The Complete Guide to IT Band Syndrome

Historically, ITBS surgeries have all focused on either removing the section of the IT band that is compressed against the side of the knee, or on loosening the IT band so that it doesn’t press on it as hard. That approach has worked to some degree, but the success rate is not as good as anyone would like, and recovery takes a while because the structural integrity of the IT band is compromised.

The evidence presented above suggests that the irritated tissue is probably not the IT band itself, but the tissue under it. Wouldn’t it be great if this idea were so well-developed that it inspired a new surgical approach to the problem? A surgical approach that worked better? A surgical approach that cured iliotibial band syndrome simply by removing that irritated tissue?

In fact, that’s exactly what happened in 2009.

From 2003 to 2007, inspired by the findings of Nemeth and Fairclough and others, a group of Belgian surgeons operated on 35 knees, trying to solve IT band syndrome in a new way, based on an upgraded understanding of the anatomy.38 Instead of the old surgical approach, they used “resection of the lateral synovial recess.” That is, they removed tissue from a fold or pocket surrounding the (previously unknown) fibres anchoring the IT band to the femur. They went into that space arthroscopically — inserting tiny instruments through a tube no bigger than a straw — which has some great surgical perks (see sidebar).

“If the inflammation39 is limited to the fibrous attachments to the femur and the surrounding fat,” they wrote, “there’s no need to resect a part of the ITB [cut it to loosen it].”

That’s it. No loosening of the IT band. And yet it seemed to work. Thirty-four knees had good or excellent results. All patients went back to sports after 3 months. The authors of the study concluded, “that arthroscopic treatment of resistant ITBS is a valid option with a consistently good outcome.” If the pain of ITBS were not coming from that fatty layer, the surgery would not have worked at all — perhaps not even one patient. “The good results of this treatment confirm the hypothesis that the inflammation is limited to the fibrous attachments to the femur and the surrounding fat. No resection of the ITB is needed.”

Replication is nice

One study alone can’t prove anything, so it’s comforting to know that another group of American surgeons tried a similar approach and also got excellent results — with some educational differences I’ll cover in the next section.

This all has to be tested more thoroughly, and it probably will be. But these are unusually promising results, and surgeons around the world are now trying it with their patients. The old methods were effectively experimental as well — this is just an experiment based on better information. Surgery is an amazingly pragmatic discipline, in which procedures are routinely (cautiously) chosen on the basis of no better than an educated guess. The old method was one guess, and it wasn’t a bad one — but it seems likely that this new method is a better guess.

The implications

The results are clinically important, but also just fascinating: a wonderful demonstration of the power of knowledge to suggest a new solution to a difficult puzzle. It’s amazing what you can do when you understand something just a little bit better. This is “reductionism” at work — the same “reductionism” that so many alternative health care professionals turn their noses up at. This is finding and treating more than just the symptoms. And it was achieved through difficult, expert scientific investigation! For years I have been reporting on the evidence about ITBS — and these doctors are actually acting on it, trying something new, and it’s working.

Meanwhile, there are literally millions of patients with ITBS, and probably 98% of them (and their doctors and therapists) still think the IT band itself is irritated and too tight. These recent surgical studies have shown that it’s not quite like that. And that is why professionals must read scientific journals (and tutorials like this one).

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It’s time to head into the here-be-dragons section of the map of IT band syndrome.

This tutorial has still not answered the question: what exactly is irritated? I haven’t answered it because I don’t know, because no one knows. The Belgian and American surgeons who have published about this removed different irritated tissues from under the IT band, but both got good results.

Because Michels et al got good results by removing fatty tissue from the lateral synovial recess, their work appears to constitute strong evidence that ITBS is probably not so much a “tendinitis” as it is a “fatty-tissue-itis.”40 The most precise description of this is an “enthesopathy” — a disorder of tissue attaching directly to bone.

Michels et al: “Because ITB overuse injuries may be more likely associated with fat compression beneath the tract, they [Fairclough et al] consider it as a form of enthesopathy.”

But the Americans took a different approach. They treated the problem like a bursitis.41 And why not? The evidence shows that there’s something under the IT band that’s the problem, and that’s the nature of bursae — they are underneath and between things. A bursa (plural bursae or bursas) is a peculiar bit of anatomy: a small sack of slimy (synovial) fluid, like raw egg white, which reduces friction between structures, like between skin and bone or between a bone and a tendon. The name comes from the Latin for purse.

“Iliotibial bursitis” has always been one of the many ways of naming iliotibial band syndrome (although out of fashion lately; it sounds as quaint as “lumbago”). Most professionals assume that there is a bursa between the IT band and the side of the knee, and most of those probably assume that the bursa is in trouble. So Hariri et al operated with the assumption that it was a bursa that was the problem. They looked for bursae, they found bursae, and they removed bursae… 

And they got good results. How puzzling! Because there aren’t actually supposed to be any bursae under the IT band.

Bursae do occasionally become painful, but it’s an overdiagnosed and usually minor condition that quickly resolves on its own. Family docs are notorious for chalking up many minor body pains they can’t explain to a bursitis, and this certainly occurs in the case of ITBS. It also works the other way around: there are two somewhat common bursitises in the area — prepatellar on the kneecap,42 and trochanteric on the side of the hip43 — that also get incorrectly diagnosed as ITBS, even though they aren’t in the right places at all.

Another bizarre scenario is that a kind of bursa may form, like a kind of internal callus, in response to stresses! These are pathological “bursa-ish” structures whose form follows the same function as bursa, and thus they are called bursa, while actually being quite different.

But the lack of a bursa under the IT band at the knee was reported by three groups of researchers we’ve already mentioned — the very same researchers who inspired new surgical approaches to the problem — plus another.

1. In 1996, Nemeth showed that “the tissue under the ITB consists of a synovium that is a lateral extension and invagination of the actual knee joint capsule and is not a separate bursa as described in the literature.” They’re saying it’s bursa-like, but specifically saying it is not actually a bursa.
2. In 2007, Fairclough et al reported that “a bursa is rarely present, but may be mistaken for the lateral recess of the knee.” They called the structure a “lateral synovial recess.”
3. Then in 2009, Michels et al actually targeted tissues in the lateral synovial recess with literally surgical precision. They didn’t find bursae either.
4. And Falvey et al “failed to demonstrate a bursae between the LFC and the ITB on a single cadaver.”

Yet Hariri et al operated on what they called “bursae,” provided nice pictures of the bursae that they removed from people’s knees, and those people were subsequently happier people.

What on Earth is going on here? Clearly not all of this can be quite right.

Maybe it’s splitting hairs. That lateral synovial recess may function much like a bursa, perhaps so much so that it’s a trivial distinction: bursa, fold, recess, pocket, callus-like-growth-of-bursa-esque tissue … whatever. If the problem is that the contents of this recess get irritated, that would be so functionally similar to a bursitis that it seems silly to quibble over the name.

But I’m not convinced by that: a bursa is not a lateral synovial recess, and enthesopathy is not the same thing as bursitis. I think precision is called for. Inconsistencies like this are exactly what should inspire scientific curiosity.

Maybe the only explanation for all of this is “all of the above.” Maybe some people have real epicondylar bursae and some do not. Maybe some have pathological bursae and some do not. And maybe some people have some irritation in their lateral synovial recess, and some do not. And probably some people have a combination of these things. And perhaps that is why the surgeries — despite generally good results — were not perfectly curative.

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“Tight” IT bands have a really bad reputation. Regardless of exactly what tissue is irritated, the most likely immediate cause of ITBS is the intensity of the contact that tissue is making with other tissues — in other words, the “tightness” of the iliotibial band. Perhaps the strongest evidence for this is the well-established fact that surgery can reliably reduce the pain by physically loosening the iliotibial band over the lateral epicondyle.

If a looser iliotibial band often solves the problem, then perhaps it’s a too-tight iliotibial band that causes it?

Not so fast. Just because loosening helps doesn’t actually mean that tightness, per se, is to blame. If you are wearing a ring and you injure your finger and your finger swells up, does that mean your ring is “too tight”? Is the ring the thing? No — but it would feel great if the ring got bigger! If you have a rock in your shoe that is uncomfortable, does that mean your shoes are “too tight”? Is the shoe the problem? No — but it would still be a huge relief to take your shoe off and get rid of that rock!

Once irritated, the pad of fat under the iliotibial band may simply be hard to calm down, regardless of whether the tightness of the iliotibial band is “normal” or “too tight” or even “kind of loose.”

What does the science say about IT band tightness? If it’s such a villain, you’d think it would have been studied. But researchers have not “gone there” much. You see authors casually claiming that it’s been studied, but the references are always to general texts, which in turn will make the claim based on indirect evidence and good old “common sense.” It’s just not good enough for me if some textbook author says ITB tightness is connected to ITB syndrome, without actually citing real research. Also, many clinicians claim to detect changes in IT band texture that correlate to symptoms, but I question that too.44

Maybe the answer is Ober here…

There’s a classic clinical test for IT band tightness, the Ober test, that is specifically intended to reveal ITB tightness. That’s what I was taught in school; that’s what it said in my orthopedics text, and every widely used source I’ve seen ever since. Basically the Obert test involves lying on the side, extending the hip, and then dropping the leg… as far is the IT band will allow it to drop.

If the leg can’t drop much, supposedly that means the movement is limited by … the IT band, right? Wrong — yet another failed assumption of musculoskeletal medicine. A straightforward 2016 test of the Ober test in American Journal of Sports Medicine found that the ITB band doesn’t restrict that particular hip movement at all — instead, it’s the hip joint and its muscles.45

And that’s that. So, after a run lasting decades, it’s all over for the Ober test: it doesn’t actually detect the ITB tightness that may or may not having anything to do with IT band syndrome anyway. We obviously oberestimated the value of the Ober test. I am ober the moon to have this cleared up. We wouldn’t want to oberanalyze it now. Are all these puns oberkill? No doubt, but you’ll get ober it.

The closest thing we have to evidence of a tightness-ITBS link we have comes from that one small study by Devan et al, discussed above … which failed to find it. But how did they do the study? “Iliotibial band flexibility was assessed via the Ober test”! *groan*

This changes everything

Does anything detect IT band tightness? Certainly nothing widely known! The Ober test still rules this roost, and I would wager that only a tiny fraction of professionals have even heard the results of Willett et al.… or accepted the implications.

Is there even any significant variation in tightness to detect, regardless of its clinical significance? And how would we know one way or the other if there’s no way to test it?

Willet et al. has even more dire implications: if a supposedly ideal stretch of the IT band, biomechanically optimized, is actually limited by the collective restrictions of the hip joint itself and all its other muscles and not the IT band, then that same stretch used for treatment is in trouble. If you can’t test the tightness of the IT band that way, then you can’t stretch it either. This means that even the best IT band stretches aren’t affecting the IT band specifically — they are just challenges to hip flexibility. This will be an important point in a much more detailed discussion of stretching later on.

