An arthroscopic technique to treat the iliotibial band syndrome

Abstract

Iliotibial band syndrome (ITBS) is an overuse injury mainly affecting runners. The initial treatment is conservative. Only, in recalcitrant cases surgery is indicated. Several open techniques have been described. The purpose of this study is to evaluate the results of a standardized arthroscopic technique for treatment of a resistant ITBS. Thirty-six athletes with a resistant ITBS were treated with a standardized arthroscopic technique, limited to the resection of lateral synovial recess. Thirty-three patients were available for follow-up (mean 2 years 4 months). Thirty-two patients (34 knees) had good or excellent results. All patients went back to sports after 3 months. In two patients a meniscal lesion was found, which required treatment. One patient with only a fair result had associated cartilage lesions of the femoral condyle. Our results show that arthroscopic treatment of resistant ITBS is a valid option with a consistently good outcome. In addition, this arthroscopic approach allows excluding or treating other intra-articular pathology.

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KNEE
An arthroscopic technique to treat the iliotibial band syndrome
F. Michels ÆS. Jambou ÆM. Allard ÆV. Bousquet Æ
P. Colombet ÆC. de Lavigne
Received: 9 May 2008 / Accepted: 15 October 2008
ÓSpringer-Verlag 2008
Abstract Iliotibial band syndrome (ITBS) is an overuse
injury mainly affecting runners. The initial treatment is
conservative. Only, in recalcitrant cases surgery is indi-
cated. Several open techniques have been described. The
purpose of this study is to evaluate the results of a stan-
dardized arthroscopic technique for treatment of a resistant
ITBS. Thirty-six athletes with a resistant ITBS were treated
with a standardized arthroscopic technique, limited to the
resection of lateral synovial recess. Thirty-three patients
were available for follow-up (mean 2 years 4 months).
Thirty-two patients (34 knees) had good or excellent
results. All patients went back to sports after 3 months. In
two patients a meniscal lesion was found, which required
treatment. One patient with only a fair result had associated
cartilage lesions of the femoral condyle. Our results show
that arthroscopic treatment of resistant ITBS is a valid
option with a consistently good outcome. In addition, this
arthroscopic approach allows excluding or treating other
intra-articular pathology.
Keywords Iliotibial tract Knee arthroscopy 
Arthroscopic treatment Lateral synvial recess 
Iliotibial band syndrome
Introduction
Iliotibial band syndrome (ITBS) is an overuse injury
mainly affecting runners [5]. The symptoms range from a
stinging sensation just on the outside of the knee to
swelling or thickening of the tissue at the point where the
band moves over the femur. ITBS can usually be treated
conservatively. Sometimes the ITBS is resistant to con-
servative therapy and surgery may be necessary. The
conventional technique is lengthening of the iliotibial band
(ITB) and removing a section of the posterior aspect of the
ITB [3,4,8]. Most reports of surgical treatment are limited
by a small number of patients [3,8–11]. Though, Drogset
et al. [1] evaluated 45 patients, and found 84.5% good to
excellent results.
An arthroscopic technique was developed for several
reasons. First, the exact pathogenesis of the ITBS is still
controversial. Earlier studies refer to excessive friction
between the tract and the lateral femoral condyle, which
causes inflammation of an underlying bursa ITBS [3,4,8].
Newer studies question this hypothesis. Recent anatomic
and microscopical studies concluded that the ITBS was
anchored to the distal femur by fibrous strands, associated
with a layer of richly innervated and vascularised fat [2,7].
Nemeth and al labelled it the lateral synovial recess [7]. In no
cadaver, volunteer or patient a bursa was seen. Fairclough
and al suggest that movement and friction of the ITB is an
illusion and they consider it as a form of enthesopathy. MRI
studies showed correlation between the ITBS and signal
intensity alterations in the fatty tissue deep to the ITB [2,6].
Our hypothesis is the following: if the inflammation is
limited to the fibrous attachments to the femur and the
surrounding fat, there’s no need to resect a part of the ITB.
Second, an intra-articular problem can mimic an ITBS
[6]. Muhle et al. found three meniscal tears on MRI in 16
F. Michels (&)
Gladiatorenstraat 29, 8510 Kortrijk, Belgium
e-mail: frederick_michels@hotmail.com
S. Jambou M. Allard V. Bousquet P. Colombet 
C. de Lavigne
Bordeaux Me
´rignac Sports Clinic, 9 rue Jean Moulin,
33700 Bordeaux-Me
´rignac, France
123
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-008-0660-5

