Knee pain is one of the most common problems we see at our institute. When it comes to a more active individual, there can be many knee pain causes. One possible cause is Iliotibial band syndrome or more often referred to as IT band syndrome. It is also commonly referred to by patients as “pain on the outside of my knee.” The people I see with this problem are usually long distance runners and those who are starting up a very aggressive exercise routine and they overdo it.
The pain of IT band syndrome is very familiar to those who have it and those who treat it. It is usually located not only on the outside of the knee but on the length of the the outer thigh from hip to knee. What causes this pain? As just mentioned, overuse injury especially in distance running and over doing it when you start a new exercise program. As you bend your knee, the IT band at its attachment at the shin bone can impinge or trap soft tissue beneath it causing pain. The friction of rubbing against this soft tissue can also thin out and wear away at the Iliotibial band itself.
So what do you do if you have IT band syndrome?
Your doctor may have already recommended to you that you:
- limit or stop running,
- ice it at 20 minute intervals,
- take recommended amounts of anti-inflammatory medications,
- get some type of brace or kineotape,
- massage therapy or foam rollers may help,
- get physical therapy and stretching guidelines.
If all this does not work then you may get a recommendation for a cortisone injection. If the cortisone does not help. You may be told to consider a surgery.
A March 2022 paper (1) discusses conservative care treatments for ITBS: “Iliotibial band syndrome (ITBS) is presumably caused by excessive tension in the iliotibial band (ITB) leading to compression and inflammation of tissues lying beneath it. Usually managed conservatively, there is a lack of scientific evidence supporting the treatment recommendations, and high symptom recurrence rates cast doubt on their causal effectiveness. . . The potential pathogenic factors are presented on the basis of a simple biomechanical model showing the forces acting on the lateral aspect of the knee. . . .ITBS may be promoted by anatomical predisposition, joint malalignments, aberrant activation of inserting muscles as well as excessive ITB stiffness. Hip abductor strengthening may correct excessive hip adduction but also increase ITB strain. Intermittent stretching interventions are unlikely to change the ITB’s length or mechanical properties. Running retraining is a promising yet understudied intervention.”
A September 2020 paper (2) tested the hypothesis that Iliotibial Band Syndrome (ITBS) is caused by excessive iliotibial band (ITB) tension, promoted by hip abductor and external rotator weakness. Then patients were evaluated to see if 6 weeks of physiotherapy on ITB stiffness helped them. To see if the physical therapy helped these patients, the researchers used Ultrasound shear wave elastography (to demonstrate stiffness or elasticity in the tendon and the muscles). Participants: 14 recreational runners with ITBS and 14 healthy controls of both sexes.
Results: “No statistical differences in ITB tension between legs as well as between patients suffering from ITBS and healthy controls were detected. Results showed significant strength deficits in hip abduction, adduction as well as external and internal rotation. Following six weeks of physiotherapy, hip muscle strength (all directions but abduction), pain and lower extremity function were significantly improved. ITB stiffness, however, was found to be increased compared to baseline measurements. . . Shear wave elastography data suggest that ITB tension is not increased in the affected legs of runners with ITBS compared to the healthy leg or a physical active control group, respectively. Current approaches to the conservative management of ITBS appear ineffective in lowering ITB tone. ”
A connection between the IT Band and the patella as a cause of knee pain
A July 2021 (3) study suggested that a maligned patella could be the culprit in iliotibial band syndrome. The points made in this study were:
- The iliotibial band (ITB) has a wide patellar insertion that provides lateral (side stability) restraint to the patella and maintains the patellofemoral joint’s stability. But there has been limited investigation into the relationship between patellofemoral malalignment and iliotibial band syndrome (ITBS).
- In a group of patients diagnosed with iliotibial band syndrome, over one third (34%, 16/47) of knees had abnormal patellofemoral measurements, including 8 (17%, 8/47) knees with patellar alta (the patella is considered to be riding too high in the knee), 11 (23.4%, 11/47) knees with an abnormally decreased LPA (the position of the patella is tilted), and 5 (10.6%, 5/47) knees with an abnormally increased LPT indicating lateral patellar tilt.
- Moreover, 8 knees had simultaneous combinations of two or three abnormality parameters, and 8 (17%, 8/47) knees presented with superolateral Hoffa’s fat pad edema.