Clinicians and runners are so used to thinking in terms of IT band tightness that its potential absence as a factor isn’t even part of the discussion. Despite the implications of Willett et al., I still err on the side of assuming that IT band tightness is something we can at least feel and might want to try to do something about. But everything that depends on the idea of tightness — and that’s almost all the conventional wisdom on this topic — is clearly on thin ice.

The PFPS connection

The reputation of IT band tightness is so huge that it also gets blamed for patellofemoral pain syndrome (PFPS, anterior pain), and there’s one small study of that possible connection — but while it did supposedly find that connection, it’s a weak piece of data.46

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There’s no solid ground here, and we truly just do not know if people with iliotibial band syndrome actually have excessively tight iliotibial bands … or just normal iliotibial bands in a bad situation.47 You can see how this lack of certainty causes a serious problem for people who are preoccupied with the “tightness” of their iliotibial band. What if it’s not really too tight in general, just too tight for the situation?

The tightness could be what we could call a “functional tightness” — not so cinched up too tightly in general, but tightening at the wrong time. There are many injuries in the body that involve dysfunctional joint control systems, where poor coordination — zigging when you should zag — either leads to a traumatic dislocation or a chronic irritation. It may be that the iliotibial band is at a perfectly normal length on average, but is tightening up excessively at just the wrong moments.

Or maybe it’s none of the above. Maybe the iliotibial band is tighter in some positions, and we just get into trouble when we spend too much time in those positions. With or without a too-tight ITB, this probably has some truth to it, and that’s what the next chapter is about.

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Most people who have iliotibial band syndrome describe a rapid onset of symptoms. It doesn’t hit all at once, like a trauma. But it is still quite quick. You notice a little pain, and then sometimes within just a few minutes your knee feels like it has burst into flames.

Rule of thumb: the people who get iliotibial band syndrome are the people who use their knees the most, the runners and cyclists. And it may be that we need look no further for the immediate cause of the pain: repetition. Enough knee movement is probably capable of pissing off nearly any knee, regardless of any other risk factor. That is probably the main explanation for how the pain gets started, but the story takes a funny turn after the pain starts.

Most runners respond to the pain in exactly the same way: they slow down. And that may be a problem. In fact, slowing down may explain why the pain speeds up.

Experts have speculated that a slower stride rate may result in spending more time with the knee at a problematic angle: around 30˚ of flexion, which just happens to be the slice of the arc of knee movement at which the iliotibial band is clamped down most tightly on the lateral epicondyle. The most widely cited example of such speculation is a paper from 1996 in American Journal of Sports Medicine by Orchard et al, who proposed that “sprinting and faster running on level ground are less likely to cause or aggravate iliotibial band friction syndrome because, at footstrike, the knee is flexed beyond the angles at which friction occurs.”48

Slowing down because of the pain could actually cause the pain to get worse much more quickly, resulting in an impressively ironic vicious cycle. If this is the case, it’s not a “tight” iliotibial band that’s the problem, per se, but just that the victim is unwittingly flexing and extending the knee primarily in the range where the ITB is naturally — not pathologically — most firmly pressed against the side of the knee.

Unfortunately, we don’t have much in the way of hard science on this topic — no study of running pace as a risk factor for ITBS has yet been done. So instead of science, I’ll supply a good anecdote. It’s not intended to prove anything, but it is intriguing …

George Ingham of Herndon, Virginia, certainly noticed the effect of running speed on his knee. George is a distance runner who picked up his first case of iliotibial band syndrome running a marathon in March, 2007. The onset was classic: “I took a week off after the marathon to allow my body to recover, and began running again. About two weeks later, I noticed some IT-band-type pain in my left knee. I immediately took two weeks off to rest, stationary biking to maintain aerobic fitness.” That was a good initial response, but it wasn’t enough. When he tried to run again, things went pretty badly …

“For the first week, I felt little-to-no-pain, but after a long, slow run with my girlfriend, my knee felt like it was exploding, and I had to have her run home to get a car to pick me up.”

A long, slow run? That may well have been exactly the wrong thing! George then went through the usual troubleshooting contortions, before ending up at this tutorial several weeks later. Contrast bathing, icing and eliminating his stationary bike training were all important factors, he thinks, but changing his recovery running speed was the most critical:

Beginning a walk/jog program so that I could run fast on my run intervals — so I would not irritate the ITB as much as running slow — loosened up my leg a lot. Had I not read your article, I probably would have gone out and jogged slowly to recover, and that would have just irritated things even more. Instead, running 30 minutes total at a faster pace on the running intervals, but breaking it up with some walking, helped a lot. In fact, if I had to pick one thing that helped most, it would probably be running fast instead of slow.

In fact, rehabilitating with faster, shorter runs helped George Ingham’s knee so much that he ran and won a 5K race just five months after his trouble started, and soon after took 2nd place in a 7K — an excellent recovery from a case of ITBS like he had!

How about a more extreme example? Extreme examples are educational

We know from the experience of ultra runners that it is possible to run in a way that is less hard on your body in general. Exhibit A: Philippe Fuchs, who ran from Paris to Beijing, covering ~5,100 miles in 161 days.49 (I know, wow!)

Fuchs’ primary concern was his “ability to keep absorbing muscular and skeletal punishment day after week after month” of course. By the time he finished, he had developed an endurance stride that was quicker and less air time. That is, he padded along with about 6% more steps per mile (a higher stride rate), a whopping 30% less time in the air, and 11% less landing force. I’m betting he wouldn’t have made it without those adjustments. Fascinating.

His case is hardly direct evidence that a higher stride rate will be better for IT band syndrome specifically, but it is consistent with that theory. More generally, it also just suggests that tinkering with your running style is probably worthwhile.

A final word about hiking. Hikers also get the vicious cycle, rapid onset of symptoms, and at the worst possible time: the problem tends to strike while descending a mountain. The knee has already been used quite a lot to get up the mountain, of course. And then, on descent, there’s less knee flexion … and no escape from the extensive repetition of knee movement right in the danger zone between 25˚ and 35˚ of flexion. Yikes! No wonder it can come on so hard and fast.

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We can’t even be sure of the proximate cause — the most immediate cause, the one-degree-of-separation cause — of iliotibial band syndrome. There is literally no direct evidence of even the proximate cause of this condition. So hoping for clear “root” or ultimate causes is pretty much a pipe dream.

That doesn’t stop therapists and doctors from trying and guessing, though! Many health care professionals believe that iliotibial band syndrome must be the tip of an iceberg of gait or postural dysfunction, and quite a few specific proposals have been made.

Another for instance: one of my primary and best sources for this tutorial, Dr. John Fairclough, buys in to the hip-strength theory … which I mentioned dismissively in the introduction. Specifically, he writes that “ITB syndrome is related to impaired function of the hip musculature and … its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.” Sadly, he does not say exactly what “biomechanics” or how they can be “properly addressed.” (Actually, he does make suggestions: he just doesn’t defend them to my satisfaction.)

You’ll find similar opinions in virtually any article by physiotherapists or chiropractors. They tend to give the impression that treating “just” the symptoms is terribly inadequate, while making much of the idea that iliotibial band syndrome will just keep coming back if you don’t pull it out by the roots and address the “real” cause … whatever they think it might be. But, like religions, they can’t all be right, and there are many possible ways of explaining just exactly how this syndrome happens, and the evidence to support all of them quite indirect, inadequate, or simply nonexistent, as in case of the bogeyman factor of pronation.50 I don’t doubt that being crooked in some way could be a main factor in some cases of iliotibial band syndrome, because it is generally clear that the human organism tends to break down outside a Goldilocks “just right” zone, especially wherever physical stresses are relentless. There is relatively good evidence that the root causes of plantar fasciitis are related to gait dysfunction and biomechanical disorders of the lower limb, for example. If it happens there, it’s plausible that it happens in the knee as well.

We also have some scraps of evidence that screening tests like the Functional Movement Screen can tell which athletes are danger of a lower limb injury.51 If you cannot do certain physical tasks well, says the logic of the test, then you’re at greater risk for injury. It’s weak evidence, and there are some serious reasons to doubt the validity of the FMS,52 but it’s something and I can’t in good conscience ignore it (even though I think it’s likely wrong).

Maybe the lack of evidence on root causes is (still) due to a lack of research, and not because there aren’t root causes.

And yet sometimes in health care, what is “true” matters less than what is practical, and I question the practical value of treating iliotibial band syndrome as a symptom of mostly hypothetical “biomechanical” problems. There are two serious challenges with trying to fix perceived gait or postural dysfunctions or muscle imbalances, the reason that I have never emphasized these factors as a therapist or a writer:

1. Trying to diagnose such root causes is just plain difficult, more art than science. Five experts are likely to give you five different opinions about your gait and posture. One will tell you that your pelvis is out of alignment, another that you have “Trendelenberg sign,” a third that you’re an ankle pronator. The fourth will see a clear tibial torsion, and the fifth might say “all of the above.”
2. Even if you have a reasonably clear gait or postural dysfunction, fixing it is probably going to be a difficult, finicky, time-consuming and uncertain business … and many causes of gait dysfunction, such as normal variations or minor deformities in your skeleton, cannot be treated at all, or only compensated for awkwardly.

I’m not saying that gait dysfunctions don’t exist in runners with iliotibial band syndrome, just that it’s hard (impossible?) to pin them down — and even when you can, it’s probably also difficult or impossible to do anything about it. These are a summary of standard problems with structuralism: an excessive preoccupation with underlying biomechanical factors in therapy.53

Also, something both patients and professionals should appreciate: meaningful and skilled gait assessment just cannot be done without slow motion video. Few therapists (arguably none) are such prodigies that they can actually get anything useful out of just watching you run.54 And diagnosis of a gait dysfunction often leads to a wild goose chase: months of therapy, advice, and lots of fiddly little therapeutic exercises that you’re never sure are actually doing anything.

I never got into gait analysis with my clients, and I don’t recommend it to my readers now. Nevertheless, despite the uncertainties, it’s probably worth giving some attention to refining your gait — or even just shaking things up a bit, almost randomly — when you’re trying to troubleshoot a tough case. This tutorial isn’t for “most patients” — it’s for those of you with the most stubborn cases of iliotibial band syndrome, who really want to get back to running (or cycling, or whatever tosses your confetti), and you may be willing to pursue even a thin theory — which is really all there is when it comes to the causes of ITBS.

Still to come in the tutorial are detailed explorations of popular ideas like the relevance of hip strength and barefoot or minimalist running. You can try to strengthen your hips, or run with naked feet, without having a specific theory about what’s wrong with your gait in the first place, and it might just make a difference, directly or indirectly. Strengthening your hips, for instance, could improve the problem not because your weak hips were the “root” cause to begin with, but because the process of strength training leads to running differently than usual, and “change is like a holiday” — for your knees, in this case. Or maybe it’s because hip weakness really was the cause in the first place, despite the problems with that theory. A main point of this tutorial will be to review the sense and science of such ideas, so that you can decide for yourself what’s worth a shot and what’s not.

Just bear in mind along the way that the root cause of iliotibial band syndrome is not running “wrong,” but simply running too much.

