IT band syndrome: Everything you need to know

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What is your IT band?

The iliotibial band (ITB), or ‘IT band’ as it’s more commonly known, is a ligament-like structure that starts at your pelvis and runs along the outside of your thigh to the outside of the top of your shinbone (tibia). When you run, your IT band stores and releases energy, just like an elastic band. As the leg comes behind us, the IT band begins to tighten. Then, as the foot leaves the ground, this stored energy helps to propel and swing the leg forward.

‘The IT band crosses your hip and your knee, so it works to stabilise both when we are moving around, including when running,’ explains Jodie Breach, national physiotherapy lead at Nuffield Health. ‘At the top of the leg, your glutes and tensor fascia latae muscles (TFL) insert into it and are able to control some of the tension running through it.’ These muscles also help to control movement at the hip and knee during the gait cycle, so weakness or a lack of control here is often the reason for someone’s knee drifting inward on landing.

What is IT band syndrome?

Somewhere between 12% and 52% of runners complain of IT band syndrome, according to Breach. While it is often called iliotibial band friction syndrome, she explains that ‘the latest accepted terminology is iliotibial band syndrome, as we no longer believe that friction is the main driver of the symptoms.’

What are the main symptoms of IT band syndrome?

The main complaint of IT band syndrome is of pain on the outside of the knee – sometimes sharp, but often aching – that comes on after an activity like running. Going up and especially down stairs and steep inclines will often be an aggravating factor, too.

The pain can sometimes spread up the outside of the leg toward the hip and it often sore to touch on the outside of your knee. ‘If it is particularly acute, it may look red and swollen,’ says Breach. ‘But as it is more often than not an overuse injury, this is unusual. Normally, it is more of a grumbling pain,’ says Breach.

If the area is acutely swollen, red or very locally tender to touch and you can remember an incident such as falling over or heavily bashing the outside of your knee while running, seek expert medical advice to rule out anything bone-related.

What causes IT band syndrome?

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‘It was thought that the cause of pain was friction between the lower end of the IT band and the outside of the knee, and that an overly tight IT band caused it to roll tightly over the outside of the knee, resulting in friction and irritating the underlying soft tissues,’ she says. ‘This led to treatments being based on attempting to stretch out the IT band to prevent this friction.

‘However, this model has now been challenged, as the IT band has numerous attachments down our femurs,’ continues Breach. ‘This means that not all of the load is placed through the knee attachment. There are also studies showing that the ITB does not ‘roll over’ the outside of the knee with flexion and extension. Instead, the pain is thought to emerge from the compression of a pain-sensitive fat pad that exists on the outside of the knee.’

Why do some runners get IT band syndrome and others do not?

Breach says that around 60% of cases of IT band syndrome in runners are caused by an element of training error, where the amount of load through the IT band has been increased too quickly. This could be a consequence of increasing running mileage too quickly, or adding in hill work – in particular, running downhill.

‘There is also evidence that those with IT band syndrome have weakness in their hip abductor and external rotation muscles, which may lead to increased adduction of the leg and therefore load through the IT band,’ adds Breach.

Some runners with IT band syndrome have also been found to have a ‘crossover’ gait, where they run with their feet close together, which increases this adduction movement. If the issue underlying the cause of your symptoms is not resolved – no matter how much rest you have – it is likely that your symptoms will, at some point, return.

Should you stop running with IT band syndrome?

Not necessarily, says Breach – it will depend on just how irritable and sore your IT band feels. ‘If you are able to modify your running by reducing mileage or hills so that you do not get an increase in pain following the run, you can keep going,’ she explains. However, if even a small amount of running causes the pain to increase significantly, you should stop until it settles down, then build up very slowly again.

If you plan to embark on some intensive cross training while managing IT band syndrome, be careful not to add too much cycling into your training routine. ‘Cycling can actually be a contributor to IT band syndrome, so you may have to adjust this as well if it increases the pain,’ says Breach.

How do you fix ITB syndrome?

The most important thing to do is to try fixing the things that are offending the IT band. ‘Sometimes the IT band is too tight, sometimes the glute muscles aren’t strong enough and sometimes the feet are rolling in, says Jordan Metzl, a sports medicine physician at the Hospital for Special Surgery in New York City. ‘All these things can contribute to overloading the IT band.’

Breach says that you should focus on rehabilitation by managing the load, so reduce your running to a manageable level to calm things down initially. Like Metzl, she suggests looking at the cause in order to manage the symptoms. ‘Another way you could try to manage load is by experimenting with gait re-education,’ she explains.

How to gently tweak your running gait

It’s never a good idea to radically change your running form. By changing how you run, you are altering where the load is being placed and the structures being exposed to it. If these structures are not robust enough to tolerate the load, injury will likely occur – but there are form ‘cues’ or drills that you can do to help.

To reduce a crossover gait, which has been linked with IT band syndrome, try running either side of a white line while making sure that each foot stays on the ‘correct’ side. Running drills such as walking lunges others say its pointless and possibly even counter-productive.

In addition, if you are someone who tends to overstride while running, you can try increasing your In addition, if you are someone who tends to overstride while running, you can try increasing your by 5-10% to see if this helps the irritation at the outside of your knee.

Any changes you choose to make must be done gradually over a period of months, to allow the muscles, tendons and other structures to adapt to this new way of moving.

What exercises help with IT band syndrome?

To begin, Breach recommends focusing on hip strength and control to help manage the load through the outside of your knee. Start in non-weight bearing positions, then progress to standing and dynamic activities.

