Some conditions in sports medicine are relatively easy to diagnose but are challenging to manage. A good example is a condition often seen in runners called IT Band syndrome or iliotibial band friction syndrome. Primarily, this common condition affects the outside of the knee. Does a cortisone injection for IT band syndrome help?
First, we need to understand the iliotibial band and the concept of IT Band syndrome.
What is the iliotibial band?
The iliotibial band begins above the hip joint from the tensor fascia lata muscle. Then, it passes from the outside of the thigh to the outer side of the shin (tibia). The IT band functions as a stabiliser for the outside of the knee. It is prone to inflammation and swelling as it passes over a bony bump outside the knee.
What causes IT band syndrome?
ITB syndrome is caused by pressure or friction of the Iliotibial band against the outside of the knee joint. Recent research suggests that pressure is a more critical factor in causing ITB syndrome and occurs maximally at 30 degrees of knee flexion. Similar to the runner’s knee, critical contributing factors to ITB syndrome found in one study include biomechanical issues such as tightness in the quadriceps muscles and weakness in the buttock muscles.
IT band syndrome symptoms
Generally, most people with IT band syndrome present with pain at the outside of the knee triggered by running that improves with rest. Runners are usually fine for the first 5-10 minutes but quickly develop sharp pain outside the knee. The pain is generally so intense that it is hard to run through. Less commonly, other activities such as hiking, walking, and cycling cause pain.
It is essential not to miss other causes of pain outside the knee. Other injuries include a torn meniscus, biceps femoris tendonitis, or pain from the back or hip. MRI or ultrasound scan is often helpful to confirm fluid under the ITB and exclude other causes.
What treatments are available for IT Band syndrome?
Firstly, we start with treatments to treat pain and inflammation. These treatments include tablets such as ibuprofen or a cortisone injection.
Secondly, working with a therapist to optimise biomechanics, such as pelvis strength and leg flexibility, is crucial. A step-by-step approach is usually more successful:
- Stop activities that aggravate the ITB, such as running and cycling.
- Start by stretching the hip flexors, ITB, and glute muscles. Deep tissue massage can help loosen muscle tightness.
- Then, commence strengthening of the ITB and glute muscles.
- Orthotics to improve foot biomechanics can reduce the load on the ITB.
- Changes in your running style, such as increasing your step rate and reducing the crossing of legs, may also help.
- Finally, a return to running should occur gradually to avoid a return of pain.
What is the best approach for IT Band syndrome including a cortisone shot?
Most people try to muddle through with bits and pieces, often unsuccessful, leading to months of pain. In addition, long-term pain usually leads to scar tissue.
Our approach is more aggressive. Overall, the best results come from complete rest from running, anti-inflammatory tablets, and a rehab program to treat biomechanics. Cortisone shot for IT Band syndrome is a great idea early to reduce swelling and help rehab. Dr Masci performs botox injections directed to the side buttock muscles for complex cases. For the best effect, cortisone in the IT Band is often performed with Botox to the tensor fascia lata. Generally, the days of muddling through are long gone.
More on cortisone shot for IT Band syndrome
Cortisone is a potent anti-inflammatory that reduces inflammation and pain. IT Band syndrome produces inflammation as it passes over the bony prominence on the outside of the knee. By directing cortisone at the IT band at the level of this bony prominence, inflammation and pain are reduced. Moreover, it is essential to use ultrasound to direct a cortisone shot for IT Band to increase the effectiveness and minimise side effects.
A cortisone shot for IT band syndrome reduced pain much better than a placebo in this study.
Dr Masci has written a paper summarising cortisone injeciton results in conditions such as IT band syndrome.
Botox vs cortisone injection for IT Band syndrome
Botox vs cortisone injection for IT Band syndrome
Recently, some practitioners have been using botox directed to the muscle outside the hip to help with chronic ITB syndrome cases.
Overall, we suspect the TFL or tensor fascia lata muscle is too tight in chronic cases of IT band syndrome. Relaxing this muscle with Botox changes the tightness of the IT band and causes less IT Band pain. It also allows the glute muscles to work better. This treatment is an exciting advance in treating chronic IT Band syndrome and may help people who have exhausted all other non-surgical options.
