ITB Ultrasound Scanning Yin-Ting Chen, MD MAJ, MC USA Director, Sports/Ultrasound Clinic Physical Medicine & Rehabilitation WRNMMC Boston, October 2015

OBJECTIVE Anatomy of ITB and adjacent structures ITB pathology on ultrasound ITB Intervention Ultrasound scanning technique

Anatomy of ITB

Anatomy ITB A thick band of fascia on the lateral aspect of the knee Extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee Thigh flexion at the hip, abduction, and medial rotation Stabilizes the knee laterally

Origin Anterior iliac crest outer lip, anterior border of the ilium, outer surface of anterior superior iliac spine Insertion Superficial to vastus lateralis Lateral epicondyle of the femur then passes in its broad expansion between lateral aspect of patella Over lateral aspect of lateral femoral condyle Gerdy’s tubercle Anterior to LCL

Anatomy

Other associated structures LCL Origin: lateral femoral condyle Insertion: fibular head Superficial to lateral meniscus Inserts to Fibula head Posterior to ITB, superficial to popliteal tendon

Lateral drawing: Insertion of iliotibial band Mid third capsular ligament Lateral collateral ligament Fabellofibular ligament Popliteus muscle and tendon Haims AH, Medvecky MJ, Pavlovich R Jr, Katz LD. MR imaging of the anatomy of and injuries to the lateral and posterolateral aspects of the knee. AJR Am J Roentgenol. 2003 Mar;180(3):647-53.

Posterior drawing Biceps femoris tendon attachment Lateral collateral ligament Popliteofibular ligament Popliteus muscle and tendon Haims AH, Medvecky MJ, Pavlovich R Jr, Katz LD. MR imaging of the anatomy of and injuries to the lateral and posterolateral aspects of the knee. AJR Am J Roentgenol. 2003 Mar;180(3):647-53.

ITB Scanning

ITB Robust tendon, 2-3 times the thickness of the LCL Runs in parallel to the patellar tendon May have significant anisotropy near its insertion on the Gerdy’s tubercle

Scan proximally to see ITB’s (r) contact with lateral condyle (LC) for ITB friction syndrome Two layers Superficial: tendinous, inserts on Gerdy’s Tubercle Deep: inserts on intermuscular septum Tear may lead to avulsion at Gerdy’s Tubercle

LCL LCL is in the same course as the popliteofibular ligament Popliteofibular ligament (s) origins on the popliteal sulcus (PS) and attaches to posteromedial fibular styloid (Fib) LCL (q) attaches to the fibular head, just superficial to the popliteofibular ligament

Biceps Femoris Fix one end of probe on the fibular end, rotate proximal end until femur disappears from view Biceps tendon inserts onto fibular head

Biceps femoris (BF) Long head inserts on middle of posterolateral fibular head (Fib) SH inserts medial to long head Avulsion injury pattern common

ITB SYNDROME/PATHOLOGY Korean J Pain. Oct 2013; 26(4): 387–391. Published online Oct 2, 2013. doi: 10.3344/kjp.2013.26.4.387 PMCID: PMC3800712 Diagnosis of Iliotibial Band Friction Syndrome and Ultrasound Guided Steroid Injection

Injection of ITB in a Runner Fluid Needle Femur Femur

Chronic ITB syndrome, refractory to conservative treatment Needle Local 25/27 G, 1-1/2” Position Lateral decubitus, injection side up Medication 1% lidocaine 20mg triamcinolone

ITB PERITENDINOUS INJECTION Skin Prep and anesthetic LAX to transducer and ITB Rotate transducer SAX to ITB Needle is placed IN PLANE VIEW(Longitudinal to transducer) Needle tip under ITB Deliver medication Pain control after the procedure

Scan Demonstration

Hands-on Scanning