Clinical Review: Current Concepts

Iliotibial Band Syndrome: Soft Tissue and

Biomechanical Factors in Evaluation and Treatment
Robert L. Baker, BSPT, MBA, Richard B. Souza, PhD, PT, Michael Fredericson, MD

Muscle performance factors and altered loading mechanics have been linked to a variety
of lower extremity musculoskeletal disorders. In this article, biomechanical risk factors
asso-ciated with iliotibial band syndrome (ITBS) are described, and a strategy for
incorporating these factors into the clinical evaluation of and treatment for that disorder is
presented. Abnormal movement patterns in runners and cyclists with ITBS are discussed,
and the pathophysiological characteristics of this syndrome are considered in light of
prior and current studies in anatomy. Differential diagnoses and the use of imaging,
medications, and injections in the treatment of ITBS are reviewed. The roles of hip
muscle strength, kinematics, and kinetics are detailed, and the assessment and treatment
of muscle perfor-mance factors are discussed, with emphasis on identifying and treating
movement dysfunc-tion. Various stages of rehabilitation, including strengthening
progressions to reduce soft-tissue injury, are described in detail. ITBS is an extremely
common orthopedic condi-tion that presents with consistent dysfunctional patterns in
muscle performance and movement deviation. Through careful assessment of lower
quarter function, the clinician can properly identify individuals and initiate treatment.
PM R 2011;3:550-561

INTRODUCTION
Iliotibial band syndrome (ITBS) is the leading cause of lateral knee pain in runners and
accounts for 15% of overuse injuries in cyclists [1-5]. While balancing the need to
promote fitness and the associated risks of repetitive-motion injuries such as ITBS,
physicians and other rehabilitation professionals have searched for methods of identifying
contributing factors for overuse injuries as well as treatments that restore function and
enable patients to maintain their exercise activities.
The first detailed case on ITBS was published by Renne [6] in 1975. The subjects studied
were military recruits whose running and training activities had increased rapidly. Hall-marks
of ITBS were pain on weight bearing at 30° of knee flexion and the exacerbation of pain after
having run more than 2 miles or having hiked more than 10 miles.
Lateral knee pain at the femoral epicondyle is a key finding in patients with ITBS [6- R.L.B. Emeryville Sports Physical Therapy,
2322 Powell Street, Emeryville, CA 94608.
8]. Noble [9] analyzed 100 patients with ITBS and developed the Noble compression test,
Address correspondence to R.L.B; e-mail:
in which compression over the lateral epicondyle of the femur at 30° of knee flexion rb415@comcast.net
elicits pain reproduction. This test is now commonly used to diagnose ITBS. Orchard et Disclosure: nothing to disclose
al [10] described ITBS in runners as an impingement zone related to the time period just R.B.S. Department of Physical Therapy
after heel strike as the knee approaches 30° of flexion. The investigators described this as and Rehabilitation Science, Department
the deceleration phase, which suggests that impingement occurs during eccentric loading of Radiol-ogy and Biomedical Imaging,
University of California, San Francisco,
of the iliotibial band during the weight-acceptance phase of running. CA Disclosure: nothing to disclose
M.F. Division of Physical Medicine and Re-
habilitation, Department of Orthopaedic
ANATOMIC CONSIDERATIONS Sur-gery, Stanford University School of
Medicine, Stanford, CA
The iliotibial band is a fascial structure composed of dense connective tissue that assists Disclosure: nothing to disclose
stance stability and is capable of resisting large varus torques at the knee [7,11,12]. Disclosure Key can be found on the Table
Proximally, the iliotibial band provides an insertion for the tensor fascia lata and gluteus of Contents and at www.pmrjournal.org
maximus muscles [13]. Based on dissections of 1 orangutan, 3 chimpanzees, 1 gorilla, 1 Submitted for publication September 16,
bear, and other 4-legged animals, Kaplan [13] concluded that, although all quadruped 2010; accepted January 4, 2011.

