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Clinical Review: Current Concepts

Iliotibial Band Syndrome: Soft Tissue andBiomechanical Factors in Evaluation and Treatment

Robert L. Baker, BSPT, MBA, Richard B. Souza, PhD, PT, Michael Fredericson, MD

Muscle performance factors and altered loading mechanics have been linked to a variety oflower extremity musculoskeletal disorders. In this article, biomechanical risk factors asso-ciated with iliotibial band syndrome (ITBS) are described, and a strategy for incorporatingthese factors into the clinical evaluation of and treatment for that disorder is presented.Abnormal movement patterns in runners and cyclists with ITBS are discussed, and thepathophysiological characteristics of this syndrome are considered in light of prior andcurrent studies in anatomy. Differential diagnoses and the use of imaging, medications, andinjections in the treatment of ITBS are reviewed. The roles of hip muscle strength,kinematics, and kinetics are detailed, and the assessment and treatment of muscle perfor-mance factors are discussed, with emphasis on identifying and treating movement dysfunc-tion. Various stages of rehabilitation, including strengthening progressions to reducesoft-tissue injury, are described in detail. ITBS is an extremely common orthopedic condi-tion that presents with consistent dysfunctional patterns in muscle performance andmovement deviation. Through careful assessment of lower quarter function, the cliniciancan properly identify individuals and initiate treatment.

PM R 2011;3:550-561

INTRODUCTION

Iliotibial band syndrome (ITBS) is the leading cause of lateral knee pain in runners andaccounts for 15% of overuse injuries in cyclists [1-5]. While balancing the need to promotefitness and the associated risks of repetitive-motion injuries such as ITBS, physicians andother rehabilitation professionals have searched for methods of identifying contributingfactors for overuse injuries as well as treatments that restore function and enable patients tomaintain their exercise activities.

The first detailed case on ITBS was published by Renne [6] in 1975. The subjects studiedwere military recruits whose running and training activities had increased rapidly. Hall-marks of ITBS were pain on weight bearing at 30° of knee flexion and the exacerbation ofpain after having run more than 2 miles or having hiked more than 10 miles.

Lateral knee pain at the femoral epicondyle is a key finding in patients with ITBS [6-8].Noble [9] analyzed 100 patients with ITBS and developed the Noble compression test, in

hich compression over the lateral epicondyle of the femur at 30° of knee flexion elicits paineproduction. This test is now commonly used to diagnose ITBS. Orchard et al [10]

described ITBS in runners as an impingement zone related to the time period just after heelstrike as the knee approaches 30° of flexion. The investigators described this as thedeceleration phase, which suggests that impingement occurs during eccentric loading of theiliotibial band during the weight-acceptance phase of running.

ANATOMIC CONSIDERATIONS

The iliotibial band is a fascial structure composed of dense connective tissue that assistsstance stability and is capable of resisting large varus torques at the knee [7,11,12].Proximally, the iliotibial band provides an insertion for the tensor fascia lata and gluteusmaximus muscles [13]. Based on dissections of 1 orangutan, 3 chimpanzees, 1 gorilla, 1

bear, and other 4-legged animals, Kaplan [13] concluded that, although all quadruped

PM&R © 2011 by the American Academy of P1934-1482/11/$36.00

Printed in U.S.A.550

R.L.B. Emeryville Sports Physical Therapy,2322 Powell Street, Emeryville, CA 94608.Address correspondence to R.L.B; e-mail:rb415@comcast.netDisclosure: nothing to disclose

R.B.S. Department of Physical Therapy andRehabilitation Science, Department of Radiol-ogy and Biomedical Imaging, University ofCalifornia, San Francisco, CADisclosure: nothing to disclose

M.F. Division of Physical Medicine and Re-habilitation, Department of Orthopaedic Sur-gery, Stanford University School of Medicine,Stanford, CADisclosure: nothing to disclose

Disclosure Key can be found on the Table ofContents and at www.pmrjournal.org

Submitted for publication September 16,2010; accepted January 4, 2011.

hysical Medicine and RehabilitationVol. 3, 550-561, June 2011

DOI: 10.1016/j.pmrj.2011.01.002

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animals have tensor fascia latae or gluteus maximus muscles,they do not all have an iliotibial band. The investigator thensuggests that the iliotibial band is an independent stabilizer ofthe lateral knee joint, essential for erect posture. The iliotibialband has 2 significant attachments, including the lateralepicondyle and the Gerdy tubercle (Figure 1) [13,14]. Thefirst iliotibial band attachment is into the distal femur at theupper edge of the lateral epicondyle [15]. The histologicmakeup is consistent with tendon and has a layer of adiposetissue underneath the iliotibial band attachment area [14,16].The adipose tissue contains pacinian corpuscles, is highlyvascular, and may be the site of the inflammation that causespain during compression. The second attachment of theiliotibial band is the insertion into the Gerdy tubercle ofthe tibia and serves as a ligament in structure and function.The Gerdy tubercle attachment is tensed during tibia internalrotation as the knee flexes during the weight-acceptancephase of gait [14,16,17]. Internal tibial rotation explains theoccasional connection between toeing in and iliotibial bandstrain [4,18].

The iliotibial band has many other distal attachments,

Figure 1. The iliotibial band and site of injury at lateral epicon-dyle of the femur.

which include the biceps femoris, vastus lateralis, lateral

patellar retinaculum, patella (by way of epicondylopatellarligament and patellar retinaculum), and patellar tendon[13,14,16]. Collectively, these anterior and lateral attach-ments form a horseshoe pattern or inverted U shape wellpositioned for anterolateral support to the knee [15,19,20].The site of injury is often associated with the insertion at thelateral epicondyle but interrelated with the forces created bythe various attachments above and below the lateral epicon-dyle (Figure 1).

