iliotibial band syndrome is a common knee injury caused by inflammation of the distal portion of the iliotibial band ( itb ) , which results in lateral knee pain .
the distal iliotibial band slides over the lateral femoral epicondyle , and during repetitive flexion and extension activities of the knee excessive friction and potential irritation results in pain .
potential risk factors for the development of iliotibial band syndrome include preexisting iliotibial band tightness , high weekly mileage , time spent walking or running on a track , interval training , and muscular weakness of knee extensors , flexors , and hip abductors [ 1 , 2 ] . populations who expose their knees to a greater amount of flexion and extension activities , such as athletes , particularly long distance athletes , put themselves at a higher risk for iliotibial band syndrome . due to the pathophysiology of it band syndrome , runners have been a group often looked at for prevalence and management of this syndrome .
itb syndrome has been documented to have as high as a 22.2% incidence of all lower extremity injuries in runners . despite a clear pathophysiology ,
few studies have shown any direct relationship between biomechanical factors and the development of iliotibial bad syndrome [ 1 , 2 , 46 ] .  
athletes with itb syndrome typically complain of a sharp or burning pain roughly 2  cm superior to the lateral joint line .
the pain may radiate proximally or distally , and in less severe cases , the pain may quickly subside upon cessation of activities . often pain will occur as activities proceed .
it is not uncommon that the athlete will experience popping on the lateral aspect of the knee with activities .  
itb syndrome is a clinical diagnosis and most often additional diagnostic studies are not necessary .
it should be suspected in overuse and nontraumatic cases of knee pain where rest has not been helpful .
ober 's test is one of numerous physical exam tests often used to assess the tightness of the itb . if the leg can be passively stretched to a position horizontal but not completely adducted to a table , this constitutes minimal tightness .
if the leg can be passively adducted to horizontal at best , this constitutes moderate tightness , and if it can not be passively adducted to horizontal , this is maximal tightness .
popping of the itb over the lateral femoral condyle can also occur in this position as the knee is brought through range of motion .
history , however , is much more important than physical exam in diagnosis and short - term resolution of symptoms following corticosteroid injection and be both diagnostic and therapeutic .
mri may be of use if there is doubt about the diagnosis as well as to exclude an intra - articular problem such as a lateral meniscal tear ; however , isolated itbfs often does not lead to mri abnormalities and can be misdiagnosed if a minor but different lesion is present .
two studies revealed that in patients with iliotibial band syndrome , mri studies have shown that the distal portion of the itb may thicken , and a bursa deep to the iliotibial band over the lateral epicondyle becomes inflamed and filled with fluid [ 8 , 9 ] .
when the athletic population was isolated , normal , or cystic , poorly defined signal intensities at the distal portion of the itb predominated . only in chronic cases was a thickening of the distal itb at the level of the lateral femoral epicondyle seen .
while the majority of patients respond to a nonsurgical , conservative approach , this does not occur for all , and escalation of treatment is necessary .
this is especially true in athletes that present with refractory cases , and at this time surgical intervention can be used .
unfortunately , refractory cases can occur quite often , and no treatment has been shown to work best . the purpose of this review is to outline both the conservative and surgical options for treatment of iliotibial band syndrome in athletes .
in order to find the most current treatment options for itb syndrome in athletes , a literature search was conducted in the pubmed database .
criteria for inclusion in this review were papers that primarily ( but not exclusively ) focused on the athletic population , achieved a level iii or greater level of evidence , addressed therapeutic options for itb syndrome ( conservative or surgical ) , and were written in english .
an initial search of iliotibial band syndrome yielded 176 results . after limiting the results to those articles that discussed treatment options , and focused on the athletic population
many of these treatment modalities have been geared toward the runner population , and certain guidelines to return to sport ( running ) have been suggested .  
table 1 illustrates four studies that outlined conservative treatment modalities . in a randomized controlled trial ( rct ) , schwellnus et al . investigated the effect of initial treatment ( day 07 : rest , ice application , and medication ) in 43 patients with unilateral itbs .
all subjects received physical therapy consisting of ultrasound , deep transverse friction massages on days 3 , 5 , and 7 and daily stretching of the it band .
medication was delivered over the 7 days in a double - blind , placebo - controlled fashion with group 1 taking a placebo anti - inflammatory , group 2 an anti - inflammatory ( voltaren ) , and group 3 an anti - inflammatory / analgesic ( myprodol ) .
compared with the other groups , group 3 had less pain during running from day 3 onward , and their running time / distance on the treadmill significantly increased from day 0 to 7 . in another
randomized controlled trial , 18 runners with acuteonset itb syndrome ( < 14 days ' duration ) were randomly assigned into two groups : group 1 received a corticosteroid injection and group 2 received a placebo injection .
