Pain in the outside of your knee? It could be IT band syndrome

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How to spot and fix ITB painlizzy thomas illustration

What is your IT band?

Your iliotibial band (ITB), or 'IT band' as it's more commonly referred to, 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 ITB begins to tighten and, as the foot leaves the ground, this stored energy helps to propel and swing the leg forwards.

'The iliotibial band crosses both 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 gluteus maximus 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 inwards on landing.

What is IT band syndrome?

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

What are the main symptoms of IT Band syndrome?

The main complaint is of pain on the outside of the knee, sometimes sharp, but often aching, that comes on after activity. Stairs and steep inclines will often be an aggravating factor, especially going down stairs.

The pain can sometimes spread up the outside of the leg towards the hip and it is often sore to touch on the outside of your knee. 'If it is particularly acute it may look red and swollen, 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 it is acutely swollen, red or very locally tender to touch and you can remember an incident such as falling over or heavily bashing the outer knee when out running, seek expert medical advice to rule out anything bone-related.

What are the main causes of IT Band syndrome?

The latest thinking on IT band syndrome has actually changed, explains Breach. 'It was thought that the cause of pain was friction between the lower end of the ITB and the outside of the knee, and that an overly tight ITB caused the band to roll tightly over the outside of the knee, causing friction and irritating the underlying soft tissues. This led to treatments being based on attempting to stretch out the ITB to prevent this friction.

'However, this model is now challenged, as the ITB has numerous attachments down our femurs, that mean not all 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 ITB syndrome and others do not?

Mostly due to other factors, says Breach. 'Around 60% of cases are thought to be caused by an element of training error, where the amount of load through the ITB has been increased too quickly, either by increasing distance too quickly, or adding in hill work – downhill particularly.

There is also evidence that those with ITB syndrome have weakness in their hip abductor and external rotation muscles, that may lead to increased adduction of the leg and therefore load through the ITB'.

Some runners with ITBS have also been found to have a 'cross-over' 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 your symptoms will, at some point, return.

Should you stop running with ITBS?

Not necessarily, says Breach – it will depend on just how irritable and sore it is. '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.

One warning for those planning to embark on intensive cross training while managing ITBS – be careful with adding in too much cycling to your training routine. 'Cycling can also actually be a contributor to ITBS, so you may have to adjust this as well if it increases the pain,' says Breach.

How do you fix IT band syndrome?

'They key thing in terms of fixing this is trying to fix those things that are offending the iliotibial band,' says Jordan Metzl, M.D., a sports medicine physician at the Hospital for Special Surgery in New York City. 'Sometimes the IT band is too tight, sometimes the glute muscles aren't strong enough and sometimes the feet are rolling in. All these things can contribute to overloading the IT Band.'

Meanwhile, says Breach, 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. Why? By changing how you run, you are altering where the load is being placed and those structures being exposed to it. If these are not robust enough to tolerate the load, injury will likely occur. But there are certainly form 'cues' or drills you can do to help.

To reduce a cross over gait, which has been linked with ITBS, you can try running either side of a white line – making sure each foot stays on the 'correct' side. Running drills such as walking lunges can also work well, where the focus is on foot placement as well as knee control.

You can also try increasing your cadence by 5-10%, if you are someone that overstrides when running, to see if this helps the irritation at the outside of your knee.

Any changes made 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.

From basic strength type exercises, to movement control exercises and running specific-drills, this is how we bring about a consistent change in someones gait, not by simply trying to force body parts into positions while running.

What exercises help with IT band syndrome?

Breach advises starting with a focus on hip strength and control, to help manage the load through the outside of your knee. Start in non-weight bearing positions, and then progress to standing and to dynamic activities.

Strength exercises

Hip thrusters

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  1. Sit on the floor with your knees bent, feet on the ground but with your upper back and shoulders onto a raised surface – a stability ball, a bench, a chair or a sofa.

  2. Looking down your body, keeping your feet firmly driven into the floor, engage your glutes and lift your hips until your body forms a straight line from shoulders to knees.

  3. Slowly lower back down.

  4. Aim for 15 reps x3.

  5. As you get stronger, bring in weight by placing one weight horizontally across your hips. As you build weight, aim for 8-10 reps, for 3-4 sets.