patients with clinical signs of ITBS [6]. Richards et al. [9]
recommend performing an associated arthroscopy to
address any intra-articular pathology. This is also possible
with an arthroscopic technique treating ITBS.
Finally, an arthroscopic technique may be less invasive
than an open technique.
Based on these findings we used an arthroscopic tech-
nique limited to the resection of the fibrous attachments to
the femur and the associated fat. The purpose of this ret-
rospective study is to evaluate the results of this technique
in a group of patients with a resistant ITBS.
Material and methods
Study population
From 2003 through 2007, 36 patients underwent 38 pro-
cedures for ITBS at the Bordeaux Merignac Sports Clinic.
Thirty-three patients (35 knees) were available for follow-
up. All patients had at least 6 months follow-up with an
average of 2 years 4 months. There were 15 women and 21
men. The mean age was 31.1 years (range 19–44). In 16
patients the right knee was affected, in 22 patients the left
knee, which includes two patients affected bilaterally.
All the patients had been treated conservatively during
at least 6 months. The conservative treatment consisted of
rest, correction of training error, shoe modification, phys-
iotherapy and local infiltration with steroids.
On average the patients had suffered from the ITBS for
18 months preoperatively (range 1–7 years). All the
patients were recreational or professional athletes: long
distance running (22), triathlon (5), cycling (4), athletics
(3), rugby (3), soccer (1), swimming (1), fencing (1) and
basketball (1). The diagnosis was based on clinical find-
ings. In all patients an ultrasonography or an MRI was
performed in an attempt to exclude other pathology.
Operation technique
We used a standardized arthroscopic technique. The patient
is placed in supine position under general or spinal
anaesthesia. Two supports are placed to keep the leg in 30
degrees of flexion, corresponding to the position in which
the ITB is compressed against the lateral condyle [2]. A
thigh tourniquet is used. Through an anteromedial portal
and an anterolateral portal the joint space is inspected and
other possible lesions are searched for and treated if
needed.
The lateral gutter is inspected. In all patients a lateral
synovial recess was found. A needle is placed percutane-
ously in this synovial recess (Fig. 1). With the knee in 30°
flexion, this recess corresponded in all the patients with the
lateral femoral epicondyle. A superolateral portal is used as
a working portal. The lateral synovial recess is debrided
with the synovial shaver (Fig. 2). The resection is com-
pleted when the bone on the lateral femoral condyle is
visible. The whole procedure is performed intra-articularly.
A drain is placed during 24 h. Postoperatively early range
of motion exercises and full weight bearing is promoted.
Slow running was allowed two months postoperatively.
Results
Two months postoperatively 74.2% was able to start slow
running, this was 100% at check-up 3 months
postoperatively.
The subjective functional results after surgery were
assessed with the score used by Drogset et al. [1]. There
were 28(80%) excellent results, 6(17.1%) good results,
1(2.9%) fair result and no poor results.
Satisfaction was assessed using the visual analogue
scale, anchored at 0 for lowest and 10 for highest satis-
faction. Patients were generally satisfied with scores
ranging from 6 to 10 points (mean 9). Had the
Fig. 1 Arthroscopic view of lateral gutter with needle in synovial
recess
Fig. 2 Arthroscopic view of lateral gutter during resection of
synovial recess with synovial shaver
Knee Surg Sports Traumatol Arthrosc
123

