band syndrome (ITBS) is the most common cause of pain on the outside of
the knee in runners, with an incidence as high as 12% of all running-related
overuse injuries. Although it is not difficult to diagnose, it can be
a challenge to treat, especially in higher mileage runners who place enormous
loads on their bodies. This article has been written to help the runner
diagnose, understand and begin to treat IT band friction syndrome.
IS THE ILIOTIBIAL BAND?
The IT band is not a muscle. It is a thick band of tissue called fascia
that starts on the outside of the hip, passes down the outside of the
thigh and inserts into the side of the patella (knee cap) and the tibia,
Fascia is a sheath-like
tissue that surrounds muscles. The ITB has the tensile strength of soft
steel, which explains why it is so difficult to mobilize.
As well as arising from
the iliac crest, (hip bone) the ITB attaches into the gluteal muscles
at the back and tensor facia lata muscle at the front. (See Figure 1)
muscles contract, they increase tension on the band. Often, one muscle
dominates the movement pattern causing an imbalance to occur, which may
lead to injury.
WHAT ARE THE SYMPTOMS
• Pain from the ITB is easily recognized as a sharp or burning pain
on the outside of the knee when running. Typically, an athlete is unable
to “run through” ITB pain.
• Early on, symptoms will subside shortly after the run is over,
but will return with the next run, usually after a reproducible amount
• Later, if there has been no positive intervention, the pain may
come on sooner and persist with walking or going up and down stairs.
• Tenderness may be felt on the outside of the knee when pressure
is applied, especially when the knee is slightly bent.
• There is not usually any swelling associated with this problem,
but the band itself may be thickened.
WHY DOES IT HURT?
As the knee bends, tension acting on the band, causes it to be pulled
backwards over the lateral femoral epicondyle, (a bony prominence of the
thigh bone on the outside of the knee). When the knee straightens, tension
on the band pulls it forward again. A thin bursa, or fluid filled sac,
separates the ITB from the femoral epicondyle, to decrease friction between
these structures. Repetitive bending and straightening of the knee can
cause inflammation of the bursa and the band itself, or irritation of
the bone due to recurrent rubbing or impingement. (See Figure 2)
A number of etiologic factors have been related to ITBS in runners, but
it is important to understand the cause is probably multifactorial. Weekly
mileage will interact with a combination of biomechanical issues, training
strategies, as well as variables imposed by an individual’s specific
muscle imbalances; once critical threshold is met, tissue breakdown will
occur. It is not necessary to sustain a specific traumatic injury to the
knee for the ITB to become a problem.
STRESSORS WHICH MAY
IMPACT THE DEVELOPMENT OF
1. Tightness in the iliotibial band.
2. Myofascial restrictions in the hip and thigh musculature, which will
increase tension on the band.
3. Weakness in hip abductors, (common in distance runners).
4. Weakness or poor control of knee muscles, especially the quads.
5. Dominance of anterior hip muscles, (TFL) over posterior hip muscles,
6. Excessively flat feet or high arches.
7. Bow legs or knock-knees.
8. Leg length inequality.
9. Limited ankle range of motion.
1. Training errors e.g. Excessive mileage
Sudden increase in mileage
Sudden increase in intensity of training
Too much hill work
Running on crowned roads
2. Over striding
3. Worn out running shoes
4. Failing to warm up or cool down properly
All of the extrinsic
and most of the intrinsic contributors can be addressed to minimize stress
on the ITB and reduce the risk of injury.
FOR THE PREVENTION OF ITBS
1. Change running shoes every 300 to 500 miles, or every 3 to 4 months,
when they have lost approximately 40 to 60 percent of their shock absorbing
abilities. High mileage runners should have two pairs of shoes to alternate
between, to allow 24 hours for the shock absorbing material to return
to its optimal form. Do not underestimate the importance of good shoes
in the prevention of many types of injuries. It’s worth the cost
in the long run.
2. Always slowly increase running mileage and if adding hills, do so gradually.
Downhill running especially increases friction on the ITB as well as fatiguing
the quadriceps, which are the main stabilizers of the knee. If too tired
they will not be able to control the knee position and this may lead to
unwanted stress and injury.
3. Avoid training on uneven surfaces, as the down leg may be predisposed
4. Always keep the knees warm. ITB seems to react adversely to cold, so
cover up your knees when running outdoors if it’s below 60 degrees.
5. After a run, cool down and stretch; ice if necessary.
Rehabilitation is aimed
at reducing inflammation, restoring flexibility of the ITB and improving
overall control, muscle imbalance and alignment of the lower extremity
• Activity modification is essential to reduce friction to the band.
