IT Band Syndrome Injury in Runners: Stretches, Preventive Exercises, and Research-Backed Treatments

IT Band RunnersThe iliotibial band, or IT band, is a long “band” of tissue that runs from the top of the hips down the outside of the thigh, crossing the outside of the knee and inserting at the very top of the tibia. While many people envision the IT band as an independent structure that can freely slide forwards and backwards relative to the rest of the leg, in reality, it is nothing more than a thickened strip of fascia, the connective tissue that encapsulates the muscles of the body. The IT band serves as a connection between many of the major hip muscles and the knee. Its main function during running seems to be stabilizing the knee during footstrike.

Iliotibial band syndrome, or ITBS, is an injury to the IT band. It most commonly occurs on the outside of the knee or just above it, though it is not unheard of to get pain further up the IT band, even as far as the top of the femur.

ITBS accounts for somewhere between 8 and 10% of all running injuries,1 and doesn’t seem to discriminate: both recreational runners and elites suffer from this injury. IT band syndrome usually hurts after a set distance into a run—you’ll feel okay for a mile or two, but the outside of your knee will start to ache, progressing from a dull stiffness to a sharp or burning pain. It is typically worse when going down hills, and you may sometimes feel pain when sitting with your leg bent for a long time. Any activity which brings the knee into 20-30 degrees of flexion can aggravate the IT band, as this is when the band itself gets squeezed against the femur the most.

Causes, what makes it worse, what’s going on

Just before the IT band crosses the knee, it runs on top of a large knob on the femur called the lateral epicondyle. The prevailing opinion for a long time was that the IT band slides back and forth across this bony knob, leading to the term “IT band friction syndrome.” However, recent anatomic studies have shown that the cause is more likely compression—the IT band is squeezed against the bone, irritating an area rich in blood vessels and nerve endings between the two structures.2

While factors like old shoes, running on cambered road surfaces, and tight turns on indoor tracks have all been proposed as risk factors for ITBS, none of these have much scientific evidence to back them up.

However, a host of studies have connected hip abductor and external rotator muscle weakness with ITBS. In a healthy and strong runner, these muscle groups keep the hip abducted and the knee externally rotated, which limits the strain on the IT band.3, 4, 5 But when these muscles are weakened, the hip adducts and the knee internally rotates after impact with the ground, crushing the IT band and the underlying sensitive tissue against the lateral femoral epicondyle. Current theories hold that the nerve endings sandwiched between the IT band and the femur are supposed to send signals to the glute muscles to fire when the IT band is being compressed—of course, when these muscles are weak or dysfunctional, this protection mechanism fails. Instead of the gluteus medius and the other main hip abductors firing, the TFL (tensor fascia lata) muscle fires, which puts even more strain on the IT band. 2

Research backed treatment options

IT band syndrome is a classic biomechanical problem. Muscular weakness and dysfunction causes a predictable and repeatable change in running mechanics, increasing strain on the IT band and causing injury. So, while the painful area is the outside of the knee, the real problem lies further up the leg. While icing, stretching, and foam rolling all have their role, a biomechanical problem ultimately needs a biomechanical solution. This is where hip strengthening exercises come in.

The best current research-approved protocol for ITBS was described in a 2000 paper by Michael Fredericson at Stanford University.4 His rather simple program consists of two stretches and two strength exercises. The stretches are performed three times per day holding the stretch for 15 seconds each on both sides. The strength exercises start with one set of 15 repeats every day, building up to three sets of 30 over time. The entire program lasts six weeks. Fredericson’s athletes avoided running during this six-week protocol, and 92% recovered completely.

The Fredericson protocol:

Lying rope hip stretch

lying rope hip stretch

Standing hip crossover stretch

Lying hip abduction

Standing hip hike

Other possible treatment options

While Fredericson’s results were impressive, his study had some flaws. For one, it had no control group, so it’s unclear how much of the improvement was from the exercises and how much was from the time off. Additionally, his protocol lacks any exercises that strengthen the external rotators. I recommend adding the following exercises to address external rotator and abductor strength at the same time, as well as adding some isometric strength, which is more similar to how these muscles function while running:

Clamshells

Glute bridge

The “up” position is held for 5 seconds

Wall isometric

The inside leg is pushed into the wall for a 5-second hold.

