ILIOTIBIAL BAND FRICTION SYNDROME

The tendinitis associated with runners and dancers is called iliotibial band friction syndrome (IBFS); it involves a tendon that runs from the hip down to the outer (lateral) side of the knee. As the knee flexes and extends, the iliotibial band rubs against the end of the thighbone (femur), which ends in two elliptical notches called condyles. (Picture a dog’s bone. The rounded endpoints are condyles.) Excessive motion or tightness of the tendon can produce irritation when it rubs against the outer condyle. Because this is an especially common problem among runners.

Symptoms

The first indication of IBFS will likely be a post-aerobic burning pain. It is a very specific pain that occurs at the end of your thighbone at a point known as the lateral femoral condyle. Soon it occurs during your aerobic acfivity and eventually prevents or limits your activity or, at the very least, limits your time due to pain. For example, the pain may become so severe that it is impossible to run more than a short distance, which may be only a fraction of your usual mileage. Sports such as squash or tennis may also produce discomfort, as will repetitive flexion-extension movements such as cycling, skiing, or weight lifting.

With running, IBFS is often associated with a rapid increase in mileage, a course that involves hills, or a running surface that is at a slight angle.

Treatment

Initial treatment may include ice/friction massage and stretching of the iliotibial band. For specific stretching exercises see Appendix A. Anti-inflammatory medication, such as aspirin, speeds recovery, and if, after three weeks, the pain is still persistent, a hydrocortisone injection may be helpful while you continue to limit activity, perform stretching exercises, and change your individual activities to prevent recurrence. The latter may involve moving your activity to a softer surface, rerouting to avoid downhill or sidehill running, andnvarying mileage patterns (alternating short distances with long). A shoe insert or orthotic may also be beneficial if there is a mild malalignment of the knee or ankle.


PATHOLOGICAL SYNOVIAI PLICAE

The diagnosis of pathological synovial plicae is over-applied and over-discussed. Yes, it does exist, but it doesn’t deserve near the attention it has received.

Plicae were once considered a harmless developmental anomaly; today they are called by some authorities “the great imitators.” These are developmental leftovers that exist in anywhere from 18 to 60 percent of normal knees, depending on the medical authority who is reporting them and his or her care in detecting these folds of the knee lining. In order to understand this problem you must know a little about how the knee develops in a human body. By the eighth week of development the knee is formed of three synovial compartments, which are separated by thin, membranous walls. During the fourth fetal month these walls are usually reabsorbed back into the body, leaving the three compartments fused into one knee. However, sometimes these walls, or some portion of them, remain. These fetal remnants are called plicae.

Prior to the advent of the arthroscope, no one paid much attention to these remnants, which were considered incapable of causing any problems. They were an annoyance to the surgeon who sometimes had to get his equipment through toughened plica tissue, but for the most part they appeared to be a pretty insignificant knee structure. Then surgeons began reporting that in some painful knees the only internal problem they could find were the fibrous bands of tissue, and when these bands were divided the pain was relieved. Eventually physicians began to recognize these structures as capable of causing acute and chronic knee pain.

Trauma can injure the plicae, producing inflammation. This may be a simple stretch, tear, or contusion, but when the body repairs the injury the fold has lost some of its elasticity and becomes more fibrous and abrasive. Activity only increases the irritation and minor trauma increases the abnormal thickening of the once pliant tissue. Eventually pain may develop with activity or a single traumatic event may cause a knee-jerk response and plenty of pain.

Symptoms

Although the incidence of plicae in the general population may be quite high, only 15 to 20 percent are ever responsible for symptoms. The most common complaints include tendemess or aching pain, over the condyles or above the kneecap, that worsens with activity. There may also be swelling or a feeling of “tightness” In the knee, weakness or instability in the knee, and sound effects much as popping, snapping, or clicking. It is rare, however, to find a patient who is fully disabled by the symptoms and incapable of pursuing either work or school activities. Individuals with this condition generally do not have pain when standing still.

Pain is increased with repetitive activities, such as running and jumping, and is commonly aggravated by a quadriceps-strengthening program, but it will subside with rest.

Here, too, the diagnosis is typically one of exclusion. Frequently the symptoms suggest either chondromalacia patella, a meniscal tear, or a number of other internal derangements of the knee. These possibilities must be carefully ruled out before concluding that a plica is the sole cause of pain.

Treatment

If your screaming plicae have resulted from overuse, you have at least an 80 percent chance of responding well to conservative measures consisting of rest, ice initially and then heat, and keeping your legs extended while sitting. Medication, such as aspirin, may be beneficial, as are hamstring-s and quadriceps-stretching exercises. lf your symptoms followed blunt trauma, such as a fall or the striking of a solid object, or a twisting injury, the prospects are pretty much reversed: Your chance of relief by conservative measures is 20 percent or less. Fortunately, 90 percent of patients undergoing arthroscopic removal of these folds report good or excellent results. Complications are rare and recovery quick. So if, after three to four months, symptomatic plicae have failed to respond to conservative measures, it’s probably time to consider anthroscopy.