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AUTHOR PROOF
Iliotibial Band Syndrome in Runners
A Systematic Review
Maarten P. van der Worp,
1
Nick van der Horst,
1
Anton de Wijer,
1,2
Frank J.G. Backx
3
and
Maria W.G. Nijhuis-van der Sanden
4
1 Academic Institute Hogeschool Utrecht, University of Applied Sciences Utrecht, Department of Physical
Therapy, Utrecht, the Netherlands
2 Radboud University Nijmegen Medical Centre, Department of Oral Function, Nijmegen, the Netherlands
3 Rudolf Magnus Institute of Neuroscience, Department of Rehabilitation, Nursing Science and Sport,
University Medical Centre Utrecht, Utrecht, the Netherlands
4 Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen,
the Netherlands
Abstract Background: The popularity of running is still growing and, as participation
increases, the incidence of running-related injuries will also rise. Iliotibial
band syndrome (ITBS) is the most common injury of the lateral side of the
knee in runners, with an incidence estimated to be between 5%and 14%.In
order to facilitate the evidence-based management of ITBS in runners, more
needs to be learned about the aetiology, diagnosis and treatment of this injury.
Objective: This article provides a systematic review of the literature on the
aetiology, diagnosis and treatment of ITBS in runners.
Search strategy: The Cochrane Library, MEDLINE, EMBASE, CINAHL,
Web of Science, and reference lists were searched for relevant articles.
Selection criteria: Systematic reviews, clinical trials or observational studies
involving adult runners (>18 years) that focused on the aetiology, diagnosis
and/or treatment of ITBS were included and articles not written in English,
French, German or Dutch were excluded.
Data collection and analysis: Two reviewers independently screened search
results, assessed methodological quality and extracted data. The sum of all
positive ratings divided by the maximum score was the percentage quality
score (QS). Only studies with a QS higher than 60%were included in the
analysis. The following data were extracted: study design; number and char-
acteristics of participants; diagnostic criteria for ITBS; exposure/treatment
characteristics; analyses/outcome variables of the study; and setting and
theoretical perspective on ITBS.
Main results: The studies of the aetiology of ITBS in runners provide limited
or conflicting evidence and it is not clear whether hip abductor weakness has
a major role in ITBS. The kinetics and kinematics of the hip, knee and/or
ankle/foot appear to be considerably different in runners with ITBS to those
Approval for publication Signed Date Number of amended pages returned
SYSTEMATIC REVIEW SportsMed 2012;42 (11): 1-24
0112-1642/12/0011-0001/$49.95/0
Adis ª2012 Springer International Publishing AG. All right s reserved.
AUTHOR PROOF
without. The biomechanical studies involved small samples, and data seem to
have been influenced by sex, height and weight of participants. Although
most studies monitored the management of ITBS using clinical tests, these
tests have not been validated for this patient group. While the articles were
inconsistent regarding the treatment of ITBS, hip/knee coordination and
running style appear to be key factors in the treatment of ITBS. Runners
might also benefit from mobilization, exercises to strengthen the hip, and
advice about running shoes and running surface.
Conclusion: The methodological quality of research into the management of
ITBS in runners is poor and the results are highly conflicting. Therefore, the
study designs should be improved to prevent selection bias and to increase the
generalizability of findings.
1. Background
In the last 30 years, running has become pop-
ular worldwide.
[1]
The Royal Dutch Athletics
Federation (KNAU) has estimated that about
12.5%of the Dutch population runs regularly,
and that the popularity of running events is still
growing.
[2]
Running is an inexpensive form of
vigorous-intensive physical activity and can be
done anywhere and at any time;
[1]
it is also a basic
aspect of many recreational and professional sports.
However, running may cause overuse injuries,
especially in the legs.
[3]
Various studies have re-
ported on the prevalence and incidence of run-
ning injuries occurring during training or races,
[3]
with injury rates varying between 25%and 65%,
[4]
although a rate of about 51%has been reported
in college athletes and between 20%and 50%in
soldiers.
[5,6]
Iliotibial band syndrome (ITBS) is the most
common running injury of the lateral side of
the knee.
[7]
It is a non-traumatic overuse injury
caused by repeated flexion and extension of
the knee that causes irritation in the structures
around the knee.
[8-11]
Orchard et al.
[12]
described
an ‘impingement zone’ occurring at, or slightly
below, 30of knee flexion during foot strike and
the early stance phase of running. During this im-
pingement period in the running cycle, eccentric
contraction of the tensor fascia latae muscle and
of the gluteus maximus muscle causes the leg to
decelerate, generating tension in the iliotibial
band.
[12,13]
ITBS is usually diagnosed on the basis of
a detailed history and physical examination.
[14]
It was first initially described by Colson and
Armour,
[15]
and later by Renne,
[8]
as pain in
the lateral side of the knee during running. The
incidence of ITBS by runners is estimated to
be between 5%and 14%
[11,16-21]
depending on the
differences in study design, sample size and run-
ning population; weekly running time/distance,
level of performance and sex. In the ITBS pop-
ulation the prevalence of women is estimated to
be between 16%and 50%
[11,17,19-22]
and for men
between 50%and 81%.
[11,17,19-21]
However, it is still difficult to establish the in-
cidence of ITBS in runners because many studies
do not specifically report the incidence of ITBS
and the characteristics of this group but, instead,
report the incidence of all knee injuries.
[13]
The aetiology of ITBS is mostly multifactorial,
involving both intrinsic and extrinsic factors.
[23]
Several authors have reported that ITBS responds
well to conservative and surgical treatment.
[11,13,24-28]
This study aims to systematically review the
literature on ITBS to gain insight into the aetiol-
ogy, diagnosis and treatment of ITBS in runners,
in order to promote evidence-based management.
2. Methods
2.1 Literature Search
We performed a computerized search of bibli-
ographical databases, including MEDLINE (from
2van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
1966 to December 2011), EMBASE (from 1980
to December 2011), CINAHL (from 1982 to
December 2011), Web of Science (from 1988 to
December 2011) and the Cochrane Library (from
2009 to December 2011) using the following search
terms: ‘iliotibial band friction syndrome’, ‘ilioti-
bial band syndrome’ and ‘iliotibial band strain’
all in combination with running and with no re-
striction for language. The first author (MvdW)
screened titles and abstracts of all identified ci-
tations to identify relevant studies and searched
the reference lists of the retrieved articles to
identify other potential studies.
Two independent reviewers (MvdW and NvdH)
screened the retrieved articles, using the following
inclusion criteria: studies that investigated the
aetiology, diagnostics and/or treatment of ITBS;
study subjects who were adult runners (aged
>18 years); study designs that were systematic
reviews, (randomized) clinical trials or observa-
tional studies (longitudinal, cross sectional or case
referent), and studies reported in English, French,
German or Dutch. Differences in article selection
between the two reviewers were resolved in a con-
sensus meeting. If consensus was not reached, a
third reviewer (AW) made the final decision for
inclusion or exclusion of the article.
2.2 Methodological Quality
The methodological quality of the articles was
assessed by two independent reviewers (NH and
MW), using appropriate Cochrane Collabora-
tion criteria.
[29]
Criteria not applicable for a given
design were not taken into account. This resulted
in nine items being scored for randomized clinical
trials, eight for cohort analyses, and six for case
referent and cross-sectional studies. Scoring of
the different study types were as follows:
Randomized clinical trials: (i) subjects were
randomly allocated to groups; (ii) allocation
was concealed; (iii) there was blinding of all
subjects/patients; (iv) there was blinding for all
care providers; (v) there was blinding of all as-
sessors who measured at least one key outcome;
(vi) groups were similar at baseline; (vii) follow-
up assessment is of sufficient length; (viii) study
included an intent-to-treat analysis; and (ix) all
groups, except those in the intervention group,
were treated similarly.
[29]
Observational studies: (i) description of the
main characteristics of the study popula-
tion or cases; (ii) description of the main
characteristics of the referents; (iii) exclusion
of selection bias; (iv) description and mea-
surement of exposure; (v) description and
measurement of the outcome variable; (vi) blind-
ing of the measurement outcome variable;
(vii) follow-up assessment is of sufficient length;
(viii) exclusion selective loss to follow-up;
(ix) inclusion of confounding variables in sta-
tistical analysis.
[29]
For each study, a quality score (QS) was
calculated by summing the positive ratings
and dividing this by the maximum score for that
type of study. The methodological QS was judged
adequate if the score was more than 60%. Dif-
ferences in the assessment of methodological
quality were settled in a consensus meeting and,
if necessary, by a third reviewer (AW). The rate
of agreement about the quality of studies was
then calculated.
