Welcome to the largest and most scientifically current tutorial about IT band pain available anywhere. This is not just a web page: it’s a book. Thousands of readers have benefited from it and contributed their stories. If you have a tough case of chronic IT band syndrome that, this is the information jackpot you’ve been looking for. What works for IT band syndrome? (Annoyingly little.) What doesn’t? (Most popular treatments.) Why? (It’s complicated!)
In the many years I’ve been writing about IT band syndrome, there has been an explosion of free information about it available on the internet. Sadly, this has not resulted in patients or health care professionals being better informed. Most of the information that you can find out there repeats the same oversimplified conventional wisdom … most of which is just wrong.2
I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about IT band syndrome for over a decade. I recovered from my own severe, bilateral case. ~ Paul Ingraham
About footnotes. There are 171 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.
Bogus ideas about and bad treatments: IT Band syndrome myths are common
Here are some examples of wrong and obsolete IT band treatment that patients encounter all too often. Detailed scientific evidence supporting these points will be provided later: this is just a taste of the debunking.
pro Strong enough for a pro But made for patients. The main text is user-friendly, but oodles of footnotes provide extra info and citations.
I do criticize many common practices and beliefs. If you disagree, let me know—I can take it, and I’ve made many changes over the years based on quality feedback.
IT band stretching is the king of the conventional wisdom, in spite of good evidence that stretches don’t work, especially the simple ones usually seen in the wild.
“Elongating” your iliotibial band [InnerBody.com] with intense massage strokes is one of the most popular alternative treatments for ITBS, but it works about as well as it would on a truck tire. Meanwhile, better targets for massage are often neglected.3
Most doctors are barely aware of IT band syndrome,4 and may neglect (or overemphasize) medical options like cortisone injections or IT band release surgery, which might actually help — but shouldn’t be the first, second, or third line of defense. Even many sports medicine doctors and orthopedic specialists simply don’t know enough to guide you in these choices. Specialists are (quite appropriately) preoccupied with other medical priorities.
Quadriceps training is a therapy for another kind of knee pain, but often gets prescribed as treatment for ITBS as well — probably a simple case of mistaken identity.5
This video goes into greater detail about some of those points, and introduces several key concepts:
An orphan injury: IT band syndrome neglected by science
No wonder therapy often fails: iliotibial band syndrome is not studied enough,67 and treatment for it is not taught.8 I have a seemingly detailed modern sports injuries text on my shelf which offers only a couple of short sentences, concluding that “the prognosis is good with appropriate treatment”9 — without even saying what the treatment is!
I have suffered from IT band syndrome myself — see my own bears-included IT band story in Appendix A — and I have seen many stubborn cases of it in my own patients (I was a massage therapist for a decade). The prognosis for iliotibial band syndrome isn’t always good, and many accepted treatments are ineffective.10 Many people recover with a little rest, icing, and stretching, but not everyone.
How can you trust this information?
I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for iliotibial band syndrome. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 180 footnotes here, drawn from a huge bibliography), and I always link to my sources.
I’ve been obsessively updating this tutorial for well over a decade now, and it’s the largest and best of its kind as far as I know. The limited competition has serious “trust issues.”1112
Is there a miracle cure for iliotibial band syndrome?
Of course not! Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But we’re nowhere close to this for IT band syndrome. So how do you manage the unmanageable?
What I can do is explain and review all the options, help you to confirm your diagnosis, and debunk bad ideas. Some people will finally enjoy a breakthrough after reading this tutorial, and get partial or complete relief of their symptoms, sometimes temporary, sometimes lasting. And maybe that is kind of miraculous!
Most therapists and doctors have not read the recent scientific research on IT band syndrome, let alone absorbed it and had a chance to practice applying it. Basic knowledge is fine for basic cases, but better information is important for difficult cases. And even if you just developed IT band pain for the first time, how long do you want to spend following poor quality advice or muddling about with partial understanding? Get started on the right foot.
There is no miracle cure, but this tutorial helps a lot of people get a lot closer to effective management than they would otherwise. Find out why most therapy fails. Overhaul your mental approach to the problem. You may be amazed by how much time and money you’ve already wasted on treatment strategies that were probably doomed to failure.