IT band stretches

With regards to stretching, the IT band itself is not particularly amenable to it, for two reasons. First, it is not a stretchy tissue. Its stiffness is more in line with a car tire than a rubber band.6 And second, stretches that purportedly target the IT band don’t actually stretch it very much, since it attaches to the femur at several places.7 Instead, research suggests that you should target the muscles that attach to the IT band: the gluteus maximus and the TFL. Fredericson’s two stretches accomplish this very well.

Foam roller for the IT band

Using a foam roller to loosen up soft tissue around the IT band is a great idea, but actually rolling over the painful area should be avoided. Remember, IT band pain stems from irritating the highly sensitive area between the bony knob on the femur and the IT band, so you don’t want to further aggravate this spot!

Some people find that a particular shoe style aggravates their IT band, but there’s no scientific evidence that points towards any kind of shoe or custom insert causing or curing IT band problems. All the evidence thus far points to the root cause being at the hips, not the feet, so your number one priority should be to strengthen your abductors and external rotators.

Outline of treatment

Conservative treatments

These are methods that are fairly simple, inexpensive, and can be done on your own at home.

Hip strengthening: Fredericson protocol + added exercises:

Fredericson protocol:

  1. Lying hip stretch with rope, 3x/day, 15sec hold each side
  2. Standing crossover stretch, 3x/day, 15sec hold each side
  3. Lying hip abduction, start with 1×15 once per day, build to 3×30 once per day
  4. Standing hip hike,  3×30 once per day

Additional exercises:

  1. Clamshell exercise, 1×15? 3×30 once per day
  2. Glute bridge with 5sec hold, 1×15 ? 2×20
  3. Wall isometric with 5sec hold, 1×15 ? 2×20

Additional therapies:

  1. Foam rolling of the quads, hamstrings, glutes, and upper hip area 1-2x per day
  2. Icing with ice cup: 10-12 minutes, 2-5 times per day

Aggressive treatments

These are treatments with more cost and less certainty about outcomes, but may prove useful in recalcitrant cases.

  1. Active Release Technique (ART) and/or Graston technique. These are soft tissue manipulation therapies that are intended to break down scar tissue in chronically injured areas. While there is little to no science backing their efficacy, some runners have found relief from ART or Graston. Most practitioners are chiropractors, so this treatment may or may not be covered by insurance. It should not be used on acute cases of ITBS, however.

Return to running:

Since IT band syndrome is the result of a biomechanical problem, your ability to return to running will be determined by your progress in hip strength. In the initial stages of the injury, you will need anywhere from a few days to a few weeks of time off for the initial inflammation on the outside of the knee to calm down. Icing often can speed this along. Once the initial irritation is gone, you will probably find that your IT band still gets irritated after a few miles of running if you haven’t worked on your hip strength. In my experience, it takes about a month of daily hip strength exercises to completely recover, though you may be able to run during this time period. You just need to keep your runs short enough so that they do not aggravate your IT band anew. If all else fails, you may need an extended break from running to rebuild your strength like the subjects in Fredericson’s study.

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References

1. Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
2. Fairclough, J.; Hayashi, K.; Toumi, H.; Lyons, K.; Bydder, G.; Phillips, N.; Best, T. M.; Benjamin, M., Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport 2007, 10 (2), 74-76.
3. Ferber, R.; Hamill, J.; Davis, I.; Noehren, B., Competitive Female Runners With a History of Iliotibial Band Syndrome Demonstrate Atypical Hip and Knee Kinematics. Journal of Orthopaedic & Sports Physical Therapy 2010, 40 (2), 52-58.
4. Fredericson, M.; Cookingham, C. L.; Chaudhari, A. M.; Dowdell, B. C.; Oestreicher, N.; Sahrmann, S. A., Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clinical Journal of Sports Medicine 2000, (10), 169-175.
5. Hamill, J.; Miller, R.; Noehren, B.; Davis, I., A prospective study of iliotibial band strain in runners. Clinical Biomechanics 2008, 23 (8), 1018-1025.
6. Murray, G., Tensile strength and elasticity tests on human fascia lata. The Journal of Bone and Joint Surgery 1931, 13 (2), 334.
7. Falvey, E.; Clark, R.; Franklyn-Miller, A.; Bryant, A.; Briggs, C.; McCrory, P., Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandanavian Journal of Medicine & Science in Sports 2010, 20 (4), 580-587.