The level of scientific evidence regarding ITBS
was as follows:
[30]
- level I, strong evidence provided by systematic
reviews;
- level II, moderate evidence provided by gen-
erally consistent findings in multiple adequate
quality studies (QS >60%);
- level III, limited evidence provided by one high-
quality study or by generally consistent find-
ings in multiple low-quality studies;
- level IV, conflicting evidence in case of incon-
sistent findings;
- level V, no evidence, expert based.
2.3 Data Extraction and Analysis
Only studies with a QS higher than 60%were
included in the analysis. The following informa-
tion was extracted from articles providing level
I–IV evidence: study design; population char-
acteristics; number of participants; how ITBS
was diagnosed; exposure/treatment characteristics;
analyses/outcome variables of the study; and set-
ting and the theoretical perspective of ITBS.
Iliotibial Band Syndrome in Runners 3
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
3. Results
3.1 Literature Search
A flow chart for article retrieval is given in
figure 1. Of 209 articles retrieved as potentially
relevant, 108 were considered eligible for full-text
screening, and 36 of these met the inclusion criteria.
Articles that failed to meet inclusion criteria were
narrative reviews,
[9,23-28,31-48]
casuistic cases,
[49-59]
case reports
[60-62]
and a commentary.
[63]
Thirteen
studies did not involve runners,
[5,7,8,64-73]
18 did
not investigate ITBS
[14,20,74-88]
and one was writ-
ten in Serbian.
[89]
3.2 Methodological Quality
The 36 included studies are ranked by QS and
subsequently in alphabetic order of first author’s
name in table I. Initially, both reviewers agreed
about 151 (60%) of the 232 items. All disagree-
ments were resolved during one consensus meet-
ing. Fourteen (11 observational and 3 randomized
clinical trials) studies fulfilled the methodological
quality criteria (QS >60%) and provided level
I–IV evidence according to the CEBM (Centre
of Evidence Based Medicine).
[30]
The three ran-
domized clinical trials met requirements regard-
ing randomization, baseline similarity of groups,
length of follow-up and similarity of treatment
(except the intervention) between groups. How-
ever, treatment allocation was not concealed (or
reported) in these three studies and it could not
be ascertained from the information provided
whether the outcome assessor was blinded in the
study of Gunter and Schwellnus.
[91]
All observa-
tional studies met the requirements regarding the
description of the population/cases and, where
appropriate, the length of follow-up.
3.3 Data Extraction and Analysis
The 14 studies investigated factors contribut-
ing to ITBS in runners,
[16,17,22,93-97]
its diagnosis,
if it was based on history, physical examination
complemented by clinical findings and supplemen-
tary tests,
[90-92,94,96-98]
and treatment.
[16,90-92,97-99]
One study
[100]
established normative data for the
Ober and modified Thomas tests. All these stud-
ies are summarized in tables II–IV, respectively,
in alphabetic order of first author’s name.
3.3.1 Aetiology
Three main factors were investigated with re-
gard to the aetiology of IBTS: the strength of the
hip abductors, biomechanics and the choice of
shoe and running surface.
Strength of the Hip Abductors
Grau et al.
[93]
measured the isometric, concentric
and eccentric peak torque of the hip abductors/
adductors at 30/s and calculated the concentric
endurance quotient at 30/s. They found no dif-
ference between runners with (n =10) or without
ITBS (n =10), matched by age, sex, weight and
weekly running distance (at least 20 km).
[93]
Fredericson et al.
[97]
compared the pre-rehabili-
tation hip abductor torque (measured with a
hand-held dynamometer; break method) between
the injured and uninjured side in runners with
and without ITBS. The ITBS group for this study
consisted of 24 consecutive collegiate and club
long-distance runners who presented to the Run-
ners’ Injury Clinic for initial evaluation and were
diagnosed with ITBS. The mean age and weight
of this group was 27.6 years (95%CI 3.66) and
58.73 kg (95%CI 4.02) for women (n =10), and
27.07 years (95%CI 4) and 71.85 kg (95%CI
2.69) for men (n =10), respectively. The control
group of 30 distance runners (14 female, 16 male)
subjects were all Stanford University cross-country
and track runners, who were randomly selected
to participate in this study during their pre-season
physicals. They found in this larger and homo-
geneous group that the pre-rehabilitation hip
abductor torque was significantly lower on the
injured side in male and female runners with
ITBS than in runners without ITBS.
[97]
Biomechanics
In another study, Grau et al.
[94]
investigated
biomechanical (kinematic and kinetic) differ-
ences between runners with and without ITBS,
using control groups of healthy runners: control
group (CG) I (n =18) unmatched, CG II (n =18)
matched for sex, and CG III (n =18) matched for
sex, height and weight. All subjects ran barefoot
along a 13 m ethylene vinyl acetate (EVA) foam
4van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
CINAHL
n = 77
Cochrane
n = 5
MEDLINE
n = 48
Articles obtained from a computerized
search of bibliographical databases
n = 209
Excluded n = 119
• on title and abstract
• duplicates
Articles obtained from a hand search of
the reference list in the identified
publications and reviews
n = 18
Full-text screened
n = 108
Articles identified for review
n = 36
Articles with an adequate quality score (>60%)
n = 14
Etiology of ITBS (n = 9)
• muscle strength
• biomechanics
• training and shoes
n = 21
n = 62
n = 13
Treatment of ITBS (n = 7)
• conservative
• surgery
n = 54
n = 25
Diagnostics of ITBS (n = 9)
• history, presentation and anamnesis
• clinical examination and/or findings
• Noble compression test
• Ober test
• test of Renne
• modified Thomas test
n = 76
n = 47
n = 78
n = 29
n = 110
n = 111
1 = [93,97]
2 = [16,17,22,94,96,95]
3 = [16]
4 = [16,90-92,97]
5 = [98,99]
6 = [90-92,94,96-98]
7 = [91,94,97,99]
8 = [16,90-92,96-98]
9 = [96,100]
10 = [91]
11 = [100]
Excluded n = 72,
caused by:
• study design
• not ITBS
• not runners
• language
n = 40
n = 18
n = 13
n = 1
EMBASE
n = 59
Web of Science
n = 20
Fig. 1. Flow chart of the search of scientific publications and the studies with an adequate quality scores in the management of iliotibial band
syndrome. ITBS =iliotibial band syndrome.
Iliotibial Band Syndrome in Runners 5
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table I. Methodological quality assessment of the randomized controlled trials and the observational studies with their quality score
Study (y) Scoring items
1
a,b
2
a,b
3
a,b
4
a,b
5
a,b
6
a,b
7
a,b
8
a,b
9
a,b
Total
scores
c
QS
RCTs
Schwellnus et al.
[90]
(1991) +-+++++-+778
Gunter and Schwellnus
[91]
(2004) +-+--++++667
Schwellnus et al.
[92]
(1992) +---+++++667
Observational studies
Grau et al.
[93]
(2008) ++++NA NR NA NA +5 100
Grau et al.
[94]
(2008) ++++NA NR NA NA +5 100
Noehren et al.
[22]
(2007) ++++NA NR NA NA +5 100
Taunton et al.
[17]
(2002) +NA +++NR NA NA +5 100
Ferber et al.
[95]
(2010) ++-+NA NR NA NA +480
Grau et al.
[96]
(2011) +++-NA NR NA NA +480
Fredericson et al.
[97]
(2000) +NA +--NR +++571
Hariri et al.
[98]
(2009) +NA -++NR ++-571
Michels et al.
[99]
(2009) +NA ++-NR ++-571
Pinshaw et al.
[16]
(1984) +NA -++NR +-+571
Ferber et al.
[100]
(2010) +NA -++-NA NA +467
Fredericson et al.
[101]
(2002) -NA -++NR NA NA +360
Hein et al.
[102]
(2011) ++-+NA NR NA NA -360
Miller et al.
[103]
(2008) ++-+NA NR NA NA -360
Drogset et al.
[104]
(1999) -NA -+-NR ++-343
Lindenberg et al.
[105]
(1984) -NA -+-NR ++-343
McNicol et al.
[11]
(1981) +NA ---NR +-+343
Sutker et al.
[21]
(1985) -NA -+-NR ++-343
Messier et al.
[19]
(1995) ---+NA NR NA NA +240
Nishimura et al.
[106]
(1997) +--+NA NR NA NA -240
Barber and Sutker
[107]
(2008) -NA -+-NR +--229
Beers et al.
[108]
(2008) -NA --+NR -+-229
Noble
[109]
(1979) -NA -+-NR +--229
Noble
[110]
(1980) -NA -+-NR --+229
Hamill et al.
[111]
(2008) ---+NA NR NA NA -120
Messier and Pittala
[112]
(1988) ---+NA NR NA NA -120
Miller et al.
[113]
(2007) ---+NA NR NA NA -120
Orchard et al.
[12]
(1996) -NA -+-NR NA NA -120
Barber and Sutker
[114]
(1992) -NA ---NR -+-114
Martens et al.
