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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

updated (first published 2008)
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

This short article introduces you to a basic concept in IT band pain that surprises almost everyone, including doctors and physical therapists.

Iliotibial band syndrome is a mysterious condition. It’s amazing how many things we still don’t understand about. You would think that science would have mastered a little thing like this long ago! But that’s not the case.

For instance, it was only recently discovered that the IT band does not actually “rub” across the side of the knee, as the conventional wisdom had always assumed (it even used to be called IT band friction syndrome for this reason).

In 2007, John Fairclough of University of Wales Institute, with seven coauthors, challenged the definition of iliotibial band syndrome, and even of the iliotibial band itself, in a paper published in the Journal of Science and Medicine in Sport. They presented a compelling analysis, concluding that “the perception of movement of the ITB across the epicondyle is an illusion.”

They were basically suggesting that the function and anatomy of the iliotibial band has been misunderstood and oversimplified for decades!

And then again in 2008 this new idea was strongly validated by a new study. Michels et al operated on 35 knees, trying to solve IT band syndrome in a completely new way, based on the new understanding of the anatomy. If the new theory was wrong, their procedure would be pointless and ineffective. But it worked!

When this study was published in 2008, I thought that was probably the end of it, but no: the debate about “rubbing” has continued. See Does the IT Band Move After All?.

So what’s actually inflamed?

If the iliotibial band is not the irritated structure in ITBS … what is?

The most likely suspect is actually a layer of fat and loose connective tissue pinched between the iliotibial band and the knee! And this isn’t just an educated guess: it is supported by MRI studies, which provide good evidence that it is a layer of tissue under the iliotibial band that is inflamed (an abnormal appearance in the scan compared to healthy knees). Dissection study has also shown evidence of this. And of course there is also the brand new study by Michels et al mentioned above.

So it’s not so much a “tendinitis” as a “layer-of-fat-itis.”

Other problems with the conventional wisdom

Oy, where do I start?!

If IT band syndrome isn’t really a tendinitis, exactly, then most of the conventional wisdom already has to go out the window right there. But there are numerous other problems and surprises, like the fact that researchers have also found that people with iliotibial band syndrome don’t have tight IT bands! Or at least, no more than anyone else.

Hip strengthening, often optimistically believed to be a cure for this condition, is under heavy scientific attack the past couple years.

An a array of structural problems such as short legs and tilted pelvises, once assumed to be the root cause of the problem, are looking less and less likely to have anything to do with runner’s knee.

So, what should you do?

You cannot actually expect to get good advice from most doctors and therapists about ITBS. Your knee pain is an important problem to you, but to most professionals it’s just a trivial entry in a textbook — probably an old textbook, that doesn’t come within ten years of including this new information. In school, I probably studied no more than a paragraph about ITBS, and perhaps I answered a single test question about the condition in three years of training. I would estimate that less than 1% of professionals have a firm grip on recent IT band science.

Fortunately, most people with IT band “tendinitis” recover reasonably well with a little rest and ice. However, many cases do become chronic, especially if some unwise trainer or therapist advises you to try to exercise your way out of it (bad idea, by the way). If you’re serious about your knees, it’s well worth it to learn all about iliotibial band syndrome … and learn it sooner rather than later.

An extremely detailed iliotibial band syndrome tutorial

In addition to hands-on therapy, I make my living by studying pain problems like iliotibial band syndrome for years, and then publishing and selling extremely best-in-class tutorials about them. I have published eight such tutorials since 1999. I set out to make each one of them the single best resource on the subject. My ITBS tutorial has always been the most popular of them — so many people have the condition, and so many people have gotten frustrated by ineffective treatment, that the tutorial seems to have found an extremely large (and grateful) audience. For many years now my tutorial has been the best thing you can find on the subject … and it is still constantly improved by reader feedback and by integrating new scientific evidence. There’s simply nothing else like it.

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61,000 words
82 sections
193 footnotes

