Move Forward Guide
Physical Therapist's Guide to
Iliotibial Band Syndrome (ITBS)
Iliotibial band syndrome (ITBS) is one of the most common causes of knee pain, particularly in individuals involved in endurance sports. It accounts for up to 12% of running injuries and up to 24% of cycling injuries. ITBS is typically managed conservatively through physical therapy and temporary activity modification.
What is Iliotibial Band Syndrome (ITBS)?
Iliotibial band syndrome (ITBS) occurs when excessive irritation causes pain at the outside (or lateral) part of the knee. The iliotibial band (ITB) is a type of soft tissue that runs along the side of the thigh from the pelvis to the knee. As it approaches the knee, its shape thickens as it crosses a prominent area of the thigh (femur) bone, called the lateral femoral condyle. Near the pelvis, it attaches to 2 important hip muscles, the tensor fascia latae (TFL) and the gluteus maximus.
Irritation and inflammation arise from friction between the ITB and underlying structures when an individual moves through repetitive straightening (extension) and bending (flexion) of the knee. Typically, ITBS pain occurs with overuse during activities such as running and cycling.
ITBS involves many lower extremity structures, including muscles, bones, and other soft tissues. Usually discomfort arises from:
- Abnormal contact between the ITB and thigh (femur) bone
- Poor alignment and/or muscular control of the lower body
- Prolonged pinching (compression) or rubbing (shearing) forces during repetitive activities
The common structures involved in ITBS are:
- Iliotibial band
- Bursa (fluid-filled sack that sits between bones and soft tissues to limit friction)
- Hip muscles
ITBS can occur in:
- Athletes performing repetitive activities, such as squatting, and endurance sports such as running and cycling
- Individuals who spend long periods of time in prolonged positions, such as sitting or standing for a long workday, climbing or squatting, or kneeling
- Individuals who quickly start a new exercise regimen without proper warm-up or preparation
Signs and Symptoms
With ITBS, you may experience:
- Stabbing or stinging pain along the outside of the knee
- A feeling of the ITB “snapping” over the knee as it bends and straightens
- Swelling near the outside of your knee
- Occasionally, tightness and pain at the outside of the hip
- Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position
Pain is usually most intense when the knee is in a slightly bent position, either right before or right after the foot strikes the ground. This is the point where the ITB rubs the most over the femur.
How Is It Diagnosed?
Your physical therapist will ask you questions about your medical history and activity regimen. A physical examination will be performed so that your physical therapist can collect movement (range of motion), strength, and flexibility measurements at the hip, knee, and ankle.
When dealing with ITBS, it is also common for a physical therapist to use special tests and complete a movement analysis, which will provide information on the way that you move and how it might contribute to your injury. This could include assessment of walking/running mechanics, foot structure, and balance. Your therapist may have you repeat the activity that causes your pain to see firsthand how your body moves when you feel pain. If you are an athlete, your therapist might also ask you about your chosen sport, shoes, training routes, and exercise routine.
Typically, medical imaging tests, such as x-ray and MRI, are not needed to diagnosis ITBS.
How Can a Physical Therapist Help?
Your physical therapist will use treatment strategies to focus on:
Range of motion
Often, abnormal motion of the hip and knee and foot joint can cause ITBS because of how the band attaches to hip muscles. Your therapist will assess the motion of your injury leg compared with expected normal motion and the motion of the hip on your uninvolved leg.
Hip and core weakness can contribute to ITBS. The "core" refers to the muscles of the abdomen, low back, and pelvis. Core strength is important, as a strong midsection will allow greater stability through the body as the arms and legs go through various motions. For athletes performing endurance sports, it is important to have a strong core to stabilize the hip and knee joints during repetitive leg motions. Your physical therapist will be able to determine which muscles are weak and provide specific exercises to target these areas.
Many physical therapists are trained in manual therapy, which means they use their hands to move and manipulate muscles and joints to improve motion and strength. These techniques can target areas that are difficult to treat on your own.
