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Doi:10.1016/j.math.2006.08.004

Iliotibial band friction syndrome—A systematic review Health Rehabilitation Research Centre, Division of Rehabilitation and Occupation Studies, Faculty of Health & Environmental Sciences, AUT University, Private Bag 92006, Auckland, New Zealand Received 19 October 2004; received in revised form 19 July 2006; accepted 30 August 2006 Iliotibial band friction syndrome (ITBFS) is a common injury of the lateral aspect of the knee particularly in runners, cyclists and endurance sports. A number of authors suggest that ITBFS responds well to conservative treatment, however, much of this opinionappears anecdotal and not supported by evidence within the literature. The purpose of this paper is to provide a systematic review ofthe literature pertaining to the conservative treatment of ITBFS.
A search to identify clinical papers referring to the iliotibial band (ITB) and ITBFS was conducted in a number of electronic databases using the keyword: iliotibial. The titles and abstracts of these papers were reviewed to identify papers specifically detailingconservative treatments of ITBFS. The PEDro Scale, a systematic tool used to critique randomized controlled trials (RCTs), wasemployed to investigate both the therapeutic effect of conservative treatment of ITBFS and also to critique the methodologicalquality of available RCTs examining the conservative treatment of ITBFS.
With respect to the management of ITBFS, four RCTs were identified. The interventions examined included the use of non- steroidal anti-inflammatory drugs (NSAIDs), deep friction massage, phonophoresis versus immobilization and corticosteroidinjection.
This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in themanagement of ITBFS. Future research will need to re-examine those conservative therapies, which have already been examined,along with others, and will need to be of sufficient quality to enable accurate clinical judgements to be made regarding their use.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Iliotibial band; Iliotibial band friction syndrome; Systematic review; Conservative treatment ). However, it isgenerally accepted that ITBFS is the most common Iliotibial band friction syndrome (ITBFS) was first running injury of the lateral knee, and has an incidence of specifically described by as a pain felt on the lateral aspect of the knee with lower limb activities such as running and cycling. Following an increase in the popularity of running and other endurance multi- to account for 15–24% of overuse injuries ( disciplinary sports, since the 1980s, ITBFS has become overall incidence of ITBFS can range from between 1.6% and 52% depending on which population you examine uncommon in the inactive population ().
The aetiology of ITBFS is multi-factorial with representation of both intrinsic and extrinsic factor Corresponding author. Tel.: +64 9 921 9999x7800; ITBFS in a non-traumatic overuse injury caused 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi: R. Ellis et al. / Manual Therapy 12 (2007) 200–208 by friction/rubbing of the distal portion of the iliotibial conducted in electronic databases, subscribed to by the band (ITB) over the lateral femoral epicondyle (LFE) Auckland University of Technology (AUT) library, with repeated flexion and extension of the knee. which included MEDLINE via PubMed (from 1966 describe an ‘impingement zone’ which occurs onwards), Cumulative Index to Nursing and Allied at approximately 301 of knee flexion during foot-strike Health Literature (CINAHL) (from 1983 onwards), and early stance phase. At approximately 301 and greater, The Cochrane Controlled Trials Register in the of knee flexion, the ITB passes over and posterior to the (from 1830 onwards), Allied and Complementary Medicine Database (AMED) (from 1985 onwards), Blackwell-Synergy, Master FILE (from 1975 onwards), Expanded Academic ASAP (from 1980 onwards), period, eccentric contraction of the tensor fascia lata Index New Zealand (INNZ) (from 1987 onwards), (TFL) and gluteus maximus, to decelerate the leg whilst Lippincott 100 Nursing and Health Science Collection, running, exert great tension through the ITB ( Physiotherapy Evidence Database (PEDro) (from 1953 Health and Medical Complete, Web of Science (from 1945 onwards), Wiley Interscience–Life and Medical The pathogenesis of ITBFS involves inflammation and Sciences Titles. This search was conducted in August– irritation of the lateral synovial recess ; The ITB and ITBFS were deemed to be relatively narrow fields to search, therefore only one Medical ), as well as continued irritation of the posterior Subject Heading (MESH) was used as a keyword: iliotibial. There was no limitation regarding date or language leading to 1260 citations being identified of ) and inflammation of the periosteum of the which many were repeated across databases.