Are you in the right place? Patellofemoral versus IT band
Let’s make sure you’re reading the right tutorial, because ITBS is often confused with the other runner’s knee injury: patellofemoral pain syndrome. Although the two conditions may seem quite similar, usually you can tell the difference just by the location of the pain.
Iliotibial band pain is truly a side of the knee condition, and the epicentre of the symptoms is always there, by definition. On the other hand, if you have pain that definitely dominates the front of your knee, there’s a good chance that you have patellofemoral pain syndrome, and you should start reading the patellofemoral pain tutorial instead. If you’re not sure which kind of knee pain you have, take the runner’s knee diagnosis test.
Front or side?
The epicentre of iliotibial band pain is always on the outside of the knee. The pain of patellofemoral pain syndrome is more variable, but usually dominates the kneecap.
There is one other common source of confusion about the location of ITBS. In fact, the number one myth of the condition is that it causes hip and thigh pain. It does not. ITBS is a knee pain condition only.
If you have hip or thigh pain and no knee pain at all, you don’t have IT band syndrome, but this tutorial is probably still useful for you anyway: confusion about IT band pain location is so common that I consider it to be normal part of learning about the condition, and the tutorial offers scads of information about common hip and thigh pain as well as knee pain. Whatever it should be called.
Nature of the Beast
What causes iliotibial band syndrome?
In the next several sections, you will learn that this is not as easy a question to answer as you probably thought. In fact, it turns out that it’s not as easy as anyone thought. Overuse injuries of all kinds have proven to be rather scientifically tricky and complicated. Things that therapists and doctors once considered “obvious” or “common sense” have turned out to be wrong, and researchers have only just begun to try to find out what’s really going on.
On the face of it, iliotibial band syndrome is still a simple condition, obviously caused by excessive knee usage and usually treated just by resting. But to anyone who can’t get rid of it just by resting, it is equally obvious that there must be more to it than that …
Iliotibial band syndrome is primarily known as a running injury, responsible for about one in twenty lower limb injuries in long-distance runners.13 But it is generally common: roughly one in twenty-five people engaged in other kinds of vigorous physical training will get a case of it.1415 I estimate that as many as a quarter or half of all long-distance runners may get the condition eventually. Just to put this in perspective, iliotibial band syndrome is probably not much less common than ankle sprains, which are generally regarded as the most common of all athletic injuries.16
Although primarily a runner’s affliction, iliotibial band syndrome is also prominent in cyclists17 — even though each stroke of the pedals is probably much less irritating to this knee condition than running, sheer repetition can certainly make up for it. Hiking, backpacking, orienteering, and frequent long walks can also cause the syndrome.18
The conventional wisdom says that iliotibial band syndrome (ITBS) is a kind of tendinitis, or at least an irritated tendon. The iliotibial band is a large tendon running down the side of the leg from the hip. If it gets too tight, it rubs painfully over a bump of bone on the side of the knee, the lateral epicondyle. For this reason, it is also commonly called iliotibial band friction syndrome (ITBFS).
Note: “iliotibial” is often mis-spelled as “ilotibial.”
Makes sense. Right? Well, not anymore. It turns out that iliotibial band friction syndrome is probably not a “friction” syndrome after all — not even a tendinitis, in fact. The irritated structure is probably not actually the iliotibial band. Nor is the IT band “too tight,” which particularly fascinates me, given that the world of physical therapy is pretty much obsessed with the tightness of IT bands!
Friction syndrome? So where’s the rub?
In 2007, John Fairclough of University of Wales Institute, with seven coauthors, issued a major challenge to the classic 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.1920 They present a compelling analysis, concluding that “the perception of movement of the ITB across the epicondyle is an illusion,” in effect suggesting that the function, dysfunction and actual anatomy of the iliotibial band has been misunderstood all along. It’s a charming example of how primitive medical science still is. Can we really still be learning anatomy this late in history? Oh yes!21 Of course.
(Not only still learning, but still arguing about it. A few years later, Jelsing et al. came along and used ultrasound to show that the IT band does move back and forth — even though they agree that the IT band really is firmly anchored to the side of the knee. There is no good solution to this paradox for now, but for a few reasons I still think it’s best to think of friction as an obsolete idea. There will be much more about Jesling’s fly-in-the-ointment evidence later.)