PM&R © 2011 by the American Academy of Physical Medicine and Rehabilitation

550 1934-1482/11/$36.00 Vol. 3, 550-561, June 2011
Printed in U.S.A. DOI: 10.1016/j.pmrj.2011.01.002
PM&R
Figure 1. The iliotibial band and site of injury at lateral epicon-dyle
of the femur.
animals have tensor fascia latae or gluteus maximus muscles,
they do not all have an iliotibial band. The investigator then
suggests that the iliotibial band is an independent stabilizer of
the lateral knee joint, essential for erect posture. The iliotibial
band has 2 significant attachments, including the lateral
epicondyle and the Gerdy tubercle (Figure 1) [13,14]. The first
iliotibial band attachment is into the distal femur at the upper
edge of the lateral epicondyle [15]. The histologic makeup is
consistent with tendon and has a layer of adipose tissue
underneath the iliotibial band attachment area [14,16]. The
adipose tissue contains pacinian corpuscles, is highly vascular,
and may be the site of the inflammation that causes pain
during compression. The second attachment of the iliotibial
band is the insertion into the Gerdy tubercle of the tibia and
serves as a ligament in structure and function. The Gerdy
tubercle attachment is tensed during tibia internal rotation as
the knee flexes during the weight-acceptance phase of gait
[14,16,17]. Internal tibial rotation explains the occasional
connection between toeing in and iliotibial band strain [4,18].
The iliotibial band has many other distal attachments,
which include the biceps femoris, vastus lateralis, lateral
Vol. 3, Iss. 6, 2011 551
patellar retinaculum, patella (by way of epicondylopatellar
ligament and patellar retinaculum), and patellar tendon
[13,14,16]. Collectively, these anterior and lateral attach-
ments form a horseshoe pattern or inverted U shape well
positioned for anterolateral support to the knee [15,19,20].
The site of injury is often associated with the insertion at
the lateral epicondyle but interrelated with the forces
created by the various attachments above and below the
lateral epicon-dyle (Figure 1).
Fairclough et al [14] described a mechanism of compres-
sion of the iliotibial band against the lateral epicondyle that
occurs at 30° of knee flexion. Their anatomic description
included the observation that compression of the adipose
tissue at the lateral epicondyle of the femur caused pain and
inflammation but that no anterior–posterior movement of the
band moving over the epicondyle took place, simply an
approximation of the iliotibial band into the lateral epicon-dyle
as the knee internally rotated during flexion from an extended
position. The investigators present an anatomical viewpoint
that contradicts the commonly held theory of a friction
syndrome [14]. Fairclough et al [14] described fric-tion as an
unlikely cause of ITBS, because the band inserts deeply and
strongly into the femur. The functional anatomy may be
relevant because a fat pad and pacinian corpuscle compression
mechanism may have different mechanorecep-tor implications
compared with a friction syndrome, al-though inflammation
remains the primary concern.
INTRINSIC CONTRIBUTING FACTORS
Biomechanics of the Hip, Knee, and Ankle
Ferber et al [21] attributed iliotibial band strain in female
runners to a greater peak hip adduction angle and greater peak
knee internal rotation angle compared with those in controls.
The investigators used a retrospective design and control
group comparison. The theory presented was in-creased tensile
stress at the hip in the frontal plane and internal rotation stress
at the knee. Interestingly, in this study, patients with ITBS
exhibited femoral external rotation versus internal rotation
when compared with control sub-jects, a factor that increased
knee internal rotation.
In 2007, Noehren et al [22] published a prospective study
of female runners that analyzed ITBS and biomechanical
factors, including hip adduction, knee internal rotation, and
rear foot eversion angles, and related hip, knee, and ankle
moments. The investigators performed bilateral, 3-dimen-
sional, lower extremity kinematic and kinetic analysis with
running. The subjects were followed up for injury findings
through 2 years by e-mail communication. Findings for the
ITBS group versus the control group included the following:
(1) greater peak hip adduction, (2) greater peak knee internal
rotation angle, (3) lower tibial internal rotation by 2.2° (not
significant), and (4) femoral external rotation. On visual
552 Baker et al
Figure 2. (A) Normal alignment. (B) Trendelenburg sign. (C) Compensated Trendelenburg sign. Reprinted with permission of the Sports and
Orthopedic Sections of the American Physical Therapy Association and Chris Powers, PhD, PT. Powers C. The influence of abnormal hip
mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42-49 [27].
inspection, the investigators noted that the subjects with
ITBS landed in greater hip adduction and knee internal
rotation. Noehren et al [22] and Ferber et al [21] support
the theory of frontal and transverse plane factors in female
run-ners, specifically, excessive hip adduction and knee
internal rotation. Further study is needed to explain why
these run-ners exhibited greater hip adduction, knee
internal rotation, and femoral external rotation. In addition,
male runners need further assessment in similar research
models. Weight-bear-ing magnetic resonance imaging and
dual fluoroscopic imag-ing may be useful to further assess
femoral rotation in male and female runners with and
without ITBS, specifically aimed at evaluating the role of
transverse plane contributing factors of the hip [23-25].
Hamill et al [12] modeled iliotibial band strain rate with
software for interactive musculoskeletal modeling (SIMM
4.0; Motion Analysis Corporation, Santa Rosa, CA). This
prospective study of female runners compared iliotibial
band strain (calculated as the change in length during
running divided by the resting length), strain rate
(calculated as the change in strain divided by the change in
time), and duration of impingement in 17 patients with
ITBS and 17 age-matched controls. The entire stance was
measured, with a focus on touch-down and peak knee
flexion. Although strain was increased versus that in the
control, only strain rate was statistically significant between
the groups. The investigators suggested that strain rate is a
factor in the development of ITBS.
Taunton et al [5] used a retrospective design to analyze data
on 2002 running injuries, including 63 men and 105 women
with ITBS. Varus knee alignment was reported in 33%, and
valgus alignment was reported in 15%. Leg-length
discrepancy, defined as a greater than 0.5-cm difference in
ILIOTIBIAL BAND SYNDROME
anterior superior iliac spine to medial malleolus, reported in
10%. McNicol et al [26] also reported on 52 cases of ITBS in
runners, including 34 men and 18 women with ITBS. The
investigators reported that 55% had mild-to-severe knee varus,
and 8% had mild knee valgus. These studies suggest that
clinical management of ITBS may involve training meth-ods
to control frontal plane dynamics at the knee, in addition to
assessing and treating transverse plane issues.
One way to theoretically visualize the relationship be-
tween the hip and knee frontal plane relationships involves
the use of ground reaction force diagrams. During normal
single-limb stance as described by Powers [27], the ground
reaction force vector may pass medial to the knee joint and
produce a varus torque at the knee (Figure 2A). However,
with excessive hip adduction during a single-limb stance
and Trendelenburg sign, the ground reaction force vector
may pass more medial, with a larger perpendicular distance
to the knee joint (Figure 2B). The result is an increased
varus torque at the knee, along with an elongated lateral hip
musculature, both of which place increased stress on the
iliotibial band [27,28]. The third possible disturbance at the
knee is a valgus stress and ground reaction force vector
lateral to the knee, combined with an increased hip
adduction, a compensated Trendelenburg sign (Figure 2C).
Abnormal mechanics at the foot and the tibia may play a
role in the development of ITBS given the anatomic connec-
tion of the iliotibial band to the tibia and the interrelationship
of the foot and the tibia. Noehren et al [22] analyzed biome-
chanical factors in the hip, knee, and rear foot in female
runners who go on to develop ITBS, and, although hip
adduction and knee internal rotation were the primary find-
ings in this cohort, these investigators were able to identify a
subset of 4 participants who exhibited excessive calcaneal
PM&R Vol. 3, Iss. 6, 2011 553

