Hi everyone, I'm Allison Schrader. I'm an assistant professor at University Hospitals and Case Western Reserve University in Cleveland, Ohio. And I'll be presenting a case on distal iliotibial band syndrome. This is a case of a 39 year old female presenting with right knee pain with atraumatic onset about three years prior. This started when she was getting back to her regular exercise routine after giving birth to her first child. Pain was in the anterior lateral knee region and worse with repetitive knee flexion, which she needed to do anytime she was working out. She denied swelling, locking, catching or clicking in the knee. And on examination, she was tender to palpation along the distal iliotibial band, which was most prominent at Gertie's tubercle. She had a positive OBERS and a mildly positive NOBLS test. So as I talked about, this is a case of distal iliotibial band friction syndrome. And I think it's always important to remember the anatomy before getting into the ultrasound findings. So the iliotibial band is a long piece of fascia that connects the tensor fasciae latae muscle with Gertie's tubercle. It crosses over the lateral femoral condyle of the knee and can be a site of friction at this location. When I'm imaging the iliotibial band, I typically utilize a mid-frequency linear ray transducer. And when I'm scanning the distal iliotibial band, I will usually start in the mid thigh and scan from proximal to distal. As I'm doing this, I'm looking for any focal thickening of the iliotibial band and can often compare it to the contralateral side as well. Throughout the presentation, I'll utilize these anatomic images with a rectangle for the transducer position. So here we have the iliotibial band marked by the asterisks sitting superficial to the lateral rectus and just deep to the skin layer with anterior on the right side of this image. I continue to scan distally and find a short axis view of the iliotibial band coursing over the lateral femoral condyle. Again, anterior is on the right side of these ultrasound images. The iliotibial band is demarcated with the asterisks. At this location, you can often see some indirect signs of iliotibial band friction syndrome, including cortical irregularity at the femur, which is not extremely prominent here, as well as some fluid within the iliotibial band bursa. Now this can be a common pitfall where fluid from the joint recess from the suprapatellar bursa extends laterally along the lateral femoral condyle and can be confused for fluid within the iliotibial band bursa. So this area should be carefully scrutinized to ensure that this is not communicating with the joint. Another thing that you can utilize is Doppler flow to determine if there is any irritation or Doppler at that location, as well as sonopalpation tenderness. So in this patient, despite this small amount of fluid within the bursa, maybe a slightly thickened IT band, there was no sonopalpation tenderness in this location and this was not her main site of pain. However, as I scanned distally, continuing down in short axis to Gertie's tubercle, we can see how thick the iliotibial band becomes with some mixed echogenicity in the loss of the typical fibular pattern. When utilizing Doppler in this location, there was extensive blood flow within the iliotibial band. And here, this just outlines and demarcates the differentiation of the iliotibial band from other soft tissue structures. When looking in long axis, we can appreciate that same distal thickening of the iliotibial band, where here, more proximally, it's much thinner and it extends and thickens as it courses down to attach on to Gertie's tubercle. And again, we can appreciate the Doppler flow at this location. So that's my typical evaluation of the iliotibial band distally, and you can see and localize differentially where the issue may lie. This case was particularly interesting as the patient was determined to have a Gaudi flare in this location that was diagnosed by dual energy computed tomography. So given the Gaudi flare, we elected to proceed with a corticosteroid injection where the needle entered from lateral to medial and corticosteroid was placed superficial to the iliotibial band, which you can see in short axis here. In this long axis image, you can see the fluid separating the iliotibial band from the superficial structures. And it's pretty rare that I jumped to performing an injection rather quickly, but there had been some time that passed and she had been doing physical therapy for about eight weeks without improvement. And this injection resulted in resolution of her symptoms.

3rd Edition, CASE 28

3rd Edition

Knee

distal iliotibial band syndrome

right knee pain

corticosteroid injection

ultrasound diagnosis

physical therapy