What causes Iliotibial Band (ITB) Syndrome?
ITB syndrome is a repetitive use injury that presents itself as localized pain to the outer part of the knee joint. It is a particularly common knee injury in runners, and cyclists, but can also be found in other athletes. The iliotibial band is a long thick band of fascial tissue that originates in the pelvis and extends down the side of the thigh and inserts into different parts of the knee. It is generally believed that ITB syndrome comes from irritation brought on by repetitive flexing and extending the knee in biking, running, and frequently walking downhill. There is not one simple cause for ITB syndrome. We will explore some of the common causes and what you can do if you think you are developing, or have, ITBS.
Weakness and Impaired Motor Control of Hip Abductor Muscles
Weak hip abductor muscles have been linked to increased risk of ITB syndrome among long distance runners. The hip abductor muscles (gluteus medius/minimus) are important stabilizer muscles for the pelvis and essential to performing single leg exercises. Running is just a series of single leg exercises in rapid succession. These muscles, along with the rest of the lower extremity, need to work together to dissipate the force from your feet pounding on the ground. If the hip abductors do not function as well as they should, the impact forces can cause increased tension and irritation to the ITB.
Another way for ITB syndrome to occur is if there are impairments in hip abduction motor control. Sometimes the muscles in your hip will overcompensate for weakness in the knees and pull hard enough to cause your knee to cave inward. The consequence of pulling more and more inward while running is increased strain on the ITB.
Weakness of Knee extensors and Flexors/Low Hamstring to Quadriceps Strength Ratio
Muscles need to work together, and if one muscle or muscle group is significantly stronger than the ones around it, they can damage those weaker muscles. ITB Syndrome is frequently caused by having quadriceps that are weaker than the hamstrings. Understrength quadriceps are not as capable of assisting in the fine control around the knee joint and will cause the ITB to be pulled excessively by other muscles. This also interferes with the legs ability to dissipate the impact forces of walking and running, putting that stress on the ITB. In both cases you are much more prone to irritating or damaging the ITB.
Excessive Foot/Ankle Pronation
Pronation is the degree the foot rolls inward from the ankle, and a little is normal. Pronation of the foot and ankle helps to absorb the shock when the foot makes contact with ground while walking and running. Generally, the arch of the foot flattens to a degree when transitioning through the middle of your stance in walking and running. However, some peoples’ ligaments, tendons, muscles and bone structure of their foot do not limit this motion enough and can lead to the hip overcompensating. This usually causes the shin bone to rotate inward more than it should, which puts excessive tension on the ITB. So, anyone who has this particular issue is much more likely to irritate or injure the ITB when going on longer runs.
Sudden Changes in Walking/Running Mileage
As with any physical activity, rapid changes in the amount and intensity can catch our bodies off guard. Especially with running, the capability of the ITB to withstand the forces has been linked to both the volume and intensity of the workout. Running can be broken down into the overall time spent and the speed at which the person is moving. One day you might run 3 miles at a 6 mph speed and then another day run 1 mile at 8 mph. These changes in the workout can put different stresses on the tissues of the knee, especially the ITB. It is recommended that individuals do not go from running 1 mile to 10 miles in short time periods as that can lead to overstressing the knee. The same goes for the speed of your running. It will likely lead to injury if you try to go from completing a mile in 10 minutes to one in 7 minutes in a matter of a day or two. Our bodies are resilient, but too much, too fast and they will break, so make sure you make steady improvements, not jumps.
Too Slow/Fast Running Cadence
Some research has shown that an individual’s step rate, or cadence, while running might be too slow or fast causing an increase in impact forces on the foot and leg. In order to help individuals track their cadence, many smartphone applications are on the market today. RUNCADENCE is an application created by two physical therapists that helps novice and experienced runners modify their cadence in order to prevent running related injuries. Additionally, a Health Loft physical therapist will be able to provide a running evaluation on your running mechanics and provide a program to improve running cadence.
What are the symptoms of ITB syndrome?
Initially, most people usually complain of a generalized dull achy pain to the outside of the affected knee especially during physical activity such as running, cycling, or walking. For ITB syndrome it is important to note that the pain is specifically on the outside of the knee. If it is found somewhere else around the knee it means that it is almost certainly something else. This pain usually occurs towards the end or just after a workout but goes away after a short time. Usually, the pain begins after a long or very intense workout. In the initial stage, the outside of the knee may be generally tender to the touch. Many people describe burning as another symptom along with the dull pain.
With time and continued physical activity the symptoms can grow stronger and make simple activities like walking a few feet or going up and down stairs in the house painful. Many people find that the pain becomes sharper and more focused on one specific area. Some individuals describe symptoms radiating up and down their leg. The pain also seems to become more apparent earlier in a workout and can linger for longer periods afterward. This pain can get so bad that it occurs at rest. In a small number of cases people felt a snapping or popping sensation with movement.
Treatments for ITB Syndrome
Many forms of manual physical therapy for knee pain are used in the treatment of ITB syndrome. A large consensus of the methods used are in relation to reducing the irritation at the sight of the insertion of the ITB across the knee and “stretching” or “lengthening” the ITB. However, when looking at the research, it shows that the ITB cannot stretch the way we think under the influence of manual therapy7. More so, the target of manual therapy should be on the musculature around the knee plus the muscles that attach to the ITB. The tensor fascia latae and the gluteus maximus are two muscles that attach to the ITB closer to the hip. Therefore, physical therapy for knee pain should be targeting myofascial restrictions/tone in those regions along with limitations in thigh flexibility and ankle mobility. Manual stretching and passive massage techniques can be directed to the TFL and gluteus maximus as ways to relieve symptoms in ITB syndrome. Also, massage to the site of pain (outside of the affected knee) can help relieve acute symptoms but this method is only a short term solution7. One of the four quadriceps muscles, vastus lateralis, can be a source of tenderness and discomfort in individuals with ITB syndrome. Techniques of physical therapy for knee pain such as sustained pressure (foam roller) on the muscle belly of the vastus lateralis can cause a decrease in tone, sensitivity to touch, and an increase in pain threshold8.
