Iliotibial band syndrome (ITBS or IT band syndrome) is an overuse injury of the connective tissues that are located on the lateral or outer part of thigh and knee. It causes pain and tenderness in those areas, especially just above the knee joint. IT band syndrome is the most common cause of lateral knee pain in runners and cyclists.
The iliotibial band is a thick band of fascia (tissue) that begins at the iliac crest in the pelvis, runs down the lateral or outside part of the thigh, and crosses the knee to attach into the top part of the tibia or shinbone. It forms from the tensor fascia latae and two of the gluteal muscles in the buttock and then stretches across the knee. The iliotibial band then helps stabilize the outside part of the knee through its range of motion.
The iliotibial band is one of the hip abductor muscles, moving the hip away from the midline. The iliotibial band also helps with both knee flexion and extension. When the knee is flexed, the IT band is located behind the femoral epicondyle, a bony outcropping of the femur or thighbone at the knee joint. The IT band moves forward across the condyle when the knee is extended. There is a sac or bursa that allows the band to glide smoothly across the condyle, however, if inflammation occurs in this area, the increased friction from repeatedly rubbing the iliotibial band across the bony condyle may cause pain, especially along the outer (lateral) aspect of the knee joint. If the symptoms are ignored, the inflammation can continue and may develop the condition in the bursa, decreasing knee range of motion and causing increasing pain with decreasing activity.
Causes & Symptoms
The IT band syndrome may be the result of a combination of issues, including:
- Improper Gait – IT band syndrome is often caused by improper form when walking or running. A person’s gait can place the IT band in a compromised position, causing the ligament to rub or snap over bone landmarks in the leg. Excessive internal rotation or valgus (where the knee collapses inward) of the thigh whilst walking or running, sometimes known as ‘knock knees’ can be an issue. This places stress on the IT band near the knee, causing the tendon to rub over the lateral epicondyle of the femur (outside the edge of the knee). Additionally, not keeping the pelvis level while running or walking can lead to the same problem.
- Poor Orthotics – Whilst not everyone needs orthotics, issues like flat feet can warrant investing in them to prevent tissues like IT band syndrome. However, quality counts; wearing poor orthotics that do not support the arch or ankle can cause the knees to internally rotate and the legs to cross over during walking or running. This internal rotation and cross-over gait causes the IT band to move over the lateral condyle of the femur, resulting in inflammation and tightness.
- Weak hip muscles – Weak hips can cause IT band syndrome and chronic IT band syndrome. Weak upper body muscles strain the ligaments in the lower body due to coordination and joint alignment imbalances, especially the large IT band. This ultimately can lead to inflammation and IT band tightness. The IT band connects into the tiny hip flexor muscle, known as the tensor fascia latae. This muscle is meant to provide stability to the hips and IT band but can quickly be overused and strain tissue when surrounding muscles are weakened, particularly the hip abductors. Poor movement patterns, prolonged sitting, and excessive flexion can weaken hip muscles.
IT band syndrome symptoms are also apparent at the knee and hip. Two of the main symptoms include the following:
- Tenderness and pain – Most commonly found on the outside of the upper knee, a stabbing or throbbing feeling while running, walking, or cycling is a key symptoms of IT band syndrome. Although, there can be tenderness and extreme sensitivity anywhere along the side of the thigh all the way up to the hip, if pain is felt in the knee when the joint is flexed to 30 degrees, IT band syndrome is the most likely cause. Standing or sitting with crossed legs can cause tenderness on the outside of the leg, meanwhile running with IT band syndrome will worsen the pain.
- Tightness or loss of flexibility – A common symptom is tightness and loss of flexibility on the outside of the leg. Abduction movements of the leg become much more difficult and painful – the TFL muscle (tensor fasciae latae), which attaches to the IT band near the hip, often becomes tight, resulting in poor knee and hip flexibility. This makes the knee and hip feel stiff and out of sync, even when making usual movements.
Who Gets It?
IT band syndrome can affect to anyone. It is especially common among runners, cyclists, and hikers. Athletes who use their knees such as basketball players, soccer players, and weightlifters are more likely to develop IT band syndrome. Usually, people who develop IT band syndrome are younger athletes or people who exercise on a regular daily basis. In most cases, it is due to mistakes in training that can normally be corrected. Training mistakes include:
- Using poor form
- Increasing training too rapidly
- Incorrect bicycle fitting
- Not warming up or cooling down properly
- Pushing yourself past your limits
- Straining your body
- Not resting enough between workouts
- Wearing improper shoes
- Training on the wrong surfaces
How Does It Affect You? How Serious Is It?
