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August 5th, 2022

Common Running Injuries: ITB Syndrome

by Tim Waanders, PT, DPT

Iliotibial band (ITB) syndrome is considered the most common running injury related to the lateral (or outer) knee. ITB syndrome is indicated by pain in the outer knee, especially when moving from a bent position of the knee to straightening the knee. It is an overuse injury, as many running injuries are, indicating the cause is due to repetitive load rather than an acute, traumatic injury. Pain is the most common symptom, but swelling of the outer knee where the ITB attaches may also be seen. The leading theories on what mechanism of injury leads to ITB syndrome is that either abnormal compression or excessive friction of the ITB occurs as it attaches to the lateral epicondyle of the knee. 

What causes ITB syndrome?

ITB syndrome onset occurs when the ITB gets strained in an overlengthened position as the knee passes from a flexed position at foot contact into an extended position as the extremity propels the body forward in gait. As with other running-related knee injuries, there can be multiple factors that are the origin of the problem. Often, weakness of the hip musculature (i.e. glutes, hip external rotators) plays a role, due to the lack of control at the knee from the top-down. This can in turn lead to excessive “collapsing” in of the knee into internal rotation and adduction, or it can lead to a hip drop on the opposite side of the problem, which both put the ITB in an overlengthened position. 

Anatomically, some runners may have a natural “varus” position of their knee. When you think of someone who may be considered “bow-legged,” this is what varus means; the femur (aka the thigh bone) and the tibia (aka the shin bone) are positioned leaning away from the midline of the body. This unfortunately puts runners with a natural varus position at a predisposition for ITB syndrome, due to the stress it can place on the outer knee. While there is nothing that can be done to change this, focusing on proper strength and running mechanics can reduce the chance of ITB syndrome onset.

Another factor that can contribute to ITB syndrome is tightness in the front of the hip, especially at the quads and/or tensor fascia latae (TFL) muscles. The ITB runs along the outer thigh, and at the top it attaches to the TFL muscle of the hip. The outer quad muscle also runs along with the ITB as they both attach down at the knee. If these muscles are “tight”, whether short due to prolonged sitting or poor posture or due to high tone via the nervous system, this can cause the ITB to pull on its attachment point at the knee, causing friction and leading to pain and swelling.

Poor running mechanics may also play a role in ITB syndrome onset; specifically, too much crossover of the foot on the affected side, leading to a narrow base of support. Again, this leads to overlengthening of the ITB at the distal attachment, and can cause onset of pain. 

How is ITB syndrome treated?

Depending on what factor is causing the onset of ITB syndrome will determine what your plan of care would be in order to treat it. Manual therapy to the quads and TFL, such as soft tissue mobilization, IASTM, and cupping can be beneficial to reduce tension surrounding the ITB. In conjunction with improving mobility of the hip in order to reduce tension in the front and outer areas (such as with dynamic stretching) and strengthening the glutes to help control the knee would be the next logical step. As with all exercises focused specifically on runners, progression to single leg exercises emphasizing stability and neuromuscular control at the knee are key. Plyometric exercises to mimic running and train the body to properly control load are also crucial.

Visual cues for runners who cross over too much when running can include placing a line of tape down the middle of a treadmill or have the runner run along a line if they are on the street. The idea is that they try to prevent their foot from crossing over the line, which can help reduce the tension into the outer knee when the foot lands. Increasing cadence if it falls too far below the accepted range (usually around 165-180 spm) can also allow for quick turnover of ground reaction forces and less strain on the joints, in this case particularly the outer knee.

If you are currently having issues with ITB syndrome, reach out to one of our qualified PT’s at Finish Line Physical Therapy for a proper assessment and rehabilitation program that fits your needs!

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