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Where Does IT Band Syndrome Hurt?

Only on the side of the knee; pain in the hip and thigh is something else

Paul Ingraham, updated

It’s a chronic point of confusion about iliotibial band syndrome (ITBS) — where exactly does it actually hurt? Many professionals incorrectly diagnose hip and thigh pain as ITBS. Unfortunately, there is no such thing as non-knee ITBS. By definition,1 ITBS occurs only on the side of the knee. More specifically:

Diagram showing iliotibial band syndrome pain location.

The condition is caused by the irritation of tissues around that anatomy. Pain anywhere else — like the thigh and hip — is something else. I promise. I’m not making this up.2

What’s in the name of a syndrome?

IT band syndrome is a “syndrome” because the pain is unexplained. We don’t know the specific mechanism, so we don’t give it a name that implies a specific cause (like “tendinitis,” for instance).

All syndromes are simply descriptions of an unexplained but distinctive pattern of symptoms. Most syndromes involve patterns of symptoms with a lot of variation, but the pattern of ITBS is more simple and specific: pain on the side of the knee, related to overuse, notably aggravated by descending stairs and slopes. It’s only unexplained insofar as no one has actually figured exactly what tissue gets into trouble.3)

Other pain locations and types that are not IT band syndrome

Pain on any other part of the thigh or hip is the most common kind of pain mistakenly attributed to ITBS, but it is definitely something else — even if it is partially related to the iliotibial band, it’s still not “IT band syndrome.” Greater trochanteric pain syndrome is the appropriate label for most unexplained hip and thigh pain. More about GTPS below.

The other big red herring is anterior knee pain: patellofemoral syndrome, the other common kind of runner’s knee, is a more imprecisely defined condition than ITBS. More on this one below as well.

Posterior knee pain has several possible causes, like popliteal artery entrapment syndrome (PAES), popliteal or biceps femoris tendinopathy.

Knee pain that is hard to locate — diffuse pain — is definitely something else. ITBS is not hard to locate! Diffuse knee pain may be arthritic in character, related to a spinal issue, a stress frature, or meniscal damage. Diffuse pain is tricky to diagnose, but it’s not ITBS.

Another source of lateral knee pain is a lateral meniscal tear. It’s usually traumatic, with pain a little too low and too deep for ITBS, and usually accompanied by other other signs and symptoms like swelling, locking, clicking, and clunking.

What about knee pain that includes the side of the knee?

Pain that includes the side of the knee but has no clear epicentre there is probably something not ITBS. No specific hot-spot on the lateral knee, no ITBS diagnosis! For instance, a stress fracture of the lateral epicondyle of the femur might cause some lateral knee pain in addition to plenty of diffuse, deep pain, but the lateral pain wouldn’t be vivid and specific enough for an ITBS diagnosis.

Pain in other locations can also occur with ITBS, of course. There’s nothing about ITBS that eliminates the possibility of other painful conditions in the region, and they may even be related. However, these other pain locations are not symptoms of iliotibial band syndrome.

Patellofemoral pain syndrome (PFPS): mostly about anterior pain, not lateral

Which condition is “runner’s knee” — ITBS or PFPS? Trick question: they both are. They are constantly confused because they both cause knee pain that is quite close together. But while ITBS causes pain on the side of the knee, PFPS is all about pain on the front of the knee.

Diagram of the knee showing IT band syndrome on the side of the knee, and patellofemoral pain syndrome on the anteriorof the knee.

Where’s the pain?

IT band syndrome dominates the side of the knee. Patellofemoral pain is more variable, but usually more in front.

PFPS is a bucket diagnosis that covers several of the possibilities, a condition of many conditions. If you have knee pain with a location that isn’t quite right for an ITBS diagnosis, it’s may be worth looking at PFPS as a possibility.

Despite the fairly simple-seeming side vs. front distinction, confusion about the difference between these conditions is routine. For a detailed comparison, see:

Greater trochanteric pain syndrome (AKA hip pain)

Nothing is mistakenly called ITBS more often that hip and thigh pain, which can be just as stubborn and baffling as ITBS. Calling it ITBS implies that it has something to do with the IT band, when in fact this kind of pain has many and likely overlapping causes.4

GTPS is the correct label for unexplained hip-o-centric pain: aching with an epicentre around the large bump of bone on the side of the hip, the greater trochanter of the femur. While it is usually experienced as “mainly” hip pain, it routinely involves widespread, diffuse pain throughout the entire region and into the thigh.

