Causes of Iliotibial (IT) Band Syndrome and Treatment Options

Everything you need to know about iliotibial band syndrome

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The iliotibial (IT) band is a strong, thick band of fibrous tissue that starts at the hip and runs along the outer thigh, attaching on the outside edge of the shin bone (tibia) just below the knee joint. The band works with the quadriceps (your thigh muscles) to provide stability to the outside of the knee joint during movement.

Injury to or irritation of the iliotibial band—called iliotibial band syndrome—may cause an aching or sharp pain often felt on the outside of the knee. Sometimes, the pain spreads to the thigh and/or hip area.

Diagnosis of IT band syndrome is often done clinically through a detailed history and physical examination. Once diagnosed, your doctor will devise a treatment plan that entails a combination of reducing activity, taking an anti-inflammatory medication, and undergoing physical therapy.

Causes of IT Band Syndrome
Illustration by Alexandra Gordon, Verywell

Symptoms

IT band syndrome is a condition most commonly seen in runners, in addition to cyclists, soccer players, field hockey players, basketball players, and rowers.

Since the IT band acts as a stabilizer during running, it can become irritated and inflamed when overused or stressed.

This irritation may gradually lead to an aching, burning pain felt on the outside (lateral) aspect of the knee or lower thigh. Sometimes, the pain is also felt near the hip. The pain is often more intense when descending stairs or getting up from a seated position.

Over time, the pain may become constant and sharp or stabbing in quality. As the pain becomes more severe, swelling over the outside knee may occur.

Causes

Common causes of IT band syndrome are excessive training and/or increasing training too quickly. Besides poor training regimens, faulty biomechanics can also make a person more vulnerable to developing IT band syndrome.

Examples of predisposed biomechanical errors include:

IT band syndrome is also common in runners who perform unbalanced, repetitive exercise, such as running only on one side of a crowned road or only running one way around a track. Most roads slope off to the sides and running along the edge causes the outside foot to be lower than the inside foot. This, in turn, causes the pelvis to tilt to one side, stressing the IT band.

Muscle tightness or a lack of flexibility in the gluteal (buttock), tensor fascia latae (a hip muscle), and quadriceps (thigh) muscles may also increase a person's risk of developing IT band syndrome.

When to See a Doctor

It's important to see your doctor for any knee pain that is severe, worsening, or persisting for more than a few days. In addition to knee pain, other signs that warrant medical attention include:

  • Inability to walk comfortably or knee locking (inability to bend the knee)
  • Swelling or skin changes (e.g., discoloration, redness, or warmth)
  • An injury or trauma that causes deformity around the knee joint
  • Presence of a fever or other unusual symptoms

Diagnosis

The diagnosis of iliotibial band syndrome is almost always clinical, meaning only a medical history and physical exam is required. Rarely, imaging is required to confirm a diagnosis of IT syndrome.

Medical History

If you are experiencing lateral knee/thigh/hip pain, it's sensible to jot down some notes about your pain prior to your doctor's appointment. For instance, try answering some of these questions, which are ones your doctor will likely ask during your visit:

  • When did your pain begin?
  • Is your pain constant or does it come and go?
  • What makes your pain worse? What makes it better?
  • Are you participating in any vigorous sports activity or a training regimen?
  • Have you experienced any recent trauma or injury?
  • Are you experiencing any other symptoms besides pain, such as swelling or knee instability?

Physical Examination

During the physical exam, your doctor will inspect and press on (palpate) your entire knee joint.

A hallmark finding for iliotibial band syndrome is pain over the lateral femoral epicondyle—a small projection of the lower thighbone where the iliotibial band passes over.

Your doctor may also perform the Nobel compression test in which your knee is flexed and extended while your provider applies pressure to the lateral femoral epicondyle with his thumb. If a popping or snapping sensation or pain is felt at or above the epicondyle when the knee is flexed (often maximal pain is felt at 30 degrees of knee flexion), the test is positive.

In addition to examining your knee joint, your doctor will evaluate the strength and flexibility of your quadriceps (located in the front of the thigh) and hamstrings (located in the back of the thigh).

Imaging

If imaging is used to confirm a diagnosis of iliotibial band syndrome, it's usually magnetic resonance imaging (MRI).

Differential Diagnoses

Many of the differential diagnoses that may be considered for iliotibial band syndrome overlap with those of general or lateral knee pain, including patellofemoral pain syndrome, lateral meniscus tear, and lateral collateral ligament tear.

