Updated: Jun 21
A lot of you want to hit the ground running, but instead, you hit the ground hurting…hurting on the outside of your knee. If that’s the case, you could have iliotibial band syndrome (ITBS) or IT band syndrome for short. IT band syndrome is an overuse injury that is common in endurance athletes like runners and bikers. It affects a tissue that runs from the side of your hip all of the way down past your knee. Most of the time, the inflammation manifests itself as pain on the outside of the knee. It can be incredibly painful and is typically a frustratingly stubborn injury to deal with. One quick look at the anatomy below can help you realize that the cause of the pain can be anywhere from the hip to the knee, so getting to the root cause can be a little tricky, but here are some solutions to a few of the most common causes of IT band syndrome.
What is the IT Band?
The illiotibial band (IT Band for short) is a thick band of of fibrous tissue that begins at the iliac crest in the hip and runs along the outside of the thigh until it connects to the tibia, or shinbone. The muscles of the buttocks and the hip joint attach to it. The IT band coordinates muscle function and stabilizes the knee. If the band becomes irritated, friction can occur during walking or running, causing pain. Sprinters are typically not susceptible. Long-distance runners who train on sloping roads can develop the injury.
Tennis players and bicyclists are also prone to ITB.
The syndrome is characterized by knee pain, especially on the sides of the kneecap. Snapping hip pain as the IT band slides over the greater trochanter or point of the hip is another sign. Patients should be evaluated for a biomechanical cause. The injury can worsen if not treated.
What is IT Band Syndrome?
Iliotibial band inflammation is an overuse syndrome that occurs most often in long-distance runners, bicyclists, and other athletes who repeatedly squat. The iliotibial band syndrome may be the result of a combination of issues, including poor training habits, poor flexibility of muscle, and other mechanical imbalances in the body, especially involving the low back, pelvis, hips, and knees.
There can be a predisposition to develop IT band syndrome. Anatomy issues may include differences in the lengths of the legs (a leg-length discrepancy), an abnormal tilt to the pelvis, or bowed legs (genu varum). These situations can cause the iliotibial band to become excessively tight, leading to increased friction when the band crosses back and forth across the femoral epicondyle during activity.
Training errors may cause runners to develop iliotibial band syndrome symptoms. Roads are canted or banked with the center of the road higher than the outside edge to allow for water runoff. If a runner always runs on the same side of the road, it produces the same effect on the body as having a leg-length discrepancy. One leg is always downhill compared to the other, and the pelvis has to tilt to accommodate the activity. Running too many hills can also cause inflammation of the IT band. Running downhill is especially stressful on the IT band as it works to stabilize the knee.
Bicyclists may develop IT band inflammation should they have improper posture on their bike and "toe in" when they pedal. The issue may be how the toe clips are aligned, forcing the foot to be internally rotated, toed in. This can cause the same effect as bowed legs, increasing the angle of the IT band as it crosses the knee and increasing the risk of inflammation.
Other activities with increased knee flexion can cause symptoms and include rowing and weight lifting, especially with excessive squatting.
IT Band Signs and Symptoms
Pain on the lateral side of the knee is the most common symptom of iliotibial band syndrome and is due to inflammation of the area where the band crosses back and forth at the femoral epicondyle. Initially, there may be a sensation of stinging or needle-like pricks that are often ignored. This can gradually progress to pain every time the heel strikes the ground and finally can become disabling with pain when walking or when climbing up or down steps.
Some patients may feel a snapping or popping sound at the knee, and there may be some swelling either where the band crosses the femoral epicondyle or below the knee where it attaches to the tibia. Occasionally, the pain may radiate along the course of the IT band all the way up to the outer side of the thigh to the hip.
Are Iliotibial Band and Hip Pain Related?
Iliotibial band and pain are related when a tight or overdeveloped iliotibial band rubs across the point of the hip, causing snapping hip pain. Patients experience pain each time the hip flexes. Cyclists, runners and other physically active people develop the condition, known as iliotibial band syndrome.
Pain and symptoms of iliotibial band syndrome topically subside with rest and disappears when the band stretches and reains flexibility. Medication relieves swelling and pain, and steroid injections ease discomfort in tender areas.
Physical therapy is also aimed at finding the underlying cause of the condition, such as a problem with muscle strength, balance, flexibility and gait. Patients with iliotibial band syndrome who are found to have gait abnormalities may benefit from the use of orthotics.
Surgery is indicated for individuals who do not find relief from physical therapy. Arthroscopy is a procedure that is used to find and cut away areas of inflammation surrounding the iliotibial joint. Another technique involves the removal of a portion of the iliotibial band, which provides it with more sliding room across the bone.
