ILIOTIBIAL BAND SYNDROME - RUNNER'S LATERAL KNEE PAIN
Friction at 30° Flexion | Hip Abductor Weakness | Activity Modification Key | Rarely Surgical
CLINICAL SEVERITY STAGES
Critical Must-Knows
- Lateral femoral epicondyle friction occurs at 30 degrees of knee flexion during foot strike
- Hip abductor weakness (gluteus medius) is the primary biomechanical cause
- Noble compression test is pathognomonic - pain at 30 degrees with compression
- Activity modification and eccentric strengthening are cornerstones of treatment
- Surgery (ITB release/lengthening) is rarely needed - less than 10% of cases
Examiner's Pearls
- "Most common cause of lateral knee pain in distance runners (12% of running injuries)
- "Friction occurs 2cm proximal to lateral femoral epicondyle at 30 degrees flexion
- "Ober test assesses ITB tightness - hip abduction contracture indicates positive
- "Downhill running and track running (always turning same direction) increase risk
Clinical Imaging
Imaging Gallery
Critical ITB Syndrome Exam Points
Friction Zone Biomechanics
ITB friction occurs at 30 degrees of knee flexion over the lateral femoral epicondyle. At angles greater than 30 degrees, the ITB moves posterior to the axis of rotation. This repetitive friction causes inflammation and pain.
Hip Abductor Weakness
Gluteus medius weakness is the root cause in 95% of cases. Weak hip abductors allow contralateral pelvic drop, increasing ITB tension. Always assess hip strength - this guides rehabilitation.
Noble Compression Test
Pathognomonic clinical test: Apply pressure 2cm proximal to lateral epicondyle while passively extending knee from 90 degrees. Pain at 30 degrees flexion is positive - reproduces the friction zone pain.
Conservative Treatment Success
More than 90% respond to non-operative management with activity modification, eccentric strengthening, and biomechanical correction. Surgery is a last resort after 6-12 months of failed conservative care.
Quick Clinical Decision Guide
| Stage | Clinical Picture | Treatment | Key Pearl |
|---|---|---|---|
| Stage 1 (Early) | Pain after running only, resolves in minutes | Activity modification + ITB stretching | Catch it early - excellent prognosis |
| Stage 2 (Mild) | Pain during run but doesn't stop activity | Structured rehab + hip strengthening | Address biomechanics - prevent progression |
| Stage 3 (Moderate) | Pain limits running distance | Cease running + intensive PT | Running break essential for healing |
| Stage 4 (Severe) | Pain with stairs, prolonged sitting | Complete rest + cortisone injection | Consider MRI to exclude other pathology |
| Refractory (Rare) | Failed 6-12 months conservative care | ITB release/lengthening surgery | Less than 10% require surgery |
FLEXITB - Friction Zone Anatomy
Memory Hook:When the knee goes into FLEX-ion past 30 degrees, the ITB moves and friction occurs
RUNNERSRUNNERS - Risk Factors for ITB Syndrome
Memory Hook:RUNNERS get ITB syndrome - remember the risk factors every distance athlete faces
REHABREHAB - Conservative Treatment Framework
Memory Hook:REHAB is the pathway - surgery rarely needed if you follow this framework
30-2-1030-2-10 Rule
Memory Hook:The 30-2-10 rule: where it hurts (30 degrees, 2cm proximal) and how rarely you operate (10%)
Overview and Epidemiology
Iliotibial band (ITB) syndrome is the second most common running injury after patellofemoral pain syndrome, accounting for approximately 12% of all running-related injuries. It presents as lateral knee pain caused by repetitive friction of the ITB over the lateral femoral epicondyle during the gait cycle.
Epidemiology:
- Distance runners are predominantly affected (especially marathon and ultramarathon)
- Cyclists are second most common (particularly with improper bike fit)
- Military recruits during basic training
- Athletes in cutting sports (basketball, soccer) less commonly
Why 'Runner's Knee' (Lateral)
ITB syndrome is sometimes called "runner's knee" (though this term more commonly refers to patellofemoral pain). The distinction is important - ITB syndrome is lateral knee pain, while patellofemoral pain is anterior. In the exam, always clarify pain location.