“The perception of movement of the ITB across the epicondyle is an illusion.”
And as for the common wisdom that the iliotibial band is “too tight”?
In 2004, a research group at University of Connecticut led by Michelle Devan decided to try to figure out the effect of “structural abnormalities” on overuse knee injuries like iliotibial band syndrome.22 So they measured a bunch of stuff in a group of athletic young women, looking for structural problems that every therapist in the world “knows” are risk factors for various knee problems, including the tightness of iliotibial bands … and then they waited to see who got what kinds of knee injuries. Based on the conventional wisdom, you would fully expect the women with tight iliotibial bands to get more ITB syndrome.
In fact, it’s “obvious”!
But of course that’s not what happened! And that’s what makes IT band syndrome such an interesting subject. Now, here’s what did happen …
Several of these young women athletes did get iliotibial band syndrome that season. Indeed, it was the most common injury in the group.23 But these expert assessors determined that not one of them had tight iliotibial bands. Not even one!
All the athletes with iliotibial band friction syndrome had a negative bilateral Ober test [their iliotibial bands were not tight].
This study involved a small number of athletes, and there’s an interesting flaw that I’ll bring up again below when we get deeper into tightness. It doesn’t detract from the message here that IT band tightness is not a straightforward thing: you really cannot assume (or do therapy on the assumption) that a tight ITB is a big deal.
The conventional wisdom was such a nice, straightforward picture of the condition that no one was apparently motivated to question it — after all, ITBS is a relatively minor condition. Most cases of iliotibial band syndrome resolve spontaneously or with conservative treatment, and the others respond pretty well to a simple surgery. Why rock the boat by challenging the very definition of the problem?
Most cases of iliotibial band syndrome resolve spontaneously or with conservative treatment, so why rock the boat?
Because that simple picture is almost certainly wrong! “Minor” or not, many consumer dollars have probably been wasted on therapies based on incorrect information and unsafe assumptions. What little research there is has been largely based on dubious assumptions about how ITBS works. If we understand the condition as it truly is, perhaps someday ITBS can be treated more efficiently and conservatively, without surgery — and perhaps with more effective surgeries as well.
So, what exactly is iliotibial band syndrome? To answer that, we need to talk anatomy. Hang on, you’re about to learn some Latin. You will be able to amaze your running buddies with your knowledge. Your authoritative command of ITB anatomy will blow them away!
So is it a tendon or what? IT bands are special
The iliotibial band is usually described as a tendon — a big one. It’s so big that it’s also called the iliotibial tract [Wikipedia]: no other tendon is known as a “tract”! It is often called the largest tendon in the body, and that’s sort of true, and yet it’s clearly not just any tendon. It’s a rather special and complicated one…
Most of these, especially the most critical points, were reported by Fairclough et al in 2006.
The IT band isn’t anchored to a bone at clear and specific spots like most tendons. Instead, it blends seamlessly into the capsule around the knee (which is why your knee seems to “cinch up” during an effective iliotibial band stretch24).
Most tendons have clear edges and are well separated from other tissues. The IT band is more of a reinforced section of the connective tissue wrapping of the whole thigh.25
This “tendon” is also technically a ligament: that is, a connective tissue structure that connects bone to bone, rather than muscle to bone. The ITB is partially attached to the pelvis.
Most tendons are dwarfed by the muscle they are attached to, but the iliotibial band is much more massive than the tiny tensor fasciae latae muscle — several times longer and much wider.
Although the gluteus maximus also partially uses the iliotibial band as a tendon, the connection is at an odd angle: the job of the gluteus maximus is probably not so much to pull along the length of iliotibial band, as with virtually all other muscle-tendon arrangements, but rather to increase the tension on it by pulling on it laterally, like drawing a bowstring.
It is tightly anchored to the full length of the femur, from hip to knee — especially just above the knee.
It’s that last one that’s really important to understand. Most professionals think of the IT band as being free to move relative to the femur, a strap that lies just underneath the skin, separated from the femur by a good thick layer of muscle (the quadriceps). But the iliotibial band is not free to move relative to the femur, or so little that it doesn’t count. It’s firmly attached to it, like a barnacle to a rock26 — even right at the location where it supposedly rubs back and forth.
