Iliotibial Band Syndrome

Iliotibial band friction syndrome

Iliotibial band friction syndrome is also known as ITBS and runners knee. 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.

Iliotibial band symptoms & diagnosis

Symptoms of ITB friction syndrome consist of:

  • Pain on the outside of the knee, more specifically at or around the bony protrusion on the outside of the knee.
  • Pain usually develops gradually over time, becoming 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.

Assessment tests

A professional therapist may do a number of tests to help diagnose your injury. Symptoms can often be reproduced when bending and straightening the leg, whilst pressing in at the side of the knee over the painful area.

Obers test

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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 asses foot biomechanics to identify possible overpronation. 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.


What is Iliotibial band syndrome?

Iliotibial band friction syndrome is also known as ITBF 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 fascia which runs down the outside of the thigh. The fascia is connective tissue which surrounds 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 the knee joint causing friction, pain, and inflammation.
  • Tight hip muscles – tight tensor fascia latae muscles and a tight (or naturally wide) Iliotibial band may increase your likelihood of injury. This is because increased tension in the band increases friction against the outside of the knee.
  • Overpronation or poor foot biomechanics may increase the risk of injury. If the foot rolls in or flattens, the lower leg rotates inwards. As a result this causes the knee to also turn inwards, again increasing friction over the knee.
  • Other factors include leg length difference, running on hills or on cambered roads.

Iliotibial band syndrome 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.


If your Iliotibial band (ITB) is tight, then your injury is very likely to recur. Simply reducing the inflammation will not cure the injury permanently.


Self-help treatment

  • 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 and pain has gone then potential causes must be addressed or your pain will most likely return.

Identify possible causes:

  • 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.

Iliotibial band syndrome exercises

Piriformis stretch in standing

Both stretching and strengthening exercises are important when treating ITB friction syndrome. Specifically exercises to stretch the tensor fascia latae muscle, and strengthening exercises for the gluteals are important.

Read more on ITBFS exercises.

ITB foam roller exercises

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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. 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.

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.
  • The may use electrotherapy treatment, such as TENS or ultrasound may help reduce pain and inflammation.
  • 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.
  • 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.

Sports massage for iliotibial band syndrome

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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. 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. 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

  1. 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.
  2. 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.
  3. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome—a systematic review. Man Ther 2007;12(3):200–8.
  4. 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.
This article has been written with reference to the bibliography.