Pain and tenderness on the outside of your knee can indicate an iliotibial band syndrome. ITB syndrome is classified as a non-traumatic, overuse injury. Non-traumatic means there was no physical incident or contact with the Iliotibial band, but occurred more due to biomechanical insufficiencies such as weak hip abductors.
Hip abductors are responsible for the outward movement of your hip. Repetitive flexion (bending) and extension (straightening) movements of the knee can cause overuse. In short, these repetitive movements cause friction between the ITB and the lateral femoral epicondyle (the bony part that sticks out on the outside of your knee). Therefore, runners and cyclists are more prone to develop Iliotibial band syndrome.
What is the iliotibial band?
The iliotibial band (ITB) runs from the outside of your thigh (at the iliac crest on your pelvis) and attaches on the outside, just below your knee, to the tibia (shin bone). It is a thick, fibrous band that follows out of the TFL (tensor fascia latae muscle) on the side of your hip. The TFL is a very small muscle that aids in the outward movement of your hip.
When the Iliotibial band inserts onto the tibia, it runs past the lateral femoral epicondyle (distal part of your thigh bone) and a part of the patella (kneecap), but due to having no attachment there, it is free to move forward and backward across these structures. With an increase in flexion, extension and wrong biomechanics during the movements, an injury is inevitable.
What does the ITB do?
The iliotibial band is a strong, fibrous reinforcement of the TFL muscle. It acts as insertion site for muscle around the hip to produce hip extension (moving backward), abduction (moving sideways) and external rotation (turning toes and leg outwards). Because of the ITB attachment to the outside of the knee it also plays a role in knee stability. Especially if you have one foot planted while moving, like running or landing from a jump.
Causes of iliotibial band syndrome
The repetition of knee bending and straightening increases your risk to develop ITB syndrome. Iliotibial band syndrome may also result from over training, muscle imbalance (running in the same direction around the track), incorrect running technique, and changes in training routine. This condition is common in sports such as running or cycling.
This doesn’t mean you should stop participating in your sport, but we can help you correct those movements and prevent the recurrence of your injury.
Other causes:
- Weak hip abductor muscles (TFL, Gluteus medius, Gluteus Maximus) which cause uncontrolled internal rotation of your hip when weight bearing. This leads to your knees “knocking” when you cycle or run. Knock knees increase the angle over which the ITB must glide, and friction escalates.
- Change of shoes.
- A sudden increase in distance or pace.
- Change of the surface you run, walk or cycle on.
- Improper bike setup.
- Incorrect running technique.
- Long distance running.
How does ITB syndrome develop?
During knee extension (straight knee), the ITB lies anterior to (just in front of) the lateral femoral epicondyle (that bony part on the outside of your knee). When your knee is bent at 30 degrees or more, the band lies to the back of the epicondyle. The forward and backward movements of the iliotibial band cause compression and the friction forces irritate the band.
Four muscles regulate ITB movement
Both the Bicep Femoris and Gluteus medius muscles regulate how much the band is pulled backwards, while the Vastus Lateralis and Tensor Fascia Lata muscle regulates the forward sliding of the iliotibial band. A discrepancy between the front and back forces cause the iliotibial band to desynchronize the forward and backward sliding of the knee when moving through its range – this is crucial to understand about this problem.
See the iliotibial band as a cable that regulates the outward stability of your upper thigh. If there is a dominant forward pull, your ITB translates forward under higher pressure due to increased tension, but exactly the opposite might also be the case with the muscles at the back. As a result of the length and strength imbalance of the muscles, pain will develop over the ITB due to these abnormal forces. This rubbing and friction causes inflammation at the site, and usually spreads upwards along your upper thigh.
This also leads to inflammation of the ITB bursa, which is a fluid filled sack that should protect the band from rubbing against the outside of the femur. With the repetitive bending & straightening of your knee it triggers the bursa and band to get inflamed and painful. Tibial rotation further complicates the problem, seeing that the ITB anchors on the head of the fibula and the front of your shin – Excessive tibial rotation inwards will aggravate your pain.
Muscle imbalance – is the most important component to fix when dealing with Iliotibial band syndrome.
Symptoms of ITB syndrome
The first sign of ITB irritation is pain on the outside of the knee, particularly when walking down stairs or running downhill. At first you’ll notice the pain is worse at the start of your run, and gets better during your run, but your pain will progressively return after you’ve jogged.
As the irritation continues you’ll notice that the activity required to bring on your pain gets easier i.e. At first only after interval running, then a slow jog or even just walking, climbing stairs brings on the pain.
Running makes the Iliotibial band syndrome pain worse, especially when going downhill. You may also notice swelling around the outside of your upper leg. Bending the knee, especially the first 30 degrees is painful. ITB syndrome starts off as pain on the outside of your knee that gradually migrates upward along the outside of your thigh.