This is why Fairclough et al suggested that “the ITB cannot actually create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee.” The anatomy only creates the illusion of a slide over the side of the knee.2728
That mental image of the IT band snapping over the side of the knee is prevalent and misleading, and the basis for several treatments that are probably doomed as a result. This is an advanced anatomy puzzle, and a professional trained 20 years ago may not be aware of the implications of some specific anatomical research published only 10 years ago. On the other hand, a lot of under-trained professionals really need to upgrade their anatomy.29 Regardless, let’s get the accurate anatomy out there: the ITB is a unique connective tissue structure with some properties of a tendon, others of a ligament, and an unusual tension control system consisting of a couple of hip muscles at the upper end, and it probably does not slide significantly over the side of the knee.
What’s actually irritated? Not the IT band …
Fairclough et al argued that the iliotibial band itself is not the irritated structure in ITBS. If not, what is? Something under the IT band is the simplest answer at this time…
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I was struck down dramatically by iliotibial band syndrome in both knees at once, on a solo backpacking trip in the Monashee Mountains in the spring of 1998. But that makes me sound more adventurous than I am.
In reality, I am a big chicken, and being in the woods alone spooked me but good. I got injured because I pushed too hard, too fast, and ended up deep into the mountains late in the day, with the trail ahead lost in snow. I decided to rush back to the trail head even if I had to hike in the dark for a while. So I practically ran down the mountain with a fifty-pound backpack — big mistake! After just an hour, both my knees started to scream.
The rest of the hike was a nightmare, certainly one of my most painful experiences. There were times when I felt certain I couldn’t take another step … yet somehow I did.
The Monashee Mountains
This is where I got iliotibial band syndrome.
I was almost at the trailhead when a momma grizzly found me. I’d seen a warning sign about her before starting the hike. In fact, I had gotten quite paranoid about crossing paths with her as I neared the trailhead!
It didn’t work.
It was deep twilight, and there was nowhere to run, and I couldn’t run anyway, and no one outruns a grizzly anyway. She charged me on the trail, and I heard her before I saw her. I thought the following two thoughts, in this order, I swear:
I guess I’m going to be maimed and killed now. Damn. This is going to hurt.
At least I won’t have to walk any further!
Grizzlies are fast! (Up to 34 mph, 55 kph.) She came at me like I was lying at the bottom of a cliff and she was falling on me. The idea of unlatching my bear spray from its “quick” release, pulling the safety pin, aiming, and firing … absolutely ridiculous! She was simply way too fast and intimidating.
And she did what grizzlies almost always do when they charge people: she veered off at the last second. Grizzlies aren’t particularly predatory, but they certainly take their cubs seriously, and her main goal was to intimidate me … and that she surely did.
And that’s my entertaining bear story! It’s given me years of dinner party material, and it will for the rest of my life. Now, back to iliotibial band syndrome …
The next day, I quite literally could not get down stairs — which was problematic, because I lived in a 3rd-storey walk-up — both due to the worst case of delayed onset (post-exercise) muscle soreness I have had in my life, and the napalm attacks on the sides of my knees. I have seen some nasty cases of iliotibial band syndrome in my career, but I feel comfortable claiming that I’ve had it worse than anyone else I’ve ever met.
I was in school at that time, and we hadn’t learned diddly-squat about iliotibial band syndrome yet, nor did we later — that’s partly how I know just how poorly informed most massage therapists are about this condition. I never would have learned more than the basics if I hadn’t been forced to learn more by my own injury. It took me one year to recover, and to this day I still suffer occasional flare-ups if I run for more than a couple hours … which I do.
That’s me, getting ready to flick the disc.
I am an enthusiastic ultimate player — that’s me there in the picture, getting ready to flick the disc — so the injury was deeply frustrating to me, and, just like every serious runner I’ve ever treated, it was nearly impossible to keep me from re-injuring myself. I simply would not stay off the field. Every return to play was premature. This was where I first made the observation that, in all likelihood, runners (and ultimate players) are more of a problem than their knees. Iliotibial band syndrome isn’t stubborn — we are!
