If you are a runner, particularly a distance runner, you will dread the stinging or swelling sensation that develops on the outside of the knee and intensifies with continued activity.  It is often a sign of iliotibial band syndrome.  It may signal either a temporary cessation of your training or longer term recovery while dealing with this painful condition.

What is iliotibial band syndrome?

The iliotibial band (IT band) is a long flat tendon on the outside of the hip, thigh, and knee. The iliotibial band slides over the bump (lateral epicondyle) on the outside (lateral side) of the knee when the knee is bent. This is where iliotibial band syndrome develops. When the knee is straight, the iliotibial band is in front of the bump. When the knee is bent, the iliotibial band is behind the bump. It slides over the bump when the knee is bent about 30 degrees.

Iliotibial band syndrome (ITBS) is a common injury to the thigh, generally associated with running, cycling, hiking or weight-lifting (standing squats).  Iliotibial band syndrome is an overuse injury caused by excessive friction between the iliotibial band and lateral epicondyle.   The IT band provides stability to the knee and assists in flexion of the knee joint. When irritated, movement of the knee joint becomes painful. Usually the pain worsens with continued movement and resolves with rest.

What are the symptoms?

ITBS symptoms range from a stinging sensation just above the knee joint (on the outside of the knee or along the entire length of the iliotibial band) to swelling or thickening of the tissue at the point where the band moves over the femur. The pain may not occur immediately during activity, but may intensify over time, especially as the foot strikes the ground. Pain might persist after activity. Pain may also be present below the knee, where the ITB actually attaches to the tibia.  ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury. It commonly occurs during pregnancy, as the connective tissues loosen and the woman gains weight—each process adding more pressure. ITBS at the hip also commonly affects the elderly.

Common symptoms of ITBS include:

• Pain over the outside of the knee joint
• Swelling at the location of discomfort
• A snapping or popping sensation as the knee is bent

Endurance athletes are especially prone to developing iliotibial band syndrome. Athletes who suddenly increase their level of activity, such as runners who increase their mileage, often develop ITBS.

What may cause iliotibial band syndrome?

It is most often seen in runners, but it is also seen in cyclist and other athletes. There are several factors that may influence developing iliotibial band syndrome:

• downhill running or running on banked surface
• bowed knees
• foot pronation
• increases in training without conditioning
• tight iliotibial bands

ITBS can result from one or more of the following training habits.

• Always running on a banked surface (such as the shoulder of a road or an indoor track) bends the downhill leg slightly inward and causes extreme stretching of the band against the femur
• Inadequate warm-up or cool-down
• Excessive up-hill and down-hill running
• In cycling, having the feet "toed-in" to an excessive angle
• Running up and down stairs
• Hiking long distances
• Rowing

How can I prevent iliotibial band syndrome?

While ilitobial band syndrome may develop despite attempts at prevention, certain measures may help to reduce the risk of developing iliotibial band syndrome. These include:

• regular stretching of the iliotibial band
• appropriate footwear and orthotics, particularly to correct foot pronation
• gradually increase training (avoid abrupt increases)
• avoid running downhill and on banked surfaces

How is iliotibial band syndrome treated?

Nonsurgical treatment is almost always successful. While ITBS pain can be acute, the iliotibial band can be rested, iced, compressed and elevated to reduce pain and inflammation, followed by stretching. Using a foam roller to loosen the iliotibial band can help prevent and treat ITBS although the treatment itself can be very painful to some. If pain persists or doesn’t respond to treatment efforts, you should consult a physical therapist or sports medicine doctor.  Some combination of the following steps is generally successful:

• Rest – Ice – Compression - Elevation (RICE)  of injured area
• Decrease in intensity and mileage
• Correction of foot pronation with appropriate shoes and/or orthotics
• Iliotibial band stretching, along with stretching of the calf, quads, and hamstrings
• Avoid hills and cambered surfaces
• Nonsteroidal anti-inflammatory medications (NSAID’s) such as ibuprofen
• Strengthening of the hip abductors and external rotators
• Gradual return to full activity once pain is controlled

Once the acute symptoms are controlled, you should make efforts to increase the flexibility and strength of the hip and knee. Most rehabilitation protocols focus on both hip and knee function, as the iliotibial band requires proper mechanics of both of these joints for normal function. Working with a physical therapist can help you ensure you are developing an appropriate treatment strategy. Runners, cyclists, and other endurance athletes should find cross-training techniques that allow maintenance of their endurance without continuation of their discomfort.

References
Iliotibial Band Syndrome, SportsMD.com
Iliotibial Band Syndrome, Wikipedia
Ilitibial Band Syndrome, About.com
Iliotibial Band Syndrome: A Common Source of Knee Pain, American Family Physician