One of the great things about keeping up with current research is that it often causes us to change course and reconsider ways that we may have been treating various pathologies. While it is certainly frustrating to have to reverse something you have been teaching for years, it is actually refreshing to develop a better understanding of how the body functions. A colleague recently sent me a link to this article on the anatomy of the iliotibial band and it is one of those things that is a radical shift from our previous understanding.

Most of us who have been immersed in the field of orthopedics, sports medicine, and biomechanics have been talking for years about iliotibial Band (ITB) friction syndrome as a repetitive overuse disorder caused by excess friction between the distal ITB and the lateral epicondyle of the femur. However, now it turns out that this concept may be mistaken.

One of the common misconceptions of the ITB is that it is a single discrete band of connective tissue running down the lateral side of the thigh. Actually it is a thickened part of a fascial sleeve that surrounds the entire thigh (the fascia lata). The authors of this study investigated a number of cadaver specimens and live individuals with MRI and found some interesting new discoveries. Apparently the ITB is firmly anchored to the distal femur and does not rub back and forth across the lateral epicondyle of the femur as most of us have been describing it. In addition, they state that there actually isn’t a bursa under the ITB, as it is often described.

When the knee moves into flexion, there is a simultaneous internal rotation of the tibia. This internal tibial rotation puts increased tensile loads on the ITB. The authors suggest that the increased tensile load on the ITB further compresses it against underlying tissue. There is a layer of fatty tissue under the distal ITB that is richly innervated with Pacinian corpuscles. They suggest it is this increased compression against the fatty tissue that is the cause of the pain and not a bursitis or friction of the ITB against the femoral epicondyle.

So, now that we know this, how should we change treatment strategies? One would think that if the primary problem in this condition were additional compression of the ITB against underlying tissues, then further direct compression in this area would not be a good idea. The authors suggest that the primary problem originates with improper function of the hip musculature (which tensions the band). As a result, the primary treatment should focus much more on correct hip muscle function and not on treating the knee region. The article and abstract are located under this citation:

Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. Mar 2006;208(3):309-316.