Iliotibial Band (IT Band) Peritendinous Injection

Treats

• Iliotibial band syndrome (ITBS) — lateral knee pain from inflammation of innervated loose connective/fat tissue deep to the distal ITB at the lateral femoral epicondyle (impingement zone at 20–30° flexion)
• Distal ITB tendinopathy or insertional enthesopathy at Gerdy tubercle (peritendinous approach)
• Diagnostic anesthetic block to confirm LFE as pain generator vs lateral meniscus, popliteus, LCL, or biceps femoris pathology
• Snapping IT band over the LFE with associated peritendinous fluid

Pre-procedure checklist

• Confirm patient identity with two identifiers (name and DOB)
• Confirm procedure, laterality, and mark the site with the patient awake
• Review allergies (local anesthetic, corticosteroid, latex, chlorhexidine/iodine) and anticoagulation status
• Confirm and document informed consent — warn specifically about fat atrophy and skin depigmentation given the superficial target
• Pre-scan the lateral knee over the LFE: identify the hyperechoic fibrillar ITB, hypoechoic peritendinous fat/fluid, and bony LFE contour
• Apply color/power Doppler to map the lateral superior and lateral inferior genicular arteries before planning the trajectory
• Time-out immediately before needle insertion (patient, site, laterality, procedure, medication, dose confirmed aloud)

Positioning

• Patient lying on side (lateral decubitus), affected side UP on the exam table.
• Contralateral hip and knee flexed ~45–60° for stability; place a pillow between the knees.
• Affected knee flexed to approximately 20–30° — the impingement angle where the ITB tensions over the LFE and peritendinous fluid is maximally accessible.
• Support the lower leg on a pillow so the tibia is parallel to the table; lateral aspect of the knee faces directly upward toward the operator.

Probe

• High-frequency linear probe, 10–18 MHz (12–18 MHz hockey-stick small-footprint preferred for the superficial lateral LFE target)
• Depth 2.0–3.0 cm; focal zone at 5–10 mm (target lies within 3–8 mm of skin in most patients)

Landmarking — find the view

• Palpate the lateral femoral epicondyle (LFE) — the prominent bony ridge on the lateral distal femur, proximal to the lateral joint line.
• Place the probe in long axis (longitudinal) to the ITB fibers centered over the LFE; identify the thin hyperechoic fibrillar ITB running parallel to skin.
• Deep to the ITB, identify the hypoechoic loose connective tissue / fat (or discrete anechoic pseudo-bursa in active ITBS) between the ITB and the convex LFE cortex.
• Slide the probe proximal and distal to find the point of maximal peritendinous thickening or fluid — usually just proximal to or directly over the LFE apex.
• Rotate 90° to short axis to confirm the crescentic fluid collection between ITB and bone.
• Apply color Doppler (low PRF) to map the lateral superior genicular artery (proximal to LFE) and lateral inferior genicular artery (near joint line/fibular head) before planning the needle trajectory.

The correct ultrasound view

• Long axis: convex hyperechoic LFE cortex deep; immediately superficial, a hypoechoic layer of loose connective tissue or anechoic fluid (the injection target); superficial to that, the thin linear hyperechoic fibrillar ITB running parallel to skin.
• On dynamic scan through 20–40° of flexion (the impingement zone), the ITB should glide smoothly over the LFE; restricted glide or tethering supports the diagnosis.
• With color Doppler, the peritendinous plane should be avascular — any vessel crossing the planned trajectory requires re-planning.

Needle corridor

• Peritendinous plane between the deep surface of the ITB and the cortex of the lateral femoral epicondyle — specifically into the hypoechoic loose connective tissue / fat / pseudo-bursa.
• Injectate should hydrodissect (lift) the ITB off the LFE cortex on real-time imaging.
• Do NOT inject intratendinously into the ITB substance — this risks tendon weakening and misses the pain generator.
• Do NOT inject into subcutaneous tissue superficial to the ITB — risk of fat atrophy and skin depigmentation.

