the development of tion of the iliotibial band to the tibia and the interrelationship
ITBS. of the foot and the tibia. Noehren et al [22] analyzed biome-
Taunton et al [5] used a retrospective design to analyze chanical factors in the hip, knee, and rear foot in female
data on 2002 running injuries, including 63 men and 105 runners who go on to develop ITBS, and, although hip
women with ITBS. Varus knee alignment was reported in adduction and knee internal rotation were the primary find-
33%, and valgus alignment was reported in 15%. Leg-length ings in this cohort, these investigators were able to identify a
discrepancy, defined as a greater than 0.5-cm difference in subset of 4 participants who exhibited excessive calcaneal
PM&R Vol. 3, Iss. 6, 2011 553
noninjured cyclists were analyzed with motion analysis and Taunton et al [5] reported on 168 cases of ITBS with a
synchronized foot-pedal forces. Findings included the fol- distribution 38% men, 62% women, average weekly hours of
lowing: (1) lower pedal reaction force at 17%-19% versus running 4.9, training years 7.3, body mass index of 23.7 for
ground reaction force in runners, and (2) shorter impinge- men and 21.2 for women, and age 31.1 years. Only age
ment zone contact time, calculated at 38 ms in cyclists versus younger than 34 years in men was a significant factor among
75 ms in runners. However, the investigators discussed the these variables. ITBS was associated with pain after a run that
issue of repetitive stress in a typical workout, commenting restricted the ability to run. McNicol et al [26] reported 52
that cycling results in more repetitions (ie, 6600 repetitions cases of ITBs; 42% were found to be related to training errors,
during a 1.25-hour ride versus 4800 repetitions during a such as rapid commencement (2 cases), sudden hill exposure
10-km run). Interestingly, Farrell et al [2] described a theo- (1 case), single severe session (12 cases), rapid increase
retical mechanism of stress to the iliotibial band in cyclists in volume of training (7 cases), and footwear and surface issues
which the shorter leg, when fixed to the pedal, is over- (4 cases). Similarly, Messier et al [29] studied 48 cases of
stretched laterally and functions in less knee flexion, thereby ITBS; compared with 70 controls and reported ITBS cases,
increasing the time spend in the impingement zone. Whether the patients had increased training mileage and less experi-
running or cycling, the factors of impingement time and ence. In summary, the subjective examination in cases of
intensity of loading are important. ITBS has the defining characteristics of lateral knee pain with
Training factors, including rapid increases in mileage and repetitive knee activity usually in a weight-bearing position
hill training, can lead to iliotibial band injury [2,29]. Orchard and associated overtraining issues.
et al [10] suggested that increased impingement zone impact Objectively, the Noble compression test may be used to
time during both downhill and slow running leads to ITBS provocate symptoms by compressing the iliotibial band at the
and sprinting may result in relatively less impact time be- lateral epicondyle with 30° knee flexion [9]. The patient is
cause of greater knee flexion beyond the impingement zone. positioned with the knee at 90° flexion, and compression is
This particular theory was not supported by Miller et al [30], applied just proximal to the lateral epicondyle as the knee
who found, during an exhaustive run, increased knee flexion is extended toward full extension. The 30° flexion is the
at heel strike in runners with a history of ITBS. Our review impingement zone specific to the iliotibial band and lateral
did not find experimental studies that evaluated the effect of femoral epicondyle as described in cadaver studies by both
sprinting on iliotibial band strain or impingement, although Orchard et al [10] and Fairclough et al [14]. Differentiating
the topic seems relevant for future research. Messier et al [29] related structures uses this impingement zone concept as
reported that less experienced runners with rapid changes in well as lack of other objective test findings for injury to the
mileage were at risk for ITBS, but hypothesized that intrinsic lateral meniscus, lateral retinaculum, popliteus and biceps
factors, including strength deficits, were necessary for extrin- femoris tendons, patellofemoral joint, and lateral collateral
sic factors to cause symptoms. The investigators also reported ligament. Although not frequently used for diagnosis, Ekman
increased cross-training habits (ie, swimming and cycling) in et al [40] used magnetic resonance imaging to evaluate 7
runners with ITBS versus the control group. patients with ITBS and 10 age- and gender-matched controls.