For me, the best treatments were probably rest, megadoses of well-timed icing (controlling inflammation at the times when it was most likely to start), and discovering that one of the taiqi moves I did was particularly good at stretching the iliotibial band and associated musculature (see Iliotibial Band Mobilization). How did I know? Because it hurt like hell! With my ultra-sensitive knees, it was really quite easy to evaluate how strongly different positions pulled on my iliotibial band — given that I was studying anatomy intensively at the time, I was in ideal circumstances to experiment. So this is how I first learned the importance of knee flexion in stretching the iliotibial band, a difference that was as clear to me as flicking a light switch: just add knee flexion to any of the standard stretches, and the iliotibial band pulls much tighter over the side of the knee. To this day, I don’t know if the stretching actually helped, but it certainly felt like a “real” stretch of the IT band, more so than any other stretch I could do.
All of this was good preparation for helping other people with iliotibial band syndrome, of course. Today, I know many things that I really wish I had known when I first hurt myself! And that’s why this very, very long tutorial exists.
Thank you to Dr. Michels and his colleagues for their important, evidence-inspired work in pioneering a new surgical treatment for ITBS, with its fascinating implications. Thank you as well to Dr. Fairclough and his research colleagues who also deserve special mention for their seminal 2007 paper on IT band syndrome, which was a game-changer and instantly made this topic much more interesting to continue writing about.
This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.
Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.
Warm thanks also to reader John J, who reported more typografic errors and other miner glitches in onelarge batch than I would ever have dreamed posssible so many years into the lyfe of this document. Many readers have helped out with such reporting, but John’s effort was truly the most remarkable yet.
What’s new in this tutorial?
This document was originally published as a much simpler article in 2002. It was expanded and republished as a book-length tutorial in April of 2007, and has been updated and revised regularly since then. An unusually large batch of improvements were made in mid-2012 in preparation for recording an audiobook.
Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 78 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).
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— Rewritten: Six years after the last re-write, another major renovation of the topic of hard-surface running and shock absorption: new ideas and advice spelled out and supported much more thoroughly.
— Minor upgrade: Added evidence from a new dissection study and edited the whole section for currency and clarity. Time flies: it’s been a long time since I last looked at this topic!
— Science update: Cited a useful new review of studies of instrument-assisted soft tissue mobilization (IASTM) — scraping massage — plus some general cleanup and clarifications about IASTM.
— Minor addition: Added peroneus longus to the list of muscles to massage, because of evidence that it contributes to IT band tension.
— New topic: A much more encouraging new conclusion to this section, endorsing simple massage for a simple reason.
— Science update: Added information about the Ober test, finally — and the brand new evidence that it doesn’t measure IT band tightness after all.
— Minor update: Added general perspective on the efficacy and safety of orthopedic surgeries.
— New section: Important new evidence that undermines my own debunking, thoroughly acknowledged and analyzed.
— Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention.
— Update: Careful and thorough editing/update of NSAID recommendations, especially with regards to safety.
— Science update: Discussed the implications of some (weak but noteworthy) evidence about screening for the risk of lower limb injuries in athletes.
— Minor science update: Added citation to shore up evidence that taping tinkers with knee sensation.
— Minor science update: Citation of Collins 2008, a review of icing evidence (or the lack of it), plus a few related edits.
— Expanded: Added several items that might cause diagnostic confusion.
— New item: Added IT band plungering. No really! If it’s stuck, suck it!
— New item: A brief but very well-researched review of platelet-rich plasma injection.
— Updated: Added good news story from a reader about a case with a cyst, and improved the information about cysts at the same time.
— Major update: The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.
— Science update: Added a bad-news citation. Sorry about that.
— New case study: Added a fascinating and extreme example of the effect of running style from a case study of an ultra-runner.
— Science update: A particularly “good news” science update about how running is, counterintuitively, actually pretty good for joints — not hard on them.
— Update: A new introduction for the chapter about the trend of anti-running “science.”
— Updated: Added more detail and a couple examples.
— Minor update: Minor but nice: a really good new quote adds some entertaining and genuinely fascinating perspective to this section.
— Minor update: Upgraded risk and safety information about Voltaren Gel.