1. 1Position patient in lateral decubitus with affected knee flexed 20–30°.
2. 2Pre-scan, map genicular vessels with color Doppler, mark skin entry, and complete time-out.
3. 3Sterile prep and drape the lateral knee; apply sterile probe cover and gel.
4. 4Place probe in long axis to the ITB over the LFE.
5. 5Raise a small skin wheal of 1% lidocaine (0.5–1 mL) with a 27–30G needle at the planned entry point — inject only into skin, not into the peritendinous plane.
6. 6Advance a 25G 1.5-inch needle in-plane along the ITB long axis at a shallow angle (20–40° to skin), entering from distal-to-proximal or proximal-to-distal based on vessel map.
7. 7Advance the needle to the deep surface of the ITB without piercing its fibers — approach from the distal or proximal edge and slide the bevel into the hypoechoic peritendinous plane between the deep ITB surface and the LFE cortex.
8. 8Inject a test bolus of 0.2–0.5 mL: the ITB should visibly lift off the bone with smooth anechoic spread. Tissue balling within the ITB = intratendinous; skin bleb = subcutaneous — reposition before continuing.
9. 9Aspirate, then slowly inject the remaining 3–5 mL total over 20–30 seconds watching real-time spread.
10. 10STOP IMMEDIATELY if patient reports shooting, electric, or paresthetic pain into the lower leg (common peroneal nerve proximity) or if resistance suddenly rises.
11. 11Withdraw needle, apply pressure for 1–2 minutes, place adhesive bandage.
12. 12Post-injection dynamic scan to confirm smooth ITB glide over the LFE through full range of motion.

Tips

• Shallow angle is critical — the target is 5–8 mm deep, so entry must be 1.5–2.5 cm away from the probe edge at 20–40° to the skin. A steep angle reduces needle visibility and risks plunging into cortex.
• Hydrodissect first, inject second — always confirm the plane opens with a 0.2–0.5 mL test bolus before committing the full volume.
• Doppler every time — lateral superior genicular artery anatomy is highly variable and frequently courses directly over the LFE.
• The ITB is one of the most superficial steroid targets at the knee — warn the patient specifically about fat atrophy and skin depigmentation; consider dexamethasone (non-particulate) if this is a concern.
• 25G is sufficient — the low-viscosity steroid/anesthetic mix does not require a larger bore; a smaller needle causes less post-procedure soreness in this superficial target.

Supplies

• 25G 1.5" Needle (injection)
• 27-30G 0.5" Needle (skin wheal)
• 18G Drawing Needle
• 3 mL or 5 mL Syringe
• 1 mL Syringe (skin wheal)
• 1% Lidocaine (2–3 mL for injectate + 0.5–1 mL for skin wheal)
• Triamcinolone 20–40 mg OR Dexamethasone 4–8 mg (non-particulate preferred given superficial target)
• Alcohol Swabs (vial tops)
• Betadine/Chloraprep
• Sterile Gloves
• Sterile 4x4 Gauze Pads
• Sterile Towels & Drapes
• Adhesive Bandage (Band-Aid)
• Washcloth/Towel (gel cleanup)
• Needle Disposal Safety Cap
• Sterile probe cover & gel
• Pillow(s) for lateral decubitus positioning

Post-procedure

• Apply a clean adhesive bandage; keep it dry for 24 hours.
• Local anesthetic relief within 5–15 minutes, lasting 1–4 hours (lidocaine) or up to 6–8 hours (bupivacaine). Corticosteroid effect begins 24–72 hours after injection and peaks at 5–10 days.
• Steroid flare (2–10% of patients, typically 6–48 hours): manage with ice 15–20 minutes every 2–3 hours and acetaminophen or a short course of NSAIDs.
• Rest from impact activity (running, cycling, plyometrics) for 48–72 hours; gentle walking is fine immediately.
• Begin prescribed PT program: hip abductor/gluteus medius strengthening, single-leg stance, foam rolling the lateral thigh (avoid rolling directly over the LFE), and running-gait/cadence retraining.
• Diabetic patients: expect a 50–150 mg/dL rise in blood glucose for 3–7 days; monitor more frequently.
• Watch for and return immediately for: spreading redness, warmth, fever >38°C, purulent drainage, or disproportionate pain not controlled with ice and OTC analgesics.
• Warn the patient about possible skin depigmentation or a 1–2 cm area of subcutaneous fat atrophy appearing 1–3 months post-injection; usually cosmetic only and partially reverses over 6–12 months.
• Maximum of 3 corticosteroid injections per year at the same site, separated by at least 3 months.
• Follow-up at 4–6 weeks to reassess, confirm PT adherence, and plan next steps.