Fairclough et al [14] described a mechanism of compres-sion of the iliotibial band against the lateral epicondyle thatoccurs at 30° of knee flexion. Their anatomic descriptionincluded the observation that compression of the adiposetissue at the lateral epicondyle of the femur caused pain andinflammation but that no anterior–posterior movement ofthe band moving over the epicondyle took place, simply anapproximation of the iliotibial band into the lateral epicon-dyle as the knee internally rotated during flexion from anextended position. The investigators present an anatomicalviewpoint that contradicts the commonly held theory of afriction syndrome [14]. Fairclough et al [14] described fric-tion as an unlikely cause of ITBS, because the band insertsdeeply and strongly into the femur. The functional anatomymay be relevant because a fat pad and pacinian corpusclecompression mechanism may have different mechanorecep-tor implications compared with a friction syndrome, al-though inflammation remains the primary concern.

INTRINSIC CONTRIBUTING FACTORS

Biomechanics of the Hip, Knee, and Ankle

Ferber et al [21] attributed iliotibial band strain in femalerunners to a greater peak hip adduction angle and greaterpeak knee internal rotation angle compared with those incontrols. The investigators used a retrospective design andcontrol group comparison. The theory presented was in-creased tensile stress at the hip in the frontal plane andinternal rotation stress at the knee. Interestingly, in thisstudy, patients with ITBS exhibited femoral external rotationversus internal rotation when compared with control sub-jects, a factor that increased knee internal rotation.

In 2007, Noehren et al [22] published a prospective studyof female runners that analyzed ITBS and biomechanicalfactors, including hip adduction, knee internal rotation, andrear foot eversion angles, and related hip, knee, and anklemoments. The investigators performed bilateral, 3-dimen-sional, lower extremity kinematic and kinetic analysis withrunning. The subjects were followed up for injury findingsthrough 2 years by e-mail communication. Findings for theITBS group versus the control group included the following:(1) greater peak hip adduction, (2) greater peak knee internalrotation angle, (3) lower tibial internal rotation by 2.2° (not

significant), and (4) femoral external rotation. On visual

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inspection, the investigators noted that the subjects withITBS landed in greater hip adduction and knee internalrotation. Noehren et al [22] and Ferber et al [21] support theheory of frontal and transverse plane factors in female run-ers, specifically, excessive hip adduction and knee internalotation. Further study is needed to explain why these run-ers exhibited greater hip adduction, knee internal rotation,nd femoral external rotation. In addition, male runners needurther assessment in similar research models. Weight-bear-ng magnetic resonance imaging and dual fluoroscopic imag-ng may be useful to further assess femoral rotation in malend female runners with and without ITBS, specificallyimed at evaluating the role of transverse plane contributingactors of the hip [23-25].

Hamill et al [12] modeled iliotibial band strain rate withoftware for interactive musculoskeletal modeling (SIMM.0; Motion Analysis Corporation, Santa Rosa, CA). Thisrospective study of female runners compared iliotibial bandtrain (calculated as the change in length during runningivided by the resting length), strain rate (calculated as thehange in strain divided by the change in time), and durationf impingement in 17 patients with ITBS and 17 age-matchedontrols. The entire stance was measured, with a focus onouch-down and peak knee flexion. Although strain wasncreased versus that in the control, only strain rate wastatistically significant between the groups. The investigatorsuggested that strain rate is a factor in the development ofTBS.

Taunton et al [5] used a retrospective design to analyzeata on 2002 running injuries, including 63 men and 105omen with ITBS. Varus knee alignment was reported in3%, and valgus alignment was reported in 15%. Leg-length

Figure 2. (A) Normal alignment. (B) Trendelenburg sign. (C) CSports and Orthopedic Sections of the American Physical Therof abnormal hip mechanics on knee injury: a biomechanical

iscrepancy, defined as a greater than 0.5-cm difference in s

nterior superior iliac spine to medial malleolus, reportedn 10%. McNicol et al [26] also reported on 52 cases of ITBSn runners, including 34 men and 18 women with ITBS. Thenvestigators reported that 55% had mild-to-severe kneearus, and 8% had mild knee valgus. These studies suggesthat clinical management of ITBS may involve training meth-ds to control frontal plane dynamics at the knee, in additiono assessing and treating transverse plane issues.

One way to theoretically visualize the relationship be-ween the hip and knee frontal plane relationships involveshe use of ground reaction force diagrams. During normalingle-limb stance as described by Powers [27], the groundeaction force vector may pass medial to the knee joint androduce a varus torque at the knee (Figure 2A). However,ith excessive hip adduction during a single-limb stance andrendelenburg sign, the ground reaction force vector mayass more medial, with a larger perpendicular distance to thenee joint (Figure 2B). The result is an increased varus torquet the knee, along with an elongated lateral hip musculature,oth of which place increased stress on the iliotibial band27,28]. The third possible disturbance at the knee is a valgustress and ground reaction force vector lateral to the knee,ombined with an increased hip adduction, a compensatedrendelenburg sign (Figure 2C).

Abnormal mechanics at the foot and the tibia may play aole in the development of ITBS given the anatomic connec-ion of the iliotibial band to the tibia and the interrelationshipf the foot and the tibia. Noehren et al [22] analyzed biome-hanical factors in the hip, knee, and rear foot in femaleunners who go on to develop ITBS, and, although hipdduction and knee internal rotation were the primary find-ngs in this cohort, these investigators were able to identify a

nsated Trendelenburg sign. Reprinted with permission of thessociation and Chris Powers, PhD, PT. Powers C. The influencective. J Orthop Sports Phys Ther 2010;40:42-49 [27].

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eversion and tibial internal rotation. In contrast, Messier et al[29] performed a cross-sectional lower extremity kinematicstudy on male and female patients with ITBS and reported nostatistically significant differences in rear foot eversion whencompared with a control group.

Miller et al [30] analyzed 16 runners, 8 with history ofITBS and 8 age-matched controls, in an exhaustive run. Atthe end of the run, the patients in the ITBS cases exhibitedgreater maximum foot inversion (3.3° ITBS and �9.5° con-trol), maximum knee flexion at heel strike (43.8° ITBS and36.5° control), and maximum knee internal rotation velocity(16.4°/s ITBS and 10.3°/s control). Further research isneeded to better understand the possible connection be-tween the foot mechanics and increased knee internal rota-tion velocity.