subjects were instructed not to run for 14 days following the injection and to apply ice to the area for 30 minutes every 12 hours .
running pain was significantly decreased in the group that received the corticosteroid injection .   in a case
series of 196 running injuries , pinshaw et al . found itbs to the third most common injury ( 12% ) behind peripatellar pain syndrome ( 22% ) and posterior tibial stress syndrome ( 18% ) . in those with
these steps included running shoes : change to softer shoes , use of in - shoe support and shoe alterations , and/or removal of the outside heel flare of the shoe for the injured side .
leg - length discrepancies : adapt shoe of the shorter leg by adding material to the mid - sole to ensure 100% correction at the heel , 50% correction in the mid - sole , and 25% correction at the ball of the foot .
training methods : if appropriate , reduce training distance and decrease running speed and amount of hill running . also , incorporate a sufficient number of days for recovery .
ice application : apply ice to the injured area for 30 minutes twice a day .
finally , in a case series done at the stanford sports medicine clinic , 24 runners ( 10 m , 14 w ) with itbs completed a 6-week rehabilitation program , which consisted of local application of ultrasound with corticosteroid gel for the first two sessions .
all patients were instructed to stretch the it band three times a day , and hip abduction exercises and pelvic drop sets to strengthen the gluteus were increased throughout the program with a goal of 3 sets of 30 repetitions .
nonsteroidal anti - inflammatory drugs were prescribed until the patients were free of pain during daily activities .
the investigators found a mean increase of 34.9% and 51.4% in the injured leg of the hip abductor torque for females and males , respectively .
twenty - two of the 24 athletes ( 91.7% ) of the athletes were able to return to running at the end of the 6-week program .
these four studies demonstrate how diverse conservative treatment for itbs can be . from clinical experience
this treatment becomes less useful as it becomes a more chronic condition when bursal and periosteal changes have set in .
there is limited evidence to support one specific approach to the treatment of itbs ; however , when looking at the desired goal of return to sport , a combination of rest ( 26 weeks ) , stretching , pain management , and modification of running habits produces a high return to sport rate .   surgery is often reserved for refractory cases that have failed other avenues of conservative management . however , in the athletic population , return to sport is a common concern , and multiple , long absences from sport due to trials of various conservative treatment approaches are often not ideal .  
suggests that conservative treatments should be maintained for an average of 9 months before consideration of surgical intervention .
others have based their decision for surgical intervention on the observation that at 30 degrees flexion , the posterior fibers of the itb are tighter against the lateral femoral epicondyle than are the more anterior fibers , in which case a surgical release in the posterior fibers is needed to correct the problem [ 14 , 15 ] . in one study ,
36 athletes with a resistant itbs were treated with a standard arthroscopic technique , limited to the resection of lateral synovial recess .
the patients had suffered from itbs for an average of 18 months ( 17 years ) .
thirty - three patients ( mean age 31.1 years ) were available for followup at least 6 months postoperatively .
prior to surgery , all patients had been treated conservatively for at least 6 months with rest , correction of training error , shoe modification , physical therapy and local infiltration with steroids .
thirty - two patients had good or excellent results based on subjective functional results at followup .
all patients went back to sports after 3 months . in 2 patients a meniscal lesion
was found , which required treatment , and an associated cartilage lesion of the femoral condyle was found in the one patient that reported a fair outcome at followup .
the author concluded that arthroscopic resection of the lateral synovial recess in resistant itbs is a valid option with a consistently good outcome , which also allows excluding or treating other intra - articular pathology .
a retrospective study on athletes in norway looked at 45 patients who failed conservative management of itbs .
the surgical procedure of choice for these resistant itbs cases was transection of the posterior half of the iliotibial band where it passes over the lateral epicondyle of the femur . with a mean age of 27 ( 1446 ) years , 38 ( 84.4% ) had excellent or good results , 6 ( 13.3% ) had fair results , and 1 ( 2.3% ) had a poor result .
return to sport was not documented in this study , but 75.6% of patients reported that they would have the operation again .
bursectomy has also been explored as a surgical treatment option for itbs . in a recent study a single surgeon performed 11 open iliotibial band bursectomies on 11 patients ( 7 m , 4 w ) .
each patient presented with persistent ( > 6 months ) symptoms despite conservative treatment , with an average age at onset of 29 ( 2441 ) years .
after a minimum of 20-month followup , all patients were able to return to their preinjury tegner activity levels , and all reported less pain ( 11-point visual analogue scale score decreased by 6 points ) .
nine of the 11 patients said that knowing what they know now they would have the surgery performed again for the same problem .
this population , however , was a mix of athletic and the general population , and the study did not separate out the results of each population .