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24 Responses on “IT Band Syndrome Injury in Runners: Stretches, Preventive Exercises, and Research-Backed Treatments

  1. Great article, down to earth and laid out in a good laymen’s terms that are easy to follow and understand (like most of your stuff) Thank you!

    I’d add traditional sports/deep tissue massage as a great treatment, though I’m not sure I’d it as “aggressive” (seeing that massage is commonplace with runners) and the cost isn’t as high as ART or Graston, plus more accessible. A good practitioner knows how to handle the ITBand and surrounding muscles (hips, glutes, TFL, etc.) ART and Graston are great, pinpoint techniques and yes, more costly, but a good round of traditional sports massages have good success too in our experiences.

    I’d also add Acupuncture to the more aggressive (and costly) list of Treatments. I’ve known many runners that have had luck, including my wife. After a debilitating bout of ITBS and 2-3 weeks of self and assisted care, 2 weeks of aggressive acupuncture did the trick (I’m sure the combination of everything helped) but it certainly stood out. (I’m a personal fan of acupuncture too and have seen it work well with many injuries and ailments.)

    If I were to order the “practitioner assisted” treatments in relation to availability/cost/effectiveness/commonality, I’d do 1) Sports/Deep Massage 2) ART Massage 3) Graston 4) Acupuncture

    Of course, the bigger picture is to get to the root causes like you point out so you don’t want to rely on massages every week, but getting through a bout of ITBS during training or leading to a race has to be dealt with, and sometimes very quickly.

    • Thanks, Blake. John really does a great job of breaking down the more complicated scientific findings into easily digestible and actionable findings.

      I like both of your suggestions on massage and acupuncture. Actually, I think it would be beneficial to look at some of the science of these two modalities in more depth, rather than just on IT band injuries specifically. I think that could open up a valuable treatment method for some injuries.

      Finally, you’re definitely right about finding the root cause. I think a lot of the hip exercises mentioned can really help address the structural weaknesses.

      Thank you for the suggestions and ideas for future research. I appreciate the comment. Best of luck with your training and racing!

  2. I was actually going to ask about acupuncture as I have been reading about it as another treatment for IT band. I have been feeling like the stretching is not so helpful, but the hip/glute strengthening exercises are. I’m able to run up to 4 miles comfortably but have not gone beyond. I did take a couple weeks off completely but that really proved to be worse! As long as I can run without discomfort, I feel much better keeping a regular running schedule! Thanks for discussing this topic-very helpful!

  3. I’ve been dealing with pain on the side of my left hip for months, and I can’t seem to get rid of it. In many ways it matches the described symptoms above, and in many ways it doesn’t. I don’t really get pain near the knee. It starts at hip level on the outside of the left buttock and goes down the outside of the leg about half way. When it’s really bad, I might feel it as far down as the knee. I’ve been doing the clamshell, and bridges and other exercises for almost 4 months to get rid of it. While I haven’t completely stopped running or riding a bike, I’ve curtailled my activity alot. Does this sound like an IT Band issue or could it be something else? I’d appreciate any feedback.

    • Hi Dave. Hard to diagnose without actually being able to see you. Since you’ve had the pain for a while, I would invest in a trip to the orthopedist or a good sports PT. Sometimes, just getting an accurate diagnosis can help target and focus the rehab process.

