Iliotibial Band Syndrome (IT Band Syndrome)

Also known as: Iliotibial band syndrome, IT band syndrome, ITBS (iliotibial band syndrome), Iliotibial band friction syndrome, Iliotibial friction syndrome, IT band friction syndrome

Last updated: December 18, 2024

Iliotibial Band Syndrome (IT band syndrome) is an overuse-related condition that causes pain on the outer side of the knee when the iliotibial band and nearby tissues become irritated near the lateral femoral epicondyle, often from friction or compression during repeated knee bending and straightening. It is common in runners and cyclists, with activity-related pain that may feel sharp or burning and can worsen with continued motion. Symptoms often improve with conservative management.

Key Facts

•Iliotibial band syndrome (IT band syndrome) be described as an overuse-related lateral knee pain condition in which the iliotibial band and adjacent tissues become irritated near the outer (lateral) aspect of the knee
•Lateral knee pain that begin during activity and intensify with continued running or cycling
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

Iliotibial band syndrome (IT band syndrome) may be described as an overuse-related lateral knee pain condition in which the iliotibial band and adjacent tissues can become irritated near the outer (lateral) aspect of the knee. It often involves friction or compression of the distal iliotibial band against the lateral femoral epicondyle during repetitive knee flexion and extension, which can contribute to local inflammation and pain. The condition typically occurs in runners and cyclists and can be associated with training changes, biomechanical factors, and hip muscle weakness. Symptoms generally relate to activity and may fluctuate with rest, load, and movement patterns.

Affected Anatomy

This condition affects several structures in and around the joint:

•Iliotibial band (distal portion near the lateral knee)
•Lateral femoral epicondyle
•Lateral tibial condyle (Gerdy tubercle insertion region)
•Tensor fasciae latae muscle (proximal contributor to IT band tension)
•Gluteus maximus muscle (proximal contributor to IT band tension)
•Lateral synovial recess and adjacent soft tissues near the lateral femoral epicondyle
•Subcutaneous tissue and potential IT band–related bursal tissue near the lateral knee
•Lateral knee joint capsule and surrounding connective tissue

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Lateral knee pain that may begin during activity and can intensify with continued running or cycling
•Pain that often localizes near the lateral femoral epicondyle and can feel sharp or burning with repetitive knee motion
•Symptoms that may worsen when running downhill, running on banked surfaces, or during prolonged cycling with repeated knee flexion-extension
•Tenderness to palpation over the outer knee, often a few centimeters above the lateral joint line
•A sensation of snapping, clicking, or friction on the outer knee that can occur with knee bending and straightening
•Stiffness or discomfort that may be more noticeable at the onset of activity and can recur after a predictable distance or duration
•Pain that may persist after activity and can occasionally be present at rest during symptom flares
•Reduced performance or altered gait mechanics that may develop as pain increases

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Repetitive knee flexion and extension that can increase friction or compression between the distal iliotibial band and the lateral femoral epicondyle
•Training load changes that may exceed tissue tolerance, including rapid increases in mileage, speed work, or hill training
•Biomechanical contributors that can increase lateral knee stress, such as increased hip adduction/internal rotation during stance or dynamic knee valgus patterns
•Muscle imbalance or weakness, particularly reduced hip abductor and external rotator strength, which can increase iliotibial band tension during gait
•Cycling-related factors that may increase repetitive lateral knee loading, including saddle height or cleat alignment issues
•Running surface factors that can alter lower-limb mechanics, including cambered roads or uneven terrain

Risk Factors

•Distance running or frequent cycling with high repetition of knee motion
•Recent increases in training volume, intensity, or hill work that can raise cumulative tissue load
•Running on sloped or banked surfaces that may increase asymmetrical lower-limb loading
•Hip abductor weakness or poor neuromuscular control that can increase hip adduction and knee valgus during stance
•Limited flexibility or increased tension in the iliotibial band–tensor fasciae latae complex that can increase lateral knee compression
•Prior lower-extremity injury or pain that can contribute to compensatory gait mechanics
•Foot and lower-limb alignment patterns that may be associated with altered loading (for example, overpronation in some individuals)
•Cycling setup factors that can increase lateral knee stress, including saddle height, saddle fore-aft position, or cleat rotation

