Case 2 - “Knife in the Knee”
By Dean Thornton
A 44 year old runner complained to his running coach that he had been experiencing a sharp, stabbing pain on the outside of his right knee after about 3 miles into his longer runs. The pain would go away when he stopped running and would not return until 3 miles into the next run. After 5 or 6 miles, the pain would become unbearable. The symptoms initially began after a long, 20 mile trail run which ended on a hard, downhill stretch of pavement. The symptoms lingered for several weeks before the runner sought medical attention.
An MRI of the knee was obtained to confirm the suspected clinical diagnosis and to rule out any other structural abnormalities.
The first MRI figure is a coronal (front-facing) image which shows a thickened, irregular and inflamed iliotibial band (arrows) as it passes along the outside of the knee, specifically over the lateral epicondyle of the femur, the bony prominence (arrowheads) along the outside of the knee just above the joint line. The iliotibial (IT) band should normally be a thin, smooth, dark structure.
The second MRI figure is a transverse (cross-section) image which again shows the thickened IT band (arrows) as it passes close to the lateral femoral epicondyle (arrowheads). This MR image better shows the inflammation (bright areas around the IT band) associated with this condition.
Iliotibial Band Friction Syndrome, or simply IT Band Syndrome (ITBS), results from inflammation caused by friction between the IT band and the underlying bone.
This anatomical drawing (courtesy of MedicineNet) depicts the IT band from the side (left image) and front (right image) of the leg. The IT band begins as a musculotendinous structure along the side of the pelvis and extends to the outside of the knee as dense, fibrous band.
As in the case of the overzealous trail runner, the IT band can develop a friction syndrome over the outside of the knee. There are many causes of ITBS including running too many miles, increasing mileage too rapidly, and running downhill or on slanted surfaces. Weakness or inactivity of the gluteal muscles can predispose to this condition.
Treatment of ITBS includes decreased running or complete rest. Cross-training with swimming may help; elliptical machines and cycling could aggravate the injury. Stretching and foam rolling may be beneficial but overdoing either could worsen the condition. Strengthening the gluteal muscles is recommended to correct muscle imbalances and prevent ITBS in the future. Anti-inflammatories and steroid injections may be required for refractory cases.
After two months of dramatically decreased mileage, stretching, foam rolling, and gluteal exercises, the intrepid trail runner was back in the woods running pain free.
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By: Dean Thornton, MD
Dean is a Musculoskeletal Radiologist with Radiology Associates of Birmingham and a Clinical Associate Professor of Radiology at UAB. He works with many local orthopedists and sports medicine physicians. He also likes to run.
Inside the Runner uses medical imaging to offer readers a chance to see what is going on inside their bodies when something breaks down. From fractures to tendonitis to muscle injuries, this series explores the imaging studies used to help doctors and other medical professionals treat running injuries.