If you’re a runner or cyclist, you’ve probably heard of the pesky iliotibial band. In fact, the IT band accounts for at least 12-15% of endurance athletes’ injuries. [1] Despite pain in the IT band being a prevalent condition, the mechanisms that cause pain to the lateral knee and the interventions to treat it are still lacking. It can be immensely frustrating to figure it out and get back to what you love.
We’re going to break down what’s known about IT band syndrome, what you shouldn’t do, and what you can add to the mix to solve that pain.
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What is IT band syndrome (ITBS)?
The iliotibial band is a band of soft tissue that begins superiorly from your tensor fasciae latae (TFL) and gluteus maximus. From those muscles, it becomes purely fascial as it travels down the lateral part of your thigh and inserts onto your tibia. As you bend your knee, it is theorized that the IT band creates a compressive force at your femoral condyle (next to your knee) directly over a fat pad. This fat pad is innervated and communicates to your brain that you’re in pain.
The repetitive knee flexion (particularly around 30 degrees) you do during cycling and running can create irritation that, over time, can become incredibly sharp and painful. Particularly on downhills, as your TFL eccentrically contracts to decelerate your leg as it hits the ground, you can feel a big spike in symptoms around your knee. [1]
To be clear, there is not one precise mechanism that has been proven to be the sole cause of ITBS, nor is there a gold standard required to receive this diagnosis. What we do know is that there are associated elements of lower extremity kinematics and strength that are variables you can change to improve your symptoms.
Why is it happening to me?
Breaking down the precise mechanism that causes this sharp lateral knee pain is complex. And, quite frankly, the literature isn’t conclusive. What most recent studies have theorized is that, for runners, when you land on one leg and the knee begins to bend, if you have a larger than average amount of knee valgus, you are putting strain on your IT band and the compression around your fat pad can start to build. To picture knee valgus, think about a knee “collapsing” inward: the kneecap will drift medially and also turn slightly toward the other leg. This combined hip adduction and internal rotation can strain the lateral structures of your knee.
What this means is, if you are female you’re at a higher risk of getting IT band syndrome—possibly secondary to the increased ratio of your hip to your knee angle. [2]
This also suggests that if you have weak hip abductors (the antagonist to the knee valgus described earlier) or incredibly tight external femoral rotators, your muscle imbalance is setting you up to be at high risk for ITBS. [2]
Which treatments work…and which don’t?
Stretching
How to stretch the IT band—and how to properly dose it—has not been elucidated in the literature. [1] There are countless versions of stretching: some focus on the fascial band itself, while some focus on the contractile TFL and gluteus maximus muscles. In fact, some studies indicate that stretching can “release” the IT band for the recreational runner, while other studies suggest that stretching can actually increase IT band stiffness for a short time. [1]
So what can you do?
If you’re a distance runner, ask your provider, PT, or coach before going to town on stretching. There are some studies that suggest while increased IT band stiffness could cause more compressive forces to your lateral knee, it might be an adaptation to store more elastic energy that translates into better, fatigue-resistant form on your long runs. [3]
Regardless of what type of athlete you are, there is some moderate-grade evidence that general hip stretching can lower your risk of developing ITBS. [4] So with that in mind: if it feels good, go for it. There are not many established negative impacts of stretching the hip beyond the theory that distance runners need that stiffness adaptation.
Keep in mind that most extensibility gains you’ll feel from stretching occur when you focus on the proximal tissue (TFL). Stretching the IT band itself is more like stretching a towel: focus on that proximal contractile tissue to get more bang for your buck!