eversion and tibial internal rotation. In contrast, Messier et al

[29] performed a cross-sectional lower extremity kinematic
study on male and female patients with ITBS and reported
no statistically significant differences in rear foot eversion
when compared with a control group.
Miller et al [30] analyzed 16 runners, 8 with history of
ITBS and 8 age-matched controls, in an exhaustive run. At
the end of the run, the patients in the ITBS cases exhibited
greater maximum foot inversion (3.3° ITBS and 9.5° con-
trol), maximum knee flexion at heel strike (43.8° ITBS and
36.5° control), and maximum knee internal rotation
velocity (16.4°/s ITBS and 10.3°/s control). Further
research is needed to better understand the possible
connection be-tween the foot mechanics and increased knee
internal rota-tion velocity.
Leg-length discrepancies have been reported as a factor
in developing ITBS. McNicol et al [26] studied 52 cases of
ITBS in runners and reported that 13% had leg-length
discrepan-cies, and, in all cases, that the side of injury
corresponded with the longer leg. However, Messier et al
[29] evaluated a variety of intrinsic and extrinsic factors in
56 patients with ITBS and 70 controls, reporting leg-length Figure 3. Muscle performance factors include a broad set of
muscle competencies, including response to the kinetic chain
discrepancies consistent between the control group and the
above and below.
injured group. Taken together in a clinical perspective,
ITBS and foot and ankle factors suggest a possible subset
of cases in runners who have abnormal foot and ankle
biomechanics, including excessive calcaneal eversion and shortened and strong. The clinical finding is increased hip
tibial internal rotation along with leg-length discrepancy. flexion in stance, along with a tendency for increased hip
internal rotation [3,32-37]. In contrast, the gluteus maximus
and gluteus medius are phasic muscles with the tendency to
Muscle Performance become lengthened and weak [36,37]. Subsequently, the
taut and relatively stronger tensor fascia lata may dominate
Messier et al [29] reported generalized strength and endur- the weaker gluteus medius posterior and gluteus maximus,
ance considerations as a possible etiologic factor in male and and may result in a postural pattern, including a Trendelen-
female participants with ITBS. Fredericson et al [3] reported burg sign (Figure 2B) or compensated Trendelenburg sign
significant hip abductor strength deficits in patients with ITBS (Figure 2C) [27,38]. These compensations during walking
compared with noninjured control runners, and good success or running may result in poor control of the hip and femur
in these injured patients after a 6-week strengthening program during stance and may lead to excessive hip adduction and
focused on strengthening the gluteus medius mus-cle. Miller et knee varus or valgus. The Janda-based analysis of muscle
al [30] reported that, on average, patients in the ITBS cases imbalance provides a theoretical construct to understand
were tighter in the iliotibial band than control runners when and treat some of the factors related to ITBS, specifically,
the Ober test was used. The investigators also reported an strengthening of the gluteus medius and gluteus maximus
increased maximum knee internal rotation ve-locity in patients muscles to better control hip adduction and knee varus and
in the ITBS cases near exhaustion, which suggests fatigue- valgus.
related factors. In a separate study that eval-uated runners
during an exhaustive run, Miller et al [31] suggested that
EXTRINSIC CONTRIBUTING FACTORS
runners with a history of ITBS use abnormal segmental
coordination patterns. The scope of muscle per-formance Extrinsic factors are related to training methods as well as
factors in ITBS includes strength, endurance, flex-ibility. and running shoes or cycle fit, and have been researched and
segmental coordination (Figure 3). reported in connection with ITBS [2,4,10,29]. Key elements in
The Janda approach to muscle imbalance provides a the- such research include repetitions at about 30° of knee flexion
oretical model that assists in the analysis of muscle strength (the impingement zone) in a closed-chain and weight-bearing
and flexibility as it relates to excessive hip adduction and position. Farrell et al [2] analyzed cycling kinematic and
knee varus or valgus. The tensor fascia lata is classified by kinetic data to reported values for running, with a focus on
Janda as a postural muscle with the tendency to become iliotibial band impingement at the knee. Ten
554 Baker et al
noninjured cyclists were analyzed with motion analysis and
synchronized foot-pedal forces. Findings included the fol-
lowing: (1) lower pedal reaction force at 17%-19% versus
ground reaction force in runners, and (2) shorter impinge-ment
zone contact time, calculated at 38 ms in cyclists versus 75 ms
in runners. However, the investigators discussed the issue of
repetitive stress in a typical workout, commenting that cycling
results in more repetitions (ie, 6600 repetitions during a 1.25-
hour ride versus 4800 repetitions during a 10-km run).
Interestingly, Farrell et al [2] described a theo-retical
mechanism of stress to the iliotibial band in cyclists in which
the shorter leg, when fixed to the pedal, is over-stretched
laterally and functions in less knee flexion, thereby increasing