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In 2012 and 2013, it seems to have become strangely fashionable to deny the health benefits of running, and to assert that it actually makes you fatter and erodes muscle and bone! For example, these claims are actually made in John Kiefer’s popular article, Why Women Should Not Run.

All this may come as a surprise to you, since you’ve probably noticed that most runners seem pretty fit compared to the average Walmart shopper. Running can be hard on bodies — you wouldn’t be reading this if it wasn’t — and it’s certainly not necessary to do high-volume cardio to be a healthy person. (And it almost certainly is possible to be fit with less exercise than most people think. See: Strength Training Frequency.)

But it takes mental gymnastics and abuse of the evidence to believe that “cardio above a walk or below a sprint is bad for you (especially if you are a woman).”55 It’s preposterous, and strongly contradicted by the evidence, which — just one key example here — actually shows that runners get less osteoarthritis,56 probably because using joints is a healthy thing to do with them

So much for a simplistic notion of running being hard on the body.

Although this is a new twist, an anti-running or fatalistic reaction to running injuries is hardly new. Many runners with stubborn knee pain have been told (almost invariably by non-runners, I think): “maybe you’re just not built for running.” When your doctor or physical therapist says that, the translation is usually just, “I don’t know what’s wrong with you and/or what to do about it.” This is unquestionably more humble and honest than the professional who overconfidently diagnoses the wrong cause and pretends to be able to fix it (with expensive therapy, probably). However, chalking your knee up to a lemon is also excessively defeatist — even though it could turn out to be correct in a few cases. Despite the admirable humility, the puzzled professional probably still believes that there is a biomechanical root cause, something that inexorably predisposes you to iliotibial band syndrome (or shin splints, or patellofemoral pain, or plantar fasciitis) … and the solution is to tell you to quit running. Or long walks. Permanently. To give up your favourite addiction, or a key component of your lifestyle.

Fortunately, there’s another way to look at the problem.

In the last section, we established in general that the importance of anatomical abnormality is probably greatly overestimated as a factor in knee pain. If not that, then what? The alternative view — and this is the beating heart of this tutorial — is that running is a knee-stressing activity by nature, regardless of whether you are anatomically average or biomechanically quirky, with or without structural curve balls. The fat pad pinched under the IT band — or whatever it is that gets irritated, exactly — is really difficult to calm down once it’s irritated. I am not denying that there are exceptions to this, that some cases might be more mechanical in nature, just asserting that they are probably exceptions to the non-biomechanical rule.

Many people can fairly easily learn to compensate for the natural tendency of the knee to get irritated by a lot of running, but only by diligently focusing on doing everything possible to give that irritated tissue a break. It’s not easy to do, so you really can’t afford any distractions from the goal, especially misguided therapies that actually increase irritation.57 ITBS can often be compensated for if you understand that sometimes your knee will cross that threshold and get pissy again, if you understand that each time that happens you’ll need to apply a specific resting strategy to get it back to the way you want it. This is tricky, but it is do-able!

Let me put it this way: summing your situation up by saying you’re not built for running is like telling an insomniac that they are “just not built for sleeping.” Insomnia is a treatable condition in virtually every case where it isn’t being caused by a disease, and every medical sleep specialist knows this.58 Most insomniacs actually are built to sleep, and no doctor would ever suggest otherwise.

And almost every human is “built” for running. In fact, we’re one of the running-est species on Earth — not the fastest by a long shot, of course, but one of the best long-distance running species, maybe the very best. In fact, it is the most distinctive feature of human athleticism, our claim to fame. For instance, as Dr. Daniel Lieberman explains, “Humans can actually compete with and often beat horses at endurance races.” Especially when it’s hot. Which is cool. Here’s the context of that quote, on not giving homo sapiens enough athletic credit, from the (fascinating) article Brains Plus Brawn (worth a reading detour, and Dr. Leiberman will come up again later in the book when it’s time to talk about natural running):

We’re actually remarkable endurance athletes, and that endurance athleticism is deeply woven into our bodies, literally from our heads to our toes. … We’ve lost sight at just how good we are at endurance athleticism, and that’s led to a perverse idea that humans really aren’t very good athletes. A good example is that every year they have races where they actually compare humans and horses. In Wales, this started a few years ago, I guess it started out as a typical sort of drunken pub bet, where some guy bet that a human couldn’t beat a horse in a marathon. They’ve been running a marathon in Wales for the last, I think 15-20 years. To be fair, most years, the horses beat the humans, but the humans often come very close. Whenever it’s hot, the humans actually beat the horses.

The point is not that humans are poor athletes, because the horses occasionally beat us, but humans can actually compete with and often beat horses at endurance races. Most people are surprised at that. … One of the interesting things about these races also is that they’re so worried about the horses getting injured, that the horses have mandatory veterinary check-ups every 20 kilometres, but not the humans, because humans can easily run 40 kilometres without injury. But if you make a horse gallop for more than 20 kilometres, you seriously risk doing long-term permanent musculoskeletal damage to the horse.

We obviously aren’t “built” to run on concrete exclusively, and we’re certainly not “built” to continue running on an irritated knee — nature has limits — but a wide range of body types, even gimpy ones, can accommodate running with good management. Remember again the evidence cited above (Williams) that runners actually get less arthritis. Because we are built to run in general, and we are built to heal.

Some people are going to find that even good knee-stress management still does not result in relief. Their capacity for running remains sharply limited. “I’m always fine until the half hour mark,” is a common scenario. “But no matter what I do, I always start hurting after that.” Is it fair to say that this patient isn’t built for running?

Even in such a case, I want to discourage that depressing interpretation, because there are still other alternatives to the structuralist view of knee pain. For instance, it may not be a matter of cursed anatomy, but of failing physiology — software instead of hardware! In cases where I am stumped by persistent knee pain, I am certainly also forced to chalk it up to unknown and probably unknowable factors. But in my case, I believe the evidence strongly suggests that it is a different sort of mysterious factor that should be considered: that there is more likely to be something about your tissue behaviour that won’t allow recovery, rather than something about your tissue structure.

If we’re stumped either way, does it matter which way we’re stumped? Of course! A better theory about why your knee pain persists could, over the years, lead to valuable refinements in how you try to manage it. Focus on a dubious theory, and you’ll be a lot less likely to make any progress. Focus on a better theory, and someday you just might succeed where you failed before. I have had many aches and pains in my life that were frustrating for a long time, until eventually they yielded as my understanding improved. So it matters very much whether you believe it is more likely to be mysterious anatomy or mysterious physiology that keeps you from healing.

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One of the major myths about iliotibial band syndrome is the inflammation myth. It is not really inflamed, and several common treatments based on the myth may fail because of this. If there’s no fire, stop hosing it down!

In fact, no repetitive strain injury (RSI) is truly “inflamed” for long, if ever — not in the classic sense of the word. Inflammation at the site of an infection or injury involves very different biochemistry than what’s happening in chronically overloaded tissue, which is much more degenerative in character. True, classic inflammation is always painful and is almost always helped by anti-inflammatory medications, at least a little. But the pain of any RSI is much less consistent, and mostly unaffected by anti-inflammatory drugs like ibuprofen. Andres and Murrell in 2008:59

Recent basic science research suggests little or no inflammation is present in these conditions.

Despite this, repetitive strain injuries are still widely assumed to be inflammatory in nature. They certainly feel like they are on fire, and the assumption is often built right into the name — the Latin suffix “-itis” means inflammation, and it’s attached to the names of several of these conditions, such as plantar fasciitis, Achilles tendinitis, and supraspinatus tendinitis.

But not IT band syndrome! Why not IT banditis? Perhaps because it sounds too silly. This exception to the naming rule is not significant: there is no doubt that ITBS is mostly an overuse injury and universally thought of as “inflamed.” To find the hidden “itis” in ITBS, look no further than the assumption of tendinitis, which is now covered by layers of wrong (not the tendon, not inflamed). And if not an inflamed tendinitis? We learned above that the true identity of ITBS could well be more of a bursitis — which also isn’t inflamed. Bursitis has an even more inflamed reputation than tendinitis, and yet, even in bursae gone bad, inflammation is either nowhere to be seen or extremely minimal. According to Khan, when researchers

examined bursal tissue in patients with so-called subacromial ‘bursitis' they found an ‘absence of plasma cells and a paucity or even absence of neutrophils and lymphocytes’. These features are incompatible with true inflammatory bursitis … .

What’s really going on has little in common with classic inflammation as we know it from infections and acute lesions, where the immune system is out in full force to repel microbes, and the presence of white blood cells is the major microscopic signature. In RSIs, the white blood cells are barely there, and the scene is dominated instead by signs of tissue failure and degeneration. It’s like premature arthritis in any overloaded tissue that can’t repair itself fast enough to keep pace with the stresses placed upon it. Tissue rot! Khan et al. again (different paper):60

Numerous investigators worldwide have shown that the pathology underlying these conditions is tendonosis or collagen degeneration.

Bottom line: if there’s no fire, stop hosing it down!

The other side of the story: don’t count inflammation out quite yet

Of course it’s more complicated. There is always another layer. The idea that RSIs aren’t inflamed is based mainly on the absence of classic, acute inflammation: the clinical and pathological signs of a vigorous immune response. But there’s almost certainly more to inflammation than redness and white blood cells swarming the tissue like police trying to control a riot.61

So maybe it’s not an absence of inflammation, but a definition of inflammation that’s too narrow. Maybe it should include a bunch of other healing and adaptation biochemistry. An infected cut hosts a soup of cells and chemicals, and biologists know quite a lot about the recipe for that soup… but they know almost nothing about what’s going on with RSIs.

But that is starting to change. Just because you can’t see it doesn’t mean it’s not there, or wasn’t there earlier. Maybe you just have to look better. And Dakin et al. looked better in 2017. They looked for more subtle signs of inflammation in Achilles tendinitis … and found them, seemingly without much ambiguity. Their paper in British Journal of Sports Medicine reported that painful and ruptured Achilles tendons “show evidence of chronic (non-resolving) inflammation.”62

Looking at Dakin et al.’s results, it’s tempting to just concede that inflammation has made a comeback — it was never absent after all, it was just more subtle than the experts thought. Those goofy experts! Always changing their story!

But — and this is important — the busting of the myth of inflamed RSIs remains valid in spirit, because plantar fasciitis is clearly not inflamed as most people understand it, or in ways that can be treated with typical anti-inflammatories, which are effective only for the acute inflammation that really does not exist in RSI.

So here’s the adjusted bottom line: If there’s no (acute) fire, stop hosing it down (with treaments for acute inflammation)! But maybe there are things that can be done for a bed of smoldering coals, and that idea will come up again and again for the rest of the tutorial.

If tissue is “rotting,” is there a point of no return?

More importantly, it’s important to understand that overuse could be doing more than just causing the side of your knee to burn with pain — chances are good that actual damage is being done, that tissue is actually failing, albeit slowly. It’s one thing to be inflamed — and quite another for tissues to be crumbling like old rubber. In the case of the Achilles tendon, for instance, rupture is common in the late stages of degeneration.

