This blog discusses current trends around the treatment of runners with ITB pain and does not constitute medical advice. If you have knee pain (or any pain for that matter) associated with your running activities, please consult with a clinician for a proper assessment.
The Iliotibial Band (ITB) Demystified: Identifying & Defining IT Band Syndrome
In part one of this multi-part blog series, Dr. Jeff Moreno down the symptoms and causes of one of the most common running injuries: ITB Syndrome. Running is one of the most popular and accessible forms of exercise: approximately 40 million people run regularly in the US alone, and 10 million of those run 100+ days per year1. With that said, running has unfortunately been associated with a high risk of injury. It has been reported that as many as 79% of runners suffer from a running-related injury in a 12-month period.2
Approximately 50% of running-related injuries are concentrated around the knee2,3. One of the most common forms of knee injuries is characterized by lateral knee pain—Iliotibial Band (ITB) pain to be specific—and is known as IT Band Syndrome, which accounts for as many as 14% of running-related injuries4.
Identifying IT Band Syndrome
Characterizing IT Band Pain
ITB pain is typically sharp and localized, located on the outside of the knee just above the point where the upper leg becomes the lower leg. The IT Band starts at the side of your hip and travels all the way down your femur to attach onto the lower leg, crossing over the outside of your knee during the process5,6. It is here that impingement, stemming from any number of factors I will discuss below, causes pain.
Connecting the Dots: Common Symptoms
My knee hurts when6…
running down hills
running slowly on flat surfaces
walking down stairs (or hills)
my leg is behind my body and moving forward
I have minimal or no pain with…
riding a bike
walking and/or running up hills
running in place (usually)
high speed running (usually less pain)
Defining IT Band Syndrome
What Specifically Causes ITB Pain?
First, every runner needs to understand that most running injuries are training load injuries! What does this mean? Let’s think about it in terms of ‘Run Banking’7.
Each runner has what I call a Run Bank Account (blog post coming soon to explain this analogy in more detail). Within that bank account is money that you have earned over time—the benefits of your previous training—that you are able to go out and spend on your next run. When you spend more on a run than you have earned and deposited into your Run Bank Account, you overdraft.
Overdrafting, or going into the red, means that the load is too high, and the stress on a specific tissue is greater than the body is ready to handle7,8,9,10. This can lead to any number of potential injuries, including IT Band Syndrome.
Dr. Kevin Maggs does an excellent job explaining and illustrating this concept
Now that you understand ‘Run Banking’ we can discuss the factors that may contribute to ITB pain.
A rapid change in workload11:
Increased volume, intensity and/or frequency
Biomechanical & stride characteristics7,12:
Narrow step width
Knee moving in (hip adduction)
Anterior pelvic tilt
Reliance on backside mechanics (my clinical observation)
Poor Muscular Stiffness (increased knee flexion during stance)
Coordination and timing
Hip weakness (those with ITB seem to have more hip weakness than those that do not)
Lack of variability—minimal change in running pace, distance, frequency, and/or running environments or limited exposure to other physical activities
What’s Going on Below the Surface
The ITB is a very dense and extremely tough band of fibrous connective tissue that is impossible to stretch. Contrary to popular belief, ITB ‘tightness’ is not the cause of your pain.The IT Band crosses over the outside of the knee at a point called the lateral femoral condyle, which is one of the two ball-like projections on the lower end of the femur (your thighbone). ITB pain results from a compression-type injury to the connective tissue, which experiences impingement at this crossover point16. Think of this like repeatedly slamming your finger into a door, but in this case, the compression is experienced by your IT Band every time you bring your leg back and flex your knee while running. This ultimately breaks down the tissue and leads to pain. The problem can become chronic when a runner gets caught in a cycle of overdrafting their Run Bank Account (poor load management), and/or with less than optimal mechanics.
Overcoming IT Band Syndrome
If you find yourself with ITB Syndrome, don’t worry: you are NOT damaged goods. With some intentional planning, you will return from this temporary injury stronger than ever. Keep an eye out for the next post in this series, which will dive into the details of how to treat IT Band Syndrome.
The first step is going to be load management, and getting your Run Bank Account into a sustainable pattern of deposits and withdrawals. I’ll identify some exercises you can do to remain in motion while the ITB heals, as well as the best protocols for directly addressing symptoms and other potential root causes.
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Running USA. 2014 state of the sport—part II: running industry report. Available at: http://www.runningusa.org/2014-running-industry-report?returnTo=annual-reports. Accessed 6 Aug 2014.
van Gent R, Siem D, van Middelkoop M, van Os A, Bierma-Zeinstra S, et al. (2007) Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br J Sports Med 41: 469–480.
Hreljac A. Impact and Overuse Injuries in Runners. Medicine & Science in Sports & Exercise. 2004;845-849.
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Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band strain in runners. Clinical Biomechanics. 2008;23:1018-1025.
Cook JL, Docking SI. “Rehabilitation will increase the ‘capacity’ of your… insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. Br J Sports Med. 2015;49:1484–1485.
Gabbett TJ, Windt J. How do training and competition workloads relate to injury? The workload-injury etiology model. Br J Sports Med. 2016;0:1-9.
Gabbett TJ, Kennelly S, Sheehan J, Hawkins R, Milsom J, King E, Whiteley R, Ekstrand J. If overuse injury is a ‘training load error’, should undertraining be viewed the same way?
Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc. 1995;27:951-960
Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomech. 2012;11:464-472.
Lenhart R, Thelen D, Heiderscheit Bk. Hip muscle loads during running at various step rates. JOSPT. 2014;44:766-773.
Hamill J, Palmer C, Van Emmerik R. Coordinative variability and overuse injury. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2012;45:1-9.
Kiely J. The robust running ape: unraveling the deep underpinnings of coordinated human running proficiency. Frontiers in Psychology. 2017;8:1-10.
Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport. 2007;10:74-76.
About Dr. Jeff Moreno
Jeff, co-founder of PWR Lab, is a Doctor of Physical Therapy and Board-Certified Orthopedic Clinical Specialist. Passionate about running and playing, Jeff fundamentally loves people and movement of any kind. He strives to raise the bar in sport by finding ways to proactively prevent injuries and prioritize the long term development of athletes. He has been successful in employing a data-driven, hands-on approach to physiotherapy with National, World & Olympic Championship medalists in Track & Field from USA, China, Canada, and Mexico as well as many NFL, NBA, MLB, NHL, Judo, and Triathlon athletes