the time spend in the impingement zone. Whether running or
cycling, the factors of impingement time and intensity of
loading are important.
Training factors, including rapid increases in mileage and
hill training, can lead to iliotibial band injury [2,29]. Orchard
et al [10] suggested that increased impingement zone impact
time during both downhill and slow running leads to ITBS and
sprinting may result in relatively less impact time be-cause of
greater knee flexion beyond the impingement zone. This
particular theory was not supported by Miller et al [30], who
found, during an exhaustive run, increased knee flexion at heel
strike in runners with a history of ITBS. Our review did not
find experimental studies that evaluated the effect of sprinting
on iliotibial band strain or impingement, although the topic
seems relevant for future research. Messier et al [29] reported
that less experienced runners with rapid changes in mileage
were at risk for ITBS, but hypothesized that intrinsic factors,
including strength deficits, were necessary for extrin-sic
factors to cause symptoms. The investigators also reported
increased cross-training habits (ie, swimming and cycling) in
runners with ITBS versus the control group.
CLINICAL EXAMINATION
Sutker et al [39] evaluated 1030 runners with lower extrem-ity
complaints and diagnosed 48 cases of ITBS. Subjectively, the
patients described lateral knee pain associated with re-petitive
loading in a weight-bearing position (ie, running and stairs).
Functionally, the runners were able to perform activ-ities such
as a hop and squat without pain. This contrasts with the cases
presented by Renne [6], in which military recruits in daily
training exhibited a limp and straight leg gait pattern. Renne
[6] also noted that the symptoms were aggra-vated by running
more than 2 miles and hiking more than10 miles. Sutker et al
[39] confirmed the diagnosis of ITBS by the history and
tenderness localized at the lateral epicondyle of the femur or
less commonly at the Gerdy tubercle. Concur-rently, the
patients did not have symptoms at the lateral joint line or
popliteal tendon, and did not have signs of intra-articular
disorders.
The subjective examination includes the clinical applica-
tion of previous information on factors associated with ITBS.
ILIOTIBIAL BAND SYNDROME
Taunton et al [5] reported on 168 cases of ITBS with a
distribution 38% men, 62% women, average weekly hours of
running 4.9, training years 7.3, body mass index of 23.7 for
men and 21.2 for women, and age 31.1 years. Only age
younger than 34 years in men was a significant factor among
these variables. ITBS was associated with pain after a run that
restricted the ability to run. McNicol et al [26] reported 52
cases of ITBs; 42% were found to be related to training errors,
such as rapid commencement (2 cases), sudden hill exposure
(1 case), single severe session (12 cases), rapid increase
volume of training (7 cases), and footwear and surface issues
(4 cases). Similarly, Messier et al [29] studied 48 cases of
ITBS; compared with 70 controls and reported ITBS cases, the
patients had increased training mileage and less experi-ence.
In summary, the subjective examination in cases of ITBS has
the defining characteristics of lateral knee pain with repetitive
knee activity usually in a weight-bearing position and
associated overtraining issues.
Objectively, the Noble compression test may be used to
provocate symptoms by compressing the iliotibial band at the
lateral epicondyle with 30° knee flexion [9]. The patient is
positioned with the knee at 90° flexion, and compression is
applied just proximal to the lateral epicondyle as the knee is
extended toward full extension. The 30° flexion is the
impingement zone specific to the iliotibial band and lateral
femoral epicondyle as described in cadaver studies by both
Orchard et al [10] and Fairclough et al [14]. Differentiating
related structures uses this impingement zone concept as well
as lack of other objective test findings for injury to the lateral
meniscus, lateral retinaculum, popliteus and biceps femoris
tendons, patellofemoral joint, and lateral collateral ligament.
Although not frequently used for diagnosis, Ekman et al [40]
used magnetic resonance imaging to evaluate 7 patients with
ITBS and 10 age- and gender-matched controls. The
investigators reported thickening of the iliotibial band over the
lateral femoral condyle (5.49 mm ITBS and 2.52 mm control;
P .05) and fluid deep to the iliotibial band at the lateral
epicondyle in 5 of 7 cases.
Clinical Assessment of Flexibility
Flexibility of the lateral hip musculature has routinely been
tested as a factor in ITBS [33]. The rationale in testing and
treating is related to muscle performance factors (Figure 3)
and biomechanical factors, given the issue of iliotibial band
compression at the lateral epicondyle of the femur. Messier et
al [29] analyzed stretching habits in 56 runners with ITBS and
70 controls and found that both groups stretched, but
differences were not established. Fredericson et al [41] ana-
lyzed the effectiveness of 3 iliotibial band stretches, in 5 male
elite distance runners, and found significant changes in the
iliotibial band length in all 3 types of stretching. The investi-
gators proposed benefits to stretching such as reducing ili-
otibial band tension by hip abductor muscle inhibition and
PM&R Vol. 3, Iss. 6, 2011 555