Australian Context:
- Running participation in Australia: more than 3 million regular runners
- Park runs and community running events have increased ITB syndrome presentations
- Coastal running (beach, trails) with camber can increase risk
Pathophysiology and Mechanisms
ITB Anatomy
The iliotibial band is a thickened fascial structure extending from the iliac crest to the lateral tibia (Gerdy's tubercle).
Proximal attachments:
- Tensor fasciae latae (anterior)
- Gluteus maximus (posterior, 75% of fibers)
- Iliac crest
Distal attachment:
- Gerdy's tubercle on anterolateral proximal tibia
- Lateral femoral epicondyle (NO anatomical attachment but friction zone)
- Lateral patellar retinaculum
The Friction Zone Concept
The ITB does not attach to the lateral femoral epicondyle - it glides over it. At knee flexion angles less than 30 degrees, the ITB is anterior to the axis of rotation (extends the knee). At angles greater than 30 degrees, it moves posterior (flexes the knee). This repetitive anterior-posterior movement at 30 degrees during running creates friction.
Biomechanics of Friction
ITB Position Throughout Knee Range of Motion
| Knee Position | ITB Position | Function | Clinical Significance |
|---|---|---|---|
| Full extension (0 degrees) | Anterior to epicondyle | Knee extensor | No friction, ITB under tension |
| 0-30 degrees flexion | Moving posterior | Transitioning | FRICTION ZONE - impingement occurs |
| Greater than 30 degrees | Posterior to epicondyle | Knee flexor | No friction, ITB relaxed |
During running gait:
- Foot strike - knee at approximately 20-30 degrees flexion → ITB compressed against epicondyle
- Mid-stance - knee extends → ITB slides anteriorly
- Toe-off - knee flexes → ITB slides posteriorly
- Swing phase - repetitive anterior-posterior gliding
This occurs approximately 1,000 times per mile of running.
Hip Abductor Role
Gluteus Medius Function
Primary hip abductor - prevents contralateral pelvic drop during single-leg stance (mid-stance of gait). Weakness leads to Trendelenburg gait pattern with increased hip adduction on stance leg.
ITB Tension Relationship
Hip adduction increases ITB tension over lateral femoral epicondyle. Weak gluteus medius → pelvic drop → increased hip adduction → increased ITB strain → friction syndrome. This is the biomechanical cascade.
Trendelenburg and ITB Syndrome
The Trendelenburg test (single-leg stance causes contralateral pelvic drop) is often positive in ITB syndrome patients. This indicates gluteus medius weakness. In the exam, always assess hip abductor strength - it's the key to understanding and treating ITB syndrome.
Classification Systems
Clinical Severity Stages
ITB syndrome is typically classified by symptom severity and functional limitation.
| Stage | Symptoms | Functional Impact | Treatment Approach |
|---|---|---|---|
| Stage 1 (Mild) | Pain after running, resolves within minutes | No limitation of distance or speed | Activity modification, ITB stretching, continue running |
| Stage 2 (Moderate) | Pain during running but tolerable | Can complete runs but painful | Structured rehabilitation, reduce mileage/intensity |
| Stage 3 (Severe) | Pain limits running distance | Cannot complete planned distance | Cease running, intensive physiotherapy |
| Stage 4 (Disabling) | Pain with daily activities (stairs, sitting) | Unable to run, affects quality of life | Complete rest, consider cortisone injection |
Progression is Preventable
Catching ITB syndrome at Stage 1 and implementing proper rehabilitation prevents progression to chronic, disabling pain. Most runners who progress to Stage 3-4 either ignored early symptoms or attempted to "run through" the pain.