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history focusing on activity-related lateral knee pain patterns, training changes, running terrain, and cycling setup factors
•Physical examination that can include inspection of gait and lower-limb alignment, palpation of the lateral femoral epicondyle region, and assessment of swelling or focal tenderness
•Range-of-motion assessment of the hip and knee, which can help identify contributing mobility limitations and reproduce symptoms in some cases
•Strength and functional testing, often emphasizing hip abductors/external rotators and single-leg control (for example, single-leg squat mechanics) to evaluate dynamic valgus tendencies
•Special tests that may be used to support the clinical impression, such as Ober-related assessments for lateral hip/IT band tightness and provocative maneuvers that can reproduce lateral knee pain
•Imaging when needed to evaluate alternative or coexisting diagnoses, with ultrasound or MRI potentially showing distal IT band thickening, adjacent soft-tissue edema, or other lateral knee pathology
•Differential diagnosis assessment to distinguish from lateral meniscus injury, lateral collateral ligament sprain, patellofemoral pain, stress injury, or referred pain from the hip or lumbar spine

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Activity modification and relative rest, which may reduce repetitive loading and can allow irritated tissues to settle while maintaining tolerated cross-training
•Ice or other symptom-modulating measures that may help with short-term pain and inflammation control after activity
•Flexibility and mobility interventions that may address contributing tightness in the hip flexors, gluteal muscles, and lateral thigh soft tissues
•Gait retraining strategies that can modify running mechanics (for example, step width or cadence adjustments) and may reduce lateral knee loading in selected individuals
•Cycling fit assessment and adjustments that can address saddle height, cleat alignment, and knee tracking to reduce repetitive lateral knee stress

Physical Therapy and Exercise

•Physical therapy approaches that can include hip and core strengthening, neuromuscular retraining, and gradual return-to-run or return-to-ride progression
•Orthotics or footwear modifications that may be considered when foot mechanics appear contributory, often alongside strengthening and gait interventions

Medications

•Nonsteroidal anti-inflammatory drugs (NSAIDs) that may be used for symptom relief in some individuals, with appropriateness generally depending on individual health factors and clinician guidance

Injections and Office-Based Procedures

•Corticosteroid injection near the distal iliotibial band region that may be considered for persistent symptoms and can provide temporary pain reduction in selected cases

Surgery

•Surgical options that may be considered when prolonged conservative management does not provide adequate relief, including procedures that can address distal IT band friction/compression or associated bursitis in selected cases

Prognosis and Recovery

The course of this condition varies between individuals:

•Symptoms often improve with conservative management, particularly when contributing training errors and biomechanical factors are addressed.
•Time to improvement can vary and may span weeks to months depending on symptom duration, training demands, and adherence to a graded loading approach.
•Recurrence can occur, particularly if rapid training progression resumes or if underlying hip strength and movement-control deficits persist.
•Persistent or atypical lateral knee pain may prompt reassessment for alternative diagnoses such as meniscal pathology, ligament injury, or stress-related bone injury.
•Individuals who integrate load management, strengthening, and technique adjustments may experience fewer flare-ups during return to sport.

Physical Therapy (Physiotherapy)(Procedure)
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Frequently Asked Questions

Common symptoms include: Lateral knee pain that may begin during activity and can intensify with continued running or cycling; Pain that often localizes near the lateral femoral epicondyle and can feel sharp or burning with repetitive knee motion; Symptoms that may worsen when running downhill, running on banked surfaces, or during prolonged cycling with repeated knee flexion-extension; Tenderness to palpation over the outer knee, often a few centimeters above the lateral joint line; A sensation of snapping, clicking, or friction on the outer knee that can occur with knee bending and straightening.

Diagnosis typically involves: Clinical history focusing on activity-related lateral knee pain patterns, training changes, running terrain, and cycling setup factors; Physical examination that can include inspection of gait and lower-limb alignment, palpation of the lateral femoral epicondyle region, and assessment of swelling or focal tenderness; Range-of-motion assessment of the hip and knee, which can help identify contributing mobility limitations and reproduce symptoms in some cases; Strength and functional testing, often emphasizing hip abductors/external rotators and single-leg control (for example, single-leg squat mechanics) to evaluate dynamic valgus tendencies.

Treatment options range from conservative measures to surgical interventions, including: Activity modification and relative rest, which may reduce repetitive loading and can allow irritated tissues to settle while maintaining tolerated cross-training; Ice or other symptom-modulating measures that may help with short-term pain and inflammation control after activity; Physical therapy approaches that can include hip and core strengthening, neuromuscular retraining, and gradual return-to-run or return-to-ride progression; Flexibility and mobility interventions that may address contributing tightness in the hip flexors, gluteal muscles, and lateral thigh soft tissues; Gait retraining strategies that can modify running mechanics (for example, step width or cadence adjustments) and may reduce lateral knee loading in selected individuals.