A patient guide to Iliotibial (IT) band syndrome
Graeme Hopper- Consultant Orthopaedic Knee Surgeon, FRCS (Trauma & Orthopaedics)
Frank Gilroy- Physiotherapy advisor Glasgow Sports Surgery Service (GSSS)
Thea Browne- Student Physiotherapist
Contents
- Anatomy
- What is IT band syndrome?
- Causes
- Symptoms
- Diagnosis
- What else could be causing the pain?
- Rehabilitation
- Activity modification
- Pain management
- Flexibility/stretching exercises
- Strengthening exercises
- Return to sport/activity
- Frequently asked questions
- References
Anatomy
The iliotibial (IT) tract is a strong band of connective tissue (known as fascia) that stretches along the length of your outside thigh, from the pelvis to below the knee.
At the top of your leg, the IT tract arises from the gluteus maximus and tensor fascia lata muscles. At your knee, its main attachment is onto your upper tibia (shin bone).
One of the functions of the IT tract is to work with the muscles that surround it to help produce movements at the hip. It also provides lateral stability to the knee.
What is IT band syndrome?
IT band syndrome is a common overuse injury that is associated with many activities but in particular running. It is estimated to affect around 7-14% of runners.
What causes it?
When you bend and straighten your knee, the IT band moves over a bony bump on the outside of the knee joint. IT band syndrome develops when the band begins to rub as it passes over the bony bump. This repetitive friction irritates the band and surrounding tissues, causing pain on the outside of the knee. Although symptoms typically affect the knee, pain and tightness can occasionally be felt along the length of the IT band.
The most common causes of IT band syndrome are:
- Sudden increases or changes in training for example, suddenly starting to run up hills or changing your route
- Starting a new activity for example, taking up running
- Old or poorly fitting trainers
Symptoms
The main symptoms are:
- Gradual onset of pain (a dull ache) on the outside of the knee
- Pain that comes on near the end of a training session or period of exercise that initially goes away with rest
- Pain that gets worse during activities involving repetitive bending and straightening of the knee
- Pain when running/walking downhill or walking down stairs
Diagnosis
A diagnosis can be made by a doctor or physiotherapist who may ask you about your symptoms and examine the area of pain. Once diagnosed, it is important to follow the advice and exercises within this guide as this will reduce your recovery time.
What else could be causing the pain?
There are several other structures that can cause lateral (outer) knee pain. These require a different treatment approach and therefore it is important to make sure you have the correct diagnosis before progressing with your rehabilitation.
Other possible causes of lateral knee pain include:
- Lateral collateral ligament sprain
- Lateral meniscal or cartilage injury
- Patellofemoral pain syndrome
- Fat pad impingement syndrome
- Biceps femoris tendinopathy
Anterior view of knee
Rehabilitation
The time it takes to recover can vary depending on your symptoms and how closely you follow the recommended advice and exercises. Frank Gilroy classifies IT band syndrome as being either grade 1, grade 2 or grade 3:
*Please note that the timescales provided are only a rough guide and it is important to discuss your own recovery timescales with your physiotherapist.
Avoid the snakes, climb the ladder!
The process of recovery is like a game of snakes and ladders:
The aim of your rehabilitation is to keep climbing up the ladder and avoid the snakes. The snakes involved in this process are the unexpected setbacks such as a flare up in symptoms or trying to return to training too soon (trying to climb the ladder too quickly!). It is important to understand that nature will heal itself and that injuries have different recovery timescales. Your physiotherapist will be able to discuss the timescale for your rehabilitation with you in order to make sure you are climbing up the ladder and not sliding down the snakes.
The key stages of rehabilitation for IT band syndrome are:
Activity modification
If it’s sore, stop!
The most important part of the rehabilitation process for IT band syndrome is activity modification. This means reducing or stopping the exercise sessions that cause you pain. It is recommended that you consider doing this for up to 6 weeks to allow the tissue irritation to settle.
It is still important to keep active and not rest completely during your rehabilitation therefore try to pick activities that don’t bring on your symptoms.
Examples include:
- Swimming
- Walking
- Yoga
- Pilates
Adjust your training
As mentioned previously, IT band syndrome most commonly develops when people try to increase or alter their training too quickly. Therefore, depending on your symptoms, adjusting how you train and reducing the volume and type of training you are doing can help.
Examples include:
- Avoid running downhill and on cambered surfaces
- Train/run on grass instead of hard surfaces
- Shorten the duration of your exercise sessions
However, often certain activities- in particular running- may need to be stopped completely for a period of time to reduce tissue irritation. Your physiotherapist will be able to discuss this further with you as this will depend on the severity of your symptoms and goals for recovery.
Pain management
- Depending on the severity of your symptoms your doctor may advise simple pain relief medication but this would be considered on an individual basis.
- ICE: applying a bag of frozen peas or crushed ice over the area of pain for 15-20 minutes can help to ease symptoms, particularly after exercise. Make sure the ice is wrapped in a damp cloth to prevent burning your skin. Repeat this every 2-3 waking hours or as necessary until your symptoms begin to reduce.
Flexibility/stretching
If hip muscle tightness has been identified as a contributing cause of your symptoms then the following exercises can be started. These exercises do not stretch the IT band itself (many physiotherapists now accept that it is too strong to stretch) but instead target the hip muscles surrounding it.