One of the most common assumptions about hip pain is that it must be arthritis. But concern about arthritis is rarely justified: most people with signs of arthritis (on X-ray) do not have any pain, and most people who have hip pain do not have arthritis.5

The most common cause of hip pain, especially in younger patients, is probably just the aching and stiffness associated with “muscle knots,” sore spots known as trigger points (TrPs).6 The TrPs themselves are usually in the hips, but the pain often spreads (“refers”) downwards into the thigh.7 A common and easy example of this phenomenon is Perfect Spot #6: the TrP is in the upper hip, but the pain spreads into the back, buttocks, and thigh. Another important example is the common trigger point in the tensor fasciae latae muscle.8

Hip muscle pain is not only a common problem in general — with or without ITBS — but is also potentially implicated in ITBS. For instance, grouchy hip muscles that control the tension on the IT band might be a minor factor causing ITBS. Many ITBS patients seem to experience significant hip discomfort in addition to their strong lateral knee pain. Treating the hip pain may or may not have any effect on ITBS, but is probably worthwhile in itself.

If you think that you might have hip muscle pain, my muscle pain tutorial should be your next stop.

Of pain sources in the leg itself, the big quadriceps trigger point is a common doozy, Perfect Spot #8. It’s referred pain tends to dominate the lower end of the thigh.

Lots more reading about IT band syndrome

These are all of the free excepts from my book about IT band syndrome available on PainScience.com. It’s a lot, but it’s only about 20% of the entire book.

Or just start reading the free introduction to the IT band syndrome book. If you find the free content useful, consider buying the book, or a donation to support user-friendly evidence-based publishing.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

JulyHeavily revised with a much stronger focus on differential diagnosis. I think the perspective makes the article much more useful.

2017Science update — Cited evidence of poor correlation between hip pain and radiographic signs of arthritis (Kim et al).

2017Miscellaneous minor improvements. Very careful clarification of the symptom location. Migrated some details to footnotes, and added some details specifically for footnotes.

2010Publication.

Notes

  1. There’s nothing formal or authoritative I can cite to support this position; there is no international standards organization defining minor musculoskeletal injuries; IT band syndrome isn’t even in the Merck Manual (a famous medical dictionary) or the Medline/Merrian Webster medical dictionary. All obscure definitions are somewhat arbitrary and a product of social concensus, and so my position is based on the definition used in most academic writing and research on the topic. My strong impression after many years of writing about ITBS is that discussions and articles that conflate hip and proximal thigh pain with knee pain are mostly amateurish, with ignorance of the condition prominently on display. BACK TO TEXT
  2. I am not making up the definition of IT band syndrome … or am I? I probably am influencing it these days! Given the prominence of PainScience.com, I may now be in a position to actually prescribe the definition, rather than to just describe what I believe it to be (which is all it was for years). Good times! BACK TO TEXT
  3. For instance, it’s probably not “friction” of the IT band, a kind of tendinitis, as implied by the common term “IT band friction syndrome.” See Is IT Band Tendinitis Really a Tendinitis? BACK TO TEXT
  4. Why would anyone call it ITBS? Basically, because the IT band spans the entire thigh, from hip to knee, and it is a favourite scapegoat. BACK TO TEXT
  5. Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351:h5983. PubMed #26631296.  PainSci #53332. 

    This analysis of thousands of patients confirmed a jarring disconnect between signs of arthritis on hip x-rays and hip pain: “Hip pain was not present in many hips with radiographic osteoarthritis, and many hips with pain did not show radiographic hip osteoarthritis.” What they mean by “many” is “practically all”: roughly 80% of patients with signs of arthritis had no pain, and at least 85% of patients with hip pain had no sign of arthritis! These numbers held up even at the extremes — most older patients with a high suspicion of hip arthritis did not in fact have arthritis that could be diagnosed with an x-ray.

    BACK TO TEXT
  6. This assertion is based primarily on my decade of clinical experience as a massage therapist, seeing many cases of hip pain attributed to things like bursitis or arthritis that were readily resolved with a little massage. It’s also just all that’s left after a relatively simple process of elimination: many of the “usual suspects” in the hip have distinctive clinical characteristics that simply aren’t present in most cases. And finally it’s based on my confidence that trigger points are a genuine ubiquitous clinical phenomenon, which no one disputes, even if their nature is controversial: see The Trigger Point Identity Crisis. BACK TO TEXT
  7. The brain is somewhat inept at precisely locating internal pain and sometimes experiences pain in a broad area around or near the cause. This is exactly the same phenomenon as heart attack pain felt mainly in the arm: the brain literally can’t figure out where the pain is coming from. Patterns of referral from the musculoskeletal system are somewhat predictable, and most referred pain spreads away from the centre and the head (laterally, distally). By contrast, visceral referral is much more erratic. Notably, referred pain from the neck probably goes “up,” causing headaches.

    This phenomenon is probably one reason the IT band gets blamed for hip pain. The referred pain from the hip simply spread down the side of the thigh, where the IT band happens to be.

    BACK TO TEXT
  8. Which is harder to describe and self-treat. It is about the size of a large pickle and “hangs” straight down from the side of the prominent bump of bone on the front of the hip, the anterior superior iliac spine. BACK TO TEXT