Leg-length discrepancies have been reported as a factor indeveloping ITBS. McNicol et al [26] studied 52 cases of ITBSin runners and reported that 13% had leg-length discrepan-cies, and, in all cases, that the side of injury correspondedwith the longer leg. However, Messier et al [29] evaluated avariety of intrinsic and extrinsic factors in 56 patients withITBS and 70 controls, reporting leg-length discrepanciesconsistent between the control group and the injured group.Taken together in a clinical perspective, ITBS and foot andankle factors suggest a possible subset of cases in runnerswho have abnormal foot and ankle biomechanics, includingexcessive calcaneal eversion and tibial internal rotation alongwith leg-length discrepancy.

Muscle Performance

Messier et al [29] reported generalized strength and endur-ance considerations as a possible etiologic factor in male andfemale participants with ITBS. Fredericson et al [3] reportedsignificant hip abductor strength deficits in patients withITBS compared with noninjured control runners, and goodsuccess in these injured patients after a 6-week strengtheningprogram focused on strengthening the gluteus medius mus-cle. Miller et al [30] reported that, on average, patients in theITBS cases were tighter in the iliotibial band than controlrunners when the Ober test was used. The investigators alsoreported an increased maximum knee internal rotation ve-locity in patients in the ITBS cases near exhaustion, whichsuggests fatigue-related factors. In a separate study that eval-uated runners during an exhaustive run, Miller et al [31]suggested that runners with a history of ITBS use abnormalsegmental coordination patterns. The scope of muscle per-formance factors in ITBS includes strength, endurance, flex-ibility. and segmental coordination (Figure 3).

The Janda approach to muscle imbalance provides a the-oretical model that assists in the analysis of muscle strengthand flexibility as it relates to excessive hip adduction andknee varus or valgus. The tensor fascia lata is classified by

Janda as a postural muscle with the tendency to become

shortened and strong. The clinical finding is increased hipflexion in stance, along with a tendency for increased hipinternal rotation [3,32-37]. In contrast, the gluteus maximusand gluteus medius are phasic muscles with the tendency tobecome lengthened and weak [36,37]. Subsequently, thetaut and relatively stronger tensor fascia lata may dominatethe weaker gluteus medius posterior and gluteus maximus,and may result in a postural pattern, including a Trendelen-burg sign (Figure 2B) or compensated Trendelenburg sign(Figure 2C) [27,38]. These compensations during walking orrunning may result in poor control of the hip and femurduring stance and may lead to excessive hip adduction andknee varus or valgus. The Janda-based analysis of muscleimbalance provides a theoretical construct to understand andtreat some of the factors related to ITBS, specifically,strengthening of the gluteus medius and gluteus maximusmuscles to better control hip adduction and knee varus andvalgus.

EXTRINSIC CONTRIBUTING FACTORS

Extrinsic factors are related to training methods as well asrunning shoes or cycle fit, and have been researched andreported in connection with ITBS [2,4,10,29]. Key elementsin such research include repetitions at about 30° of kneeflexion (the impingement zone) in a closed-chain andweight-bearing position. Farrell et al [2] analyzed cyclingkinematic and kinetic data to reported values for running,

Figure 3. Muscle performance factors include a broad set ofmuscle competencies, including response to the kinetic chainabove and below.

with a focus on iliotibial band impingement at the knee. Ten

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noninjured cyclists were analyzed with motion analysis andsynchronized foot-pedal forces. Findings included the fol-lowing: (1) lower pedal reaction force at 17%-19% versusground reaction force in runners, and (2) shorter impinge-ment zone contact time, calculated at 38 ms in cyclists versus75 ms in runners. However, the investigators discussed theissue of repetitive stress in a typical workout, commentingthat cycling results in more repetitions (ie, 6600 repetitionsduring a 1.25-hour ride versus 4800 repetitions during a10-km run). Interestingly, Farrell et al [2] described a theo-retical mechanism of stress to the iliotibial band in cyclists inwhich the shorter leg, when fixed to the pedal, is over-stretched laterally and functions in less knee flexion, therebyincreasing the time spend in the impingement zone. Whetherrunning or cycling, the factors of impingement time andintensity of loading are important.

Training factors, including rapid increases in mileage andhill training, can lead to iliotibial band injury [2,29]. Orchardet al [10] suggested that increased impingement zone impacttime during both downhill and slow running leads to ITBSand sprinting may result in relatively less impact time be-cause of greater knee flexion beyond the impingement zone.This particular theory was not supported by Miller et al [30],

ho found, during an exhaustive run, increased knee flexiont heel strike in runners with a history of ITBS. Our reviewid not find experimental studies that evaluated the effect ofprinting on iliotibial band strain or impingement, althoughhe topic seems relevant for future research. Messier et al [29]eported that less experienced runners with rapid changes inileage were at risk for ITBS, but hypothesized that intrinsic

actors, including strength deficits, were necessary for extrin-ic factors to cause symptoms. The investigators also reportedncreased cross-training habits (ie, swimming and cycling) inunners with ITBS versus the control group.

CLINICAL EXAMINATION

Sutker et al [39] evaluated 1030 runners with lower extrem-ity complaints and diagnosed 48 cases of ITBS. Subjectively,the patients described lateral knee pain associated with re-petitive loading in a weight-bearing position (ie, running andstairs). Functionally, the runners were able to perform activ-ities such as a hop and squat without pain. This contrastswith the cases presented by Renne [6], in which militaryrecruits in daily training exhibited a limp and straight leg gaitpattern. Renne [6] also noted that the symptoms were aggra-vated by running more than 2 miles and hiking more than10miles. Sutker et al [39] confirmed the diagnosis of ITBS by the

istory and tenderness localized at the lateral epicondyle ofhe femur or less commonly at the Gerdy tubercle. Concur-ently, the patients did not have symptoms at the lateral jointine or popliteal tendon, and did not have signs of intra-rticular disorders.

