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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Iliotibial band friction syndrome: A common cause of lateral knee pain in long-distance runners
Pooja Gupta1, Deep Yadav1, Kamlesh Kumar Singh2, Saikat Bhattacharjee3
1 Department of Radiodiagnosis and Imaging, Command Hospital (AF), Bengaluru, Karnataka, India
2 Department of Pathology, Institute of Aerospace Medicine, Bengaluru, Karnataka, India
3 Department of Radiodiagnosis and Imaging, Command Hospital, Lucknow, Uttar Pradesh, India
| Date of Submission | 30-Mar-2022 |
| Date of Decision | 10-Jun-2022 |
| Date of Acceptance | 22-Jun-2022 |
| Date of Web Publication | 17-Oct-2022 |
Correspondence Address:
Pooja Gupta,
Department of Radiodiagnosis and Imaging, Command Hospital (AF), Agram Post, Bengaluru - 560 007, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_49_22
Introduction: Iliotibial band friction syndrome (ITBFS) is an injury of the knee joint which is common in long distance runners and cyclists. It is caused by repetitive friction between the iliotibial band and the lateral femoral epicondyle during active flexion and extension of the knee. Methods: Magnetic resonance imaging of the knee was performed for 45 long distance runners who presented with lateral knee pain after long distance running for 6 months. The analysis of the images was done by two radiologists in all the three planes to confirm or rule out any findings suggestive of ITBFS. The various imaging features which were noted in the MRI scans by the radiologists to label it as ITBFS were poorly defined abnormal signal intensity deep to the iliotibial band as the primary finding and other associated MRI findings such as fluid collection medial to the iliotibial band, increased thickness of the iliotibial band and joint effusion. Results: Out of these 45 runners 30 patients had ITBFS, 3 had lateral collateral ligament sprain, 3 had a grade III tear of the lateral meniscus, 3 had synovial effusion and six had normal scans. Discussion: Iliotibial band friction syndrome occurs because of overuse and can be confused with other disorders and MRI is able to differentiate it from other conditions.
Keywords: Iliotibial band, magnetic resonance imaging, runners
| Introduction | |  |
Iliotibial band friction syndrome (ITBFS) is an injury of the knee joint caused by intense physical activity and overuse causing repetitive compression and friction between the iliotibial band and the lateral femoral epicondyle, whenever there is active flexion and extension of the knee. It is common in long-distance runners and cyclists. It accounts for 12% of overuse injuries due to running.[1],[2] Iliotibial band is a thickened fascia that inserts proximally on the supracondylar tubercle of the lateral femoral condyle and distally attaches into Gerdy's tubercle.[3] Patients with ITBFS present with pain on the lateral side of the knee with tenderness over the lateral femoral epicondyle. The clinical picture of ITBFS can be confused with lateral collateral ligament sprain, lateral meniscal tear, popliteus strain, or lateral hamstring strain.
| Materials and Methods | | |
A total of 2000 long-distance runners enrolled in an institute of physical training were included in this study. These runners were required to run every day for a distance varying between 5 and 13 km as a part of their physical training program and were closely monitored for the development of any signs and symptoms pertaining to ITBFS for of 6 months. All the runners were male in the age group of 18–20 years. Apart from running, these runners were regularly into swimming practice. Out of these, 90 runners presented with physical complaints of knee pain. In 45 of these runners detailed clinical evaluation revealed signs and symptoms suggestive of injury involving the lateral compartment of the knee. None of these patients had any previous history of knee pain. These 45 cases further underwent magnetic resonance imaging (MRI) of the knee for detailed imaging evaluation. The scans were performed on a 1.5–T MRI scanner of GE Healthcare using a standard knee protocol. Sagittal fast spin-echo T2-weighted (TR/TE: 4520/86.8); sagittal, coronal, and axial proton density-weighted (TR/TE: 2420:33.1) images with fat suppression and coronal T1-weighted (TR/TE: 380:12.9) images were obtained. The field of view was 15 cm and the matrix size was 320 × 224. The number of averages for the fast spin-echo images and the proton-density images was four. A prospective analysis of the MRI scans was done by two radiologists (each with at least 3 years of experience) and any discrepancy in the findings was resolved by consensus. The analysis of the images was done in all the three planes to confirm or rule out any findings suggestive of ITBFS. The various imaging features which were noted in the MRI scans by the radiologists to label it as ITBFS were poorly defined abnormal signal intensity deep to the iliotibial band as the primary finding and other associated MRI findings such as fluid collection medial to the iliotibial band, increased thickness of the iliotibial band and joint effusion.
