Iliotibial Band Syndrome (ITBD) is a common condition causing pain on the outside of the knee. This condition is the leading cause of lateral knee pain in runners, cyclists and any other activities which require repetitive knee flexion and extension – such as soccer, hockey, and skiing.
The ITB is a thick band of fascia which forms from superior musculature such as glute max/med and tensor fascia latae (TFL). This band runs superficially along the outside of the leg and inserts onto the outside of the knee on a bony landmark named Gerdy’s tubercle.
- Sharp pain at the outside of the knee
- May also report referral along outside of thigh and calf
- Generally, will report increased symptoms with running or going down stairs
- Sometimes swelling or a snapping sensation at the outside of the knee
The mechanism of this injury is normally non-traumatic and relates to overuse. There are a few theories on the pathophysiological changes to cause this pain. The primary thought is to be compression of a sensitive fat pad under the ITB at the outside of the knee. Other causes hypothesised are repetitive friction of the ITB on a bony aspect of the knee, as well as chronic inflammation of the bursa. Although exact cause is debated, we do know ITBS is a multi-factorial overuse condition which can be impacted by a range of risk factors. This can include to sudden changes to training and activity levels increasing load through the ITB. Running down hills or on a slope can make symptoms worse, as can anatomical factors such as rotation of the leg and weakness at the hip muscles.
Non-operative management, such as physiotherapy, is the first line of treatment for ITBS and is quite effective in ensuring a return to usual activities. In some cases, surgical opinion may be warranted, however this is generally after a thorough trial of conservative management.
Load management is one of the primary aspects of recovery and is integral to settling down symptoms. Tissue has less capacity to tolerate load when injured therefore reducing aggravating activity is essential. Depending on the severity and irritability of symptoms, your physiotherapist will discuss possible changes to training and activity. This may involve a period of rest of the aggravating movement (e.g. running) or modifying the parameters in which the activity is taking place. For example, rather than completing a 5km run up and down hills, a shorter period of activity on flat surface may be more comfortable and not provoke symptoms. Cross training can also be beneficial in maintaining general fitness, this could include walking, cycling, swimming or resistance training.
Exercise therapy is another important aspect to the management of ITBS. Addressing potential underlying hip abductor strength deficits and loading the ITB can be achieved through a progressive strengthening program. A tailored strengthening program will be introduced early within the rehabilitation and will generally start with gluteal and lower limb exercises which are not provocative. Exercises will then be progressed as able to ensure appropriate loading of the ITB and lower limb chain. Plyometric exercises are also very important a return to running plan to ensure energy storage and release capacity of lower limb tissues are addressed.
Modifications for Running
As mentioned, modifying the environment, and incorporating a gradual return to running is integral within the rehabilitation of ITBS. This will generally involve finding a distance, frequency and intensity of activity which does not bring on symptoms. Downhill and trail/uneven surfaces will most likely be the most difficult to return to. Cadence is another aspect of running which your physiotherapist may discuss modifying to reduce ITB strain. Cadence is the number of steps taken per minute and is tracked by most running watches.