The subjective examination includes the clinical applica-

ion of previous information on factors associated with ITBS. o

aunton et al [5] reported on 168 cases of ITBS with aistribution 38% men, 62% women, average weekly hours ofunning 4.9, training years 7.3, body mass index of 23.7 foren and 21.2 for women, and age 31.1 years. Only age

ounger than 34 years in men was a significant factor amonghese variables. ITBS was associated with pain after a run thatestricted the ability to run. McNicol et al [26] reported 52ases of ITBs; 42% were found to be related to training errors,uch as rapid commencement (2 cases), sudden hill exposure1 case), single severe session (12 cases), rapid increaseolume of training (7 cases), and footwear and surface issues4 cases). Similarly, Messier et al [29] studied 48 cases ofTBS; compared with 70 controls and reported ITBS cases,he patients had increased training mileage and less experi-nce. In summary, the subjective examination in cases ofTBS has the defining characteristics of lateral knee pain withepetitive knee activity usually in a weight-bearing positionnd associated overtraining issues.

Objectively, the Noble compression test may be used torovocate symptoms by compressing the iliotibial band at the

ateral epicondyle with 30° knee flexion [9]. The patient isositioned with the knee at 90° flexion, and compression ispplied just proximal to the lateral epicondyle as the knees extended toward full extension. The 30° flexion is thempingement zone specific to the iliotibial band and lateralemoral epicondyle as described in cadaver studies by bothrchard et al [10] and Fairclough et al [14]. Differentiating

elated structures uses this impingement zone concept asell as lack of other objective test findings for injury to the

ateral meniscus, lateral retinaculum, popliteus and bicepsemoris tendons, patellofemoral joint, and lateral collateraligament. Although not frequently used for diagnosis, Ekmant al [40] used magnetic resonance imaging to evaluate 7atients with ITBS and 10 age- and gender-matched controls.he investigators reported thickening of the iliotibial bandver the lateral femoral condyle (5.49 mm ITBS and 2.52 mmontrol; P � .05) and fluid deep to the iliotibial band at theateral epicondyle in 5 of 7 cases.

Clinical Assessment of Flexibility

Flexibility of the lateral hip musculature has routinely beentested as a factor in ITBS [33]. The rationale in testing andtreating is related to muscle performance factors (Figure 3)and biomechanical factors, given the issue of iliotibial bandcompression at the lateral epicondyle of the femur. Messier etal [29] analyzed stretching habits in 56 runners with ITBSnd 70 controls and found that both groups stretched, butifferences were not established. Fredericson et al [41] ana-

yzed the effectiveness of 3 iliotibial band stretches, in 5 malelite distance runners, and found significant changes in theliotibial band length in all 3 types of stretching. The investi-ators proposed benefits to stretching such as reducing ili-

tibial band tension by hip abductor muscle inhibition and

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improvement in fascial adhesions and myofascial triggerpoints.

The Ober test is commonly performed to assess iliotibialband length. Gose and Schweizer [42] describe the Ober testas follows: (1) position the patient on side, lying with thetested leg up; (2) with the knee flexed to 90° and the pelvisstabilized, position the hip in a flexed and abducted posture;(3) extend the hip to achieve adequate extension so that theiliotibial band is over or behind the greater trochanter; and(4) allow the thigh to fall into adduction (Figure 4). Theiliotibial band restriction is designated as follows: (a) mini-mal (adducted past the horizontal but not fully to the table),(b) moderate (adducted to the horizontal), and (c) maximal(patient is unable to adduct to the horizontal).

Because the Ober test requires adequate hip extension(approximately to a neutral hip with knee flexed 90°), the useof the modified Thomas test is also recommended. Clapis etal [43] evaluated 42 noninjured subjects in the modified

homas test by using an inclinometer and goniometer toeasure joint ranges. The subjects sat close to the edge of the

able, supported the left thigh to the chest, and rolled back tohe supine position. The right leg was positioned to hang offhe table. To standardize the measurements, the lumbarordosis was flattened and palpated in that position duringhe test. The tested hip was placed in neutral hip abduction–dduction. A goniometer was aligned proximally with theidline of pelvis and distally with the midline of the femur.

nterclass correlation (ICC) measurements by goniometerere 0.92 and by inclinometer were 0.89. Harvey [44] ana-

yzed the modified Thomas test in 117 elite athletes in tennis,unning, rowing, and basketball. ICCs were 0.91-0.94, andndings were as follows: (1) psoas averaged �11.9° (belowhe horizontal), (2) quadriceps was 52.5°, and (3) tensor

Figure 4. The Ober test.

ascia lata–iliotibial band averaged 15.6° abduction.

Clinical Assessment of Strength

The functionally weak gluteus medius and gluteus maximusreduces eccentric control of the hip and femur in stance[33,34]. To detect hip muscle imbalance between the tensorfascia lata and the gluteus medius and maximus, the cliniciancan perform surface electromyography (EMG) to observe formuscle substitution: (1) tensor fascia lata may substitute forthe posterior fibers of the gluteus medius, and (2) hamstringmay substitute for the gluteus maximus as described byKendall et al [38]. Functional tests offer insight into musclesubstitutions on a regional basis, such as trunk and lower-extremity strength, including signs of excessive femur inter-nal rotation, ipsilateral hip adduction, and contralateral hipdrop during a step-down test or Trendelenburg test (Figures5 and 6) [37,45,46]. The utility of the standing functionalests is debated based on minimal detectable change andhether or not weakness exists in the hip musculature (ie,luteal muscles) or core stabilizers (ie, internal obliques,ransverse abdominus, multifidus) [37,46]. However, theunctional tests may identify muscle performance factors thatpatient can see firsthand, a powerful motivator in treatmentompliance. The gluteus maximus muscle strength shouldlso be tested, given its role of hip stabilizer in the frontallane [47] and ability to influence femur rotation (ie, con-entric femur external rotation and eccentric femur internalotation) [36,38,47]. Testing the gluteus maximus can beerformed with the patient in the prone position with thenee flexed to 90° and the hip in neutral rotation by using aanual muscle test or hand-held dynamometer against the

Figure 5. Normal step-down test on a 6-inch (15.24-cm) boxdemonstrates level hips at 10 repetitions. Performed on 8-inch

(20.32-cm) box if normal at 6-inch (15.24-cm) height.