Try cross training into other aerobic activities that don’t cause
pain during or after activity. Pool running may work despite the fact
the band is still moving over the epicondyle because it is non-weight
bearing. This will take tension off the band. Swimming with a pool buoy
between the legs will reduce any mechanical irritation completely and
may be best for the first few days.
• The elliptical machine and cycling may be attempted, as the biomechanics
are different from running even though the knee is bending and straightening,
but if pain does occur discontinue.
• Everyone is different, depending on the level and exact mode of
inflammation, tolerance to cross training will vary. In this author’s
opinion, if it doesn’t hurt before or after activity, then it should
be OK to continue. Sometimes “a change is as good as a rest.”
• Ice! Ice! Ice! Ice applied locally for 10 minutes at a time should
be carried out at least 4 times a day. Ice will help to reduce inflammation
and will continue to be beneficial throughout the course of treatment.
• Oral nonsteroidal anti-inflammatory medications, such as Motrin
may help reduce pain and inflammation. Generic brands of Ibuprofen are
exactly the same and therefore equally as effective as the more expensive
name brand “Motrin”, so save your money and buy in bulk.
• Sleep with a pillow between the knees to decrease tension on the
SUB ACUTE PHASE
• Soft tissue treatments, such as massage and release of myofascial
restrictions can be started once the acute phase
has subsided. This may be performed by a physical therapist or massage
• An effective way to address tight areas and trigger points independently,
is to purchase a foam bolster and to apply direct pressure to problem
areas by rolling back and forth, emphasizing those tight painful spots.
This will help release the tight tissue, and will decrease tension on
the band; consequently a significant part of the pain pattern will be
reduced. (See Figure 3)
• Stretching exercises are usually
necessary to lengthen the ITB, which is found to be contracted in most
individuals with this problem. However, the ITB is a difficult structure
to stretch effectively for the following reasons:
1. The ITB does not have stretch receptors, in other words, it is not
‘stretch sensitive’, and therefore it is difficult for the
athlete to know if the stretch is effective while it is being performed.
The sensation of stretch may be coming from neighboring tissues and is
2. Most of the “old school” ITB stretches documented and passed
down from athlete to athlete are inadequate. They fail to stretch the
band along its entire length. Because the ITB passes over more than one
joint, it is very difficult to lengthen without compensations.
ILIOTIBIAL BAND STRETCH
Sit on the edge of a table or firm bed.
Roll back pulling the unaffected leg to the chest to flatten out the low
Lower the affected leg to the table and bend the knee to 90 degrees.
Now, without allowing
the lower leg to rotate or twist, move the thigh across the midline. As
you do this, do not let the thigh rise up from the table, it needs to
stay down to stretch the ITB over the hip joint. Hold for 20 to 30 seconds,
repeat 3 to 5 times. (See Figure 4)
of stretch may vary from one individual to another due to the absence
of stretch receptors in the band. Some will feel a pull on the inside
of the kneecap, which will go away once the stretch is over.
the band is warmed prior to stretching. This can be done with heating
pads or a warm shower. Alternatively stretching can be carried out after
a work out.
& STABILITY PHASE
An athlete is most likely
to be successful returning from injury if specific weakness or muscle
imbalances have been addressed. As the ITB arises from muscles in the
hip, the relative control and stability these muscles offer will directly
affect the more “passive” IT band. Runners with ITB problems
have weaker hip muscles than those without this particular problem. It
has been well documented recently that core strength and stability can
help reduce injury and improve efficiency and performance. The following
are three exercises that will improve control of the pelvis, hip and knees:
WITH SINGLE LEG RAISE
This exercise is great for improving a runner’s pelvic stability
and hip control. It strengthens the gluts, obliques and thigh muscles
while teaching them to work together efficiently for a strong core.
Lie on back with hands
resting on hipbones.
Lift pelvis and shift weight slowly onto one foot.
Extend the other leg, but do not allow the pelvis on this side to drop,
your hands should remain level.
Hold for 10 seconds, lower the pelvis back down and repeat on the other
side. (See Figure 5)
Repeat with other leg.
Work up to 10 repetitions on each leg.
Remember that quality of movement is important, so stop sooner if you’re
unable to be stable.
This exercise improves the control and function of the gluteus medius,
a muscle found to be weak in distance runners with ITBS. By working it
in this way, the balance between the anterior and posterior hip muscles
will be restored. It is not OK to substitute this exercise for the multi
hip machine at the gym!
Lie on side with hips
at 45 degrees and knees at 90 degrees.
Keep heels together and lift upper knee by turning out at the hip. (See
It is essential to keep the pelvis perpendicular to the bed rather than
rolling backwards. Hold for 10 seconds; work up to 10 repetitions. Repeat
3. STEP DOWNS
This exercise will improve
knee control and strengthen the quads for
downhill running and softer more economical running.