Two additional diagnoses—popliteal tendonitis and bicep femoris tendinopathy—have a significant overlap with IT band syndrome because they also often result from excessive running, especially downhill running.

The good news is that a physical exam along with an MRI (in some cases) can generally differentiate between these diagnoses.

Popliteal Tendonitis

The popliteal tendon connects the thighbone to the popliteal muscle (a small muscle located at the back of the knee). The popliteal muscle works with the popliteal tendon to control forward motion and rotation of the knee.

Popliteal tendonitis—which refers to irritation of the popliteal tendon—usually results from excessive downhill running and walking and causes pain on the outside of the knee that sometimes spreads to the back of the knee. Swelling and redness along the outside of the knee, along with knee instability may also be present.

Biceps Femoris Tendinopathy

The biceps femoris tendon connects the biceps femoris muscle (one of three hamstring muscles) to the lateral knee. Similar to iliotibial band syndrome, excessive running can lead to irritation of the biceps femoris tendon insertion site causing pain on the outside of the knee.

Treatment

Treating IT syndrome generally includes a comprehensive approach, including the following.

R.I.C.E. Protocol

The R.I.C.E. protocol is important for the immediate and initial care of pain related to the iliotibial band.

  • Rest (or Reduce Activity): Whether you have been diagnosed with or suspect iliotibial band syndrome, your first step should be to rest the affected leg.
  • Ice: Placing ice (e.g., a cold gel pack or bag of frozen vegetables) along with a thin towel on the outside of your knee for 15-minute sessions every two hours can soothe your pain and help relieve inflammation.
  • Compression: If you have been diagnosed with IT band syndrome, talk with your doctor about wrapping an Ace bandage or an IT band compression pad just above your knee. Compressing this area can help stabilize the knee and reduce friction (as the iliotibial band slides over the lateral epicondyle of the knee).
  • Elevation: When icing your knee, do your best to keep your leg elevated above your heart.

Medication

To ease the pain and inflammation from iliotibial band syndrome, talk to your doctor about taking a nonsteroidal anti-inflammatory (NSAID). If you cannot tolerate oral NSAIDs, like ibuprofen or Aleve (naproxen), talk with your doctor about taking a topical (applied over the skin) NSAID.

In the short-term, a steroid (cortisone) injection may provide pain relief. This treatment is generally considered if a person continues to have pain despite adhering to the R.I.C.E. protocol, taking an NSAID (if possible), and undergoing physical therapy for six to 12 weeks.

Physical Therapy

Once the initial IT band inflammation and pain subsides, physical therapy is the next key step to healing. A physical therapist will utilize different techniques to improve leg strength, mobility, and flexibility.

In addition to teaching you how to perform proper strengthening and flexibility exercises, a skilled PT can also help you correct any biomechanical errors and make corrections in technique or muscle weakness or tightness.

Surgery

Surgery to lengthen the IT band is rarely required to treat IT band syndrome. It's usually only indicated if pain persists and is limiting activities, despite adhering to conservative therapies for six months or so.

While there are various types of surgical IT band-lengthening procedures, and the recovery depends on the specific one performed, most patients are able to return to running activities within six to twelve weeks.

Prevention

Since runners are most commonly affected by IT band syndrome, here are some running tips to help you prevent IT band irritation and pain:

  • When training, do not increase your distance by more than 10 percent per week, take a rest day between running days, and build your speed or incline intensity gradually.
  • Since the amount of support or cushion in your shoes can either aggravate or alleviate IT band issues, be sure to choose proper running footwear and replace aging running shoes (at least every 400 miles).
  • Avoid overtraining and get adequate rest and recovery. Frequent high-intensity running workouts can do more harm than good.
  • Consider mixing up your training to balance out your body (e.g., swimming or kayaking)
  • Run on a soft, level surface or alternate directions on the road to avoid stressing the IT band.
  • Try backward running to correct muscle imbalance and reduce pressure on the knees.
  • Talk with your doctor about using orthotics or inserts, especially if you have high arches.

A Word From Verywell

For the vast majority, IT band pain can heal well with simple measures, like reducing your activity and taking an NSAID. In order to prevent a recurrence of IT pain, it's essential to address potential underlying problems like excessive training, faulty biomechanics, and tight muscles.

Remain proactive in your IT band health—for instance, talk with your doctor and physical therapist about exercises you can do at home to strengthen the IT band's surrounding muscles. Moreover, if you are an avid runner or sports player, get help devising a training program that is gentle, straightforward and progressive.

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