Clinical Assessment of Strength

The functionally weak gluteus medius and gluteus maximus
reduces eccentric control of the hip and femur in stance
[33,34]. To detect hip muscle imbalance between the tensor
fascia lata and the gluteus medius and maximus, the clinician
can perform surface electromyography (EMG) to observe for
muscle substitution: (1) tensor fascia lata may substitute for
the posterior fibers of the gluteus medius, and (2) hamstring
may substitute for the gluteus maximus as described by
Kendall et al [38]. Functional tests offer insight into muscle
substitutions on a regional basis, such as trunk and lower-
extremity strength, including signs of excessive femur inter-
nal rotation, ipsilateral hip adduction, and contralateral hip
drop during a step-down test or Trendelenburg test (Figures 5
and 6) [37,45,46]. The utility of the standing functional tests is
debated based on minimal detectable change and whether or
Figure 4. The Ober test.
not weakness exists in the hip musculature (ie, gluteal
muscles) or core stabilizers (ie, internal obliques, transverse
abdominus, multifidus) [37,46]. However, the functional tests
may identify muscle performance factors that a patient can see
improvement in fascial adhesions and myofascial trigger
points. firsthand, a powerful motivator in treatment compliance. The
gluteus maximus muscle strength should also be tested, given
The Ober test is commonly performed to assess iliotibial
its role of hip stabilizer in the frontal plane [47] and ability to
band length. Gose and Schweizer [42] describe the Ober test
influence femur rotation (ie, con-centric femur external
as follows: (1) position the patient on side, lying with the
rotation and eccentric femur internal rotation) [36,38,47].
tested leg up; (2) with the knee flexed to 90° and the pelvis
Testing the gluteus maximus can be performed with the patient
stabilized, position the hip in a flexed and abducted posture;
in the prone position with the knee flexed to 90° and the hip in
(3) extend the hip to achieve adequate extension so that the
neutral rotation by using a manual muscle test or hand-held
iliotibial band is over or behind the greater trochanter; and
dynamometer against the
(4) allow the thigh to fall into adduction (Figure 4). The
iliotibial band restriction is designated as follows: (a) mini-
mal (adducted past the horizontal but not fully to the table),
(b) moderate (adducted to the horizontal), and (c) maximal
(patient is unable to adduct to the horizontal).
Because the Ober test requires adequate hip extension
(approximately to a neutral hip with knee flexed 90°), the use
of the modified Thomas test is also recommended. Clapis et al
[43] evaluated 42 noninjured subjects in the modified Thomas
test by using an inclinometer and goniometer to measure joint
ranges. The subjects sat close to the edge of the table,
supported the left thigh to the chest, and rolled back to the
supine position. The right leg was positioned to hang off the
table. To standardize the measurements, the lumbar lordosis
was flattened and palpated in that position during the test. The
tested hip was placed in neutral hip abduction– adduction. A
goniometer was aligned proximally with the midline of pelvis
and distally with the midline of the femur. Interclass
correlation (ICC) measurements by goniometer were 0.92 and
by inclinometer were 0.89. Harvey [44] ana-lyzed the
modified Thomas test in 117 elite athletes in tennis, running,
rowing, and basketball. ICCs were 0.91-0.94, and findings
were as follows: (1) psoas averaged 11.9° (below the Figure 5. Normal step-down test on a 6-inch (15.24-cm) box
demonstrates level hips at 10 repetitions. Performed on 8-inch
horizontal), (2) quadriceps was 52.5°, and (3) tensor fascia
(20.32-cm) box if normal at 6-inch (15.24-cm) height.
lata–iliotibial band averaged 15.6° abduction.
556 Baker et al
Figure 6. Abnormal step-down test exhibits a contralateral hip drop
during the step down.
lower portion of the posterior femur [36,38,48]. The patient
should be able to fully resist without a break and should
have symmetrical strength side to side. The deep external
rotator muscles are important stabilizers of the hip,
including the obturator internus and externus, gemellus
superior and infe-rior, quadratus femoris, and piriformis
[49]. The muscle test position described by Janda [36] is
supine, test leg off the table and nontest leg flexed at the
hip and the knee, with the foot on the table, fixate below
the distal femur, and resistance applied above the medial
malleolus as the patient moves through full range.
Treatment
Fredericson and Wolf [33] developed a useful format for
stages of treatment (Table 1): acute, subacute, and recovery
strengthening. Treatment of ITBS is driven by the
pathophys-iology of inflammation and the biomechanics of
iliotibial band strain [32,33]. The path to recovery involves
correction of contributing factors such as weakness of the
gluteus me-dius and excessive hip adduction and knee
internal rotation, leg-length discrepancies, and excessive
knee varus or valgus strain.
Given the finding of soft-tissue thickening and fluid under
the iliotibial band at the lateral epicondyle [8,40], the early use
of anti-inflammatory medications, soft-tissue mobiliza-tion,
and stretching are advised [7,8,33,39,50]. Ellis et al [1]
performed a systematic review of conservative treatments for
ITBS. By using the Physiotherapy Evidence Database criteria,
corticosteroid injection and nonsteroidal anti-inflammatory
medications were moderately supported within the first 14
ILIOTIBIAL BAND SYNDROME
days and anti-inflammatory–analgesic after 14 days. If
there is significant swelling or tenderness at the lateral
epicondyle resistant to oral anti-inflammatory medication
and physical therapy modalities, then a corticosteroid
injection at the lateral epicondyle of the femur should be
considered early in the treatment course [51].
Patient education is critical to success. Extrinsic factors
have been described, including excessive weekly mileage,
overtraining, hill training, and other activities that place the
iliotibial band in the impingement zone, for example,
swim-ming [5,26,29]. Sutker et al [39] reported on 48 cases
of ITBS and found a trend in running 20-40 miles per week
for more than 1 year. McNicol et al [26] reported on 52
cases of ITBS in athletes and found that 26 cases involved
training-related issues.
Exercise approaches for ITBS have thus far supported
strengthening of the gluteus medius (ie, side-lying hip ab-
duction and hip hiking) [3,52]. Approaches to hip strength-
ening are rapidly increasing, especially targeted to the
gluteus medius and maximus [53,54]. Some experts (ie,
Fredericson, Geraci) have recommended innovative closed
chain ap-proaches to treating ITBS, such as triplanar lunge
and squat exercises [33,34].
EMG activation studies of the gluteal muscles provide
direction to therapeutic exercise programs. Distefano et al
[55] analyzed mean EMG as a percentage of maximal volun-
Table 1. Phases of rehabilitation recommended by Frederic-son
and Wolf [33]
Acute Phase
Goal: Reduce inflammation of the iliotibial band at the lateral
femoral epicondyle (Figure 1)
1. Control extrinsic factors, such as rest from running and
cycling
2. In severe cases patients should avoid any activities with
repetitive knee flexion-extension and swim using only their
arms and a pool buoy
3. The use of concurrent therapies is advised (ie, ice,
phonophoresis, or iontophoresis) [1,50]
4. Oral, nonsteroidal anti-inflammatory medication is
recommended
5. Corticosteroid injection, if no response to the above
methods
6. Up to 2 pain-free weeks before return to running or
cycling in a graded progression
Subacute Phase
Goal: Achieve flexibility in the iliotibial band as a foundation to
strength training without pain
1. Iliotibial band stretching (Figure 7)
2. Soft tissue mobilization to reduce myofascial adhesions
Recovery Strengthening Phase
Goal: Strengthen the gluteus medius muscle including
multiplanar closed chain exercises
1. Exercises should be pain free
2. Repetitions and sets of exercises are 8-15 repetitions and 2-3
sets
3. Recommend the exercises of sidelying hip abduction, single
leg activities, pelvic drops, and multiplanar lunges
PM&R Vol. 3, Iss. 6, 2011 557

