Iliotibial band syndrome is a painful condition that most often affects runners, especially those who run long distances, other athletes whose sports involve a lot of running or legwork, such as skiers, cyclists, and soccer players, or those who are new to exercise, but anyone may suffer from it. I am not an athlete, but my own left IT band and thigh are tender to the touch. Since I can reach that area myself, I frequently massage it. After warming the tissue with a lighter massage, I put as much pressure as I can using the heel of my hand or my knuckles.
I cannot say self-massage helps much, but I feel better to think I am doing something to help it. During the Covid-19 pandemic, I have been doing self-massage since early March, breaking a habit of three decades of getting frequent massages.
The frequency of IT band syndrome is inexact, depending on which study you are reading. A 2012 systematic review estimated the incidence to be between 5 to 14 percent. In reality, those numbers are based on the number of people who actually sought treatment or agreed to participate in a research project. Therefore, the actual numbers may be higher.
During my own 20-plus years as a massage therapist (currently on hiatus due to Covid-19), I worked with many runners who had symptoms, most of whom had not sought any diagnosis or treatment at all, and kept running in spite of it. Maybe it was their dislike of going to the doctor, their stubbornness, or the old “no pain, no gain” attitude at play.
While healthcare providers (including some massage therapists, as they are classified as such in some U.S. states) and personal trainers are familiar with anatomy and biomechanics, most of the general public, including those who run, may have only rudimentary knowledge, such as where the hamstrings and quadriceps are located. Instead of a client reporting to me that their IT band hurts, they are more apt to say, “I have this pain on the side of my knee.”
Anatomy and biomechanics of the IT band
The iliotibial band, also referred to as the iliotibial tract, is somewhat of an enigma. Researchers disagree on the exact anatomy of the iliotibial band and the exact etiology of symptoms associated with iliotibial band syndrome. Basically, it is a strong, thickening fibrous band of the fascia lata of the lateral thigh, beginning at the iliac crest, crossing over the knee, and extending to just below the knee on the outer side of the anterior tibia.
Where the tendon passes the knee (lateral femoral condyle), there is a bursa, a small, fluid-filled sac between the bone and the tendon. Bursae serve as cushions between tendon and bone, and/or muscles around most major joints, reducing friction caused by movement. This tendon moves over a bony process, or bump, at the outer knee as it passes in front and behind it. While many animals share anatomical features similar to those of humans, the function of the iliotibial band is unique to humans. Innervation to the tensor fascia lata arises from the superior gluteal nerve.
The IT band stabilizes the knee, both in extension and partial flexion, and is used constantly during walking and running. When you lean forward with the knee slightly flexed, the IT band is the main support of the knee against gravity.
The tensor fascia latae attaches to the anterior edge of the IT band and part of the gluteus maximus attaches to the posterior edge. Together, they tense and control this deep fascia. The function of the IT band depends on the position of the knee; tensor fascia latae pulls on the IT band to serve as a flexor, abductor, and medial rotator of the hip, while the force of the gluteus maximus on the IT band produces extension, abduction, and lateral rotation of the hip.
The IT band functions as a knee extensor when the knee is less than 30 degrees of flexion but becomes a knee flexor after exceeding 30 degrees of flexion. Thus, the IT band may acquire a more posterior position relative to the lateral femoral epicondyle with increasing degrees of flexion.
Iliotibial band syndrome symptoms
Iliotibial band friction syndrome, as it was called when first identified in 1975 by James W. Renee, was described as “a painful disabling condition lateral to the knee.” Renee, a Lieutenant Commander in the U.S. Naval Reserve Medical Corps, observed this phenomenon in soldiers who were undergoing rigorous physical training on a daily basis. There was no trauma or injury to the knee itself.
Renee noted that the symptoms of pain and limping were most evident after running for two miles or more or hiking ten miles or more (It is also likely that the recruits were doing at least some of these activities while carrying heavy packs and equipment).
Renee noted that walking became painful, and in his words, running became nearly impossible. He also said that the symptoms generally lasted from two to five days and occurred in intervals ranging from three months to five years. The main symptom is pain on the lateral knee, but IT band pain may occur anywhere along the band from the hip to the knee, including pain on the back of the knee. Inflammation and swelling may be present.
Pain intensity may be related to the position of the knee at any given time. Sufferers have frequently reported that the pain was worse when their feet were striking the ground and that full extension of the affected leg provided some relief.