The titles and/or abstracts of these citations were reviewed to identify papers specifically detailing the aetiology and conservative treatment of ITBFS and the with repetitive soft tissue irritation there is simply not anatomy and biomechanics of the ITB. The bibliogra- enough time for the body to repair these damaged tissues.
phies of each paper were also used for cross-referencing This may lead to further irritation and injury which, in theory, would extend the area of the impingement zone andincrease the risk of irritation ).
A number of authors have commented that ITBFS responds well to conservative treatment (; Inclusion criteria: The following criteria were used in order to select relevant papers to be included within this different treatment options are reported in the literature,however, it should be questioned whether these treat-ments are delivered based on sound evidence.
Type of participant: Participants to be 18 years of age The purpose of this paper is to perform a systematic and older, of either gender and have a clinical review, evaluating the efficacy of conservative treatment diagnosis of ITBFS for greater than 14 days duration.
of ITBFS, in order to highlight key concepts to guide Type of study design: Randomized controlled trials.
evidence-based practice in the management of ITBFS.
Type of intervention: Conservative treatment of Relevant functional anatomical and biomechanical contributions to the aetiology and pathomechanics of Outcome measurements: To include at least one of the ITBFS will also be discussed and related back to the following outcome measurements: pain rating (e.g.
Visual Analogue Scale (VAS)), function-specific VAS(i.e. work or sport related pain), time from diagnosisuntil symptom free, return to work and/or sport Exclusion criteria: The following criteria were used to eliminate papers from this review: papers written in non- A search to identify clinical papers, clinical reviews English languages, non-RCTs, RCTs which utilized and clinical trials pertaining to the ITB and ITBFS, was non-conservative treatment, i.e. surgical interventions.
R. Ellis et al. / Manual Therapy 12 (2007) 200–208 The PEDro Scale is an 11-item scale. The various Three reviewers independently assessed each of the items deal with differing aspects of RCT analysis RCTs identified for their respective methodological quality. The PEDro Scale (see ), developed by statistics. In order to allow quantitative analysis of The Centre of Evidence-Based Physiotherapy (CEBP) the overall methodological quality of each study, was utilized to assess each paper. The PEDro Scale is an seven items which relate to internal validity were 11-item scale, which is a validated and versatile tool identified. These seven items include the following items used to rate RCTs for the PEDro Database ( numbers 2, 3, 5, 6, 7, 8, 9 (refer to The positive scores of each of these seven items is added together to An overall score of methodological quality, or quality calculate an Internal Validity Score (IVS) ( score (QS), was determined for each paper by each of the three reviewers as a total of positive scores for eachof the 11 items. A consensus method was used to discussand resolve discrepancies between the markings of each paper between the reviewers. The agreed QS for each Based on the IVS of each paper, it is possible to make a qualitative assessment about the methodological quality. In the instance whereby the RCTs reviewedare not clinically heterogeneous, it is appropriate to use a qualitative method of analysis as quantitative analysis is made difficult in that the RCTs may not be directly The qualitative assessment used within this review is an adaptation of those used by several authors modified specifically for IVS obtained in this review Level 1: Strong evidence—when provided by generally consistent findings in multiple RCTs of high quality were obtained from more than 85% ofinitially allocated subjects Level 2: Moderate evidence—when provided by generally consistent findings in one RCT of high quality (i.e. IVS ¼ 6–7) and one or more lower-quality RCTs Level 3: Limited evidence—when provided by gen- erally consistent findings in one RCT of moderate quality (i.e. IVS ¼ 4–5) and one or more low-quality Level 4: Insufficient evidence—when provided by measures and measures or variability forat least one key outcome generally consistent findings of one or more RCTs oflimited quality (i.e. IVSp3), no RCTs available or Table 2Randomized controlled trials of the conservative treatment of ITBFS in order of PEDro score Note: QS ¼ overall quality score; IVS ¼ internal validity score.