postoperative result been known beforehand, all but one of
the patients would have been operated on again.
Associated lesions
The only patient with a fair result had associated cartilage
lesions of the femoral condyle.
In two patients a meniscal lesion was found, which
required treatment. The lesions had not been noticed on the
preoperative MRI. In one patient a calcified loose body was
found trapped in the lateral synovial recess and resected
arthroscopically.
Complications
One patient developed a haematoma that required evacu-
ation four days postoperatively. Finally the patient healed
without complications.
Discussion
The most important finding of the present study was that
the arthroscopic treatment is a suitable and reproducible
technique with good results.
The initial treatment of the iliotibial band syndrome
consists of activity modification, a trial of anti-inflamma-
tory, local modalities, stretching, physical therapy, shoe
modification, and possibly a cortisone injection. Only in
recalcitrant cases surgery is indicated [1,4,8,10].
Several open techniques have been described to dimin-
ish the tension on the posterior part. In 1979 Noble et al. [8]
described a 2-cm incision across the fibers of the posterior
iliotibial band at the level of the lateral epicondyle. Holmes
et al. [3] resected an elliptical portion of the posterior ITB.
Martens et al. did a triangular resection [4]. Drogset et al.
[1] did a more extensive resection. They published a ret-
rospective study of 45 patients with good or excellent
results in 84.5% of the patients. In this study we had 97.1%
good or excellent results with the same rating scale.
Sangkaew reported a mesh technique in a case report [10].
Richards et al. [9] performed a Z-lengthening associated
with a diagnostic arthroscopy.
The exact pathogenesis of the ITBS is still controversial.
The iliotibial band syndrome was believed to be associated
with excessive friction between the tract and the lateral
femoral condyle which inflames the tract or bursa [3,4,8].
In 1996, in a cadaver study, Nemeth and Sanders found
that this sac, is actually a lateral extension of the joint cap-
sule and suprapatellar synovial cavity of the knee joint [7].
Biopsies of this lateral recess in patients with ITBS showed
histopathologic changes consisting of chronic inflammation,
hyperplasia, fibrosis and mucoid degeneration [7].
In 1999, the MRI study of Muhle et al. [6] revealed
correlation between the ITBS and signal intensity altera-
tions in the fatty tissue deep to the ITB. Similar MR signal
changes were found by other authors [2]. The ITB dem-
onstrated normal signal intensity on all MR images [6].
The cadaver study Fairclough et al. [2] in 2006 found
that the ITB was firmly anchored to the distal femur by
fibrous strands, associated with a layer of richly innervated
and vascularised fat. This femoral anchorage prevents the
ITB from rolling over the epicondyle. They suggest that the
perception of movement of the ITB across the epicondyle
is an illusion because of changing tension in its anterior and
posterior fibres. Because ITB overuse injuries may be more
likely associated with fat compression beneath the tract,
they consider it as a form of enthesopathy.
The arthroscopic technique in this study was limited to
the resection of the fibrous attachments to the femur and
the associated fat. The good results of this treatment con-
firm the hypothesis that the inflammation is limited to the
fibrous attachments to the femur and the surrounding fat.
No resection of the ITB is needed.
In addition, this arthroscopic approach allows excluding
and treating other intra-articular pathology. In this study
two patients had meniscal lesions requiring treatment; one
patient had important cartilage lesions.
Calcified loose bodies trapped in the lateral synovial
recess are already described by Tomlinson et al. [11].
However, with our technique we succeeded to remove the
fragments arthroscopically.
Because of the risk of haematoma we recommend to
deflate the tourniquet before closure and achieve haemo-
stasis if needed. We leave a drain during 24 h.
In conclusion, ITBS is an overuse syndrome mainly
affecting runners. We emphasize that a prolonged nonop-
erative trial must be attempted before surgery. The
presented study shows that the arthroscopic treatment is a
suitable and reproducible technique with good results. In
addition it allows assessment and treatment of any intra-
articular pathology.
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