HSS What's the Diagnosis Case #139

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Findings The radiographs are normal. On the MRI, there is a loss of the normal fat deep to the iliotibial (IT) band. Prominent increased T2 hyper-intense, inflammatory tissue is present in the space deep to the iliotibial band and insinuated between the IT band and the lateral condyle.

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Diagnosis: Iliotibial Band Friction Syndrome The iliotibial (IT) band or tract is an independent structure that begins at the pelvis and receives contributions from many structures but principally the tensor fascia lata and gluteus maximus at the level of the hip. The IT band then becomes a focal area of thickening or condensation of the lateral aspect of the crural fascia which is the investing fascia surrounding the musculature of the lower extremity. IT band friction syndrome is the most common injury in runners at the lateral aspect of the knee but is also seen commonly in cycling or other sports with repetitive knee flexion. In the normal situation there should be a fat plane between the IT band at the level of the knee and the underlying lateral condyle. In IT band friction syndrome this area of fat gets effaced by inflammatory tissue. This case represents one of the more florid cases that we have seen. Although some think there may be an underlying bursa, if a focal area of fluid is present it most likely represents an adventitial and not a true bursa. A focal fluid collection is however very rarely seen. Although originally thought related to anterior posterior shifting of the IT band over the lateral condyle, many now believe this relates to a compression of the IT band over the condyle precipitating these inflammatory changes. Interestingly, as in this case, the IT band itself has a normal architecture and the pathology is present in the tissue deep to the IT band. This pathology is frequently amenable to conservative measures but at times recalcitrant cases necessitate excision of the inflammatory tissue or adventitial bursa.

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References The iliotibial tract: imaging, anatomy, injuries, and other pathology. Flato R, Passanante GJ, Skalski MR, Patel DB, White EA, Matcuk GR Jr. Skeletal Radiol. 2017 May;46(5):605-622. doi: 10.1007/s00256-017-2604-y. Epub 2017 Feb 25. Iliotibial band friction syndrome. Lavine R. Curr Rev Musculoskelet Med. 2010 Jul 20;3(1-4):18-22. doi: 10.1007/s12178-010-9061-8.

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