IT Band Syndrome (Knee) Rehabilitation Protocol

Pathophysiology

Iliotibial (IT) band syndrome (ITBS) is a common overuse injury causing lateral knee pain, often experienced by runners and cyclists. The IT band is a thick band of fibrous tissue originating at the iliac crest and inserting at Gerdy’s tubercle on the lateral tibia. It functions as a dynamic stabilizer of the knee and hip. ITBS is not a true “tightening” of the IT band, but rather an irritation and inflammation where the IT band rubs over the lateral femoral epicondyle during knee flexion and extension. This friction is exacerbated by repetitive activities, muscle imbalances (weak hip abductors, tight TFL), and biomechanical factors (e.g., excessive pronation, genu varum).

Key contributing factors include:

• Repetitive knee flexion and extension (running, cycling).
• Weak hip abductor muscles (gluteus medius and minimus).
• Tight tensor fasciae latae (TFL) and IT band.
• Inadequate warm-up or cool-down.
• Sudden increases in training volume or intensity.
• Biomechanical abnormalities (e.g., leg length discrepancy, excessive pronation, genu varum).
• Inappropriate footwear or cycling setup.

Common Special Tests

• Ober’s Test: Patient lies on their side with the affected leg uppermost. The examiner passively abducts and extends the hip. Then, the examiner slowly adducts the hip towards the table. A positive test is indicated by the inability to adduct the leg past the midline.
• Noble Compression Test: Patient lies supine. The examiner applies pressure over the lateral femoral epicondyle while passively extending and flexing the knee. Pain is elicited when the knee is near 30 degrees of flexion.
• René Test: The patient stands on the affected leg and squats down, then the patient straightens back up. The test is positive if pain is felt at the lateral femoral epicondyle during the motion.

Rehabilitation Protocol

This rehabilitation protocol is a guideline. Progression through phases depends on individual patient presentation, pain levels, and functional abilities. Consistent communication between the patient and physical therapist is crucial.

Phase I: Protection/Pain Management (Week 1-2)

Goals: Reduce pain and inflammation, protect the injured tissues.

• Activity Modification: Avoid activities that aggravate the pain (running, cycling). Consider cross-training activities like swimming or elliptical with low impact.
• Pain Management:
  • RICE Protocol: Rest, Ice (15-20 minutes every 2-3 hours), Compression, Elevation.
  • NSAIDs: As prescribed by a physician.
  • Modalities: Electrical stimulation (TENS, IFC), ultrasound, or iontophoresis to reduce pain and inflammation, if indicated.
• Range of Motion Exercises:
  • Gentle active range of motion (AROM) of the knee and hip within a pain-free range.
  • Static stretching of the hip flexors, hamstrings, and quadriceps (hold 30 seconds, repeat 3 times).
• Isometric Exercises:
  • Isometric quadriceps sets.
  • Isometric hamstring sets.
  • Isometric hip abduction exercises (e.g., squeezing a pillow between the knees).

Phase II: Loading/Strength (Week 3-6)

Goals: Restore pain-free range of motion, improve muscle strength and endurance, address biomechanical factors.

• Range of Motion: Continue AROM exercises. Add gentle passive range of motion (PROM) if needed.
• Flexibility:
  • IT band stretching: Modified Ober's stretch, foam rolling (avoid direct pressure on the lateral femoral epicondyle), cross-legged stretch.
  • Hip flexor, hamstring, quadriceps stretching.
• Strengthening Exercises:
  • Hip Abductors: Side-lying hip abduction, clamshells, standing hip abduction with resistance band. Progress to standing hip abduction against wall with resistance band and finally standing hip abduction away from the wall with resistance band.
  • Gluteal Muscles: Bridging exercises (single and double leg), hip thrusts, squats (partial range initially), lunges (progressively increasing depth).
  • Core Strengthening: Plank, side plank, bird dog.
  • Knee Strengthening: Short arc quadriceps, hamstring curls with resistance band or weight.
  • Calf Strengthening: Calf raises (progressing to single leg).
• Proprioception/Balance:
  • Single leg stance (progress from eyes open to eyes closed).
  • BOSU ball activities (e.g., squats, balance exercises).
• Cardiovascular Training:
  • Low-impact activities such as cycling (monitor knee pain and adjust saddle height accordingly) or elliptical.

Phase III: Return to Function (Week 7-12+)

Goals: Return to sport or activity, optimize strength and endurance, prevent recurrence.

• Continued Strengthening: Progress to more challenging exercises. Add plyometrics if appropriate.
• Agility Training:
  • Cone drills, ladder drills, shuttle runs.
• Sport-Specific Training:
  • Gradual return to running or cycling.
  • Monitor pain levels and adjust training volume and intensity accordingly.
  • Focus on proper biomechanics (e.g., running form, cycling setup).
• Maintenance Program:
  • Continue flexibility and strengthening exercises to maintain muscle balance and prevent recurrence.
  • Proper warm-up and cool-down routines.
  • Address any biomechanical factors (e.g., orthotics, bike fitting).

Progression Criteria: Pain-free range of motion, adequate strength and endurance, successful completion of functional testing.

Note: This protocol is a general guideline and should be individualized based on the patient’s specific needs and progress. Consultation with a physical therapist is recommended for proper diagnosis and treatment.