BUT… not everyone needs to stretch and in fact too much stretching or stretching when it is not required can actually make your symptoms worse. It is therefore important to follow the advice of your physiotherapist.
- Hold each stretch for up to 30 seconds and repeat 3 times
- Complete 3 times a day, 5 days a week
- Stretches should be completed before strengthening exercises
1. Hamstring stretch
Lie on your back, with both legs straight
Bend the knee of your painful side and grasp behind your thigh with both hands
In this position try to straighten your knee until you feel a stretch up the back of your thigh
Hold this position for 30 seconds and repeat 3 times.
Repeat on the opposite side
2. Outer hip stretch– there are two different ways of performing this stretch, pick whichever one you feel is the most effective for you.
a) Half kneeling outer hip stretch
Start in a half kneeling position with your unaffected leg forwards
Transfer your weight forwards and then outwards towards the side of your front leg
You should feel a stretch on the outside of the upper thigh of your back leg
Hold this position for up to 30 seconds and repeat 3 times
Repeat on the opposite side
b)Standing outer hip stretch
Stand upright and cross your painful leg behind your unaffected leg
With one arm above your head, lean away from your painful side
Make sure you are not bending forward instead of side ways
You should feel a stretch along the upper thigh/outer hip on your painful side
Hold this position for up to 30 seconds and repeat 3 times
Repeat on the opposite side
3. Quadriceps stretch
Stand on one leg, if you need support hold onto a stable object such as a wall or a chair
Bend your knee to bring your heel towards your buttock
Reach back for your ankle with your opposite hand
Stand up straight, and try to keep your knees next to each other
You should feel a stretch along the front of your thigh and hip
Hold this position for up to 30 seconds and repeat 3 times
Repeat on your opposite leg
Strengthening
The following strengthening exercise programmes are recommended if your physiotherapist has identified muscle weakness as a contributing cause of your IT band syndrome.
You can access these programmes by clicking on the links below:
What about squats and lunges?
When you squat and lunge, your knees are being repetitively bent and straightened. As outlined above in causes of IT band syndrome, this is the movement that can irritate your IT band. It is advised that you avoid squats and lunges during your rehabilitation as this can flare up your symptoms and delay your recovery.
Return to sport/activity
Once your symptoms have resolved you can begin to return to the sports/activities you did previously. This should be a gradual process to reduce the risk of your symptoms returning. If you have a specific sport you wish to return to or goals for recovery it is important to discuss this with your physiotherapist.
Returning to running
Some top tips:
- Follow a return to run programme (see below)
- Run/train on soft surfaces for example, grass rather than on the road or a treadmill as this reduces the strain on the IT band
- To begin with, avoid running downhill
- If you need to run on a circuit track, alternate the direction in which you run
- Check your trainers- make sure you have a pair of supportive running shoes that are not worn out
It is advised that a return to running programme like the example set out below is followed in agreement with your physiotherapist:
* Progress by building up your pace from ½ to ¾ to full pace
Frequently asked questions
Should I use a foam roller?
A foam roller is a cylindrical piece of equipment made of foam that can be used to self-massage tissues. It involves using your own body weight to apply pressure to specific soft tissues by rolling on it.
Foam rolling is often talked about in relation to IT band syndrome however, because it is another form of compression, it can actually make your symptoms worse. It is advised that if you do want to use a foam roller that it is used further up the leg on the hip muscles rather than the IT band itself (see image below).
References
FLATO, R., PASSANANTE, G.J., SKALSKI, M.R., PATEL, D.B., WHITE, E.A. & MATCUK, G.R., 2017. The iliotibial tract: imaging, anatomy, injuries, and other pathology. Skeletal Radiology [online]. 46, pp.605-622. [viewed 12 July 2021]. Available from: DOI 10.1007/s00256-017-2604-y INJURYMAP, 2021. Runner #3 [online image]. [viewed 12 July 2021]. Available from: https://www.injurymap.com/free-human-anatomy-illustrations”>Injurymap</a>
INJURYMAP, 2021. Yoga [online image]. [viewed 12 July 2021]. Available from: https://www.injurymap.com/free-human-anatomy-illustrations”>Injurymap</a>
NORRIS, C.M., 2018. Sports and Soft Tissue Injuries: A Guide for Students and Therapists. 5th ed. Taylor and Francis Group.
PEGRUM, J., SELF, A. & HALL, N., 2019. Iliotibial band syndrome. The British Medical Journal [online]. 364 [viewed 08 July 2021]. Available from: doi: 10.1136/bmj.l980
RECONSTRUCTIVE REVIEW, 2018. Understanding Iliotibial Band [online image]. [viewed 13 July 2021]. Available from: http://www.bing.com/images/search
THE BRITISH MEDICAL JOURNAL, 2019. IT band syndrome: Information for patients. The British Medical Journal [online]. [viewed 16 June 2021]. Available from: https://www.bmj.com/content/bmj/suppl/2019/03/21/bmj.l980.DC1/itband_pis_v32.pdf
WALTER, R., FRONTERA, J., SILVER, K. & THOMAS, D., 2020. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain and Rehabilitation. 4th ed. Elsevier. [viewed 21 June 2021]. Available from: https://doi.org/10.1016/C2015-0-05620-9
WIKIMEDIA COMMONS, 2019. Runners-knee [online image] modified. [viewed 13th July 2021]. Available from: https://commons.wikimedia.org/wiki/File:Runners-knee_SAG.jpg