Clinical Presentation and Assessment
History
Pain Characteristics
- Location: Lateral knee, 2-3cm proximal to joint line
- Quality: Sharp, burning, or aching
- Onset: Gradual over days-weeks
- Timing: During running, especially on hills or turns
- Relieving: Rest, stopping running
Running History
- Recent training changes: Increased mileage, intensity, hills
- Surface: Track (always same direction), camber, downhill
- Footwear: New shoes, worn-out shoes
- Previous ITB issues: Recurrence common if rehab incomplete
- Cross-training: Cycling (also risk factor)
Red flag questions (exclude other pathology):
- Locking or catching (meniscal tear)
- Giving way (ligament injury)
- Night pain (tumor, infection)
- Systemic symptoms (inflammatory arthropathy)
Physical Examination
Systematic Examination
- Gait: Trendelenburg gait pattern (hip drops on opposite side during stance)
- Alignment: Genu varum (bow-legged) increases ITB tension
- Muscle wasting: Gluteus medius atrophy (chronic cases)
- Point tenderness: 2cm proximal to lateral femoral epicondyle
- ITB tightness: Palpate along entire ITB from iliac crest to Gerdy tubercle
- Lateral joint line: Ensure not meniscal tenderness
- Noble compression test (pathognomonic)
- Ober test (ITB tightness)
- Trendelenburg test (hip abductor weakness)
- Single-leg squat (biomechanical assessment)
- Knee ROM: Usually full (pain may limit terminal extension)
- Hip ROM: Assess for limited abduction (tight ITB)
- Hip abduction strength: Gluteus medius manual muscle testing (often 3-4/5)
- Knee stability: ACL/PCL/collateral ligaments (exclude instability)
Noble Compression Test (Pathognomonic)
Technique:
- Patient supine or standing
- Flex knee to 90 degrees
- Apply pressure with thumb 2cm proximal to lateral femoral epicondyle
- While maintaining pressure, passively extend the knee
- Positive test: Pain at approximately 30 degrees of flexion (friction zone)
Noble Test Specificity
The Noble compression test has high specificity (greater than 90%) for ITB syndrome. Pain at the 30-degree position reproduces the exact biomechanical impingement that occurs during running. This is the single most important clinical test.
Ober Test (ITB Tightness)
Technique:
- Patient side-lying (affected side up)
- Flex lower knee to 90 degrees for stability
- Flex upper hip and knee to 90 degrees
- Extend upper hip (bring leg in line with trunk)
- Abduct upper hip, then release and let gravity adduct
- Positive test: Leg remains abducted (does not fall to table) - indicates ITB contracture
Interpretation: Positive Ober test indicates ITB tightness but is not specific for ITB syndrome (many asymptomatic individuals have positive Ober).
Trendelenburg Test (Hip Abductor Strength)
Technique:
- Patient stands on affected leg (single-leg stance)
- Observe pelvis from behind
- Positive test: Contralateral pelvis drops (weak gluteus medius cannot stabilize pelvis)
Significance: Positive Trendelenburg indicates the biomechanical cause of ITB syndrome. This must be addressed in rehabilitation.
Investigations
Imaging Protocol
Investigation Algorithm
ITB syndrome is a clinical diagnosis. Imaging is not required for typical presentation with positive Noble test and clear running history.
Indications for imaging:
- Atypical features (young patient, no running history)
- Failed conservative treatment (exclude other pathology)
- Severe symptoms (Stage 4)
- Medicolegal or compensation cases
Views: AP and lateral knee
Purpose: Exclude bony pathology
- Usually normal in ITB syndrome
- Look for: lateral compartment osteoarthritis, osteochondral lesions, avulsion fractures
Findings in ITB syndrome: May show soft tissue swelling lateral to knee (non-specific)
Gold standard for soft tissue assessment
Typical findings in ITB syndrome:
- T2 hyperintensity deep to ITB at lateral femoral epicondyle (fluid signal)
- Thickening of ITB over epicondyle
- Periosteal edema at lateral epicondyle (bone stress)
- Bursal fluid (if bursa present)
Excludes:
- Meniscal tears (lateral meniscus)
- Lateral collateral ligament injury
- Popliteus tendinopathy
- Lateral femoral condyle osteochondral lesion
- Proximal tibiofibular joint pathology
Dynamic assessment of ITB movement
Findings:
- Thickening of ITB
- Fluid deep to ITB
- Can demonstrate ITB snapping over epicondyle with knee flexion/extension
Limited use: Operator-dependent, MRI preferred if imaging needed
Imaging Overuse
Do not routinely order imaging for ITB syndrome. It is a clinical diagnosis based on history (runner, lateral knee pain), examination (Noble test positive), and biomechanical assessment (hip weakness). Imaging is for atypical cases or failed treatment.
