One out of every four adults have knee pain which is a frequent cause of diminished mobility and low quality of life. Iliotibial band syndrome (ITBS) can be ruled out among the different causes of lateral knee pain. This was initially described in 1975 in U.S. Marine Corps recruits during training and has since been commonly described in endurance athletes like long-distance runners, bikers and skiers and in athletes of sports like hockey, basketball and soccer. These exercises entail repetitive and prolonged knee flexion and extension which are some of the major causes of ITBS. Liotibial band (ITB) is the distal muscular fascia extension of the tensor fasciae latae, gluteus medius and gluteus maximus. It courses shallowly across the vastus lateralis, and is mainly inserted into the tubercle of Gerdy, on the lateral side of the tibia, and partially into supracondylar ridge of lateral femur. There is also an anterior part, which is iliopatellar band, and is attached to the lateral patella and serves to restrain the medial patellar movement.Â
Epidemiology
Iliotibial band syndrome (ITBS) is known to be the most common cause of lateral knee pain in runners and bicycle riders, as well as in those who perform other sporting activities like tennis, soccer, skiing, and weight training. Its occurrence has been reported to be between 1.6 and 12% among runners and other athletes who engage in lower limb movements that are repeated. It tends to be slightly more common in women compared to men as well as it is not commonly seen in people with sedentary lifestyles. This prevalence of ITBS in military recruits was observed to be 6.2% in a cross sectional study where U.S. Marine Corps indicated that running and overuse injuries constituted about 12% of all injuries sustained by its personnel.Â
Anatomy
Pathophysiology
Iliotibial band syndrome (ITBS) is believed to result from a combination of mechanical, anatomical, and inflammatory factors. Traditionally, repetitive friction between the distal ITB and the lateral femoral epicondyle during knee flexion and extension, particularly around 30 degrees of flexion which corresponds to foot strike in running, was considered the primary cause. This area, often referred to as the impingement zone, was thought to develop localized inflammation. However, anatomical studies suggest that instead of gliding friction, compression of a highly innervated fat pad beneath the distal ITB may be the main source of pain. Chronic inflammation of a fluid-filled ITB bursa located between the ITB and lateral epicondyle may also contribute.Â
Risk factors that increase ITB tension include biomechanical and anatomical variations such as internal tibial torsion, weakness of the hip abductors, excessive foot pronation, and medial compartment osteoarthritis causing genu varum. Training factors such as running on cambered surfaces, hill running, and sudden increases in intensity also increase stress on the ITB. Altered proximal biomechanics can lead to associated conditions including greater trochanteric pain syndrome and patellofemoral pain syndrome due to tension transmitted along the iliotibial and iliopatellar bands.Â
Etiology
The etiology of iliotibial band syndrome (ITBS) remains debated and is likely multifactorial. One proposed mechanism suggests that repeated friction between the ITB and the lateral femoral epicondyle during knee flexion and extension leads to inflammation at the contact site, which occurs around 30 degrees of flexion, corresponding to the foot strike during running. This region is often referred to as the “impingement zone.” However, anatomical studies have not consistently demonstrated such gliding of the ITB over the lateral epicondyle. Histological analysis of cadaveric specimens has identified a highly innervated fat pad beneath the distal ITB, and compression of this structure is thought to contribute to lateral knee pain. Another theory implicates chronic inflammation of a fluid-filled ITB bursa located between the ITB and the lateral epicondyle. At present, it remains unclear whether a single mechanism predominates or whether ITBS arises from multiple contributing factors.Â
Genetics
Prognostic Factors
Approximately fifty to 90 % of patients experience improvement with four to eight weeks of non-surgical treatment. Surgical interventions have also demonstrated good to excellent outcomes. Iliotibial band syndrome generally follows a fluctuating course and may recur at any stage during treatment or after returning to activity.Â
Clinical History
Age group:Â
Iliotibial band syndrome most commonly affects young to middle-aged adults, particularly those engaged in repetitive activities such as running, cycling, and sports requiring frequent knee flexion and extension. It is less commonly observed in older adults or individuals with a sedentary lifestyle.Â
