Steroid Injection for Iliotibial Band Friction Syndrome (ITBFS)

ITB friction syndrome is a painful condition that causes pain on the outside of the knee most commonly with activities like running or cycling. It is most commonly painful just before the knee fully extends. 

Causes

The cause of this condition can be multifactorial but common culprits are:

• Poor running biomechanics with a long stride length
• Inadequate running shoes
• Minimal stretching after exercises likely to tighten up the muscles affecting the ITB eg cycling
• Running on a camber
• Sudden increase in training load
• Hill running

These conditions may cause the ITB to rub more over the outside of the knee and specifically the ITB bursa. Bursa are pain sensitive structures and may then become inflamed. Once this occurs, previous exercise and loading which was tolerated before can become painful and limit ones ability to run or do other sports.

Symptoms of ITBFS

The Most common symptoms of ITBFS are: 

• Pain as you swing your leg through during walking or running on the outside of the knee
• Pain with going up or down stairs
• Pain cycling

Anatomy

The knee is a hinge joint that gains extra stability on either side of the joint by tendons from the muscles in the thigh. Medially the adductor and hamstring tendons stabilise the knee and laterally (on the outside) the Iliotibial band.

It originates from muscles around the hip called tensor fascia lata and the gluteals. They form the thick fibrous band that starts on the outside of the hip and this continues down the leg to insert on the outside of the shin bone (tibia) below the knee. Other muscles like the quadriceps also attach into the side of the ITB which can affect its mobility.

The ITB can act as a flexor or extender of the knee depending on the position of the hip. It  can do this due to its close approximation with the outside of the knee joint. Just under the ITB as it crosses the most prominent part of the lower leg is the ITB bursa. A bursa is a fluid filled sack that helps provide lubrication for the band to glide over the outside of the knee.

How to diagnose

If you have tenderness over the outside of the knee which mimics your pain with activity then this could be ITB friction syndrome.

One of our clinicians will carry out a biomechanical assessment and perform some special tests on the knee to identify the source of the pain. We also can use a diagnostic ultrasound scan to assess the ITB dynamically as it passes over the outside of the knee to check for swelling, impingement and any changes in the distal ITB.

Treatment

ITB friction syndrome is usually successfully treated with Physiotherapy which may include:

• Stretching and strengthening exercises
• Gait analysis to identify poor biomechanics or inappropriate footwear
• anti-inflammatories to reduce the inflammation in the ITB bursa.
• Short period of rest from aggravating factors – particularly slow running and cycling
• Manual therapy around any structures that may be contributing to the load on the ITB bursa
• Running retaining ie modifying stride length and or running style is a promising form of treatment (Friede, et al 2022).

ITBFS Steroid Injection therapy

Unfortunately not everyone responds the same and occasionally symptoms can linger. There is a lack of consensus as to the best treatment approach due to limited good quality studies (Ellis, et al 2007, Friede, et al 2022).

If things have not improved after 6 weeks of physiotherapy, you may want to consider an ultrasound guided steroid injection into the ITB bursa. Studies have shown that this can reduce the pain associated with this condition when running (Gunter, et al 2004).

Due to the location of the Bursa it is important that we locate it with the Ultrasound before injecting as swelling from the lateral knee joint can also pass up under the ITB giving the impression of an ITB bursitis but may need treating in a different way.  

A steroid injection in this location can take down the swelling in the bursa and allow you to return to your sport. Unfortunately it will not correct the initial cause of the problem so it is important that you continue with your prescribed Physiotherapy programme as well. 

Other Knee Conditions:

• Patellofemoral Pain Syndrome
• Knee Osteoarthritis