Table 3Randomized controlled trials of the conservative treatment of ITBFS ‘‘Total pain duringrunning’’ (VAS): repeated on days 7 and 14 afterinjection (Mean taken) group 2 mean 6.178.1weeks, group 3 mean7.4713.1 weeks 14. Ultrasound to thedistal ITB from days 3 to14 (VAS)—mean painmeasured over 14 days.
R. Ellis et al. / Manual Therapy 12 (2007) 200–208 For this review it was decided amongst the reviewers that in using a seven-item IVS, taken from the initialPEDro score (QS), a study of high methodological Because four different therapeutic interventions were quality was one with an IVS of between 6 and 7, used, it is difficult to make direct comparison of moderate quality between 4 and 5, limited quality therapeutic benefit using quantitative analysis. How- ever, qualitative analysis is possible when assessing themethodological quality of the RCTs examining con-servative treatment of ITBFS. Of the four RCTs identified, three had IVS’s of 4 (refer to Usingthe qualitative rating system, as mentioned earlier, it When RCTs were clinically and therapeutically appears there is limited evidence (Level 3) to support the use of conservative interventions in the treatment of directly assess the relative benefit (or lack thereof) of ITBFS. Some discussion of the key features of these one intervention versus another. In this instance, studies is reported by intervention as follows.
previous systematic reviews have decided to notinclude quantitative analysis for this very reason 3.4.1. Non-steroidal anti-inflammatory drugs (NSAIDs) to perform any quantitative analysis, as no direct patients with unilateral ITBFS with pain that was severe comparison could be made to determine clinical or enough to limit running or who had had to stop running therapeutic benefit between the RCTs and interventions as a consequence of the pain. Subjects were randomly allocated to three groups. Initial treatment to all subjectsconsisted of rest, ice application and medication fromday 0 to 7. From day 3 to 7 all subjects received standard physiotherapy treatment consisting of ultra-sound, transverse friction massage (on days 3, 5 and 7) and daily ITB stretching. The medication was deliveredover the 7 days in a double blind, placebo-controlled Four RCT’s regarding conservative management of fashion with Group 1 given a placebo anti-inflammatory ITBFS meeting the inclusion criteria were identified medication, Group 2 an anti-inflammatory only (50 mg following the electronic and cross-referencing searches.
diclofenac) and Group 3 a combined anti-inflammatory/ analgesic (400 mg ibuprofen, 500 mg paracetamol, 20 mgcodeine phosphate) medications. Outcome measuresincluded both daily pain and running pain, each measured via the visual analogue scale (VAS). Runningpain was measured by a validated treadmill test at 3 and The methodological quality, statistically represented by the IVS, for each paper is detailed within .
Results of this study demonstrated that during the Three of the four RCTs reviewed were given an IVS of first week of treatment, physiotherapy in conjunction four. This suggests that the authors felt that these with combined anti-inflammatory/analgesic medication studies were of moderate methodological quality. One of was the most effective management. Significant differ- the RCTs was given an IVS of three, suggesting the ences were seen in the combined group with decreased authors felt this study was of limited methodological running pain and increased running time/distance from 0 to 7 days, compared to the other experimental groups.
All of the four RCTs satisfied the item relating to The combined group was also the only group to show a random allocation of subjects (Item 2). Otherwise, there significant decrease in running pain at the 3-day test. It were no clear trend towards any of the other internal was of interest to note that there was a significant validity rated items (3, 5, 6, 7, 8, 9) either being reduction in daily pain seen across all groups.
3.4.2. Deep transverse friction massage (DTFM) DTFM, in the treatment of ITFBS, is often reported on The first important point to note is that all of the four the basis of anecdotal evidence that it might be effective.