| Results | | |
Out of the total number of 2000 long-distance runners who were closely monitored for 6 months only, 90 runners (4.5%) developed the physical complaints of pain or instability in the knee joint. Detailed clinical and local examination of these ninety runners revealed localization of the pathology to the lateral compartment of the knee in 45 (2.25%) of them. None of these 45 patients showed any features suggestive of knee or hip instability. Further, MRI evaluation of the knee in 45 runners revealed imaging features consistent with ITBFS in 30 runners. Of these 30 patients Ober's test (suggestive of ITBFS) was positive in 20 patients. Three runners showed features of lateral collateral ligament sprain, three had Grade III tear of the lateral meniscus, synovial effusion was evident in three, whereas six showed normal scans [Table 1]. The three runners with radiological evidence of lateral meniscal tear gave a history of twisting injury to the knee while running, whereas two runners with synovial effusion had a history of fall while running. Out of the 30 candidates with features of ITBFS on MRI, 18 gave a history of pain developing after 60 days of running, while 12 gave a history of pain occurring in the 4th week of running cross-country. MRI showed poorly defined abnormal signal intensity suggestive of edema deep to the iliotibial band [Figure 1] in all the 30 cases. Six cases had fluid collection medial to the iliotibial band [Figure 2], 21 cases had associated synovial effusion and only three cases had increased thickness with hyperintensity of the iliotibial band. Three cases had associated finding of Grade I anterior cruciate ligament sprain [Figure 3] and [Table 2]. | Figure 1: MRI coronal PDFS image shows ill-defined hyperintensity suggestive of edema deep to the iliotibial band, MRI: Magnetic resonance imaging, PDFS: Proton density fat saturated
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 | Figure 2: MRI coronal PDFS image shows fluid collection medial to the iliotibial band, MRI: Magnetic resonance imaging, PDFS: Proton density fat saturated
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 | Figure 3: MRI sagittal PDFS image shows the anterior cruciate ligament is bulky and slightly edematous suggestive of Grade I sprain, MRI: Magnetic resonance imaging, PDFS: Proton density fat saturated
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 | Table 1: Magnetic resonance imaging findings in 45 patients presenting with lateral knee pain
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 | Table 2: Imaging findings in 30 patients with iliotibial band friction syndrome on magnetic resonance imaging
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| Discussion | | |
ITBFS is one of the most common causes of lateral knee pain in runners and cyclists.[4],[5],[6] It occurs when the iliotibial band, the ligament that runs down the lateral aspect of the thigh from the hip to shin is tight or inflamed. In our study, out of 90 long-distance runners who presented with knee pain the pathology was localized to the lateral compartment in 50% (45) of these cases. On further imaging evaluation, 66% (30) of these 45 candidates with lateral knee pain had imaging features of ITBFS.
The iliotibial band is a wide sheath of connective tissue formed at the level of the greater trochanter of the femur by the fusion of the tensor fasciae latae, the gluteus medius, and the gluteus maximus muscles. It travels along the lateral aspect of the thigh, and around the knee joint the iliotibial band sends some fibers to the patellar retinaculum and it continues further to insert at the lateral condyle of the tibia at the Gerdy's tubercle. A wide layer of fatty tissue separates the iliotibial band from the femoral shaft. At the level of the lateral femoral condyle, the iliotibial band is anchored to the lateral femoral epicondyle by obliquely oriented fibrous strands.[6]
The iliotibial band attaches to the knee and helps in stabilizing and moving the joint. Repetitive flexion and extension movements during repeated running activities cause sliding of the distal iliotibial band over the lateral femoral epicondyle causing friction, inflammation, and lateral femoral pain.[4],[5] The development of ITBFS in 30 of the 2000 long-distance runners was attributable to the constant stress and strain on the iliotibial band due to prolonged and repeated flexion and extension movements at the knee. In a study conducted by Taunton et al. who studied running-related injuries, ITBFS was the second-most common overuse injury second only to patellofemoral pain syndrome.[7] Long-distance runners with ITBFS were seen to have weaker hip abduction strength.[8] Messier et al. found that runners with ITBFS versus a noninjured control group were less experienced, were doing greater weekly mileage, and had a greater percentage of their training on the track.[9] In our study, the runners were relatively very young with no previous exposure and experience of long-distance running. In addition to long-distance running the participants were also subjected to additional physical activities as mandated by their training.
MRI shows specific finding in ITBFS in the form of ill-defined increased T2-weighted signal intensity in the soft tissues between the iliotibial band and lateral femoral epicondyle.[10] This finding was noted in all our 30 cases. Other findings which may be noted are fluid collections medial to the iliotibial band, increased thickness of the iliotibial band over the lateral femoral epicondyle and joint effusion. MRI also rules out any other associated pathology in the knee.
In these 30 cases with ITBFS in our study, six had fluid collection medial to the iliotibial band, three had increased thickness with hyperintensity of the iliotibial band and 21 cases had associated synovial effusion. Three cases had associated finding of Grade I anterior cruciate ligament sprain.
There are other conditions which can mimic and should be considered before making a diagnosis of ITBFS such as lateral collateral ligament sprain, lateral meniscal tear, popliteal tendon strain, and lateral hamstring strain which is in congruence with our study as in some of the patients presenting with lateral knee pain had atypical findings on MRI with three of the patients showing imaging features suggestive of lateral collateral ligament sprain, Grade III tear of the lateral meniscus being present in three others, while synovial effusion depicted as the only finding on MRI in three of the participants. The treatment of ITBFS requires modification of activity, physiotherapy aiming to strengthen the affected limb, stretching exercises, and nonsteroidal anti-inflammatory medications. Corticosteroid injections are administered in cases of the persistence of swelling and pain. Surgery is considered in patients who do not respond to the conservative management.
| Conclusion | | |
ITBFS occurs in individuals who engage in intense physical activity involving repeated and prolonged stress and strain such as long-distance running on hard surface causing inflammation of the distal part of the iliotibial band. It occurs because of overuse and combined biomechanical factors. ITBFS may be confused with other disorders, and MRI is able to differentiate it from other conditions. It is an important entity but is often missed and an underestimated clinical condition, an early identification of which can prevent occurrence of irreversible ligamental and tendon injuries at knee joint.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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