Preventing the ankle from bending the foot upward during walking and running may cause increased ankle pronation which can cause ITB irritation. Joint mobilizations, passive stretching, and soft tissue massage can help improve ankle mobility. Joint mobilizations should address joint restrictions not only in the ankle but in the foot as well. The big toe plays a huge role in the mechanics of pushing off while walking and running. Any limitations in big toe extension can cause the ankle to increase in a pronatory manner.
Activity Modification/Footwear Evaluation
Running, walking, speed, distance, and cadence all effect the ITB and can be modified to allow for better treatment and healing of ITB syndrome. Some people who present with ITB syndrome as a result of running/cycling may need to stop performing the activity that is making their ITB syndrome worse for a little while. This allows time for the tissues to calm down in regard to inflammation and nervous system sensitivity. The amount of time required before you can resume your favorite activity depends both on the person and the amount of damage to the ITB. This could be as little as a week or as much as a month. Once you are able to start your activity again, it is important for you to slowly increase your distance/speed over a longer period of time.
It is possible that you may not need to stop altogether. You may be able to just reduce the distance you are traveling while exercising. It is very important for you to ease back into a running/cycling program with graduated steps. The timeline of these steps may take 2-3 times longer than expected. The general time frame of returning to running/cycling is variable but expect 3-4 weeks as a guide though can be up to 8 if the injury was severe.
Swimming, weight training, rowing, yoga, elliptical, and even walking are all alternative activities that can be performed if running is primarily causing your pain. If your pain comes from cycling, you should also avoid using an elliptical because they operate in a very similar fashion. Otherwise, the other activities are perfect substitutes to help maintain fitness and general well-being.
Remember that excessive ankle pronation can be a mechanical flaw in your gait causing ITB syndrome. Over the past 10 years as more and more individuals invest in running as their preferred form exercise. Consequently, your choice regarding the right footwear can be an important factor in your return to running/walking.
Footwear, to a moderate extent, has an effect on the mechanics of the foot and ankle. Many shoe-wear companies perform extensive product testing in order to create running/walking sneakers that help control excessive pronation at the foot and ankle. The anti-pronation aka “motion control” sneaker consists of a medial support at the arch of the foot to prevent flattening when weight bearing. Most shoe-wear companies have their own guides to understand how much pronation an individual has and whether someone is an “overpronator”. Some of these stores determine this via 3-D foot mapping or video gait analysis. If you have bought this type of sneaker, a wearing schedule must be followed. Running in shoes you are not used to can lead to further injuries. We covered the topic of choosing the right shoe for yourself in one of our previous blogposts, helping you understand what kind of shoe would work best for you.
Strength and Neuromuscular Control Exercises
It is important that the exercises specifically target the hip abductors/external rotators, knee extensors/flexors, and ankle pronators/supinators.
- Side Lying Straight Leg Raises
- Knee Extensions
- Hamstring Exercises
- Foot Doming – ankle supinator exercise
- Wall Sits
As the program continues, closed chain concentric exercises can be started such as squats, leg presses, lunges, and step ups.
Eccentric closed and open chain exercises are next in the progression. These include step downs, single leg squats, eccentric single leg press, Nordic hamstring curls, single leg balancing exercises.
- Step Downs
- Single Leg Squat
- Eccentric Single Leg Press
- Nordic Hamstring Curl (very high-level exercise)
- ITB stretch in standing
- Pigeon Pose to stretch the gluteus maximus
- Lying Figure 4 Stretch to stretch the gluteus maximus
- Child’s Pose to stretch the vastus lateralis
- Hip Flexor Stretches
- Ankle Dorsiflexion Stretches
Motor control exercises for the whole lower extremity and hip begin as soon as the acute pain phase is over (~1-2 weeks). Some strengthening exercises can overlap with some of the motor control exercises as there are similar components to each movement. Focusing on single leg balance exercises will comprise this component of the rehab program.
A variety of stretching protocols have been suggested in treating ITB syndrome. Most of these protocols focus on trying to stretch the ITB. As was stated before, the ITB cannot be stretched by means of exercise. Fortunately, there are ways to increase flexibility to the muscles that are attached to the ITB. There are stretches specific to the TFL, gluteus maximus, and vastus lateralis. Stretches to secondary areas will also be detailed below.
How long will ITB syndrome take to heal?
When combined with physical therapy treatments, most people are able to return to normal activity in 4 to 6 weeks. If the damage to the ITB is more severe it has been known to take up to 12 weeks. It has been shown that conservative therapy has resolved symptoms in 92% of treated cases. Many people feel symptom relief in as little as 2 weeks.
For an individualized treatment plan to help you with your ITB syndrome and to avail physical therapy for knee pain, consult with one of our physical therapists in Chicago (virtually via our telehealth platform or in person) by calling us at (312) 374-5399 or by scheduling an appointment online. If you have further questions we would also be happy to answer them. Remember to also check out our Facebook, Instagram, and Twitter pages for more fun facts and articles on nutrition, physical therapy, and exercise!
Written by Dustin Passigli PT, DPT, OCS, MA Edited by Alexander Franz Reviewed by James Caginalp PT, DPT, CSCS, CES, PES
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