The onset of IT band syndrome is not a “sudden” pain, such as spraining an ankle. Instead, it is more apt to become evident at the end of a run, when running uphill, or even climbing stairs.
Although Renee named the condition with the word “friction” included, and it is sometimes still referred to as such, there is conflicting evidence that friction has anything to do with it. In fact, there’s conflicting evidence on almost everything to do with the IT band, including anatomy, causes of the syndrome, and effective treatments.
Paul Ingraham, a science writer and former registered massage therapist in British Columbia, said that iliotibial band syndrome is surprisingly “neglected by science” and “remains mostly unexplained.” While several myths about it persist — like the idea that it is a “friction” syndrome, which the evidence clearly points away from—Ingraham later backed up on that when newer research was published.
For example, a 2006 study by Fairclough et al. challenged Renee’s theory of friction and the anatomy of the iliotibial band. The newer theory was that IT band overuse injuries may be more likely to be associated with fat compression beneath the iliotibial tract rather than with repetitive friction as the knee flexes and extends.
The researchers based their findings on 15 cadaver studies, plus magnetic resonance imaging (MRI) on six asymptomatic volunteers, and two athletes with acute cases of IT band syndrome. The study concludes that the perception of movement of the IT band across the epicondyle is an illusion.
In 2013, another study by Jelsing et al, in Ingraham’s words, “debunked his debunkery.” Jelsing utilized sonographic evaluation and concluded that the IT band does in fact move anteroposterior relative to the lateral femoral epicondyle during knee flexion-extension and relative to the femur during the functional changes of knee motion.
Iliotibial band syndrome causes
The condition is common enough among runners that it is often referred to as “runner’s knee”—not to be confused with the other “runner’s knee,” patellofemoral pain syndrome—which causes pain on the anterior knee, not the lateral knee associated with iliotibial band syndrome.
The biomechanical studies have involved small samples, and data seems to have been influenced by sex, height, and weight of participants. One conclusion was that females may be more predisposed to develop the condition. As mentioned earlier, there is disagreement among researchers on the exact etiology of iliotibial band syndrome, and it is generally viewed as an overuse injury. These differences of opinion are based on conflicting evidence found in data collections using runners as subjects.
For example, it is not clear whether hip abductor weakness is a factor. The 2012 systematic review analysis showed that the movement and forces of the hip, knee, ankle, and foot appear to be considerably different in runners diagnosed with iliotibial band syndrome to those without it.
A 2020 paper on IT band syndrome states there is another theory that inflammation of the bursa sac is involved, but that it is unclear whether that is causative or multifactorial. However, according to Fairclough’s study that disputed friction being the cause, bursa is rarely present, but may be mistaken for the lateral recess of the knee.
While IT band syndrome is not indicative of trauma of the knee itself, there are times when an underlying pathology in the knee, including arthritis or a previous injury, could cause exacerbation of the symptoms. People may not think of running as a particularly dangerous sport—certainly not as dangerous as downhill skiing or running Pamplona Bull Run—but a literature review concluded that the risk of incurring a running-related injury ranges from 24 to 85 percent.
That is a big range and there could be many factors at play, such as what type of surface you are running on, whether you are wearing good running shoes, and even the weather. A 2013 literature review identifies risk factors for IT band syndrome: pre-existing tightness of the IT band, high weekly mileage, time spent running or walking on a track, interval training, and muscular weakness of knee extensors, flexors, and hip abductors.
Overuse, in this paradigm, is synonymous with a repetitive motion injury: you do something enough times, and it puts strain on an area. Running, skiing, rowing, cycling, and even walking all involve repetitive motions, and when one is doing an activity competitively, intense and/or speedy repetitive motions. The harder you push yourself, and the more frequently you do so without adequate recovery time in between, the more likely an overuse injury becomes.
Diagnosis of iliotibial band syndrome
It is common for doctors to diagnose iliotibial band syndrome based on a health history, interview, and physical examination without any expensive diagnostic tests. Depending on the location and severity of the pain, some may X-ray the knee to rule out other types of hip pain and pathologies. Some physicians may go as far as recommending a MRI (magnetic resonance imaging), which has been a frequent tool used for research studies of the condition, as have videotapes of subjects.
There is usually no reason for an MRI unless the doctor suspects that something is actually torn. The die-hard rule for a diagnosis is the precise sore spot on the outer side of the knee, at or just above the bony prominence known as the lateral epicondyle. The painful spot is superficial, not in the joint.
Iliotibial band stretches: does it work?