Physical Examination
Physical Examination Â
On examination, patients with iliotibial band syndrome often demonstrate localized tenderness over the lateral femoral epicondyle or the Gerdy tubercle. Pain may be elicited by direct palpation, particularly when the knee is flexed to approximately 30 degrees. The Noble compression test, performed by applying pressure over the lateral femoral epicondyle while passively extending the flexed knee, often reproduces symptoms. The Ober test can assess ITB tightness and hip abductor flexibility. Gait analysis may reveal altered biomechanics, including lateral knee thrust or hip drop. Range of motion is usually preserved, and strength testing may identify weakness in the hip abductors or gluteal muscles. It is important to evaluate for associated conditions such as patellofemoral pain syndrome or greater trochanteric pain syndrome, which may influence management.Â
Age group
Associated comorbidity
Associated Comorbidity or Activity:Â
Iliotibial band syndrome is frequently associated with activities that involve repetitive knee flexion and extension, including running, cycling, soccer, tennis, skiing, and weight training. Anatomical or biomechanical factors such as hip abductor weakness, excessive foot pronation, internal tibial torsion, and medial compartment osteoarthritis can increase ITB tension and contribute to the condition.Â
Associated activity
Acuity of presentation
Acuity of presentation:Â
Iliotibial band syndrome usually presents as a gradual onset of lateral knee pain that worsens with repetitive activity. Acute episodes are uncommon, and symptoms often develop over days to weeks rather than suddenly.Â
Differential Diagnoses
Differential Diagnoses Â
Popliteal tendinopathyÂ
Patellofemoral syndromeÂ
Radiation from hip pathologyÂ
Biceps femoris tendinopathyÂ
Lateral collateral ligament strainÂ
Lateral compartment of the knee osteoarthritisÂ
Lateral meniscus tearÂ
Stress fracture of the lateral tibial plateauÂ
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment Paradigm Â
Nonoperative treatment is the first-line approach for most patients with iliotibial band syndrome. Patients should avoid the activity that triggers symptoms until pain resolves. Intermittent ice therapy can relieve acute flares, and a gradual return to activity is recommended once the patient is pain-free with both movement and palpation. Physical therapy focusing on ITB stretching and hip abductor strengthening helps reduce tension, while manual therapy, such as myofascial release with a foam roller, can break up adhesions. Proper ergonomics and posture during activity should also be taught.Â
Nonsteroidal anti-inflammatory drugs can help reduce inflammation, and corticosteroid injections may provide both diagnostic and therapeutic relief. Shoe modifications, foot orthoses, and sport-specific technique training can help prevent recurrence. Most patients achieve full symptom relief and return to activity within six to eight weeks. Gradual progression should start with short runs on flat surfaces, increasing frequency and distance over several weeks before introducing hills or cambered surfaces. Any relapse requires restarting the progression with a period of rest.Â
Surgery is reserved for refractory cases unresponsive to at least six months of conservative management. Options include open or percutaneous ITB release, ITB lengthening via Z-plasty, ITB bursectomy, and arthroscopic ITB debridement. Techniques for ITB release vary, including resection of a triangular distal portion, a 2 x 4 cm section over the lateral femoral epicondyle, or a V-shaped incision. ITB bursectomy involves excision of the underlying bursa while preserving the ITB and has shown high patient satisfaction. Minimally invasive arthroscopic techniques targeting the lateral synovial recess and innervated synovial fat have also demonstrated excellent outcomes, with patients returning to full activity in nearly all cases.Â
Adjusting the training or activity environment can help prevent and manage iliotibial band syndrome. Strategies include running on flat surfaces instead of cambered roads, avoiding downhill running, alternating training surfaces, and ensuring proper footwear. Foot orthoses or shoe modifications may also reduce biomechanical stress on the ITB and help prevent recurrence.Â
Effectiveness of NSAID’s in treating Iliotibial Band Syndrome
Naproxen (Naprelan, Naprosyn, Anaprox) Naproxen provides relief from mild to moderate pain by reducing inflammation and discomfort. It works through inhibition of the cyclooxygenase (COX) enzyme, leading to decreased prostaglandin production, which helps alleviate pain and swelling.Â
Ibuprofen (Motrin, Ibuprin) Ibuprofen is commonly used as a first-line medication for mild to moderate pain. Its therapeutic effect results from inhibition of prostaglandin synthesis, which reduces both inflammation and pain perception.Â
