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ITB Release Surgery – What Orthopedic Surgeons Won’t Tell You

POSTED ON IN Hip Latest News BY Chris Centeno

itb surgical release

Tight ITBs (iliotibial bands) are a cottage industry now. There are many cool devices designed to loosen up your ITB and a trip to any local gym will always turn up a few individuals aggressively stretching this area. When these efforts fail to produce results, some people turn to ITB release surgery. And while ITB release surgery may seem like a reasonable concept on the surface, the negative implications for the knee joint can be significant.

Iliotibial Band Release Surgery = Bad Idea

The ITB is a tight band that runs down the side of the leg from the hip to the knee. The structure supports the lateral stability of the spine, hip, and knee and has fascial connections that extend all the way down to the bottom of the foot. Tightness here is common, so physical therapists, personal trainers, and athletic trainers usually recommend that patients stretch or roll out this area. However, many athletes turn to ITB release surgery looking for a solution to this problem.

ITB release surgery involves the surgeon cutting a piece of the tendon out (usually near it’s attachment at the side of the knee), with the goal of weakening the tendon a bit so it lengthens and then hopefully heals over. While this typically accomplishes the goal of lengthening the tendon and reducing the tightness, this structural change to a delicately balanced system can have some real downside consequences.

Had ITB Surgery and Now Regrets It

Case in point is the runner I evaluated this past week who had the surgery and now regrets it. The patient is an avid weekend warrior who runs, bikes, hikes, and cross country skis. He had an ITB release surgery several years back that at first seemed successful. However, shortly thereafter he had a medial (inside) meniscus tear in the same knee. He didn’t connect the dots at the time and neither did his surgeon.

His images are above and arranged from earliest to latest. As you can see, his first MRI didn’t have any issues, which is what lead to the release surgery. Then a few months later, a meniscus tear shows up with some swelling in the bone (dashed white line and whitish color in the otherwise dark bone). He then underwent a partial menisectomy surgery, one of the most common elective surgeries in the U.S. today. His knee got a bit better for awhile, but then he re-tore the meniscus and had his second surgery. By that time, almost a year later, the cartilage on that side of the knee is beginning to erode. This is the lack of grey cartilage in the white dashed circle and the femur bone swelling (becoming whiter in color) in the third image. A second surgery was then performed, taking out even more meniscus. This lead to his current state and the MRI image on the far right, where his medial compartment cartilage is toast. At that point he was offered a partial knee replacement, but he chose a Regenexx stem cell procedure instead.

Where ITB Release Surgery Falls Apart

So why did an otherwise healthy runner’s knee go from almost perfect to totally destroyed in 24 months? The ITB release surgery. Check out the diagram below and read on…

ITB surgery
Knee Destabilization From ITB Release Surgery

The normal healthy knee on the left has tight “duct tape” on the sides that are there to keep each side of the knee stable with activity. The knee on the right after the surgical release of the ITB (which blends in with the lateral collateral ligament) has had the outside of the joint destabilized. Now that duct tape isn’t intact, or as tight. This allows the outside of the joint to open, which causes the inside (medial) to compress. This is why our runner’s medial meniscus was damaged and his cartilage was eventually chewed up. All of this was confirmed with a stress ultrasound exam, which shows that the outside of the knee is now horribly unstable.

The upshot? What seems like a simple surgical solution to a chronically tight ITB has wrecked this runner’s knee. Why? the body is tuned to micro-millimeter precision and disturbing that balance by cutting tight ligaments and tendons is a bad idea. In this case his ITB tightness went away, but resulted in an unstable and overloaded knee. Chances are good that his orthopedic surgeon lacked the bio mechanical insight to link these two things (cutting his ITB and frying his medial knee compartment) and considered the procedure a resounding success! There are countless ways to treat a tight ITB and it’s important to be aware that it’s often caused by irritated nerves in the back or pelvic instability. Platelet rich plasma and other interventional and non-surgical techniques can now help heal this problem, so consider regenerative alternatives before signing up for this surgery!

    comments

    BL says

    Thanks for sharing this. Can you summarize what kind of functional outcome he can expect post Regennex treatment? One or two stem cell injections are not going to regrow the articular cartilage, and help resolve that horrid bone edema. I assume you may directly inject the meniscus with BMAC and that may help regrow some lost meniscus.