Some clinicians may recommend stretching the IT band, but it is almost impossible to stretch. It is thick, fibrous, and tough, and it would take superhuman strength to make a tiny change in its structure. As mentioned earlier, the IT band is unique to humans, but you can get some idea of how tough it is by examining the fascia on a piece of meat, such as a whole tenderloin.
When “peeling” a tenderloin to prepare it for cooking, you insert a sharp butcher knife at one end of the silver-looking fascia and slide the knife directly under it down the length of the meat, and it will “peel” right off. Put one end in each hand and try to stretch it. Good luck with that! It is the same with your IT band, and it is as tough as that fascia. However, that has not stopped many doctors, physical therapists, and personal trainers from recommending stretching for it.
There are no stretches or exercises that specifically isolate the IT band. Most lower body strength exercises, such as squats and lunges, integrate the IT band with the other hip and leg muscles. Exercise in general could have an analgesic effect on pain.
Foam rolling has become a popular treatment for enhancing athletic performance and for accelerating post-exercise recovery. Basically, the athlete uses their own body weight to apply pressure to the soft tissues via the foam roller. The rolling motion stretches the soft tissue and creates friction between the tissue and the foam roller.
A meta-analysis of 21 studies on athletes using foam rollers (14 studies looked at pre-event use; seven looked at post-event use) concluded that effects on athletic performance and recovery is probably minor, and that it is probably more valuable as a warm-up method than a recovery tool. We should remember, though, that people who are in pain, athletes or not, are looking for something to help them feel better, and as foam rollers are cheap and easy to use with minimal instructions, some sufferers may find them helpful.
Other treatments for iliotibial band syndrome
Since there is a lack of good evidence that exercise or stretching could help, the next best thing for any repetitive motion injury is rest. While a runner who is training for the Olympics may be distressed by the mere thought of taking a day off from training, the average person who is running for exercise and health reasons is not going to lose much by taking a week off. As previously mentioned, most flare-ups last a few days, and although the condition may recur, it is not generally a chronic condition with constant pain for months at a time.
The RICE (Rest, Ice, Compression, Elevation) protocol, which was put forth by Dr. Gabe Mirkin in his 1978 best selling “The Sportsmedicine Book,” was for years the most popular treatment for athletes and used by many coaches. In 2015, he denounced his own theory. He changed his recommendation because more current evidence shows that ice delays recovery, and that the inflammatory process at an injury site should be allowed to happen in order to facilitate healing.
Although icing could reduce swelling, it was found not to enhance recovery time. Mirkin further stated that a review of 22 scientific studies found no evidence that ice and elevation did anything to enhance recovery over compression when used alone.
Mirkin also lists other common treatments that interfere with healing, which can be summarized in short order: anything that interferes with the body’s natural immune system, of which inflammation is a key component. This includes steroids, such as cortisone; any anti-inflammatory pain-relieving medicines, including over-the-counter medicines such as ibuprofen; immunosuppressants such as those that are taken by people with arthritis or cancer patients; applying cold packs or ice, or anything else that interferes with the body’s own anti-inflammatory response.
Often, the best thing to do is let nature take its course. That is not to say that ice or anti-inflammatories or pain relievers should not be used at all, but Mirkin says it is best to let inflammation do its job. Considering the popularity of the RICE treatment, it takes a lot of integrity to come out and say, “I was wrong, don’t do that anymore” the way he did.
Although Mirkin changed his mind about RICE and inflammation, many doctors, physical therapists, coaches, and trainers continue to recommend it.
The previously mentioned 2013 review of ten studies states, “the best management options are not clearly established.” Another systematic review of treatment options conducted by physician members of the Arthroscopy Association of North America (AANA), published in 2020 states, “The management of ITBS most commonly begins with a course of conservative therapy, with surgical options reserved for cases unresponsive to conservative measures.
“Commonly used nonoperative treatment options for ITBS include physical therapy with an emphasis on iliotibial band stretching and strengthening of the hip abductors, local injection therapy to reduce inflammation and pain, and/or oral anti-inflammatory medications.”
Surgery is a last-resort treatment for iliotibial band syndrome and most commonly would be done if there is severe inflammation that refuses to get better. It consists of excision or release of the pathological distal portion (nearest the knee, for the layman) of the iliotibial band, or bursectomy.
Considerations for massage therapy of iliotibial band syndrome
Unless a client is an athlete who happens to be savvy about injuries, or one who has actually been to a doctor for a diagnosis, they may not know what is going on. All they know is they are in pain. What’s a massage therapist to do?