[115]
(1989) -NA -+-NR ---114
Nillson and Staff
[116]
(1973) -NA ---NR -+-114
Nemeth and Sanders
[10]
(1996) -NA ---NR ---00
Noehren et al.
[117]
(2006) ----NA NR NA NA -00
a Scoring items –RCT: 1 =randomization; 2 =treatment allocation concealed; 3 =patient blinded; 4=care-prov ider blinded; 5=outcome
assessor blinded; 6=groups similar at baseline; 7 =follow-up of sufficient length; 8=include d an intent-to-treat analysis; 9 =all groups,
except intervention, treated similarly.
b Scoring items –observational studies: 1 =description population/cases; 2 =description referents; 3 =exclusion selection bias;
4=description and measurement exposure; 5 =description and measurement outcome variable; 6 =blinding measurement outcome
variable; 7 =follow-up of sufficient length; 8 =exclusion selective loss to follow-up; 9 =inclusion confounding variables.
c Total score from both RCT and observational studies.
NA =not applicable; NR =not relevant; QS =quality score; RCTs =randomized controlled trials; +indicates yes; -indicates no.
6van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table II. Observational studies: aetiology of iliotibial band syndrome in runners
Study (y) Design Population
a
Follow
up
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
b
Setting Theoretical
perspective
Ferber
et al.
[95]
(2010)
Case
referent
N=400; 100%F; runners, minimum
30 km/wk; aged between 18 and
45 y:
ITBS group in the past
-N=35; all F
- Age 35.47 –10.35 y
- Height 1.65 –0.06 m
- Weight 58.62 –3.97 kg
- MRD 123.82 –62.64 km
CG:
-N=35; 100%F
- Age 31.23 –11.05 y
- Height 1.67 –0.07 m
- Weight 61.30 –6.97 kg
- MRD 119.27 –52.02 km
NA NF All subjects ran along 25 m
runway
- Speed; 3.65 m/s
- Data from 5 trails were
averaged:
Foot
Peak RFEA, RFIM
Knee
Peak knee IR angle, peak
knee ERM, peak KF angle
Hip
Peak (HADD), peak HABM
Foot (ITBS vs CG)
- RFEV: 8.94 –3.16vs
10.04 –3.22;p=0.36
- RFIM: 014 –0.13 Nm/kg vs
0.09 –0.08 Nm/kg; p =0.05
Knee (ITBS vs CG)
- IR: 1.75 –5.94vs -1.14 –4.94;
p=0.03
- ERM: 0.09 –0.06 Nm/kg vs
0.09 –0.05; Nm/kg p =0.68
- KF; 45.30 –4.50vs
45.21 –5.00;p=0.95
Hip (ITBS vs CG)
- HADD: 10.39 –4.36vs
7.92 –5.84;p=0.05
- HABM; 15.33 –0.24 Nm/kg vs
1.33 –0.18 Nm/kg; p =0.94
NF
(lab?)
NF
Fredericson
et al.
[97]
(2000)
Cohort:
longitudinal
prospective
N=54; 26 M, 28 F; ITBS group:
-N=24; 10 M, 14 F; distance
runners;
M:
- Age 27.07 y (95%CI 4.0)
- Height 1.78 m (95%CI 0.03)
- Weight 71.85 kg (95%CI 2.69)
F:
- Age 27.6 y (95%CI 3.66)
- Height 1.67 m (95%CI 0.06)
- Weight 58.73 kg (95%CI 4.02)
CG:
-N=30, 16 M, 14 F distance
runners; cross-country and track
team
6 wk History,
presentation,
clinical
examination
and Noble
compression
test
ITBS group: 6 wk
standardized rehabilitation
programme:
- No running at the
beginning
- Once a wk physical
therapy;
Ultrasound with
corticosteroid gel, etc.
- NSAIDs until pain free
with daily activities
- Stretch exercises for
iliotibial band (3 ·day)
- Hip abd exercises and
pelvic drop exercise 5 sets
of 30 reps
Pre-rehab. hip abd torque
M:
- ITBS: 6.86 –1.19%injured leg
- ITBS: 8.62 –1.16%non-injured
leg
- CG: 9.73 –1.3%
F:
- ITBS: 7.82 –1.93%injured leg
- ITBS: 9.82 –2.987%non-injured
leg
- CG: 10.19 –1.10%
All groups differed significantly
p£0.05
Post-rehab. hip abd torque
- ITBS: M 51%increase
- ITBS: F 34.9%increase
After 6 wk 22 athletes pain free
and running. After 6 mo no
reports of recurrence
Stanford
University
Sports
Medicine
Clinics,
California,
USA
Biomedical;
iliotibial band
Continued next page
Iliotibial Band Syndrome in Runners 7
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table II. Contd
Study (y) Design Population
a
Follow
up
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
b
Setting Theoretical
perspective
Grau
et al.
[93]
(2008)
Case
Referent
N=20; 14 M, 6 F; ITBS group:
-N=10; 7 M, 3 F
- Age 41 –7y
- Height 178 –8cm
- Weight 69 –9kg
- Weekly running >20 km
CG:
-N=10; 7 M, 3 F; healthy runners
- Age 38 –6y
- Height 179 –8cm
- Weight 70 –98 kg
- Weekly running >20 km
NA NF Isokinetic measurement
(30/s)
- Isometric hip abd/add
- Concentric hip abd/add
- Eccentric hip abd/add
- Endurance (concentric)
20 reps at 30/s, 3 max.
of the last 5 contractions
divided by 3 max. of the first
5 contractions
No significant difference between
the CG and the ITBS group for
isometric, concentric, eccentric
and the endurance contractions.
No significant difference between
the injured and non-injured side
ITBS group for isometric,
concentric, eccentric and the
endurance contractions
Department
of Sports
Medicine,
Medical
Clinic
University of
Tu
¨bingen,
Tu
¨bingen
Germany
Biomedical;
liotibial band
Grau
et al.
[94]
(2008)
Case
referent
N=70; runners
ITBS group:
-N=18; 13 M, 5 F
- Age 35.7 –6.8 y
- Height 177 –8.6 cm
- Weight 71 –11.6 kg
- BMI 22 –2.6 kg/m
2
CG I healthy runners:
-N=18; 11 M, 7 F
- Age 36.6 –6.7 y
- Height 172 –8cm
- Weight 65 –11.6 kg
- BMI 22 –2.2 kg/m
2
CG II sex-matched healthy runners:
-N=18; 13 M, 5 F
- Age 41.8 –6.5 y
- Height 173 –7.8 cm
- Weight 66 –9,8 kg
- BMI 22 –2.0 kg/m
2
CG III sex/age/height/weight-
matched healthy runners:
-N=18; 13 M, 5 F
- Age 41.8 –6.5 y
- Height 173 –7.8 cm
- Weight 66 –9.8 kg
- BMI 22 –2.0 kg/m
2
NA History and
clinical
examination
Running barefoot with a
speed of 3.3 m/s(–5%)on
a 13 m EVA foam runway
- Kinematics
measurements:
Hip joint add, tibia IR
and subtalar joint eversion;
At touchdown and max.
Kinetics measurements:
Pressure distribution of
the feet
Max. force normalized
to bodyweight and relative
force-time integral
- ITBS vs CG I ‡AddTD,
diff. =3.2p=0.49, AddMax
diff. =2.2p=0.081, IRTD
diff. =1.5p=0.44, IRMax
diff. =1.1p=0.355, EVTD
diff. =1.2p=0.318, EVMax
diff. =1.0,p=0.359
- ITBS vs CG II => AddTD
diff. =3.8p=0.008, AddMax
diff. =3.0p=0.024, IRTD
diff. =1.8p=0.03, IRMax
diff. =1.3p=0.193, EVTD
diff. =2.7p=0.053, EVMax
diff. =1.2p=0.311
- ITBS vs CG III ‡AddTD
diff. =3.9p=0.006, AddMax
diff. =3.0p=0.008, IRTD
diff. =2.0p=0.008, IRMax diff.
=1.8,p=0.052, EVTD diff. =3.2
p=0.002, EVMax diff. =1.9
p=0.081
Pressure measurements also
depend on the matching process,
with decreasing (NS) between
ITBS and CG after refining the
process (ITBS vs CG I ‡ITBS vs
CG III)
Department
of Sports
Medicine,
Medical
Clinic
University of
Tu
¨bingen,
Tu
¨bingen
Germany
Biomedical;
iliotibial band
Continued next page
8van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table II. Contd
Study (y) Design Population
a
Follow
up
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
b
Setting Theoretical
perspective
Grau
et al.