Fortunately, in the case of iliotibial band syndrome, the degeneration is probably not as bad as it sounds. After all, we are pretty confident that it’s not the structurally critical IT band itself that is rotting, and it is literally unheard of for IT bands to rupture — it just does not happen. If anything is degenerating, it’s the tissue underneath it. It’s unclear how functionally important that tissue is over the long term — it may be no more important than a callous on your foot, or it could be as important as the cartilage in your knee. For instance, it’s possible that the reason some cases of IT band pain are so chronic and incurable is that the tissue under the IT band decays beyond the point of recovery. Like a case of advanced arthritis, such a knee could be more or less permanently messed up. This is pure speculation, but it’s not unreasonable.

Cautious patients should probably err on the side of assuming the worst. I hope that you will find this insight inspiring and clarifying: it should encourage a significant attitude shift in favour of rest as a necessary component of treatment. It is easier to justify and accept taking it easy when you understand that stubborn overuse may be slowly destroying a bit of your anatomy.

But don’t panic either — based on the evidence we’ve already discussed, it’s more likely that the only tissue that’s in trouble is not the “structural” substance of the IT band itself, just some tissue underneath it. You don’t exactly want that to be degenerating either, but it’s certainly less alarming a mental picture than “rot” of the IT band proper.

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Trigger points are so-called “muscle knots”: small patches of dysfunctional, clenched muscle tissue that cause pain and weakness. Everybody has at least a few, like pimples, yet they tend to be ignored by most health care professionals, primarily for lack of education in the subject. They can mimic, complicate, or even directly cause virtually any other musculoskeletal problem — including IT band syndrome.

Assuming they actually exist, that is. They are a little bit controversial. Not hugely. But a little.63

There are three possible ways that trigger points might be relevant to ITBS (or anything else, for that matter):

1. Mimicking ITBS. In rare cases, trigger points in the quadriceps muscles may cause pain to spread into the side of the knee, which is called “referred pain” — in other words, it hurts in the same place as ITBS, but it’s not actually ITBS. This is not a common situation, but it is not unheard of, and I’ve encountered a handful of cases over the years of people who seemed to have a hot spot of pain on the side of the knee that didn’t otherwise fit the description of ITBS very well, and was effectively treated by massage of the thigh muscles — which shouldn’t work on a true case of ITBS. Particularly if combined with another minor knee problem or two, or perhaps just a bit of IT band syndrome, this kind of pain can mimic full-blown stubborn ITBS.
2. Causing ITBS. Another possibility is that trigger points could be a root cause of ITBS: the chicken that came before the egg. This is really no more likely than any other totally hypothetical root cause, but it’s not impossible, and it makes for interesting contrast. For instance, trigger points could be the reason why hips are weak, which in turn is one of the other proposed root causes of IT band syndrome — not one I take very seriously, but a proposed root cause nevertheless. And yet the roots may go deeper, to trigger points. Trigger points tend to be extremely common throughout the core: the low back, buttocks and hips are all prime trigger point real estate.
3. Complicating ITBS. Finally, and probably the most common and plausible scenario, muscle pain may arise in reaction to a case of ITBS, which naturally tends to make it seem worse, more stubborn, and more complicated. Treating for these trigger points may relieve some symptoms and “simplify” the clinical situation. Alert readers will notice that this problem could in principle feed back into the others: once formed, reactionary trigger points could cause ITBS-like pain and cause problems like hip weakness that actually directly cause more IT band trouble.

Despite this trinity of trouble, the role of trigger points in ITBS is probably quite limited — it remains predominantly a repetitive strain injury, more affected by overall volume of knee stress than any other factor.

Trigger points also get a mention here for a sneaky fourth reason:

4. Red herring! Trigger points also routinely cause hip and thigh pain that has nothing whatsoever to do with ITBS … but still gets diagnosed that way.

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Hip and thigh pain is extremely common, and nothing is mistakenly called ITBS more often than 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, and doesn’t have much to do with the IT band specifically.

Why would anyone call hip pain ITBS? Three reasons:

1. The IT band is long and crosses the hip joint as well as the knee.
2. Hip pain can spread well down the thigh, as far as the knee, sometimes even beyond.
3. Hip pain and runner’s knee often co-exist.

There is a link, but it’s not a strong one, and hip pain is not ITBS. Even if hip pain is partially related to the iliotibial band, it’s still not “IT band syndrome.” So what is it?

Greater trochanteric pain syndrome

GTPS is the most useful and accepted 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.

Even as far down as the knee. Hence the confusion. (At its sharpest and most widespread, GTPS is easily mistaken for sciatica.)

The greater trochanter just happens to be — just barely — underneath the top end of the IT band. This is partly why some pros mistakenly assume hip pain is an IT band issue.65

The most common cause of hip pain, especially in younger patients, is probably just the aching and stiffness associated with trigger points (which is why this topic follows the introduction to trigger points). Hips and thighs are extremely common places for trigger point pain — probably about third in line, after the neck and shoulders, and the low back.66

Many of my readers turn out to need more help with their hip and thigh musculature than they do with their knees. In fact, this is a likely explanation for some seemingly “miraculous” cures of ITBS, and especially the popularity of self-massage with foam rollers: a little massage often relieves hip and thigh pain, creating the illusion of a quick cure from a case of iliotibial band syndrome … that you never actually had in the first place.

Hip pain as a complication and partial cause of ITBS

Many ITBS patients do seem to experience some hip discomfort in addition to their (stronger) lateral knee pain. Anecdotally, that correlation is strong: easily half of ITBS patients seem to have hip and thigh pain as well. Salt in the wound. Adding insult to injury.

GTPS is not the same thing as ITBS, but it might contribute to it and muddy the diagnostic waters. For instance, grouchy hip muscles that control the tension on the IT band might make a minor contribution to ITBS — a speculative biomechanical factor I don’t put much weight on, but I’ll give it a nod at least. It’s possible.

The pure sensory contribution of hip pain is probably more important. Pain spreading from the hip down to the knee may make an existing, legitimate case of ITBS feel much louder. A patient with both kinds of pain would probably have hip and knee pain, without either one obviously dominating. If you didn’t actually have ITBS, the hip pain would dominate. But if you do have ITBS, and some hip pain, then the hip pain might be making the knee pain worse. (The reverse is less likely to be the case.67)

A vicious cycle between ITBS and GTPS might also be possible. Hip pain might well develop as a complication of the knee pain… and then feed back into the knee pain. (And again, the reverse is less likely to be the case.68) If you didn’t have hip and thigh pain when you first got a case of true IT band syndrome, then there is a chance that you do now.

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Treating hip and thigh pain may or may not have any effect on a full-blown case of ITBS, but is worthwhile in itself at least. And so some of the basics of treating GTPS are integrated into the treatment options below, especially massage, and especially trigger point therapy for “perfect spots” #6 and #8. Massage is probably the best available means of treating muscle pain, and it will be covered thoroughly in the treatment sections below.

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The huge majority of iliotibial band syndrome appears to be closely associated with overuse and repetitive strain. However, there are clearly exceptions.

The most common example seems to be ITBS that arises as a complication of trauma to the knee, either due to accident or surgery. Quite a few people have written to me over the years to inquire about such cases, but I have little knowledge of them — and neither does anyone else. Even typical ITBS is generally under-studied, as you’ve seen. Atypical cases like this are not on anyone’s radar, and there is simply no hard information about them that I know of. All I can do is offer a few educated guesses about why they happen and how it might affect treatment.

Trauma may simply cause new biomechanical problems and stresses, which make you more vulnerable to ITBS. In these cases, it simply takes less repetitive strain to develop a problem, but it is really no different from any other case of ITBS. There’s not really any more hope of knowing or correcting the biomechanics than there is with a normal case.

Or there might be a more exotic explanation.

Most of the time it’s hard not to heal. The body will recover from most kinds of injuries, almost no matter what — it’s just a matter of time, and you couldn’t stop it if you tried, not that you’d want to.

So why do repetitive strain injuries often seem immune to recovery? This is what makes them both terrible and fascinating. Usually the explanation for their stubbornness is just that they are never given enough of a chance to rest, or because it’s hard to rest them. (Anal fissures are the most unpleasant, vivid example of a lesion that is extremely difficult to protect. Sorry to inflict that mental image on you, but they really are a perfect example.) Dealing with that kind of scenario is what most of this book is about.

But sometimes healing fails. Pain can persist even after the tissues have recovered — a neurological malfunction. And/or sometimes tissue recovery fails altogether, even when conditions are ideal. For instance, a low but predictable percentage of bone fractures simply do not heal, and no one knows why. It’s a disturbing problem. Surgeon Robert Becker describes it:

As an orthopedic surgeon, I often pondered one particular breakdown of that [healing] energy, my specialty’s major unsolved problem — nonunion of fractures. Normally a broken bone will begin to grow together in a few weeks if the ends are held close together to each other without movement. Occasionally, however, a bone will refuse to knit despite a year or more of casts and surgery. This is a disaster for the patient and a bitter defeat for the doctor, who must amputate the arm or leg and fit a prosthetic substitute.

Throughout this century, most biologists have been sure only chemical processes were involved in growth and healing. As a result, most work on nonunions has concentrated on calcium metabolism and hormone relationships. Surgeons have also “freshened,” or scraped, the fracture surface and devised ever more complicated plates and screws to hold the bone ends rigidly in place. These approaches seemed superficial to me. I doubted that we would ever understand the failure to heal unless we truly understood healing itself.

The body electric, by Robert O Becker and Gary Selden, p. 29–30

And I have a personal example: for no apparent reason, I never healed properly from laser eye surgery. My right cornea has never recovered from being burned (while the left recovered perfectly), and I still suffer routine pain and irritation, as though the wound was still almost fresh. My surgeon is apparently one of the world’s most expert cornea specialists. The last time I saw him I asked why a cornea would fail to heal and he literally shrugged — humility, not indifference. He knows as much as anyone has ever known about corneas, but he doesn’t know why mine won’t heal.

There are actually countless similar examples in medicine. Healing of all kinds can fail, and in unpredictable ways. As Becker pointed out, we cannot “understand the failure to heal unless we truly understood healing itself,” which we clearly don’t. (Although Becker certainly found some fascinating biological clues in salamanders … which is why a salamander represents PainScience.com.) It’s fascinating that one organism can literally regrow entire complex limbs, yet we can fail to heal from a little irritation (more about regenerative medicine for ITBS later on in the book).

Super-powered healing

Salamanders have truly extraordinary regenerative capabilities — far more impressive than any other known macroscopic vertebrate. We don’t know how healing can work so well in salamanders … or why it can fail so completely in humans.

So when tissue on the side of the knee is disturbed by accident or trauma, it may not heal properly — a kind of “simulation” of a repetitive strain injury. Without knowing why the tissue refuses to heal, there’s no way to know if it will ever recover. However, this is not particularly different from standard issue ITBS, which is also an injury, and which may also not be healing properly (even when repetitive strain is removed). Screwed up healing may be exactly what makes some nasty cases so nasty in the first place.