- This study confirmed that a higher position or lateral tilt of the patella and a steeper morphology of the anterior part of the lateral femoral condyle were associated with the development of ITBS, which is helpful in understanding and further exploring the mechanism of ITBS.
- Results indicate that IT Band syndrome is a complex knee pathology.
PRP for knee tendons. The IT Band is considered a knee tendon
There is limited research as well in the role of PRP in helping patients with patellar tendinopathy. However a 2017 study (4) stated: “These limited studies are encouraging and indicate that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.” One of the studies reviewed was a study from researchers in the Netherlands. In this study, outcomes of patients with patellar tendinopathy treated with platelet-rich plasma injections (PRP) were evaluated to determine whether certain characteristics, such as activity level or previous treatment affected the results. What they found was: “After PRP treatment, patients with patellar tendinopathy showed a statistically significant improvement. In addition, these improvements can also be considered clinically meaningful.”
A 2014 study in The American journal of sports medicine (5) offered these results and assessments:
- “Chronic patellar tendinopathy is one of the most common overuse knee disorders. Platelet-rich plasma (PRP) appears to be a reliable nonoperative therapy for chronic patellar tendinopathy.”
This 2014 study was cited in 2021 research (6) which further outlined PRP treatments. “Conservative treatment of tendinopathy includes eccentric strengthening of the quadriceps, avoidance of aggravating activities, proprioceptive training, bracing, nitroglycerin patches, and heat therapy. Platelet-rich plasma (PRP) and autologous blood have also been proposed as treatments in tendinopathy. PRP has high concentrations of growth factors and bioactive molecules, including vascular endothelial growth factor, transforming growth factor beta 1, platelet-derived growth factor subunit A, platelet-derived growth factor subunit B, and insulin-like growth factor 1 The presence of these growth factors encourages cell and vascular growth, matrix formation, and differentiation that influence ligament, tendon, muscle, and bone healing.”
Surgery and conservative care for IT band syndrome
An August 2020 study (7) tried to compare conservative treatments to surgical treatments for IT Band syndrome. Because of limited comparison studies an overall outcome recommendation could not be given. However, the researchers said that the most important finding of their study was that, at short-term follow-up time, conservative therapy for distal IT Band syndrome appeared to reduce pain, and surgical therapy (open, arthroscopic) was effective in returning the athletes to their sport. But, there was severe literature inconsistency and low quality of evidence on the outcomes following both the nonoperative and operative management of IT Band syndrome in active individuals, including non-running athletes. That is why they could not make a firm recommendation. In essence the researchers noted that treatment of IT Band Syndrome was mostly empirical and dependent on the doctor or surgeon seeing the patient. If you decided to go to surgeon, it is likely that you will be prescribed the conservative care options above until they did not work, then you would be recommended to the surgery.
According to the researchers, the principles of surgical management for distal IT Band syndrome are based on cutting away the inflamed part of the IT Band to reduce the athlete’s pain and to prevent the the IT Band from rubbing against the bone. However, since the IT Band has been shown to contribute to the rotational stability of the knee, the surgeon should be careful with the amount of tissue excised in order to avoid compromising the function of the knee joint postoperatively.
A paper from August 2022 (8) writes: “Multiple surgical techniques have been described to treat refractory ITBS, such as a posterior triangular resection of the iliotibial band, elliptical resection, transverse sectioning of the posterior half, multiple punctures of the band, or the mesh technique, isolated bursectomy, digastric release from Gerdy’s tubercle, and the Z-plasty lengthening technique. Despite the broad range of surgical procedures, the Z-plasty lengthening and bursectomy technique appears as an attractive procedure that combines the treatment of 2 of the most accepted pathophysiologic mechanisms. On the one hand, it lengthens the ITB, decreasing the friction between the band and the lateral epicondyle. On the other hand, removing the inflammatory tissue, especially the bursae, reduces pain and inflammation. Due to its broader approach, this merging surgical technique should be a more appropriate method to treat refractory ITBS.”
Platelet Rich Plasma Injections
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
We use PRP for numerous musculoskeletal disorders and there is a lot of research, including that published by our office which supports the use of PRP injections for problems such as IT Band Syndrome. However, there is little published research in regard to PRP specifically treating IT Band syndrome. As the IT Band is connected at the hip and the knee there is indirect evidence that PRP treatments can help IT Band syndrome by treating Greater Trochanter pain and knee problems cause by patellar tendinopathy and patella cartilage breakdown which something co-exists with IT Band syndrome.