[96]
(2011)
Case
referent
N=36; 26 M, 10 F
ITBS group runners:
-N=18; 13 M, 5 F
- Age 36 –7y
- Height 177 –8cm
- Weight 71 –12 kg
- BMI 23 –3kg/m
2
- Runner type
1 forefoot (forefoot-heel-
forefoot)
17 rearfoot (heel-forefoot)
Training speed 3.3 m /s
CG healthy runners:
-N=18; 13 M, 5 F
- Age 37 –9y
- Height 177 –9cm
- Mass 70 –10 kg
- BMI 22 –2kg/m
2
- Runner type:
1 forefoot (forefoot-heel-
forefoot)
17 rearfoot (heel-forefoot)
- Training speed 3.3 m/s
NA History,
presentation
and positive
Ober test or
Noble
compression
test
Running barefoot with a
speed of 3.3 m/s a 13 m
EVA foam
Kinematic measurements:
- Max. values (), ROM
values () and max. velocity
values (/s) of sagittal hip
motion and frontal hip
motion, sagittal knee
motion, sagittal ankle
motion and frontal rearfoot
motion for CG and ITBS
subjects
- Timing of max. joint angle
excursions relative to the %
of the ROP; joint
coordination:
‡hip flexion, hip add, KF,
internal tibial rotation, ankle
flexion and RFEV for
control group and ITBS
subjects
- Kinematic evaluation:
ITBS group: less hip add (at
the point of max. add at about
32%of ground contact) and
frontal ROM at the hip joint in
runners with ITBS
- Kinetic evaluation
ITBS group: max. hip flexion
velocity and max. KF velocity
were lower
No difference between
groups with regard to ankle joint
and rear foot motions
- Lack of joint coordination
(earlier hip flexion [p <0.05] and a
tendency toward earlier KF) ITBS
compared with CG subjects
Department
of Sports
Medicine,
Medical
Clinic
University of
Tu
¨bingen,
Tu
¨bingen
Germany
Biomedical;
fad pad
compression
beneath the
iliotibial band
Noehren
et al.
[22]
(2007)
Case
referent
N=400; 100%F
runners, minimum 20 miles/wk;
18–45 y
Incidence rate of ITBS 16%among
all reported injuries
ITBS group:
-N=18; 100%F
- Age 26.8 y
- Monthly mileage 96.2
- BMI 21.9 kg/m
2
CG:
-N=18; all F
- Age 28.5 y
- Monthly MRD 99.3
- BMI 22.1 kg/m
2
2 y NF An instrumented gait
analysis:
- Peak moments of hip,
knee and rear foot angles
during stand phase of
running
- Averaged over the five
running trails (25 m of 3 m/s
[–5%]) and averaged
across groups
Significant
- Hip add peak; ITBS 14.1 –2.5,
CG 10.6 –5.1;p=0.01
- Knee IR peak ITBS 3.9 –3.7,
CG 0.02 –4.6;p=0.01
- Femur in lab.; peak -4.6 –6.9,
CG 1.3 –7.5;p=0.02
- Moment: hip abd, knee external
rotation and rear foot inversion;
NS
- Tibia in lab.; peak and KF at heel
strike; NS
NF Biomedical:
iliotibial band
Continued next page
Iliotibial Band Syndrome in Runners 9
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table II. Contd
Study (y) Design Population
a
Follow
up
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
b
Setting Theoretical
perspective
Pinshaw
et al.
[16]
(1984)
Cohort:
longitudinal
prospective
N=210; sex NF
- Consecutive pts over a period of
6mo
- 14 were excluded because of no
running athletes:
-N=196; 169 M 27 F
Four common injuries (78%):
1. Peri-patellar pain syndrome
(runner’s knee); n =42
2. Shin splints; n =36
3. ITBS group n =24; sex =NF
-2%combination with runner’s
knee/shin splints
4. Chronic muscle injuries; n =11
8 wk Noble
compression
test
Treatment ITBS; applicable
advice:
- Running shoes: change to
‘soft’ running shoes
- Foot orthoses and shoe
alterations: the outside heel
flare of the shoe
corresponding injured side
removed
- Leg-length discrepancies;
full correction at the heel,
50%correction mid-sole
and 25%correction at the
ball of the foot
- Training methods:
appropriate advice in
training distances, running
speed, amount of hill
running and adequate rest
days
- Ice application:
encouraged to apply ice
twice a day for 30 min
ITBS pts:
-50%previous seen a GP,
orthopaedic surgeon or non-
medical practitioner
- Not found below age of 20 y
and evenly distributed between
all groups >20 y
- ITBS was common among
athletes who run <1 y, running
41–80 km/wk, 70–80%middle-
distance runners, 70%
performing stretching exercise
<10 min/day, knee varus 52%and
normal 48%, patellar medially
pointing 10%and normal 89%
- Foot alignment 12%normal,
35%mild, 47%moderate and 6%
severe varus
- Running shoe: 28%Adidas,
30%New Balance, 23%Nike
Treatment ITBS: 78%runners
were seen 8 wk later:
-44%were 100%cured, 67%
followed advice;
-22%were 75%cured, 75%
followed advice;
-11%were 50%cured, 50%
followed advice;
-7%were 25%cured, 25%
followed advice;
-16%were 0%cured, 75%
followed advice
Cape Town
SAB Sports
Injury Clinic,
Cape Town,
South Africa
Biomedical:
iliotibial band
Taunton
et al.
[17]
(2002)
Cross
sectional
N=2002; 926 M, 1076 F runners;
ITBS group:
-N=168; 63 M, 105 F
- Age 32.2 y
- Activity history 7.3 y
- Weekly h 4.9
M:
Height 169.9 cm
Weight 75.7 kg
NA NF Biomechanical
assessment:
- Leg length inequality;
>0.05
- Leg alignment; genu
valgus/genu varum
- Q angle; >16
- Patellar position; Patellar
squinting through femoral
- Leg length inequality n =17
- Leg alignment
valgus n =25
varus n =54
- Q angle n =3
- Patellar position
patellar squinting n =13
- Arch position
pes planus n =25
AMSMC
University of
British
Colombia,
Vancouver,
BC, Canada
NF
Continued next page
10 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
runway at a speed of 3.3 m/s. Analysis showed
that the differences in kinematic variables (hip
joint adduction, tibia internal rotation and sub-
talar joint eversion) became more pronounced in
comparisons with more closely matched controls.
Hip joint adduction at touchdown was signif-
icantly lower in the ITBS group than in the three
CGs. Maximal adduction at the hip was lower in
the ITBS group and was significantly different
from that in the CG II and CG III groups.
Internal knee rotation at touchdown was sig-
nificantly lower in the ITBS group than in the
three CGs, but the maximal knee internal rota-
tion was not significantly different. Subtalar joint
eversion was significantly lower at touchdown in
the ITBS group than in CG III. The differences in
kinetic variables (rearfoot loading and forefoot
loading) became less pronounced in comparisons
with more closely matched controls. Only the
lateral rearfoot (force time integral) and medial
forefoot (maximum force normalized to body-
weight) forces were significantly greater and
lower in the ITBS group than in the CG I group,
respectively.
[94]
In 2007, Noehren et al.
[22]
followedup400run-
ners for 2 years, as part of a larger prospective in-
vestigation of lower limb injuries in female runners.
Eighteen runners developed ITBS and their run-
ning kinematics and kinetics were compared with
those of age-, body mass index- and monthly mile-
age-matched controls. The subjects wore standard
neutral running shoes and ran along a 25 m runway
at a speed of 3.7 m/s(–5%), striking a force plate at
its centre. The ITBS group exhibited greater peak
hip adduction, peak knee internal rotation and
femoral external rotation, and remained more
adducted throughout stance than did the control
group. No difference was found in rearfoot ever-
sion, tibia rotation (in global) and knee flexion.
Group analyses in the ITBS group showed that
subjects (n =4) with a greater peak rearfoot mo-
tion than the mean, showed a higher tibial internal
rotation.
[22]
In a retrospective study, Taunton et al.
[17]
analysed data on 2002 individuals with running-
related injuries, including 63 men and 105 women
with ITBS. The most common overuse running
injury was patello-femoral pain syndrome (PFPS),
Table II. Contd
Study (y) Design Population
a
Follow
up
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
b
Setting Theoretical
perspective
BMI 23. 7 kg /m
3
F:
Height 158.1 cm
Weight 60.0 kg
BMI 21.2 kg/m
3
anteversion
- Arch position
(low/normal/high)
History and anamnestic
- Previous injury to same
anatomical area
- Running ability on level of
competition; recreational/
competitive (provincial,
national or international)
pes cavus n =12
<34-y-old risk factor for men; OR
2.77 (95%CI 1.42 to 5.40)
a Population data are presented as means, means –SDs and 95%confidence intervals where stated.
b Analyses/outcome data are presented as means –SDs where stated.
abd =abduction; add =adduction; AddMax =maximal hip add; AddTD =hip add at touchdown; AMSMC =Allan McGavin Sports Medicine Centre; BMI =body mass index;
CG =control group; CI =confidence interval; diff. =difference; ERM =knee external rotation moment; EVA =ethylene vinyl acetate; EVMax =maximal subtalar joint eversion;
EVTD =subtalar joint eversion at touchdown; F=female; GP =general practitioner; HABM =hip abductor moment; HADD =hip adduction angel; IR =internal rotation;
IRMax =maximal internal rotation of the knee; IRTD =knee internal rotation at touchdown; ITBS =iliotibial band syndrome; KF =knee flexion; lab. =laboratory; M=male;
max. =maximum; MRD =monthly running distance; NA =not applicable; NF =not found; N/n=number; NS=not significant; NSAIDs=non-steroidal anti-inflammatory drugs; OR =odds
ratio; pts =patients; rehab.=rehabilitation; reps. =repetitions; RFEV =rear foot eversion angle; RFIM =peak rear foot invertor moment; ROM =range of motion; ROP =roll over process;
? indicates the setting was possibly a laboratory but was not explicitly mentioned/found in this study.
