Iliotibial Band Bursa Injection

Indications and Clinical Considerations

Bursae are formed from synovial sacs that allow easy sliding of muscles and tendons across one another at areas of repeated movement. These synovial sacs are lined with a synovial membrane invested with a network of blood vessels that secrete synovial fluid. Inflammation of the bursa results in an increase in the production of synovial fluid with swelling of the bursal sac. With overuse or misuse, these bursae may become inflamed, enlarged, and on rare occasions infected. Although there is significant intrapatient variability as to the number, size, and location of bursae, anatomists have identified a number of clinically relevant bursae, including the iliotibial band bursa. The iliotibial band bursa lies beneath the iliotibial band tendon, which is an extension of the deep fascia of the thigh that attaches to the lateral condyle of the tibia ( Figs. 162.1, 162.2, and 162.3 ). The rubbing back and forth of the iliotibial band across the lateral condyle of the femur during running or bicycling may cause inflammation of the iliotibial bursa as well as the iliotibial band ( Figs. 162.4 and 162.5 ). This bursa may exist as a single bursal sac or in some patients as a multisegmented series of sacs that may be loculated in nature.

Patients with iliotibial band bursitis experience pain over the lateral side of the distal femur just over the lateral femoral condyle. The onset of iliotibial band bursitis frequently occurs after long-distance biking or jogging with worn-out shoes without proper cushioning. Activity, especially involving resisted abduction and passive adduction of the lower extremity, makes the pain worse; rest and heat provide some relief. Flexion of the affected knee also reproduces the pain in many patients with iliotibial band bursitis. Often, the patient is unable to kneel or walk down stairs. The pain is constant and is characterized as aching in nature. The pain may interfere with sleep. Coexistent bursitis, tendinitis, arthritis, or internal derangement of the knee may confuse the clinical picture after trauma to the knee joint. If the inflammation of the iliotibial band bursa becomes chronic, calcification of the bursa may occur.

Physical examination may reveal point tenderness over the lateral condyle of the femur just above the tendinous insertion of the iliotibial band ( Fig. 162.6 ). Swelling and fluid accumulation often surround the bursa. Palpation of this area while having the patient flex and extend the knee may result in a creaking or “catching” sensation. Active resisted abduction of the lower extremity reproduces the pain, as does passive adduction. Sudden release of resistance during this maneuver markedly increases the pain. Pain is exacerbated by having the patient stand with all the weight on the affected extremity and then flex the affected knee 30 to 40 degrees.

Plain radiographs of the knee may reveal calcification of the bursa and associated structures, including the iliotibial band tendon, consistent with chronic inflammation. Magnetic resonance imaging and/or ultrasound imaging scan is indicated if bursitis, internal derangement, occult mass, or tumor of the knee is suspected ( Fig. 162.7 ). Electromyography helps distinguish iliotibial band bursitis from neuropathy, lumbar radiculopathy, and plexopathy. The following injection technique serves as a diagnostic and a therapeutic maneuver.