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    Regenexx Team says

    BL,
    On this page, http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/, you will find Knee Function Improvement Data, Knee Meniscus Outcome Data, Knee Patient Outcome Data and How Regenexx SD stacks up to Knee Replacement Data. Just open the Toggles, and follow the links. The condition of the articular cartilage, the bone, the meniscus and the catabolic microenvironment of the knee are things that Regenexx SD helps to repair and halt the progression of and are directly targeted in treatment. One of the biggest misunderstandings about OA though is that the condition of those structures are what cause the pain. This blog sheds some light on that subject: http://www.regenexx.com/osteoarthritis-pain-not-related-to-structure-again/. Additionally, we look at the back, and knee ligaments in exam as often treating just the knee in isolation does not solve the problem.

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    BL says

    I see this case differently. This guy did not have biochemical OA as the reason for the breakdown of meniscus + articular cartilage. It's clear that the mechanical imbalance created by the index surgery is what caused the structural breakdown. So from this perspective, it seems more appropriate that a restoration of IT-band, meniscus + articular cartilage would help him out more effectively, longer-term. I'm not knocking Regennex for OA.

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    Regenexx Team says

    BL,
    If you mean he needs more surgery, regrettably given that overly aggressive surgery caused the problem, that's like saying that he just lost big at the casino so he should go double or nothing. If you mean that those are stem cell targets, yes, that's what we've planned.

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    Kristy Zordel says

    Would you please call me with information and costs to have two hips and one knee done... Preferably all at one time in the San Francisco

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    Regenexx Team says

    Kristy,
    We'd be happy to. There is no phone number in message so I sent your request to our Regenexx Patient Liason, and she will be contacting you. That is who would have been calling and will know about costs and scheduling. If you would prefer to be contacted by phone, please leave phone number.In the meantime, her is some info on Regenexx Procedures for Knees: http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/ and Regenexx Procedures for Hips: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ Please let us know if we can be of further assistance.

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    al says

    is this the same as lateral release surgery?

    thanks

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    Regenexx Team says

    No, a lateral release is when a surgeon cuts the retinaculum that holds the knee cap. It's also a horribly dumb idea...

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    BL says

    The surgeon who did this to this poor guy's knee has probably performed this surgery hundreds of times......how can he continue justifying this outcome? Any thoughts? I'm trying to understand this mindset. The surgeons are not going to stop, so is there not a way to get the health insurance companies to stop covering the surgery? That will probably go a long way to protecting the public against it.

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    Regenexx Team says

    BL,
    Today's blog will give good insight into the entrenched paradigms which move the cogs of the wheel: http://www.regenexx.com/knee-surgery-for-meniscus-tear/ The health insurance industry is definitely a player, but unlikely to pull the plug, as they benefit from the current paradigm.

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    Trish says

    I find this so interesting. I played soccer at the collegiate level and any player who went in to have their knees worked on by the team orthopedic surgeon also received an ITB release. You would just find out the extra little ITB snip post-op. I had cartilage removed every season thereafter and strictly bike these days.

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    Regenexx Team says

    Trish,
    This is exactly the type of thing we're talking about but that personal story does a great job of putting it into context!

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    Greg Hymes says

    So what is your answer for a tight IT Band that won't respond to anything? I have been through the gamut of options from stretching to strengthening to a tenex procedure to guided cortisone shots into the bursa. I rested for more than a year before I received any relief. After the time off I slowly started building my miles up. Within a year of starting to run again the same pain is back.

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    Regenexx Team says

    Greg Hymes,
    Determining the cause, and treating both the cause and the ITB. Please see: http://www.regenexx.com/pain-in-the-side-of-the-hip-whats-wrong-andhttp://www.regenexx.com/pain-in-the-side-of-the-hip-whats-wrong-and-how-to-fix-it/-how-to-fix-it/

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    Pat says

    Can you repost this link as it dead ? The best the exact same situation to above

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    Regenexx Team says

    Pat,
    Just checked and the link is definitely working...

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    Elaine says

    I am 71yo and had a bursectomy on my left hip 10 months ago. The Dr said my ITB was tight and swollen so he created a small window around the joint area. I still have pain and a lot of tenderness in that area. In addition, when I am sitting and cross my left leg over the right, I have a snapping or feeling like something slips over the joint! Thankfully I don't have to use a cane but after lying down or sitting, it is painful when I get up for first 10 steps or so, then pain eases with more steps but never goes away! Also, I have always been a bit overweight but never athletic and certainly never a runner!!! A 7mth post op MRI left hip was negative with normal appearing joint. Would I be a candidate for PRP? The map showed no GA locations but one a couple hours away in TN. Thanks!

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    Regenexx Team says

    Elaine,
    It would have been important to do determine why the ITB band was tight rather than "creating a window", as now the same forces presumably from your back, are pulling on something of which the structural integrity has been altered. If you'd like to see if we can help and if you'd be a Candidate, please submit the Candidate form so we can take a look at a recent MRI and medical history.

