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ITB Friction Syndrome

ITB Friction Syndrome or Iliotibial Band Friction Syndrome is a repetitive stress injury that results from friction of the ITB as it slides over the prominent lateral femoral condyle at approximately 30 degrees of knee flexion.

ITB Friction Syndrome is the most common overuse syndrome of the knee (2-15% of all overuse injuries of the knee joint). It’s most common in long-distance runners (20–40 miles/week).

Risk Factors

Risk factors for ITB Friction Syndrome include:

  • Long-distance runners who train on hilly terrain, graded slopes, or road cambers. especially if their runs include downhill running, which positions the knee in significantly less flexion than normal at initial contact.
  • Running on canted surfaces can result in a leg-length inequality and a change in the Q-angle, which can increase the stress on the ITB.
  • Activity that requires repetitive knee flexion and extension, such as downhill skiing, circuit training, weight lifting, and jumping sports, is prone to developing this pathology.
  • ITBFS is also common in cyclists: This is thought to be due to the pedaling stroke, which causes the ITB to be pulled anteriorly on the downstroke and posteriorly on the upstroke.

Extrinsic factors include excessive bike seat height or cleat position on the pedal. If the cleats are excessively internally rotated on the pedal, the tibia also internally rotates, resulting in a valgus force on the knee and increased tension of the ITB.

See Also: Knee Ligaments Anatomy

ITB Syndrome Pathophysiology

The friction has been found to occur at the posterior edge of the band, which is felt to be tighter against the lateral femoral condyle than the anterior fibers. The friction causes a gradual development of a reddish-brown bursal thickening at the lateral femoral condyle.

Some fibers of the ITB remained in contact with the lateral femoral condyle during extension. With further flexion, the ITB moves posteriorly and contacts the lateral femoral epicondyle and LCL, indicating a phase during knee flexion during which an impingement of the band occurs.

In runners, this impingement phase occurs predominantly during the early stance phase, very soon after initial contact.

In general, the faster the speed of running, the less the time spent in the impingement zone, because the knee flexion angle at initial contact increases with speed of running.

Impingement occurs at a 30 degress of knee flexion.

Iliotibial Band Friction Syndrome
Iliotibial Band Friction Syndrome

Iliotibial Band Anatomy

The Iliotibial Band or Maissiat’s band is a longitudinal fibrous sheath that runs along the lateral thigh, it’s a continuation of tensor fascia lata muscle, it inserts the Gerdy tubercle on the proximal tibia.

It’s nnervation comes from superior gluteal nerve (L1-3).

Proximally, the ITB function as:

  1. Hip extension
  2. Hip abduction
  3. Lateral hip rotation

Distally, ITB function depends on the position of the knee joint:

  • 0 degrees/full extension to 20 to 30 degrees of flexion: it’s an active knee extensor, where the ITB lies anterior to the lateral femoral epicondyle.
  • 20 to 30 degrees of flexion to full flexion ROM: it’s an active knee flexor, where the ITB lies posterior relative to the lateral femoral epicondyle.
Iliotibial Band anatomy
Iliotibial Band Anatomy

Clinical Evaluation

ITB Friction Syndrome symptoms include:

  • The patient reports pain with the repetitive motions of the knee. There is rarely a history of trauma.
  • Although walking on level surfaces does not generally reproduce symptoms, especially if a stiff-legged gait is used, climbing or descending stairs often aggravates the pain.
  • Patients do not usually complain of pain during sprinting, squatting, or during such stop-and-go activities as tennis, racquetball, or squash.
  • The progression of symptoms is often associated with changes in training surfaces, increased mileage, or training on crowned roads.
  • The lateral knee pain is described as diffuse and hard to localize.

Physical examination includes:

There is localized tenderness to palpation at the lateral femoral condyle or Gerdy’s tubercle on the anterolateral
portion of the proximal tibia.

The resisted tests are likely to be negative for pain.

The special tests for the ITB include:

  1. Ober’s test,
  2. Noble compression test,
  3. Creak test.

These tests should be positive for pain, or crepitus, or both, especially at 30 degrees of weightbearing knee flexion.

In addition to an adaptively shortened ITB, the following findings have all been associated with ITB friction problems, although they have yet to be substantiated:

  1. cavus foot (calcaneal varus) structure,
  2. leg-length difference (with the syndrome developing on the shorter side),
  3. fatigue,
  4. internal tibial torsion (increased lateral retinaculum tension),
  5. anatomically prominent lateral femoral epicondyle,
  6. genu varum.

Long-distance runners with Iliotibial Band Friction Syndrome have weaker hip abduction strength in the involved leg compared with the uninvolved leg and symptoms improved with a successful return of hip abductor strength.

To control coronal plane movement during stance phase, the gluteus medius and TFL must exert a continuous hip abductor movement. Fatigued runners or those with weak gluteus medius muscles are prone to increased thigh adduction and internal rotation at midstance. This, in turn, leads to an increased valgus vector at the knee and increased tension on the ITB, making it more prone to impingement.

ITB Friction Syndrome Treatment

IT band Syndrome treatment consists of the following:

  1. Activity modification to reduce the irritating stress (decreasing mileage, changing the bike seat position, and changing the training surfaces),
  2. Using new running shoes,
  3. Heat or ice applications,
  4. Strengthening of the hip abductors, and stretching of the ITB.

ITB Friction Syndrome Surgery consists of:

  1. Excision of a cyst, burse or lateral synovial recess.
  2. Resection of the posterior half of the ITB at the level that passes over the lateral femoral condyle.
  3. Z plasty of iliotibial band only indicated in refractory cases.


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