  4. I just wanted to say thank you very much for this helpful and well-researched article. There is so much conflicting advice online but this all makes sense. I will be doing those strengthening exercises from now on! I might still be able to run my marathon in April now after all! :-)

  5. I’ve been struggling off an on with IT band pain for a couple of years now. I’ve read all about it and I know that hip exercises are supposed to be the way to get over it, but I find that whenever I do the exercises or stretches, it just makes my IT band pain flare up again. It seems like it makes things worse rather than better! I’m planning a big vacation in a couple of months that includes backpacking, so I’d love to get this IT band stuff behind me once and for all. Any advice?

    • Hmm, that’s a tough situation. My advice would be to tackle the pain first. Meaning, don’t start the exercises until you are feeling 100%. Then, once you have the pain managed, start with the exercises and continue with the therapy as if the leg was injured. After a few weeks, you should be able to do the exercises pain-free and then be able to run/walk

  6. I have had IT band issues for about 4 months now, I have been doing the strengthening exercise for 2 weeks, managing up to 3 sets of 30 on everything but the lying hip abduction (which hopefully wont be too far off). IT band feels looser and definatly more comfortable, but im really concerned as when i feel down the outside of the leg (vastus lateralis) there are what feel like large knots and lumps? Ive tried massage and foam rolling but wont break up, any ideas or advice would be great please.

  7. Great article and description of the exercises.

    Kind of a segue from Dave’s question. I have had tension (and only very slight pain) on the outside of my right hip for almost 4 years. It also cracks sometimes, while the other side does not.

    I took up running again 6 months ago, but needed to stop when I developed sharp pain on the outside of my right knee.

    I only connected to the two to IT band upon reading these types of articles.

    In addition to the stereotypical symptom of sharp pain in the knee, I have the tension and weak pain in my hip, and do you believe this accompanying (and possibly less common?) hip tension differentiates me from what is typically recommended for runners with IT problems as described in this article? Thank you!

  8. Sorry, second question here. I read the article from the Stanford group. I wonder, do athletes ever over-strengthen their injured side? That is, do they ever follow this sort of protocol only to reverse the strength/flexibility imbalance and develop IT-band injury on the other side? Thanks :o)

    • Hi Stella,

      First, I don’t think your hip tension/weakness in the knee is any different than the norm. Your pain/symptoms just happen to manifest itself at the actual point of origin.

      As for “over strengthening”, I don’t think this can happen (although I’ve never studied it). Theoretically, you could over-rely on one leg, but if both hips are strong it wouldn’t hurt. Plus, it’s always a good idea to balance by doing some of the same exercises on both legs.

  9. i have struggled with many injuries over the past twenty years itb the most common. i ran new york half after a patch of never running better in my life and itb showed its face at 4 km. i ran through it, took three weeks off completely and ran Paris Marathon. both knees went at 8km….. stupidly hobbled through. after 6 weeks of strength rehab i am having a bilateral itb release in an hour…. will keep you all posted. remember this is a last resort after twenty years of running and many marathons xxx

  10. Just wondering if anyone has had cortisone shots in legs or hips?
    My legs are just getting worse, it has been a year now, no running, no cardio, standing, sitting causes the pain down both legs burning pain
    I have done physio, months of the runnersconnect it band protocol and any hip strength improvements can not be sustained. I have tried ART and dry needling results were poor
    Depressed now, lost all the gains in fitness, put on 20 pounds and the pain and edema is brutal
    Sports med doctors hvae not been helpful at Umich in ann arbor, cortisone shots are my last resort

  11. I don’t have pain on the side of my knee unless something touches it then the pain is severe for a little while. Could this be the It band? Had this for a very long time.

  12. I bought the runners connect program 8 months ago and I think it is awesome, I wish I bought it before I began running. Unfortunately my itbs has lasted 18 months and I have given up running for the foreseeable future. Surgery might be needed

  13. I am so glad I found this website…. I am current doing the exercises for an IT/periformis injury I’ve had for a while…. I actually tore one of my glutinous muscles by being too vigorous with PT exercises. Since your website suggests exercises/ stretches it would be great to have a verbal explanation on how to do the exercises correctly along with the pictures .

  14. It’s actually a great and useful piece of info.
    I am satisfied that you shared this helpful info with us.
    Please stay us up to date like this. Thanks for sharing.

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