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IT Band Stretching Does Not Work

Stretching the iliotibial band is a popular idea, but it’s very hard to do it right, and it’s probably not worth it

updated (first published 2012)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com
IT band stretches do not work as advertised.

What’s wrong with this picture?

She’s not doing much with this classic IT band stretch — even if her technique was good (it’s not). Read on to find out why.

Iliotibial band stretches don’t work? Really?! So why does it seem like they are prescribed for iliotibial band syndrome — runners’ knee — by practically every physical therapist in the world?

IT band stretching is just another obsolete bit of simplistic conventional wisdom, like countless other shabby old ideas that have been repeated ad nauseum on the Internet. At best, stretching your iliotibial band is probably only slightly helpful. At worst, IT band stretching is just a waste of your time, and reinforces misconceptions the cause of IT band pain.

And that’s assuming you are actually even applying tension your IT band in the first place — which is biomechanically tricky.

Most people never succeed in pulling firmly on their iliotibial bands. All the commonly prescribed stretches are mechanically ineffective.1 There is research available that shows how to apply tension to the IT band, but it appears to be unknown to most doctors, therapists, and trainers.

Prefer video? Here’s a video tour of basic IT band myths, including the stretching myth:


3 IT Band Myths & Common Treatment Mistakes 8:11

Stretching is over-rated in general, but especially so for runner’s knee

Stretching has a much better reputation than it deserves,2 and an especially so in this case. Stretching is by far the most common advice given to people with lateral knee pain. Most ITBS patients are told to stretch by a doctor, physical therapist, or massage therapist. But there is no evidence that stretching will prevent3 or fix4 IT band pain. No researchers have studied the problem properly, and the preliminary data is underwhelming. Not only is the IT band a difficult structure to stretch, but it is doubtful that IT band tightness is even a problem that needs solving.

It is not safe to assume that stretching works just on the say-so of your physiotherapist, or running mates who swear by it, or because it’s recommended by almost every article on the internet about IT band syndrome.

Applying strong tension to the IT band is just really tricky

It’s not easy to stretch the iliotibial band. Not easy at all. In fact, it’s possible that it’s impossible.

The most common kind of stretches recommended for the iliotibial band are also the least likely to be effective, simply because they are focused on stretching the iliotibial band and the tensor fasciae latae muscle, and there is no good way of applying any significant amount of stretch to these structures. Not everything in the body can be stretched, just like not every muscle can hoist a heavy barbell.5 There are biomechanical difficulties with stretching some anatomy, like all three of the structures most relevant to IT band syndrome:

Diagram of iliotibial band anatomy.

Two things missing from standard iliotibial band stretches

The usual IT band stretches are missing a crucial component: knee flexion. For any hope of stretching this structure, you simply have to include knee flexion. And yet almost no one does.

As discussed above, the iliotibial band does not have a well-defined attachment point on the knee, the way most tendons do. Instead, it spreads out and blends into the capsule of connective tissue that surrounds the knee. Thus, knee position clearly affects tension on the iliotibial band — and it has long been recognized that the iliotibial band is tightest around 30˚ of flexion,9 though some evidence shows than flexion beyond 90˚ may apply even more tension.10An iliotibial band stretch without knee flexion is just not much of an iliotibial band stretch.

And there’s more.

Another element that is important but often overlooked is “anchoring” the pelvis. The IT band “hangs” from a “hook” on the front of the pelvis called the anterior superior iliac spine (ASIS). If you want to stretch something attached to the ASIS, the ASIS has to be held still, or pulled the other way. Just lean your torso away from that corner of the pelvis. This takes up the slack in the lateral and anterior abdominal muscles, pulling up on the front of the pelvis. Raising the arms too: that takes up a lot of slack in the very long latissimus dorsi muscles, which tightens the broad thoracolumbar fascia like a girdle, which helps to anchor the pelvis.11

No elongation: you can’t make your IT band longer

Even if you do everything right, even if you perform the ideal stretch and manage to pull firmly on your IT band for a couple minutes — which is longer than most people ever bother — how much would you actually change the length of your IT band? How far would it move?

Roughly 2 millimeters — an overall change in length of less than half a percent.

You still won’t actually change its length, any more than you can make a leather belt longer by pulling on it. This is the most important thing IT band stretchers need to understand.

Schematic of the change in length fo the ITB band with stretch: <0.5%.

In 2010, Irish researcher Dr. Eanna Falvey and her colleagues measured the mechanical effect of a basic IT band stretch (like the standard one illustrated at right) plus a more sophisticated stretch, and found virtually no difference: the IT band was effectively unaffected. And that was including knee flexion, in a stretch carefully applied to corpses by anatomists!1213 In an even more aggressive experiment in 2017, the IT band was completely excised, washed, frozen, thawed, and machine-stretched… and it still stretched only a few millimetres.14

If those tactics can’t elongate the IT band, runners don’t stand a chance.

And so, unfortunately, conventional iliotibial band stretches, prescribed and described practically everywhere — even the better ones — are simply not able to do the job. Assuming it’s even a job worth doing.

Some stretching hope: a better iliotibial stretch?

