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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.
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
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KillTest The safer , easier way to help you pass any IT exams. Exam : A00-205 Version : DEMO The safer , easier way to help you pass any IT exams. prefix="sasads"%> <html><body> <sasads:Connection id="connection1" scope="session" initialStatement="libname db '.';" /> <sasads:Submit connection="connection1" display
Clinica e terapia dei disturbi da uso di sostanze. Stimolanti del Sistema Nervoso Centrale Introduzione Gli stimolanti del SNC (S-SNC) agiscono da potenti simpaticomimetici periferici edesplicano, in vari gradi, effetti stimolanti sul piano psicomotorio. Gli stimolanti di piùcomune abuso sono la cocaina e le amfetamine. Anche se per tali farmaci esiste unlimitato uso terapeutico (le amf