Even when an individual has normal motion and strength, it is important to teach the body how to perform controlled and coordinated movements so there is no longer excessive stress at the previously injured structures. Your physical therapist will develop a functional training program specific to your desired activity. This means creating exercises that will replicate your activities and challenge your body to learn the correct way to move.
Your physical therapist will also work with you to develop an individualized treatment program specific to your personal goals. He or she will offer tips to help you prevent your injury from reoccurring.
Can this Injury or Condition be Prevented?
Maintaining core and lower extremity strength and flexibility and monitoring your activity best prevents ITBS. It is important to modify your activity and contact your physical therapist soon after first feeling pain. Research indicates that when soft tissues are irritated and the offending activity is continued, the body does not have time to repair the injured area. This often leads to persistent pain, and the condition becomes more difficult to resolve.
Once you are involved in a rehabilitation program, your physical therapist will help you determine when you are ready to progress back to your previous activity level. He or she will make sure that your body is ready to handle the demands of your activities so that your injury does not return. You will also receive a program to perform at home that will help you maintain the improvements that you gained during rehabilitation.
Real Life Experiences
Sarah is a 31-year-old mother training for her first triathlon. With a young child at home, she has to squeeze in her training sessions early in the morning. She rarely has time to cool down or stretch after riding her bike or running because she has to get home before her child wakes up.
Sarah signs up for her first race and begins to increase her cycling and running in preparation. One day during the middle of a long run, she feels a sharp pain at the outside of her knee. It starts hurting with every step, and doesn't go away, even after she stops and stretches. Far from home, she has to finish her run despite the nagging pain. When she gets home, she puts ice on it, but for the rest of the day she has trouble going up and down stairs, or squatting to pick up her son, and feels pain when standing up after driving the car. The next day, she tries to ride her bike, but the knee pain is still there and feels worse.
Wisely, Sarah stops running and cycling and contacts her physical therapist.
Sarah's physical therapist conducts a comprehensive evaluation of her hip and knee motion, strength, balance, and running mechanics. She uses special tests and measures to determine if Sarah’s pain is related to her iliotibial band or if there are other problems occurring simultaneously. She talks with Sarah about her training routine, including equipment (shoes, position on the bike, etc), the routes she runs and their surfaces, and her stretching program. The therapist diagnoses Sarah with iliotibial band syndrome. She guides Sarah through specific exercises in the clinic, including manual stretching of the hip joint by the therapist, sidelying leg raises for hip strengthening, and single leg squats to promote integrated core, hip, knee, and ankle function. Sarah will also perform these exercises at home as a part of her daily exercise routine to maximize improvement and help ensure her sustainable success.
Sarah's physical therapist helps her develop strategies for training, taking into consideration her lifestyle as a busy mother, to help her stay injury-free. Together, they outline a 6-week rehabilitation program for iliotibial band syndrome. Sarah will come to the clinic 1-2 times each week, where her therapist will assess her progress, perform manual therapy techniques, and advance her exercise program as appropriate. Sarah will also have a daily exercise routine to perform independently at home, including stretching and strengthening activities.
In 6 weeks, Sarah has met all of her physical therapy goals and completes her rehabilitation in the clinic. After building her training gradually over the next month, she is able to train and successfully crosses the finish line just as planned!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
- A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as he or she will have advanced knowledge, experience, and skills that apply to an athletic population.
You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with ITBS.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of ITBS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011;19:726–736. Free Article.
Ellis R, Hing W, Reid D. Iliotibial band friction syndrome: a systematic review. Man Ther. 2007;12:200–208. Article Summary on PubMed.
Fredericson M, Weir A. Practical management of iliotibial band syndrome in runners. Clin J Sports Med. 2006;16:261–268. Article Summary on PubMed.
Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35:451–459. Article Summary on PubMed.
Levin J. Run down: battling IT band syndrome in long distance runners. Biomechanics. 2003;1:22–25. Article Summary Not Available.
Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med. 2000;10:169–175. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Acknowledgements: Laura Stanley, PT, DPT, SCS