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556 Baker et al ILIOTIBIAL BAND SYNDROME

lower portion of the posterior femur [36,38,48]. The patientshould be able to fully resist without a break and should havesymmetrical strength side to side. The deep external rotatormuscles are important stabilizers of the hip, including theobturator internus and externus, gemellus superior and infe-rior, quadratus femoris, and piriformis [49]. The muscle testposition described by Janda [36] is supine, test leg off theable and nontest leg flexed at the hip and the knee, with theoot on the table, fixate below the distal femur, and resistancepplied above the medial malleolus as the patient moveshrough full range.

Treatment

Fredericson and Wolf [33] developed a useful format fortages of treatment (Table 1): acute, subacute, and recoverytrengthening. Treatment of ITBS is driven by the pathophys-ology of inflammation and the biomechanics of iliotibialand strain [32,33]. The path to recovery involves correctionf contributing factors such as weakness of the gluteus me-ius and excessive hip adduction and knee internal rotation,

eg-length discrepancies, and excessive knee varus or valgustrain.

Given the finding of soft-tissue thickening and fluid underhe iliotibial band at the lateral epicondyle [8,40], the early

use of anti-inflammatory medications, soft-tissue mobiliza-tion, and stretching are advised [7,8,33,39,50]. Ellis et al [1]performed a systematic review of conservative treatments forITBS. By using the Physiotherapy Evidence Database criteria,corticosteroid injection and nonsteroidal anti-inflammatory

Figure 6. Abnormal step-down test exhibits a contralateral hipdrop during the step down.

medications were moderately supported within the first 14

days and anti-inflammatory–analgesic after 14 days. If thereis significant swelling or tenderness at the lateral epicondyleresistant to oral anti-inflammatory medication and physicaltherapy modalities, then a corticosteroid injection at thelateral epicondyle of the femur should be considered early inthe treatment course [51].

Patient education is critical to success. Extrinsic factorshave been described, including excessive weekly mileage,overtraining, hill training, and other activities that place theiliotibial band in the impingement zone, for example, swim-ming [5,26,29]. Sutker et al [39] reported on 48 cases of ITBSand found a trend in running 20-40 miles per week for morethan 1 year. McNicol et al [26] reported on 52 cases of ITBSin athletes and found that 26 cases involved training-relatedissues.

Exercise approaches for ITBS have thus far supportedstrengthening of the gluteus medius (ie, side-lying hip ab-duction and hip hiking) [3,52]. Approaches to hip strength-ening are rapidly increasing, especially targeted to the gluteusmedius and maximus [53,54]. Some experts (ie, Fredericson,Geraci) have recommended innovative closed chain ap-proaches to treating ITBS, such as triplanar lunge and squatexercises [33,34].

EMG activation studies of the gluteal muscles providedirection to therapeutic exercise programs. Distefano et al[55] analyzed mean EMG as a percentage of maximal volun-

Table 1. Phases of rehabilitation recommended by Frederic-son and Wolf [33]

Acute PhaseGoal: Reduce inflammation of the iliotibial band at thelateral femoral epicondyle (Figure 1)

1. Control extrinsic factors, such as rest from running andcycling

2. In severe cases patients should avoid any activities withrepetitive knee flexion-extension and swim using only theirarms and a pool buoy

3. The use of concurrent therapies is advised (ie, ice,phonophoresis, or iontophoresis) [1,50]

4. Oral, nonsteroidal anti-inflammatory medication isrecommended

5. Corticosteroid injection, if no response to the abovemethods

6. Up to 2 pain-free weeks before return to running orcycling in a graded progression

Subacute PhaseGoal: Achieve flexibility in the iliotibial band as a foundationto strength training without pain

1. Iliotibial band stretching (Figure 7)2. Soft tissue mobilization to reduce myofascial adhesionsRecovery Strengthening PhaseGoal: Strengthen the gluteus medius muscle includingmultiplanar closed chain exercises

1. Exercises should be pain free2. Repetitions and sets of exercises are 8-15 repetitions and

2-3 sets3. Recommend the exercises of sidelying hip abduction,

single leg activities, pelvic drops, and multiplanar lunges

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tary isometric contraction in 21 healthy subjects during avariety of open and closed chain exercises for the gluteusmedius and gluteus maximus. The only resistance was seg-mental body weight, gravity, and resistance bands. The in-vestigators were careful to use positions that promoted agluteal recruitment pattern, such as a vertical tibia withlunging and forward trunk by hip flexion with squat activity.The list of compared exercises included side-lying hip abduc-tion, clam shell, lateral band walks, single-limb squat, single-limb dead lift, multiplanar lunges, and multiplanar hops. TheICC3,1 were 0.85-0.98 for gluteus maximus and 0.93-0.98gluteus medius except for multiplanar hops. The investiga-tors proposed that 60% or greater normalized EMG as apercentage of maximal voluntary isometric contraction wasthe requirement for a strengthening exercise [55,56]. Thegluteus medius averaged 61% lateral band walk, 64% single-limb squat, and 81% side-lying hip abduction. The gluteusmaximus averaged 59% in single-limb dead lift and single-limb squat. The side-lying clam shell did not use a resistanceband and achieved 38%-40% activation in the gluteus me-dius. This study supported the use of functional-based exer-cises and open chain resistance exercises to strengthen thegluteal muscles from the viewpoint of EMG patterns.

