Approach
Characteristic history and exam findings are often sufficient to diagnose ITBS. However, in cases of diagnostic uncertainty, or where recurrent or refractory ITBS is suspected, further investigation with imaging may be warranted.[29]
History
Initially, patients with ITBS report diffuse pain in the lateral region of the knee although, as the condition progresses, this pain usually localizes and becomes sharper or develops into a burning sensation.[30][31] Often, ITBS pain occurs several minutes into, or following, the completion of physical activity but, with worsening ITBS, symptoms can occur even at rest. Patients may complain of pain flaring at specific instances such as when running down hills, lengthening their stride, or sitting for prolonged periods of time with their knee flexed. Pain may radiate proximally or distally.
In addition to exploring pain, the history should also elicit (extrinsic) risk factors for ITBS including:[5][12][21]
Type of physical activity engaged in
Level of experience with physical activity
Estimated weekly mileage (if applicable)
Training schedule
Use of worn-out running shoes
Type of training surfaces used (if running)
Athletes predisposed to ITBS are typically in a phase of overtraining and may describe a rapid progression in weekly mileage.[12][17]
Physical exam
A standard knee exam should be undertaken, with particular special (provocative) tests used to support diagnosis.
Palpation of the iliotibial band (ITB) 2-3 cm superior to the lateral joint line will usually cause tenderness, though exam may be normal in mild ITBS.[30][31] Swelling of the distal ITB may be evident on palpation. In more severe cases, local edema or crepitations may also be noted on exam.
Joint effusion or positive results on a meniscal test raises suspicion of an intra-articular problem.
The physical exam should also identify any intrinsic factors that may contribute to ITB tightness and muscle weakness including: genu varum (bow leg); pes cavus (high arch); prominent lateral femoral epicondyle; tight iliotibial tract, lateral retinaculum, tensor fascia lata, rectus femoris, and hamstrings.[20][21]
An attending physician demonstrates knee exam techniques, inspecting the biomechanics of the knee and assessing for effusion, wasting, or hypertension. The physician performs tests for the integrity of the medial and lateral collateral ligaments, damage to the cruciate ligaments (Lackman test, Drawer test, Pivot shift test), tests of the patella (patella apprehension test, Clarke test), and tests of the iliotibial band (Ober test).
Special tests
The Noble, Ober, and modified Thomas tests are special tests undertaken, in addition to standard knee exam, where ITBS is suspected.[30][31] These tests support the diagnosis of ITBS, but are not ''true'' diagnostic tests in themselves.
The Noble test specifically assesses pain associated with ITBS. The Ober test is recommended to assess ITB tightness and the modified Thomas test is recommended to assess the flexibility of hip flexors (iliopsoas, rectus femoris, and the tensor fascia lata [TFL]/ITB complex).
Noble test: the patient lies supine or on their side with the unaffected side down. The examiner applies pressure over the lateral femoral epicondyle while extending the knee from 90° of flexion. In a positive test, pain occurs when knee is flexed around 30°.
Ober test: the patient lies down with the unaffected side down with the unaffected hip and knee at a 90° angle. The examiner stabilizes the pelvis and then flexes the affected leg to 90° at the knee, before extending and abducting the hip. The affected leg should then be slowly lowered to the exam table (hip adduction). In a positive test (i.e., ITB is tight), the affected leg cannot be passively adducted to horizontal.
Modified Thomas test: the patient sits on the end of an examining table, rolls back to a supine position, and holds both knees to the chest. The patient holds the knee on the asymptomatic side close to the chest, keeping the hips on the table, and avoiding excessive posterior tilt. They should then slowly lower the affected limb toward the floor. In a positive test the angle of the femur is below horizontal.
Be aware that patients often will compensate for weakness or inhibition of the gluteus medius with substitution of the TFL, the quadratus lumborum muscles, or both. Leg-length discrepancies also contribute to ITBS and are assessed as part of a routine examination.
Imaging
As ITBS is a clinical diagnosis, imaging of the knee is not usually undertaken as part of the initial workup. However, where there is diagnostic uncertainty, further investigation with imaging may be warranted.
The American College of Radiology advises that radiography of the knee is usually appropriate as initial imaging for patients with chronic knee pain.[32] X-ray may be normal or show signs suggestive of other knee pathologies (e.g., joint effusion, osteochondral injuries [fracture/osteochondritis dissecans or a loose body], avascular necrosis, or internal derangement [Segond fracture, deep lateral femoral notch sign]), but it will not be diagnostic for ITBS.
Ultrasound may be considered; findings suggestive of ITBS include soft tissue swelling and fluid collection between the ITB and lateral femoral epicondyle.[29] Use of MRI has also been reported in the literature; findings suggestive of ITBS include: thickening of the ITB over the lateral femoral epicondyle, poorly defined signal intensity changes under the ITB, joint effusion, and fluid collection medial to the ITB.[4][33]
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