tary isometric contraction in 21 healthy subjects during a

variety of open and closed chain exercises for the gluteus
medius and gluteus maximus. The only resistance was seg-
mental body weight, gravity, and resistance bands. The in-
vestigators were careful to use positions that promoted a
gluteal recruitment pattern, such as a vertical tibia with
lunging and forward trunk by hip flexion with squat activity.
The list of compared exercises included side-lying hip abduc-
tion, clam shell, lateral band walks, single-limb squat, single-
limb dead lift, multiplanar lunges, and multiplanar hops. The
ICC3,1 were 0.85-0.98 for gluteus maximus and 0.93-0.98
gluteus medius except for multiplanar hops. The investiga-tors
proposed that 60% or greater normalized EMG as a percentage
of maximal voluntary isometric contraction was the
requirement for a strengthening exercise [55,56]. The gluteus
medius averaged 61% lateral band walk, 64% single-limb
squat, and 81% side-lying hip abduction. The gluteus maximus Figure 8. Resisted clam shell is a beginning-level exercise for
averaged 59% in single-limb dead lift and single-limb squat. gluteal muscle recruitment.
The side-lying clam shell did not use a resistance band and
achieved 38%-40% activation in the gluteus me-dius. This
study supported the use of functional-based exer-cises and
open chain resistance exercises to strengthen the gluteal investigators demonstrated that the 25-lb (0.91-kg) lift with
muscles from the viewpoint of EMG patterns. knees flexed and tibias forward generated a strong quadri-ceps
EMG and minimal gluteus maximus EMG. The straight knee
The positioning of the trunk and degree of knee flexion
and trunk flexed 25-lb (0.91-kg) lift produced minimal
may change the EMG in the gluteus medius and maximus.
quadriceps and gluteus maximus EMG but strong hamstring
Fischer and Houtz [57] analyzed a floor-to-waist lift of 25 lb
EMG. The sacrospinalis muscle was active in both lifts. When
(0.91 kg) with the knees straight and the trunk and hips flexed
compared with the EMG and exercise activities in the Diste-
versus hips and knees flexed (ie, forward tibias) in 11 healthy
fano study [55], the differences may be related to the position
women, aged 15-23 years. EMG activity was mea-sured in the
of the tibia, because Fischer and Houtz [57] allowed a much
gluteus maximus, sacrospinalis, medial and lateral hamstrings,
greater forward position of the tibia. In addition, Fischer and
and quadriceps femoris muscles. The
Houtz [57] used a bilateral leg activity in the sagittal plane,
whereas Distefano et al [55] chose more unilateral limb
activities and multiplanar tasks. The clinical significance is
that the biomechanical details in functional exercise are crit-
ical to strengthening the gluteal muscles (ie, single leg, mul-
tiplanar, vertical tibia).
Noehren et al [58] used real-time visual biofeedback to
successfully train 10 female subjects with anterior knee pain
and a diagnosis of patellofemoral pain syndrome. Inclusion
also required excessive hip adduction on motion analysis. The
hip adduction angle was displayed onto a monitor placed in
front of the treadmill. Instructions were to contract the gluteal
muscles and run with the knees pointed straight ahead, and to
maintain a level pelvis. The sessions progressed from 15-30
minutes over 8 sessions, and the visual feedback was faded in
sessions 5-8. The participants were not allowed to run outside
this training. The program involved faded feedback over 8
treatment sessions (4 times per week for 2 weeks). The result
was a 23% decrease in ipsilateral hip adduction during running
that was maintained at 1-month follow-up. Although
patellofemoral pain cases with other biomechanical issues
such as increased hip internal rotation, the relevance to ITBS
is the possible use of faded feedback in running to control
Figure 7. Iliotibial band stretch in standing [41].
excessive hip adduction. Similarly, Barrios
558 Baker et al ILIOTIBIAL BAND SYNDROME

Figure 9. Resisted hip abduction and bridge is a beginning- Figure 11. Resisted hip extension, external rotation, and ab-
level exercise that facilitates gluteal recruitment. duction comprise a beginning-level exercise that facilitates
gluteus maximus and gluteus medius recruitment.

et al [59] studied visual faded feedback to reduce excessive

cognitive component that allows biomechanical improve-
knee external adduction moment during treadmill walking in 8
ments in 8 sessions.
noninjured participants with varus knee alignment, aged 18-35
The exercises that have been researched specific to ITBS
years. The verbal cues to the participants were “bring the
have included side-lying hip abduction and pelvic drops at 3
thighs closer” and “walk with your knees closer together”
sets and 30 repetitions and 6 weeks of treatment [3]. The side-
while maintaining a normal foot progression angle. The
lying hip abduction exhibited strong EMG activation in the
training was 8 sessions with faded feedback in sessions 5
study by Distefano et al [55], and single leg functional activity
through 8. Statistical significance was reported before to after
demonstrated higher EMG activation versus double-leg closed
training for knee external adduction moment, on average 20%
chain exercise. Furthermore, as stated previously,
reduction (P .027). Although performed on nonin-jured
participants with varus alignment, this particular ap-proach
may assist patients in ITBS cases with excessive knee varus.
In practice, real-time visual feedback has a strong