Management Algorithm
Conservative Care is Standard of Care
More than 90% of ITB syndrome cases respond to non-operative management. Surgery should only be considered after 6-12 months of comprehensive conservative treatment failure. The key is addressing the biomechanical cause (hip weakness), not just symptomatic treatment.
Conservative Treatment Algorithm
Early Stage Management
Goal: Reduce inflammation, continue running with modifications
Treatment Steps
- Reduce running mileage by 25-50%
- Avoid provocative activities: Downhill running, track (same direction), steep hills
- Cross-training: Swimming, pool running (maintains fitness without impact)
- Surface change: Treadmill (flat), grass, trails (varied terrain)
- Ice: 15-20 minutes after running, 3-4 times daily
- NSAIDs: Ibuprofen 400mg TDS or Naproxen 500mg BD for 1-2 weeks
- Topical NSAIDs: Diclofenac gel applied to lateral knee
- Standing cross-leg stretch: Cross affected leg behind, lean away from affected side
- Side-lying ITB stretch: Bottom leg straight, top leg crosses over, rotate trunk
- Foam rolling: 30 seconds along ITB (may be very painful initially)
- Hold stretches: 30-60 seconds, repeat 3-5 times daily
- Side-lying hip abduction: 3 sets of 15 repetitions
- Clamshells: With resistance band, 3 sets of 15
- Single-leg bridge: Progress to single-leg, 3 sets of 10
- Single-leg squat: Progress difficulty as tolerated
Eccentric Focus
Eccentric strengthening of hip abductors is more effective than concentric. Slow lowering phase (3-5 seconds) during exercises creates greater strength gains.
- Gait analysis: Running store or sports physiotherapist
- Footwear assessment: Replace shoes if over 500-800km
- Orthotics consideration: If significant pronation or supination
- Running form coaching: Increase cadence (reduce stride length), avoid crossover gait
Return to Running Criteria (must meet all before progressing):
Pain-free with daily activities / Negative Noble test / Hip abduction strength 90% of opposite side / Pain-free single-leg squat
Surgical Management (Rarely Indicated)
Indications for Surgery
Last Resort Only
Surgery for ITB syndrome is indicated in less than 10% of cases and only after:
- 6-12 months of failed comprehensive conservative treatment
- Confirmed compliance with physiotherapy and activity modification
- Exclusion of other pathology (MRI scan)
- Documented biomechanical correction attempt
- Impact on quality of life (unable to work, exercise, daily activities)
Surgical Options
Surgical Techniques
| Procedure | Technique | Rationale | Evidence |
|---|---|---|---|
| ITB Z-lengthening | Z-plasty incision in ITB at friction zone to lengthen | Reduces tension over lateral epicondyle | Most common, 80-90% good results in selected cases |
| ITB release (bursectomy) | Excision of posterior 2cm of ITB over epicondyle ± bursa | Removes impinging tissue | Good results but some reports of weakness |
| Elliptical excision | Remove ellipse of ITB (4×2cm) over friction zone | Decompression and reduces friction | Variable results, theoretical weakness concern |
ITB Z-Lengthening (Most Common)
Operative Steps
- Position: Supine, affected leg free-draped or lateral decubitus
- Tourniquet: Optional (improves visualization)
- Landmarks: Mark lateral femoral epicondyle (palpate), Gerdy tubercle
- Incision: 5-7cm longitudinal over lateral femoral epicondyle
- Dissection: Through subcutaneous tissue, identify ITB
- Bursa: Excise if present (usually not)
- Proximal limb: Incise ITB in line with fibers, 2cm proximal to epicondyle, from anterior edge posteriorly (leave 1cm intact posteriorly)
- Distal limb: 2cm distal to epicondyle, from posterior edge anteriorly (leave 1cm intact anteriorly)
- Result: Z-shaped cut allows lengthening
- Tension: Gently separate the two limbs to lengthen ITB by 1-2cm
- Do not repair Z-plasty (allow lengthening to persist)
- Close subcutaneous tissue and skin
- No drain typically needed
Surgical Outcomes
Success rates (selected patients):
- 80-90% return to pre-injury activity level
- Higher success in those who failed conservative care due to anatomical factors (vs poor compliance)
- Failures often due to persistent biomechanical issues (hip weakness not addressed)
Surgery Doesn't Fix Biomechanics
Critical concept: Surgery addresses the local anatomical issue (tight ITB) but does not correct hip weakness or running biomechanics. Post-surgical rehabilitation MUST include the same hip strengthening and gait retraining as conservative care, or symptoms recur.