Generally, we recommend injecting Dysport (Botulinum toxin) into the tensor facia lata muscle belly under ultrasound guidance. Resting the muscle for 48 hours is critical to prevent the toxin from spreading to the other muscles. After a few days, you can slowly resume normal activities. The toxin effects start at about one week and last up to three months.
Working with your physiotherapist after the injection is essential to improving your lower limb and pelvic biomechanics. You should focus on enhancing glute strength in the lying and standing positions. Generally, we recommend at least six weeks of physiotherapy after a Botox injection.
A recent study found that over 80% of patients with IT Band syndrome improved after a Dysport injection into the TFL muscle. Moreover, 69% said their pain had disappeared. This group remained pain-free at 4-5 year follow-up. Only one patient reported increased pain after the intervention.
What about iliotibial band surgery?
Usually, surgery involves releasing the IT band at the level of the outside of the knee. The surgery can be open or keyhole, with mixed results.
We strongly suggest runners avoid surgery in almost all cases. The iliotibial band friction surgery results are unpredictable and may lead to a worse outcome. Five-year follow-up patients after IT Band surgery show that 80% have ongoing knee pain, and 74% have reduced or stopped running.
Therefore, we recommend at least 12 months of conservative treatment before surgery.
Other frequently asked questions about cortisone injection for IT band syndrome.
Should you rest after a cortisone shot for IT Band?
Yes. Generally, we recommend resting from running for a week. This rest prevents a flare, which usually presents 24-48 hours after an injeciton.
Are there side effects from a cortisone injection for IT band syndrome?
Although there are a few side effects, a cortisone shot for the IT band may not work. Other risks include skin changes, infection, and a steroid flare.
Can you run with IT band syndrome?
It depends on how bad your symptoms are. For example, most people with IT band syndrome can’t run because of pain. However, in mild cases, you might be able to manage your symptoms with intensive physiotherapy.
What cardio can I do with IT band syndrome?
Generally, we recommend you avoid running until the inflammation settles and you see a physiotherapist. However, people with this condition can usually walk, cycle, swim, and cross-train.
Does stretching help IT band syndrome?
Yes. Most people with IT band syndrome have a tight ITB, hamstring, and tensor fascia lata tendon. We suggest you focus on relaxing this tendon. Stretching, Yoga, and foam roller massage are all effective.
Are there other injection options for ITB friction syndrome besides cortisone?
Yes. Some practitioners use Botox to relax the tensor fascia lata, a hip muscle, for the tensor fascia lata. Often, Dr Masci performs a combination of cortisone for the IT Band and Botox for the tensor fascia lata in cases of persistent IT Band friction syndrome resistant to physiotherapy.
Can shockwave therapy help IT Band syndrome?
Maybe. Some studies show that shockwave therapy might help manage IT Band pain during a race or marathon build-up. Compared to injections, shockwave has the advantage of no downtime compared to a cortisone or botox injection.
Final word from Sportdoctorlondon about cortisone injection for IT band syndrome
IT Band syndrome is a complex condition in runners. We suggest aggressive treatment early, including an ITB injection if the pain is severe. In general, rehab is significant. The bottom line is this: Ignore IT Band syndrome at your peril.
Dr Masci performs a combination of cortisone injection for the IT Band and Botox for the tensor fascia lata muscles for chronic IT Band friction syndrome. For further information on this procedure, including costs, please get in touch with his staff. Please review his fees here.
I had total hip replacement surgury 19 months ago. Ever since I keep getting the same diagnosis IT BAND syndrome. I just had a cortisone shot 5 days ago & started physio. The pain in my thigh & the outside of my knee are excruciating & I never get relief for very long. I work & walk 5 to 13 kms 7 days a week ,& have quit golfing because of the pain. Are there any good alternatives to IT Band surgury ?