Self Test
How bad is my ITB syndrome?
If you experience one incident of lateral (on the outside) knee pain as a runner, statistics should be enough to get you in a consultation room. Van der Worp et al. (2012) found that 5-14% of runners experience ITB friction syndrome. In one way or another, the ITB can be responsible for 22% of all lower limb injuries. For a small muscle belly (TFL) and a large tendon, that is a lot of blame to carry.
The ITB is the perfect scape goat though, it crosses the hip and the knee for one, which means a problem with one can result in a problem with the other. If there are any imbalances between the outside and front of the thigh, the ITB and quadriceps (specifically the vastus lateralis) or imbalance between the front and back of the thigh, quadriceps and hamstring (specifically the bicep femoris) it ultimately influences your hip stability (gluteus medius). Imbalance can then cause uneven distribution of forces across the joint (hip or knee).
Repetitive flexion extension (bending & straightening), together with inefficient load transfer, causes friction on the lateral femoral condyle. This friction cause inflammation of the bursa (bursitis). As the inflammation in the area stays, the tendon undergo changes. Tendons have poorer blood supply than muscles and therefor take longer to heal. Tendons like being warm, so initially exercise may reduce your symptoms, but later – not so much.
When your ITB is sore during, after and the day following exercise the tendon becomes degenerative. This degeneration will lead to micro tears, which causes more inflammation. This avalanche of change, partial tears, vascularization and chronic inflammation, prolong your healing, and may further influence biomechanics.
Diagnosis of iliotibial band syndrome
Our physiotherapists use tests to help determine your diagnosis. During our subjective evaluation, where we ask you questions and talk about your symptoms, it may already become clear whether you are suffering from ITB syndrome. Then we do a physical examination during which we assess all the structures surrounding your knee to pinpoint the problem and ensure if there’s any other structures involved.
We’re confident that we’ll diagnose the severity of your Iliotibial band syndrome pain and explain what we find. In most cases other tests like X-rays, CT-scans or MRI scans are not necessary. Clinical tests include :
- Ober’s test
- Noble’s compression test
- Thomas test
- Standing Bow test
- Quadriceps length test
- Step down test
Ultrasound (diagnostic)
This is the preferred test to establish if you have ITB syndrome, if your physiotherapist deems it necessary to go for further tests. We will be able to see that the tendon has a larger diameter in comparison to the unaffected side. Ultrasound will also show changes of water content within the tendon, collagen integrity as well as bursa swelling. An ultrasound will be sufficient to determine what we need to know and confirm your diagnosis.
Doppler
A Doppler test will show neovascularization, this is when arteries grow into the tendon in an attempt to improve blood supply. This however is not a good thing. Iliotibial band syndrome that’s neglected for a long time ends up with severe pathological changes to the IT band.
MRI, CT or other imaging tests
Other imaging tests will not be necessary but may be useful to exclude other conditions. Doing an MRI for suspecting ITB syndrome is expensive and unnecessary.
Why is the pain not going away?
Once the ilitotibial band becomes inflamed because of friction, any friction will offset the inflammatory response. Rest may improve your symptoms, but if you don’t address the cause of the friction (faulty biomechanics, muscle weakness) it will keep coming back.
Rest needs to be considered as responsibly as activity and training. Too little rest don’t give the tissues the time off needed to heal in between training or treatment sessions. Too much rest reconditions the muscles, which may actually worsens symptoms when you do get back too training. You need to be Goldilocks and find what is “just right”. We can help you find the balance.
What NOT to do
Making the injury worse
A big problem we see with ITB syndrome
“I hoped it would get better by itself” or “resting helped in the beginning”, both these hopes or attitudes delay athletes to seek treatment. It ultimately prolongs your recovery, because of the snowball that turns into an avalanche.
There are many different structures around the knee and even more structures from the back, hip, calf and ankle that can influence the load on your ITB. Accurate diagnosis of the structures involved, and structures contributing to your unique problem, is essential to treat and prevent recurrence.
You won’t walk with a crutch for weeks, so why would you jog with a compression brace without getting your ITB checked? Any type of “crutch” is for temporary symptom relief, not for long term use.
Risk for complication due to compensation
Untreated ITB syndrome symptoms may lead to persistent long-term pain in your knee that progresses towards your hip. This will affect your ability to cycle and/or run at the intensity and distance you would like to, and it may even progress to such an extent that you may have to stop participating in your sporting events until your ITB heals.
The likelihood of injury is higher in women than men, due to an increase in what we call the “Q-angle”, which is the angle formed between the lateral hip and inside of the knee. Hormone levels, tendon cartilage thickness and glute strength can also deem women more vulnerable to injury.