RCTs assess different therapeutic interventions. There- fore, they were clinically and therapeutically hetero- contradictory that friction techniques may be beneficial geneous. See for detail of the each study’s in an injury where the mechanism of the injury is friction. In order to test these two statements R. Ellis et al. / Manual Therapy 12 (2007) 200–208 groups, a significant (P ¼ 0.01) decrease (30%) in therapeutic benefit of DTFM. Twenty subjects with running pain (measured with a VAS following a chronic ITBFS (414 days duration) were randomly treadmill test) was observed in the cortisone injection divided into two groups. Both groups received treatment consisting of rest (apart from treadmill running exercisetests), ice twice a day and baseline physiotherapytreatment of daily stretching exercises to the ITB and 5 min of therapeutic low dose ultrasound on days 3, 5, 7and 10. The intervention group were also given DTFM 4.1. The conservative management of ITBFS for 10 min on the treatment days whereas the controlgroup received only the general physiotherapy treatment The results of this review identified only four RCTs on the same days. Results of this study found that daily regarding the conservative management of ITBFS.
pain and treadmill running pain levels were both These RCTs investigated four different types of treat- significantly reduced (P ¼ 0.0005) in both groups with ments including NSAIDs deep friction massage, pho- the authors concluding that the addition of deep friction nophoresis versus immobilization, and corticosteroid massage did not alter the therapeutic outcome of the injection. Some discussion of the key features of these studies is pertinent. Following the qualitative statisticalanalysis, the authors of this review concluded that there 3.4.3. Phonophoresis versus immobilization is limited evidence to suggest that the conservative treatments analysed here are beneficial in the treatment phonophoresis (using 10% hydrocortisone cream as the active drug) and knee immobilization, over a 2-week From this review, it is evident that in the majority of period in a group of navy diving students who had studies a course of physiotherapy treatment was used as developed ITBFS as a result of rigorous physical baseline, which involved a combination of ice, ultra- training involving a significant amount of running. All sound, deep friction massage and stretching. Indeed, it is subjects were of similar age (22–23 years) and had not uncommon to find reference to the conservative symptoms for 15–17 days prior to entering the trial. The treatments, within the literature pertaining to treatment subjects were randomly assigned to either the knee of ITBFS. In light of the analysis contained within this immobilization group (three panel knee immobilizer) or systematic review, it seems ironic that many of these the phonophoresis group. All subjects received ice interventions are commonly used within clinical practice massage and non-steroidal anti-inflammatory medica- and their use appears to be based on no firm evidence- tion. Outcome measures in this study were the number of days required until pain free on examination and theability to run on a treadmill at 6.5 miles per hour.
Results of this study concluded subjects in the phono-phoresis group recovered from the injury in fewer than 10 days and had significantly less pain during the treadmill running test than the immobilization group.
IVS of four suggesting the authors felt that these studieswere of moderate methodological quality. Analysis of these studies, indicate there appears to be some benefit from using NSAIDs/analgesics and corticosteroid injec- looking at 18 runners with an acute onset of ITBFS tions and no benefit from using DTFM.
(o14 days duration). Subjects were randomly allocated into two groups: Group A receiving an injection of phonophoresis versus immobilization. This study con- corticosteroid (40 mg methylprednisilone and 10 mg 1% cluded that phonophoresis was more beneficial com- lignocaine hydrochloride) deep to the distal ITB, and pared to immobilization. However, there was no Group B receiving a placebo injection (20 mg 1% blinding evident throughout this RCT and the present lignocaine hydrochloride). Subjects were instructed not authors deemed that this study was of limited metho- to run for 14 days following the injection and to apply dological quality. It is very difficult to therefore deem ice to the area twice daily at 12 h intervals for 30 min. No this study worthy of consideration when making physiotherapy treatment was provided to subjects in this educated judgement as to the true effectiveness of these study. Outcome measures were pain measured with a interventions in the management of ITBFS.
VAS and an ability to perform a treadmill running test Of most interest was the lack of attention of all the for 30 min at the subjects best recent 10 km running studies to the various aspects of blinding. For example, speed on days 7 and 14 following the injection.
