Iliotibial band friction syndrome (ITBFS) is a common running overuse injury. Traditionally, ITBFS is diagnosed by the presence of iliotibial band tightness, pain to palpation along the lateral tibia (Gerdy’s tubercle), and pain to palpation along the distal IT band fibers. A common (although only partially accurate) explanation for IT band pain in runners is excessive friction of the IT band as it slides in an anterior-posterior direction as the knee moves from an extended to flexed position.i Further anatomical investigation coupled with the relatively poor results through conservative treatment of IT band pain warrant further explanation regarding the true underlying causes of lateral knee pain and ITBFS.

The iliotibial band is a large fibrous connective tissue band extending from the tensor fascia latae (TFL) and gluteal musculature. A closer look at the lateral leg musculature reveals the extensive vastus lateralis quadriceps muscle which travels beneath the IT band (from anterior to posterior). The vastus lateralis (lateral quadriceps) is often a muscle which is hypertrophied, tight, and tender to palpation in runners with lateral leg/knee pain rather than the often-accused IT band. Similarly, overuse of the TFL muscle increased tension which is transferred via the IT band to the lateral knee. The true compensations which occur during running (hip drop, cross-over gait, knee valgus, foot/ankle pronation) must be identified in order to effectively treat the cause of lateral leg/knee pain. A 2D video running gait analysis is an excellent way to identify and quantify biomechanical compensations.


The IT band is not composed of non-contractile tissue. While the overlying fascia can be released through fascial release techniques (active release techniques, contract-relax, muscle
energy, integrated dry needling, ISTM, ASTM), the IT band itself is not capable of being tight or stretched. The surrounding structures, such as the vastus lateralis, TFL, hip and gluteal musculature, should be evaluated for weakness and/or dysfunction. The IT band is an extension of the TFL which encases the upper thigh. In addition to its attachment to the tibia (Gerdy’s tubercle), the IT band also has fibrous anchors to the femur, making significant movement of the IT band over the femur unlikely.ii A richly innervated layer of fatty tissue beneath the IT band becomes inflamed and painful when tension under load (running) increases through the IT band (Fairclough, it al). The cause of this tension, however, is the key to effectively treating ITBFS.


Muscular weakness in the gluteus medius and gluteus maximus muscles results in overuse or over-compensation of the TFL, and vastus lateralis. The thin TFL muscle is located on the anterior and slightly lateral aspects of the hip. Overuse of the TFL, which flexes the hip and internally rotates the femur, leads to increased IT band tension and irritation of the insertion on the lateral knee.iii The vastus lateralis, however, is often ignored when evaluating and treating lateral leg or knee pain. Similarly, our sedentary, seated lifestyles cause hip flexor muscle shortening (TFL, psoas, iliacus, rectus femoris) which leads to an anterior tilt of the pelvis and ineffective gluteal muscle activation and function. Without adequate proximal stabilization via the gluteus medius and gluteus maximus musculature, foot strike often results in an internal rotation of the femur, inward motion of the knee, and increased lateral leg and IT band tension.


Stiffness in the ankle can limit dorsiflexion which is necessary for proper running biomechanics. Compensatory ankle eversion (toe-out position) and increased pronation (arch falling inward) increases the likelihood of knee valgus (knee collapsing inward). Such compensations at the ankle and knee joints increase lead to over-active hip adductor and TFL contraction and inhibited gluteus medius/maximus firing. Such compensations may be manifested as lateral leg or knee pain with the IT band being the alleged culprit.


Pain in the area of the lateral knee and proximal tib-fib joint which does not respond to conservative treatment or a thorough assessment of the true underlying cause warrants medical diagnostic testing. Second only to metatarsal stress fractures, stress fractures in the tibia and fibula are common due to the torsional stress through the long tibia and fibula while running. An X-ray may show a stress fracture, but the fracture may not show up on an X-ray prior to the formation of a bone callous later in the healing phase. Magnetic Resonance Imaging (MRI) may more accurately show a stress fracture but the cost is much higher.

Evaluation and treatment techniques, therefore, must effectively address each of the possible contributing factors, to bring about a comprehensive, effective, long-term solution. A physical therapist skilled in exercise and manual therapy techniques specific to runners can be a source of information and treatment knowledge to get you back to your favorite running routes and and trails.

John Fiore, PT

i Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med, 1992;14(2):144-8. ii Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension

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