Complications and Management
Conservative Treatment Complications
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Recurrence with return to running | 30-40% if rehab incomplete | Complete 6-8 week return protocol, maintain hip strengthening |
| Chronic pain (failed conservative) | 5-10% | Ensure compliance, exclude other pathology (MRI), consider surgery |
| Loss of fitness (running cessation) | Common | Cross-training (swimming, cycling), maintain cardiovascular fitness |
Surgical Complications
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Recurrent symptoms | 10-20% | Comprehensive post-op rehab, biomechanical correction |
| Wound infection | Less than 5% | Sterile technique, prophylactic antibiotics |
| Lateral knee weakness | Rare (excessive release) | Conservative Z-lengthening, avoid excessive ITB excision |
| Nerve injury (common peroneal) | Rare (less than 2%) | Careful dissection, avoid deep dissection near fibular head |
Postoperative Care and Rehabilitation
Note: This section applies to the less than 10% of patients who undergo surgical intervention (ITB Z-lengthening or release).
Post-Surgical Rehabilitation Protocol
Goals: Wound healing, pain control, prevent stiffness
Weight-bearing: Full weight-bearing as tolerated with crutches for comfort
ROM: Immediate knee range of motion exercises (avoid stiffness)
Exercises: Gentle ankle pumps, quadriceps sets, passive knee flexion/extension
Pain management: Paracetamol, NSAIDs, ice elevation
Wound care: Keep dressing dry, remove sutures at 10-14 days
Goals: Restore full ROM, begin strengthening, wean crutches
Mobility: Wean crutches as comfortable (usually by week 3-4)
ROM: Active and active-assisted knee ROM (goal: full ROM by week 6)
Strengthening: Begin gentle hip abductor strengthening
Hip exercises: Side-lying hip abduction (light resistance), clamshells, bridges
Cycling: Stationary bike (start week 3-4) for ROM and cardiovascular fitness
Avoid: Running, jumping, impact activities
Goals: Build strength, prepare for running
Strengthening: Intensive hip and knee strengthening program
Exercises: Single-leg squats, single-leg deadlifts, step-ups, resistance band work
Proprioception: Single-leg balance, perturbation exercises
Cardiovascular: Continue cycling, add elliptical if pain-free
Functional testing: Pain-free single-leg hop, single-leg squat (10 repetitions)
Goals: Safe return to running
Prerequisites: Must meet all criteria before starting running:
Pain-free daily activities for 2+ weeks
Full knee ROM
Hip abduction strength equal to or greater than 90% of contralateral
Pain-free single-leg hop (within 90% of opposite)
Running protocol: Follow the same 6-8 week graded return protocol (see Management section, Return to Running tab)
Start: Walk-run intervals on flat, soft surface
Goals: Return to pre-injury activity level
Expected: Full return to running by 3-6 months post-surgery
Maintenance: Lifelong hip strengthening 2 times per week minimum
Prevention: Proper running biomechanics, appropriate mileage progression (10% rule), avoid training errors
Surgery Doesn't Fix Biomechanics
Critical concept: Surgical Z-lengthening or release addresses the tight ITB but does not correct hip abductor weakness or running biomechanics. Post-surgical rehabilitation MUST include the same hip strengthening and gait retraining as conservative treatment. Failure to address biomechanics leads to recurrence.