Iliotibial Band Syndrome in Runners 11
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
followed by ITBS. Varus and valgus knee align-
ment were present in 33%and 15%of the ITBS
group, respectively, and the length of the right
versus left leg varied by 10%. Multivariate anal-
ysis revealed younger age (mean <34 years) to be
a risk factor for ITBS in men; odds ratio of 2.77
(95%CI 1.42 to 5.40). Risk factors for ITBS in
women were not identified.
[17]
Ferber et al.
[95]
investigated female runners,
comparing 35 females who had previously sus-
tained ITBS with 35 healthy age- and running-
distance-matched healthy females. All the sub-
jects involved in this study were part of a larger,
ongoing prospective investigation of female run-
ners (n =400; ages 18–45 years, minimum running
distance of 30 km/wk). Subjects ran along a 25 m
runway at a speed of 3.7 m/s(–5%), striking a
force plate at its centre. The footwear was not
described. Women with ITBS had a greater peak
hip adduction angle, knee internal rotation angle
and peak rearfoot invertor moment than the
controls.
[95]
Grau et al.
[96]
subsequently investigated the
same group of runners with ITBS, as in their
earlier study.
[94]
The subjects, all rearfoot strik-
ers, ran barefoot along a 13 m EVA foam run-
way at a pre-specified speed of 3.3 m/s. In the
kinematic evaluation, hip adduction was found
to be smaller in the ITBS group (n =18) com-
pared with the sex-, height- and weight-matched
control runners (n =18). Furthermore, maximum
hip flexion velocity and maximum knee flexion
velocity were lower in runners with ITBS. Joint
coordination, expressed as earlier hip flexion and
a tendency toward earlier knee flexion, was also
poorer in the ITBS group. No differences were
found between the groups with regard to ankle
joint and rearfoot motion.
[96]
Pinshaw et al.
[16]
studied a series of 169
running injuries to determine the nature of the
common injuries, the type of runners with
the different injuries, specific factors causing the
most common injuries and the response of these
injuries to correction of the biomechanical ab-
normalities believed to have caused them. Over
6 months they diagnosed 24 runners with ITBS;
in 37%of these runners one leg was shorter than
the other, and these runners had injuries such as
Table III. Observational study diagnostics of iliotibial band syndrome in runners
Study (y) Design Population
a
Diagnostics
ITBS
Exposure/treatment Analyses/outcome
a
Setting Theoretical
Construct
Ferber et al.
[100]
(2010)
Cohort:
cross
sectional
N=300; 125 M, 175 F
Recreational athletes;
minimal 30 min activity,
3·wk:
-N=250 injured; 104
M, 146 F
ITBS group:
-N=31; 10 M, 21 F
- Age 32.3 –9.7 y
- Height 167 –29.2 cm
- Weight 73.7 –21.4 kg
NF Ober test and
modified Thomas
test
Ober test:
Overall =-24.59–7.27,n=600
Negative =-27.13–5.53,n=432
Positive =-16.29–6.87,n=168
Critical criteria =-23.16, inter-
agreement =95%
Modified Thomas test:
Overall =-10.60–9.61,n=600
Negative =-15.51–5.82,n=382
Positive =-0.34–7.00,n=208
Critical criteria =-6.69, inter-
agreement =97.6%
Running Injury Clinic and
Faculties of Kinesiology
and Nursing, University
of Calgary. Calgary, AB,
Canada
NF
a Population data and Analyses/outcome data are presented as means –SDs where stated.
F=female; ITBS =iliotibial band syndrome; M=male; NF =not found.
12 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table IV. Observational studies and randomized clinical trials: treatment of iliotibial band syndrome in runners
Study (y) Design Population
a
Follow-
up
a
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
a
Setting Theoretical
Construct
Gunter and
Schwellnus
[91]
(2004)
RCT N =9; sex NF
Runners with ITBS
Experimental group:
-N=9; sex NF
- Age 29.0 –6.5 y
- Height 176.4 –8.3 cm
- Weight 73.3 –7.3 kg
- Total weekly distance running:
83.3 –9.7 km
- Best 10 km time 46.8 –6.9 min
CG:
-N=9; sex NF
- Age 28.9 –5.0 y
- Height 177.9 –11.1 cm
- Weight 70.5 –8.0 kg
- Total weekly distance running:
- 82.5 –9.3 km
- Best 10 km time 46.6 –6.7 min
14
days
History,
presentation,
clinical
examination,
Noble
compression
test and test of
Renne
EG:
-40mg
methylprednisolone
acetate mixed with
local anaesthetic
CG:
- Local anaesthetic
Treadmill running
test:
- VAS per min
- Total pain during
running
- Days 0, 7 and 17
There was a tendency (p =0.07)
for a greater decrease in total
pain during the treadmill running
in EG vs CG from day 0
EG =mean 222 (SEM 71),
CG =mean 197 (SEM 31) to day
7EG=mean 140 (SEM 87),
CG =mean 178 (SEM 76)
There was a significant
(p =0.01) decrease of total pain
during running from day 7
EG =mean 140 (SEM 87),
CG =mean 178 (SEM 76) to day
14 EG =mean 103 (SEM 89),
CG =mean 157 (SEM 109)
in the EG vs CG)
Sports Medicine
Clinic of a Staff
Model Health
Maintenance
Organization in
South Africa
Biomedical:
tissue
beneath the
iliotibial
band
Hariri et al.
[98]
(2009)
Cohort:
longitudinal
retrospective
N=11; 7 M, 4 F
pts with ITBS
- Age of onset symptoms:
29 –8y
- Age at surgery:
32 –5y
- BMI 24 –47 kg/m
3
38 –16
mo
History,
presentation
and Noble
compression
test
Iliotibial band
bursectomy by a
single surgeon
Post-operative
- Tegner activity score:
Pre-operative
Post-operative 5 –2 (NS)
- VAS
Pre-operative 8 –2
Post-operative 2 –3
- Lysholm score: excellent
7 pts, good in 4 pts
- IKDC 88 –11
Surgical outcome; 6 pts
completely satisfied, 3 mostly
satisfied, 2 somewhat satisfied
Division of
Sports
Medicine,
Department of
Orthopedic
Surgery,
Boston, MA,
USA
Biomedical:
Bursa
Continued next page
Iliotibial Band Syndrome in Runners 13
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table IV. Contd
Study (y) Design Population
a
Follow-
up
a
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
a
Setting Theoretical
Construct
Michels
et al.
[99]
(2009)
Cohort:
longitudinal
prospective
N=36: 21 M,15 F
Pts with ITBS, 33 pts for
follow-up:
-N=33; sex NF
- Age 31.1 range 19–44 y
- Suffering from ITBS for 18 mo
preoperatively, range 1–7y
- Recreational or professional
athletes: running (n =22),
triathlon (n =5), cycling (n =4),
athletics (n =3), rugby (n =3),
soccer (n =1), swimming (n =1),
fencing (n =1) and basketball
(n =1)
2 y and
4 mo,
at least
6mo
Clinical
findings
Standardized
arthroscopic
technique, limited to
the resection of
lateral synovial
recess: 16 right
knees, 22 left,
2 pts bilaterally
Running:
- 2 mo post-operative 74.2 %
start slow running, 100%at
3mo
Results:
- 28 (80%) excellent, 6 (17.1%)
good, 1 (2.9%) fair
Satisfaction
- mean 6, range 6–10 points
Complications:
- 1 pt cartilage lesions of the
femoral condyle, 2 pts with a
menisci lesion, 1 pt calcified
loose body in the lateral
synovial recess, 1 developed a
haematoma
Bordeaux
Merignac Sports
Clinic
Biomedical:
Fibrous and
fat tissue
Schwellnus
et al.