iliotibial band syndrome ( also called iliotibial band friction syndrome ) is a common problem encountered in the knees ' of athletes , especially endurance athletes whose sport requires repetitive knee flexion .
itbs can often recur in the athletic population , causing significant morbidity and delay in return to sport .
there is debate on whether iliotibial band syndrome is truly a friction syndrome where the itb itself is pathologic or whether a pathologic bursa forms between the itb and the lateral femoral condyle , causing the pain .
this is an important concept because successful surgical treatment of the syndrome must address the underlying pathological causes .
regardless of stance on the pathophysiology , conservative management is the first line of therapy for itbs .
however , both conservative and surgical therapies play a major role in recalcitrant cases . a combination of therapies ( rest , pain relief , stretching , strength training , and running habit modification ) works best for returning athletes to their preinjury level and reducing their symptoms .
however , a systematic regimen involving all aspects of conservative therapy has not been established .
a recent systematic review on iliotibial band syndrome in runners concluded that there is limited evidence to support one specific approach to the diagnosis and treatment of itbs , suggesting that additional research is needed to elucidate an optimal treatment regimen . in our review , conservative therapy alone
was found to have a 44% complete cure rate with return to sport at 8 weeks and a 91.7% return to sport rate at 6 months [ 2 , 12 ] .
most surgeons who have published in the literature ascribe to the iliotibial friction band syndrome theory , and numerous procedures that excise or release this supposedly pathologic portion of the itb have been described .
cortisone injections should still be used first in these scenarios , as itbs is considered an inflammatory friction syndrome . however , as the duration of symptoms increases and conservative measures fail , surgical treatment may be needed for resolution of symptoms .
three of these procedures have been described above , all in athletes , with a return to sport rate of 100% at an average of 3 months   and 7 weeks .
did not find a bursa in either the 6 cadaveric specimens they dissected or the 2 symptomatic patients on whom they performed an mri
. in patients with iliotibial band syndrome mri findings of the itb can be normal . in a study of 16 patients with itbs
, 31% had a discrete fluid collection medial to the itb , with a normal looking itb .
however , it was hypothesized that this collection likely arose from chronic inflammation beneath the itb , resulting in the formation of a secondary or adventitious bursa rather than from the inflammation of an existing primary bursa .
there are also those that ascribe to the theory that the itb itself is not pathological in patients with iliotibial band syndrome , but rather the pain and functional deficits are generated by a pathological bursa that forms beneath the itb due to compression of that underlying tissue rather than a friction mechanism . in the study performed by hariri et al .
described above , they consistently found what appears to be an inflamed bursa underlying a benign - appearing itb .
this study , however , was not done solely on the athletic population whereas the ones described which favor the friction theory of iliotibial band syndrome were .
surgical intervention is often only utilized after patients have failed conservative management for itbs , making return to preinjury level a difficult task .
although there are two theories on the pathophysiology of itbs , when looking at return to sport rate in the athletic population , resection of the lateral synovial recess , after failure of conservative therapy provides an excellent return to sport rate .
iliotibial band syndrome is a common cause of lateral knee pain in the athlete , especially runners and other endurance athletes . both conservative and surgical approaches are viable treatment options , and both need to be considered during treatment planning .
while the majority of cases resolve with conservative management , resistant cases are seen in many athletes , requiring surgical intervention .
the cases that require surgical intervention are often chronic in nature , and it is important to recognize the duration of symptoms so that surgical treatment can be initiated early . despite many options for both surgical and conservative treatment , there has yet to be consensus on one standard of care . further research is needed to delineate the true pathology behind iliotibial band syndrome in athletes , as well as the optimal treatment regimen .
 iliotibial band syndrome ( itbs ) is a common injury in runners and other long distance athletes with the best management options not clearly established . 
 this review outlines both the conservative and surgical options for the treatment of iliotibial band syndrome in the athletic population . 
 ten studies met the inclusion criteria by focusing on the athletic population in their discussion of the treatment for iliotibial band syndrome , both conservative and surgical . 
 conservative management consisting of a combination of rest ( 26 weeks ) , stretching , pain management , and modification of running habits produced a 44% complete cure rate , with return to sport at 8 weeks and a 91.7% cure rate with return to sport at 6 months after injury . 
 surgical therapy , often only used for refractory cases , consisted of excision or release of the pathologic distal portion of the iliotibial band or bursectomy . 
 those studies focusing on the excision or release of the pathologic distal portion of the iliotibial band showed a 100% return to sport rate at both 7 weeks and 3 months after injury . despite many options for both surgical and conservative treatment 
 , there has yet to be consensus on one standard of care . 
 certain treatments , both conservative and surgical , in our review are shown to be more effective than others ; however , further research is needed to delineate the true pathophysiology of iliotibial band syndrome in athletes , as well as the optimal treatment regimen . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion