IT Band Pain – iRunFar

Welcome to a new article series! This series will become a comprehensive how-to guide for self-treating many of running’s most complex aches, pains, and injuries. This first article begins with one of the most common runner ailments, iliotibial (IT) band pain, also called IT band syndrome.

I began orthopedic and sports medicine writing 15 years ago, when the ink was barely dry on my physical therapy diploma. My writing motivation was borne from my earliest days of running, when I craved — and scoured the internet for — information that could help me overcome stubborn running injuries.

My writing goal then was, and still is today, to provide general help and unique insights into running-related pain and injuries.

After 15 years of clinical practice, 20-plus of coaching, and nearly 30 years of competitive running, I finally feel comfortable sharing my comprehensive strategies for overcoming many of running’s greatest injury obstacles.

Joe’s Fix-It Series will aim to alleviate common running injuries and get you back on the road or trail. Photo: iRunFar/Eszter Horanyi

How This Series Works

These articles will be constructed similarly with the following sections:

• Introduction to the injury
• What the injury is thought to be, versus what it is: A key challenge to many running injuries begins with how they are defined and understood. We will identify the conventional definitions of each issue and we will discuss what we think actually creates and perpetuates the specific problems.
• Self-treatment strategies: We will identify a series of comprehensive, multi-dimensional, self-treatment strategies. These strategies not only cover multiple body parts and types of body tissue, but are also structured in the four dimensions of comprehensive care and function to include mobility, strength and stability, run efficiency, and pacing — in that order. The type and sequencing of this care are important. To move well first requires mobility. Strength and stability are then required to move those parts with balance, efficiency, and power. Then, can those parts — and the whole body — move in an efficient way? We will identify strategies for each, creating a comprehensive care plan that will get you feeling and moving better, faster!

Disclaimer

All medical advice found online is for educational purposes only, including in these articles. It is not intended to diagnose or treat yours or any other specific illness, injury, or dysfunction. All readers should consult with a licensed medical professional as to whether or not these approaches are safe and appropriate for their specific needs.

Introduction to Iliotibial (IT) Band Pain

Iliotibial (IT) band pain includes any knee pain that occurs on the lateral or outside part of the knee. There are many structures that can cause pain on the outer knee (similar to the foot). Specifically, the IT band is a wide band of very strong fascia that runs from the pelvis to the lateral knee, inserting onto the upper shin. IT band syndrome refers to any pain related to this fascial structure, or in the region of the lateral hip, thigh, and knee.

Diagram showing the anatomy of the IT band and where pain typically presents in IT band injuries. Photo: Shutterstock

What IT Band Pain Is Thought to Be

IT band pain, as defined by WebMD, is “an injury often caused by activities where you bend your knee repeatedly, like running, cycling, hiking, and walking long distances.”

It is thought to be an overuse and excess friction problem, continues WebMD: “The problem is friction where the IT band crosses over your knee. A fluid-filled sac called a bursa normally helps the IT band glide smoothly over your knee as you bend and straighten your leg. But if your IT band is too tight, bending your knee creates friction. Your IT band and the bursa can both start to swell, which leads to the pain of IT band syndrome.”

How does an IT band get too tight and create excess friction? Per WebMD:

• “Not using the right training techniques
• Not doing enough to stretch, warm up, and cool down
• … Go[ing] too far or for too long
• Not resting long enough between workouts
• Wearing worn-out sneakers
• Running or training on the wrong surfaces
• Running downhill
• Running only on one side of the road. Because roads slope toward the curb, your outside foot is lower, which tilts your hips and throws your body off.
• Training on banked, rather than flat, surfaces. Most running tracks are slightly banked.”

Conventional treatment approaches to IT band pain and IT band syndrome, include:

• Rest and ice
• IT band stretching
• Footwear adjustment
• Training adjustments: less volume, more warm-up and cool-down

What IT Band Pain Actually Is

Lateral knee pain when running is often the result of one or both of the following:

• Excessive lateral impact force: Landing in such a way that the lateral leg absorbs excessive force. Either too much force is being absorbed, in general, or it is concentrating in the outer leg, particularly the knee.
• Excessive torsion and shear forces at the knee joint: Torsion, or rotational stress, and shear, or side-to-side stress, was outlined in our article about knee pain, The Complex Knee.

The knee is designed to do more than the simple hinge motion of bending and straightening. Its efficient movement includes both internal and external rotation, with small amounts of side-to-side motion.