Return to Running Criteria (Post-Surgery)
Must achieve ALL before starting graded running protocol:
Functional Milestones
| Category | Criteria | Test |
|---|---|---|
| Pain | Pain-free daily activities 2+ weeks | Stairs, prolonged walking, single-leg stance |
| ROM | Full active knee ROM | 0-135 degrees minimum, symmetrical |
| Strength | Hip abduction 90%+ of opposite | Manual muscle testing or dynamometry |
| Function | Pain-free single-leg squat (10 reps) | Controlled descent, no pain |
| Hop test | Single-leg hop distance 90%+ of opposite | Within 10% limb symmetry |
Prevention Strategies
Primary Prevention (For All Runners)
Training Principles
- 10% rule: Increase weekly mileage by no more than 10%
- Vary surfaces: Mix road, trail, grass, treadmill
- Avoid camber: Running same side of cambered road increases ITB tension
- Track direction: Alternate clockwise/counterclockwise on track
- Hill training: Gradual introduction, avoid excessive downhill
Strength Training
- Hip abductor strengthening: 2-3 times per week
- Gluteus medius focus: Side-lying abduction, clamshells, single-leg work
- Core strengthening: Plank variations, rotational exercises
- Running-specific: Single-leg squats, single-leg deadlifts
Footwear and Equipment
- Replace shoes: Every 500-800km (300-500 miles)
- Gait analysis: Professional running store assessment
- Orthotics: If biomechanical abnormalities (pronation, leg length discrepancy)
- Bike fit: For cyclists, proper saddle height and cleat position
Flexibility and Recovery
- ITB stretching: Daily after running
- Foam rolling: ITB, quadriceps, hip flexors
- Rest days: Include in training schedule (not every day running)
- Listen to body: Early lateral knee discomfort = reduce training immediately
Secondary Prevention (Preventing Recurrence)
After ITB syndrome episode:
- Lifelong hip strengthening: Maintenance program 2 times per week minimum
- Running form: Higher cadence (reduce stride length), avoid crossover gait
- Gradual progressions: Never rapid increases in mileage or intensity
- Early intervention: At first sign of lateral knee pain, modify training immediately
Recurrence is Common Without Prevention
30-40% recurrence rate if runners return to previous training patterns without addressing biomechanical causes. The key to preventing recurrence is lifelong hip abductor strengthening - this is not just for rehabilitation, it's a permanent addition to training.
Outcomes and Prognosis
Conservative Treatment Outcomes
Time to recovery:
- Stage 1-2: 4-6 weeks average
- Stage 3-4: 8-12 weeks average
- Refractory: Consider surgery after 6-12 months
Prognostic factors (favorable):
- Early presentation (Stage 1-2)
- Good compliance with rehabilitation
- Correction of biomechanical factors (hip strengthening)
- Appropriate return to running protocol
Prognostic factors (unfavorable):
- Late presentation (chronic symptoms more than 6 months)
- Poor compliance or continued running despite pain
- Persistent hip weakness
- Rapid return to high mileage
Surgical Outcomes
Success rates (return to pre-injury activity):
- 80-90% in selected patients
- Better outcomes in patients with:
- Clear mechanical cause (tight ITB on examination)
- Failed appropriate conservative trial
- Absence of other knee pathology
- Commitment to post-operative rehabilitation
Failures typically due to:
- Persistent biomechanical issues not addressed
- Other unrecognized knee pathology
- Inadequate post-operative rehabilitation
Evidence Base and Key Studies
- Case-control study: 24 runners with ITB syndrome vs 30 controls
- ITB syndrome group had significantly weaker hip abductors (mean 22.8 Nm vs 32.4 Nm torque)
- All ITB patients improved with hip abductor strengthening program
- No patients required surgery with comprehensive strengthening
- RCT: Corticosteroid injection vs placebo in 45 runners with ITB syndrome
- Significant pain reduction at 4 weeks (VAS 6.2 to 2.1 in steroid group)
- No difference at 3 months between groups
- All patients received concurrent physiotherapy
- MRI findings in 22 patients with ITB syndrome
- T2 hyperintensity deep to ITB in 100% of cases
- Thickening of ITB in 68%
- Periosteal edema at lateral epicondyle in 45%
- 3D gait analysis: 20 runners with ITB syndrome vs 20 controls
- ITB group showed increased hip adduction during stance (5.8 degrees vs 3.2 degrees)
- Increased peak knee internal rotation (4.2 degrees vs 2.1 degrees)
- Gait retraining reduced hip adduction and improved symptoms
- Prospective cohort: 2,500 recreational runners in Australia over 12 months
- ITB syndrome incidence: 12% of all running injuries (second only to patellofemoral pain at 17%)
- Higher incidence in marathon runners (15%) vs shorter distances (9%)
- Female runners had higher incidence (14% vs 10% male)
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Classic Presentation (2-3 min)
"A 32-year-old female recreational marathon runner presents with 3 weeks of lateral knee pain. She is training for her first marathon and increased her weekly mileage from 40km to 70km over the past month. The pain starts after about 5km of running and worsens on downhill sections. It resolves with rest but returns with the next run. On examination, she has point tenderness 2cm proximal to the lateral femoral epicondyle. Noble compression test is positive at 30 degrees. What is your assessment and management?"