Training errors may cause runners to develop IT band syndrome symptoms. Roads are canted or banked with the center of the road higher than the outside edge to allow for water runoff; if a runner always runs on the same side of the road, it produces the same effect on the body as having a leg-length discrepancy – one leg is always downhill compared to the other, and the pelvis has to tilt to accommodate the activity. Running too many hills can also cause inflammation of the IT band. Running downhill is especially stressful on the IT band as it works to stabilize the knee. Cyclists may develop IT band inflammation when they have improper posture on their bike and “toe in” when they pedal. The issue may be how the toe clips are aligned, forcing the foot to be internally rotated; toed in. This can cause the same effect as bowed legs, increasing the angle of the IT band as it crosses the knee and increasing the risk of inflammation. Other activities with increased knee flexion (such as rowing and weightlifting) can cause symptoms linked to IT band syndrome, especially with excessive squatting. As a person continues to run or participate in a similar activity, the IT band will continue to rub against the outside of the knee, leading to swelling and severe pain.
Recommended Treatment & Rehabilitation
The best IT band syndrome treatment options will be based upon your specific needs and the severity of your injury. As mentioned earlier, IT band syndrome is a common overuse injury among runners and cyclists. It is typically caused by overly tight ligaments and a combination of other factors, like weak hip muscles or poor running form. Conservative treatment can start at home with options like rest and stretching. If your injury becomes more severe then medical treatment may be necessary. Sometimes IT band syndrome needs more than home remedies to fully treat the injury – when that happens, it is time to seek a physical therapist for their medical advice. This advice may include:
- Physiotherapy – A physiotherapist is an expert on injuries like IT band syndrome. When you first visit your physiotherapist they will perform a physical exam of your injury, then they will come up with a specialized treatment plan. Their treatments typically involve targeted exercises and stretches. If you have additional risk factors like poor running form or weak hip muscles, they will work on correcting your biomechanics and weaknesses as well.
- Ultrasound – Ultrasound is used to warm up the muscles, break up scar tissue, and increase the blood flow to the area. Together, these items can improve healing time. Ultrasound treatment can be performed in your physiotherapist’s clinic. There is no downtime after a treatment, and it has little side effects.
- Corticosteroids – Corticosteroid injections use a powerful steroid medication that is injected directly into the site of the injury. These treatments can help reduce swelling and pain, providing excellent relief to some patients. However, steroid injections are not meant for everyone and cannot be used on-going due to the potentially negative long-term effects on the body.
- Surgery – If you have exhausted all other treatment options then your doctor may recommend IT band release surgery. This procedure involves a small incision around the kneecap and removal of an area of the IT band that is rubbing against the thighbone. Full recovery from this outpatient surgery can take 4 to 6 weeks.
Although there is some debate regarding the exact mechanism of IT band syndrome as to whether it is caused by weakness of the gluteal muscles or due to overuse and subsequent pain causing motor control changes, one thing is clear – exercise is essential for a resolution of symptoms. Below are a few exercises to perform and help reduce certain symptoms regarding IT band syndrome:
Hip bridges with resistance band – Begin by lying on the floor. Afterward, place a resistance band around the hip. Slightly abduct the legs while simultaneously performing a hip bridge. Slowly lower the hips to start position. Finally, perform the same procedure with 3 sets of 10 reps.
Side lying hip abduction – Begin by lying on one side on the floor. The top leg should attain a straight line. Afterwards, activate the core muscles. Lift the top leg upward, and finally slowly return back to the starting position. Repeat the same steps for 3 sets of 10 repetitions.
Standing IT band stretch – Stand upright with an IT band, then lean to the side until a “good stretch” is felt. Hold this position for 30 seconds, then repeat the same procedure for 3 times.
Alternative & Homeopathic Treatments
Knee and hip pain from IT band syndrome can interfere with almost every physical activity. Since IT band syndrome is an overuse condition, rest is one of the best at-home treatments that every patient should begin with. Here are some of the best at-home treatments to perform at ease:
- Stretches and exercises – One of the causes of IT band syndrome is weak connective tissue around the hip muscles. Through strengthening exercises that focus on muscles like the gluteus medius, hamstrings, and quadriceps you can prevent further injury and support your joints. In addition to exercise, adding a stretching program will improve your range of motion and prevent stiffness until the pain on the outside of the knee subsides.
- Massage – Massage for IT band pain will work on tight muscles to release tension and soothe soreness. A massage therapist would focus their efforts on tight hip muscles, leg muscles, and even your lower back. They will work out any muscle knots or trigger points to help get you to move pain-free.
- Foam rolling – This small workout accessory has been used by athletes for a long time and has now become a mainstream treatment option for just about everyone! The foam roller works like a deep tissue massage, pressing deep into your muscles to work out the tension. However, there is a right and wrong way to a foam roll so good technique is very important.
- Medication – When you are suffering from IT band pain, home treatment with an over-the-counter medication can be a great option. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can reduce swelling and pain. The anti-inflammatory properties of these medications are what makes them so effective.
- Ice – Lateral knee pain from IT band syndrome can be treated at home with ice. The cold will minimize swelling by reducing blood flow to the area which limits the amount of fluid that can get pushed out into the tissues. Ice also brings pain relief by numbing the skin and interrupting the pain signal. You can use an ice pack or even try submerging your knee in an ice bath.