[92]
(1992)
RCT N =17; sex NF
Pts with unilateral ITBS
Group A:
-N=9; sex NF
- Age 25 –6y
- Duration of injury 23 –17 wk
- Years of running 7.7 –5.5
- Weekly training distance
45 –15 km
- Grade of injury 3.4 –0.5 units
Group B:
-N=8; sex NF
- Age 29 –5y
- Duration of injury 74 –95 wk
- Years of running 5.4 –6.2
- Weekly training distance
64 –30 km
- Grade of injury 3.4 –0.5 units
14
days
History,
presentation
and test of
Noble
Treatment:
- Rest
- Ice; twice daily
local application
20 min
- Basic
physiotherapy
Daily stretching
of the iliotibial band
Ultrasound on
day 3, 4, 5, 6, 7
and 10
- Deep transverse
friction for group A
on days 3, 5, 7 and
10
Daily pain recall:
- The mean daily pain scores
recorded for overall pain over
three treatments periods (days
0–2, days 3–6 and days 7–14)
significantly decrease for both
group with no difference
between group A and B
Treadmill running:
- Total pain experienced during
running (area under the pain vs
time curve) was not significantly
decreased between the groups
of any of the days (days 0, 3, 7
and 14)
- Significant decrease in the pain
values and maximum pain
experienced (%) over the
treatment period. But not
significant between groups
Sports Injury
Clinic at the
University of
Cape Town
Sports Center,
Cape Town,
South Africa
Biomedical:
Under the
iliotibial tract
over the
lateral
epicondyle
Continued next page
14 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
Table IV. Contd
Study (y) Design Population
a
Follow-
up
a
Diagnostic
ITBS
Exposure/treatment Analyses/outcome
a
Setting Theoretical
Construct
Schwellnus
et al.
[90]
(1991)
RCT N =43; sex NF
Pts with unilateral IBTS
Group 1:
-N=13, sex NF
- Age 22 –5y
- Weight 74 –5kg
- Height 181 –3cm
- Years of running 10 –5
- Duration of symptoms
6.8 –7.1 wk
- Weekly training distance
44 –29 km
- Training speed
4.9 –0.3 min/km
- Grade of injury 3.2 –0.4 units
Group 2:
-N=14, sex NF
- Age 24 –6y
- Mass 72 –6kg
- Height 181 –6cm
- Years of running 5 –5
- Duration of symptoms
6.1 –6.1 wk
- Weekly training distance
48 –33 km
- Training speed
4.6 –1.0 min/km
- Grade of injury 3.1 –0.5 units
Group 3:
-N=16, sex NF
- Age 22 –2y
- Weight 68 –7kg
- Height 178 –4cm
- Years of running 6 –6y
- Duration of symptoms
7.4 –13.1 wk
- Weekly training distance
39 –14 km
- Training speed
4.6 –0.8 min/km
- Grade of injury 3.2 –0.4 units
7 days Anamnesis and
compression
test of Noble
Treatment:
- Rest
- Ice; twice daily
local application
- Physiotherapy;
day 3 till day 7
Daily stretching
Iliotibial band;
Daily
ultrasongraphy;
Deep
transverse friction
on days 3, 5 and 7
- Medication
Group 1;
placebo capsule;
3·/day
Group 2; 50 mg.
diclophenac
sodium;
3·/day
Group 3; 400 mg
ibuprofen, 500 mg
paracetamol
(acetaminophen)
and 20 mg codeine
phosphate; 3 ·/day
Daily 24 h recall pain:
- Decreased significantly for the
three groups over the treatment
period
Group 3 ‡significantly
decrease from day 0 to day 3
Group 1 and 3 ‡significantly
decreased from day 3 to day 7
All groups ‡significantly
decreased from day 0 to day 6
- No difference between groups
Treadmill running test (day 0, 3
and 7)
- Total running time did not differ
significantly between groups on
each of the test days. Total
distance run did not differ
significantly on each of the test
days
- In all three groups the total
distance run, did not change
significantly from day 0 to day 3,
but did significantly change from
day 3 to day 7. Group 3 distance
significantly increased from day
0 to day 7
- Group 3 improved their total
running time and distance from
day 0 to day 7 and group 1 and
group 2 improved from day 3 to
day 7
- In all groups the area under the
pain vs time curve decreased
from day 0 to day 7
Two sports
injury clinics,
South Africa
Biomedical:
Under the
iliotibial tract
over the
lateral
epicondyle
a Population, follow-up and analyses/outcome data are presented as means –SDs where stated.
BMI =body mass index; CG =control group; EG =experimental group; IKDC =International Knee Documentation Committee; ITBS =iliotibial band syndrome; Pt/s=patient/s;
VAS =visual analogue scale.
Iliotibial Band Syndrome in Runners 15
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
ITBS, shin splints and PFPS. The prevalence
of genu varum was similar in runners with these
injuries, but runners with ITBS were more likely
to have normal patellar alignment. Pinshaw
at al.
[16]
concluded that runners with ITBS
were more likely to have a ‘normal’ lower limb
structure than runners with either PFPS or shin
splints.
Training and Shoes
Neither the type of training (as a percentage
of time spent running long distances at low
speed) nor the training surface influenced the
type of injury sustained in the study of Pinshaw
et al.,
[16]
although most runners with ITBS spent
more than 90%of their training time running
long distances at low speed wearing ‘New Bal-
ance’ shoes and mainly running on tar and dirt
roads.
[16]
Summary
Studies of the aetiology of ITBS in runners
provide limited or conflicting evidence, and it
is currently not clear whether hip abductor
weakness has a role in ITBS. The kinetics and
kinematics of the hip, knee and ankle/foot ap-
pear to be different in runners with and with-
out ITBS,
[22,94-96]
although results regarding the
kinematics of adduction of the hip, (maximal)
internal rotation of the knee and the inversion
and eversion of the ankle/foot are conflict-
ing.
[22,94-96]
There is limited evidence that runners
with ITBS have poor joint coordination, showing
earlier hip flexion and a tendency toward earlier
knee flexion.
[22,94-96]
These biomechanical studies
involved small samples, and data seemed to have
been influenced by the sex, height and weight
of participants. Many runners with ITBS have
one leg shorter than the other,
[16,17]
but have a
normal patella alignment.
[16]
These runners ten-
ded to train by running long distances at low
speed, wearing ‘New Balance’ shoes, and to run
on tar and dirt roads.
[16]
Young (aged <34 years)
male runners were at the highest risk of sustaining
an ITBS injury.
[17]
However, the small size of
these uncontrolled studies
[16,17]
means that firm
conclusions cannot be drawn about factors that
could promote ITBS.
3.3.2 Diagnosis
ITBS in runners tend to be diagnosed on the
basis of the history and presentation,
[90-92,94,96-98]
complemented by clinical findings.
[91,94,97,99]
In
most studies,
[16,90-92,96-98]
the Noble compression
test is used to confirm the diagnosis of ITBS. Sup-
plementary tests such as the Ober test
[118]
and the
test of Renne
[8]
canbeusedtoverifyITBS.
[91,96,100]
See tables II–IV and figure 1. The absence of any
other signs in the knee such as effusion, joint line
tenderness or a positive McMurray’s test is often
confirmed/rejected with MRI.
[17,93,94,96,99]
The Noble
[109]
compression test confirms the
presence of ITBS.
[109]
The subject’s knee is flexed
to 90then pressure is applied to the lateral epi-
condyle or a 1–2 cm proximal to it and then the
knee is gradually extended. At 30flexion the
patient will complain of severe pain over the lat-
eral epicondyle; the pain has the same quality as
that experienced when running.
[109]
The Ober test
measures the flexibility of the iliotibial band.
[118]
The subject is positioned on the side with the ex-
tremity to be tested facing upward. The examiner
flexes the knee to be tested to 90and abducts and
extends the hip so that the hip is in line with the
trunk. The examiner then allows the force of
gravity to cause the extremity to adduct as far as
possible. The degree of adduction of the hip re-
flects the flexibility of the iliotibial band.
[100]
The
Renne test evokes the pain experienced during
running; the subject is asked to stand on the af-
fected leg while the knee is held in a 30–40flex-
ion.
[8]
Two studies
[90,92,105]
classified the severity
of ITBS using the ‘injury grade’ of Lindenberg
et al.
[105]
This system has four grades of pain as
follows: (i) pain comes on after running, but does
not restrict distance or speed; (ii) pain comes on
during running, but does not restrict distance or
speed; (iii) pain comes on during running and
restricts distance or speed; and (iv) pain is so se-
vere that it prevents running.
Muscle/Ligament Flexibility
In a cross-sectional study, Ferber et al.
[100]
established normative values for the flexibility
of the iliotibial band and iliopsoas muscle, an
aspect that is important in the management of
ITBS.
[22,95,96]
Using a digital inclinometer, the
16 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
iliotibial band flexibility (Ober test) and the
iliopsoas muscle flexibility (modified Thomas
test) were determined in 300 athletes (125 men
and 175 women): 250 with ITBS and 50 controls.