Physiotherapy treatment of ITB syndrome
The treatment for ITB injury is conservative. Physiotherapy should be your first line of treatment. We have the skills to identify the contributing factors, diagnose the problem and guide you in your rehabilitation. Physiotherapy will be aimed to address the whole problem. Myofascial release and deep dry needling can be used to gain muscle length, electrotherapy is used to decrease inflammation and pain and specific strengthening exercises will get you back to your sport.
Phase 1: Acute inflammatory response
We help modify your activity and promote active rest during this period. For example, we will advise that you lower your intensity and distance with running, but to substitute your activity with something like swimming. This will help alleviate your symptoms but you will maintain a certain level of your conditioning at least. It can last anything between 1 to 4 weeks of rest, depending on your severity.
Modalities may include Ultrasound, Dry Needling and strapping for support and to offload the tendon.
Home advice:
- Self massage of your iliotibial band with a hard foam roller (even if it is painful)
- Core stability and glute exercises, to maintain overall fitness and hip stability
- Ice after any activity that may have aggravated your ITB
Phase 2: Regain muscle length
Treatment during this time will focus on restoring the muscle length imbalance between your gluteus, hamstring, quad and calf muscles. This eliminates abnormal forces onto the ITB and it’s anchor site on the outside of your knee. It’s of very important to address theses imbalances to minimize the continuous friction. Dynamic or static stretches of the structures around your upper thigh is crucial to clear your Iliotibial band syndrome pain.
You may begin:
- Dynamic stretches
- Static stretches
- No resistance cycling
Phase 3: Regain hip stability
Treatment during this time will focus on restoring the muscle strength, especially the ITB’s ability to withstand the repetitive loading – without flaring up your pain. We reintroduce loading and strengthening exercises aimed at your gluteus, hamstring, quadriceps muscles. These muscles play a vital roll in providing knee stability as you move your knee through its range of motion.
Muscles on the outside of your knee should contract simultaneously to prevent your knee from bucking inward. You should now be able to perform weight-bearing glute exercises without pain. This stage usually lasts 4 to 6 weeks, but again, it all depends on your specific degree of injury.
You may begin:
- Functional warm-up drills
- Walking such as lunges & squats
- Working on a cross trainer and stepper as the pain allows
Phase 4: Endurance
Gradual build up into your previous intensity of training and to determine if the ITB injury is able to withstand the repetitive loading without causing an irritation over the femur. Our physiotherapist guides you to reengage in safe increments. We’ll follow your progress and adapt where needed.
You may begin:
- Slow jogging
- High function training
- Plyometrics
Phase 5: Final rehabilitation
This is the final stage of rehabilitation and can last anything from 6 weeks to 4 months. Your treatment will still include myofascial and trigger point release, electrotherapy, but functional rehabilitation is most important during this phase.
Our physios will help you to get back on (the) track, so to speak. During this stage you will build up to your ideal mileage and intensity again, with maintenance sessions on a bi-monthly basis. We will keep an eye on the hip and knee stability muscles and the length of your TFL, glutes, hamstrings and quads. Here we make sure your biomechanics are correct and that your running and cycling style is sustainable, to prevent recurrence of your Iliotibial band syndrome pain. Finally, we include plyometrics, drills and endurance activities to your program.
Here you may:
- Enjoy your running
- Cycle
- Monitor your symptoms while participating
- Keep rolling and icing after events and training
Cover all your planes of movement
One of the main culprits that causes ITB syndrome is a knee that falls in when running. (You have seen and laughed at this before. It looks like your feet flap towards the outsides of your legs, like Phoebe in Friends). Get your running buddy to take a video of you running directly towards or away from them, so that you can laugh at yourself if necessary. This happens because of weak lateral control of the pelvis and the hip. A common problem due to the single plane emphasis with running and cycling. These sports have very few side to side (lateral) movements. If this is not addressed early in your rehabilitation it will lead to the same issues.
One of the best exercises to perform to assist with this is a rear foot elevated split squat, also known as a Bulgarian split squat. This exercise can be weighted, with the weights at shoulder level or in the overhead position to raise the center of gravity. As the center of gravity is raised higher than the pelvis, more pelvic stability is required to perform the exercise. The exercise should be done in front of a mirror to make sure the front knee doesn’t fall in. A theraband can be used to assist the front leg to slightly push the knee outwards to prevent the collapse.
There are various exercises that can be used to improve the inwards collapse of the knee. The split squat should however form part and parcel of your strength training. The exercise is extremely versatile and provides considerable feedback if there are any weak links in the kinetic chain.
If your ITB symptoms have not improved within a month despite rest and short-term treatment
Your physiotherapist will refer you to a specialist to give you an injection into the area to relieve the pain. In very rare circumstances if all non surgical treatment fails your Physio may refer you to an Orthopaedic surgeon to surgically reduce the friction on the ITB tendon.
Surgery for ITB syndrome
Surgical release of the ITB can be done with the aim of increasing length and decreasing friction. The back part of the tendon is cut through. Essentially you get a surgical tear of your ITB. Recovery takes 6 – 8 months.