Diclofenac (Cataflam, Voltaren) Diclofenac, a phenylacetic acid derivative with anti-inflammatory and analgesic effects, acts primarily by inhibiting cyclooxygenase, an enzyme involved in prostaglandin synthesis. Because diclofenac may cause liver toxicity, monitoring of liver enzyme levels during the first several weeks of therapy is recommended.Â
Surgical intervention is reserved for patients who fail to respond to at least six months of conservative treatment. Several surgical techniques are available, including percutaneous or open iliotibial band (ITB) release, ITB lengthening using a Z-plasty approach, ITB bursectomy, and arthroscopic ITB debridement. Various methods for open ITB release have been described, such as excising a triangular segment of the distal posterior band, removing a 2 Ă— 4 cm section over the lateral femoral epicondyle, or performing a V-shaped incision to reduce tension.Â
ITB bursectomy is typically indicated when MRI findings show inflammation of the bursa without ITB thickening. The procedure involves removal of the inflamed bursa while preserving the integrity of the ITB and has shown high patient satisfaction rates. Minimally invasive arthroscopic approaches have also been developed to excise the lateral synovial recess and associated innervated fat. In one study, Michels and colleagues reported good to excellent outcomes in 97% of patients, all of whom returned to full activity following the arthroscopic technique.Â
In the acute phase, the goal is to reduce pain and inflammation. This is achieved through rest and avoidance of aggravating activities like running or cycling. Ice packs are applied for 15 to 20 minutes several times a day, and short-term use of NSAIDs may help relieve pain. Compression, elevation, and gentle massage can further ease symptoms. If inflammation persists despite conservative treatment, a corticosteroid injection around the lateral femoral condyle may be used.Â
The subacute phase aims to restore flexibility, strength, and correct biomechanical imbalances. Stretching of the iliotibial band, tensor fascia lata, gluteal muscles, hamstrings, and quadriceps helps improve mobility. Foam rolling and self-myofascial release reduce tightness, while strengthening the gluteus medius, gluteus maximus, and hip abductors improves stability. Core strengthening and gait retraining are also introduced to correct movement faults. Guidance from a physical therapist can optimize recovery and prevent recurrence.Â
In the return-to-activity phase, the focus is on gradually resuming physical activity. Training should begin at a low intensity and short duration, increasing progressively while monitoring for pain. Downhill running and uneven surfaces should be avoided early on. Proper footwear and orthotics may be recommended to correct biomechanical issues. Continued stretching, strengthening, and education on proper warm-up, cool-down, and load management are essential to prevent recurrence.Â
In chronic or resistant cases, when conservative therapy fails, options such as corticosteroid injections, platelet-rich plasma (PRP) therapy, or surgical release of the iliotibial band may be considered. However, most patients recover well with a structured, progressive rehabilitation program that emphasizes pain control, strengthening, and gradual return to activity.Â
One out of every four adults have knee pain which is a frequent cause of diminished mobility and low quality of life. Iliotibial band syndrome (ITBS) can be ruled out among the different causes of lateral knee pain. This was initially described in 1975 in U.S. Marine Corps recruits during training and has since been commonly described in endurance athletes like long-distance runners, bikers and skiers and in athletes of sports like hockey, basketball and soccer. These exercises entail repetitive and prolonged knee flexion and extension which are some of the major causes of ITBS. Liotibial band (ITB) is the distal muscular fascia extension of the tensor fasciae latae, gluteus medius and gluteus maximus. It courses shallowly across the vastus lateralis, and is mainly inserted into the tubercle of Gerdy, on the lateral side of the tibia, and partially into supracondylar ridge of lateral femur. There is also an anterior part, which is iliopatellar band, and is attached to the lateral patella and serves to restrain the medial patellar movement.Â
Iliotibial band syndrome (ITBS) is known to be the most common cause of lateral knee pain in runners and bicycle riders, as well as in those who perform other sporting activities like tennis, soccer, skiing, and weight training. Its occurrence has been reported to be between 1.6 and 12% among runners and other athletes who engage in lower limb movements that are repeated. It tends to be slightly more common in women compared to men as well as it is not commonly seen in people with sedentary lifestyles. This prevalence of ITBS in military recruits was observed to be 6.2% in a cross sectional study where U.S. Marine Corps indicated that running and overuse injuries constituted about 12% of all injuries sustained by its personnel.Â