Figure 10. Resisted hip extension and knee flexion in quadru- Figure 12. Contralateral pelvic drop (starting position) is an
ped is a beginning-level exercise that facilitates gluteus max- intermediate-level exercise used successfully to strengthen hip
imus recruitment. abductors in runners with ITBS [3].
PM&R
Figure 13. Resisted squat is an intermediate exercise that uses
hip abduction and vertical tibial alignment to facilitate gluteus
maximus control.
the study by Distefano et al [55] used several other useful
modifications in functional exercises that seemed to
facilitate gluteal recruitment: (1) more vertical tibia, (2)
forward trunk lean, (3) resistance band with side walks, (4)
multiplanar activity, and (5) good control of trunk position.
The clam shell exercise without the resistance band, and the
lunge patterns without use of added weight, demonstrated
gluteal muscle EMG less than 60%, therefore, we
recommend use of resistance with these exercises.
Based on these EMG studies [55,57], research on exercise
and ITBS [3,52], and recent case studies focused on strength-
ening the gluteal muscles [53,54], our recommended pro-
gressions of therapeutic exercise include one iliotibial band
Figure 14. Resisted staggered squat is an intermediate exer-
cise to facilitate gluteal muscles and an alternative functional
stance.
Vol. 3, Iss. 6, 2011 559
Figure 15. Resisted squat with a single-leg emphasis is a more
vigorous exercise to facilitate single-leg control with the gluteal
muscles, facilitated by hip abduction and external rotation.
stretch, side-lying hip abduction and pelvic drops, and a
progression of technique-driven closed chain exercises, as
illustrated in Figures 7-17 (ie, vertical tibia and trunk
flexion from the hips). The bilateral closed chain exercises
are rela-tively low vigor and were used early in the
recovery to promote technique in squats, whereas the
single-leg activities are of higher vigor and intended for
strengthening the gluteal muscles.
RESUMING PARTICIPATION IN SPORTS
Participation in sports is dependent upon being able to perform
exercises in proper form without pain [11,33]. Other outcome
measures include strength testing the gluteus
Figure 16. Posterior lunge slide is a more vigorous leg exercise
for functional hip control.
560 Baker et al
Figure 17. Single-leg dead lift is a more vigorous single-leg
exercise to emphasize gluteus maximus, gluteus medius, and hip
control.
medius and gluteus maximus with a normal result [36,38].
The flexibility of the iliotibial band and rectus femoris can
be assessed with a modified Thomas test as previously
described [43,44]. The Ober test can be used to assess hip
adduction range of motion as previously described [42].
Our recom-mendation on flexibility testing and return to
sports is pain-free range of motion in hip adduction. There
should be a negative Noble compression test, with the
absence of tender-ness at the lateral epicondyle of the
femur at 30° knee flexion [9].
Runners and cyclists should train on level ground every
other day [33,60]. The distance and frequency of training
should be increased incrementally and monitored for the
recurrence of symptoms. Cross training is not
recommended if the activities involve repeated knee flexion
through the impingement zone, such as combining hill
running, track running, swimming, and cycling [10,29].
Orthotic recom-mendations are worth considering in a
runner if the patient has excessive calcaneal eversion and
tibial internal rotation during functional tasks and increased
leg length greater than 0.5 cm [5,26].
The cyclist is advised to check bicycle fit for factors related
to the 30° impingement zone and the toe-in position [2].
Wanich et al [60] recommended lowering the seat beyond the
typical height to decrease knee extension and related iliotibial
band stress, and more upright handlebars and a forward seat to
reduce passive stretch to the gluteus maximus and iliotibial
band. The investigators also recommended addressing cleat
position and use of orthotics, such as wedges, to control
excessive tibial internal rotation and foot hyperpronation.
Flexibility was emphasized for the gluteus maximus and
iliotibial band and, more generally for the hamstrings and
gastroc-soleus muscles. Holmes et al [4] treated 61 cyclists
with ITBS by using the following training
ILIOTIBIAL BAND SYNDROME
modifications: (1) flat terrains, (2) controlled mileage (ie,
1/2 mile for 2 weeks), (3) easy pedalling at 80 revolutions
per minute, and (4) pain free.The investigators also
modified the bicycles based on misalignments identified
during the eval-uation of bicycle fit, for example, adjusting
cleat or pedal positions to reflect the cyclist’s normal off-
bicycle alignment and lowering the seat to achieve 30°-32°
of knee flexion at the bottom center of the pedaling stroke.
Floating pedal systems were selected when fixed pedals did
not allow for correction of anatomic variants, and 2-mm
spacers were used to correct a short leg.
CONCLUSION
Several intrinsic and extrinsic contributing factors for ITBS
have been described. Reduced hip muscle performance and
abnormal hip and knee mechanics during functional tasks may
be primary contributors to ITBS. Addressing these un-derlying
factors is critical to the efficient management of patients with
this condition. Although controversy exists regarding the
mechanism of ITBS, controlling inflammation and symptoms
during early phases and progressive strength-ening in later
phases is recommended. ITBS remains a com-mon and
challenging dysfunction in many athletes; but, through early
diagnosis and proper biomechanical move-ment analysis,
appropriate interventions can be implemented to decrease pain
and to improve function.
REFERENCES
1. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome—a
systematic review. Man Ther 2007;12:200-208.
2. Farrell KC, Reisinger KD, Tillman MD. Force and repetition in
cycling: possible implications for iliotibial band friction syndrome.
Knee 2003; 10:103-109.
3. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oest-
reicher N, Sahrmann SA. Hip abductor weakness in distance runners
with iliotibial band syndrome. Clin J Sport Med 2000;10:169-175.
4. Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in
cyclists. Am J Sports Med 1993;21:419-424.
5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith
DR, Zumbo BD. A retrospective case-control analysis of 2002
running injuries. Br J Sports Med 2002;36:95-101.
6. Renne JW. The iliotibial band friction syndrome. J Bone Joint Surg
Am 1975;57:1110-1111.
7. Kirk KL, Kuklo T, Klemme W. Iliotibial band friction syndrome.
Orthopedics 2000;23:1209-1214.
8. Orava S. Iliotibial tract friction syndrome in athletes—an uncommon
exertion syndrome on the lateral side of the knee. Br J Sports Med
1978;12:69-73.
9. Noble C. Iliotibial band friction syndrome in runners. Am J Sports
Med 1980;8:232-234.
10. Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial
band friction syndrome in runners. Am J Sports Med 1996;24:375-379.
11. Adams WB. Treatment options in overuse injuries of the knee: patell-
ofemoral syndrome, iliotibial band syndrome, and degenerative
menis-cal tears. Curr Sports Med Rep 2004;3:256-260.
12. Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial
band strain in runners. Clin Biomech (Bristol, Avon) 2008;23:1018-1025.
PM&R
13. Kaplan EB. The iliotibial tract; clinical and morphological
significance. J Bone Joint Surg Am 1958;40-A:817-832.
14. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the
