Iliotibial Band Syndrome

Otherwise known as ‘runner’s knee’, Iliotibial Band Syndrome (ITBS) is a common injury present at the Physical Therapy clinic.  We could just as easily refer to this as ‘Hiker’s knee’ as ITBS affects backpackers, cyclists, and those who walk regularly for exercise.

What is it?

Iliotibial Band Syndrome (ITBS) describes an inflammation or irritation of the tract of connective tissue that runs along the outside of your thigh (your IT Band) at the point where it compresses against the thigh bone (femur) about an inch or two above the knee joint.


Pain is typically experienced along the outside of the knee and lower thigh.

Pain is typically blamed on a rubbing or ‘friction’ as the band rubs over the bone with each stride. Recent research, however, challenges this long-standing belief and seems to indicate other pathology.  1 2

What we can say with some certainty is that the IT band and the pad of adipose tissue beneath it become inflamed or irritated while walking or running.

Who Get’s it?

Estimates of prevalence are in the range of 5% – 14% of ‘active people’ and upwards of 30-50+% in distance runners. Women are affected more often than men.

What does it feel like?

Symptoms of ‘Iliotibial Band Syndrome’ (ITBS) range from ‘sharp’ or ‘stinging’ pain (typically during exercise/activity) to a ‘deep aching’ (typically after activity).

While running is the most common repetitive stress leading to ITBS, once ‘flared up’ you may feel these symptoms with basic daily movements such as getting up from a chair or turning a corner.

How to Diagnose?

X-rays will not show this. An MRI or Ultrsound can demonstrate tissue changes that implicate ITBS, but this is expensive and unnecessary most of the time; conservative management has a > 90% success rate. 3

To Test if you have ITBS – assume a ‘narrow’ stance. Squat down slowly. If you reproduce your lateral thigh/knee pain at about a 30 > 45 degree knee bend, you may have ITBS.

A clinical exam by your Physical Therapist can reliably determine the existence of ITBS.

 What to do?

Of course, as is the case with most repetitive stress injuries, there are a myriad of potentially contributing factors – poor sleep, poor nutrition, poor shoe selection (for sure!). Common ‘training errors’ that can increase the likelihood of ITBS include rapid increase in running (or hiking) volume, sudden increase in hill work (especially downhill), lack of ‘periodization’ or inadequate rest days, etc.

Interestingly, studies show decreased biomechanical stress to the distal IT Band at faster paces. It seems speed work may, counter-intuitively, be less strenuous to the ITB than long slow jogs.

Another common cause of ITBS is the introduction of running (or hiking/walking) on un-level surfaces.  A quick / sudden transition to trails for instance. Other considerations are roads that are aggressively ‘banked’ to shed rainwater. Consider alternating which side of the road you run on and/or alternating the direction you run on a track. Better still, find a scenic deserted road and run in the center!

(* Side note- this can also result from a poor bike fit. 4 )

Prevention is KEY! Once ITBS is really flared up, it requires treatment and rest…  yes, the ‘R’ word.

A particularly bad case will take months to recover from. A little bit of ‘Proactive Rest’ (when symptoms are just starting) can go a long way.  In mild cases you may be able to aqua jog or get on an elliptical while recovering. If you manage the initial onset of symptoms well, you could be looking at 4-5 days off with a graded return. Decrease training volume by 30-40% the first week and then ‘ramp up’ slowly and deliberately from there.  An ‘acceptable’ pace for increasing volume for runners is variable and depends on many factors. However, for most runners the 10% rule will suffice – 10% increase per week max.

In addition to addressing training errors – you will want to identify potential biomechanical stresses that lead to increased strain on the IT Band. Consider the following:

Tightness in specific tissues surrounding the IT Band can contribute to ITBS.  The IT Band itself does not, in fact, stretch. Studies show that the IT band is only capable of ½% elongation (That’s right, half of one percent – don’t bother).  So we’re really talking about trying to stretch or ‘soften’ the muscles that surround and ‘tension’ the IT Band.  Common muscles to address include the Tensor Fascia Late (TFL) muscle and the Vastus Lateralis (the outside portion of your thigh muscle).


Stretching and self-massage to these tissues can be helpful in some cases.  However, I encourage caution here! Done improperly, stretching exercises can cause more harm than good. I once treated a runner that was shown an ‘IT Band Stretch’ by a Physical Therapist. He was hammering away at this for weeks without results. So, what did he do? He went harder. Longer. Eventually he tore through the muscle in the side of his hip and needed surgery!

To complicate things, we often see people present with ITBS without ‘tightness’ in these structures. Clearly these people have another issue and shouldn’t waste their time stretching (other than what is probably just ‘good for them’ anyway).

The video below demonstrates some safe generic tissue mobilization and stretching strategies for the lateral hip/thigh:

Weakness in the hips and core muscles contribute to ITBS. The mechanisms at work here can be complex. The overall picture is that poor strength and (perhaps more importantly) poor body control of the trunk, hips/pelvis and thighbone (femur) will result in sloppy mechanics at the joints lower down (e.g. the knee).  The knee is built to be a hinge joint (more or less). When the body does a poor job controlling sideways and rotational stresses (because of weak trunk and pelvic muscles) that ‘hinge’ starts to experience trouble – e.g. ITBS (among others).

Despite being a ‘sagittal plane’ sport (i.e. straight forward) running inefficiencies and most running related injuries are associated with poor body control / stability in the other planes (e.g. poor side-to-side hip/pelvic control or poor rotational control in the trunk/spine).

This appears to be true for ITBS. 5

Also, remember, the body ‘tightens’ up around areas of weakness. If you body cannot ‘stabilize’ properly using muscle strength and healthy movement habits, local tissues will contracture in order to create stability.  My experience is that weakness is at the root of most ITBS cases (potentially in combination with other issues).  Your body will be much more resilient to ITBS with a strong core.

Research backs this up. 6

Poor Running Form can lead to ITBS. ITBS is a repetitive stress injury; referring to it as an ‘overuse’ injury is a misnomer. The presence of IT Band irritation likely indicates a biomechanical fault.  Sure faulty mechanics will still require repetition to lead to injury, but significant faults will lead to injury at relatively low reps. This is why ITBS effects beginner and low volume runners almost as frequently as experienced runners.


Common form mistakes include over-striding, increased ‘cross over’ (legs crossing midline while running) and excessive hip ‘drop’ during stance phase. Having a professional perform a video gait analysis can be very helpful.

Gait training has been shown to reduce ITBS. 7

Disclaimer – Lateral thigh/knee pain can be caused by numerous other ailments. If these basic strategies do not prove effective for you – seek the advice of a sports physical therapist.

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