Iliotibial band syndrome (ITBS) is believed to result from a combination of mechanical, anatomical, and inflammatory factors. Traditionally, repetitive friction between the distal ITB and the lateral femoral epicondyle during knee flexion and extension, particularly around 30 degrees of flexion which corresponds to foot strike in running, was considered the primary cause. This area, often referred to as the impingement zone, was thought to develop localized inflammation. However, anatomical studies suggest that instead of gliding friction, compression of a highly innervated fat pad beneath the distal ITB may be the main source of pain. Chronic inflammation of a fluid-filled ITB bursa located between the ITB and lateral epicondyle may also contribute.Â
Risk factors that increase ITB tension include biomechanical and anatomical variations such as internal tibial torsion, weakness of the hip abductors, excessive foot pronation, and medial compartment osteoarthritis causing genu varum. Training factors such as running on cambered surfaces, hill running, and sudden increases in intensity also increase stress on the ITB. Altered proximal biomechanics can lead to associated conditions including greater trochanteric pain syndrome and patellofemoral pain syndrome due to tension transmitted along the iliotibial and iliopatellar bands.Â
The etiology of iliotibial band syndrome (ITBS) remains debated and is likely multifactorial. One proposed mechanism suggests that repeated friction between the ITB and the lateral femoral epicondyle during knee flexion and extension leads to inflammation at the contact site, which occurs around 30 degrees of flexion, corresponding to the foot strike during running. This region is often referred to as the “impingement zone.” However, anatomical studies have not consistently demonstrated such gliding of the ITB over the lateral epicondyle. Histological analysis of cadaveric specimens has identified a highly innervated fat pad beneath the distal ITB, and compression of this structure is thought to contribute to lateral knee pain. Another theory implicates chronic inflammation of a fluid-filled ITB bursa located between the ITB and the lateral epicondyle. At present, it remains unclear whether a single mechanism predominates or whether ITBS arises from multiple contributing factors.Â
Approximately fifty to 90 % of patients experience improvement with four to eight weeks of non-surgical treatment. Surgical interventions have also demonstrated good to excellent outcomes. Iliotibial band syndrome generally follows a fluctuating course and may recur at any stage during treatment or after returning to activity.Â
Age group:Â
Iliotibial band syndrome most commonly affects young to middle-aged adults, particularly those engaged in repetitive activities such as running, cycling, and sports requiring frequent knee flexion and extension. It is less commonly observed in older adults or individuals with a sedentary lifestyle.Â
Physical Examination Â
On examination, patients with iliotibial band syndrome often demonstrate localized tenderness over the lateral femoral epicondyle or the Gerdy tubercle. Pain may be elicited by direct palpation, particularly when the knee is flexed to approximately 30 degrees. The Noble compression test, performed by applying pressure over the lateral femoral epicondyle while passively extending the flexed knee, often reproduces symptoms. The Ober test can assess ITB tightness and hip abductor flexibility. Gait analysis may reveal altered biomechanics, including lateral knee thrust or hip drop. Range of motion is usually preserved, and strength testing may identify weakness in the hip abductors or gluteal muscles. It is important to evaluate for associated conditions such as patellofemoral pain syndrome or greater trochanteric pain syndrome, which may influence management.Â
Associated Comorbidity or Activity:Â
Iliotibial band syndrome is frequently associated with activities that involve repetitive knee flexion and extension, including running, cycling, soccer, tennis, skiing, and weight training. Anatomical or biomechanical factors such as hip abductor weakness, excessive foot pronation, internal tibial torsion, and medial compartment osteoarthritis can increase ITB tension and contribute to the condition.Â
Acuity of presentation:Â
Iliotibial band syndrome usually presents as a gradual onset of lateral knee pain that worsens with repetitive activity. Acute episodes are uncommon, and symptoms often develop over days to weeks rather than suddenly.Â
