Iliotibial band friction syndrome is also known as ITBS. It is an overuse injury and is a common cause of pain on the outside of the knee, especially in runners. Here we explain the symptoms, causes, treatment, and exercises.
Medically reviewed by Dr. Chaminda Goonetilleke, 22nd Dec. 2021
Iliotibial band symptoms & diagnosis
Symptoms of ITB friction syndrome consist of:
- Pain on the outside of the knee.
- Symptoms usually develop gradually over time and become progressively worse.
- In runners, symptoms often occur at exactly the same time into a run and become progressively worse. After a period of rest, symptoms disappear only to return when the patient returns to normal training.
- Pain is made worse by running, particularly downhill.
Your physio or doctor may do a number of tests to help diagnose your injury. Symptoms can often be reproduced by getting you to bend and straighten your leg, whilst your physio presses in at the side of your knee.
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A therapist or trainer may use Ober’s test to assess how tight the hip muscles and iliotibial band are.
They may also assess foot biomechanics to identify possible overpronation. Weakness in hip abduction (moving the leg out sideways) is another common sign. Tender trigger points may also be present in the gluteal muscles or buttocks.
What is Iliotibial band syndrome?
Iliotibial band friction syndrome is also known as ITBF syndrome or Iliotibial band friction syndrome. It is inflammation of the long tendon of the tensor fascia latae muscle in the hip as it passes over the outside of the knee.
The Iliotibial band is a long fascia that runs down the outside of the thigh. The fascia is the connective tissue surrounding the muscle, connecting the tensor fascia latae muscle and gluteus maximus in the hip to the tibia (shin bone) just below the knee.
What causes ITB friction syndrome?
ITBFS is primarily an overuse injury, however, a number of factors can increase your risk of injury.
Weak gluteal muscles
If these are weak, your iliotibial band rubs against the outside of your knee joint causing friction, pain, and inflammation.
Tight hip muscles
If the tensor fascia latae muscles are tight then friction between the band and your knee is increased.
Likewise, if you have a naturally wide ITB then this also increases your likelihood of injury.
Overpronation or poor foot biomechanics may increase the risk of injury. If your foot rolls in or flattens, the lower leg rotates inwards. As a result, your knee also turns inwards, increasing friction.
Other factors include leg length difference, running on hills or on cambered roads.
Iliotibial band syndrome treatment
Treatment for ITB friction syndrome involves reducing the pain and inflammation, identifying any underlying causes, then stretching and conditioning the hip muscle and iliotibial band. A gradual return to full fitness is important 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, active rest involving activities other than running, for example, swimming or cycling can be done.
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.
Later this can be reduced to 2 or 3 times a day and/or after exercise is a good idea to ensure the pain does not return.
Iliotibial band strap
An ITB strap applies pressure to the tendon just above the knee. So the strain on the outside of the knee is reduced.
A doctor may prescribe anti-inflammatory medication, such as NSAID 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 means they could cause harm, for example, asthmatics should not take Ibuprofen.
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.
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.
Using a foam roller 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.
Identify possible causes:
Once inflammation and pain have gone then address potential causes. Otherwise, your pain will most likely return.
- Keep a training diary. This allows you to look back and identify possible factors contributing to injury and therefore avoid them in the future. Check your training diary for any significant increase in running mileage, change of surface, change of job, or anything else out of the ordinary.
- Errors in training should be identified and corrected. These may 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 you begin training again, try and avoid downhill running where possible.
- 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.
- Electrotherapy – such as TENS or ultrasound may help reduce pain and inflammation.
- Acupuncture or dry-needling techniques are thought to be beneficial in reducing chronic or long-term pain. This is performed by inserting needles into specific points around the knee joint.
- In acute or prolonged cases a corticosteroid injection into the site of irritation may provide pain relief.
Exercises & rehabilitation
Both stretching and strengthening exercises are important when treating ITB friction syndrome. The following exercises to stretch the tensor fascia latae muscle, and strengthen the gluteals are important:
- Tensor fascia latae stretch
- Gluteal muscle stretches
- Heel drop
- Abduction with band
- Partner stretching
ITB foam roller exercises
- View all Iliotibial band exercises
Preventing Iliotibial band syndrome
- 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. Increase distance 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. 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.
References & research
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.