Iliotibial band syndrome is an injury of the tissues located in the outer part of the thigh and knee. Symptoms include pain and tenderness above the knee joint. Patients who do not seek prompt treatment may eventually experience a decreased range of motion, increased pain and decreased activity of the affected area.
What Exercises Should be Avoided with Iliotibial Band (IT band) Syndrome?
Most patients recover from iliotibial band syndrome, but it can take from weeks to months to return to full activity without pain. Patience in allowing the body to heal is required for optimal results.
Understanding the importance of symmetry in the body is helpful in preventing iliotibial band syndrome. When activities alter that symmetry, symptoms may occur.
Symptoms may occur in runners who always run in the same direction on an indoor track or who always run on the same side of a banked road. This causes an artificial tilt to the pelvis and increases the risk of developing inflammation and pain. When running indoors, it is wise to change directions when running longer distances. Some tracks have the runners change directions every few minutes while others change direction on alternate days. While running toward traffic is an important safety strategy, finding a way to run on the opposite side of the street safely may minimize the risk of developing iliotibial band syndrome.
Bicyclists are at risk for iliotibial band syndrome if they tend to pedal with their toes turned in (internally rotated), which can cause abnormal stretching of the iliotibial band at the knee. Being aware of pedaling technique and setting the pedals and clips properly may minimize the risk of developing symptoms.
Keeping muscles and other structures stretched is an important part of prevention of many musculoskeletal injuries, including iliotibial band syndrome.
Solutions to a Few of the Most Common Causes of IT Band Syndrome
Technically, IT band syndrome is an overuse injury. It’s kind of a misleading classification since there are usually other factors than overuse, but approaching IT band syndrome as an overuse injury is an important first step towards recovery. After icing and resting for a few days, you may need to change up your training regimen. Sometimes this can be as easy as avoiding repetition.
Try changing your running route or getting away from the treadmill or track for a jog outside. If getting in shape or building up your endurance is your goal, try some cross-training while you slowly ramp up your mileage. Keep in mind that while overuse is usually one of the causes of IT band syndrome, there are usually other factors contributing to your pain, so some of the other interventions below may be necessary.
2. Tight Tissues
Tight muscles in your hips or along the side of the leg can be a major contributing factor to IT band syndrome. All of these tissues are connected, so even though the location of the pain is in the knee, the hips can very well be the area that need the most attention.
Stretching the IT band and the connected muscle is fairly simple. Just cross your legs, keeping the affected leg in back (position 1). Lean away from the painful leg until you feel a stretch along the side of the leg (position 2). Hold that for 20 to 30 seconds and repeat 5 times.
In addition to stretching I’ve had success by utilizing foam rolling or work with a tennis ball to loosen up tight tissues and release any tightness in your hip muscles. I strongly encourage you to stretch and roll both of your legs as tight tissues on one leg can cause pain on the opposite side. If there still seems to be some lingering tight spots after you try the at-home solutions, you may need to see a professional for some individualized hands-on work.
3. Weak Hip Muscles
Researchers at Stanford found that weak hip muscles can be one of the biggest reasons people get IT band syndrome. Weak muscles in the hip tend to cause your running form to break down, which puts a lot of stress on the tissues in the knee. To strengthen the muscles most commonly affected, you can try some of the exercises suggested at this link. In addition, another one of my favorites (pictured below) is referred to as “the clam.” While on your side, bend your knees to 90 degrees. Keeping your ankles together, rotate the knee of your tip leg towards the ceiling. Return to the starting position and repeat 30 times. Again, it’s important to strengthen both legs as one side of the body can easily affect the other.
4. Poor Running Form
Sometimes getting rid of IT band syndrome can be as simple as changing the way that you run. Having a professional look at your running gait can reveal some problems that you may have never noticed. Some of the more common problems are over-striding (taking too long of steps) and strides that cross over the midline of the body. These are pretty easy to notice and can sometimes be pointed about by an experienced runner. Sometimes, however, the breakdown in form can be more subtle and require something more involved like a video gait analysis.
5. Shoe or Orthotic Issues
You can correct every issue in your body, but if what comes between your foot and the ground is the cause of your problem, you’ll never see relief. Overworn shoes can cause your foot to land at awkward angles, which transfers a lot of stress up to the knee and hip, so keeping your shoes within their recommended mileage is critical.
Also, adjusting to minimalist shoes (or none at all) will require you to adjust your running style, so be sure to do your research and be patient while adjusting. Finally, arch or ankle problems may require you to get orthotics so you can run with a safer gait.
With all of these suggestions, you can expect for improvement to take some time. If your pain lingers for longer than a few weeks, it may be time to talk to a healthcare provider for some more individualized treatment.