  6. Do this exercise twice weekly.

Hip hikes

  1. Place your right leg on a step with your left leg suspended to the side.

  2. Allow your left leg to slowly fall towards the ground (but without touching) by allowing your pelvis to slowly drop down. Keep your right leg as straight as possible.

  3. 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.

  4. Aim for 15 reps, x3.

  5. Once this is too easy you can progress by adding a small weight (5-10kg) into the hand opposite to the standing leg – this will challenge the standing leg gluteus medius more.

  6. Do this twice weekly.

Banded glute pulley

  1. Stand with a band around both ankles, balancing on one leg.

  2. On the standing leg, keep the foot facing forwards, with the knee slightly bent and aligned over the third and fourth toes – maintain this position throughout.

  3. Keeping the opposite leg straight, perform a ‘pulley’ motion where you pull the leg diagonally back to 45 degrees. The movement should be purely from the hip, do not rotate or twist from the waist or upper body.

  4. Gentle ‘brace’ through the trunk throughout and do not allow your lower back to arch or your body to lean forwards excessively.

  5. Do 15 reps x3.

  6. Do this twice weekly.

Movement control exercises

Banded split squat

  1. 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.

  2. With your feet hip-width apart, take a big step backwards with your left leg onto your toes, so that you are in a split squat position.

  3. Keeping your torso upright, drop the back knee towards 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.

  4. 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 inwards.

  5. Perform 15 repetitions, x3, on both legs.

  6. Do this 2-3 times weekly.

High knee into reverse lunge

  1. To make the banded split squat more challenging, you can perform the high knee into reverse lunge, where you perform the exact same movement, however, as you raise up from the squat position, you will drive the back leg up and over the resistance band into a high-knee position.

  2. From here, take the leg back over the resistance band and step back into a reverse lunge.

  3. The focus, again, is on ensuring the front knee remains over the middle of the front foot throughout the movement.

  4. Perform 10-15 repetitions, x3, on both legs.

  5. Do this 2-3 times weekly.

Next level exercises

Once the above exercises feel easy and your pain is settling, Jodie Breach recommends progressing to more dynamic exercises like step-ups, making sure you keep your pelvis in a neutral position so that your lateral glutes are working.

Step ups

  1. Start by standing in front of a small box – a box 30cm in height will be a good start.

  2. Begin with your left leg aleady planted on the box

  3. Perform the movement by pushing through your left leg to lift yourself up, driving your right leg through in front of you into a high knee position.

  4. Step back down with your right foot, focusing on bending at the hip and knee on the left leg ensuring that the knee remains over the middle of the foot and doesn’t collapse in.

  5. 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.

  6. Perform 10-15 repetitions, x3.

  7. Do this twice weekly.

Chartered physiotherapist Matt Bergin also recommends working running drill into your routine, such as walking lunges. 'These will challenge the control around your pelvis, hip and knee, as well as working on your foot placement,' he says.

Walking lunges

  1. Start standing with feet-hip width apart.

  2. Take a big step forward onto your right leg – ensure your feet don’t zig-zag and cross over.

  3. Drop the back knee down towards 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 forwards with the left leg.

  4. Repeat for 10-15m, for 2-3 sets, or before a run.

What else can you do to treat IT band syndrome?

'Often times, a poorly controlled foot and ankle can really change the force mechanics around the knee and the hip and that’s 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 you’re wearing appropriate running shoes for the job.’

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Should you foam roll the IT Band?

It's a surprisingly divisive issue – some physios have recommended foam rolling and others say it's pointless and possibly even counter-productive. 'We don’t think that you can actually stretch the ITB 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 ITB 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 of 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.'

Although research is limited there is some suggested short-term benefits to foam rolling in terms of range of motion across a joint. So, spending 5-10 minutes rolling your quadricep muscles, especially the outer quadriceps will do no harm, and if it provides some relief, brilliant, but addressing training modifications and rehab work is where the focus should be.

How long will it take me to recover?

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

Mild injury: 100% after 2-4 weeks

Average injury: 100% after 7-8 weeks

Severe injury: 100% after 9-24 weeks

'We treat the ITB as being like a tendon' says Breach, 'these type of injuries tend to take at least three months to recover, 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.'


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