<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>Documento sem título</title>
</head>
<body><DIV style="TEXT-ALIGN: justify; MARGIN-TOP: 10px; PADDING-LEFT: 10px; PADDING-RIGHT: 10px">
<DIV style="PADDING-RIGHT: 9px; FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 11px">
<P>aTrainee Physician in the Hip Group, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
<br>
bAttending Physician in the Hip Group, EPM/UNIFESP, São Paulo, SP, Brazil<br>
cSpecialist Radiologist in the Musculoskeletal Field and Collaborator in the Department of Radiology and Imaging Diagnostics, EPM/
UNIFESP, São Paulo, SP, Brazil<br>
dMSc in Orthopedics from EPM/UNIFESP; Head of the Hip Group, EPM/UNIFESP, São Paulo, SP, Brazil</P></DIV><BR>
<DIV style="FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 14px; FONT-WEIGHT: bold; PADDING-TOP: 3px">INTRODUCTION</DIV>
<DIV style="PADDING-RIGHT: 10px; FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 13px"></DIV>
<DIV style="PADDING-RIGHT: 10px; FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 13px">
<P>Overload injuries to the hip joint occur commonly among
sports practitioners and are now frequently diagnosed because
of technical advances in imaging diagnostics, especially
magnetic resonance imaging (MRI). Among these injuries,
tendinopathy, rupture of the gluteus medius and gluteus
minimus, peritrochanteric bursitis, stress fractures and
adductor injuries can be highlighted.
<br>
<br>
Recently, Sher et al.1 studied a group of patients (all female)
with pain and edema in the region of the iliac tubercle was
assessed. T2-weighted MRI showed higher signal in the
enthesis of the iliotibial band (ITB) along the lower border of
the iliac tubercle.<br>
<br>
The present study had the aims of reviewing the anatomy
of the ITB and raising the possibility of diagnosing proximal
ITB injuries in women with hip pain.
<br>
<br>
Case report<br>
<br>
A 34-year-old female patient who was a non-professional
10-kilometer runner, was evaluated at the hip outpatient clinic
of EPM/UNIFESP. She had had a complaint of pain in the region
of the left ilium for four months, initially at low intensity that
did not impede her training, but which progressively intensified
and made her running activities impossible two months later.
She had sought other services and had been treated as a case
of bursitis of the hip.
<br>
<br>
In the physical examination, there were no abnormalities
in either static or dynamic inspection of the left hip. However,
there was pain on palpation of the iliac tubercle, and also in
Ober's maneuver and in a test performed in dorsal decubitus
with the contralateral hip and knee flexed and the hip of
interest in passive external rotation and adduction.
Radiographic examination did not demonstrate any
abnormalities and MRI was then requested (Fig. 1).
<br>
<br>
Enthesitis of the origin of the iliotibial band was
diagnosed and this, together with the fact that it was
in a woman with the clinical examination described
above, was named proximal iliotibial band syndrome.
<P align="center"><img src="http://www.rbo.org.br/images/SBOT/imagens_revista/48-4-ing/figura59.png" width="397" height="139">
<P align="center">Figure 1 - Enthesitis at the origin of the ITB.<br>
Magnetic resonance imaging in the coronal plane (left) and<br>
sagittal plane (center) with T2 weighting and fat saturation,<br>
and in the axial plane after contrast administration<br>
(right), which demonstrates focal thickening of the ITB<br>
(arrows) at its origin at the iliac crest, adjacent to the iliac<br>
tubercle (asterisk), with a small intrasubstance rupture/<br>
delamination and surrounding inflammatory alterations,<br>
which also involve the underlying fibers of the gluteus<br>
medius, at its origin in the external plate of the ilium. Note<br>
the evident post-contrast highlighting on the right side,<br>
suggestive of an inflammatory component.
<P align="left">Treatment with systemic hormonal anti-inflammatory
agents was started, given that there was no response to the
non-hormonal type, and the treatment was administered in
association with specific motor physiotherapy, with analgesic
measures and, especially, exercises to stretch the iliotibial band
and strengthen the stabilizers of the pelvis and the abdominal
and lumbar musculature. This controlled the symptoms and
allowed the patient to gradually return to training activities
three months after the treatment.
<br>
<br>
Discussion
<P align="left"><br>
There is a discussion in the literature regarding the proximal
anatomy of the ITB. There is a description of a proximal insertion
in the iliac crest,2,3 formed by fusion of the tendon fibers of the
gluteus maximus and tensor fasciae latae muscles at the level
of the greater trochanter.4,5 Other reports have described the ITB as a broad fascia with its main insertion in the iliac tubercle and
other secondary insertions in the iliac crest.6,7<br>
<br>
Sher et al.1 demonstrated that the fascia lata has an
insertion along the entire lower border of the iliac crest. At
the iliac tubercle, thickening of the fascia lata occurs, with
formation of the ITB. This is a fibrous structure of longitudinal
orientation that receives contributions from the tendons of
the gluteus maximus and tensor fasciae latae muscles at the
<P align="left">
<P align="center"><img src="http://www.rbo.org.br/images/SBOT/imagens_revista/48-4-ing/figura60.png" width="177" height="463">
<P align="left">Figure 2 - Anatomical specimen that demonstrates the<br>
origin (wide arrow) and insertion (narrow arrow) of the<br>
iliotibial tract.