In the modified Thomas test,
[100]
the subject sits
on the end of the plinth, rolls backwards onto the
plinth and then holds both knees to the chest. The
subject holds the contralateral hip in maximal
flexion with the arms, while the test limb is low-
ered toward the floor. The degree of extension of
the hip reflects the flexibility of the iliopsoas
muscle.
[78]
The results showed an average ilioti-
bial band flexibility of -24.59and iliopsoas
flexibility of -10.60. The critical criteria for the
iliotibial band and iliopsoas flexibility were deter-
mined to be -23.16and -9.69, respectively.
[100]
Summary
Most studies used clinical tests to diag-
nose,
[16,90-92,94,96-99]
classify
[16,17,90,92]
and/or eval-
uate
[90-92]
ITBS in runners. These tests would
appear not to have been validated for this patient
group but seem to have a good face validity.
Ferber et al.
[100]
provided normative data for the
Ober test and the Modified Thomas test. Only
two studies
[96,100]
used the Ober test to evaluate
runners with ITBS; no studies have described the
use of the modified Thomas test in the manage-
ment of ITBS.
3.3.3 Treatment
Conservative
In a randomized controlled trial (RCT),
Schwellnus et al.
[90]
investigated the effect of ini-
tial treatment (day 0–7; rest, ice application and
medication) in 43 patients with unilateral ITBS.
All subjects received physical therapy consisting
of ultrasound, deep transverse friction massages
(DTFM) on days 3, 5 and 7, and daily stretching
of the iliotibial band. Medication was delivered
over the 7 days in a double-blind, placebo-
controlled fashion. Group 1 was given a placebo
anti-inflammatory medication, group II an anti-
inflammatory agent and group III a combined
anti-inflammatory/analgesic. Compared with the
other groups, in group III, pain during running
significantly decreased from day 3 onward and
running time/distance on the treadmill running
test significantly increased from day 0 to 7.
[90]
Schwellnus et al.
[92]
investigated the therapeutic
benefit of DTFM. Twenty subjects with ITBS
(>14 days’ duration) were randomly divided into
two groups. Both groups received treatment
consisting of rest, ice twice a day and physical
therapy (daily stretching of the iliotibial band and
5 minutes of low-dose ultrasound therapy) on
days 3, 5 and 7. The intervention group was also
given DTFM for 10 minutes on days 3, 5 and 7.
The results showed that daily pain and treadmill
running pain were significantly reduced in both
groups after treatment. The authors concluded
that the addition of DTFM did not alter the
therapeutic outcome of ITBS.
[92]
In an RCT, Gunter and Schwellnus
[91]
investi-
gated 18 runners with acute-onset ITBS (<14 days’
duration). Subjects were randomly allocated into
two groups: group I received a corticosteroid in-
jection and group II received a placebo injection.
Subjects were instructed not to run for 14 days
following the injection and to apply ice to the area
for 30 minutes every 12 hours. Running pain was
significantly decreased in the group that received
the corticosteroid injection.
[91]
Fredericson et al.
[97]
tested the effectiveness of
a 6-week standardized rehabilitation programme
in 10 female and 14 male runners with ITBS. The
programme consisted of a local application of
ultrasound with corticosteroid gel for the first
two sessions. All patients were instructed to stretch
the iliotibial band three times a day. Hip abduc-
tion exercises and pelvic drops to strengthen the
gluteus were started at 1 set of 15 repetitions over
a course of several weeks and increased to the
goal of 3 sets of 30 repetitions. The patients were
instructed to increase the workout by 5 repetitions
per day if there was no significant post-workout
soreness the following day. Nonsteroidal anti-
inflammatory drugs were prescribed until the
patients were pain free during daily activities.
All subjects were instructed to discontinue run-
ning and any other activities that continued to
cause pain. The investigators found a mean in-
crease of 34.9%and 51.4%in the injured limb
of the hip abductor torque for females and
males, respectively. Twenty-two of the 24 athletes
Iliotibial Band Syndrome in Runners 17
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
were able to return to running after 6 weeks of
rehabilitation.
[97]
Pinshaw et al.
[16]
gave runners with ITBS the
following advice about:
1. Running shoes: change to softer running
shoes, use of in-shoe supports and shoe altera-
tions and/or removal of the outside heel flare of
the shoe for the injured side.
2. Leg-length discrepancies: adapt shoe of the
shorter leg by adding material to the mid-sole to
ensure 100%correction at the heel, 50%correc-
tion in the mid-sole and 25%correction at the ball
of the foot.
3. Training methods: if appropriate, one could
reduce training distance, decrease running speed
and amount of hill running, and one could incor-
porate a sufficient number of days for recovery.
4. Ice application: apply ice to the injured area
for 30 minutes twice a day.
After 8 weeks, 44%of the runners with ITBS
were 100%cured, 22%were 75%cured and 34%
were 50%cured or less.
[16,97]
Surgery
Hariri et al.
[98]
described the effect of bursect-
omy in 11 consecutive patients with ITBS (7 men
and 4 women; mean –standard deviation age at
symptom onset 29 –8 years) who had persistent
(>6 months) symptoms despite conservative treat-
ment. After a minimum of 20 months follow-up,
all patients were able to return to their pre-injury
activity levels and reported less pain (11-point
visual analogue scale score decreased by 6 points).
The majority of patients were highly satisfied with
the results of the procedure.
[98]
Michels et al.
[99]
evaluated arthroscopic resec-
tion of the lateral synovial recess as treatment for
resistant ITBS. Thirty-six patients underwent 38
procedures; 33 patients (15 women, 21 men; mean
age 31.1 years, range 19–44 years; 35 knees) were
followed up for at least 6 months (mean 2 years
and 4 months). Prior to surgery, all patients had
been treated conservatively for at least 6 months
with rest, correction of training error, shoe
modification, physical therapy and local infiltra-
tion with steroids. The patients had suffered from
ITBS for 18 months (range 1–7 years). The sub-
jective functional results after surgery were ex-
cellent (80%), good (17.1%) and fair (2.9%), and
patients were satisfied with the procedure (mean
score 9 of 11). In retrospect, all but one patient
would still have had the procedure.
[99]
Summary
Overall, the results of the five studies
[16,90-92,97]
on the conservative treatment of ITBS provided
some evidence of the effectiveness of different
treatment modalities; pain medication/injection,
stretching of the iliotibial band, hip abduction
exercises and pelvic drops to strengthen the glu-
teus muscles, and advice about training, shoe
inlays and shoes. Two studies provided limited
evidence of the beneficial effect of two differ-
ent surgical interventions in selected groups of
patients.
[98,99]
4. Discussion
This extensive, quality-controlled, systematic
review revealed that there is limited evidence to
support a specific approach to the aetiology, diag-
nosis and treatment of ITBS. Only one systematic
review was found,
[7]
but this review investigated
conservative treatments only and included other
sufferers of ITBS beside runners and included
only RCTs. We included observational studies as
well to identify other potentially relevant types
of treatment. Other narrative reviews
[9,23-28,31-48]
merely reported the subjective results achieved
with the ITBS management protocol used by the
authors.
4.1 Methodological Quality
The Cochrane Collaboration criteria were
used to assess the methodological quality of the
studies identified by the computerized database
search.
[29]
While the usefulness of quality control
is disputed,
[119,120]
and it is difficult to determine
how to weight each item in an overall QS,
[121]
sum
scores are considered helpful in a systematic re-
view to make a distinction between studies with
both a low and high risk of bias, and there is
empirical evidence to support this view.
[122]
We evaluated the QS of the studies in order to
gain insight into the risk of bias within the re-
sults
[121]
and excluded studies of poor methodo-
18 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
logical quality to enable us to draw meaningful
conclusions.
A point of concern is the lack of blinding of
treatment allocation in three RCTs,
[90-92]
which
could affect results.
[123]
Inadequate or unclear
allocation concealment can lead to higher esti-
mated treatment effects. However, it is not gen-
erally possible to predict the magnitude or even
the direction of possible selection bias and con-
sequent distortions of treatment effects, as a result of
inadequate or unclear allocation concealment.
[123]
The methodological flaws of poor-quality observa-
tional studies mainly concerned the poor descrip-
tion of the population,
[10,12,19,21,101,104,105,107-117]
selection bias,
[10,12,19,21,101,103-117]
and the poor
description of potential confounding vari-
ables.
[10,12,21,103-109,111-117]
These aspects help
readers understand the applicability of the results,
and the lack of this information limits general-
izability.
[124]
The study by Grau et al.
[94]
showed
that, in addition to generally accepted confounders,
participants’ sex, height and weight also affected
study outcomes.
To summarize, the poor methodological quality
of the studies makes it difficult to draw firm
conclusions about the management of ITBS in
runners. Future studies should take into account
the problems of concealing treatment allocation,
the description of the population, potential se-
lection bias and the description of confounding
variables.