Scenario 2: Biomechanics Deep Dive (3-4 min)
"The examiner asks: Explain the biomechanics of ITB syndrome. Why does friction occur at 30 degrees of flexion? What is the role of hip abductor weakness?"
Scenario 3: Refractory Case - Considering Surgery (2-3 min)
"A 28-year-old male competitive runner presents after 10 months of ITB syndrome symptoms. He has failed comprehensive conservative treatment including physiotherapy (3 months of hip strengthening documented), activity modification, two corticosteroid injections, and biomechanical assessment with orthotics. MRI shows thickening of the ITB with T2 hyperintensity deep to the band at the lateral epicondyle. He is unable to run more than 2km without severe lateral knee pain and this is affecting his career as a professional athlete. He asks about surgery. How would you manage this?"
Scenario 4: Differential Diagnosis Challenge (2-3 min)
"A 45-year-old recreational runner presents with lateral knee pain. She thinks she has ITB syndrome because her friend had it. However, the pain is more localized to the lateral joint line, she describes occasional catching, and there was an acute onset after a twisting injury playing tennis 2 weeks ago. Noble compression test is negative. What is your assessment?"
MCQ Practice Points
Friction Zone Question
Q: At what angle of knee flexion does ITB friction occur over the lateral femoral epicondyle? A: 30 degrees of flexion. At this angle, the ITB transitions from anterior to posterior to the knee's axis of rotation. This is when compression and friction are maximal. This is why the Noble compression test is positive at 30 degrees.
Biomechanics Question
Q: What is the primary biomechanical cause of ITB syndrome in runners? A: Gluteus medius (hip abductor) weakness. Weak hip abductors cannot stabilize the pelvis during single-leg stance, leading to contralateral pelvic drop (Trendelenburg), increased hip adduction on the stance leg, and increased ITB tension over the lateral femoral epicondyle.
Clinical Test Question
Q: Describe the Noble compression test and its significance in ITB syndrome. A: Apply thumb pressure 2cm proximal to the lateral femoral epicondyle while passively extending the knee from 90 degrees flexion. Positive test = pain at 30 degrees of flexion. This is pathognomonic (highly specific, more than 90%) for ITB syndrome as it reproduces the exact friction zone pain.
Epidemiology Question
Q: What percentage of running injuries are caused by ITB syndrome? A: Approximately 12% of all running injuries, making it the second most common running injury after patellofemoral pain syndrome (17%). It is particularly common in distance runners (marathons, ultramarathons).
Treatment Question
Q: What percentage of ITB syndrome cases respond to conservative management? A: More than 90% respond to conservative treatment with activity modification, hip abductor strengthening, and biomechanical correction. Less than 10% require surgical intervention.
Surgical Indication Question
Q: What are the indications for surgical management of ITB syndrome? A: Surgery is indicated only after 6-12 months of failed comprehensive conservative treatment including documented physiotherapy compliance, activity modification, biomechanical correction, and consideration of corticosteroid injection. The patient must have significant functional impairment affecting quality of life or career.
