Updated: Jun 15, 2022
Part 1: understanding the condition
First off, there is very little quality evidence regarding the diagnosis and management of Iliotibial band pain, so much of this article is influenced from the work of Dr. Rich Willy and Tom Goom, Physiotherapist.
What is the Iliotibial Band Pain?
Iliotibial (IT) Band pain, also referred to as IT Band Pain Syndrome or IT Band Friction Syndrome, is common in runners and cyclists, and is the primary source of lateral knee pain in runners. Pain is localized over the lateral femoral epicondyle (see photo below) as the knee flexes and extends over an arc of roughly 25-35 degrees of knee flexion, classically known as the impingement zone (2). Knee pain is reproduced as the hip extends while the knee flexes as the tensor fascia latae musculature is loaded eccentrically, as with downhill running or stair descent. Runners with acute IT Band pain describe the pain as sharp and intense, often stopping them right in their tracks.
Quick Anatomy Review -
The gluteus maximus and tensor fascia lata muscles attach to the IT Band at its proximal end. The IT Band has extensive distal attachments, which include the patella, patellar
tendon, the lateral femoral condyle, the fibular head, and gerdy’s tubercle located on the anterolateral aspect of the tibia. It is also attached to the femur along its entire length. All of these attachments contribute to its quite robust structure.
So who gets IT Band Pain?
Novice male runners seem to have the highest propensity to develop IT Band pain. This is typically from being overzealous and doing too much too soon, which may also occur in experienced runners returning to sport after some time off. All running injuries are considered to be training load injuries.
Runners who rapidly increase running volume, particularly downhill, are at risk for IT Band
Long and steep mountain descents while hiking may also lead to acute injury of the IT Band. Running with a narrow stance
width, as seen with single track trail running (see Fig. 1), increases the strain on the IT Band. This is known as a crossover gait pattern, which involves higher amounts of hip adduction.
Most importantly, a runner may participate in the aforementioned activities and possess relatively low tissue capacity, but the onset of symptoms will likely not occur without a rapid increase in training loads. Once the IT Band becomes acutely sensitive, relatively benign tasks such as descending stairs may be very painful. In most simple terms, the runner is no longer tolerating the load requirements at the lateral knee. The graph below (figure 2) does a great job of showing the relationship between the load demands of the task vs. the current load tolerated by the runner.
Should I just rest?
A common recommendation given by medical professionals is, “Well if it hurts to run, stop running.” This may be appropriate in the very short term as the sharp pain subsides, but by completely resting the runner is unknowingly causing the IT Band to lose even more load capacity.
Avoidance of loading the sensitive structure is also known as stress shielding, and is the incorrect way of going about rehabbing the IT Band.
Here’s how the cycle plays out – Injury occurs – runner offloads the IT Band, and unknowingly loses capacity – runner now has decreased or no pain – runner returns to running too quickly – re-injury/re-exacerbation occurs. (See Figure 3.)
Figure 3: Cycle of loss of load capacity
This cycle may repeat itself for a year or more, leaving the runner feeling very frustrated and defeated. IT Band pain is not a self limiting condition, meaning it typically does not resolve on its own over time if training loads remain unchanged. This is why early intervention is recommended from a qualified healthcare professional or running expert who has experience working with runners.
In part 2 of this blog series we will debunk some of the common myths around IT Band pain and in part 3 we will discuss rehab and return to sport recommendations.
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.
Iliotibial Band Pain in the Runner Part 1: Etiology and Assessment. (2019, August 21). Physio Network. https://www.physio-network.com/blog/iliotibial-band-pain-in-the-runner-part-1-etiology-and-assessment/
Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996;24:375-379.
Van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports medicine. 2012;42:969-992.