Iliotibial Band Bursitis – The Clinical Syndrome
With the increased interest in jogging and long-distance bicycling, iliotibial band bursitis is being encountered more frequently in clinical practice.
The iliotibial band bursa lies between the iliotibial band and the lateral condyle of the femur. The iliotibial band is an extension of the fascia lata, which inserts at the lateral condyle of the tibia.
The iliotibial band can rub back and forth over the lateral epicondyle of the femur and irritate the iliotibial bursa beneath it.
Patients with iliotibial band bursitis present with pain over the lateral side of the distal femur just over the lateral femoral condyle.
The onset of iliotibial bursitis frequently occurs after long-distance cycling or jogging with worn-out shoes without proper cushioning.
Activity, especially involving resisted abduction and passive adduction of the lower extremity, worsens the pain; rest and heat provide some relief.
Flexion of the affected knee also reproduces the pain in many patients with iliotibial band bursitis. Often, the patient is unable to kneel or walk down stairs.
The pain is constant and characterized as aching. The pain may interfere with sleep. Coexistent bursitis, tendinitis, arthritis, or internal derangement of the knee may confuse the clinical picture after trauma to the knee joint.
If the inflammation of the iliotibial band bursa becomes chronic, calcification of the bursa may occur.
How common is Iliotibial Band Bursitis?
Epidemiology
Iliotibial band syndrome commonly affects young patients who are physically active, most often long-distance runners or cyclists.
The exact prevalence is unknown, but one study has found the prevalence among actively-training marines to be higher than 20%.
Iliotibial band syndrome accounts for 12% of running-related overuse injuries
What are the Symptoms of Iliotibial Band Bursitis?
Physical examination may reveal point tenderness over the lateral condyle of the femur just above the tendinous insertion of the iliotibial band. Swelling and fluid accumulation surrounding the bursa is often present.
Palpation of this area while having the patient flex and extend the knee may result in a creaking or catching sensation.
Active resisted abduction of the lower extremity and passive adduction reproduce the pain. Sudden release of resistance during this maneuver markedly increases the pain.
Pain is exacerbated by having the patient stand with all weight on the affected extremity and then flexing the affected knee 30 to 40 degrees.
How is Iliotibial Band Bursitis diagnosed?
Plain radiographs of the knee may reveal calcification of the bursa and associated structures, including the iliotibial band tendon, consistent with chronic inflammation.
Magnetic resonance imaging (MRI) and ultrasound imaging is indicated if internal derangement, occult mass, or tumor of the knee is suspected as well as to confirm the diagnosis.
If arthritis is suspected, screening laboratory tests, including a complete blood cell count, erythrocyte sedimentation rate, automated chemistries, and antinuclear antibody testing, should be obtained.
Electromyography helps distinguish iliotibial band bursitis from neuropathy, lumbar radiculopathy, and plexopathy. The following injection technique serves as a diagnostic and therapeutic maneuver.
Differential Diagnosis
The most common cause of lateral knee pain is degenerative arthritis of the knee. Other pathological processes may mimic the pain and functional disability of iliotibial band bursitis.
Lumbar radiculopathy may cause pain and disability similar to that of iliotibial band bursitis.
In such patients, back pain is usually present, and the knee examination should be negative.
Entrapment neuropathies of the lower extremity, such as meralgia paresthetica, and bursitis of the knee also may confuse the diagnosis; both conditions may coexist with iliotibial band bursitis.
Primary and metastatic tumors of the femur and spine may manifest in a manner analogous to iliotibial band bursitis.
Treatment
Initial treatment of the pain and functional disability associated with iliotibial band bursitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy.
Local application of heat and cold also may be beneficial.
For patients who do not respond to these treatment modalities, injection of the iliotibial band bursa with a local anesthetic and steroid may be a reasonable next step.
The iliotibial band bursa is injected by placing the patient in the supine position with a rolled blanket underneath the knee to flex the joint gently. The skin over the lateral epicondyle of the femur is prepared with antiseptic solution.
A sterile syringe containing 2 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 25-gauge, 1½-inch needle using strict aseptic technique.
With strict aseptic technique, the iliotibial band bursa is located by identifying the point of maximal tenderness over the lateral condyle of the femur. The bursa usually is identified by point tenderness at that spot.
At this point, the needle is inserted at a 45-degree angle to the femoral condyle to pass through the skin, subcutaneous tissues, and iliotibial band into the iliotibial band bursa.
If the needle strikes the femur, it is withdrawn slightly into the substance of the bursa. When the needle is in position in proximity to the iliotibial band bursa, the contents of the syringe are gently injected. Little resistance to injection should be noted.
If resistance is encountered, the needle is probably in a ligament or tendon and should be advanced or withdrawn slightly until the injection proceeds without significant resistance.
The needle is removed, and a sterile pressure dressing and ice pack are placed at the injection site.
Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
Complications and Pitfalls
Failure to identify primary or metastatic tumor of the knee or spine that is responsible for the patient’s pain may yield disastrous results.
The major complication of injection of the iliotibial band bursa is infection.
This complication should be exceedingly rare if strict aseptic technique is followed.
Approximately 25% of patients report a transient increase in pain after injection of the iliotibial band bursa, and patients should be warned of this possibility.
Clinical Pearls
Coexistent bursitis and tendinitis may contribute to knee pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid.
Injection of the iliotibial band bursa is extremely effective in the treatment of pain secondary to iliotibial band bursitis.
This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected.
The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for knee pain.
Vigorous exercises should be avoided because they would exacerbate the symptoms.
