Iliotibial band syndrome is a common cause of pain on the outside of the knee, thought to be caused by friction as the tendon rubs across the bone. Symptoms usually develop gradually over time becoming progressively worse. Typically the athlete will rest for a period of time until symptoms go, only for them to return when training resumes
- Symptoms & diagnosis
- Causes & anatomy
- Treatment & Rehabilitation
- Sports massage
Symptoms & diagnosis
In runners symptoms may often occur at exactly the same time into a run and become progressively worse, eventually forcing the runner to stop. After a period of rest, symptoms disappear only to return when the patient returns to normal training. Pain is normally aggravated by running, particularly downhill. Symptoms may be reproduced when bending and straightening the knee whilst pressing in at the side of the knee over the painful area.
A therapist or trainer may use Ober's test (play video) to assess IT band tightness. They may also asses foot biomechanics to identify possible over pronation. Weakness in hip abduction (moving the leg out sideways) is another common sign. Tender trigger points in the gluteal muscles or buttocks area may also be present.
Iliotibial band syndrome causes & anatomy
Iliotibial band friction syndrome (play video) is also known as ITB syndrome, Iliotibial band friction syndrome and is sometimes referred to as runner's knee.
What is the Iliotibial band?
The Iliotibial band is a long tendon which runs down the outside of the thigh, connecting the tensor fascia latae muscle in the hip to the tibia (shin bone) just below the knee.
What causes ITB friction syndrome?
It is commonly thought to occur when the iliotibial band (or IT band) rubs against the outside of the knee joint resulting in friction, pain, and inflammation. It is an overuse injury, however, certain factors may make you more susceptible to developing the injury. These include:
- Tight tensor fascia
lataemuscles and a tight (or naturally wide) IT band may make someone more susceptible to this injury.
- Weak hip muscles, particularly the gluteus medius are also thought to be a significant contributing factor.
- Overpronation or poor foot biomechanics may increase the risk of injury. If the foot rolls in or flattens, the lower leg rotates inwards causing the knee to also turn inwards which increases the likelihood of friction as the band or tendon rubs on the outside of the knee.
- Other factors include leg length difference, running on hills or on cambered roads.
Treatment & Rehabilitation
Treatment for ITB friction syndrome involves reducing the pain and inflammation, identifying any underlying causes, then stretching and conditioning the muscle and iliotibial band along with a gradual return to full fitness so the injury does not recur.
Rest is important to allow the inflamed tendon to heal. Continuing to run with ITB syndrome will most likely make it worse. Initially, complete rest is a good idea but later activities other than running which does not make the pain worse such as swimming or cycling should be done to maintain fitness.
Apply cold therapy or ice to reduce pain and inflammation. Ice should be applied for 10 to 15 minutes every hour until the initial pain has gone then later 2 or 3 times a day and/or after exercise is a good idea to ensure the pain does not return. Once the inflammation has gone then potential causes must be addressed such as a tight ITB or the pain will most likely return.
Identify possible causes! Check your training diary for any significant increase in running mileage, change of surface, change of job or anything else out of the ordinary which could have helped cause the injury. Keeping a training diary allows you to look back and identify possible factors contributing to injury and avoid them in the future.
See a podiatrist or similar professional who can perform a full biomechanical analysis to identify any foot problems such as overpronation which may be causing the leg to rotate inwards twisting the knee.
Using a foam roller (play video) on the IT band and gluteal muscles can help stretch the iliotibial band and remove any tight knots or lumps in the tendon and therefore, friction on the side of the knee. Self-massage techniques can also be very helpful in correcting excessive ITB tightness, especially where access to a massage therapist on a regular basis is not possible.
Errors in training should be identified and corrected. These can include overtraining or increasing running mileage too quickly. As a general rule, a runner should not increase mileage by more than 10% per week. Running across a slope or camber in the road for long periods or poor foot biomechanics should be considered. When training starts again to avoid too much downhill running.
Return to full fitness gradually! This can often start within two weeks of initial treatment but will depend on the extent of the injury. Build up running time from a much lower point than you left off before the injury. A reduction to 50% of original mileage or time should be okay. Apply ice to the knee for 15 minutes after training, even if it doesn't hurt. This will help keep any potential inflammation in check.
Increase running time rather than distance for the first few runs. Running distance should be increased by no more than 10% a week (depending on original fitness levels). If you feel pain or the inflammation comes back then go back a couple of steps to reduce the inflammation and start again.
It is important to continue to stretch and do foam roller exercises. If the Iliotibial band (ITB) is tight then the injury is very likely to recur. Simply reducing the inflammation will not cure the injury permanently. Even when fully fit it is a good idea to get a regular sports massage which will eliminate tight spots and knots that can cause the ITB to tighten.