Strength exercises

Hip thrusters

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Sit on the floor with your knees bent and feet on the ground, but with your upper back and shoulders onto a raised surface like a stability ball, bench, chair or sofa.
Looking down your body, keeping your feet firmly driven into the floor, engage your glutes and lift up your hips until your body forms a straight line from shoulders to knees.
In addition, if you are someone who tends to overstride while running, you can try increasing your.
Aim for three sets of 15 reps.
As you get stronger, bring in weight by placing one weight horizontally across your hips. As you build weight, aim for three or four sets of 8-10 reps.
Do this exercise twice a week.

Hip hikes

Place your right leg on a step with your left leg suspended to the side.
Allow your left leg to slowly fall towards the ground (without touching it) by allowing your pelvis to slowly drop down. Keep your right leg as straight as possible.
Hold for a couple of seconds before using your hip muscles in your standing leg to raise your pelvis back up to the starting position.
Aim for three sets of 15 reps.
Once this exercise feels too easy, you can progress by adding a small weight (5-10kg) in the hand opposite to the standing leg. This will challenge the glute in the standing leg more.
Do this twice a week.

Banded glute pulley

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others say its pointless and possibly even counter-productive.
On the standing leg, keep the foot facing forward with the knee slightly bent and aligned over the third and fourth toes. Maintain this position throughout.
Keeping the opposite leg straight, perform a ‘pulley’ motion, whereby you pull the leg diagonally back to 45 degrees. The movement should be purely from the hip, so don’t rotate or twist from the waist or upper body.
Gently ‘brace’ through your trunk throughout the exercise and do not allow your lower back to arch, or your body to lean forward excessively.
Aim for three sets of 15 reps.
Do this twice a week.

Movement control exercises

Banded split squat

Place a resistance band around your right leg, just below the knee, and secure it to a secure, heavy object directly to your left side.
With your feet hip-width apart, take a big step backward with your left leg onto your toes so that you are in a split squat position.
Keeping your torso upright, drop the back knee toward the floor until the shin is parallel with the ground. Your front knee should bend to 90 degrees and not go beyond the end of your toes.
The focus is on keeping the front knee aligned over the middle of the foot, against the resistance of the band pulling the front leg inward.
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Do this two or three times a week.

High knee into reverse lunge

This is a slightly tougher version of the banded split squat. Perform the exact same movement, only drive the back leg up and over the resistance band into a high knee position as you rise up from the squat position.
From here, take the leg back over the resistance band and step back into a reverse lunge.
The focus, again, is on ensuring that the front knee remains over the middle of the front foot throughout the movement.
Do men and women process pain differently on both legs.
Do this two or three times a week.

More challenging exercises

Step-ups

If you feel that the strength and movement control exercises detailed above are getting easy and your IT band pain is settling, Breach suggests progressing to more dynamic exercises like step-ups. Be sure to keep your pelvis in a neutral position so that your lateral glutes are working.

Start by standing in front of a small box – one that is 30cm in height is a good start.
Begin with your left leg already planted on the box.
Push through your left leg to lift yourself up, driving your right leg through in front of you into a high knee position.
Step back down with your right foot. Focus on bending at the hip and knee on the left leg to ensure that the knee remains over the middle of the foot and doesn’t collapse inward.
To make this more challenging, begin with the front foot hovering over the step so that you have to plant the foot down into the step to lift yourself up.
Do men and women process pain differently.
Do this twice a week.

Walking lunges

Chartered physiotherapist Matt Bergin recommends working running drill like walking lunges into your routine. ‘These will challenge the control around your pelvis, hip and knee and work on your foot placement,’ he says.

Stand with your feet hip-width apart.
Take a big step forward onto your right leg, ensuring that your feet don’t zig-zag and cross over.
Drop the back knee down toward the floor until the shin is roughly horizontal with the ground. Using your front foot, push through the ground to lift yourself into the next forward lunge, this time stepping forward with the left leg.
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What else can you do to treat IT band syndrome?

‘Often, a poorly controlled foot and ankle can really change the force mechanics around the knee and hip, and that has been implicated in IT band syndrome as well,’ says Metzl. ‘If you demonstrate poor foot and ankle control when running and you’re getting IT band syndrome, it may be time to think about strengthening those muscles and working on the control around the ankle. This, alongside wearing an orthotic or simply ensuring that you’re wearing appropriate running shoes for the job.’

Should you foam roll the IT band?

It’s a surprisingly divisive issue – while some physiotherapists have recommended foam rolling, others say it's pointless and possibly even counter-productive.

‘We don’t think that you can actually stretch the IT band at all, as it is such a tough, strong band,’ explains Breach. ‘It has been shown that the force required to change the length of the IT band by just 1% is far beyond what any stretch or manual therapy such as foam rolling can achieve. So although I do not believe that foam rolling will do any harm, it will be very painful and not necessarily produce any benefit!’

Foam rolling over the sore area on the outside of the knee could also provoke further pain, she explains. ‘However, your glutes and TFL insert into the band, so could themselves be stretched to see if that gives some symptomatic relief.’

That said, limited research suggests that foam rolling may still have short-term benefits in terms of range of motion across a joint. So, spending up to 10 minutes rolling your quadricep muscles – especially the outer quadriceps – will do no harm and may even provide some relief. But, addressing and modifying your training and doing rehabilitation work should be your main area of focus.

How long does it take to recover from IT band syndrome?

According to Jenkins, these are the recovery rates of IT band syndrome, depending on the severity of your injury...

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‘We treat the IT band as being like a tendon,’ says Breach. ‘These type of injuries tend to take at least three months to recover from, so you need to dedicate some time to the progressive loading exercises and listen to your body to work out if you need to slow down. Overall, however, the prognosis is good and you will recover.

‘If you are not making any progress despite following this advice, it is important to seek the advice of a physiotherapist so they can individually assess you and see if there are any other factors influencing your recovery,’ she adds.