Pain along the outside (lateral) knee is sure to get anyone's attention but especially the active athlete preparing for competition. There are a half dozen problems that can cause this type of symptom but the most common is a condition known as the iliotibial band syndrome (ITBS).
In this review article, orthopedic surgeons and a physiotherapist team up to provide us with an updated understanding of the iliotibial band syndrome (ITBS). They review the involved anatomy, offer ideas as to the possible cause(s) of ITBS, and discuss treatment approaches. The surgeons present specifics of surgical care while the physiotherapist highlights the nonsurgical management.
What exactly is iliotibial band syndrome (ITBS)? Iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. Athletes who participate in skiing, rowing, triathlons, and field hockey have also reported ITBS as a problem limiting their sports activities. As mentioned, it causes pain on the outside of the knee just above the joint.
The ITB is actually a long tendon. (Tendons connect muscles to bone.) It attaches to a short muscle at the top of the pelvis called the tensor fascia lata. The ITB runs down the side of the thigh and connects to the outside edge of the tibia (shinbone) just below the middle of the knee joint. You can feel the tendon on the outside of your thigh when you tighten your leg muscles. The ITB crosses over the side of the knee joint, giving added stability to the knee.
The lower end of the ITB passes over the outer edge of the lateral femoral condyle, the area where the lower part of the femur (thighbone) bulges out above the knee joint. When the knee is bent and straightened, the tendon glides across the edge of the femoral condyle.
The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn't a problem. But the bursa (fluid-filled protective pad) between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions while walking, running, or biking.
In long distance runners, impingement of the iliotibial band against the lateral femoral condyle causes enough friction to create this condition. As the knee bends 30 degrees and straightens fully (to zero degrees), the iliotibial band slides through an area called the impingement zone.
People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes impingement leading to this syndrome.
Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. Pronation of the foot occurs when the arch flattens.
An accurate diagnosis and examination is important so that the proper treatment can be applied. For example, impingement versus bursitis versus flat feet would be treated differently from a tendon that is simply too short and too tight. In almost all cases, conservative care is tried first before considering surgery.
The physiotherapist evaluates each patient and performs clinical tests that assess iliotibial band tightness and function. A program of activity modification, stretching, manual therapy (e.g., soft-tissue mobilization to break up adhesions), and equipment change are key features of the physiotherapy program.
The therapist will also evaluate the athlete's equipment (shoes, cleat type and position, bicycle seat and handlebars) and make recommendations for changes. Running form and training programs are reviewed and instruction given to reduce iliotibial band impingement.
But when nonoperative care fails to change the symptoms, it's time to consider something else. No amount of activity modification, stretching, or change in shoe wear helps the patient with a chronically shortened, tight iliotibial band. Surgery to release the tissue is the treatment of choice. The surgeon may inject the area with cortisone to see if surgery will help. Studies show that patients who respond well to the injection tend to have good surgical outcomes.
Surgery may be done percutaneously (through the skin without a large incision) but open incision may be required. Using diagrams (drawings), the surgeons show and describe the type of surgical Z-lengthening procedure used to lengthen the iliotibial band.
They report being able to increase the stretch of the band by 1.5 centimeters (that's a little more than half an inch). That may not seem like much but combined with a bursectomy (removal of the inflamed or irritated bursa), it is enough to give relief from the painful symptoms. In many cases, the athletes are able to return to full participation in their chosen sport within eight weeks' time after the procedure.
In summary, iliotibial band syndrome is a fairly common problem among many athletes, especially runners. Working with a physiotherapist to change posture, form, flexibility, and movement patterns is the first place to start. Only in persistent, chronic cases of inflammation is surgery considered as the preferred treatment method. The goal of all treatment is to return the athlete to pain free full participation in sports and activities.
Reference: Eric J. Strauss, MD, et al. Iliotibial Band Syndrome: Evaluation and Management. In Journal of the American Academy of Orthopaedic Surgeons. December 2011. Vol. 19. No. 12. Pp. 728-736.
Parkway Physiotherapy provides services for physiotherapy in Victoria, Westshore, Langford, Sooke.