by Robert Raines, M.D.
Member, American Orthopaedic Foot and Ankle Society

The iliotibial band friction syndrome is one of the most common overuse injuries of long distance runners and is the second most common cause of knee pain in runners. It is estimated that it will afflict 20% of runners at some time in his/her life. I became formally introduced to the iliotibial band friction syndrome (ITBFS) during a 5-mile training run for the Chicago marathon. In the middle of a not-particularly-fast workout, I began to notice soreness on the outside of my left knee that worsened with ever step.

Eventually I had to abort the run and limp home.  I came to realize that I was suffering my initial (though not final) episode of ITBFS.  After altering my training, instituting some new stretches, and taking a short cycle of anti-inflammatories, I was able to resume my training and eventually complete the marathon. ITBFS remains a common, yet commonly misdiagnosed injury in runners. The key to recovering from ITBFS and returning to running is recognizing that you have the syndrome and beginning specific treatment  This article will catalogue the common causes, symptoms, and physical findings of ITBFS and will discuss treatment options so that you will know if you get the syndrome and how to get rid of it.

The iliotibial band is a dense sheet of tendon-like tissue that runs down the outside of the thighs from the hip to the knee

If you pass your hand down the outside of your thigh, you will feel a dense band of tissue just above the knee. This is the iliotibial band. It begins as a muscle of the thigh and ends as a tendon that inserts on the outside of the tibia, the large bone of the lower leg. In its course across the outside of the knee, the iliotibial band passes directly over a large bump of bone on the end of the femur called the femoral condyle. The peculiar part of this anatomy is that when your knee is straight, the iliotibial band sits in front of the femoral condyle, but when you flex your knee, the iliotibial band jumps over the condyle and rests behind it. The result is a tendon that snaps over a relatively large bump of bone with every stride. As you might imagine, this tendon can become inflamed on its underside with the repeated rubbing (or friction) on the bone. Over time the inflammation will lead to pain on the outside of the knee that is associated with running. This is the iliotibial band friction syndrome.

Many researchers have looked for specific causes of the ITBFS.  What all doctors agree upon is that the most common causes of the ITBFS are excessive hill training, specifically downhill running, and an excessively tight iliotibial band. It appears that when running downhill, your knee is at or near 30 degree of flexion on impact. This flexion moment causes the iliotibial band to snap with the greatest force over the femoral condyle and incites the inflammation. A tight iliotibial band exacerbates this friction. While some have suggested that factors like leg length discrepancy, rigid shoes, and supination of the forefoot can cause ITBFS, these have never been scientifically confirmed.

ITBFS has specific characteristics that will aid in its diagnosis.

Firstly, the pain is always on the outside of the knee, never in the front or on the inside. You will feel a tender spot on the outside of the knee just above the joint itself that becomes most tender when the knee is flexed to about 30 degrees.

Sometimes but not always this tender spot will be slightly swollen. Characteristically, the pain comes on after several minutes of activity and will abate if running stops. Finally, ITBFS does not cause swelling inside the knee and will not cause knee popping or locking.

The vast majority of cases of ITBFS can be successfully treated without the need for long periods of time off from running or surgery. The four components of initial treatment are:

1) a short period of time off running (5-7 days) and then resumption of running with reduced hill work

2) a short course of anti-inflammatory medication (7-10 days of over the counter ibuprofen)

3) icing of the iliotibial band for 10-15 minutes for the first 2-3 days after you feel the pain, and most importantly

4) performing iliotibial band stretches for 10 minutes several times a day while recovering, and adding these stretches to your warm-up and warm-down routine for the rest of your life. Here is how you stretch the iliotibial band (for ITBFS of the left side in this example): in a standing position, cross your right leg in front of your left. Place your left hand on a table or chair for balance. Now, begin to slide your left foot away from your right while making sure that both feet remain flat on the ground. As your left foot slides away from your right, you will need to begin to slightly flex the right knee. You will eventually feel a strong pull on the outside of your knee as it slides away from the right. Once you have slid the left foot as far from the right as possible while still keeping both feet flat on the floor (for me about 2 feet), hold that position for 30 seconds. Perform multiple repetitions on each leg.

Most runners will be able to return to running within 1-2 weeks if this protocol is followed. If you do not respond, you may need to stay off running for up to a month. During this time, continue the stretching religiously. If you are still unable to run after a month of rest and stretching, you may want to consult an orthopaedic surgeon or sports medicine doctor. You may have mistakenly diagnosed yourself with ITBFS, or you may be one of the rare runners who require a cortisone injection in the iliotibial band.

ITBFS is a common overuse injury of runners.  It can almost always be eradicated with relatively little time off if you know the diagnosis and how to treat it.  Take the advice of one who has survived ITBFS. Stretch your iliotibial band now before it hurts.   Preventing disease beats treating it every time.

Women in Motion May 2001