When this motion becomes excessive, it causes pain. A healthy IT band has plenty of mobility to allow potentially hundreds of thousands of bend-straighten motions in a day. But it only allows for a small amount of torsion and shear movement. Excessive torsion and/or shear motion is the factor that causes overt strain on the IT band. The origin of excessive rotation and shear is mostly above and below the knee: at the pelvis and hip, and the foot and ankle.

Thus, the true solution to IT band or any other lateral knee tissue pain is to correct these excess movements by addressing all of the joints surrounding the knee: pelvis, hip, foot, and ankle. Doing so will immediately decrease the strain on the IT band, often resulting in rapid improvement in pain, mobility, and running tolerance.

Lateral knee pain can quickly stop a runner in their tracks. Photo: Shutterstock

Step 1: Mobility-Based IT Band Pain Self-Treatment Strategies

The first step in decreasing the strain on the IT band is not simply to massage and stretch the IT band, itself. Rather, we need to restore full motion to all the parts around it: the pelvis, hip, knee, ankle, and foot. The video below gives an overview of the issue and its treatment.

Pelvis and Hips Mobility

A great deal of the rotational stress at the knee stems from the hip. The hip is supposed to rotate a lot, in all aspects of athletic movement, but also in walking and running. Loss of rotation — or an imbalance of motion where a hip might internally rotate excessively but be limited in external rotation — is very common and often subtle.

Indeed, a loss of hip external rotation often creates excess internal rotation or medial shearing of the femur, creating an inward strain on the knee — often combined with an external rotation strain created at the ankle.

The pelvis is the foundation of the hip complex. It, too, needs to move, in small-but-crucial amounts. Restrictions in its motion and/or malalignment — anterior pelvic tilt, for example — can change how the femur bone moves, causing strain at the knee.

Restoring full hip and pelvic mobility and efficient alignment is a crucial step in any knee-pain treatment, especially IT band pain.

• Self-massage: Free the pelvis and hip by working the soft tissues around these bones.
  1. Use a massage ball (such as a tennis, lacrosse, or custom-made massage ball) to soften the myofascial tissue around the rim of the pelvis.
  2. Then work the hip joint, where the thigh meets the pelvis, in all directions: front (hip flexors), outside and back (glutes), and inside (adductors).
  3. Pay special attention to the tensor fascia lata muscle. This is the muscular part of the IT band, found on the anterior-lateral part of the pelvis, and is the most effective part of the IT band complex to mobilize. Here is a deep-dive on how to perform three-dimensional hip self-massage.
• Stretches: Key stretches to restore hip and pelvic mobility include:
  1. Hurdler stretch, discussed in our hip abduction/rotation article
  2. Boogie board and side lunge, or ninja pose, as seen in our pelvic mobility article
  3. Hip and pelvic roll and reach
  4. Runner’s lunge

Runner’s lunge, back view. Photo: Joe Uhan

Foot and Ankle Mobility

The opposite bookend of the functional knee resides at the foot and ankle. The tibia, the bottom half of the knee joint and insertion point of the IT band, is the dominant bone of the ankle. Stiffness at the ankle is a major factor in knee pain. If the ankle joint cannot properly dorsiflex, it often rotates excessively. This external rotation can create substantial torsion strain at the knee, especially when combined with femoral internal rotation.

A big twist can equal big pain in the IT band and other knee tissues!

• Self-massage: Work all aspects of the foot and lower leg. Massage balls are great to free the tissues of the plantar foot, which includes tendons that run the length of the tibia and fibula. Also mobilize the inner and outer shin, and the calf and Achilles complex, using a foam roller or other massage tool.

Massage balls are great to free the tissues of the foot. Photo: iRunFar/Eszter Horanyi

• Stretches: By far the most important stretch for the foot and ankle complex is the belt ankle stretch. This is because the belt applies the requisite force to ensure the tibia and fibula properly move into dorsiflexion, without excessive external rotation or side-to-side shearing force.

Ribcage Mobility

The thoracic spine, comprised of thoracic vertebrae and ribs, plays a subtle but incredibly important role in the alignment and motion of the hips — and the overall alignment of the entire leg, including the knee. Having good, balanced trunk motion feels good, aids in posture and breathing, and may also ensure efficiency at the knee.

• Self-massage: The easiest way to perform basic mobility, including soft tissue mobilization, is by rolling the ribcage with a foam roll. Perform side-to-side, up-and-down, and arch-over maneuvers to improve mobility.
• Stretches: My favorite thoracic spine and ribcage stretch is this technique using a therapy ball. This stretch promotes elongation and rotation in the running pattern.

