IT Band Syndrome Injury in Runners: Stretches, Preventive Exercises, and Research-Backed Treatments
The 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
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:
The “up” position is held for 5 seconds
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
These are methods that are fairly simple, inexpensive, and can be done on your own at home.
Hip strengthening: Fredericson protocol + added exercises:
- Lying hip stretch with rope, 3x/day, 15sec hold each side
- Standing crossover stretch, 3x/day, 15sec hold each side
- Lying hip abduction, start with 1×15 once per day, build to 3×30 once per day
- Standing hip hike, 3×30 once per day
- Clamshell exercise, 1×15? 3×30 once per day
- Glute bridge with 5sec hold, 1×15 ? 2×20
- Wall isometric with 5sec hold, 1×15 ? 2×20
- Foam rolling of the quads, hamstrings, glutes, and upper hip area 1-2x per day
- Icing with ice cup: 10-12 minutes, 2-5 times per day
These are treatments with more cost and less certainty about outcomes, but may prove useful in recalcitrant cases.
- 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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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.