The positioning of the trunk and degree of knee flexionmay change the EMG in the gluteus medius and maximus.Fischer and Houtz [57] analyzed a floor-to-waist lift of 25 lb(0.91 kg) with the knees straight and the trunk and hipsflexed versus hips and knees flexed (ie, forward tibias) in 11healthy women, aged 15-23 years. EMG activity was mea-sured in the gluteus maximus, sacrospinalis, medial andlateral hamstrings, and quadriceps femoris muscles. The

Figure 7. Iliotibial band stretch in standing [41].

investigators demonstrated that the 25-lb (0.91-kg) lift withknees flexed and tibias forward generated a strong quadri-ceps EMG and minimal gluteus maximus EMG. The straightknee and trunk flexed 25-lb (0.91-kg) lift produced minimalquadriceps and gluteus maximus EMG but strong hamstringEMG. The sacrospinalis muscle was active in both lifts. Whencompared with the EMG and exercise activities in the Diste-fano study [55], the differences may be related to the positionof the tibia, because Fischer and Houtz [57] allowed a muchgreater forward position of the tibia. In addition, Fischer andHoutz [57] used a bilateral leg activity in the sagittal plane,whereas Distefano et al [55] chose more unilateral limbactivities and multiplanar tasks. The clinical significance isthat the biomechanical details in functional exercise are crit-ical to strengthening the gluteal muscles (ie, single leg, mul-tiplanar, vertical tibia).

Noehren et al [58] used real-time visual biofeedback tosuccessfully train 10 female subjects with anterior knee painand a diagnosis of patellofemoral pain syndrome. Inclusionalso required excessive hip adduction on motion analysis.The hip adduction angle was displayed onto a monitor placedin front of the treadmill. Instructions were to contract thegluteal muscles and run with the knees pointed straightahead, and to maintain a level pelvis. The sessions progressedfrom 15-30 minutes over 8 sessions, and the visual feedbackwas faded in sessions 5-8. The participants were not allowedto run outside this training. The program involved fadedfeedback over 8 treatment sessions (4 times per week for 2weeks). The result was a 23% decrease in ipsilateral hipadduction during running that was maintained at 1-monthfollow-up. Although patellofemoral pain cases with otherbiomechanical issues such as increased hip internal rotation,the relevance to ITBS is the possible use of faded feedback in

Figure 8. Resisted clam shell is a beginning-level exercise forgluteal muscle recruitment.

running to control excessive hip adduction. Similarly, Barrios

jpv

cm

hsstal

pi

558 Baker et al ILIOTIBIAL BAND SYNDROME

et al [59] studied visual faded feedback to reduce excessiveknee external adduction moment during treadmill walking in8 noninjured participants with varus knee alignment, aged18-35 years. The verbal cues to the participants were “bringthe thighs closer” and “walk with your knees closer together”while maintaining a normal foot progression angle. Thetraining was 8 sessions with faded feedback in sessions 5through 8. Statistical significance was reported before to aftertraining for knee external adduction moment, on average20% reduction (P � .027). Although performed on nonin-ured participants with varus alignment, this particular ap-roach may assist patients in ITBS cases with excessive kneearus. In practice, real-time visual feedback has a strong

Figure 9. Resisted hip abduction and bridge is a beginning-level exercise that facilitates gluteal recruitment.

Figure 10. Resisted hip extension and knee flexion in quadru-ed is a beginning-level exercise that facilitates gluteus max-

mus recruitment.

ognitive component that allows biomechanical improve-ents in 8 sessions.The exercises that have been researched specific to ITBS

ave included side-lying hip abduction and pelvic drops at 3ets and 30 repetitions and 6 weeks of treatment [3]. Theide-lying hip abduction exhibited strong EMG activation inhe study by Distefano et al [55], and single leg functionalctivity demonstrated higher EMG activation versus double-eg closed chain exercise. Furthermore, as stated previously,

Figure 11. Resisted hip extension, external rotation, and ab-duction comprise a beginning-level exercise that facilitatesgluteus maximus and gluteus medius recruitment.

Figure 12. Contralateral pelvic drop (starting position) is anintermediate-level exercise used successfully to strengthen hip

abductors in runners with ITBS [3].

eg

ftpam

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the study by Distefano et al [55] used several other usefulmodifications in functional exercises that seemed to facilitategluteal recruitment: (1) more vertical tibia, (2) forward trunklean, (3) resistance band with side walks, (4) multiplanaractivity, and (5) good control of trunk position. The clamshell exercise without the resistance band, and the lungepatterns without use of added weight, demonstrated glutealmuscle EMG less than 60%, therefore, we recommend use ofresistance with these exercises.

Based on these EMG studies [55,57], research on exerciseand ITBS [3,52], and recent case studies focused on strength-ning the gluteal muscles [53,54], our recommended pro-ressions of therapeutic exercise include one iliotibial band

Figure 13. Resisted squat is an intermediate exercise that useship abduction and vertical tibial alignment to facilitate gluteusmaximus control.

Figure 14. Resisted staggered squat is an intermediate exer-cise to facilitate gluteal muscles and an alternative functional

stance.

stretch, side-lying hip abduction and pelvic drops, and aprogression of technique-driven closed chain exercises, asillustrated in Figures 7-17 (ie, vertical tibia and trunk flexionrom the hips). The bilateral closed chain exercises are rela-ively low vigor and were used early in the recovery toromote technique in squats, whereas the single-leg activitiesre of higher vigor and intended for strengthening the glutealuscles.

RESUMING PARTICIPATION IN SPORTS

Participation in sports is dependent upon being able toperform exercises in proper form without pain [11,33].Other outcome measures include strength testing the gluteus

Figure 15. Resisted squat with a single-leg emphasis is a morevigorous exercise to facilitate single-leg control with the glutealmuscles, facilitated by hip abduction and external rotation.

Figure 16. Posterior lunge slide is a more vigorous leg exercise

for functional hip control.

t

560 Baker et al ILIOTIBIAL BAND SYNDROME

medius and gluteus maximus with a normal result [36,38].The flexibility of the iliotibial band and rectus femoris can beassessed with a modified Thomas test as previously described[43,44]. The Ober test can be used to assess hip adductionrange of motion as previously described [42]. Our recom-mendation on flexibility testing and return to sports is pain-free range of motion in hip adduction. There should be anegative Noble compression test, with the absence of tender-ness at the lateral epicondyle of the femur at 30° kneeflexion [9].