In regard to how long you should hold your stretch, I recommend stretching tissue related to the IT band at least 15 minutes a week. Whether you want to split it up with shorter bouts multiple times a day or longer stretches once a day, pick something and stick to it. The pros and cons of different hold times is a big can of worms to get into, but be reassured that you can follow your dreams and see some improvement, regardless of time held. [1]
Foam Rolling
Foam rolling is another doozy of a topic. There are a lot of conflicting articles and opinions about how to foam roll and how effective it is. For your IT band, you can gain short-term mobility gains and a significant decrease in pain during your activity (cycling, running) if you put your bodyweight through a foam roller onto the tender parts (myofascial trigger points) of your lateral thigh. [1] In fact, one study additionally showed cyclists could have an immediate improvement in pedal power following one foam-rolling session. [1]
Unfortunately, similar to stretching, dosing has been sporadically reported and rarely consistent in the literature. [1]
The takeaway: Foam roll your IT band, focusing on your TFL, for 10 minutes a week. Split up the time however you would like, but do this in conjunction with a stretching and strengthening program. By itself, foam rolling hasn’t been proven to “fix” or “release” your IT band. [4]
Correcting muscle imbalances
If you had to pick only one intervention to throw at your knee, get started on an exercise program that will improve your hip abduction, hip extension, and quadriceps strength.
A recent study assessed how runner’s gait mechanics change before and after an exhausting run effort on a treadmill. They found that IT band stiffness increased at faster running speeds (no surprise there) but that, when fatigued, runners’ peak hip adduction angle and IT band stiffness increased substantially. [5]
So, you need to work on creating muscular endurance to avoid exhaustion and consequential collapse in your running or cycling form. After your body fatigues, the compression to your knee increases. More strength means less pain! Your goal is to address any weaknesses that are influencing your knee pain: namely, strengthen the major players that control your knee’s ability to flex.
Some excellent starter exercises can be found in our article, “How to Bulletproof Yourself Against Runner’s Knee.”
When your IT band syndrome persists
If you’ve been doing your clamshells but not seeing any improvement, then there’s a missing piece to the puzzle. To return to pain-free activity, you still need to reload in a functional way. What this means is that you need someone to watch you do the motion that causes you pain. Your provider, PT, or coach should watch your run or bike to ensure that your cadence, hip flexion, and knee flexion look controlled and appropriate. More so, if you aren’t getting progressive exercises that lead to running- or cycling-like motions, there’s more you can do to get back out there.
There are some other elements that you can also consider getting assessed: your leg length discrepancy, footwear, and the types of runs or rides you do can all be looked at to improve your symptoms. There is absolutely a conversation to be had with your provider about if an injection or other modality can also be added to the mix as well.
If you want to find out more about your own knee pain, please feel free to contact me for a biomechanics or sports therapy consult. Happy trails!
References
- Opara M, Kozinc Ž. Stretching and Releasing of Iliotibial Band Complex in Patients with Iliotibial Band Syndrome: A Narrative Review. Journal of Functional Morphology and Kinesiology. 2023; 8(2):74. https://doi.org/10.3390/jfmk8020074
- Phinyomark A, Osis S, Hettinga BA, Leigh R, Ferber R. Gender differences in gait kinematics in runners with iliotibial band syndrome. Scand J Med Sci Sports. 2015 Dec;25(6):744-53. doi: 10.1111/sms.12394. Epub 2015 Jan 26. PMID: 25622800.
- Grau S, Krauss I, Maiwald C, Axmann D, Horstmann T, Best R. Kinematic classification of iliotibial band syndrome in runners. Scand J Med Sci Sports. 2011 Apr;21(2):184-9. doi: 10.1111/j.1600-0838.2009.01045.x. PMID: 19903313.
- Chen S, Wang Y, Bing F, Zhang M. Effects of Running Speeds and Exhaustion on Iliotibial Band Strain during Running. Bioengineering. 2023; 10(4):417. https://doi.org/10.3390/bioengineering10040417
- Anh Phong Nguyen, Christine Detrembleur, Joachim Van Cant, Conservative treatment for iliotibial band syndrome: Are we facing a research gap? A scoping review of 98 studies with clinical perspectives, Physical Therapy in Sport, Volume 62, 2023, Pages 25-31, https://doi.org/10.1016/j.ptsp.2023.05.002