— Product upgrade: Audiobook version now available. See the announcement for more information.
— Minor update: Added some fun stuff and context about bad anatomy.
— Expanded: Added much more detailed self-help information for trigger points.
— Science update: Added evidence from the first foam rolling research ever done.
— Major update: Numerous significant clarifications, revisions, and new references, and a generally stronger recommendation.
— Rewritten: Now about four times more detailed than before and much more strongly focussed on the positive, what my final recommendations are, and how to “put it all together.”
— Nice upgrade: After years of procrastination, I have finally created a video demonstration of a tricky ITBS stretch! About time!
— New section: New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan.
— New diagram: Nice new diagram, “Key locations for massage treatment of ITBS.”
— Minor update: Very simple swimming tip added. Hat tip to reader Eric C.
— Major update: Rewritten and expanded, much clearer and more detailed. Not much new science, though — ITBS+orthotics science is pretty scarce!
— Minor update: Added a paragraph about elliptical machines.
— Minor update: Added an example of surgery gone wrong.
— New section: No notes. Just a new section.
— Revised: Some modernization and clarifications. Now also discusses the notion of “just rubbing” the hot spot.
— Rewritten: Another “like new” rewrite: this section now offers much more detailed resting advice, perspective, and troubleshooting.
— Rewritten: This section is “like new” and much beefier, and links to an upgraded main contrasting article as well.
— Rewritten: Major changes: new science, new recommendations, more detail, and some explanation of the (very difficult) problem of why anti-inflammatory injections might work despite the fact that IT band syndrome doesn’t involve much inflammation.
— Rewritten: Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.”
— Rewritten: Completely revised to reflect new science and new understanding of the interaction of NSAIDs with “inflammation.”
— Major Update: Expanded and revised summary of treatment options, with emphasis on new and better recommendations about “anti-inflammatory” treatments.
— Updated: Advice on “running through” has changed, with more emphasis on the unknown but plausible risk of permanent damage.
— Major revision: Extensive editing and re-writing concerning the nature of inflammation. The main point of the section remains unchanged, but the section now does a much better job of explaining why ITBS isn’t really inflamed, and why it matters. Although not cited, this update drew heavily on some new scientific papers.
— Updated: Added new information and some pie charts about the success rate of arthroscopic surgery for ITBS.
— Minor update: Addressed some common fears about the threat of getting out of shape while resting.
— Trivial update: Added an example of unusually bad ITBS information, made widely available.
— Major update: Clearer and more thorough content throughout several sections about the “Nature of the Beast” and “Diagnosis,” especially from the discussion of root causes and onwards. I am producing the audio version of this tutorial, and I am revising and improving content significantly as I go. Information about trigger points was completely re-written, and there’s a whole new section about hip and thigh pain.
— Updated: Modernization and revision for clarity.
— New section: Stretching is such a hot topic that I decided to break the discussion up with a new section focussed on stretching the IT band itself. It was inspired by important new scientific evidence: researchers have found that IT band stretching is not a very moving experience…
— Major update: Significant modernization and clarifications. Much better description of why this kind of stretch might be worth trying.
— New science: Added more anatomical evidence that the IT band is particularly impossible to stretch or even move.
— New section: No notes. Just a new section.
— Minor update: Clarifications about the location of IT band syndrome pain.
— Updated: Added new research evidence that stretching doesn’t prevent injuries, including (of course) ITBS.
— New video: Section now includes a new video, summarizing myths and treatment mistakes.
— Minor update: Added reference to Kong et al, about the effect of shoe wear.
— Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman.
— Rewritten: Evidence about the real but surprisingly weak connection between impact forces and injury from Zadpoor et al has prompted a bunch of revision and new recommendations for runners.
— Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.
— New section: No notes. Just a new section.
— New section: Finally, long overdue, a new section on this topic.
— New section: New short section for both this book and the patellofemoral pain book covering potentially confusing alternative diagnoses, such as politeal artery entrapment syndrome (PAES).
— Overhauled: Rewrote section to accommodate some new science. The new evidence is interesting, but not particularly illuminating: it mostly just emphasizes how we really (still) don’t know if IT band tightness is actually a problem.