The major difference between the two scenarios is just how they started, the speed of the tissue insult — traumatically quick, or overuse in slow-motion. With traumatically induced ITBS, you know that the knee isn’t recovering properly — that’s why there’s a problem. But with overuse ITBS, it’s an open question whether it will recover when given a proper opportunity, when the “siege” of stress is lifted. When that siege is lifted, perhaps your knee will recover quickly and thoroughly. Or perhaps it won’t. Regardless of how it started, you have to give it that chance, and so your approach to the problem is going to be roughly the same: protect the tissues as well as you can, giving them the best possible chance to regain homeostasis.

Until we learn nature’s deep secrets about how healing works, that is the best that you can do.

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Portrait, attributed to Bartolomé Esteban Murillo, of Galileo Galilei gazing at the wall of his prison cell, on which are scratched the words "E pur si muove" (not legible in the original image).

Oops! I thought the science of the IT band and its movements was settled. Specifically, I had high confidence that it does not move back-and-forth across the side of the knee (causing IT Band syndrome). My confidence was based on compelling evidence that it can’t move like that — an anatomical impossibility, or near enough. And so debunking “friction” in runner’s knee became one of the mythbusting pillars of my writings on this topic.

It all seemed so clear! I really never expected any controversy about this.

And yet there is. Science seems determined to be perpetually unfinished.

Quick review: the case against IT band movement and friction

As discussed more thoroughly above, for a long time everyone mostly assumed that the IT band was irritated by rubbing back and forth over a bump of bone on the side of the knee, the lateral epicondyle. That old version of the IT band story was challenged about a decade ago by Fairclough et al in a dissection study showing that the IT band is firmly anchored to the bone it is supposedly rubbing over. Rather than rubbing, it seemed more likely that the IT band was simply compressing the tissue underneath it over and over again, and any appearance of movement was an illusion created by a “wave” of tautness moving through the fibres.

This seemed like a decisive change in how IT band should be described: for most people paying attention to it, myself included, Fairclough’s paper more or less put the idea of “friction” in ITBS out to pasture. Friction became a myth to be busted, and I busted it.

But a 2013 ultrasound study by Jelsing et al has set the pendulum back in motion again, back towards friction.69 The science of this is no longer settled.

The challenge: the case for movement back-and-forth is back

Fairclough et al. basically made an assumption that the IT band cannot move back-and-forth, based on the anatomy — a reasonable assumption, perhaps, but an assumption nevertheless.70 Jelsing et al. decided to actually properly check what happens in living subjects using ultrasound. Why not?

“In our opinion,” they write, “the well-documented fascial attachments of the ITB to the lateral femur may limit anteroposterior ITB motion but do not preclude such motion.”

And, of course — because science is just like this — they found that the IT band does move.

The distance from the anterior fibers of the ITB to the apex of the lateral femoral epicondyle decreased from the fully extended to 30° and the fully extended to 45° positions. … We have clearly documented that the ITB does in fact move anteroposteriorly relative to the lateral femoral epicondyle within the functional ranges of knee flexion-extension.

Fascinating. How inconvenient for me! So much for all my tidy, confident debunking of the friction myth.

Jelsing et al.: the results and possible problem

The study was straightforward: they used ultrasound to carefully examine 40 knees in 20 healthy recreational runners (five men and 15 women). They measured the distance between the forward edge of the IT band and the lateral femoral epicondyle, through the first 45˚of knee flexion, and found that it moved backwards .71cm on average.71

This evidence is inherently simple and compelling. I’ve read the entire paper carefully, twice now, and it’s hard to find much fault with it. It’s well-written and covers all the bases. The authors candidly acknowledge a few notable weaknesses, but none are obvious deal-breakers.72 The biggest is that “we did not specifically determine the reliability of our measurements or their accuracy relative to a reference standard.” Which is related to my own main concern …

The results depend completely on the expert observations of a single ultrasound expert, who might have been gunning for Fairclough and found what he wanted to find (evidence that Fairclough was wrong). Like all imaging technology, ultrasound really does require expertise to correctly interpret. The images are cryptic to non-experts. But experts can have selective perception too, and the history of science is chock-a-block with good examples of that.

Highlighting the general problem with interpreting ultrasound images: they knew they really need to look at the back edge of the band (more on this below), and yet it was so difficult to actually see that they were only able to measure it in 4 of 20 patients.73

And yet I doubt that’s actually what happened here. The tone of the whole paper is quite reasonable, fairly represents all key relevant points, and strikes me as an earnest attempt to discover the truth and not just to prove someone else wrong. The results certainly need to be replicated, but I wouldn’t waste my money betting against it. I suspect another examiner will find the same thing.

Could the movement still be an illusion?

Possibly. The authors themselves raised the possibility that it only looks like the IT band is moving, much as Fairclough et al. originally suggested:

Although these data clearly showed that the anterior ITB moved relative to the LFE, we did consider the possibility that this motion may not represent translation [sliding across the LFE]. It would be possible for the anterior fibers of the ITB to move closer to the LFE as a function of ITB tightening due to increased tension.

This is why they tried to look at the back edge of the band as well as the front. Was the whole thing moving, both edges together? The edge was so hard to see in most people they could only get data on it from four subjects … but in those four, the back edge did move in tandem with the forward edge. And so:

Given that both the anterior and posterior fibers of the ITB moved posteriorly during knee flexion, it is reasonable to conclude that the ITB does translate to some extent over the LFE during knee flexion.

However, just because it moves does not mean there’s friction or that the movement is clinically significant. And may still not be “sliding” at all, but moving more like the 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 — mostly eliminating the possibility of any significant friction. If the Jelsing and Fairclough studies can be reconciled, that’s probably how.

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Adding more to the credibility of this paper, the authors graciously point out that “our findings are not necessarily wholly contradictory to those published by Fairclough and colleagues,” because the anchoring of the IT band to the underlying bone may indeed limit any rubbing motion, but without completely eliminating it.

Maybe that anchor is more secure in some people than others. Maybe that’s why some people get IT band syndrome — because they have looser IT bands at that location, and there’s more friction. Anatomical variation is the norm!

Back to the IT band drawing board?

Obviously I am now going to have to reconsider and maybe eventually revise everything I’ve written above about “friction” in IT band syndrome being a myth. However, I’m not going to quite rush to actually reverse my position. The impact of this study is that the whole topic is now unsettled science, rather than settled in a new place. I was confident in what I thought I knew. Now I just don’t know again, and that’s how I’ll handle it for now. I can live with the uncertainty.

I will re-write the friction-debunking if and when more evidence makes this clearer … so it could be a while. Until then, I think the only reasonable thing to do is simply present the conflicting evidence and deal with the discrepancy as best as we can.

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The tensor fascia latae (TFL) muscle.

It’s a common idea in musculoskeletal medicine that muscles can be “dysfunctional,” boosting injury risk over time, and otherwise letting us down. Dysfunction of the slightly obscure tensor fascia latae (TFL) muscle is one of the more usual suspects, often blamed for contributing to several hip and knee injuries and issues, but mostly IT band syndrome, greater trochanteric pain syndrome, and patellofemoral pain.

The TFL is blamed for IT band syndrome because, of course, it is attached to it: the IT band is the TFL’s tendon. It partially controls the tension on it, along with the gluteus maximus — and yet it’s the TFL that seems to get the blame! I’ve never heard anyone attribute ITBS to dysfunctional buttocks.74

So obviously I should have written this chapter years ago. The reason I haven’t until 2021 is that the link is so speculative and weak.75

Having been blamed for causing ITBS, the TFL is often the specific target of treatment for ITBS. I have even portrayed neglect of the TFL as one of the classic common problems with IT band syndrome treatment — but really only in contrast to even more simplistic therapeutic attacks on the IT band itself, which doesn’t really make any sense at all. I actually do think it’s worth trying to make the TFL “happier,” albeit without much enthusiasm, mostly with strengthening, massage, or stretch. I only take that position because it is at least theoretically possible for the TFL to affect this knee condition.

I certainly don’t do it because the TFL-ITBS link is evidence-based!

The barely-there TFL-ITBS research

Besomi et al reviewed seventeen studies of the TFL in people both with and without several conditions.76 Eight of the studies were of the size of the TFL (“structure”), and ten were studies of its electrical activity while contracting (“activation”). They found a handful of minor, uninformative differences in these measurements — which is completely unsurprising. There are a few reasons why I wouldn’t expect such studies to shed much light on anything.

Above all, muscle “dysfunction” is an extremely poorly defined concept. Activation and size are just a couple things about a muscle that we can easily measure — “looking where the light is good”77 — but without dramatic differences they are rather unlikely to tell us anything about how well a muscle is working. There are other ways that a muscle could plausibly be dysfunctional which were not considered by these studies at all.

Also, some of these studies were looking for more implausible links with other injuries. It’s a bit of a reach to blame the TFL for anything at all, but knee ligament tears? Hip arthritis? Come on! I would be shocked if those conditions were TFL-sensitive.

But even when the research is focused on a condition with a more plausible link — like Baker et al looking specifically at a TFL-ITBS link78 — there’s hardly a smoking gun there either. They found basically nothing.

So Besomi et al reasonably concluded that the “common clinical assumptions” about the TFL’s role in injury are “not well investigated and poorly supported.” Indeed! These kinds of ideas have always just been speculative, just professionals spitballing about how muscles and joints work. Most of them have yet to be studied at all, let alone well.

There is maybe one slightly useful thing this study can tell us: there is nothing terribly obvious wrong with the TFL in people with these injuries, or it probably would have shown up in the seventeen studies reviewed. But that’s kind of like saying “if bigfoot was as tall as King Kong, he would have been found ages ago.”

Bottom line: No one really has any idea if there’s any such thing as a glitchy tensor fascia latae, let alone whether it causes injuries, and Besomi et al does nothing to confirm the idea… which isn’t surprising, because it’s really quite a reach.

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On the one hand, it seems a bit ridiculous to me that anyone should need to bother with an MRI to confirm a diagnosis of iliotibial band syndrome — usually the features described above are more than enough to make the call one way or the other.

On the other hand, if you have a difficult case which doesn’t quite fit the classic signs, symptoms and circumstances — entirely possible, if you’re reading this tutorial — then by all means, get an MRI. They do work.

MRI has been shown to be a perfectly good way of clinching the diagnosis.8384 It might not be such a bad idea, considering how this condition seems to be given only the most basic attention by most health care professionals. If there is chronic uncertainty about the cause of your chronic knee pain, an MRI could finally put the question to rest.

Another reason to get an MRI is to make sure that there isn’t anything else wrong with the knee that may be complicating the situation, like a cyst. Consider this case report in the journal Knee:85

We present the case of a 28-year-old competitive runner with iliotibial band (ITB) friction syndrome associated with a synovial cyst. Magnetic resonance imaging (MRI) did not demonstrate a fluid collection. However, open exploration revealed a large cyst beneath the ITB arising from the capsule of the knee proximal to the lateral meniscus. The cyst disappeared on extension. The pre-operative MRI scan may have revealed the cyst, if it had been taken with the knee flexed.