As with any session, the first step is a thorough health history and intake interview. A gait assessment is useful with any issues affecting the leg(s). People who have IT band syndrome may be limping. Once the client is on the table, palpation will reveal the areas of soreness. Passive joint mobilizations can reveal if range of motion is limited or if certain movements cause pain.
Remember, if they do not have a diagnosis, you are not going to give them one. You may suspect that the problem is IT band syndrome, based on them telling you they ran a marathon last weekend and have been in pain ever since, but refrain from diagnosing.
Remember, when asking a patient or client to “rate your pain on a scale of 1-10,” that is relative only to that individual. People have different levels of pain tolerance. Asking before and after the session may indicate to you (and them) that you have done some good, but short of asking them to run laps around the parking lot, you may not know how much, if any, improvement in functionality may have taken place. There are both pros and cons to the Numeric Rating Scale.
On the positive side, it takes less than a minute to fill out and less than a minute to score; it has been deemed valid and reliable for rating pain intensity, and it can be done verbally or in writing, making it accessible for more people. However, the only thing it measures is intensity of pain. Factor in any past pain experiences or fluctuations in pain, and it only evaluates pain experienced in the past 24 hours or an average pain intensity.
Activities of Daily Living Indexes (ADL), or in this case, a Lower Extremity Functional Scale (may also be titled Lower Extremity Functional Index), are helpful for evaluating exactly how pain and/or dysfunction is interfering in someone’s life. Below is an example index and it is free. There may be slight variations of the index, depending on the source. There are functional indexes for all regions of the body.
There is no cookie-cutter massage routine for iliotibial band syndrome (nor hopefully, a cookie cutter routine for any issue). Each individual is unique, and although the pain from this syndrome may be located in the same place on numerous clients, the response to it depends on the individual. Some people have a high pain tolerance, some are stoic or stubborn about pain, and people with a low pain tolerance may seem more debilitated by it.
Regardless of modality, warm the area and do not work beyond the client’s comfort level. Some therapists think they need to go to the bone, regardless of the problem or how tender the client is, and that is not being client-centered in any way. The idea that light work is not as effective as using a heavy hand is false and outdated.
That is not a directive not to use deep tissue massage, but a reminder to honor the client’s comfort level. When you hurt a client, especially one who is already in pain, they tend to tense up even more. The same goes for doing joint mobilizations and stretches, both active and passive stretching. Do not go beyond the client’s pain tolerance.
Some physical therapists recommend foam rollers, and those are not out of scope for massage therapists. Massage tools that mimic the action of the human hand as within scope. Some therapists may use a vibrating tool with the intention of “loosening up” the IT band and thighs. If you do choose to use something, be sure it is within your scope of practice, which varies according to your jurisdiction and whether or not massage is regulated in your state or country.
Topicals may provide temporary relief. Avoid applying anything that is medicated or using essential oils without checking with the client. They may have allergies or just plain dislike the smell or sensation of something.
A 2013 review comparing ten studies utilizing varied treatments used with athletes diagnosed with iliotibial band syndrome, including deep tissue massage with transverse friction utilized in one study, ends with this summary: from clinical experience, rest is the best treatment for the acute cases. This treatment becomes less useful as it becomes a more chronic condition when bursal and periosteal changes have set in.
There is limited evidence to support one specific approach to the treatment of iliotibial band syndrome. However, when looking at the desired goal of return to sport, a combination of rest of about two to six weeks, stretching, pain management, and modification of running habits produces a high return to sport rate. The takeaway there is there is limited evidence to support one specific approach to the treatment of iliotibial band syndrome.
While we would like to think massage therapy is helpful for everything and everybody, that is simply not true. One person may have a great outcome while another calls you the next day to say they have not felt any relief. Do your best work and don’t take it personally.
One thing that is certain about the IT band and iliotibial band syndrome is that nothing is certain. While there are many studies on knee pain in medical databases, the number of studies on iliotibial band syndrome are relatively small, compared to many other pain problems.
For comparison’s sake, a search on PubMed for “iliotibial band syndrome” has 332 results, but a search for “rotator cuff tear” more than 8,800 results, and “ankle sprain” has more than 19,000 results. The only thing that trumps science is better science, and the hope for the future (as most studies have concluded is necessary) is that more and better research on iliotibial band syndrome will be done.
Feature photo by Tania Dimas.