Diagnosis of Iliotibial Band Friction Syndrome and Ultrasound Guided Steroid Injection
A 64-year-old woman came to our pain clinic with the symptom of right lateral side thigh pain which occurred from one year ago. Her pain started from knee lateral side and the pain was radiated to buttock area. When she started to walk, the pain was triggered and whenever symptoms aggravated, she could feel the tingling sensation through a whole leg which made her limping. She described her pain as pin pricking or stabbing with her pain severitiy 7-8/10 on the visual analogue scale (VAS).\nBefore she felt the lateral leg pain, she had the lipoma removing surgery around the lower knee. However, we did not think it is the main problem causing the symptom.\nAlthough her pain always started from knee lateral side, ultimately she could feel severe pain coming from entire thigh. Therefore, we performed straight leg raising and Patrick test to rule out any spine and pelvic problem. She was negative to all these tests and did not show any local tenderness around back or buttock. However, we could check significant local tenderness on right lateral side of knee. Also we performed knee instability test on both side which showed no abnormality. She showed local tightness around the lateral side of thigh compared to nonpainful side.\nAs the pain always started from the knee and aggravated by walking, we suspected some pathologic changes from inside the knee like meniscus or cruciate ligament. We decided to evaluate knee magnetic resonance imaging (MRI) study and simple X-ray. Her MRI study showed slight degenerative change on meniscus which seemed to be unrelated to the current pain. However, we could identify high signal intensity appearing at ITB through coronal and axial image (). We assessed that ITB syndrome is causing the pain.\nTo alleviate her symptom, we prescribed 37.5 mg tramadol/375 mg acetaminophen combination tablet (Paramacet tab: Donga, Seoul, Korea), 5 mg amitriptyline per os twice daily but had little effect. We educated her about the ITB specific stretching exercise which was known to improve the symptom by lengthening of the ITB. She continued to perform this stretching exercise for a month but the pain relief was not satisfactory.\nTo improve her symptom, we planned local corticosteroid injection by ultrasound guidance. We explained about the procedure, efficacy, and possible side effects of local corticosteroid injection. The skin was aseptically draped with betadine and the ultrasound transducer was covered with a sterile transparent sheath and aseptic gel. We used a 10-12 MHz linear transducer (IU 22, Philips, Netherlands). First, we marked the maximal tenderness area and the transducer was applied longitudinally to the lateral side of the knee. We could easily identify the ITB, femoral lateral condyle, tibia, and recess. Also we could find the local fluid collection under the ITB () which should not appear normally. Before injection, we checked whether the transducer was covering the maximal tenderness area. We targeted the needle tip beneath the iliotibial band and confirmed its location by injecting small amount of saline (). We payed close attention not to inject the medication into ITB itself. Following negative aspiration, 1% lidocaine 1ml and triamcinolone 20 mg was injected.\nAfter one week, the patient was followed up and she was fully recovered from previous pain. She told us that she never felt any kind of pain after injection. One month later, she was followed up again and she could not feel any pain around knee and thigh.