W125: Advanced Therapeutic Exercises and
Ultrasound-Guided Procedures for Iliotibial
Band Syndrome
John Vasudevan, MD1*
Michael Fredericson, MD2
Robert Baker, PT, OCS3
Yin-Ting Chen, MD4
Eugene Roh, MD2
Michael Khadavi, MD2
Jacob Sellon, MD5
1.
Department of Physical Medicine & Rehabilitation, University of Pennsylvania, Philadelphia, PA.
2.
Division of PM&R, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
3.
Emeryville Sports Physical Therapy, Emeryville, CA.
4.
Department of Orthopaedics & Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD.
5.
Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN.
*Course Director
Iliotibial Band Syndrome:
Not just what…but why
John Vasudevan, MD
PM&R Sports Medicine
Assistant Professor, University of Pennsylvania
November 2014
Objectives
1. Define the anatomy and pathophysiology of
iliotibial band syndrome (ITBS)
2. Learn the pearls of exam and treatment, and
their supporting evidence
3. Understand common contributing factors
ITBS: The What
• 2nd most common cause of knee pain in runners
• Lateral knee pain, insidious, progressive
– Worse with hills, slower running speed
– Initially predictable at certain point of run, but then progresses
• Cause: friction of ITB against lateral femoral condyle
– Or (less likely) distal insertional pain at Gerdy’s tubercle
– “Impingement zone” at ~20-30° knee flexion
– Inflammation of IT bursa…if it exists
ITB Anatomy
• Definition: lateral thickening of the fascia lata in
the thigh, dense fibrous tissue
– Has superficial and deep layers, enclosing tensor
fascia latae prior to anchoring at iliac crest
– Receives majority of gluteus maximus tendon
– Superficial and deep layers, enclosing tensor fasciae
TFL/ITB Anatomy
• Origin: Iliac crest just posterior to the anterior iliac
spine
• Insertion: lateral femoral condyle, lateral retinaculum
of knee, lateral patella, and Gerdy’s tubercle on lateral
tibial plateau
• Innervation: superior gluteal, L4, L5, S1
• Action: hip flexion, abduction, internal rotation
IT Bursa?
• Anatomic Findings:
– ITB is firmly anchored to lateral femoral condyle
– More medial-lateral translation rather than anterior-
posterior
– No bursa identified, but fibers integrated in fat pad
between ITB and lateral femoral condyle
• Conclusion: Pain may be from compression of fat, not
sliding over bursa
Fairclough 2006; Falvey 2010
IT Band & “Bursa”
Fredericson 2011; Fairclough 2006
IT “Bursa” arising from lateral
recess of knee joint
Jelsing 2013
ITBS: The Why
• Anatomic
– Static: leg length discrepancy, genu varum, pes planus
– Dynamic: Tight TFL/ITB, weak hip abductors, tight heel
cords, excess femoral/tibial internal rotation
• Training Considerations
– Cambered surfaces
– Downhill running
Strauss 2013; *Fredericson 2005
ITBS: The What Else
• Lateral meniscal tear
• Lateral compartment degenerative joint disease
• Biceps femoris tendinopathy
• Stress fracture
• Patellofemoral syndrome
• Lateral collateral ligament sprain/tear
ITBS: Keys to Exam
• Palpate over LFC and Gerdy’s tubercle
• Ober Test
• Noble Compression Test
• Assess other contributing factors:
– Hip abductor weakness (single-leg squat)
– Heel cord tightness
ITBS: Treatment
• NSAIDs beneficial with PT*
• Steroid injection^ (US-guidance?)
• Physical Therapy
– Transverse friction massage (no clear evidence)**; lateral retinacular
release, medial patellar mobilization
– Gluteal strengthening
– The super-fun FOAM ROLLER!
• Surgical options (release, lengthening, resection of “bursa”)
* Schwellnus 1991; **Schwellnus 1992; ^Gunter 2004; Ellis 2007; Strauss 2013
Gaps in the Evidence
• No clear evidence to support:
– Stretching the ITB (role of TFL in ITB “lengthening”)
– Strengthening the Gluteus Medius
– Trigger Point Therapy
• BUT we suggest that strengthening will fail if myofascial restrictions persist
• Limited Evidence to support:
– NSAIDs and corticosteroid for short-term relief
• No study comparing US-guided to landmark-guided
– Surgical treatment options (debridement, resection)
ITBS: Treatment
Strauss 2013
Conclusions
1. While evidence-base is limited or conflicting,
outcomes with conservative treatment are
very encouraging
2. Consider distal AND proximal factors
3. Don’t just ask what, but why and what else
to optimize results and prevent recurrence
References
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Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for
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Thank you!