Differential Diagnoses Â
Popliteal tendinopathyÂ
Patellofemoral syndromeÂ
Radiation from hip pathologyÂ
Biceps femoris tendinopathyÂ
Lateral collateral ligament strainÂ
Lateral compartment of the knee osteoarthritisÂ
Lateral meniscus tearÂ
Stress fracture of the lateral tibial plateauÂ
Treatment Paradigm Â
Nonoperative treatment is the first-line approach for most patients with iliotibial band syndrome. Patients should avoid the activity that triggers symptoms until pain resolves. Intermittent ice therapy can relieve acute flares, and a gradual return to activity is recommended once the patient is pain-free with both movement and palpation. Physical therapy focusing on ITB stretching and hip abductor strengthening helps reduce tension, while manual therapy, such as myofascial release with a foam roller, can break up adhesions. Proper ergonomics and posture during activity should also be taught.Â
Nonsteroidal anti-inflammatory drugs can help reduce inflammation, and corticosteroid injections may provide both diagnostic and therapeutic relief. Shoe modifications, foot orthoses, and sport-specific technique training can help prevent recurrence. Most patients achieve full symptom relief and return to activity within six to eight weeks. Gradual progression should start with short runs on flat surfaces, increasing frequency and distance over several weeks before introducing hills or cambered surfaces. Any relapse requires restarting the progression with a period of rest.Â
Surgery is reserved for refractory cases unresponsive to at least six months of conservative management. Options include open or percutaneous ITB release, ITB lengthening via Z-plasty, ITB bursectomy, and arthroscopic ITB debridement. Techniques for ITB release vary, including resection of a triangular distal portion, a 2 x 4 cm section over the lateral femoral epicondyle, or a V-shaped incision. ITB bursectomy involves excision of the underlying bursa while preserving the ITB and has shown high patient satisfaction. Minimally invasive arthroscopic techniques targeting the lateral synovial recess and innervated synovial fat have also demonstrated excellent outcomes, with patients returning to full activity in nearly all cases.Â
Other Clinical
Adjusting the training or activity environment can help prevent and manage iliotibial band syndrome. Strategies include running on flat surfaces instead of cambered roads, avoiding downhill running, alternating training surfaces, and ensuring proper footwear. Foot orthoses or shoe modifications may also reduce biomechanical stress on the ITB and help prevent recurrence.Â
Other Clinical
Naproxen (Naprelan, Naprosyn, Anaprox) Naproxen provides relief from mild to moderate pain by reducing inflammation and discomfort. It works through inhibition of the cyclooxygenase (COX) enzyme, leading to decreased prostaglandin production, which helps alleviate pain and swelling.Â
Ibuprofen (Motrin, Ibuprin) Ibuprofen is commonly used as a first-line medication for mild to moderate pain. Its therapeutic effect results from inhibition of prostaglandin synthesis, which reduces both inflammation and pain perception.Â
Diclofenac (Cataflam, Voltaren) Diclofenac, a phenylacetic acid derivative with anti-inflammatory and analgesic effects, acts primarily by inhibiting cyclooxygenase, an enzyme involved in prostaglandin synthesis. Because diclofenac may cause liver toxicity, monitoring of liver enzyme levels during the first several weeks of therapy is recommended.Â
Other Clinical
Surgical intervention is reserved for patients who fail to respond to at least six months of conservative treatment. Several surgical techniques are available, including percutaneous or open iliotibial band (ITB) release, ITB lengthening using a Z-plasty approach, ITB bursectomy, and arthroscopic ITB debridement. Various methods for open ITB release have been described, such as excising a triangular segment of the distal posterior band, removing a 2 Ă— 4 cm section over the lateral femoral epicondyle, or performing a V-shaped incision to reduce tension.Â
ITB bursectomy is typically indicated when MRI findings show inflammation of the bursa without ITB thickening. The procedure involves removal of the inflamed bursa while preserving the integrity of the ITB and has shown high patient satisfaction rates. Minimally invasive arthroscopic approaches have also been developed to excise the lateral synovial recess and associated innervated fat. In one study, Michels and colleagues reported good to excellent outcomes in 97% of patients, all of whom returned to full activity following the arthroscopic technique.Â
Sports MedicineÂ
Â