Choose a stable step
2” to 6” in height.
Step down from the step slowly. (See Figure 7)
Your knee should follow the toes and should not knock in towards the other
Use a mirror
to check that the pelvis stays level, it may help to place hands on hipbones
to monitor this. Work up to 3 sets of 10. If this
exercise is too easy, then you’re not performing it slowly enough.
With all three exercises, compare left and right sides. Are there asymmetries?
Is one side harder to do properly than the other? Stay focused and concentrate
TO RUNNING PHASE
Returning to running
will vary from one individual to another, depending on the severity of
the problem and the pre injury condition of the runner.
• Most importantly, remember that returning to running after injury
is an art. The tissues need to be coaxed back to health. They need enough
stimulus to adapt positively to the demands of running, but if loaded
too much, will continue to negatively react by breaking down further,
thus increasing the time of recovery.
• Running can be attempted when there is no pain with walking and
generally the level of inflammation seems to be down (i.e. less discomfort
when exercises are performed).
• Start with easy sprints on level ground, as studies show that
running at a faster pace is less likely to aggravate the ITB than slow
paced running. Recover between intervals by walking rather than jogging.
• Run every other day for the first week, then gradually increase
distance and frequency as tolerated. Vary the speed of these runs to avoid
placing too much stress on one primary area of inflammation. Cross training
will help maintain aerobic capacity on the off days and allow the ITB
to settle between runs.
• Do not add intensity or hill workouts until you have been symptom
free for 3 to 6 weeks and have re established an adequate base.
• Initially it may be better to choose softer surfaces to run on
for extra cushioning; training on firmer surfaces may follow as symptoms
• Do not add intensity or hill workouts until you have been symptom
free for 3 to 6 weeks and have re established an adequate base.
Cortisone injection is an option for those not responding to therapy,
or athletes needing immediate relief to meet race obligations.
Surgery is only rarely required for treatment of Iliotibial band friction
syndrome. It is usually only necessary for those athletes unwilling to
modify their activity level, or professionals unable to afford time off
from training. It involves excision of a small portion of the band over
the femoral epicondyle.
It will help to consider those first early runs as “therapy”
for the injured limb, rather than training for improved performance. To
be limited to a five minute run is frustrating and may seem like a waste
of time unless you keep in mind the real purpose of the run.
When returning from
any injury, go out with a positive attitude and keep the specific goal
for that particular run in mind. You’re out there for rehabilitation,
not a personal best. This run has its place just like any other run in
your program. Understand the necessity for gradual return and set yourself
up for success.
to run for longer than planned, especially if you feel good, but you can
do that the next time out. Respect the limitations your injury has placed
upon you and you’ll recover faster. We often have to learn the hard
way; instead try learning the smart way.
A full lower extremity
examination is ideal to fully implement an effective program, specifically
for an individual’s needs. To optimize your alignment, muscle balance
and stability with movement, call or email for an appointment:
CONTROL PHYSICAL THERAPY
Ann Schofield, RPT
Phone (970) 226-5840
Cell (970) 581-0467
1. Comerford M, Dynamic
control and muscle balance of the lower quadrant. Kinetic control movement
dysfunction course, 2001
2. Ekman EF, Pope T, Martin DF, et al: Magnetic Resonance Imaging of iliotibial
band syndrome. American Journal of Sports Medicine 1994 851-854
3. Fredericson M, Cookingham, CL, Sahrmann SA, et al: Hip abductor weakness
in distance Runners with iliotibial band syndrome. Clinical Journal of
Sports Med 2000: 169-175
4. Fredericson M, Guillet M, DeBenedictis L: Quick solutions for iliotibial
band syndrome. Physician & Sportsmedicine 2000 Volume 28
5. Messier SP, Edwards DG, Martin DF, et al: Etiology of iliotibial band
friction syndrome in distance runners. Med Sci Exer 1995: 951-960
6. Kendall FP, McGreary EK, Provance PG. Muscles: Testing and Function,
4th ed. Baltimore: Williams & Wilkins, 1993
7. Noble CA, The treatment of iliotibial band friction syndrome, British
Journal of Sports Medicine 1979 51-54
8. Orchard JW, Fricker PA, Abud AT, Mason BR: Biomechanics of iliotibial
band friction syndrome in runners. American Journal Sports Medicine 1996:
9. Sutker AN, Barber FA, Douglas W, et al: Iliotibial band syndrome in
distance runners. Sports Medicine 1985 447-451
10. Terry GC, Hughston JC, Norwood LA, The anatomy of the iliopatella
band iliotibial tract. American Journal of Sports Medicine 1986 39-45