Runners and cyclists should train on level ground everyother day [33,60]. The distance and frequency of trainingshould be increased incrementally and monitored for therecurrence of symptoms. Cross training is not recommendedif the activities involve repeated knee flexion through theimpingement zone, such as combining hill running, trackrunning, swimming, and cycling [10,29]. Orthotic recom-mendations are worth considering in a runner if the patienthas excessive calcaneal eversion and tibial internal rotationduring functional tasks and increased leg length greater than0.5 cm [5,26].

The cyclist is advised to check bicycle fit for factors relatedo the 30° impingement zone and the toe-in position [2].

Wanich et al [60] recommended lowering the seat beyondthe typical height to decrease knee extension and relatediliotibial band stress, and more upright handlebars and aforward seat to reduce passive stretch to the gluteus maximusand iliotibial band. The investigators also recommendedaddressing cleat position and use of orthotics, such aswedges, to control excessive tibial internal rotation and foothyperpronation. Flexibility was emphasized for the gluteusmaximus and iliotibial band and, more generally for thehamstrings and gastroc-soleus muscles. Holmes et al [4]

Figure 17. Single-leg dead lift is a more vigorous single-legexercise to emphasize gluteus maximus, gluteus medius, andhip control.

treated 61 cyclists with ITBS by using the following training

modifications: (1) flat terrains, (2) controlled mileage (ie, 1/2mile for 2 weeks), (3) easy pedalling at 80 revolutions perminute, and (4) pain free.The investigators also modified thebicycles based on misalignments identified during the eval-uation of bicycle fit, for example, adjusting cleat or pedalpositions to reflect the cyclist’s normal off-bicycle alignmentand lowering the seat to achieve 30°-32° of knee flexion at thebottom center of the pedaling stroke. Floating pedal systemswere selected when fixed pedals did not allow for correctionof anatomic variants, and 2-mm spacers were used to correcta short leg.

CONCLUSION

Several intrinsic and extrinsic contributing factors for ITBShave been described. Reduced hip muscle performance andabnormal hip and knee mechanics during functional tasksmay be primary contributors to ITBS. Addressing these un-derlying factors is critical to the efficient management ofpatients with this condition. Although controversy existsregarding the mechanism of ITBS, controlling inflammationand symptoms during early phases and progressive strength-ening in later phases is recommended. ITBS remains a com-mon and challenging dysfunction in many athletes; but,through early diagnosis and proper biomechanical move-ment analysis, appropriate interventions can be implementedto decrease pain and to improve function.

REFERENCES1. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome—a systematic

review. Man Ther 2007;12:200-208.2. Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling:

possible implications for iliotibial band friction syndrome. Knee 2003;10:103-109.

3. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oest-reicher N, Sahrmann SA. Hip abductor weakness in distance runnerswith iliotibial band syndrome. Clin J Sport Med 2000;10:169-175.

4. Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in cyclists.Am J Sports Med 1993;21:419-424.

5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR,Zumbo BD. A retrospective case-control analysis of 2002 runninginjuries. Br J Sports Med 2002;36:95-101.

6. Renne JW. The iliotibial band friction syndrome. J Bone Joint Surg Am1975;57:1110-1111.

7. Kirk KL, Kuklo T, Klemme W. Iliotibial band friction syndrome.Orthopedics 2000;23:1209-1214.

8. Orava S. Iliotibial tract friction syndrome in athletes—an uncommonexertion syndrome on the lateral side of the knee. Br J Sports Med1978;12:69-73.

9. Noble C. Iliotibial band friction syndrome in runners. Am J Sports Med1980;8:232-234.

10. Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial bandfriction syndrome in runners. Am J Sports Med 1996;24:375-379.

11. Adams WB. Treatment options in overuse injuries of the knee: patell-ofemoral syndrome, iliotibial band syndrome, and degenerative menis-cal tears. Curr Sports Med Rep 2004;3:256-260.

12. Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band

strain in runners. Clin Biomech (Bristol, Avon) 2008;23:1018-1025.

561PM&R Vol. 3, Iss. 6, 2011

13. Kaplan EB. The iliotibial tract; clinical and morphological significance.J Bone Joint Surg Am 1958;40-A:817-832.

14. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of theiliotibial band during flexion and extension of the knee: implicationsfor understanding iliotibial band syndrome. J Anat 2006;208:309-316.

15. Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M. Ananatomic study of the iliotibial tract. Arthroscopy 2007;23:269-274.

16. Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndromereally a friction syndrome? J Sci Med Sport 2007;10:74-78.

17. Kelly A, Winston I. Iliotibial band syndrome in cyclists. Am J SportsMed 1994;22:150.

18. Reischl SF, Powers CM, Rao S, Perry J. Relationship between footpronation and rotation of the tibia and femur during walking. FootAnkle Int 1999;20:513-520.

19. Terry GC, Hughston JC, Norwood LA. The anatomy of the iliopatellarband and iliotibial tract. Am J Sports Med 1986;14:39-45.

20. Terry GC, Norwood LA, Hughston JC, Caldwell KM. How iliotibialtract injuries of the knee combine with acute anterior cruciate ligamenttears to influence abnormal anterior tibial displacement. Am J SportsMed 1993;21:55-60.

21. Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runnerswith a history of iliotibial band syndrome demonstrate atypical hip andknee kinematics. J Orthop Sports Phys Ther 2010;40:52-58.

22. Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006prospective study of the biomechanical factors associated with iliotibial bandsyndrome. Clin Biomech (Bristol, Avon) 2007;22:951-956.

23. Souza RB, Draper CE, Fredericson M, Powers CM. Femur rotation andpatellofemoral joint kinematics: a weight-bearing magnetic resonanceimaging analysis. J Orthop Sports Phys Ther 2010;40:277-285.

24. Li G, Van de Velde SK, Bingham JT. Validation of a non-invasivefluoroscopic imaging technique for the measurement of dynamic kneejoint motion. J Biomech 2008;41:1616-1622.

25. Anderst W, Zauel R, Bishop J, Demps E, Tashman S. Validation ofthree-dimensional model-based tibio-femoral tracking during running.Med Eng Phys 2009;31:10-16.