<P align="left">greater trochanter. In the distal region, the ITB is inserted into
the Gerdy tubercle (Fig. 2).<br>
<br>
The symptom most frequently related to the ITB is the
friction syndrome of its distal insertion. This presents as a
condition of pain in the lateral region of the knee, relating to
friction between the ITB and the lateral femoral condyle.1 It
commonly occurs in long-distance runners, cyclists and soccer
players and is the commonest cause of lateral knee pain in
runners.8-11 It can be identified on MRI as T2 hypersignal in
the lateral synovial recess, interposed between the ITB and the
lateral femoral condyle.12,13<br>
<br>
There is little discussion of the involvement of the region
proximal to the ITB in the current literature. The great majority
of the cases reported affect female patients, especially
runners or obese elderly women.1 Biomechanical studies
have indicated that the greater ratio between pelvic width
and femoral length that occurs in women generates greater
hip adductor movement and generates overload in the lateral
musculature with the purpose of maintaining pelvic balance.14
While running, women present greater activity of the adductor
musculature and a higher degree of internal rotation of the hip,
which also leads to overloading of the ITB.15
<br>
<br>
These patients generally complain of pain at the proximal
insertion of the ITB (i.e. the iliac tubercle, which is located
posteroinferiorly to the anterosuperior iliac spine), which is
exacerbated by local palpation and by Ober's maneuver.16<br>
<br>
In our case, there was pain when the maneuver was
performed with the patient in dorsal decubitus and the
contralateral hip flexed so as to rectify the lumbar lordosis.
From this point, adduction and external rotation can be
performed passively, which tensions the iliotibial band and
provokes pain (test suggested by the present authors).<br>
<br>
MRI is mandatory for the diagnosis, given that the clinical
condition can be confounded with several other diseases, i.e. both
intra and extra-articular conditions of the hip. However, it needs
to be emphasized here that MRI should be requested not only to investigate the hip but also to cover the entire ilium. If not, the
proximal portion of the ITB will not be correctly evaluated.<br>
<br>
There has been little discussion about the treatment. All
the patients reported in the literature responded to rest and
physiotherapeutic treatment for stretching and strengthening
the muscles of the ITB.1<br>
<br>
The proximal iliotibial band syndrome is a painful hip
condition that, although infrequent, needs to be correctly dealt
with by general orthopedists. Its diagnosis should be suspected
from the clinical picture, especially among women who are
runners or obese elderly women, and should be confirmed by
means of properly requested MRI.
Conflicts of interest
The authors declare no conflicts of interest.</DIV>
<DIV style="FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 14px; FONT-WEIGHT: bold; PADDING-TOP: 3px">REFERENCES</DIV>
<DIV style="PADDING-RIGHT: 9px; FONT-FAMILY: 'Century Gothic', Arial; COLOR: #495e37; FONT-SIZE: 11px">
<P>1. Sher I, Umans H, Downie SA, Tobin K, Arora R, Olson TR.
Proximal iliotibial band syndrome: what is it and where is it?
Skeletal Radiol. 2011;40(12):1553-6.
<br>
2. Kaplan E. The iliotibial tract: clinical and morphological
significance. J Bone Joint Surg Am. 1958;40(4):817-32.<br>
3. Hollinshead WH. Anatomy for surgeons. New York: Harper and
Row Hoeber Medical Division; 1964.
<br>
4. Birnbaum K, Siebert CH, Pandorf T, Schopphoff E, Prescher A,
Niethard FU. Anatomic and biomechanical investigations of the
iliotibial tract. Surg Radiol Anat. 2004;26(6):433-46.<br>
5. Last RJ. Anatomy regional and applied. 5th ed. Edinburgh:
Churchill Livingstone; 1972.<br>
6. Evans P. The postural function of the iliotibial tract. Ann R Coll
Surg Engl. 1979;61(4):271-80.<br>
7. Standring S. Gray's anatomy: the anatomical basis for clinical
practice. 39th ed. Edinburgh: Churchill Livingstone/Elsevier;
2005.<br>
8. Noble CA. Iliotibial band friction syndrome in runners. Am J
Sports Med. 1980;8(4):232-4.<br>
9. Martens M, Libbrecht P, Burssens A. Surgical treatment of the
iliotibial band syndrome. Am J Sports Med.1989;17(5):651-4.<br>
10 McNicol K, Traunton JE, Clement DB. Iliotibial tract friction
syndrome in athletes. Can J Appl Sports Sci. 1981;6(2):76-80.<br>
11. Fredericson M, Weir A. Practical management of iliotibial band
friction syndrome in runners. Clin J Sport Med. 2006;16(3):261-8.<br>
12. Murphy BJ, Hechtman KS, Uribe JW, Selesnick H, Smith RL,
Zlatkin MB. Iliotibial band friction syndrome: MR imaging
findings. Radiology. 1992;185(2):569-71.
<br>
13. Muhle C, Ahn JM, Yeh L, Bergman GA, Boutin RD, Schweitzer M,
et al. Iliotibial band friction syndrome:
MR imaging findings in 16 patients and MR
arthrographic study of six cadaveric knees. Radiology.
1999;212(1):103-10.
<br>
14. Ferber R, Davis IM, Williams DS 3rd. Gender differences in lower
extremity mechanics during running. Clin Biomech (Bristol,
Avon). 2003;18(4):350-7.<br>
15. Chumanov ES, Wall-Scheffler C, Heiderscheit BC. Gender
differences in walking and running on level and inclined
surfaces. Clin Biomech. 2008;23(10):1260-8.<br>
16. Ober FR. The role of the iliotibial band and fascia lata as a
factor in the causation of low back disabilities and sciatica. J
Bone Joint Surg AM. 1936;18:105-10. </P></DIV></DIV>
</body>
</html>
