Iliotibial Band Syndrome (ITBS)

What the IT band is and why it hurts

The iliotibial band is a thick strip of connective tissue running down the outside of the thigh. It starts at the hip, where the tensor fasciae latae and gluteus maximus muscles attach to it, and ends just below the knee on the shinbone. It stabilizes the outer knee and hip, especially when one leg bears your weight.

When the knee bends to about 20 to 30 degrees, the band passes over the lateral femoral epicondyle, the bony bump on the outside of the lower thighbone. This happens just after the foot strikes the ground in running. Older theory blamed the band "rubbing" back and forth. Current evidence suggests the pain comes from compression of a sensitive layer of fat and tissue under the band at that point. Either way, repetitive loading without enough recovery inflames the area.

Symptoms

• Sharp, stinging or burning pain on the outside of the knee, a few centimeters above the joint line
• Pain that starts at a fairly consistent time or distance into a run
• Worse running downhill, descending stairs and with long strides
• Pain that may spread up the outside of the thigh toward the hip
• Sometimes a clicking or snapping sensation over the outer knee
• Little or no swelling, and the knee does not lock or give way

Early on, pain stops soon after exercise. Untreated, it can come on sooner, persist after exercise and hurt with walking.

Causes and risk factors

Training errors (the most common cause)

• A rapid increase in weekly mileage, speed or long runs
• Lots of downhill running
• Always running on the same side of a cambered road
• Running on a track in the same direction
• Cycling with a saddle set too high or cleats turned inward

Body factors

• Weak hip abductor muscles, especially the gluteus medius, letting the knee drift inward
• Previous IT band syndrome
• Leg length difference
• Bowed legs (genu varum)
• Excessive inward rolling of the foot, though evidence here is mixed

How ITBS is diagnosed

A doctor or physical therapist diagnoses ITBS from your history and examination:

• tenderness over the lateral femoral epicondyle, about 2 to 3 cm above the joint line
• Noble compression test: pressing over the bony bump while bending and straightening the knee reproduces pain at about 30 degrees
• Ober test: checks tightness of the IT band and hip
• Hip strength testing: single-leg squats often show the knee collapsing inward

X-rays and MRI are usually not needed. An MRI may be used if symptoms do not improve, to rule out a meniscus tear or stress fracture.

ITBS vs other causes of knee pain

People often call ITBS "runner's knee", but that name is more commonly used for patellofemoral pain. See runner's knee for front-of-knee pain.

Treatment

Phase 1: settle the pain (first 1 to 2 weeks)

• Reduce the load, rather than stopping all activity. Cut mileage, stop downhill running and speedwork, and cross-train with swimming or flat cycling if pain-free.
• Ice the outer knee for 15 minutes after activity if it helps.
• NSAIDs such as ibuprofen can ease pain for a few days. Follow the label dose and avoid them if you have kidney problems, stomach ulcers or take blood thinners.

Phase 2: strengthen and correct

• Hip strengthening: side-lying leg raises, clamshells, side planks, single-leg squats and step-downs, focusing on keeping the knee in line over the foot.
• Stretching and mobility: hip flexor and glute stretches. Foam rolling the outer thigh may ease tightness for some people, though it does not lengthen the band itself. For more on tightness and rolling, see tight IT band.
• Running form changes: increasing step rate (cadence) by about 5% to 10% shortens the stride and reduces load on the outer knee.

Phase 3: return to running

• Start with short, flat runs on alternate days, stopping before pain starts.
• Increase distance by no more than about 10% a week.
• Add downhill running last.

When symptoms persist

• Corticosteroid injection into the area can relieve pain short term when other measures fail.
• Surgery to release or lengthen part of the band is reserved for rare cases with symptoms lasting more than 6 months despite good rehab.

Recovery time

Mild cases often settle in 2 to 4 weeks. Most people return to full running within 4 to 8 weeks. Long-standing cases can take 3 months or more. Rushing back to previous mileage is the most common reason for relapse.

Preventing IT band syndrome

• Build mileage gradually and include rest days.
• Keep strength training for the hips and glutes year-round.
• Vary running surfaces and switch direction on tracks and cambered roads.
• Replace running shoes every 500 to 800 km (300 to 500 miles).
• Check bike fit, especially saddle height and cleat position.

Frequently asked questions

What does IT band syndrome feel like?

Usually a sharp, burning or stinging pain on the outside of the knee, just above the joint, that comes on at a similar point in each run or ride. It is often worse going downhill or down stairs and eases with rest.

How long does IT band syndrome take to heal?

Most people improve within 4 to 8 weeks with reduced training and hip strengthening. Mild cases may settle in 2 to 4 weeks. Long-lasting cases can take 3 months or more, especially if training is increased too quickly.

Can I keep running with IT band syndrome?

You can often keep running shorter, flatter distances if you stop before pain begins. Running through sharp pain usually prolongs recovery. Cross-training such as swimming helps maintain fitness while the knee settles.

Does foam rolling fix IT band syndrome?

Foam rolling may reduce the feeling of tightness and ease pain for a short time, but it cannot stretch the IT band itself, which is very stiff tissue. Strengthening the hip muscles and adjusting training load are the treatments with the best evidence.

What is the best exercise for IT band syndrome?

Exercises that strengthen the hip abductors, especially the gluteus medius, work best. Side-lying leg raises, clamshells, side planks and single-leg squats with the knee kept in line are good starting points, done several times a week.