Please remember that nothing has been done to the biomechanics of your knee and thigh – so I’d caution you before you opt for surgery. After the surgery you’d have to follow a rehabilitation program for 2 – 6 months to ensure your Iliotibial band pain doesn’t return.
Recovery time
Rest and pain medication should alleviate your symptoms, but we must tend to the underlying biomechanical fault to ensure complete recovery. If this biomechanical fault is not restored, the pain will resume every time you take part in your activity again. With appropriate management you should recover fully within 8 weeks. On rare occasions that surgery is necessary, most people recover fully within 12 weeks of the operation.
Other medical treatment for ITB syndrome
Analgesics (pain killers) and anti inflammatories can be prescribed by your GP or recommended by a pharmacist. We strongly advise you to not take anti inflammatory medication within the first 48 hours after your symptoms start. Inflammation kick starts healing, don’t hinder your body’s internal healing protocols. Analgesic medication makes you comfortable while actively pursuing your rehabilitation. Medication won’t heal your Iliotibial band syndrome.
Injections is a quick fix in terms of pain reduction because it takes all the inflammation away. No initial inflammation actually halts tissue healing and influences the integrity of the ITB. If you load, strain and inject you may contribute to long term bad movement patterns and ultimately compensation strategies that will be difficult to break.
A knee brace may feel good because of the compression it applies to the outside of your Iliotibial band. There is no instability in your knee with ITB syndrome, so you don’t need a brace for stability. Restricting your movement (in that first ouchie 30 degrees flexion) can relieve friction and decrease inflammation. This is better achieved with strapping that a brace of the shelve.
Biokineticists can be consulted during the final phase of your rehabilitation to continue conditioning. This aids your endurance and strength and improve your overall performance. Discipline is necessary to maintain what you have gained during treatment to prevent recurrence.
What else could the pain be?
Injury to the meniscus normally involves a rotation upon landing, think landing from a jump and changing direction. Pain will be felt more with weight bearing and deeper than ITB syndrome.
Lateral collateral ligament injury usually accompanies lateral meniscus injuries. Pain from this structure will be more superficial and elicited with pressure that tensions the ligament.
Bursa are found throughout the body as a little pouch of fluid that decrease friction. Inflammation or increased fluid will be seen as swelling on the outside of the knee and may feel warm to the touch.
The vastus lateralis is part of the quadriceps muscle. Injury to this part of the muscle usually accompanies a powerful contraction against resistance, like lifting weight in the gym (knee extension machine) or blunt force trauma (rugby tackle).
Peroneal nerve impingement
The peroneal nerve can become impinged where it curls behind the superior tibiofibular joint and will give “nervy” symptoms, like numbness or pins and needles.
Patellar maltracking
Different angles of the patella or muscle imbalances, may cause the knee cap to follow a less than optimal path along the femur as the knee bends which can cause strain to the structures involved.
Superior tibiofemoral joint sprain
Injury to the joint just below the knee, where the tibia and fibula articulate can be caused by repetitive ankle sprains.
Referred pain from the lower back
Structures from the lower back may refer pain down the glutes into the outside of the thigh. This may have “nervy” qualities (numbness, pins & needles) and be unusually painful without a history of knee injury or overuse.
To stretch or not to stretch the ITB….that is the question
ITB syndrome is a common running and cycling overuse injury that we treat. The incidence is as high as 12% of all running-related, overuse injuries.
This is commonly managed by foam rolling the ITB itself or prescribed stretches. The structure of this specialised connective tissue doesn’t allow for stretching! It can be tensed but not stretched. In cadaver studies it has been shown to be ‘stretched’ by almost 2mm. In a 2017 study the ITB was completely dissected out and machine stretched, resulting surprisingly in only a few millimeters stretch. Now to put that in perspective: In an ideal alignment, with the band totally isolated and machine stretch it still has less stretch than a towing rope or a rock climbing rope.
The second method is foam rolling. Now with the above mentioned in mind how will direct application of force over the band change its length? Simple: it doesn’t! It could assist in a minor way is by rolling the Vastus Lateralis (Quadriceps muscle), Biceps femoris (hamstring muscle) and the Tensor Fascia Latae (Hip flexor muscle). This means that you should not roll on a 90 degree angle on the ITB, but at 45 degrees to the ITB and making sure it goes up high enough to reach the Tensor Fascia Latae.
We specialize in:
- Marathon and Ultra marathon runners including Comrades and Two Oceans
- Trail runners, social runners, park runners
- Cyclists in all forms: MTB, road, adventure
- People who want to look after their bodies while functioning at their highest possible level
ITB also known as
- Iliotibial band syndrome
- ITBFS (Iliotibial band friction syndrome)
- Iliotibial band pain
- inflamed ITB