In the acute phase, the goal is to reduce pain and inflammation. This is achieved through rest and avoidance of aggravating activities like running or cycling. Ice packs are applied for 15 to 20 minutes several times a day, and short-term use of NSAIDs may help relieve pain. Compression, elevation, and gentle massage can further ease symptoms. If inflammation persists despite conservative treatment, a corticosteroid injection around the lateral femoral condyle may be used.Â
The subacute phase aims to restore flexibility, strength, and correct biomechanical imbalances. Stretching of the iliotibial band, tensor fascia lata, gluteal muscles, hamstrings, and quadriceps helps improve mobility. Foam rolling and self-myofascial release reduce tightness, while strengthening the gluteus medius, gluteus maximus, and hip abductors improves stability. Core strengthening and gait retraining are also introduced to correct movement faults. Guidance from a physical therapist can optimize recovery and prevent recurrence.Â
In the return-to-activity phase, the focus is on gradually resuming physical activity. Training should begin at a low intensity and short duration, increasing progressively while monitoring for pain. Downhill running and uneven surfaces should be avoided early on. Proper footwear and orthotics may be recommended to correct biomechanical issues. Continued stretching, strengthening, and education on proper warm-up, cool-down, and load management are essential to prevent recurrence.Â
In chronic or resistant cases, when conservative therapy fails, options such as corticosteroid injections, platelet-rich plasma (PRP) therapy, or surgical release of the iliotibial band may be considered. However, most patients recover well with a structured, progressive rehabilitation program that emphasizes pain control, strengthening, and gradual return to activity.Â
One out of every four adults have knee pain which is a frequent cause of diminished mobility and low quality of life. Iliotibial band syndrome (ITBS) can be ruled out among the different causes of lateral knee pain. This was initially described in 1975 in U.S. Marine Corps recruits during training and has since been commonly described in endurance athletes like long-distance runners, bikers and skiers and in athletes of sports like hockey, basketball and soccer. These exercises entail repetitive and prolonged knee flexion and extension which are some of the major causes of ITBS. Liotibial band (ITB) is the distal muscular fascia extension of the tensor fasciae latae, gluteus medius and gluteus maximus. It courses shallowly across the vastus lateralis, and is mainly inserted into the tubercle of Gerdy, on the lateral side of the tibia, and partially into supracondylar ridge of lateral femur. There is also an anterior part, which is iliopatellar band, and is attached to the lateral patella and serves to restrain the medial patellar movement.Â
Iliotibial band syndrome (ITBS) is known to be the most common cause of lateral knee pain in runners and bicycle riders, as well as in those who perform other sporting activities like tennis, soccer, skiing, and weight training. Its occurrence has been reported to be between 1.6 and 12% among runners and other athletes who engage in lower limb movements that are repeated. It tends to be slightly more common in women compared to men as well as it is not commonly seen in people with sedentary lifestyles. This prevalence of ITBS in military recruits was observed to be 6.2% in a cross sectional study where U.S. Marine Corps indicated that running and overuse injuries constituted about 12% of all injuries sustained by its personnel.Â
Iliotibial band syndrome (ITBS) is believed to result from a combination of mechanical, anatomical, and inflammatory factors. Traditionally, repetitive friction between the distal ITB and the lateral femoral epicondyle during knee flexion and extension, particularly around 30 degrees of flexion which corresponds to foot strike in running, was considered the primary cause. This area, often referred to as the impingement zone, was thought to develop localized inflammation. However, anatomical studies suggest that instead of gliding friction, compression of a highly innervated fat pad beneath the distal ITB may be the main source of pain. Chronic inflammation of a fluid-filled ITB bursa located between the ITB and lateral epicondyle may also contribute.Â
Risk factors that increase ITB tension include biomechanical and anatomical variations such as internal tibial torsion, weakness of the hip abductors, excessive foot pronation, and medial compartment osteoarthritis causing genu varum. Training factors such as running on cambered surfaces, hill running, and sudden increases in intensity also increase stress on the ITB. Altered proximal biomechanics can lead to associated conditions including greater trochanteric pain syndrome and patellofemoral pain syndrome due to tension transmitted along the iliotibial and iliopatellar bands.Â
