Ultrasound Guided IT Band Injection
Introduction
The iliotibial band is a common source of pain in runners. IT band syndrome is characterized by lateral knee pain with activity (5). The Iliotibial band (ITB) is a lateral thickening of the tensor fascia latae that consists of dense connective tissue (8). The IT band will have both superficial and deep fibrous insertions. The deep fibers of the ITB insert on the lateral femur and are historically called the Kaplan fibers (2). The superficial fibers will insert along the lateral tibia at Gerdy’s tubercle (1). The Kaplan fibers have been identified to serve a role in rotatory stability of the knee (2). Despite these fibrous connections, there is still anteroposterior motion of the ITB at the level of the lateral femoral condyle with flexion and extension of the knee (6). The motion identified at the lateral femoral condyle does give support to this being a friction syndrome (6).
Case Vignette
A) Kaplan fibers
B) Cohen fibers
C) Gerdy’s tubercle
D) Osgood fibers
The iliotibial band on ultrasound appears as a homogeneous fibrillar structure that is thin in appearance (9). Patient’s with ITB syndrome can have thickening of the IT band at the level of the lateral femoral condyle (10). There may also be fluid located in the iliotibial bursa, which is located between the deepest portion of the IT band and the lateral femoral condyle (10).
Image 1: Anatomy of the IT band insertion (1)
Injection
First line treatment typically involves activity modification and physical therapy (7). Corticosteroid injection can also be done with the use of ultrasound or palpation guidance. In a study published in the British Journal of Sports Medicine, they found that a corticosteroid injection given under palpation guidance to the area where the IT band crosses over the lateral femoral condyle led to a statistically significant improvement in pain compared to placebo (7).
Ultrasound guided injection of the distal IT band is an option for patients with IT band friction syndrome. The level of the injection is the lateral femoral condyle. In order to find the IT band at the level of the lateral femoral condyle, providers should trace the IT band from its insertion on Gerdy’s tubercle (3). When deciding on where to inject, providers can also apply pressure to the area with the transducer to see if this is the area of maximal tenderness (8). Once identified, the IT band can be injected via a posterolateral or anterolateral approach (3). Using an in-plane approach, the needle can be guided into the IT band bursa located in the space between the IT band and the lateral femoral condyle (4). Corticosteroids should not be injected directly into the IT band (8). Care must be taken to also avoid the common fibular nerve (4).
Image 2: Posterolateral approach of IT band (4)
Conclusion
IT band friction syndrome is commonly seen in runners. In those runners that continues to have pain despite conservative measures, an ultrasound guided IT band injection can be considered.
By: Gregory Rubin, DO
Rubinsportsmed.com
– IT Band Syndrome @ Wiki Sports Medicine: https://wikism.org/Iliotibial_Band_Syndrome
Case Conclusion
Correct Answer: A Kaplan fibers. The distal insertion of the IT band occurs along the distal femur and the more proximal fibers insert at Gerdy’s tubercle along the lateral tibia. The femoral attachment distally occurs with the Kaplan fibers. The Kaplan fibers aid in rotatory stability of the knee.
References
1) Godin, Jonathan A., et al. “A Comprehensive Reanalysis of the Distal Iliotibial Band: Quantitative Anatomy, Radiographic Markers, and Biomechanical Properties.” The American Journal of Sports Medicine, vol. 45, no. 11, Sept. 2017, pp. 2595–603. PubMed, https://doi.org/10.1177/0363546517707961.
2) Batty, Lachlan, et al. “The Kaplan Fibers of the Iliotibial Band Can Be Identified on Routine Knee Magnetic Resonance Imaging.” The American Journal of Sports Medicine, vol. 47, no. 12, Oct. 2019, pp. 2895–903. PubMed, https://doi.org/10.1177/0363546519868219.
3) Mcnally, Eugene. “Specific Intervention Techniques.” Practical Musculoskeletal Ultrasound.
4) Lueders, Daniel R., et al. “Ultrasound-Guided Knee Procedures.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 631–48. PubMed, https://doi.org/10.1016/j.pmr.2016.04.010.
5) Jelsing, Elena J., et al. “The Source of Fluid Deep to the Iliotibial Band: Documentation of a Potential Intra-Articular Source.” PM & R: The Journal of Injury, Function, and Rehabilitation, vol. 6, no. 2, Feb. 2014, pp. 134–38; quiz 138. PubMed, https://doi.org/10.1016/j.pmrj.2013.08.594.
6) Jelsing, Elena J., et al. “Sonographic Evaluation of the Iliotibial Band at the Lateral Femoral Epicondyle: Does the Iliotibial Band Move?” Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, vol. 32, no. 7, July 2013, pp. 1199–206. PubMed, https://doi.org/10.7863/ultra.32.7.1199.
7) Gunter, P., and M. P. Schwellnus. “Local Corticosteroid Injection in Iliotibial Band Friction Syndrome in Runners: A Randomised Controlled Trial.” British Journal of Sports Medicine, vol. 38, no. 3, June 2004, pp. 269–72; discussion 272. PubMed, https://doi.org/10.1136/bjsm.2003.000283.
8) Hong, Ji Hee, and Ji Sub Kim. “Diagnosis of Iliotibial Band Friction Syndrome and Ultrasound Guided Steroid Injection.” The Korean Journal of Pain, vol. 26, no. 4, Oct. 2013, pp. 387–91. PubMed, https://doi.org/10.3344/kjp.2013.26.4.387.
9) Chundru, Usha. “Internal Derangement of the Knee: Tendon Injuries.” Musculoskeletal Imaging, Elsevier.
10) Bonaldi, V. M., et al. “Iliotibial Band Friction Syndrome: Sonographic Findings.” Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, vol. 17, no. 4, Apr. 1998, pp. 257–60. PubMed, https://doi.org/10.7863/jum.1998.17.4.257.