The investigators reported thickening of the iliotibial band
CLINICAL EXAMINATION over the lateral femoral condyle (5.49 mm ITBS and 2.52 mm
control; P ⬍ .05) and fluid deep to the iliotibial band at the
Sutker et al [39] evaluated 1030 runners with lower extrem- lateral epicondyle in 5 of 7 cases.
ity complaints and diagnosed 48 cases of ITBS. Subjectively,
the patients described lateral knee pain associated with re-
petitive loading in a weight-bearing position (ie, running and
Clinical Assessment of Flexibility
stairs). Functionally, the runners were able to perform activ-
ities such as a hop and squat without pain. This contrasts Flexibility of the lateral hip musculature has routinely been
with the cases presented by Renne [6], in which military tested as a factor in ITBS [33]. The rationale in testing and
recruits in daily training exhibited a limp and straight leg gait treating is related to muscle performance factors (Figure 3)
pattern. Renne [6] also noted that the symptoms were aggra- and biomechanical factors, given the issue of iliotibial band
vated by running more than 2 miles and hiking more than10 compression at the lateral epicondyle of the femur. Messier et
miles. Sutker et al [39] confirmed the diagnosis of ITBS by the al [29] analyzed stretching habits in 56 runners with ITBS
history and tenderness localized at the lateral epicondyle of and 70 controls and found that both groups stretched, but
the femur or less commonly at the Gerdy tubercle. Concur- differences were not established. Fredericson et al [41] ana-
rently, the patients did not have symptoms at the lateral joint lyzed the effectiveness of 3 iliotibial band stretches, in 5 male
line or popliteal tendon, and did not have signs of intra- elite distance runners, and found significant changes in the
articular disorders. iliotibial band length in all 3 types of stretching. The investi-
The subjective examination includes the clinical applica- gators proposed benefits to stretching such as reducing ili-
tion of previous information on factors associated with ITBS. otibial band tension by hip abductor muscle inhibition and
PM&R Vol. 3, Iss. 6, 2011 555
Figure 9. Resisted hip abduction and bridge is a beginning- Figure 11. Resisted hip extension, external rotation, and ab-
level exercise that facilitates gluteal recruitment. duction comprise a beginning-level exercise that facilitates
gluteus maximus and gluteus medius recruitment.
Figure 10. Resisted hip extension and knee flexion in quadru- Figure 12. Contralateral pelvic drop (starting position) is an
ped is a beginning-level exercise that facilitates gluteus max- intermediate-level exercise used successfully to strengthen hip
imus recruitment. abductors in runners with ITBS [3].
PM&R Vol. 3, Iss. 6, 2011 559
Figure 13. Resisted squat is an intermediate exercise that uses Figure 15. Resisted squat with a single-leg emphasis is a more
hip abduction and vertical tibial alignment to facilitate gluteus vigorous exercise to facilitate single-leg control with the gluteal
maximus control. muscles, facilitated by hip abduction and external rotation.
the study by Distefano et al [55] used several other useful stretch, side-lying hip abduction and pelvic drops, and a
modifications in functional exercises that seemed to facilitate progression of technique-driven closed chain exercises, as
gluteal recruitment: (1) more vertical tibia, (2) forward trunk illustrated in Figures 7-17 (ie, vertical tibia and trunk flexion
lean, (3) resistance band with side walks, (4) multiplanar from the hips). The bilateral closed chain exercises are rela-
activity, and (5) good control of trunk position. The clam tively low vigor and were used early in the recovery to
shell exercise without the resistance band, and the lunge promote technique in squats, whereas the single-leg activities
patterns without use of added weight, demonstrated gluteal are of higher vigor and intended for strengthening the gluteal
muscle EMG less than 60%, therefore, we recommend use of muscles.
resistance with these exercises.
Based on these EMG studies [55,57], research on exercise RESUMING PARTICIPATION IN SPORTS
and ITBS [3,52], and recent case studies focused on strength-
ening the gluteal muscles [53,54], our recommended pro- Participation in sports is dependent upon being able to
gressions of therapeutic exercise include one iliotibial band perform exercises in proper form without pain [11,33].
Other outcome measures include strength testing the gluteus
CONCLUSION
Several intrinsic and extrinsic contributing factors for ITBS
have been described. Reduced hip muscle performance and
Figure 17. Single-leg dead lift is a more vigorous single-leg abnormal hip and knee mechanics during functional tasks
exercise to emphasize gluteus maximus, gluteus medius, and may be primary contributors to ITBS. Addressing these un-
hip control. derlying factors is critical to the efficient management of
patients with this condition. Although controversy exists
medius and gluteus maximus with a normal result [36,38]. regarding the mechanism of ITBS, controlling inflammation
The flexibility of the iliotibial band and rectus femoris can be and symptoms during early phases and progressive strength-
assessed with a modified Thomas test as previously described ening in later phases is recommended. ITBS remains a com-
[43,44]. The Ober test can be used to assess hip adduction mon and challenging dysfunction in many athletes; but,
range of motion as previously described [42]. Our recom- through early diagnosis and proper biomechanical move-
mendation on flexibility testing and return to sports is pain- ment analysis, appropriate interventions can be implemented
free range of motion in hip adduction. There should be a to decrease pain and to improve function.
negative Noble compression test, with the absence of tender-
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