all myths & controversies
all diagnostic issues
all treatment options
  • 1 Introduction
  • 1.1 Bogus ideas about and bad treatments: IT Band syndrome myths are common
  • 1.2 IT band syndrome symptoms
  • 1.3 Are you in the right place? Patellofemoral versus IT band pain
  • 1.4 An orphan injury: IT band syndrome neglected by science
  • 2 Nature of the Beast
    What causes iliotibial band syndrome?
  • 2.1 The conventional wisdom
  • 2.2 Friction syndrome? So where’s the rub?
  • 2.3 So is it a tendon or what? IT bands are special
  • 2.4 What’s actually irritated? Not the IT band …
  • 2.5 A new surgery works without loosening anything tight
  • 2.6 The bursitis possibility
  • 2.7 Like a rock in your shoe: the mechanism of irritation and the red herring of tightness
  • 2.8 Why does IT band pain gets so nasty so fast? A vicious cycle related to running pace
  • 2.9 What are the root causes of iliotibial band syndrome?
  • 2.10 “Maybe you’re just not built for running”
  • 2.11 Where’s the fire? The inflammation myth
  • 2.12 What’s muscle got to do with it? The role of trigger points (muscle knots)
  • 2.13 Hip and thigh pain: part of the problem, or red herring?
  • 2.14 When ITBS isn’t a repetitive strain injury
  • 2.15 Does the iliotibial band move after all?
  • 3 Diagnosis
    How do you know you’ve got iliotibial band syndrome?
  • 3.1 Should you get an MRI?
  • 3.2 Knee pain getting you “down”? ITBS and descent pain
  • 3.3 ITBS vs. PFPS: A more detailed comparison, with checklists
  • 3.4 What about the hips? Could hip pain be ITBS?
  • 3.5 Could there be something else wrong, deeper inside the knee?
  • 3.6 Is patellar misalignment evidence of a tight IT band?
  • 3.7 Misdiagnosis horror story #1: Not even wrong
  • 3.8 Misdiagnosis horror story #2: The strange case of Ms. Strange
  • 3.9 Misdiagnosis horror story #3: X-ray for iliotibial band syndrome? No!
  • 3.10 Other possible diagnoses and sources of diagnostic confusion
  • 4 Prognosis
    What’s the worst case scenario for iliotibial band syndrome?
  • 4.1 The risk of recurrence
  • 4.2 Special warning to hikers
  • 4.3 Can you “run through” iliotibial band syndrome?
  • 5 Treatment
    What can you do about iliotibial band syndrome?
  • 5.1 So what’s the plan?
  • 5.2 Some important things to keep in mind about placebos
  • 5.3 Steroid injections: a complicated mix of certain risks and uncertain rewards
  • 5.4 The old surgery: snipping the band
  • 5.5 The new surgery: excision of tissue from under the IT band
  • 5.6 Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel
  • 5.7 Icing: more is better?
  • 5.8 Contrast hydrotherapy: exercising tissues with quick temperature changes
  • 5.9 INTERLUDE: “I have a lot of money for you if you would just lie to me about what works”
  • 5.10 The art of rest: the biggest challenge and opportunity for patients who have supposedly “tried everything”
  • 5.11 The fear of rest, and relative resting: how to maintain fitness while protecting your knees
  • 5.12 Hip strengthening is badly over-hyped
  • 5.13 IT band massage, foam rollers, and Graston Technique® — a big fat waste of time and/or money
  • 5.14 Mis-treatment horror story: intense massage on an obviously inflamed thigh
  • 5.15 Trigger point therapy for your hips, glutes, quads, and calves
  • 5.16 Deep transverse friction massage
  • 5.17 Stretching to prevent or treat IT band syndrome
  • 5.18 The trouble with stretching the IT band in particular
  • 5.19 Some stretching hope: a better iliotibial stretch?
  • 5.20 Mobilize and stretch the hip musculature
  • 5.21 Soft knee straps (and/or Kinesio Taping) are worth a shot
  • 5.22 Orthotics for IT band syndrome: a worthwhile long shot
  • 5.23 Should you run naked? On faddish running styles and running shoes (or the lack thereof)
  • 5.24 Hitting the road: shoes, surfaces, impact, and the spring in your step
  • 5.25 ITBS and leg length
  • 5.26 Pacing: run less, but run fast!
  • 5.27 Don’t bother with Traumeel
  • 5.28 Some nuggets of wisdom about long term prevention
  • 5.29 Brief debunkery of several therapies that you should be particularly skeptical of
  • 6 Now what?
    An action-oriented summary of recommendations
  • 7 Appendices
  • 7.1 Appendix A: My own iliotibial band syndrome story … grizzly bears included
  • 7.2 Reader feedback … good and bad
  • 7.3 Acknowledgements
  • 7.4 What’s new in this tutorial?
  • 7.5 Notes
dots before headings indicate updated sections ?There’s a detailed description of all updates at the bottom of the tutorial, and it’s nice to be able to see what’s new at a glance in the table of contents. Any section updated in the last 400 days is marked (hotter colours = fresher updates).

I really appreciate your objectivity. ~ Dr. Bryan Allf, MD, North Carolina

Very much improved since reading your tips and admonitions ... ~ Leanne Schultz, runner, Victoria, Canada

I appreciate your research on this subject, and that you have clearly debunked lots of poor quality ‘science.’ ~ Sukey Jacobsen, Mount Vernon, Washington

Keep reading for free! Other free samples from the book and closely related articles on PainScience.com:

BUY NOW $1995 USD
Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
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The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small business. However, my business never actually handles card info: it goes straight from your web browser to Stripe.com [opens new tab/window], a major payment processor with a great reputation. So using a credit card here is as safe as using it in any store, probably safer.

But you can pay with PayPal. Although automatic order processing is only available for credit card customers, you can “manually” login to PayPal and send payment of 19.95 USD to . Please specify the book you are ordering!

I process orders promptly during working hours, usually within two hours, often much less; night orders are processed early the next day. You will receive order confirmation and access information by email.

Important reminders!

  1. Confirmation emails are often mis-identified as junk email. If you don’t get yours, please check your spam folder!
  2. Again, please specify which book (just the topic is fine, e.g. “plantar fasciitis”).
read on any device, no passwords
refund at any time, in a week or a year
call 778-968-0930 for purchase help

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.