Hi Robert – your problem is a tough one. I’d suggest physio combined with one or two cortisone shots. As I mention in my blog, some practitioners are using Botox to relax the muscle called TFL (tensor fascia lata) close to the hip bone. We think this muscle becomes tight and is a factor in causing ITB friction.
all the best
Lorenzo
Ciao Lorenzo,
I am a retired physician in the USA with a laurea from the the Faculty of Medicine and Surgery from Bologna.
At this time I have severe pain over the lateral aspect of my left knee andhave osteoarthritis of the same joint.
I have been receiving physiotherapy for the last 6 months with no great success and have had Kenalog 40 injections, one in April and the second in the first week of August.
Unfortunately, neither of these have appeared to be successful.
I read with great interest, your paper on ultrasound-guided corticosteroid injections and think that my treatment has been going down the incorrect path. I am scheduled for an MRI this next week
Since I reside about 80 miles north of NYC, I wondered whether you know of any Sports Medicine physines the do these procedures?
I thank you for your patience in reading my email.
With Regards,
Dr. Michael A. Solomon
Hi Michael,
Sorry to hear about your problem.
In general, I think that cortisone has little benefit in someone who has lateral compartment osteoarthritis. You should consider either hyaluronic acid or PRP as an adjunct to exercise therapy and a knee brace. See my blogs on hyaluronic acid, PRP in knee osteoarthritis and treatment for osteoarthritis.
https://sportdoctorlondon.com/prp-injections-for-knees/
https://sportdoctorlondon.com/hyaluronic-acid-injection/
In regard to your specific question: I don’t know anyone in the New York area.
All the best
Lorenzo
Hello Dr. Masci,
Ten years ago at age 62 I sustained a femoral head fracture due to a fall while running and to the degree of osteoporosis in my hips. An orthopedic surgeon has diagnosed the current pain radiating down my left leg as irritation of the IT band caused by the heads of the screws in the hip and a little resulting bursitis. He could feel the nail heads while pressing on my hip. He said since there’s no fracture or arthritis and the cartilage is excellent he recommends physical therapy, anti-inflammatories, and Voltaren gel, to be followed by Corticosteroid injection if the initial measures don’t work, to be followed finally by hip replacement if injection isn’t successful.
Do you think Botox to relax TFL close to the hip bone as described on your website would be a possible treatment for me, or does that muscle have nothing to do with my situation? My osteoporosis is severe per my last dexa scan in 2020 – hip T score was -2.9. Doctors have given me little to no guidance with treating it over the years. I took Fosamax twice for several years each but have read it can make bones more brittle. I asked about Prolia but my doctor said it’s not good if you have acid reflux (which I have on occasion but not regularly). I had initially been on Evista as a preventive but subsequent doctors have not wanted to prescribe it. Serious potential side effects of all treatments are also concerning. Any thoughts you might have would be welcome.
Many thanks.
so to answer your question about ITB – I think you should exhaust other treatments such as physical therapy and a cortisone injection before considering botox. However, I think botox in the TFL could be an option even in your special situation. But I’d try the other options first. And I’d certainly try botox before a hip replacement. Lorenzo
Thank you very much for your prompt and helpful reply – I appreciate it! My doctor prescribed Gabapentin yesterday for the pain so I can get off Ibuprofen and I start PT tomorrow.
My left it band is frozen. It causes low back pain. A recent mri shows l4,5,6 bulging disc. I feel the cause of my spinal problems is due to the it band. Can this be the case?
It could be. You need to speak to your doctor.
LM
I had bilteral knee replacement 14 years ago. I workout 4 days a week and walk approximately 12-15,000 steps per day, I am not an athlete like your other questioners have been. I am though truly suffering from from IT band pain on both legs. This radiates on the outside of my legs from about 4 inches below my hips and about 4 inches above my knees with the most severe pain being in the middle (of the outside) of my legs. I do IT stretches every day along with a foam roller that hurts terribly. Do you have any suggestions? I’ve just reade about botox treatments. I look forward to hearing from you.
Hi Diane – I mention the Botox option in the blog. It’s a potential option for persistent ITB syndrome.
LM