Australian Context
Epidemiology in Australia
Running participation:
- More than 3 million regular runners in Australia
- Parkrun movement has dramatically increased recreational running
- Coastal and trail running popular (variable terrain can increase ITB syndrome risk)
Sports Medicine services:
- Sports physiotherapists widely available in metropolitan and regional centers
- Running clinics and gait analysis services in major cities
- Sports Medicine Australia (SMA) provides guidelines for running injury management
Management Considerations
Primary Care Access
- GP initial assessment: Most ITB syndrome presents to general practice
- Physiotherapy referral: No specialist referral needed for physio access
- Sports physician: Consider referral for refractory cases or elite athletes
- Orthopaedic surgeon: Only for surgical consideration after failed conservative care
Healthcare Costs
- Physiotherapy: Not covered by Medicare, private health insurance may cover
- Conservative treatment: Out-of-pocket costs AUD 800-1,500 (physio, orthotics)
- Cortisone injection: GP or sports physician (Medicare rebate available)
- MRI: Medicare rebate if specialist referral (out-of-pocket AUD 200-400)
- Surgery: Private health insurance or public hospital waitlist (6-12 months)
Australian Clinical Guidelines
Sports Medicine Australia recommendations:
- Early intervention with activity modification and physiotherapy
- Emphasis on biomechanical assessment and correction
- Graduated return to running protocols
- Prevention through strength training and appropriate training progression
No specific Australian national guideline for ITB syndrome - management follows international evidence-based practice.
Workplace and Compensation
Workers' compensation:
- Rarely applicable (not typically work-related)
- May apply to military/police/fire service where running is occupational requirement
- TAC (Transport Accident Commission) in Victoria if injury related to motor vehicle accident
Return to work:
- Desk-based work: Usually no time off work required
- Manual labor: May need modified duties for 2-6 weeks
- Professional runners/athletes: May need 6-12 weeks off competition
Medicolegal Considerations
Documentation Requirements
Key documentation for ITB syndrome:
- Detailed history of training error or biomechanical factors
- Documented physical examination including Noble test, Trendelenburg test
- Clear management plan with physiotherapy referral
- Patient education about activity modification and return to running protocol
- If surgery considered: Document comprehensive conservative trial (duration, compliance, interventions)
Common litigation issues:
- Delayed diagnosis leading to chronic pain (rare - usually benign condition)
- Inappropriate surgical intervention without adequate conservative trial
- Failure to identify and address biomechanical causes leading to recurrence
ILIOTIBIAL BAND SYNDROME
High-Yield Exam Summary
Key Anatomy
- •ITB = fascial band from iliac crest to Gerdy tubercle (lateral tibia)
- •Receives 75% fibers from gluteus maximus, 25% from tensor fasciae latae
- •Friction zone = 2cm proximal to lateral femoral epicondyle
- •At 30° flexion, ITB transitions anterior to posterior (friction occurs)
- •ITB glides over epicondyle (no anatomical attachment)
Clinical Diagnosis
- •12% of running injuries (second most common after patellofemoral pain)
- •Lateral knee pain 2cm proximal to joint line, worse during running
- •Noble test: pain at 30° with compression = pathognomonic
- •Ober test: ITB tightness (hip abduction contracture)
- •Trendelenburg test: hip abductor weakness (primary cause)
Biomechanical Cascade
- •Gluteus medius weakness → pelvic drop → hip adduction
- •Hip adduction → increased ITB tension → friction at epicondyle
- •1,000 foot strikes per mile = 1,000 friction cycles
- •Risk factors: training error, downhill running, genu varum, leg length discrepancy
Conservative Treatment (90% Success)
- •Activity modification: reduce mileage 50%, avoid downhill/track
- •Hip abductor strengthening: gluteus medius exercises (cornerstone)
- •ITB stretching and foam rolling
- •NSAIDs for 1-2 weeks, ice after running
- •Return to running: graded 6-8 week protocol, 10% rule
- •Cortisone injection: short-term benefit (4-8 weeks) to facilitate rehab
Surgical Management (Less Than 10%)
- •Indications: failed 6-12 months comprehensive conservative care
- •ITB Z-lengthening preferred technique
- •Success rate: 80-90% in selected patients
- •Recovery: 3-6 months to return to competitive running
- •Post-op rehab MUST include hip strengthening (surgery doesn't fix biomechanics)
Key Numbers
- •30° = friction zone knee flexion angle
- •2cm = proximal to lateral femoral epicondyle (friction site)
- •12% = percentage of running injuries
- •90% = conservative treatment success rate
- •10% = maximum who need surgery
- •10% rule = maximum weekly mileage increase
- •30-40% = recurrence rate if incomplete rehab