— New cover: At last! E-book finally has a “cover.”
“Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.” And many of those are IT band syndrome cases. That quote is from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame. BACK TO TEXT
If the road to Hell is paved with good intentions, nothing has helped more people drive there than the internet. For many years, if you Googled “iliotibial band syndrome,” the abominable www.itbs.info was the #1 result: a shabby, shallow, stale website by a well-intentioned amateur. Barely updated since 2000, it finally dropped off the first page of results sometime in 2013, and then finally disappeared…but it had been at the top for about fifteen years, even though there was hardly even anything there: a hilariously incomplete snapshot of wilted conventional wisdom posing as a useful resource for people who actually need help. (Apparently a hundred thousand of them between 1997 and 2002, while I was writing the first version of this book.) Sadly, even with the fading of itbs.info, there is not much improvement in the first few pages of Google’s search results: a lot of it is basic, poorly written, full of myths and old, dead ideas, and so on. It’s just a mess! And that opinion is backed up by experts: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
The muscles that actually control the tension on the iliotibial band, such as the tensor fasciae latae and gluteus maximus.BACK TO TEXT
Quadriceps strengthening is a major treatment option patellofemoral pain syndrome — a similar but different kind of overuse injury of the knee (more on this below). Although strengthening some muscles (hip and gluteals) has been proposed as a treatment for ITBS, quadriceps training is not even really on the table as an option. I assume that it gets prescribed anyway simply because these two knee pain conditions are often confused — a simple case of mistaken identity. BACK TO TEXT
As of 2015, only just over 200 search results in PubMed! Compare that to 5200 for adhesive capsulitis (frozen shoulder), or 9000 for carpal tunnel syndrome. Also, more so in the case of iliotibial band syndrome than other conditions, a great number of those papers are tutorials for professionals, not primary research. To an amazing degree, they all tend to repeat conventional wisdom and reference each other and clinical experience instead of actual science. BACK TO TEXT
This 2007 scientific review paper makes it extremely clear that there is a “paucity in quantity and quality of research” about iliotibial band syndrome. They also conclude that what information exists is not particularly helpful! “There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.” Yet it is absolutely routine for therapists and doctors, and even so-called experts, to make claims of therapeutic effectiveness! What are they basing that optimism on? The truth is, they simply don’t really know what they are talking about. They can’t — no one does!
In my own 3000 hours of training — three full years of nothing but studying aches and pains and how to treat them — it was barely even mentioned. Unless a massage therapist has gone out of his or her way to study the condition, he or she knows no more than anyone else who spends twenty minutes looking it up on the internet … and perhaps less! BACK TO TEXT
A while ago I noticed that a new book about iliotibial band syndrome had appeared on Amazon, The Official Patient's Sourcebook on Iliotibial Band Syndrome. I made a note to myself read it, and hopefully learn something — had someone finally written something that might compete with this tutorial? When I returned recently to buy it, I found the following review:
Complete ripoff. This is not a book about Iliotibial Band Syndrome, even tho the title would lead you to believe it is. The book contains a few sentences about IBS, and then chapter after chapter of boilerplate about things like how to find a doctor, or how to research nutrition, how to use a library. I am astonished that the publishers had the gall to publish such a ripoff.
I didn’t waste my money verifying this: the world is already awash in scammy, useless information about this problem and all the others. I have no doubt the “book” is just as empty and pointless as the reviewer says it is.
Amusing addendum to the previous note. Earlier in the intro, there’s a long footnote about a particularly terrible website, www.itbs.info, which tragically dominated Google search results for 15 years. After years of stagnation, the author “updated” www.itbs.info by recommending the not-actually-a-book Sourcebook. That was his update! *facepalm* BACK TO TEXT
In a study of 1300 US Marine Corp recruits in training, nearly 40% got hurt, and 78% of them got repetitive strain injuries, and those injuries tended to happen during the weeks with the most training. “The most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%), iliotibial band syndrome (5.3%), and stress fractures (4.0%) were the most common diagnoses.” The findings suggest that “[vigorous] training, particularly running, and abrupt increases in training volume may further contribute to injury risk.”