This person could easily have gone through a dozen doctors and therapists before finally getting some answers! And with no one really to blame. Note that a positive MRI was hardly guaranteed — only maybe if it had been “taken with the knee flexed.” More informally, reader Eric C. has a similar cyst story:

After struggling with this for many years I finally had surgery in the fall of 2013. Interestingly, they found a cyst right below the incision. It wasn’t apparent on the MRI. They did remove the cyst and do an oval window removal of part of the IT band. I’ve just taken the winter somewhat off, doing mostly rehab and weights.

The results have been good so far. The real test will be in a few months as I slowly ramp up the hiking to see how it does … but already I can tell it’s better. My “ITBS” had progressed to where I could barely walk down any type of shallow slope without getting occasional but knee buckling stabs of pain, which is no longer the case. For instance, recently I was able to walk all around Six Flags Magic Mountain on vacation without problems. I decided to get surgery last year when I couldn’t walk across a tiny amusement park.

I’m happy to report that Eric was still out of pain when I checked back with him in early 2015. We’ll never know for sure that the cyst was the specific problem — because the surgery did more than just remove a cyst — but it seems likely.

MRI clearly cannot identify all such problems (Eric’s knee was not flexed for the MRI, as suggested by Costa et al, so perhaps that’s why his MRI did not show his cyst). But there are other issues that it might reveal. See a few sections below for a little more information about even “deeper” knee problems that MRI might be useful in diagnosing.

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One of the clearest signals that you’ve got ITB syndrome and not some other knee problem is “descent pain,” which is physio-speak for “it really hurts when I go down stairs and hills.” The symptoms of iliotibial band syndrome are routinely worse when going down.86

This “descent pain” on the lateral knee is one of those things that I think of as a dead-give-away symptom. If you experience more pain going up hills than down them, you probably have something else.87

With milder cases, runners may or may not notice whether the pain is worse descending or ascending, but simply remember that hilly routes are generally a problem. A test on a long or especially steep hill will usually reveal that going down is the painful part! For those that live in high-rise buildings, it’s particularly easy to test: just take an elevator ride to the top, and then walk down 20–30 stories … if you can get that far.

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A lot of runners with hurting knees have started reading up on their syndromes, and are not sure whether they’ve got the patellofemoral flavour, or the iliotibial. Patellofemoral syndrome and iliotibial band syndrome are extremely common (and fairly similar) injuries for anyone who uses their knees a lot, so I spend a fair amount of time ‘splaining the difference.

In a perfect, neat, and tidy world, it’s actually very simple: PFPS makes the front of your knee hurt, and ITBS makes the side of your knee hurt. Now, if only the world were perfect and neat and tidy.

In practice, of course, people with knee pain rarely have well-behaved symptoms that stick to just one spot. Both ITBS and PFPS have the potential to produce atypical symptoms. Generally speaking, there will still be a clear and identifying epicentre of pain on either the side (ITBS) or the front (PFPS) of the knee. But symptoms often do spread from the epicentre where they “should” be into other parts of the knee. There are at least two clear reasons why this would happen:

• As discussed above, muscular trigger points are probably involved as both causal and complicating factors in both conditions. And spreading, erratic pain is what trigger points do best. With nasty muscle knots in the hips, hamstrings and/or quadriceps, virtually any kind of knee pain is possible. It will not usually be as acute or focused as the core PFPS or ITBS tissue irritation … but it can be plenty bad enough to confuse things.
• The two conditions are probably biomechanically related. The ITB probably has direct anatomical relevance to patellar tracking problems — that is, the ITB is crucial to lateral knee stability, and when tight may actually pull the patella laterally. In fact, given the close working relationship between the ITB and the patella, it seems quite surprising that the two conditions rarely co-exist. Nevertheless, there have got to be ways in which the ITB affects the patella and vice versa.

In cases where it’s hard to tell the difference between the two conditions, this comparison checklist will help you nail it down:

Tell the difference between ITBS and PFPS

Instructions: check all that apply. The condition with the most check marks wins! This is not a form — you do not have to “submit” it. Just use the check boxes for visual reference.
Iliotibial Band Syndrome (ITBS)		Patellofemoral Syndrome (PFPS)
	The epicentre of the pain is on the side of the knee. Symptoms may occur nearly anywhere around the entire knee, particularly in severe cases, but the worst spot has to be on the side of the knee.		The epicentre of the pain is somewhere under the kneecap. As with ITBS, symptoms may occur nearly anywhere, but it must be mainly on the front of the knee under the kneecap.
	There is a spot on the side of your knee, right around the most sticky-outy bump, that is sensitive to poking pressure, and your kneecap is not particularly sensitive when pushed firmly straight into the knee.		It’s not very comfortable pushing your kneecap straight onto your knee, but there is no particularly sensitive spot on the side of your knee.
	Pain tends to be worse when descending stairs or hills.		Pain tends to be worse when ascending stairs or hills.
	Started while going downhill.		Started while going uphill.
	Both PFPS and ITBS can start over the course of a few hours or a day, but ITBS almost always does. If the pain started relatively quickly, check this box.		If your pain grew relatively slowly, over months or years, check this box.
	Doing a deep knee bend does not especially hurt.		Doing a deep knee bend hurts.
	Pain is not particularly affected by sitting, although it might get worse after sitting for quite a while (longer than an hour).		Pain is quite clearly aggravated by sitting with knees bent. When you get up, it hurts more than it did when you sat down.
	You do not have any obvious structural problems in the legs.		You are a little knock-kneed, have flat feet, or your kneecaps seem to be at a funny angle.
If this column has more checks, congratulations — you are probably reading the right guide!		If this column has more checks, you may be reading the wrong article! Go to the PFPS book:

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Sorta. In a way. But mostly no … not really. In fact, hip pain is excluded by definition.

This section is redundant review — I already introduced hip pain thoroughly above, while discussing the nature of the beast — but I want to review exclusively in terms of diagnosis. I cannot overstate how often people are confused about this point, so I think it’s worth covering as thoroughly as possible. To recap…

A hip pain cannot be called ITBS any more than you can have a headache in your elbow. Too often you will encounter professionals who diagnose hip pain as ITBS, but it simply isn’t correct.

Unexplained hip pain is not ITBS but GTPS — greater trochanteric pain syndrome — and it can have many causes. GTPS might make some contributions to ITBS, or emerge as a complication of ITBS, but it is not the same as ITBS.

The most likely important link between them is simply that hip pain can probably spread down to the knee, adding to any knee pain that is already there — adding insult to injury.

So they may well go together, but hip pain on its own should never be diagnosed as ITBS.

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Yes, there could be. A problem inside the knee joint — an intra-articular problem — can mimic ITBS. Chances are good that it won’t be a perfect mimicry, and there will be something that “gives it away” as another condition. However, it’s all too easy to miss something like this and go for a long time with a case of a not-actually-ITBS without ever being the wiser. One of my physician readers emphasized the potential for confusion:

I have practiced medicine for 50 years and have missed the diagnosis of a cracked lateral meniscus that was eventually picked up on an MRI.

How likely is this? Muhle et al used MRI to find three meniscal tears in sixteen patients with clinical signs of ITBS.88 Michels et al found four intra-articular problems out of the 35 knees they investigated: one case of femoral cartilage damage, two mensical tears, and a knee with some “gravel” in it — a “calcified loose body.”89

On the one hand, that seems like a lot: in Muhle’s study, 18% of people with the symptoms of ITBS had meniscal tears. In Michels’, 5% had tears and 5% had some other problem. Yikes! Practically one in five.

But, on the other hand, remember that minor internal knee problems are common and not necessarily much of a problem. Meniscal tears in particular are often asymptomatic, or cause only painless symptoms (i.e. a little clicking and nothing else). You could easily have a little meniscal tear that was causing you no symptoms whatsoever, or only minor symptoms … and which may have nothing to do with your iliotibial band syndrome.

So, what we really want to know is: how many people with ITBS have a meniscal tear that is actually causing ITBS-like symptoms? Probably not very many, but unfortunately, nobody has a clue one way or the other. All we can take from the science so far is that it’s certainly possible, but not particularly likely.

In difficult cases, the possibility of another, deeper knee problem can be addressed by MRI and arthroscopy. This will be discussed below in the surgery section.

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A “wonky kneecap” diagnosis is commonly used to dubiously shore up a diagnosis of iliotibial band syndrome — which is usually unnecessary, because we can diagnose ITBS quite well without examining any kneecaps at all.

The idea here is that a crooked patella is a sign of a tight IT band. In one popular theory, a tight IT band must drag the patella out of alignment by pulling hard on the side of the knee. Since the IT band blends into the entire lateral knee joint capsule, it does seem reasonable that an unusually tight IT band could be yanking the kneecap to the outside. And there probably are a few cases of ITBS co-existing with an obvious patellar alignment problem.

However, we’ve already determined in this tutorial that IT band “tightness” may be something of a red herring, either meaningless or not terribly meaningful: a factor, perhaps, but not the main factor. In practice, kneecap alignment doesn’t seem to be involved much in ITBS. I know this because lots of people have ITBS, but many have not the slightest trace of a poorly aligned patella.

And a serious problem with basing diagnosis or therapy on the idea of misalignment of the kneecap: therapists cannot agree on the location of people’s kneecaps!

Examination of kneecap position is a reflex for most manual therapists — a staple of knee pain diagnosis, as inevitable as a doctor asking you to say “ah.” Kneecap alignment is almost universally regarded as a sign of patellofemoral pain syndrome and patellar instability, and accurate assessment of knee position is essential for meaningful taping (a popular treatment method for most kinds of knee pain). Obviously you can’t use tape to align a kneecap if you don’t know how it’s misaligned to begin with.

But is accurate assessment of patellar alignment actually reliable? Turns out probably not. As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals. In fact, a 2009 paper in Manual Therapy reviewed nine reliability studies of 306 knees.90 What evidence there is showed that assessment of patellar position was “variable” from one therapist to the next — if you get a bunch of clinicians to assess the same kneecap, they will come up with different diagnoses.91

Despite these problems, poor patellar tracking continues to be used as evidence of a tight IT band, and then used as a justification for probably time-wasting and money-wasting therapies and therapeutic exercises. Elaborate and tedious work to try to “align” kneecaps are almost as common as the testing procedure itself. Take your hurtin’ knees to a manual therapist, and odds are excellent that they will not only conclude that you have an alignment problem, but also that you need therapy and exercise to fix it.

If you’re doing a bunch of therapy based on the idea of patellar misalignment — and I mean both patients and professionals — you should reconsider it.

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Medical ignorance of sports medicine (see Stockard) has exposed me to some bizarre tales of misdiagnosis and mismanagement of iliotibial band syndrome. I don’t want to pick on the doctors specifically about this — by no means are they the only offenders — but all of three of the disturbing examples I have on file here involve doctors (in addition to a supporting cast of other kinds of professionals).

