I have seen several cases of IT band syndrome this week in the office and as the weather gets a little bit better, people are starting to get out and run more. The iliotibial band syndromes are a very common cause of pain on the outside of the knee and most commonly seen in active athletic population. This can occur in up to 12% of runners and among cyclist can account for 15-24% of all overuse injuries. It can be seen in any sports, but these are the most common.
There is the thick band which goes from the pelvis all the way down to the tibia or shin bone on the outside called the iliotibial band. This rubs over the prominence of the lower femur on the outside of the knee causing friction. The iliotibial band is a large piece of fascia and it basically has very little give to it, unlike a muscle. As it rubs across the prominence on the outside of the knee it causes friction, inflammation, and then pain which is very localized. Newer theories as to the cause of the pain is that there is a layer of fat underneath of the band where it crosses over the edge of the femur and it is this structure that causes the pain rather than the band itself. A third theory is that it is a small bursa or sac behind the band that can cause pain.
Most commonly the cause of iliotibial band are training errors including rapid increase in training routine, running on hills, increased milage, running on uneven or down slopping surfaces, and downhill running. In addition, if you have a slightly “bowed leg”, increased foot pronation, weakness in your hips or some rotation of your tibia these can predispose or cause you up to develop IT band syndrome.
Other conditions that can look like iliotibial band syndromes include lateral meniscus or cartilage tear, arthritis of the outer compartment of the knee, stress fractures, or patellar pain syndromes. Most cases can be diagnosed with a simple physical examination and some tests to check for tightness in the IT band. MRI can be used as a diagnostic tool if basic treatment fails. It is usually not needed, unless surgery is considered.
Nonsurgical treatment generally includes anti-inflammatory medications for reducing the pain and acute inflammation, but overall that has not been that helpful. Cortisone injections are done infrequently, and primarily done to confirm the diagnosis. Physical therapy however is a very important part of the nonsurgical management and includes stretching of the IT band, strengthening and stretching of the hip musculature, use of a foam roller to massage and break up any adhesions present there, in addition to ice. Obviously getting to the cause of the IT band syndrome is most important with occasional reevaluating foot, shoe wear, and running techniques. Most people get better in 6-8 weeks with nonsurgical treatment and only a small percentage come to surgery.
Surgery: The fact that there are many different types of surgery to treat IT band syndrome that has failed conservative treatment, really indicates that one is not superior to the other, and the jury is still out as to which one is the best technique. Personally, I am very slow to recommend surgery in these conditions unless nonsurgical treatment has been exhausted. Most of these require an open incision either lengthening of the IT band, removal of tissue or bursa underneath the IT band or removal of the fat that may be cause of the pain. A recent arthroscopic technique has been described which holds some promise, and has had very encouraging results.
As always, prevention is the best cure, so make sure you check your shoes, increase your mileage slowly and keep those hips and hamstrings flexible! And enjoy the weather!
– Lesley J Anderson, MD