It’s a chronic point of confusion about iliotibial band syndrome (ITBS) — where exactly does it hurt? Many professionals incorrectly diagnose hip and thigh pain as ITBS. There is no such thing as non-knee ITBS. By definition,1 ITBS occurs only on the side of the knee. More specifically:
- the outward-facing side of the knee
- at or just above the prominent bump of bone (lateral epicondyle)
- well-defined pain location, an epicentre you can point to with precision
The condition is caused by the irritation of tissues around that anatomy. Pain anywhere else is something else. I promise. I’m not making this up.2
Knee pain that is hard to locate — diffuse pain — is definitely something else.
Pain that includes the side of the knee but has no clear epicentre there is definitely something else.
Pain on any other part of the leg or hip is definitely something else — even if it’s related to the iliotibial band, it’s still not “IT band syndrome.” For an ITBS diagnosis, you must have a clear hot spot mainly on the outer surface of the knee!
Pain in other locations may occur with ITBS, of course. There’s nothing about ITBS that eliminates the possibility of other painful conditions in the region. They may even be related. However, these other pain problems are other pain problems — not iliotibial band syndrome.
Muscle is the most common source of hip and thigh pain in younger people
Although many things can cause pain in the hip and thigh, a common assumption 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.3 Most hip pain is something else, and the most plausible explanation is simple muscle pain caused by trigger points (TrPs), AKA muscle “knots.”4 Typical hip muscle pain feels like a deep, nagging ache, that is generally soothed by heat and massage. The pain may be widespread, or fairly well-focused on the bump of bone on the side of the hip (the greater trochanter).
The trigger points themselves are usually in the hips, but the pain often spreads (“refers”) downwards into the thigh.5 A common and easy example of this phenomenon is Perfect Spot #6: the trigger point 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.6
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.
Not exactly on the side: non-lateral knee pains
What if you have knee pain that is almost lateral? It’s still something else!
Since the IT band merges broadly with the connective tissue wrappings around the whole knee, occasionally we see IT band syndrome causing symptoms in other parts of the knee — but never clearly. The standard ITBS location must still be clearly dominant for the ITBS diagnosis to stick.
There are many, many kinds of knee pain, with symptoms occurring anywhere around and on the knee. Unlike with the hip, no one condition can explain most of these other cases. But patellofemoral pain syndrome comes close …
Patellofemoral pain syndrome: the bucket diagnosis
However, patellofemoral syndrome (PFPS) is a bucket diagnosis that covers several of the possibilities. PFPS is a condition of many conditions. If you have knee pain with a location that isn’t right for an ITBS diagnosis, it’s probably worth looking at PFPS as a possibility. Generally speaking, PFPS tends to cause pain on the front of the knee.
For a detailed comparison of ITBS and PFPS, see:
More reading about IT band syndrome
- EXCERPT IT Band Stretching Does Not Work
- EXCERPT Does the IT Band Move After All?
- EXCERPT Iliotibial Band & Patellofemoral Pain Defy Biomechanical Expectations
- EXCERPT Do IT Band Straps Work for Runner’s Knee?
- PS Iliotibial Band Syndrome: Location, Location, Location! — There is no such thing as “IT band syndrome” that is not at the knee
- PS How I (Eventually) Recovered from IT Band Pain (Runner’s Knee) — The story of how I got a nasty case of chronic IT band syndrome in both knees & then studied the condition intensively so I could finally beat it
- PS Is IT Band Tendinitis Really a Tendinitis? — Recent research has clearly shown that the IT band itself is not the anatomy that gets inflamed, which has significant implications for treatment
About Paul Ingraham
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?
2017 — Science update — Cited evidence of poor correlation between hip pain and radiographic signs of arthritis (Kim et al).
2017 — Miscellaneous minor improvements. Very careful clarification of the symptom location. Migrated some details to footnotes, and added some details specifically for footnotes.
- 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
- 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
- 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
- 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
- The brain is somewhat inept at precisely locating internal pain and thus experiences muscle pain in a broad area around or near a trigger point (exactly like heart attacks are felt in the arm as well as the chest). The pattern for each muscle is somewhat predictable, and most referred pain spreads away from the centre and the head (laterally, distally). BACK TO TEXT
- 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