Iliotibial band friction syndrome

Weak hip abductors?

It would be logical to correlate the presence of weak hip abductors with iliotibial band friction syndrome, since weak abductors might lead to increased hip adduction during the stance phase of gait with a consequent increase strain of the iliotibial band and a greater tendency for it to compress the tissues underneath.

MacMahon and colleagues, Noehren et al., and Fredericson et al. all reported that ITBFS sufferers had abductor weakness or increased hip adduction during the stance phase of gait, a finding which could be interpreted as being due to abductor weakness [4, 16, 17].

On the other hand, Grau et al., using a dynamometer that was mechanically stabilized instead of hand-held, did not find hip abductor weakness in their study of 10 runners with ITBFS as compared to healthy matched controls [18].

Thus, we may have more to learn about the relationship of iliotibial band friction syndrome to hip abductor weakness or to the related issues of the timing and magnitude of hip abductor activation during the gait cycle and the amount of hip adduction that occurs during the stance phase of gait.

Tight iliotibial band?

It is also logical to link tightness of the ITB with iliotibial band friction syndrome, since presumably a tighter band would lead to greater compression of the underlying tissues with each gait cycle.

The Ober test is most commonly used to assess tightness of the iliotibial band. As described by Gajdoski et al. [19], the Ober test is performed with the examiner standing behind the side-lying patient. The examiner stabilizes the pelvis with one hand, flexes the uppermost thigh, and then moves it into maximal abduction. He or she then maintains the abduction while moving the thigh into extension. The examiner then lowers the limb into adduction until it stops, or until the pelvis starts to tilt. The angle of hip joint adduction (or abduction, if the thigh cannot adduct even to neutral) is considered to be a measurement of ITB length or distensibility. Gajdoski’s article also describes variations of the Ober test that call for the knee of the side being tested to be either flexed or extended.

However, no study to date has actually correlated the findings of the Ober test (or any other test for ITB distensibility) with iliotibial band friction syndrome. Moreover, Devan and others did not find a correlation between a positive Ober test and the occurrence of ITBFS in female college athletes [8].

On the other hand, Fredericson [20] believes that most athletes with ITBFS exhibit a tight iliotibial band, though the Ober test and other clinical examination methods, as they are used in common clinical practice, may not be sensitive enough to detect it.

In 2007, Hamill, Miller, Noehren, and David published findings that showed that runners with ITBFS had a “looser” iliotibial band, exhibiting increased strain (it elongated more when subject to an external load) and, to a statistically significant degree, an increased strain rate (it elongated more rapidly) during running [21].

These findings seem to contradict the commonly asserted link between a tight iliotibial band and ITBFS. Furthermore, they would imply that stretching the ITB—insofar as the purpose of stretching would be to increase the distensibility of the band—could accentuate the symptoms of ITBFS.

Angle of knee flexion during stance phase?

The portion of the knee range of motion at which the ITB is most likely to rub against or compress the underlying structures is with the knee flexed about 20°–30°. Perhaps differences in the degree of knee flexion between individual runners play a role in the onset of ITBFS. The commonly held association of ITBFS with running downhill [22, 23] may be due to the fact that downhill running results in a higher degree of knee flexion at heel strike, thus increasing the friction of the ITB with the lateral epicondyle or the pressure the ITB places on the underlying soft-tissues.

However, Orchard et al. found no difference in the angle of knee flexion between runners with or without ITBFS when running on a treadmill [22]. This finding was echoed by Noehren et al. [17].

An additional subtlety was studied by Miller and others in 2006 [24]. Hypothesizing that a runner’s biomechanics might deteriorate adversely with fatigue, they tested runners’ biomechanics at the end of an exhaustive run. Indeed, runners with a history of ITBFS exhibited an increased angle of flexion of the knee at heel strike.

Rearfoot eversion?

Busseuil et al. found a higher incidence of ITBFS and other lower extremity injuries in athletes who over-pronated [25].