4.2 Pathogenesis, Diagnosis and
Management of Iliotibial Band Syndrome
Knowledge of the pathogenesis of ITBS is es-
sential for providing runners with appropriate
treatment and advice.
[34]
However, the exact pa-
thogenesis of ITBS is still controversial. It was
originally thought to be due to excessive friction
between the tract and the lateral femoral condyle,
leading to inflammation of the tract or bursa.
[109,115]
However, Nemeth and Sanders
[10]
found that
the lateral femoral condyle is actually a lateral
extension of the joint capsule and suprapatellar
synovial cavity of the knee joint. In runners with
ITBS, histopathology studies have revealed
chronic inflammation, hyperplasia, fibrosis and
mucoid degeneration of the lateral femoral re-
cess.
[10]
Muhle et al.
[125]
found ITBS to be corre-
lated with MRI signal intensity alterations in the
fatty tissue deep in the iliotibial band. Using ca-
davers, Fairclough et al.
[51]
showed that the ilio-
tibial band is firmly anchored to the distal femur
by fibrous strands, associated with a layer of
richly innervated and vascular fat. This femoral
anchorage prevents the iliotibial band from roll-
ing over the epicondyle.
Eight observational studies investigated the role
of muscle strength,
[93,97]
biomechanics,
[16,17,22,94-96]
training, and shoes
[16]
in the aetiology of ITBS.
While deficits in the hip abductors are pre-
sumed to be a major factor in the development of
ITBS in runners,
[36]
we found conflicting evidence
that hip abductor weakness is important to the
aetiology of ITBS in runners. Possible reasons for
the different findings might be the measurement
device, the variables measured, sample size and
the heterogeneous population (age, sex and level
of performance).
[93,97]
Future studies should measure hip abduc-
tor strength in more patients (>30) in a more
functional way, to reflect the reality of runn-
ing and include a control group.
[93,97,126]
Pro-
spective studies could determine whether runners
with weakness in their hip abductors are at a
greater risk of developing ITBS or whether
weakness of the muscle is caused by ITBS,
[97]
with
a focus on the endurance and muscle activation
patterns.
[96]
From studies of biomechanics (kinetics and
kinematics) in runners both with and without
ITBS, it is not clear whether ITBS appeared be-
fore the change in biomechanics or if a difference
in biomechanics caused the ITBS. However, the
results of the studies of Grau et al.
[96]
and Ferber
et al.
[95]
suggest that lower extremity running me-
chanics do not change as a result of ITBS. In
contrast, the results of Grau et al.
[94]
showed that
biomechanical differences between healthy run-
ners and those with ITBS do depend on the
matching (weight, height and sex) of the partici-
pants. For instance, it is unclear whether there is
a sex-specific biomechanical aspect to the devel-
opment of ITBS in runners.
[17,96]
Other studies
showed that differences between runners with
Iliotibial Band Syndrome in Runners 19
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
or without ITBS might also depend on the acuity
of ITBS (i.e. painful or not painful), the method
of the diagnosis, running style, running experience
(i.e. elite, competitive and casual), shoe, surface
and speed of the runner.
[127-130]
Thus, in the future, it might be advisable to
consider running shoes, running surface and
speed as matching variables when investigating
the biomechanics of ITBS based on resulting
differences in running style.
[127-130]
Attention
should also be paid to the study design (e.g. only
one study is a prospective study that focuses on
kinematic deviations
[22]
), sample size, the age of
the population and possible sex-specific differ-
ences in biomechanics, in order to generate qua-
litatively good studies of adequate size.
In the studies included in this review, ITBS
was mainly diagnosed based on the history, signs
and symptoms, and clinical findings.
[90-92,94,96-99]
However, in many cases, the signs and symptoms
were not adequately described, which makes the
validity of the diagnosis of ITBS difficult to de-
termine in several studies.
[17,93,95,100]
Clinical in-
vestigations included palpation, compression test
of Noble and/or the test of Renne.
[16,90-92,96-98]
Further research should focus on the validation
of these tests for runners with ITBS. The func-
tional running test to assess the efficacy of the
treatment of ITBS seemed to be more sensitive
than conventional pain-recall methods,
[90]
but
further clinometric research is necessary to iden-
tify its reliability and responsiveness in runners
with ITBS. The severity of ITBS was classified
according to the ‘injury grade’ of Lindenberg
et al.
[90,92,105]
This classification tool has good
face validity and was validated in the study of
Schwellnus et al.,
[90]
but no clinometric studies
are available. Future studies should focus on the
reliability of this tool and whether it can be used
to identify subgroups of ITBS to enable more
effective treatment of the condition.
[131]
The flexibility of the iliotibial band and iliop-
soas muscle seems to be an important aspect in
the management of ITBS.
[22,95,96]
The Ober test
and the modified Thomas test can be used in daily
practice to identify runners with a high risk of
ITBS and to evaluate the effect of stretching ex-
ercises as a component of ITBS treatment. Further
research with these tests should focus on the dif-
ferential effect of stiffness of the iliotibial band
and iliopsoas muscle, and of acute, sub-acute and
chronic ITBS on treatment outcomes. In the acute
phase (<14 days duration), corticosteroid injec-
tion appears to be beneficial, with runners being
able to run pain free within 14 days.
[91]
In the
subacute stage (>14 days duration), a combination
of anti-inflammatory/analgesic medication appeared
to be more beneficial than anti-inflammatory
medication alone.
[90]
The use of DTFM is sup-
ported by anecdotal evidence of its effectiveness.
However, it seems somewhat illogical to use fric-
tion techniques to treat an injury that might be
caused by friction.
[7]
Schwellnus et al.
[90]
found
DTFM in combination with ultrasound and
stretching exercises to be no better than ultra-
sound and stretching alone,
[90]
as both treatment
regimens reduced daily pain and pain experienced
on treadmill running.
Overall, the studies confirm the benefits for
the conservative treatment of ITBS in runners;
pain medication/injection, stretching of the ilio-
tibial band, hip abduction exercises/pelvic drops
to strengthen the gluteus muscles and advice
about training, inlays and shoes.
[16,90-92,97]
Un-
fortunately, to date, no (randomized) clinical
trials have investigated the benefit of these dif-
ferent modalities in isolation.
[7]
Although ilioti-
bial band bursectomy and arthroscopic resection
of the lateral synovial recess proved effective in
runners with chronic (>6 months) ITBS,
[98,99]
the
studies investigating these techniques were small.
In summary, conservative treatment appears
to be beneficial in the management of ITBS in
runners, although the evidence supporting this
comes from studies with small, heterogeneous
samples. Further investigation of the specific
clinical benefit of conservative therapies for run-
ners with ITBS will be of great importance to the
evidence-based management of this condition
and to research.
[7]
Surgical approaches appear to
be effective, and the arthroscopic technique would
seem especially appropriate because it allows as-
sessment and treatment of any intra-articular
pathology. In the future, it would be interesting
to compare these treatments in an RCT with
more participants.
20 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
AUTHOR PROOF
5. Conclusion
ITBS is a common injury of the lateral aspect
of the knee in runners.
[7]
Although several inves-
tigations have been published, there is a paucity
of research of adequate quality on the manage-
ment of ITBS in runners. As the studies included
in this review provided limited evidence, hard
conclusions about the prevention and treatment
of this injury cannot be drawn.
This review shows that future research on the
management of ITBS in runners should pay more
attention to the methodological aspects of the
study design, such as concealing treatment alloca-
tion and adequately describing the study popula-
tion, exclusion criteria and confounding variables.
Knowledge of the pathology of ITBS could con-
tribute to the development of a diagnostic pro-
tocol for ITBS in runners. In addition, uniformity
in the diagnostic protocol for ITBS in runners is
essential for the effective management of this type
of musculoskeletal injury.
On the basis of the limited evidence generated in
this review, treatment of ITBS should include advice
about coordination and running style, choice of
shoes and an appropriate running surface in com-
bination with training to strengthen the hip muscles.
Acknowledgements
No sources of funding were used to assist in the prepara-
tion of this review. The authors have no conflicts of interest
that are directly relevant to the content of this review. The
authors would like to acknowledge the following persons who
made substantial contributions: Petra Habets, Amsterdam
Medical Centre, University of Amsterdam, the Netherlands,
and co-workers at the library of the Department of Physical
Therapy, Hogeschool Utrecht, University of Applied Sciences
Utrecht, the Netherlands.
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Correspondence: M.P. van der Worp, MSc., Academic In-
stitute Hogeschool Utrecht, University of Applied Sciences
Utrecht, Department of Physical Therapy, Utrecht, the
Netherlands.
E-mail: MvdWorp@Gmail.com
24 van der Worp et al.
Adis ª2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (11)
