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The latest on how to manage your ITB

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The latest on how to manage your ITB

Understand the pain on the outside of your knee.

By Doug James – intraining Podiatrist & Physio at intraining Running Injury Clinic

Let the ITB be!

Illio-Tibial Band (ITB) Syndrome affects between 7-14% of runners at some point in their running career (1-5). It tends to affect runners in the lead-up to events where there is a temptation to ‘cram’ additional training, so we tend to see lots of cases during the winter months in Brisbane for the peak of the road running season. Compared to other injuries this condition is more likely to prompt the affected runner to seek treatment due to the level of discomfort and inability to ‘run through’ the pain.NEWSLETTER 600 x 503px 2

The ITB is a much-maligned part of the human anatomy. It’s named and shamed as the culprit responsible for a painful knee injury (ITB Syndrome) in runners and cyclists, though it’s really more of an innocent bystander. Despite this, the ITB cops plenty of abuse (both verbally and physically) as long-held ‘treatments’ for ITB Syndrome involve aggressive massage and foam rolling on the side of the thigh. This usually isn’t particularly successful and tends to neglect the true nature of the injury.

What is the ITB?

The ITB is a long strip of connective tissue (like a long flat tendon) that originates on the outside of the hip arising from the Tensor Fascia Latae (TFL) and Gluteus Maximus muscles. It extends along the outside of the thigh and knee before attaching to the front of the knee just below the kneecap. It provides movement at the hip and may help to improve the stability of the knee.

What is ITB Syndrome?

ITB Syndrome is known for producing a fairly intense, sharp pain on the outside of the knee while running or cycling. It usually takes a bit of time to start (it can start after 10km, but often less distance will provoke it in more severe cases), but usually has a fast onset and causes significant discomfort until stopping exercise, at which point it can settle fairly quickly.

For years ITB Syndrome was referred to as ITB ‘Friction’ Syndrome[2,5]. Previously it was thought that the ITB itself was becoming painful from friction as it rubbed back and forwards on the outside of the knee when it bends and straightens during running. While the movement of the knee is the main mechanism behind the injury, it has been disproved that the ITB is a painful structure. Other theories suggested that a bursa (fluid sac) was being inflamed by the ITB, but again this has been discredited. 

Where does the pain come from?

The ITB is not the painful part of ITB Syndrome. The ITB passes over the Lateral Femoral Condyle (a boney lumpy bit on the side of the knee) which is covered in a layer of fat with a large number of nerve endings in it. It is now believed that it is the nerves in the fatty tissue that create the painful sensation of ITB Syndrome. With this in mind, a more accurate title for this injury would be to refer to it as “Irritated Nerve Endings In Fatty Tissue Adjacent To The Lateral Femoral Epicondyle” Syndrome, or INEIFTATTLFE Syndrome for short (I’m not too sure it will catch on).

What are the risk factors?

INEIFTATTLFE Syndrome (Ok, I’ll stop now) :)

ITB Syndrome is largely a running injury, though some cyclists can also experience it. The high frequency of bending and straightening the knee in each sport likely contributes to an increased sensitivity of the nerves that progressively becomes worse with further exertion. While most runners can run without experiencing ITB Syndrome symptoms, those that significantly increase their volume of training or amount of downhill running in a short period are more likely to develop this injury.

Females tend to be more likely to develop this injury due to anatomical reasons – e.g. having a relatively broader pelvis creating a steeper angle from the hip to the knee (Q Angle)[4]. Additionally, relatively reduced hip external rotator (outside glutes) strength, and/or increased flexibility in the hip joint may contribute to an increased likelihood of the injury through more internal rotation of the knee on landing.

Running technique may also have a bearing, though running volume increases are generally more predictive of the injury developing.

3 Tips you should know to fix your ITB

You need to let the ITB, be. Definitely don’t try to rub or foam roll over the sore area as this tends to further increase the sensitivity of the irritated nerve endings. Sometimes aggressive foam rolling can actually commence the injury.

Here are my three tips to manage ITB pain:

Tip ONE:  Identify the causative factor 

Identifying the causative factor is tantamount to treating and preventing the reoccurrence of ITB Syndrome. This should involve determining if a training error (too much, too soon) occurred, or if it is related to glute strength (too little) or hip flexibility (too much). Avoid the traditional (and brutal) approaches of deep tissue massage or foam rolling over the sore area as research shows ITB Syndrome responds better to an active approach whereby any muscle imbalances are identified and rectified [2,5,6].

Tip TWO: Avoid downhills in your return to running plan

In planning rehabilitation, one should be mindful to include a return to running plan that includes some walking intervals and minimisation of downhill running to be successful.

Tip THREE:  Get a running gait assessment

A running gait assessment is also worth including as this can help identify if you are overstriding (landing on an outstretched leg too far in front of your hips) which seems to have a role, as does running with too slow of a cadence (foot strike rate). 

If you’ve had a prior history of ITB Syndrome or looking to take a proactive approach to injury prevention – some injuries may be avoided by following a custom running plan designed with your running goals and injury risk profile in mind. 

If you have been suffering pain from running or are returning to running after having ITB syndrome or other injuries, it’s worth contacting the intraining running injury clinic to book an appointment with our physiotherapist or podiatry team.  

Book an appointment

Call: 3367 3088 | Email: [email protected]

Doug James Colour 2020 1



Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes through to elite athletes.

Bachelor of Podiatry (Honours), Master of Physiotherapy Studies.

Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment.

Doug is also a keen runner having completed the New York Marathon.

Book an appointment

Call: 3367 3088 | Email: [email protected]


[1] Jelsing, E; Finnoff, J; Cheville, Andrea L ; Levy, Bruce A ; Smith, Jay, Sonographic evaluation of the iliotibial band at the lateral femoral epicondyle: does the iliotibial band move? Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, July 2013, Vol.32(7), pp.1199-1206

[2] Orchard, J. Is iliotibial band syndrome a friction syndrome?

Journal of Science and Medicine in Sport, 2007, Vol.10(2), pp.77-78

[3] Pegrum, J; Self A; Hall N; Iliotibial band syndrome. British Medical Journal (Online), Mar 21, 2019, Vol.364, pp. 1-6

[4] Wilhelm, M; et. al. Deformation response of the iliotibial band – tensor fascia lata complex to clinical-grad longitudinal tension loading in-vitro. International journal of sports physical therapy, February 2017, Vol.12(1), pp.16-24

[5] Falvey, E; et. al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine and Science in Sports. August 2010, Vol 20. (4), pp580-587.

[6] Troilo, Lindsay; Davis, Irene. Successful Treatment Of The Underlying Cause Of ITB Syndrome. Medicine & Science in Sports & Exercise

Issue: Volume 48(5S) Supplement 1, May 2016, p 647.

[7] Fairclough; Hayashi (2006). The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome.   “Journal of Anatomy. 208 (3): 309–316.