In Clinical Guide to Sports Injuries, on p340, iliotibial band syndrome is listed as a “less common” cause of knee pain, after the “most common” conditions of patellofemoral syndrome, patellar and quadriceps tendinopathy, meniscus injuries and knee instability … all of which contradicts my own experience. I have seen more iliotibial band syndrome in my practice than all of those other “more common” conditions combined. This may reflect the nature of my practice more than reality for the rest of the world, but I’m just sayin’. BACK TO TEXT
This is surprisingly hard to prove, because the vast majority of ankle sprains are minor and go unreported and untreated. However, clinical experience and many years of personal experience playing ultimate (a Frisbee team sport with an intensity like soccer) indicates that ankle sprains are probably more common than any other significant injury. BACK TO TEXT
Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and 'rolls over') the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30 degrees of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.
Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present, but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.
The science of anatomy was surprisingly slow to develop historically, and remains surprisingly incomplete. My Heart Will Go On, by Robert Krulwich & Adam Cole, explores the goofiness of historical beliefs about anatomy, especially the heart. For example, the influential Roman physician Galen made many declarations about human anatomy without ever doing a human dissection, and then no one else checked his work for another 1000 years, and so everyone thought that the liver was a pump just like the heart. Those crazy Romans! Don’t be too quick to laugh, though. Are you sure that you’re own mental anatomy text is accurate? Modern people still have many odd misconceptions about anatomy. People are often “great believers in” treatments based on ideas that are literally anatomically impossible … and wrong IT band anatomy is actually one of the best examples. BACK TO TEXT
Followed, predictably, by patellofemoral pain syndrome. BACK TO TEXT
Anyone who has felt that knows exactly what I mean, but the sensation eludes many people, because it’s difficult to apply enough tension to the IT band to achieve it. Many people will simply never feel it. More about this in the stretching section.BACK TO TEXT
More detail: most tendons could be snipped at either end and then tied in a bow. They are mostly disconnected from other tissues, except at the ends where they are attached to muscle and bone. In contrast, the iliotibial band is simply a massive thickened section of the sausage wrapping of connective tissue that surrounds the whole thigh. BACK TO TEXT
How is this possible? Fairclough et al explain that “our cadaveric dissections confirm that the ITB is simply a thickened, lateral part of the fascia lata. It completely surrounds the thigh, is anchored to the femoral shaft by the lateral intermuscular septum.” In general, muscle sheaths are no more free to move relative to the muscle they contain than a sausage wrapper is free to move relative to the sausage. In this case, the wrapping is even stronger, because it actually penetrates to the bone, attaching to the femur along most of the length of the femur (on the linea aspera). This was backed up by another dissection study in 2009, which also found that the IT band is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the thigh. This thing does not slide around.BACK TO TEXT
As the knee bends, tension on the IT band shifts from the front to the back. That is, it “pops out” a bit, first a little ahead of the knee, then further back — which can look an awful lot like movement. But it’s just parallel fibres tightening in sequence, like a wave, as the knee changes position. Other tendons actually do slide around and snap over other structures, but the IT band is not free to do this. BACK TO TEXT
Although this has been contradicted by other evidence — Jelsing 2013 — for now I’m working with the assumption that any movement is probably trivial and not a sliding at all, like the slight swaying of seaweed anchored to rocks in shallow water. That is, it’s not “rubbing” back and forth so much as flexing to and fro. BACK TO TEXT
I often hear athletes, trainers, and therapists talking about the anatomy of injuries with great ignorance and confidence — a nasty combination. They believe pain is coming from a part of them that literally doesn’t exist, or not in that neck of their woods. Many lesser-trained professionals make so many mistakes that it’s clear that they could not pass an anatomy exam … like the massage therapist I saw once who tried to base his treatment of me on a completely imaginary muscle — a weird hybrid of two or three others, like the quadriglutator or the sternobiceptoid. (I would have laughed, if he hadn’t been carelessly handling my fairly badly injured shoulder at the time, trying to find my … whatever he thought he was looking for.) It may sound absurd, but we live in a world where some people believe that ketchup is a vegetable — and anatomy is much harder than food identification. It’s one thing to be wrong, but the overconfidence of these anatomical fantasies really tickles my funny bone. BACK TO TEXT
There are 142 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.