Pain at the IT Band and the hip
The iliotibial band can cause hip pain, either through damage to itself or by causing an impingement of the gluteal tendons and hip bursa at the greater trochanter by the iliotibial band (ITB) as the hip moves into adduction, as when you lift your leg to the side.
In my article PRP treatments for hip bursitis and Greater trochanteric pain syndrome, I note:
- Lately PRP has become very popular among the orthopedic community as a minimally invasive way of enhancing tissue healing. It is thought that PRP promotes soft tissue healing by delivering a higher than normal concentration of platelets and therefore increased concentration of platelet derived growth factors to the diseased area. This has been shown in various studies.
- A January 2020 study published in the medical journal Cureus, (9) offered the following on the superiority of PRP treatments to cortisone:
- 24 patients with greater trochanteric pain syndrome were enrolled and randomized into two study groups
- In Group A patients received ultrasound-guided PRP injection treatment, while group B patients received ultrasound-guided cortisone injections. Clinical outcomes in both groups were evaluated and compared using various patient reported scoring systems.
- Both groups showed improved scores compared to the pre-injection period, but patients in the PRP group had a statistically significant decrease in pain and increase in functionality at the last follow-up (24 weeks post-injection). No complications were reported.
The IT Band can be even more complicated
The problems described above are general overviews. When you get into actual patient stories, things can get much more complicated. Often our office will get contacted by someone who has a lot of issues and the IT Band being one of the many factors. A more typical email will tell us about knee and hip pain. The knee pain surrounds the patella and one of the many problems of maltracking or a patella out of groove. The same side hip will make snapping and clicking noises and create pain at the IT Band attachment. Back pain will creep in and despite physical therapy, exercise and any number of things you can buy on the internet as a self-help apparatus, nothing helps. From here the pain now creep into the groin. If this sounds like you. Send me an email so we can assess your candidacy for our treatments.
References
1 Friede MC, Innerhofer G, Fink C, Alegre LM, Csapo R. Conservative treatment of iliotibial band syndrome in runners: Are we targeting the right goals?. Physical Therapy in Sport. 2021 Dec 27.
2 Friede MC, Klauser A, Fink C, Csapo R. Stiffness of the iliotibial band and associated muscles in runner’s knee: assessing the effects of physiotherapy through ultrasound shear wave elastography. Physical Therapy in Sport. 2020 Sep 1;45:126-34.
3 Li J, Sheng B, Qiu L, Yu F, Lv FJ, Lv FR, Yang H. A quantitative MRI investigation of the association between iliotibial band syndrome and patellofemoral malalignment. Quant Imaging Med Surg. 2021 Jul;11(7):3209-3218. doi: 10.21037/qims-20-1101. PMID: 34249647; PMCID: PMC8250009.
4 Shahid M, Kundra R. Platelet-rich plasma (PRP) for knee disorders. EFORT Open Reviews. 2017 Feb;2(2):28.
5 Charousset C, Zaoui A, Bellaiche L, Bouyer B. Are multiple platelet-rich plasma injections useful for treatment of chronic patellar tendinopathy in athletes? a prospective study. The American journal of sports medicine. 2014 Apr;42(4):906-11. News42
6 Fahy KE, Miller EM, Kobayashi Y, Gottschalk AW. Efficacy of Platelet-Rich Plasma on Symptom Reduction in Patellar Tendinopathy. The Ochsner Journal. 2021;21(3):232.
7 Bolia IK, Gammons P, Scholten DJ, Weber AE, Waterman BR. Operative Versus Nonoperative Management of Distal Iliotibial Band Syndrome—Where Do We Stand? A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2020 Jun 10.
8 Vaisman A, Guiloff R, Andreani D. Knee Iliotibial Band Z-Plasty Lengthening and Bursectomy Technique. Arthroscopy techniques. 2022 Aug 1;11(8):e1381-5.
9 Begkas D, Chatzopoulos ST, Touzopoulos P, Balanika A, Pastroudis A. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study. Cureus. 2020 Jan;12(1).