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Knee Ligament Injury

Iliotibial Band Syndrome

Minute Read

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Posted 6 months ago

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Last updated: 29/11/2022

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by James McCormack

What are the symptoms of an IT band injury?

Iliotibial band syndrome is a painful condition relating to the connective tissue band that runs on the outside of the leg. This syndrome, for most people, presents with knee pain, on the outside of the knee. It can affect one side only, or both knees. Some people will feel hip pain, thigh or quad pain, and sometimes shin pain. Below you will see the detailed anatomy of the iliotibial band and it can cause pain at any of the many points of attachment.

The most common site of pain is at the lateral epicondyle of the femur. Because the IT band moves over this bony prominence when the knee is bent through 20-30º. It is also, therefore, at this angle of knee bend that most knee symptoms are felt. Unfortunately, we move our knees through this range when walking, running, and sometime when cycling or driving so this condition can be very debilitating. Many people find the pain so high they are unable to run through it, and in extreme cases can’t walk without aggravating it.

The pain felt, is usually described as a dull ache, and when IT band syndrome is getting worse, the pain might become sharp or burning. Some people describe it as a nerve pain on the outside of the knee. As well as certain activities, there are positions that aggravate it, such as lying on your side. Some people have night pain, or feel it while sleeping.

Anatomy

The iliotibial band is a band of connective tissue that runs down the outside of the leg. Originating from the outside of the iliac crest, the top of our pelvis, and it inserts at its lowest point to the tibia, our shin bone. The iliotibial band has connections into multiple structures down the outside of the leg.

Diagram of iliotibial band syndrome

Muscle attachments:

  • Tensor Fascia Lata
  • Gluteals, primarily the maximus and medius
  • Vastus lateralis, part of the quadriceps
  • Biceps femoris, part of the hamstrings
  • Calf

Bony attachments:

  • The greater trochanter, the bony prominence of the femur on the outside of the hip
  • Gerdy’s tubercle, the outer part of the knee joint
  • Patella, our kneecap

Iliotibial Band Function

The primary function of the iliotibial band is to stabilise the pelvis and for the control of posture. It does this by assisting with hip extension, abduction, and external rotation.

At the knee, the IT band can assist with the knee extension when the knee is slightly flexed (less than 20-30º) and knee flexion when the knee is more flexed (more than 20-30º). It is able to have these seemingly opposite functions due to its lack of attachments to the lower part of the femur. Therefore, when the knee is 20-30º flexed the iliotibial band will move over the lateral femoral epicondyle, the widened part at the lower end of the femur. It, therefore, is in front of this epicondyle when the knee is less than 20-30º flexed and behind it when it is more than 20-30º flexed.

As there is repetitive movement of the soft tissue of the iliotibial band over the hard bony tissue of the lateral epicondyle there is a protective fat pad in position to prevent injury to the IT band. It is the persistent compression and irritation of this fat pad that results in iliotibial band syndrome. The fat pad is the painful part rather than the iliotibial band.

More can be learnt about the functional anatomy of the iliotibial band in this paper (Fairclough et al. 2006).

An additional role that is more recently discussed is the mechanosensory role. Like a ligament, when the IT band is under tension there is feedback of this to our brain via receptors. Therefore it can help us with the coordination of movement as it offers some sensory feedback.

Learn the answers to Iliotibial Band Syndrome FAQs.

Diagnosis

Subjective assessment and physical examination are essential parts of diagnosis. The subjective assessment will highlight if there is a specific mechanism of injury (MOI), such as if it is caused by the trauma of a fall, or related to a training error. The physical examination will look at biomechanics, strength, flexibility, and diagnosis tests.

There are some specific biomechanics that can increase the risk of this injury such as flat feet, poor hip or knee control, or hypermobility. Special tests or diagnostic tests can put the IT band under tension and compress the sensitive area. Two such tests is the Ober’s test and Noble’s Compression test. These are done frequently by a therapist, taking the leg into a position to stretch the IT band and apply additional compression to the outside of the knee over the lateral epicondyle, described in more detail in the full paper (Noble, 1979). Pain on stretch or application of compression represents a positive test.

Confirmation of a clinical diagnosis can come from radiology investigations. MRI scans and ultrasound imaging are two accurate and effective ways to do this. Both MRI and ultrasound findings will show inflammation or swelling of the iliotibial band and underlying fat pad. X-ray is not sensitive for this condition and will not show valuable information.

Photo of ultrasound diagnosis for iliotibial band syndrome

Differential diagnosis

There are other conditions that can present similarly to IT band pain. Trochanteric bursitis, pes anserine, or meniscus tear. Therefore it is important to have an assessment with an experienced clinician to get the correct evaluation and management plan.

Causes of Iliotibial Band Syndrome

Iliotibial band syndrome is caused by repeated compression of the iliotibial band and underlying fat pad, most commonly at the knee but also at the hip. Therefore there are some sports and activities that are more at risk.

Iliotibial band syndrome and running

ITB syndrome is common in runners, especially as individuals transition up in distance. Marathon training is a common cause of IT band pain as manly people underestimate the time needed to condition their bodies. Common training errors are, increasing running distance, frequency or speed too quickly, or a sudden change of terrain such as running on narrow paths or changing the style and support of shoes. With running the biomechanics of your movement will also affect your risk level for ITB pain. A greater angle of adduction and/or internal rotation at the hip, which can result in a narrow running gait, where your feet or knees cross over will increase the tension and compression of the IT band, (Noehren et al, 2007). Similarly, if there is poor strength and control around the hip and pelvis.

Read about the best IT Band Syndrome Exercises.

Iliotibial Band Syndrome and Other Sports

If you are not a runner you can still develop IT band syndrome. Other sports that are regularly related to this injury are cycling, long-distance walking, and sometimes golf. In these sports, there is still a significant repetition of bending of the knee through the provocative range of 20-30º of knee bend, irritating the structures on the outside of the knee.

 

Outside of sport, ITB syndrome can develop due to being overweight or obese. The additional weight on the joints accompanied by the often poor conditioning or weakness put this group at risk. Similarly during pregnancy, due to the increase in laxity of the ligaments as a result of hormone changes, and increased weight. The reduction of strength in the elderly puts them at a greater risk also. After knee or hip replacement, the reduction of strength, as well as the change of biomechanics, can also trigger the onset the knee pain or hip pain of ITB syndrome.

Find out more about iliotibial band syndrome by reading: What exercise can I do with Iliotibial Band Syndrome? and How do you fix Iliotibial Band Syndrome?

Physiotherapy with James McCormack

This is not medical advice and we recommend a consultation with a medical professional such as James McCormack to achieve a diagnosis. He offers Online Physiotherapy Appointments for £45.

 

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