Physical Medicine and Rehabilitation for Iliotibial Band Syndrome Clinical Presentation

• Author: John M Martinez, MD; Chief Editor: Stephen Kishner, MD, MHA

The physical examination should include the entire lower extremity to rule out other causes of lateral knee or hip pain. In most cases, point tenderness occurs with palpation of the lateral femoral condyle or lateral tibial condyle, especially when flexing or extending the knee, as the iliotibial band (ITB) slides across the lateral femoral condyle. Some patients may have tenderness over the greater trochanteric region of the hip.^[6]

• Strength testing - Strength testing may reveal knee flexor or extensor weakness or hip abductor weakness.
• Tests - Increased or noticeable tightness of the ITB also may be noted upon examination with the Ober test. A modified Thomas test can be performed to assess flexibility of the hip flexors, hamstrings, and ITB. See the images below.The Thomas test can be used to evaluate restriction in the iliotibial band and hip flexors.The Ober test.

Physical Therapy

Treatment for iliotibial band syndrome (ITBS) usually is conservative. Conservative treatment consists of (1) relative rest by decreasing the amount of exercise or training, (2) the use of superficial heat and stretching prior to exercise, and (3) the use of ice after the activity. Heat should be applied before and during stretching for at least 5-10 minutes, and ice treatments should be employed using a cold pack applied to the area for 10-15 minutes or using an ice massage, which involves rubbing ice over the inflamed region for 3-5 minutes or until the area is numb.

Physical therapy is one of the mainstays of treatment for ITBS, in addition to reducing the amount of inflammation and irritation.^{[2, 3, 6]} The physical therapist can advise the athlete about ways to modify his/her training program so that faster results are seen with therapy. Running and cycling should be decreased or avoided to prevent further repetitive stress to the ITB. Wearing proper shoes also is very important in individuals with ITBS. Frequently, patients with ITBS demonstrate excessive pronation of their feet. The physical therapist should evaluate the patient's biomechanics during walking and running and should assist him/her in obtaining custom-made orthotics to correct faulty mechanics that may be causing the ITBS.

Physical therapy treatment in the acute stage may include modalities such as phonophoresis or iontophoresis in addition to cryotherapy to decrease the inflammation. Since some cases of ITBS are caused by excessive tension on the ITB, physical therapy can help to incorporate proper stretching techniques into the patient's exercise routine. These exercises concentrate on increasing flexibility of the ITB and of the gluteus muscles. Other muscles that commonly need attention for flexibility include the hamstrings, quadriceps, gastrocnemius, and soleus. See the images below.

This illustration demonstrates active stretching of the iliotibial band (ITB). The athlete stands a comfortable distance from a wall and, with the contralateral knee extended, leans the proximal shoulder against the wall to stretch the ipsilateral ITB.This illustration demonstrates iliotibial band syndrome stretching performed in a side-lying position.

Soft-tissue mobilization and massage techniques may be used to assist with lengthening of the sore ITB. Prior to mobilizing the tissues, the physical therapist may perform an ultrasonographic treatment over the ITB to increase blood flow to the area and prepare the tissues to be stretched. Massage should generally be performed with the ITB in a lengthened state.

As the patient's symptoms improve, the physical therapy can progress toward strength development and maintenance. The physical therapist should instruct the patient in a home exercise program that continues to improve the strength and endurance of the hip and knee, as well as the back and abdominals. Strengthening of the hip abductors and knee flexors and extensors is an important component of rehabilitation. Once the patient is able to complete all strengthening exercises without discomfort, he/she may gradually return to the previous training regimen.

A study by Noehren et al suggested that in men with ITBS, treatment that addresses hip and knee neuromuscular control may be particularly beneficial. Examining differences between 17 men with ITBS and 17 healthy controls, the investigators found that, although ITB length was somewhat reduced in males with ITBS and hip external rotators were somewhat weaker, the largest differences occurred in internal rotation of the hip and adduction of the knee, both of which were significantly greater in the ITBS subjects.^[13]

Occupational Therapy

Occupational therapy usually is not indicated in the treatment of individuals with iliotibial band syndrome.