Although there was a clinical improvement in both R. Ellis et al. / Manual Therapy 12 (2007) 200–208 blinding (Item 5). The other two RCTs either did not With respect to outcome measures, it is not only adequately blind the subjects or did not mention this.
important to gain some homogeneity in intervention Only one of the four RCTs satisfied the respective items selection but also consistency in outcome measures selected if there is going to be quantitative analysis of therapeutic benefit of conservative treatments for any of the items relating to blinding, either because there quantitative comparison, within the realms of systematic was no blinding or that blinding was not mentioned.
review, is very difficult when interventions, and alsooutcome measurements for that matter, are heteroge- neous. Throughout three of the four RCTs reviewed; Following the extensive literature search, carried out ) the same previously validated treadmill running for this review, there is an obvious paucity of research test was used to score running pain. This outcome concerning the conservative management of ITBFS. Not measure seems to be appropriate for ITBFS and is also only is there a lack in quantity of such research, upon becoming more widely used. Perhaps a validated test dissection of the scarce research that is available, there like this could become a standard test in ITBFS seems to also be a paucity of quality.
It now seems apparent that for any of the many From a biomechanical and pathological perspective, varieties of conservative therapies, for treatment of the knowledge base regarding ITBFS seems to be ITBFS, that there is no research base available to healthy. The clinical application of such theories is both conclude any clear benefit from the clinical use of any of possible and plausible. There now needs to be research the conservative therapies mentioned. If this is indeed the of sufficient quality and quantity to enable these theories case, then future research must attempt to fill this void.
to be challenged and either accepted or discarded.
From the RCTs that were available, it seems that the methodological quality of all these studies was wellbelow a level that allowed any credible conclusions or answers to be sought. Additionally, common to all thesestudies was a lack of systematic blinding. It would be ITBFS is a common repetitive strain injury of the advisable for future research to acknowledge this lateral aspect of the knee. The pathomechanics and problem and attempt to organize more robust metho- clinical presentation are well understood. However, dology in order to answer the important research trying to determine the most appropriate choice of conservative therapy has been made difficult by paucity Not only were the interventions heterogeneous in quality and quantity of RCTs to examine therapeutic through the four RCTs reviewed, so to were a number of other key features including outcome measures and The aetiology of ITBFS is multifactorial, with a duration of subjects symptoms. With regard to duration combination of intrinsic and extrinsic factors. The of symptoms, some papers looked at the more acute causes of ITBFS are in response to the complex functional anatomy of the ITB and its action as an independent structure and indirectly through the mus- cles that it provides attachment to.
approximately 2 months or greater). It would be Reviewing the efficacy of the conservative manage- pertinent for future research to acknowledge clearly ment of ITBFS has highlighted that there are a small the duration of symptoms (i.e. acute versus chronic) as it number of RCTs investigating the effects of therapeutic is likely that some conservative treatments may have interventions on ITBFS. Within the acute stage of the relatively greater or lesser impact at different patholo- presenting symptoms (less than 14 days duration) gical stages throughout the course of ITBFS presenta- corticosteroid injection alone appears to be beneficial tion. For example, the studies looking at corticosteroid with subjects able to return to running pain-free with 14 days of the intervention. In the more chronic presenta- tions (greater than 14 days duration), there appears to early phase of ITBFS where acute inflammation may be be benefit gained from using both combined anti- more of a clinical problem and needing to be addressed.
inflammatory/analgesic medication over anti-inflamma- Further to this point, for more chronic presentations of tories alone. The inclusion of DTFM to a standard ITBFS, it may be more appropriate to guide research to physiotherapy programme of ultrasound and stretching look at more rehabilitation management, such as ITB exercises, does not appear to produce any additional stretching, pelvic and knee muscle stabilization, DTFM, benefit. In all of the reviewed trials this generalized physiotherapy programme proved to be beneficial in R. Ellis et al. / Manual Therapy 12 (2007) 200–208 reducing both daily pain and pain experienced on Holmes J, Pruitt A. Iliotibial band syndrome in cyclists. The American treadmill running. Although this provides positive Journal of Sports Medicine 1993;21(3):419–24.
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Source: http://www.healthzone.org.nz/site/healthzonel/files/ITBFS%20systematic%20review.pdf

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