The etiology of iliotibial band syndrome (ITBS) remains debated and is likely multifactorial. One proposed mechanism suggests that repeated friction between the ITB and the lateral femoral epicondyle during knee flexion and extension leads to inflammation at the contact site, which occurs around 30 degrees of flexion, corresponding to the foot strike during running. This region is often referred to as the “impingement zone.” However, anatomical studies have not consistently demonstrated such gliding of the ITB over the lateral epicondyle. Histological analysis of cadaveric specimens has identified a highly innervated fat pad beneath the distal ITB, and compression of this structure is thought to contribute to lateral knee pain. Another theory implicates chronic inflammation of a fluid-filled ITB bursa located between the ITB and the lateral epicondyle. At present, it remains unclear whether a single mechanism predominates or whether ITBS arises from multiple contributing factors.Â
Approximately fifty to 90 % of patients experience improvement with four to eight weeks of non-surgical treatment. Surgical interventions have also demonstrated good to excellent outcomes. Iliotibial band syndrome generally follows a fluctuating course and may recur at any stage during treatment or after returning to activity.Â
Age group:Â
Iliotibial band syndrome most commonly affects young to middle-aged adults, particularly those engaged in repetitive activities such as running, cycling, and sports requiring frequent knee flexion and extension. It is less commonly observed in older adults or individuals with a sedentary lifestyle.Â
Physical Examination Â
On examination, patients with iliotibial band syndrome often demonstrate localized tenderness over the lateral femoral epicondyle or the Gerdy tubercle. Pain may be elicited by direct palpation, particularly when the knee is flexed to approximately 30 degrees. The Noble compression test, performed by applying pressure over the lateral femoral epicondyle while passively extending the flexed knee, often reproduces symptoms. The Ober test can assess ITB tightness and hip abductor flexibility. Gait analysis may reveal altered biomechanics, including lateral knee thrust or hip drop. Range of motion is usually preserved, and strength testing may identify weakness in the hip abductors or gluteal muscles. It is important to evaluate for associated conditions such as patellofemoral pain syndrome or greater trochanteric pain syndrome, which may influence management.Â
Associated Comorbidity or Activity:Â
Iliotibial band syndrome is frequently associated with activities that involve repetitive knee flexion and extension, including running, cycling, soccer, tennis, skiing, and weight training. Anatomical or biomechanical factors such as hip abductor weakness, excessive foot pronation, internal tibial torsion, and medial compartment osteoarthritis can increase ITB tension and contribute to the condition.Â
Acuity of presentation:Â
Iliotibial band syndrome usually presents as a gradual onset of lateral knee pain that worsens with repetitive activity. Acute episodes are uncommon, and symptoms often develop over days to weeks rather than suddenly.Â
Differential Diagnoses Â
Popliteal tendinopathyÂ
Patellofemoral syndromeÂ
Radiation from hip pathologyÂ
Biceps femoris tendinopathyÂ
Lateral collateral ligament strainÂ
Lateral compartment of the knee osteoarthritisÂ
Lateral meniscus tearÂ
Stress fracture of the lateral tibial plateauÂ
Treatment Paradigm Â
Nonoperative treatment is the first-line approach for most patients with iliotibial band syndrome. Patients should avoid the activity that triggers symptoms until pain resolves. Intermittent ice therapy can relieve acute flares, and a gradual return to activity is recommended once the patient is pain-free with both movement and palpation. Physical therapy focusing on ITB stretching and hip abductor strengthening helps reduce tension, while manual therapy, such as myofascial release with a foam roller, can break up adhesions. Proper ergonomics and posture during activity should also be taught.Â
Nonsteroidal anti-inflammatory drugs can help reduce inflammation, and corticosteroid injections may provide both diagnostic and therapeutic relief. Shoe modifications, foot orthoses, and sport-specific technique training can help prevent recurrence. Most patients achieve full symptom relief and return to activity within six to eight weeks. Gradual progression should start with short runs on flat surfaces, increasing frequency and distance over several weeks before introducing hills or cambered surfaces. Any relapse requires restarting the progression with a period of rest.Â