However, Messier et al. and Noehren’s group reached the opposite conclusion, that runners with ITBFS had reduced rearfoot pronation as compared to controls [3, 17].

Other biomechanical factors

Other biomechanical factors that have been linked with iliotibial band friction syndrome include: increased landing forces, increased knee internal rotation, low hamstring strength as compared to the quadriceps strength on the same side, and genu recurvatum [3, 8, 17, 25].

Acute phase treatment to limit the inflammatory response

Care in the acute phase focuses on activity limitation or modification, and measures to relieve pain and inflammation, such as ice, oral NSAID’s, or corticosteroids delivered via phonophoresis or injection.

There is a limited body of research establishing the effectiveness of any of these measures in ITBFS. Ellis et al., in a review of published trials of therapy for ITBFS, found only one prior study of adequate quality that tested the use of NSAIDs, and two other studies that focused on the use of corticosteroids, in one case applied via phonophoresis and in the other via injection. In all three studies, improvement was demonstrated in both the control group and the treatment group, but the groups receiving anti-inflammatory agents showed significant improvement compared to those that did not [33].

On the other hand, other research, not specific to ITBFS, points to the risks of these anti-inflammatory measures when treating connective tissue injuries, and raises the possibility that the pharmaceutical limitation of the inflammatory stage in connective tissue injury actually leads to a delay in healing or to poorer healing [34, 35].

Stretching of the iliotibial band and related structures

Stretching of the iliotibial band, lateral fascia, gluteus medius, and other muscles is frequently recommended as part of the treatment plan for ITBFS.

A variety of stretching protocols have been suggested. Fredericson measured the change in length of the iliotibial band while athletes performed variations of ITB stretches, and found that a particular stretch—with the athlete standing, placing the affected foot adducted and behind the other, and laterally flexing away from the affected side with the arms stretched overhead—created the greatest lengthening of the band [36].

On the other hand, Falvey et al. found that the optimal stretch varied considerably from individual to individual [37].

Neither study documents a link between short term distension of the iliotibial band, such as during a stretching routine, and longer-term changes in the tissue’s mechanical response, in improved running mechanics, or in relief of ITBFS. In addition, in light of the discussion above on the questionable role of iliotibial band tightness on the etiology of the disease, there may be reason to question the rationale for attempting to stretch the ITB.

Connective tissue manipulation

Manual therapy techniques to release myofascial restrictions in the iliotibial band and related structures are also frequently recommended.

Pedowitz reported on a single case that he treated effectively with strain–counterstrain technique [38]. Hammer emphasizes the use of connective tissue treatment methods to release restrictions not only in the ITB but in the gluteal muscles and any other areas found to be restricted in the hip area, thigh, or lower extremity [31]. Fredericson agrees that treatment of trigger points in the band can help significantly [20].

On the other hand, of the scarce published data that has tested the efficacy of these measures, Ellis et al. found a single trial of deep transverse friction massage used in the treatment of ITBFS. It was not found to confer any added benefit [33].

Strengthening of the hip abductors

Though no trials have been published on the efficacy of strengthening exercises in the treatment of ITBFS, strengthening of hip abductors is often recommended [32].

Improved neuromuscular coordination

Improving neuromuscular control of gait is also frequently mentioned as a useful approach in the treatment of ITBFS. Fredericson et al. depicted a number of exercises to train complex multidimensional movement patterns involving weight shift and other aspects of hip abductor function [32]. Pettit and Dolski also described the successful application of a multi-dimensional corrective therapeutic exercise program combined with stretching, massage, soft tissue mobilization, shoe modification, and electrical stimulation [39].

Surgical excision of a cyst, bursa, or lateral synovial recess

Practitioners utilizing conservative means report a satisfactorily high rate of positive response, so that few patients should require surgical intervention [2, 40, 41, 42]. Yet a number of case series reporting resolution of ITBFS from the surgical excision of a bursa, cyst, or portion of a lateral synovial recess have been published [11, 12, 13, 43].