iliotibial band during flexion and extension of the knee: implications for
understanding iliotibial band syndrome. J Anat 2006;208:309-316.
15. Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M.
An anatomic study of the iliotibial tract. Arthroscopy 2007;23:269-274.
16. Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome
really a friction syndrome? J Sci Med Sport 2007;10:74-78.
17. Kelly A, Winston I. Iliotibial band syndrome in cyclists. Am J Sports
Med 1994;22:150.
18. Reischl SF, Powers CM, Rao S, Perry J. Relationship between foot
pronation and rotation of the tibia and femur during walking. Foot
Ankle Int 1999;20:513-520.
19. Terry GC, Hughston JC, Norwood LA. The anatomy of the
iliopatellar band and iliotibial tract. Am J Sports Med 1986;14:39-45.
20. Terry GC, Norwood LA, Hughston JC, Caldwell KM. How iliotibial
tract injuries of the knee combine with acute anterior cruciate
ligament tears to influence abnormal anterior tibial displacement. Am
J Sports Med 1993;21:55-60.
21. Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners
with a history of iliotibial band syndrome demonstrate atypical hip
and knee kinematics. J Orthop Sports Phys Ther 2010;40:52-58.
22. Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner
2006 prospective study of the biomechanical factors associated with
iliotibial band syndrome. Clin Biomech (Bristol, Avon) 2007;22:951-956.
23. Souza RB, Draper CE, Fredericson M, Powers CM. Femur rotation and
patellofemoral joint kinematics: a weight-bearing magnetic resonance
imaging analysis. J Orthop Sports Phys Ther 2010;40:277-285.
24. Li G, Van de Velde SK, Bingham JT. Validation of a non-invasive
fluoroscopic imaging technique for the measurement of dynamic
knee joint motion. J Biomech 2008;41:1616-1622.
25. Anderst W, Zauel R, Bishop J, Demps E, Tashman S. Validation of
three-dimensional model-based tibio-femoral tracking during
running. Med Eng Phys 2009;31:10-16.
26. McNicol K, Taunton JE, Clement DB. Iliotibial tract friction
syndrome in athletes. Can J Appl Sport Sci 1981;6:76-80.
27. Powers C. The influence of abnormal hip mechanics on knee injury: a
biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42-49.
28. Andriacchi TP. Dynamics of knee malalignment. Orthop Clin North
Am 1994;25:395-403.
29. Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction
syndrome in distance runners. Med Sci Sports Exerc 1995;27:951-960.
30. Miller RH, Lowry JL, Meardon SA, Gillette JC. Lower extremity me-
chanics of iliotibial band syndrome during an exhaustive run. Gait
Posture 2007;26:407-413.
31. Miller RH, Meardon SA, Derrick TR, Gillette JC. Continuous relative
phase variability during an exhaustive run in runners with a history of
iliotibial band syndrome. J Appl Biomech 2008;24:262-270.
32. Fredericson M, Weir A. Practical management of iliotibial band
friction syndrome in runners. Clin J Sport Med 2006;16:261-268.
33. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innova-
tions in treatment. Sports Med 2005;35:451-459.
34. Geraci MC Jr, Brown W. Evidence-based treatment of hip and pelvic
injuries in runners. Phys Med Rehabil Clin North Am 2005;16:711-747.
35. Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle
weakness and overuse injuries in recreational runners. Clin J Sport
Med 2005; 15:14-21.
36. Janda V. Muscle Function Testing. London: Butterworths; 1983.
37. Page P, Frank C, Lardner R. Assessment and Treatment of Muscle
Imbalance: The Janda Approach. Chicago, IL: Human Kinetics; 2010.
38. Kendall F, McGreary E, Provance P. Muscles: Testing and Function. 4th
ed. Baltimore, MD: Williams & Wilkins; 1993.
Vol. 3, Iss. 6, 2011 561
39. Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band
syndrome in distance runners. Sports Med 1985;2:447-451.
40. Ekman E, Pope T, Martin D, Curl W. Magnetic resonance imaging of
iliotibial band syndrome. Am J Sports Med 1994;22:851-854.
41. Fredericson M, White JJ, Macmahon JM, Andriacchi TP.
Quantitative analysis of the relative effectiveness of 3 iliotibial band
stretches. Arch Phys Med Rehabil 2002;83:589-592.
42. Gose JC, Schweizer P. Iliotibial band tightness. J Orthop Sports Phys
Ther 1989;10:399-407.
43. Clapis PA, Davis SM, Davis RO. Reliability of inclinometer and
gonio-metric measurements of hip extension flexibility using the
modified Thomas test. Physiother Theory Pract 2008;24:135-141.
44. Harvey D. Assessment of the flexibility of elite athletes using the
modified Thomas test. Br J Sports Med 1998;32:68-70.
45. Hollman JH, Ginos BE, Kozuchowski J, Vaughn AS, Krause DA,
Youdas JW. Relationships between knee valgus, hip-muscle strength,
and hip-muscle recruitment during a single-limb step-down. J Sport
Reha-bil 2009;18:104-117.
46. Youdas JW, Mraz ST, Norstad BJ, Schinke JJ, Hollman JH.
Determining meaningful changes in pelvic-on-femoral position
during the Tren-delenburg test. J Sport Rehabil 2007;16:326-335.
47. Lyons K, Perry J, Gronley JK, Barnes L, Antonelli D. Timing and relative
intensity of hip extensor and abductor muscle action during level and stair
ambulation. An EMG study. Phys Ther 1983;63:1597-1605.
48. Bell DR, Padua DA, Clark MA. Muscle strength and flexibility
charac-teristics of people displaying excessive medial knee
displacement. Arch Phys Med Rehabil 2008;89:1323-1328.
49. Neumann DA. Kinesiology of the hip: a focus on muscular actions. J
Orthop Sports Phys Ther 2010;40:82-94.
50. Gurney AB, Wascher DC. Absorption of dexamethasone sodium
phos-phate in human connective tissue using iontophoresis. Am J
Sports Med 2008;36:753-759.
51. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial
band friction syndrome in runners: a randomised controlled trial. Br J
Sports Med 2004;38:269-272.
52. Beers A, Ryan M, Kasubuchi Z, Fraser S, Taunton JE. Effects of multi-
modal physiotherapy, including hip abductor strengthening, in patients
with iliotibial band friction syndrome. Physiother Can 2008;60:180-188.
53. Tonley J, Yun S, Kochevar R, Dye J, Farrokhi S, Powers C.
Treatment of an individual with piriformis syndrome focusing on hip
muscle strengthening and movement reeducation: a case report. J
Orthop Sports Phys Ther 2010;40:103-111.
54. Wagner T, Behnia N, Lau Ancheta W, Shen R, Farrokhi S, Powers
CM. Strengthening and neuromuscular reeducation of the gluteus
maximus in a triathlete with exercise-associated cramping of the
hamstrings. J Orthop Sports Phys Ther 2010;40:112-119.
55. Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal
muscle activation during common therapeutic exercises. J Orthop
Sports Phys Ther 2009;39:532-540.
56. Ayotte NW, Stetts DM, Keenan G, Greenway EH. Electromyographical
analysis of selected lower extremity muscles during 5 unilateral weight
bearing exercises. J Orthop Sports Phys Ther 2007;37:48-55.
57. Fischer FJ, Houtz SJ. Evaluation of the function of the gluteus maximus
muscle. An electromyographic study. Am J Phys Med 1968;47:182-191.
58. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip
kinematics, pain and function in subjects with patellofemoral pain
syndrome. Br J Sports Med 2010, doi:1136/069112. Available at http://
bjsm.bmj.com/content/early/2010/06/27/bjsm.2009.069112.full. Ac-
cessed July 18, 2010.
59. Barrios JA, Crossley KM, Davis IS. Gait retraining to reduce the
knee adduction moment through real-time visual feedback of
dynamic knee alignment. J Biomech 43:2208 –2213.
60. Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG. Cycling
injuries of the lower extremity. J Am Acad Orthop Surg 2007;15:748-756.