Surgery is reserved for refractory cases unresponsive to at least six months of conservative management. Options include open or percutaneous ITB release, ITB lengthening via Z-plasty, ITB bursectomy, and arthroscopic ITB debridement. Techniques for ITB release vary, including resection of a triangular distal portion, a 2 x 4 cm section over the lateral femoral epicondyle, or a V-shaped incision. ITB bursectomy involves excision of the underlying bursa while preserving the ITB and has shown high patient satisfaction. Minimally invasive arthroscopic techniques targeting the lateral synovial recess and innervated synovial fat have also demonstrated excellent outcomes, with patients returning to full activity in nearly all cases.Â
Other Clinical
Adjusting the training or activity environment can help prevent and manage iliotibial band syndrome. Strategies include running on flat surfaces instead of cambered roads, avoiding downhill running, alternating training surfaces, and ensuring proper footwear. Foot orthoses or shoe modifications may also reduce biomechanical stress on the ITB and help prevent recurrence.Â
Other Clinical
Naproxen (Naprelan, Naprosyn, Anaprox) Naproxen provides relief from mild to moderate pain by reducing inflammation and discomfort. It works through inhibition of the cyclooxygenase (COX) enzyme, leading to decreased prostaglandin production, which helps alleviate pain and swelling.Â
Ibuprofen (Motrin, Ibuprin) Ibuprofen is commonly used as a first-line medication for mild to moderate pain. Its therapeutic effect results from inhibition of prostaglandin synthesis, which reduces both inflammation and pain perception.Â
Diclofenac (Cataflam, Voltaren) Diclofenac, a phenylacetic acid derivative with anti-inflammatory and analgesic effects, acts primarily by inhibiting cyclooxygenase, an enzyme involved in prostaglandin synthesis. Because diclofenac may cause liver toxicity, monitoring of liver enzyme levels during the first several weeks of therapy is recommended.Â
Other Clinical
Surgical intervention is reserved for patients who fail to respond to at least six months of conservative treatment. Several surgical techniques are available, including percutaneous or open iliotibial band (ITB) release, ITB lengthening using a Z-plasty approach, ITB bursectomy, and arthroscopic ITB debridement. Various methods for open ITB release have been described, such as excising a triangular segment of the distal posterior band, removing a 2 Ă— 4 cm section over the lateral femoral epicondyle, or performing a V-shaped incision to reduce tension.Â
ITB bursectomy is typically indicated when MRI findings show inflammation of the bursa without ITB thickening. The procedure involves removal of the inflamed bursa while preserving the integrity of the ITB and has shown high patient satisfaction rates. Minimally invasive arthroscopic approaches have also been developed to excise the lateral synovial recess and associated innervated fat. In one study, Michels and colleagues reported good to excellent outcomes in 97% of patients, all of whom returned to full activity following the arthroscopic technique.Â
Sports MedicineÂ
Â
In the acute phase, the goal is to reduce pain and inflammation. This is achieved through rest and avoidance of aggravating activities like running or cycling. Ice packs are applied for 15 to 20 minutes several times a day, and short-term use of NSAIDs may help relieve pain. Compression, elevation, and gentle massage can further ease symptoms. If inflammation persists despite conservative treatment, a corticosteroid injection around the lateral femoral condyle may be used.Â
The subacute phase aims to restore flexibility, strength, and correct biomechanical imbalances. Stretching of the iliotibial band, tensor fascia lata, gluteal muscles, hamstrings, and quadriceps helps improve mobility. Foam rolling and self-myofascial release reduce tightness, while strengthening the gluteus medius, gluteus maximus, and hip abductors improves stability. Core strengthening and gait retraining are also introduced to correct movement faults. Guidance from a physical therapist can optimize recovery and prevent recurrence.Â
In the return-to-activity phase, the focus is on gradually resuming physical activity. Training should begin at a low intensity and short duration, increasing progressively while monitoring for pain. Downhill running and uneven surfaces should be avoided early on. Proper footwear and orthotics may be recommended to correct biomechanical issues. Continued stretching, strengthening, and education on proper warm-up, cool-down, and load management are essential to prevent recurrence.Â
In chronic or resistant cases, when conservative therapy fails, options such as corticosteroid injections, platelet-rich plasma (PRP) therapy, or surgical release of the iliotibial band may be considered. However, most patients recover well with a structured, progressive rehabilitation program that emphasizes pain control, strengthening, and gradual return to activity.Â
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