There are better IT band stretches than the conventional stretches — primarily adding knee flexion, though some other refinements are also possible — and there are some reasons to suspect that applying tension might still be a little bit therapeutically useful even if actual elongation is impossible. As with most therapies, the neurology of sensation is probably more important than any alleged tissue change: stretching the IT band may change how the brain “feels” about the knee.15 I have seen stretching appear to help IT band syndrome.

But there are better treatment options for IT band syndrome than stretching. Practically everyone who is looking for IT band stretching information would be better off learning much more about IT band syndrome first, because the subject is a minefield of myths and misconceptions (not just about stretching):

Some health professionals have taken the time to study ITB syndrome properly, of course. But it’s usually impossible to luck out and find one before your training schedule is blown to smithereens.

There are no miracle cures for IT band syndrome

This is an excerpt from a much larger tutorial for both patients and professionals. The whole thing contains basically everything there is to know about ITB syndrome. There is no foolproof system for beating iliotibial band syndrome, or even a reasonably reliable one (and please do not believe anyone who says there is). But if you read the full tutorial, I can guarantee that you will know the condition better than most doctors, and you will understand the imperfect options and how to prioritize them.

Full access to the ITBS tutorial is available immediately for USD$1995, or you can start by reading several free introductory sections.

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If you choose to buy, thanks in advance for your business, and please feel free to write to me about something unusual or interesting about your case. I routinely make improvements to the tutorial as a result of feedback from runners and readers and health care professionals around the world.

Paul Ingraham
, PainScience.com Publisher


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Mildly amusing humorous definition of IT Band Friction Syndrome. Arrows pointing to the different parts of the term and whimsically translate them to create “ITBS is a weird hip to shin police problem?”



What’s new in this article?

Four updates have been logged for this article since publication (2012). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

DecemberCited and discussed the implications of Eng 2015, which purports to show that the IT band uses elastic energy to enhance running efficiency.

AugustAdded important new point about why the IT band is hard to stretch, based on Willett et al.

JulyAdded a new citation to Umehara et al on the effect of knee flexion on stretching, added an important point about the relevance of central sensitization, updated the footnote about stretching being overrated overall, added a related reading section.

MarchMajor update. Comprehensive editing and modernization, added a key new reference to Wilhelm et al, several clarifications and a new (and more optimistic) ending, and corrected minor errors that had accumulated over time.

2012Publication.

Related Reading

Notes

  1. Not universally, of course. Some therapists will know this stuff. But let me put it this way: I worked with ITBS patients routinely for a decade, and in that time the number of patients I saw who’d been taught to stretch properly by another therapist … I can count them on one hand. The huge majority were given the standard, inadequate stretch. BACK TO TEXT
  2. Research has clearly shown that conventional stretching isn’t good for much, and may even be harmful (minor harm to perform, some risk of injury). Although it can increase flexibility, that has no inherent value if you don’t actually need it (martial arts, gymanstics, etc), and flexibility can also be achieved by full ROM strength training — and why wouldn’t you want to get stronger at the same time you’re building flexibility? Stretching certainly feels good and the movement and stimulation is probably good for us in subtle ways, but it’s value is much less clear than most people believe. See Quite a Stretch: Stretching Hype Debunked: Stretching science shows that a stretching habit isn’t doing much of what people hope. BACK TO TEXT
  3. Brushøj C, Larsen K, Albrecht-Beste E, et al. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008 Apr;36(4):663–670. PubMed #18337359. This study showed “no significant differences in incidence of injury” in soldiers doing preventative exercises for commmon overuse knee injuries, especially iliotibial band syndrome and patellofemoral pain syndrome (two kinds of runner’s knee). The authors concluded that the exercises “did not influence the risk of developing overuse knee injuries or medial tibial stress syndrome in subjects undergoing an increase in physical activity.” The exercise regimen certainly included static stretching, and it certainly did not work any prevention miracles for iliotibial band syndrome. BACK TO TEXT
  4. Khaund R, Flynn S. Iliotibial Band Syndrome: A Common Source of Knee Pain. Am Fam Physician. 2005 Apr 15;71(8). PainSci #56763. From the article: “…studies have not demonstrated that stretching hastens recovery from [iliotibial band] syndrome.” BACK TO TEXT
  5. PS Ingraham. The Unstretchables: Eleven major muscles you can’t stretch (no matter how hard you try). PainScience.com. 1982 words. BACK TO TEXT
  6. Willett GM, Keim SA, Shostrom VK, Lomneth CS. An Anatomic Investigation of the Ober Test. Am J Sports Med. 2016 Mar;44(3):696–701. PubMed #26755689. BACK TO TEXT
  7. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309–316. PubMed #16533314. PainSci #56738. Many therapists don’t believe this at first — it doesn’t jibe with the anatomy they learned in school. But this anchoring arrangement was discovered (or clarified) by researchers many years ago now. The attachment is not through the big thigh muscles, but behind them. Attachment is more direct in the distal femur. Here’s the relevant sentence from the paper: “This layer of deep fascia completely ensheathed the thigh and was continuous with the strong lateral intermuscular septum, which was firmly anchored to the linea aspera of the femur.” BACK TO TEXT
  8. Eng 2015, op. cit. Briefly recapping: this study shows that the IT band “may contribute to energy savings during locomotion,” an elastic energy storage structure like the Achilles tendon. Although all tendons are extensible to a point, not all of them are equally elastic, and most don’t use their elasticity to actively put energy back into the system (it might only be these two that have that trick). BACK TO TEXT
  9. As early 1979, Noble wrote that, “Tenderness over the lateral epicondyle associated with pain at 30 degrees of flexion on compressing the iliotibial band against the lateral epicondyle is diagnostic.” In 1996 Orchard shows the practical, painful reality of this in the biomechanics of running. In 2006, Fairclough confirmed that tension on the iliotibial band is greatest at 30˚ of flexion. BACK TO TEXT
  10. Umehara J, Ikezoe T, Nishishita S, et al. Effect of hip and knee position on tensor fasciae latae elongation during stretching: An ultrasonic shear wave elastography study. Clin Biomech (Bristol, Avon). 2015 Dec;30(10):1056–9. PubMed #26388173. “…investigate the effects of hip rotation and knee angle on tensor fasciae latae elongation during stretching in vivo using ultrasonic shear wave elastography…” BACK TO TEXT
  11. Fredericson M, White JJ, Macmahon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83(5):589–592. “Adding an overhead arm extension to the most common standing ITB stretch may increase average ITB length change … in elite-level distance runners.” Not that we can actually change the length of the IT band… BACK TO TEXT
  12. Falvey EC, Clark RA, Franklyn-Miller A, et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010 Aug;20(4):580–7. PubMed #19706004. BACK TO TEXT
  13. Many people will reasonably question the value of a dissection study — so different than the living body! However, the clinical relevance of studies on corpses varies with context. Certainly many things can and have been learned from dissection. In this case, we’re looking exclusively at whether or not an anatomical structure can be elongated when pulled on. It’s not a test of stretching effectiveness in the real world, but of the mechanics and anatomy of the stretch. If a well-executed passive stretch does not elongate the IT band in a corpse, is it likely that a living person could do any better? Do live IT bands respond very differently to being pulled on? I doubt that.

