History and exam
Key diagnostic factors
common
sharp or burning pain superior to the lateral joint line
Athletes will often complain of a sharp or burning pain roughly 2 cm superior to the lateral knee joint line. The pain may radiate proximally or distally. In less severe cases, the pain begins after a reproducible time or distance and subsides quickly upon cessation of activities. With increasing severity, normal walking or sitting with the knee in flexion may become painful.
positive Noble's test
Physician applies pressure over the lateral femoral epicondyle while extending the knee from 90° of flexion.[7] Pain occurs when knee is flexed around 30°.
positive Ober's test
positive modified Thomas's test
The patient sits on the end of an examining table, rolls back to a supine position, and holds both knees to the chest. The patient holds the knee on the asymptomatic side close to the chest, keeping the hips on the table, and avoiding excessive posterior tilt (lumbar lordosis flattened).[32] The examiner then slowly lowers the affected limb towards the floor.[7]The test is positive if the femur is above the horizontal of the table (psoas), knee extends (rectus femoris and psoas), and abduction of the femur deepens the iliotibial band (tensor fascia lata and iliotibial band).[32][33][34]
Other diagnostic factors
common
reduced hip abductor muscle strength
Hip abductor muscle strength is evaluated in the side-lying position. Patients often compensate for weakness or inhibition of the gluteus medius with substitution of the tensor fascia lata, the quadratus lumborum muscles, or both. Hip abduction may be obtained by internal rotation and flexion of the hip owing to the tensor fascia lata, or hip elevation may be noted because the quadratus lumborum over-activates. A dysfunctional firing pattern may also be the source of chronic tensor fascia lata tightness. The normal firing pattern is gluteus medius, followed by tensor fascia lata, ipsilateral quadratus lumborum, and erector spinae.[7]
genu varum (bow leg)
Intrinsic factor that contributes to iliotibial band tightness and muscle weakness (quadriceps and gluteus medius).[19]
hind-foot and fore-foot varum
Intrinsic factor that contributes to iliotibial band tightness and muscle weakness (quadriceps and gluteus medius).[19]
pes cavus (high arch)
Intrinsic factor that contributes to iliotibial band tightness and muscle weakness (quadriceps and gluteus medius).[19]
prominent lateral femoral epicondyle, tight iliotibial tract and tensor fascia lata
Repetitive irritation can lead to chronic inflammation, especially beneath the posterior fibres of the iliotibial band, which are thought to be tighter against the lateral femoral epicondyle than the anterior fibres.
weak gluteus medius, gluteus maximus, and tensor fascia lata
uncommon
pain on sitting or walking
Typically, athletes complain of lateral knee pain present on the onset of walking.
local oedema
Local oedema may be noted at the distal iliotibial band, and thorough palpation of the affected limb may reveal multiple trigger points in the vastus lateralis, gluteus medius, and biceps femoris.
crepitation
May occur when the knee is bent and then straightened.
Risk factors
strong
athlete
ITBS is primarily seen in runners and cyclists but may also be observed in athletes participating in volleyball, tennis, soccer, skiing, weight lifting, and aerobics. More experienced runners may be less likely to develop ITBS.[15] It is unusual in non-athletes.
high weekly mileage
time spent walking or running on a track
interval training
muscular weakness of knee extensors, knee flexors, and hip abductors
Studies have demonstrated that weakness or inhibition of the lateral gluteal muscles is a causative factor in this injury. When these muscles do not fire properly throughout the support phase of the running cycle, there is a decreased ability to stabilise the pelvis and eccentrically control hip abduction. As a result, other muscles must compensate, often leading to excessive soft-tissue tightness and myofascial restrictions.[15][27][28]
lack of running experience
May lead to over training with a sudden increase in mileage, or running at an improper pace.[15]
use of worn-out running shoes
Lack of proper foot support will increase the pressure on the bursa and iliotibial band.
downhill running, or running on a cambered or slippery surface
Increases the pressure on the bursa and iliotibial band, as excessive friction of the distal iliotibial band (ITB) sliding over the lateral femoral epicondyle occurs as the knee flexes during deceleration into stance-phase running.[5]
weak
pre-existing iliotibial band tightness
Weak evidence exists for ITBS runners as less flexible than age-matched non-ITBS runners.[20] More research is needed to better quantify iliotibial band length, both static and dynamic, in patients with ITBS.
leg-length discrepancies
Leg-length discrepancies also contribute to ITBS and are assessed as part of a routine examination.
step width
Increased strain rate in the iliotibial band has been reported as a factor in ITBS.[25] Limited evidence exists that narrow step width increases iliotibial band strain rate in healthy runners.[29] More research is needed to evaluate the step width in runners with ITBS, and the relationship between excessive hip adduction and step width.
knee varus in male runners
Results from one small study demonstrated that men with ITBS exhibit significantly greater knee adduction angles during running compared with men with no ITBS.[23]
muscular weakness in hip external rotator muscles in male runners
Results from one small study demonstrated that men with ITBS exhibit weaker hip external rotators compared with men with no ITBS.[23]
excessive hip internal rotation in male runners
Results from one small study demonstrated that men with ITBS exhibit significantly greater hip internal rotation during running compared with men with no ITBS.[23]
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