Iliotibial Band Syndrome (Runner's Knee): Causes, Symptoms, and How We Can Help
- staystrongtherapy
- Jun 30
- 5 min read
All information in this blog is supported by peer-reviewed research. There is currently no dedicated NICE guideline for this condition, so current evidence is used throughout. Reference numbers appear throughout, with the full list at the bottom of the page.
What Is Iliotibial Band Syndrome?
Iliotibial band syndrome (ITBS) is the second most common running injury and the leading cause of lateral (outer) knee pain in runners, accounting for around 10% of all running-related injuries. ¹ ² It typically presents without any specific traumatic history, described as a strong, acute pain at the outer side of the knee, brought on during flexion-extension movements, particularly when the knee bends between 25 and 35 degrees, often forcing the person to stop running. ²
A Genuinely Important Correction: It's Not Actually "Friction"
This is worth knowing, since the older explanation for ITBS has been the standard textbook story for years but doesn't hold up under current scrutiny. The original theory, that ITBS is caused by friction between the iliotibial band and the lateral femoral epicondyle (a bony bump on the outer knee) as the band repeatedly rubs back and forth, is now considered unlikely based on more recent research. ³ Current understanding instead points toward a more complex, multifactorial picture involving compression of the tissue beneath the band, alongside biomechanical and neuromuscular factors, rather than simple friction. ³ ⁴
Common Signs and Symptoms
Pain or tenderness on the outer side of the knee, just above the joint line
Pain that comes on during running, often after a predictable distance, then forces a stop to activity
Pain typically worst around 25 to 35 degrees of knee flexion
No history of a specific injury or trauma
Pain that may worsen with downhill running
Risk Factors
A large study of over 76,000 race entrants and a systematic review of intrinsic risk factors have identified the following: ⁵ ⁶
Distance running, with ITBS recognised as the second most common running injury overall ²
Increased peak hip adduction during running, identified in female runners who went on to develop ITBS ⁷
Increased peak knee internal rotation during stance, also identified as a contributing biomechanical factor ⁷
Cycling and military training, both also recognised as activities associated with ITBS, alongside running ³
Various morphological, neuromuscular, and biomechanical factors, though research notes the overall evidence quality for many specific biomechanical risk factors ranges from limited to conflicting ⁸ ⁶
It's worth being honest that, despite considerable research, no single consensus risk factor profile has been firmly established, reflecting how genuinely multifactorial this condition is. ⁶
What to Look Out For
Please seek medical assessment if you experience:
A visible deformity or significant swelling following injury
True locking of the knee
Significant pain at rest, unrelated to activity
Fever or warmth around the knee
How Is It Diagnosed?
Diagnosis is usually based on a characteristic history, the pattern of activity-related lateral knee pain without trauma, alongside clinical examination. ² Imaging is not generally required to confirm the diagnosis.
Myths vs Facts
"My ITB is just rubbing against my knee bone." This was the long-standing explanation, but current research suggests the simple friction theory is unlikely to be the actual mechanism. The real picture is more complex, involving compression of underlying tissue and broader biomechanical factors.
"I should stretch my IT band more." Given the band itself is a thick, largely inextensible fascial structure, the evidence-based approach focuses more on strengthening the muscles controlling hip and knee mechanics rather than aggressive direct stretching alone.
How We Can Help
Conservative management remains the main course of treatment for ITBS, with a consistent, structured programme typically resulting in genuine improvement of symptoms. ³
Osteopathic manual techniques and manual therapy: addressing restriction and tension around the hip, pelvis, and knee, supporting overall biomechanics and movement quality.
Deep tissue and sports massage: targeted soft tissue work for the tensor fasciae latae and gluteal muscles, which attach into the iliotibial band, alongside the surrounding thigh musculature.
Medical acupuncture and cupping: used alongside exercise-based treatment to support pain management.
Exercise: The Cornerstone of Recovery
Given the biomechanical risk factors identified, particularly around hip control during running, targeted strengthening forms the foundation of treatment. ⁷
Hip abductor and gluteal strengthening: directly addressing the increased hip adduction pattern identified as a contributing biomechanical factor in runners who develop ITBS. ⁷
Hip external rotator strengthening: addressing the rotational control linked to knee mechanics during running.
Running gait and load management: temporarily modifying training volume, terrain (particularly downhill running), and pace while strengthening is established.
Graded return to running: a structured, progressive return, since different exercise programmes can yield different results, but a consistent, well-structured programme is what reliably produces improvement. ³
Your practitioner will guide a programme addressing the hip and pelvic control most consistently linked to this condition, rather than focusing on the iliotibial band itself in isolation.
What to Expect at Your First Appointment
We will take a thorough history, including your running volume, terrain, and any recent changes in training, and carry out a hands-on and movement assessment of your hip, pelvis, and knee mechanics. We will explain clearly what we find, using current understanding rather than the outdated friction explanation, and build a progressive, evidence-based treatment plan.
Frequently Asked Questions
Do I need a scan? No, this is a clinical diagnosis based on history and examination.
Can I keep running while this heals? Often with modification, your practitioner will guide appropriate changes to volume, terrain, and pace while your treatment programme takes effect.
Why are you focusing on my hip strength rather than my IT band? Because the evidence points toward hip and pelvic control during running as a key contributing factor, rather than the band itself being the structural problem, addressing the cause tends to produce better, longer-lasting results than treating the band directly.
How long will it take to improve? This varies, but a consistent, structured exercise programme typically leads to genuine improvement, though exact timelines depend on your training history and how the condition developed.
Recognise these symptoms? Get in touch using the contact form and we will assess and build the right treatment plan for you.
References
Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review. Frontiers in Sports and Active Living. 2024. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11377285/
Intrinsic risk factors associated with iliotibial band syndrome: A systematic review. Turkish Journal of Sports Medicine. 2023;58(2). Available at: https://journalofsportsmedicine.org/full-text/702/eng
Bonoan M, Morales M, Liu XW, et al. Iliotibial Band Syndrome Current Evidence. Current Physical Medicine and Rehabilitation Reports. 2024;12:193-199. Available at: https://link.springer.com/article/10.1007/s40141-024-00442-w
Iliotibial Band Syndrome in runners: a systematic review. PubMed. Available at: https://pubmed.ncbi.nlm.nih.gov/22994651/?tool=bestpractice.com
Risk factors associated with a history of iliotibial band syndrome (hITBS) in distance runners: a cross-sectional study in 76,654 race entrants, a SAFER XXXIII study. 2024. Available at: https://www.tandfonline.com/doi/full/10.1080/00913847.2024.2341607
Intrinsic risk factors associated with iliotibial band syndrome: A systematic review. Turkish Journal of Sports Medicine. 2023. Available at: https://journalofsportsmedicine.org/full-text/702/eng
Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders. 2015;16:356. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4647699/
Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review. Frontiers in Sports and Active Living. 2024. Available at: https://www.frontiersin.org/journals/sports-and-active-living/articles/10.3389/fspor.2024.1386456/full
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