What can a professional therapist/doctor do?
A doctor may prescribe anti-inflammatory medication such as NSAID’s e.g. Ibuprofen. This is useful in the early acute stage to reduce pain and inflammation. Long term it is not likely to be of benefit, particularly if it is just being used to mask an injury and not as part of the treatment. Always check with a doctor before taking medication in case you have contraindications which mean they could cause harm, for example, asthmatics should not take Ibuprofen. Use of electrotherapeutic treatment techniques such as TENS or ultrasound may help reduce pain and inflammation.
Sports massage for iliotibial band syndrome
Sports massage () applied to the iliotibial band can help relax and loosen the tissues, in particular, myofascial release techniques have been shown to be highly effective. In acute or prolonged cases a corticosteroid injection into the site of irritation may provide pain relief.
Expert interview (play video): Susan Findlay of the North London School of Sports Massage explains the use of sports massage therapy in treating Iliotibial band syndrome
Acupuncture or dry-needling techniques or acupuncture may be beneficial also. Acupuncture is performed by inserting needles of various lengths and diameters into specific points over the body and in this case around the knee joint. The needle is usually inserted, rotated and then either removed immediately or left in place for several minutes. It is thought to be beneficial in reducing chronic or long-term pain.
Expert interview (play video): Sports Podiatrist Ian Sadler talks about the biomechanics and causes of Iliotibial band syndrome.
Iliotibial band syndrome exercises
Both stretching and strengthening exercises are an important part of any ITB rehabilitation program and may include static stretches, partner assisted stretching and muscle energy techniques. Exercises should be done at least twice a day whilst recovering from injury.
This static stretch (see above) can be done by the athlete themselves. Place the leg you want to stretch behind the other one. Keep the foot on the floor and push your hips out to the other side until a stretch is felt in the outer hip. You may also feel a stretch down the outside of the thigh. Hold for 30 seconds, repeat 5 times and do this at least three times a day. It is important not to bounce when stretching, always ease into it gently and try to relax. If you need to, lean forwards on to a table to help with balance or to increase the stretch.
This is probably the most effective stretch for the iliotibial band and tensor fascia
It can also be done in the form of a muscle energy technique. The patient attempts to push the bottom leg against resistance contracting the muscles being stretched at approximately 25% of maximum effort for 10 seconds. They then relax and the therapist increases the stretch as far as it will go before the contraction is repeated. This is continued for 4 or 5 times or until no further gains are achieved.
This stretch (play video) lengthens the tensor fascia
Lay on your back with one leg flat on the floor. Pull the other knee up to your chest. Then pull it across your body until you feel a stretch in the buttock and outer hip. Hold for 30 seconds.
Strengthening exercises for Iliotibial band friction syndrome
Strengthening exercises for the muscles on the outside of the hip which abduct the leg will help prevent the knee turning inwards when running or walking and therefore help reduce the friction on the ITB tendon at the knee. In particular strengthening exercises for the tensor
The heel drop exercise (play video) strengthens the muscles that stabilize the hips. Stand on one leg and slowly squat down on the affected leg as if you are going to step off the step. Don't let either side of the pelvis drop down. This should only be done if the knee is free of pain and inflammation. Perform two sets of as many as you can comfortably manage. Try to get the number in each set equal. Have a minutes rest in between sets. Gradually increase the number you perform, up to 3 sets of 15-20. Repeat the exercises every day.
Clam exercise (play video) - Lay on your side with the knees together and bent with the feet in line with your spine. Keep the feet together as you lift the top knee up as far as comfortable. Ensure you keep your back still and do not rotate backward to increase the range. It may only be a small movement initially but this will improve as your strength increases. Start with 2 sets of 10 if you
Use a resistance band (play video) wrapped around the ankle. Pull the leg out to the side, keeping the knee straight. Slowly return to the start position and repeat. Start with 2 sets of 10 and gradually increase to 3 sets of 15-20. Make sure the iliotibial band is stretched after performing
Walking hip abduction
Walking hip adduction exercise (play video)
Baker RL, Fredericson M. Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Phys Med Rehabil Clin N Am 2016;27(1):53–77.
Fairclough J, Hayashi K, Toumi H et al. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport 2007;10(2):74–6.
Ellis R, Hing W, Reid D. Iliotibial band friction syndrome—a systematic review. Man Ther 2007;12(3):200–8.
Falvey EC, Clark RA, Franklyn-Miller A et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports 2010;20:580–7.