The first concerns a young woman in my care who was told that she had iliotibial band syndrome. She was prone to muscle pain — she was getting trigger points the way some teens get acne, a frustrating situation, but apparently benign — and I often reassured her that there was probably no more ominous cause of her pain. But she was constantly (understandably) looking for some other explanation for her discomfort. There must be, she figured, something broken or torn or inflamed. Even though she was in otherwise excellent health, took good care of herself, and did not participate in any athletic activity to excess, she tended to assume that she must have hurt herself in some way. Such fears often exacerbate pain.

This psychological dimension to her problem was quite prominent. It was heartbreaking to see her constantly worrying whether some harmless activity had damaged her! It made it hard for her to enjoy things, more difficult than the symptoms alone would make it. But if it were that easy to get injured, no one could leave the house. Whatever was causing her to have so many minor sore spots, it wasn’t an injury … and it certainly was not iliotibial band syndrome.

So I had been working with this woman, and half my job was calming her down. And then one day she came in and announced that she’d been to the doctor about her pain, and before she even told me anything, I thought, “Uh oh.” You see, doctors too often scare people with speculations about possible causes of pain … and I’d been trying to calm this client down for weeks. Sure enough, she announced in a firm I’ve-got-this-figured-out now voice, “My doctor says I have iliotibial band syndrome.”

Ridiculous. There are any number of things I could have missed, which a doctor might have diagnosed. But not that.

Medical diagnosis of body pain is often so wrong that it seems disconnected from reality. I find myself thinking uncharitable thoughts about such doctors, things like, “Was he high?” and “Did she get her credentials by mail order?” But this diagnosis was particularly impressive in its irrelevancy, its drunken-game-of-darts inaccuracy.

That patient had erratic aches and pains in every part of her lower body. Back pains, hip pains, leg pains, knee pains … shifting by the hour, by the moment, like evil aurora borealis in her muscles. She has ascent pain in the knee, not descent pain that would indicate ITBS. Her knee pain was far from her most prominent problem, and when she got it, it was on the front of the knee … not the side, which is necessary for an ITBS diagnosis by definition (as I have now mentioned at least a half dozen times, because it cannot be said enough). She had no history of long distance running or any activity that would cause iliotibial band syndrome, no history of developing knee symptoms during any kind of activity that might cause iliotibial band syndrome. And then she had a mixed bag of other symptoms, typical for fibromyalgia or myofascial pain syndrome, but entirely unlike anything iliotibial band syndrome should ever cause.

The diagnosis was as wrong as if the doc had mistaken acne for smallpox.

Yet there she was, standing before me, desperate and deeply distracted by this wrong idea. Clients with unexplained, widespread pain often crave the solid ground of a concrete injury diagnosis, and who can blame them? And the doctor had played right into that, his authority to validate a bizarre red herring of a diagnosis. It took most of a delicate, diplomatic hour to talk her down … time that could have been spent in many better ways.

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Here’s another good one from the “d’oh” files. This one is a tale of serial misdiagnoses: a string of health care professionals diagnosing non-existent ITBS, one after the other, each one’s failure to see the reality of the situation all the more amazing in light of the failure of the previous therapy attempts.

Natalie Baxter Strange, of Norwich, England, managed to go through sixteen months of pain and attempted therapies for ITBS without any one of six different health care professionals ever so much as hinting that ITBS was a garbage diagnosis — wrong by definition, wrong like calling shoulder pain a knee problem wrong — not even the right body part.

She saw a general practitioner, a sports physiotherapist, another sports physiotherapist, an acupuncturist, another physiotherapist, a massage therapist, and a personal trainer who “specializes in remedial weight training.” (Natalie points out that her massage therapist was not asked to diagnose.) That’s at least six professionals who should have known better — while Natalie continued to have pain that never significantly responded to any therapy for knee pain. Every single one of them either confirmed or went along with the ITBS diagnosis.

But here’s the strange part: Natalie Baxter Strange did not have knee pain.

“I have started to have knee pain,” she told me on the phone. “Just in the last two or three months. Mostly I have hip pain. It’s always been mostly a hip problem. Sometimes it spreads down the thigh, along the iliotibial band.”

Hence the confusion. The pain was near and sometimes overlapping the iliotibial band, and this infamous anatomical structure with its very own syndrome apparently attracted their blame. They could just as well have fixated on an incorrect hip pain diagnosis like bursitis or sciatica … but they chose iliotibial band syndrome, because the pain seemed to be on the iliotibial band. But — as you should now be tiring of hearing, and know better than the health care professionals that Natalie was “helped” by — iliotibial band syndrome is, by definition, a painful condition on the side of the knee.

I asked her if she had ever felt, even recently, that the pain was primarily on the side of the knee?

“No,” she confirmed. “I have never had strong lateral knee pain.”

“Ever?”

“Never.”

•sigh•

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Here is a third and final story of terrible knee pain diagnosis.

TJ McMorrow is a young running star. With a state-wide competition just three weeks away, his mother Annette contacted me, a bit desperate, because TJ’s training had been brought to a halt by a pain problem, allegedly iliotibial band syndrome. This story gets “daft diagnosis” status because of his doctor’s deeply flawed logic. Annette wrote:

“The doctor said his X-rays showed a perfect set up for IT band due to the sharp turning in of his hip, as opposed to most that have a more gradual turning in.”

A couple of physiotherapists had not contradicted this and were treating him as an ITBS case.

And yet, just like Natalie Strange, it turns out that TJ didn’t even have knee pain. “TJ’s main source of pain is not his knee, it’s his left hip,” his mother confirmed initially, and then again more emphatically a few days later, “I verified with TJ that he has no knee pain at all.”

Diagnosing ITBS by X-ray is absurd. It’s not an X-ray-able condition. It’s like diagnosing the flu by X-ray. It’s completely ridiculous. It’s simply the wrong tool for the job. If the doctor knew the slightest thing about the condition he had named as the problem, he would know that.

But the absurdity of an X-ray diagnosis is topped by referencing a single biomechanical factor … and not just any biomechanical factor, but an anatomical variation that isn’t even one of the standard biomechanical problems this problem gets blamed on. What a spectacular example of the foolishness of structuralism!

And, unfortunately, the misfortune of this story was compounded by a fairly typical scenario — although I was easily able to persuade Annette herself that the diagnosis was wrong by definition, she was unable to persuade anyone else involved. The last I heard, her son’s coach, her husband, and her son were all still determined to proceed with ITBS treatment, with a knee steroid injection planned … in the absence of knee pain!

And there are many more such stories

Sadly, these kinds of stories are not isolated incidents, and the scale of the misdiagnosis problem is quite shocking. Although these are best-of-breed examples, I have heard many others from patients, and readers around the world. This is just the typical level of “expertise” you can generally expect on the subject of iliotibial band syndrome.

In the examples above, IT band syndrome was diagnosed in its absence, but there are horror stories in the reverse: true cases that go undiagnosed. Imagine that you actually have iliotibial band syndrome — and, hey, you probably don’t have to imagine it, if you’re reading this! You have the real McCoy, and off you go to see a professional. Ironically, despite the more common predilection for diagnosing iliotibial band syndrome when it is nowhere to be found, odds of failing to diagnose genuine IT band syndrome are also quite high.

Multiply the diagnostic incompetence by the hundreds of thousands of professionals throughout those parts of the world where running and cycling are popular (which is quite a lot). How many athletes have been misdiagnosed, misled, mistreated? How is it, this late in medical history, that such a relatively minor diagnostic challenge can still be such a mess?

Iliotibial band syndrome is an incredibly common condition, simply because of the popularity of running. Every year I watch several tens of thousands of Vancouver runners stream past my house for the annual Vancouver Sun Run. The math of it is impressive: a significant number of them probably either have this knee problem already … or will by the end of the race! That’s quite a few cases. Sadly, few of them will receive appropriate advice.

It’s not a medical issue on the scale of cancer or heart disease, but it ain’t nothing. That’s a lot of troubled knees. If you add up all of the incompetent musculoskeletal health care out there, including the truly staggering economic costs of back pain, and it’s surprising that our civilization can progress at all.

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There aren’t many things that IT band syndrome can get confused with (other than patellofemoral pain syndrome, already thoroughly discussed). Most of these are unlikely misdiagnoses. That will mostly be the theme of this section: in each case, the question “Could it be … ?” will best be answered with “probably not.”

Still, it’s wise to be thorough, and it’s unwise to underestimate just how far wrong ITBS diagnosis can go. This first item, popliteal artery92 entrapment, was pointed out to me by a physician reader. When I told him that I couldn’t recall ever encountering any diagnostic confusion on this point, he replied:

Most physicians are not astute enough and lack the clinical expertise to tell the difference between popliteus syndrome and IT band syndrome.

Oh, dear. I hate to think that a physician wouldn’t be able to tell the difference between a calf that’s dying for lack of blood and lateral knee that’s irritated by overuse. That seems almost too cynical about the state of musculoskeletal health care even for me. Almost! So, here you are …

Could it be popliteal artery entrapment syndrome (PAES)? Probably not. This is an uncommon problem, and one not much like ITBS. A large artery passes through the soft hollow behind the knee, and sometimes it is pinched off by an anatomical deformity and/or scar tissue that forms in response to an overuse injury — so it can be provoked by running. Obviously it doesn’t completely shut down the artery, or you’d lose your leg below the knee (tragically, that does happen to some people, but if that was your problem, you wouldn’t be reading this). Instead it just causes severe pain, and gives you an obviously pale and cold calf.

There is another structure behind the knee that can do a better “impression” of IT band syndrome.

Could it be popliteal tendinitis? This condition is rare, but it probably more closely mimics IT band syndrome than any other condition described here. The popliteus is a tiny muscle in the back of the knee. One end of it attaches to the side of the femur — right close to where IT band syndrome occurs. Irritation of this tendon may be superficially indistinguishable from IT band syndrome.

So what’s the difference? The trick to telling them apart is that the small popliteus muscle has a specific and finicky job to do, so you can provoke pain by resisting knee bending while the lower leg is rotated outwards — awkward but exact.94 If that motion particularly hurts, you may have popliteal tendinopathy, not IT band syndrome. Also, though popliteal tendinitis will be irritated by activity in general (like any tendinitis), it probably won’t be so distinctively bothered by going down hills, the way ITBS is.

And now for one more tendon in the area …

Could it be biceps femoris tendinopathy? Biceps femoris is the lateral hamstring muscle, which attaches well below the bulk of the knee on the head of the fibula (a small bony projection on the side of the upper leg), which is usually where it hurts. This injury could be mistaken for IT band syndrome briefly because of its lateral-ness, but in the end it should obviously be too low and/or too far around to the back of the knee, and too sensitive to hamstring contraction specifically.

Could it be a lateral collateral ligament sprain? Unlikely. This is the ligament on the side of the knee. The locations of ITBS and LCL sprain certainly overlap — but that’s where the similarity ends. Tearing a ligament is a trauma that requires considerable force: it would happen suddenly and nastily, difficult to confuse with IT band syndrome. Even though ITBS can come on surprisingly rapidly, it’s still not abrupt the way ripping a ligament is.