Knee Mobility

Finally, we get to the knee! For most of my clients, I achieve 80 to 90% pain resolution through working all aspects around the knee, without working the knee itself. Yet, to put the finishing touches on a comprehensive IT band treatment requires some work at the knee joint — but in ways besides IT band stretching and massage alone.

• Self-massage: Massaging the lateral thigh is important, but not necessarily to mobilize the IT band. Evidence-based research has shown that the IT band actually has little-to-no stretch capacity. What it needs instead is to have enhanced mobility, away from the lateral quad. To do that, massage the quads three-dimensionally, by pushing them away from the femur bone.
  1. The best ways to do that are by working the lateral quad with a ball or foam roller from below, or at a 45-degree angle. This is a way to mobilize the lateral quad and IT band away from its possible restrictions with the knee, hamstrings, and other adjacent tissues. This is more effective — and far less painful — than directly rolling it, which only mashes the IT band and quad tighter into the femur.
  2. Here is an in-depth look at how to effectively mobilize the muscles of the femur, including the lateral quad and IT band.

• Stretches: Nearly all IT band stretches are a form of hip and pelvis mobility.
  1. To directly address the knee, a good starting point is a simple quad stretch. But the knee itself often needs a specific de-rotation strategy, that will reverse the most common inefficient pattern: excessive femoral internal rotation and tibia external rotation.
  2. A simple-but-potent way to do that is using the swivel stretch. This is an active strategy that externally rotates the femurs on a stable (relatively internally rotated) tibia, as the knee passes from flexion to extension.

Step 2. Strength- and Stability-Based IT Band Pain Self-Treatment Strategies

Strength and stability are relatively less important than the restoration of mobility. However, once mobility is restored, strength work is needed to maintain that new motion, and prevent the whole leg from returning to its previous, inefficient pattern.

Key exercises that work on efficient hips, knees, and ankles include:

• Split squat: This exercise works on efficient hip and pelvis loading. The key aspect of the split squat is twofold: an efficient pelvis that is level and pointed straight ahead.

The author demonstrates the proper down position of the split squat, the posture differentiating it from a regular squat. Photo: Joe Uhan

• Runner heel raise plus toe-up: This whole-leg exercise works on a strong foot and ankle plantar flexion, while the opposite foot, knee, and hip flexes upward.
• Plyometrics: Various hopping exercises while maintaining efficient alignment — hip hinge, frontal plane knee alignment, and balanced foot loading — promote a balanced and strong ground contact. A few easy-but-effective hopping exercises can be found in this plyometrics article.

Step 3. Run Efficiency-Based IT Band Pain Self-Treatment Strategies

Efficient running involves the efficient use of the hip, pelvis, knee, foot, and ankle joints. Here are some key efficiency concepts to doublecheck when you are ready to run again:

• Hip hinge — This posture optimizes the use of the hip in an efficient way while running.
• Knee out and foot in alignment — This strategy ensures the knee is in balanced alignment without excessive medial or lateral movement in the running motion.
• Avoid an overstriding, overreaching landing — Ensuring your foot and leg land mostly below your body’s center of mass while you are running is crucial to avoid excessive braking force, and excess energy absorption into your knee. A foot-under-body landing strategy usually corrects for a hyper-lateral foot strike that can transmit excessive energy to the lateral knee. Use a vertical hip strategy and its upward leg action to create a more natural, downward, and efficient foot strike.

Lithuania’s Aleksandr Sorokin demonstrates a foot-under-body landing on his way to winning the 2023 IAU 24-Hour World Championships. Photo: International Association of Ultrarunners

Step 4. Pacing-Based IT Band Pain Self-Treatment Strategies

By the time most runners restore motion, improve strength, and enhance efficiency, most if not all of their pain is gone. If the lateral knee and IT band tissue continues to be painful, then a gradual return to activity is required.

Guidelines include:

• A runner should be able to repetitively squat, step, and hop with minimal or no pain before returning to running.
• Initial running should be on flat, mostly even, and smooth terrain. Avoid terrain that’s either too hard or too soft.
• Avoid hilly running until one can run on flat, even surfaces, with minimal pain, for four to five miles.

Conclusion

As we will outline in future articles, the majority of conventional approaches to specific running aches, pains, and injuries fail to look beyond the pain itself. But as we outlined in this article, a sustainable pain-relief strategy requires a comprehensive, multi-dimensional, whole-body approach. This approach to IT band pain, also called IT band syndrome, is surely that, but it’s also the most effective at quickly fixing what for many is a protracted and frustrating battle.

Call for Comments

Give it a try, and share your experience in the comments section. And, let us know what other pesky runner problems you would like us to address in future articles.