What is Iliotibial Band Syndrome?


ITBS is a common knee injury that usually presents as outside knee pain caused by inflammation of the bottom of the iliotibial band; occasionally, however, the iliotibial band becomes inflamed at the top of band and causes referred hip pain.

The iliotibial band is a thick band of fascia that is formed at the hip by the confluence of fascia from hip flexors, extensors, and abductors. The band originates at the lateral iliac crest and extends down to the patella, tibia, and biceps femoris tendon.

ITBS is caused by excessive friction of the base of the iliotibial band as it slides over the bony lump on the outside of the knee (lateral femoral epicondyle) during repetitive flexion and extension of the knee resulting in friction and potential irritation. In patients with iliotibial syndrome, studies have shown that the base of the iliotibial band becomes thickened and that the potential space deep to the iliotibial band over the outside of the knee becomes inflamed and filled with fluid.

It is also sometimes referred to as Ilio Tibial Band Friction Syndrome (ITBFS).

Some risk factors are thought to contribute to ITBS such as pre-existing iliotibial band tightness; high weekly mileage; time spent walking or running on a track; interval training; and muscular weakness of knee extensors, knee flexors, and hip abductors. Hip abductor weakness seems to contribute to the development of iliotibial band syndrome.

The primary initial complaint in patients with iliotibial band syndrome is diffuse pain over the outside of the knee. These patients frequently are unable to indicate one specific area of tenderness, but tend to use the palm of the hand to indicate pain over the entire outside edge of the knee. With time and continued activity, the initial lateral achiness progresses into a more painful, sharp, and localized discomfort over the lateral femoral epicondyle and/or the lateral tibial tubercle. Typically, the pain begins after the completion of a run or several minutes into a run; however, as the iliotibial band becomes increasingly irritated, the symptoms typically begin earlier in an exercise session and can even occur when the person is at rest. Patients often note that the pain is aggravated while running down hills, lengthening their stride, or sitting for long periods of time with the knee in the flexed position.


The initial goal of treatment should be to alleviate inflammation by using ice and anti-inflammatory medications. Patient education and activity modification are crucial to successful treatment. Any activity that requires repeated knee flexion and extension is prohibited. During treatment, the patient may swim to maintain cardiovascular fitness. If visible swelling or pain with walking persists for more than three days after initiating treatment, a local corticosteroid injection should be considered.
Strengthening of the hip abductors has led to symptom improvement.

imageThis shows an ITB stretch.
Once the patient can perform stretching without pain, a strengthening program should be initiated. Strength training should be an integral part of any runner’s regimen; however, for patients with iliotibial band syndrome particular emphasis needs to be placed on the gluteus medius muscle. A strengthening exercise geared toward the gluteus medius is shown below.image
Exercise for strengthening of the right gluteus medius muscle in a weight-bearing position. (A) The patient stands on a platform and lowers the left leg toward the ground slowly. (B) Through contraction of the right gluteus medius, the patient then elevates the leg, returning the pelvis to a level position.

Running should be resumed only after the patient is able to perform all of the strength exercises without pain. The return to running should be gradual, starting at an easy pace on a level surface. If the patient is able to tolerate this type of running without pain, mileage can be increased slowly. For the first week, patients should run only every other day, starting with easy sprints on a level surface. Most patients improve within three to six weeks if they are compliant with their stretching and activity limitations!