26. McNicol K, Taunton JE, Clement DB. Iliotibial tract friction syndromein athletes. Can J Appl Sport Sci 1981;6:76-80.

27. Powers C. The influence of abnormal hip mechanics on knee injury: abiomechanical perspective. J Orthop Sports Phys Ther 2010;40:42-49.

28. Andriacchi TP. Dynamics of knee malalignment. Orthop Clin NorthAm 1994;25:395-403.

29. Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band frictionsyndrome in distance runners. Med Sci Sports Exerc 1995;27:951-960.

30. Miller RH, Lowry JL, Meardon SA, Gillette JC. Lower extremity me-chanics of iliotibial band syndrome during an exhaustive run. GaitPosture 2007;26:407-413.

31. Miller RH, Meardon SA, Derrick TR, Gillette JC. Continuous relativephase variability during an exhaustive run in runners with a history ofiliotibial band syndrome. J Appl Biomech 2008;24:262-270.

32. Fredericson M, Weir A. Practical management of iliotibial band frictionsyndrome in runners. Clin J Sport Med 2006;16:261-268.

33. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innova-tions in treatment. Sports Med 2005;35:451-459.

34. GeraciMCJr,BrownW.Evidence-basedtreatmentofhipandpelvic injuries inrunners. Phys Med Rehabil Clin North Am 2005;16:711-747.

35. Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle weaknessand overuse injuries in recreational runners. Clin J Sport Med 2005;15:14-21.

36. Janda V. Muscle Function Testing. London: Butterworths; 1983.37. Page P, Frank C, Lardner R. Assessment and Treatment of Muscle

Imbalance: The Janda Approach. Chicago, IL: Human Kinetics; 2010.38. Kendall F, McGreary E, Provance P. Muscles: Testing and Function. 4th

ed. Baltimore, MD: Williams & Wilkins; 1993.

39. Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial bandsyndrome in distance runners. Sports Med 1985;2:447-451.

40. Ekman E, Pope T, Martin D, Curl W. Magnetic resonance imaging ofiliotibial band syndrome. Am J Sports Med 1994;22:851-854.

41. Fredericson M, White JJ, Macmahon JM, Andriacchi TP. Quantitativeanalysis of the relative effectiveness of 3 iliotibial band stretches. ArchPhys Med Rehabil 2002;83:589-592.

42. Gose JC, Schweizer P. Iliotibial band tightness. J Orthop Sports PhysTher 1989;10:399-407.

43. Clapis PA, Davis SM, Davis RO. Reliability of inclinometer and gonio-metric measurements of hip extension flexibility using the modifiedThomas test. Physiother Theory Pract 2008;24:135-141.

44. Harvey D. Assessment of the flexibility of elite athletes using themodified Thomas test. Br J Sports Med 1998;32:68-70.

45. Hollman JH, Ginos BE, Kozuchowski J, Vaughn AS, Krause DA, YoudasJW. Relationships between knee valgus, hip-muscle strength, andhip-muscle recruitment during a single-limb step-down. J Sport Reha-bil 2009;18:104-117.

46. Youdas JW, Mraz ST, Norstad BJ, Schinke JJ, Hollman JH. Determiningmeaningful changes in pelvic-on-femoral position during the Tren-delenburg test. J Sport Rehabil 2007;16:326-335.

47. Lyons K, Perry J, Gronley JK, Barnes L, Antonelli D. Timing and relativeintensity of hip extensor and abductor muscle action during level andstair ambulation. An EMG study. Phys Ther 1983;63:1597-1605.

48. Bell DR, Padua DA, Clark MA. Muscle strength and flexibility charac-teristics of people displaying excessive medial knee displacement. ArchPhys Med Rehabil 2008;89:1323-1328.

49. Neumann DA. Kinesiology of the hip: a focus on muscular actions.J Orthop Sports Phys Ther 2010;40:82-94.

50. Gurney AB, Wascher DC. Absorption of dexamethasone sodium phos-phate in human connective tissue using iontophoresis. Am J SportsMed 2008;36:753-759.

51. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibialband friction syndrome in runners: a randomised controlled trial. Br JSports Med 2004;38:269-272.

52. Beers A, Ryan M, Kasubuchi Z, Fraser S, Taunton JE. Effects of multi-modalphysiotherapy, includinghipabductor strengthening, inpatientswith iliotibialband friction syndrome. Physiother Can 2008;60:180-188.

53. Tonley J, Yun S, Kochevar R, Dye J, Farrokhi S, Powers C. Treatment ofan individual with piriformis syndrome focusing on hip musclestrengthening and movement reeducation: a case report. J OrthopSports Phys Ther 2010;40:103-111.

54. Wagner T, Behnia N, Lau Ancheta W, Shen R, Farrokhi S, Powers CM.Strengthening and neuromuscular reeducation of the gluteus maximusin a triathlete with exercise-associated cramping of the hamstrings.J Orthop Sports Phys Ther 2010;40:112-119.

55. Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscleactivation during common therapeutic exercises. J Orthop Sports PhysTher 2009;39:532-540.

56. Ayotte NW, Stetts DM, Keenan G, Greenway EH. Electromyographicalanalysis of selected lower extremity muscles during 5 unilateral weightbearing exercises. J Orthop Sports Phys Ther 2007;37:48-55.

57. Fischer FJ, Houtz SJ. Evaluation of the function of the gluteus maximusmuscle. An electromyographic study. Am J Phys Med 1968;47:182-191.

58. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining onhip kinematics, pain and function in subjects with patellofemoral painsyndrome. Br J Sports Med 2010, doi:1136/069112. Available at http://bjsm.bmj.com/content/early/2010/06/27/bjsm.2009.069112.full. Ac-cessed July 18, 2010.

59. Barrios JA, Crossley KM, Davis IS. Gait retraining to reduce the kneeadduction moment through real-time visual feedback of dynamic kneealignment. J Biomech 43:2208–2213.

60. Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG. Cycling

injuries of the lower extremity. J Am Acad Orthop Surg 2007;15:748-756.