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    KBN says

    In my case, I wouldn't have had an option anyway.
    I was suffering from bursitis in the hip. That, added to my ITB band being too tight, led to excruciating pain whenever I moved. I'd tried everything that my doctor recommended. Physical Therapy caused more pain, ultrasounds/massage and bandages releasing medicine were less than useless, and cortisone shots made it worse. Surgery was my last option. And what I'm reading, was that it was for nothing?

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    Regenexx Team says

    KBN,

    ITB Release surgery is generally not a good solution as it disrupts the micro-millimeter precision of the knee and weakens structures. But when we talk about the ineffectiveness of surgeries, we are talking about an unacceptable complication rate in large groups of patients, not an individual patient. Hope it helps in your case!

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    Michelle says

    I had a TKR four years ago on my right knee. I have been in pain ever since, especially walking. I have gone to a different Ortho Doctor who says that the ITB is rubbing on the bone. He suggests going in laterally and shaving off some of the bone that the band is rubbing, removing a bone spur and possible cement that is sticking out. What are your thoughts on this?

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    Regenexx Team says

    Michelle,
    We'd need to see an MRI and examine you to see what is actually going on. The problem is one surgery tends to lead to another and so on. For us to weigh in, please submit the Candidate form here: https://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/

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    Kev says

    I had IT band surgery in March of 2017. I injured it cycling. When I hit the 110 mile mark I felt a painful sting. Tried resting, stretching, and loads of medicine. Nothing worked. The more I read about this the more I discovered that its the bursa underneath that causes the pain. My surgeon cut a triangle hole in the IT band in the area that runs over the bursa. He also removed parts of the bursa. Said it was one of the worst he has seen. 2 months later I was back on the bike riding again. Now, not everything is perfect. After riding my knee is tight for a few days. I went into the gym and started leg strengthing. The tightness worries me but so far no pain. I do feel that surgery was my only option. I am 49 so I was not planning on it healing itself. I plan on going back to talk to him about the tightness. Break in the weather a few weeks ago let me ride 70 miles. Recently played pickleball and my knee was in a little bit of pain and worried it may have come back. Won't know until it warms up and I can get back on the bike. Should have stayed away from pickle ball. :)

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    Regenexx Team says

    Kev,
    The good news is, most ITB band issues and it's causes can be treated with precise image guided injections of your own platelets or stem cells. The bad news is an ITB release can destabilize the knee, throwing the structural balance out of whack and creating a domino effect of problems over time. Pickle ball looks like great fun and a great workout, but it also looks like it involves a lot of quick directional changes which can be hard on knees.

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    Kara Petroske says

    Can you explain how platelets help? I stumbled onto this page because I discovered my pain is from my Itb. Realized it’s from going on cardio machines that do not have “shapely” women in mind. The feet are so close together causing one with female hips to turn more inward. When I use another machine with feet spread more wide or the treadmill I’m fine. So I guess no more elliptical for me (I do long cardio sessions; sometimes 2 hours of mild/moderate cardio).

    I like looking at surgery pics out of curiosity (seeing the band up close). That’s how I found this page. What struck me as interesting was how platelets were mentioned. I have a bleeding disorder called ITP. Right now I’m waiting on some iV meds to increase my platelet count. I’ve lived with it for 15 years. It’s considered an inflammatory condition. I understand how platelets have a job in healing (God’s bandaid as I tell my 3 young children). As I approach a lower platelet count the more I feel tired and weakened. Thankfully I have a wonderful oncologist who listens. Anyway, my point is I found this article very interesting. I would love to hear more in depth about the role of platelets in healing. Thank you!

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    Chris Centeno says

    Platelets release growth factors that promote healing of tissues. In this case, the ITB is damaged and has small micro-tears, the growth factors act as espresso shots for the local repair cells-see https://www.regenexx.com/platelet-rich-plasma/ If your platelet count is low due to ITP, we can usually adjust for that by increasing the concentration of the PRP.

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    Judy says

    I had a fill knee replacement last June and they had to tighten my IT band The problem being now is the IT band is too tight and gives me severe pain on the outside of the knee replacement leg. I’ve been going to therapy but that doesn’t seem to be helping and can you give me any suggestions

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    Regenexx Team says

    Judy,
    Generally, a tight ITB band originates with a pinched nerve in the low back, and treating the nerve helps. In this case, "Tightening" the IT band in surgery means physically shortening it so a very different thing, and because the whole system of the low back and pelvis to the foot is interdependent, causes problems. Think of a very elaborate precision timed pulley system in which you shorten one side of the rope. Please see: https://www.regenexx.com/what-is-the-itb/ We'd need to examine you to see if we can help.

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    About the Author

    Chris Centeno

    Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…

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