    The result is also consistent with a lot of other evidence and with other aspects of the anatomy of the structure, established in this and other studies, particularly that it is anchored to the femur along most or all of its length. It is not an “elongatable” structure. This can be established as well on a corpse as in the living — probably better.

    We then can decide what to make of that — that is, what clinical implications arise — but the biomechanical facts are difficult to dispute here. The response that “it’s just a dissection study” is a convenient way to dispose of inconvenient, myth-busting evidence. But dissection studies have their place and are very good at determining things just like this, and that’s why we do them. BACK TO TEXT
  14. Wilhelm M, Matthijs O, Browne K, et al. Deformation Response of the Iliotibial Band-Tensor Fascia Lata Complex to Clinical-Grade Longitudinal Tension Loading in-Vitro. Int J Sports Phys Ther. 2017 Feb;12(1):16–24. PubMed #28217413. PainSci #53506.

    This is an in vitro study of the effect of pulling on a dissected IT band, removed from a corpse. This is not necessarily a pointless thing to do (in vitro experiments have their uses), but in this case the IT band was aggressively harvested: completely removed from its complex anatomical context, cleaned, frozen, warmed up to 20˚ C, and then machine-stretched… although we can learn things from this, it’s important to emphasize that the differences from biological and clinical reality are piled high here.

    The abstract of the paper “advertises” a statistically significant effect of machine stretching on an excised IT band… but not a clinically significant effect. They report an elongation of just a few millimeters. In the main text, they concede that “the current study’s findings are in agreement with those of Falvey et al. demonstrating minimal stretching of the ITB”! (Falvey et al is the paper most cited to argue that the IT band cannot be meaningfully stretched, and this paper is “in agreement” with it, demonstrating “minimal stretching.”)

    They also write: “it is unlikely that …‘clinical stretching’ produces permanent ITB deformation.” So despite superficial appearances to the contrary, this paper clearly actually reinforces the point that IT band stretching is futile (to the extent that stretching a completely dissected IT band can tell us anything at all).

    I got a chuckle out of this:

    “While the tissue used for the present analysis was harvested from a specimen sample that was older than those individuals who would likely develop ITB pain, it is difficult to obtain cadaveric tissue samples from a younger population for testing.”

    Indeed.

    BACK TO TEXT
  15. By far the clearest result of 21st Century pain science so far is that chronic pain is aggressively multifactorial, and routinely has a strong component of central sensitization: an over-reactive, paranoid central nervous system that is producing a louder, longer alarm (pain) in reaction to less and less actual trouble in the tissue. Anything that “reassures” the brain and convinces it that there’s no actual danger, and therefore no need for pain, may be quite helpful. There’s no direct evidence that stretching can help ITBS by this mechanism, but the phenomenon of central sensitization is very well-etablished, and it’s much more plausible than the idea that stretching causes a helpful change in the IT band itself. BACK TO TEXT