Degenerative joint disease, arthritis? Arthritic pain will mostly never be limited to the classic IT band patch on the outside of the knee. But maybe! Deep hip joint pain (common with osteoarthritis of the hip) is routinely felt all over the hip and buttocks, and can easily be confused with greater trochanteric pain syndrome, which is in turn very commonly confused with hip-centric ITBS. But it gets worse: a painful hip joint can spread pain into the thigh as well, especially the lateral thigh down to the knee, which also makes it surprisingly likely to be mistaken for IT band syndrome.95 That pain would almost certainly not be felt just in the knee, but all over the lateral thigh, which should make it clear that it’s not ITBS … but lots of people incorrectly think that ITBS is a hip and thigh issue.

Three more possibilities, all relatively unlikely and needing only a few words of clarification. Could it be …

• Lateral meniscal tear? This injury is usually traumatic, with pain a little too low for ITBS, and often accompanied by other symptoms like locking and clicking and clunking.
• Referred pain from lumbar spine? Possible, but rarely limited to a single well-defined spot like ITBS. Likely there would be other symptoms as well.
• Stress fracture? — This would be quite a rare source of confusion, but not impossible (see above re hip joint pain). Stress fractures in the hip are probably going to be more obviously sensitive to jarring and load-bearing than ITBS.

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Knees are noisy. Even cat knees.

For twelve years I was step-dad to my wife’s lovely cat. She was a cat that defied stereotypes: she had none of the aloof disdainfulness for which cats are notorious. She was charismatic, amiable, even polite. (This isn’t relevant to knee noise, I’m just adding colour, and I miss her.)

And her knees were noisy for the last several years of her life. Everywhere she went: snap, crackle, pop! You could hear her coming.

And so it is for me now as well. If I do a set of squats, the neighbours can probably hear it — every second or third squat! It sounds like there’s kindling in there.

What the heck is going on? And does it have anything to do with knee pain?

Science reports what every pro knows

Robertson et al interviewed eleven patients with knee pain and crepitus — joint noise — as one of their symptoms. They reported their impressions and concluded that:

1. people don’t like it
2. they believe it’s related to the cause of their pain
3. they try to avoid it by moving differently

Eleven patients! I got this from my readers eleven times last week. But it’s nice to have the formal confirmation. (But why is it that science seems to either confirm the obvious or it’s hopelessly complex and conflicted? Someone should study that.)

Clunking and grinding are another matter

Snaps, crackles, and pops are one thing — clunking and grinding, especially paired with other more “mechanical” symptoms like locking and instability, is much more likely to be a symptom of frayed mensici, the noise of a joint that’s having trouble moving properly.

Clinically uninterpretable

Ordinary joint noise is mostly just clinically uninterpretable, especially knee noise. The knee is just a naturally noisy joint, and it does not correlate well with problems at all. So you can be in trouble ... silently. And you can be fine... noisily.

And the latter is more common. A lot more common. Practically every knee that is more than 30 years old starts to get noisy, without any pain involved. Even with noise being much more common in painful knees, the painful knees are relatively rare, greatly outnumbered by noisy-but-happy knees.

Women with noisy knees are four times more likely to have the other runner’s knee, patellofemoral pain.96 (There is no equivalent data for ITBS, but PFPS is a decent stand-in for our purposes here.) So there’s some kind of link between joint noise and PFPS, but it’s not an important one: the noisy-kneed women in this study were no worse off (or better) than the quiet-kneed. Crepitus is probably a harmless side effect.

Joint noise may be a side effect of pain and/or inflammation

Joints seem to pop more loudly, and more often, in painful and injured areas. This has never been formally observed, as far as I know — it’s my own clinical observation. It may not be true. If it is true, it’s unexplained. Example: in February 2010, my wife was in a terrible car accident — while travelling alone in Asia no less — and she had a great deal of healing to do afterwards. One of the most obvious effects of the accident was a spectacular increase in joint popping, especially in her spine near her crushed vertebra. It was quite impressive. She had never really popped her spine before the accident.

This phenomenon underscores the fact that no one really knows what the $!#@&! joint popping actually is, despite some commonly floated theories97 and fascinating observations.98 Certainly no one knows why it might increase in the presence of pain and trauma, but my guess is that there’s biochemistry involved — inflammation probably affects the phenomenon.

Chances are good that painful knees crack more because they are hurting, and not the other way around.

Note that cracking is probably not hazardous in and of itself. In 1998, Dr. Donald Unger won an “Ig Nobel Prize” for diligently cracking the knuckles of his left hand only — never his right — every day for more than sixty (60) years. What did he find? “There was no arthritis in either hand, and no apparent differences between the two hands.… there is no apparent relationship between knuckle cracking and the subsequent development of arthritis of the fingers.”99

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Another sobering reality for ITBS sufferers, regardless of the severity of your case: this condition can also go dormant until your next big hike or run, or wait even longer to revisit you. I am not aware of any hard data about how common recurrence is. However, my clinical experience and exposure to reader reports like this have certainly led me to believe that it happens quite a bit.

I have a very stubborn case that took 7 months to “go away” for just a few weeks, and now seems to be rearing its head again. I hate not being able to hike, bike, or sometimes even walk … .

Lanina Spencer, Lincoln, CA

Most recurrences are no more serious than the original. If you had mild ITBS to begin with, chances are that you will have relatively mild recurrences. However, even relatively mild ITBS symptoms, if they recur frequently, can really be a problem. I have seen runners retire from the sport, not because their iliotibial band syndrome would not resolve in the short term, but because it just kept coming back with every major effort.

The only defense against recurrent iliotibial band syndrome is to continue to train carefully, take preventative measures, sometimes rather heroic ones, and even then your safety can hardly be guaranteed. You can go for months or even years without noticing it, only to have it flare up again at the worst possible time.

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Although this condition primarily affects runners, it also particularly affects hikers — usually striking rather inconveniently on the way down a mountainside. Many a hiker has gotten into trouble trying to come down a mountain as a new case of iliotibial band syndrome gets started, or an old one flares up. Hikers who have a history with iliotibial band syndrome should definitely be aware of this, and leave enough time for a slow descent.

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You crazy runners often ask me this, and often insist that you’ll do anything to get better except stop running. This is kind of like saying that you’ll do anything to stop your headache as long as you can carry on banging your head against a brick wall. But — oddly enough — sometimes it actually makes tactical sense for a runner to push through the pain of iliotibial band syndrome … and you can get away with it.

There are no truly serious risks, like you have with, say, shin splints. Never try to run through shin splints — danger, Will Robinson! Shin splints are the perfect contrasting example, because there is real danger involved in pushing your luck.

The stakes aren’t so high with most other overuse conditions. While I don’t exactly recommend it, I have to admit that serious harm to your knees is unlikely. I’ve done a little running through iliotibial band syndrome myself. It can hurt a lot — probably enough to stop your foolishness, no matter how hard core you are. And it will probably become three times harder to get rid of your ITBS — and three times more likely to be a problem in the future.

But, no, you won’t “blow” your knee. Your iliotibial band will not snap (like Achilles tendons actually do), and your knee will not break. So if you absolutely must run the next marathon … knock yourself out. I’ve seen runners do this with both iliotibial band syndrome and plantar fasciitis, two common and painful conditions, and more or less get away with it — recovery was slow and difficult afterwards, but they thought it was a fair trade. If you can handle the pain, it’s not impossible. And if there’s one thing runners are good at, it’s handling the pain!

(But I repeat, do not even think about doing this with shin splints — that is a very different scenario.)

But don’t kid yourself that it’s risk free. Your IT band may not snap, but — disclaimer, disclaimer, disclaimer! — you could nevertheless do damage that cannot be undone. I already covered this while explaining the implications of “rot” above in the inflammation myth section, but it’s a pretty important point to repeat: although structural integrity is not at stake, the nature of repetitive strain injury is the slow but steady degeneration of stressed tissue, which may be irreversible past a certain point. The “padding” under the IT band could be destroyed by long-term severe ITBS. This could even explain some severe ITBS chronicity.

At present, this is just reasonable speculation. There’s no way to know if your ITBS has progressed to some point of no return, like with bone-on-bone arthritis. The risk goes up with age and duration of pain — the longer you’ve had the problem, and the older you are, the more concerned you should be about the possibility of irreversible damage. I can imagine a 60-year old marathoner with a 20-year history of intermittent ITBS pain deciding to either (a) avoid running through the pain (skip a marathon) because of the risk of permanent damage and the desire to keep running for many more years, or (b) choosing to run through for one last important race and then hanging up the shoes.

Risk tolerance is an intensely personal matter. All I can do is inform you that it certainly seems possible that ITBS could become irreversible, at some unknowable point.

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Before I dive into the treatment options, I’d like to respond to a common reader concern that I do too much “debunking,” and not enough telling you what works and exactly how to do it. Although I get few refund requests — way below industry averages — most of the requests I do get are caused by this specific concern: Doesn’t $20 get me a road map to a cure? A step-by-step action plan? The savvy exercise regimen that will make the pain stop?

These things just don’t exist, as I warned in the introduction. I have not sold you a book without mentioning that.

Even if they did exist, prescribing a treatment “plan” is simply out of the question, because every case really is different — that’s not just a platitude. What works for one person really is not going to work for the next. I promise that I’m not holding out on you. I am not a cure salesman, and I will not tell you what you want to hear. There is no specific method or series of logical steps that will reliably cure any kind of chronic pain problem, least of all the tough kind I write books about.

No plan survives contact with the enemy.

Helmuth von Moltke the Elder

Many people reading this probably think plenty of debunking is quite reasonable, normal, and even ethical. But imagine some of the unreasonable expectations I hear from a few customers. For instance, one woman asked me for a refund because my book offered her “only suggestions”! What else is there? What did she expect? Binding arbitration? Click this link for a cure? Free magic wand with every purchase?

Historical perspective and the Age of Hype

The disappointing truth is that there is only a motley assortment of rather underwhelming options with complex pros and cons, but usually more “cons.” Some are better than others, but quite a few are dodgy, for obvious reasons: hope sells, and so there are many more poor options than there should be. Please blame reality for this … not me.

And blame the people who have given you false hope and raised your expectations of musculoskeletal medicine far beyond what it can possibly deliver.

We are living in the “Information Age,” but sometimes it seems more like it’s the Age of Marketing and Hype. An almost unbelievable amount of the information we consume is generated to promote products and services. The result has been an unprecedented flood of being told what we want to hear about absolutely anything.

The reality is that musculoskeletal medicine is surprisingly primitive. Medicine has always had bigger, scarier fish to fry than treating mere aches and pains and injuries, which were barely studied at all until the 1980s. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything. Even sports medicine specifically, with so much potential funding and relevance to occupational injuries, has been bizarrely slow to build its evidence base.

The trouble with pseudo-quackery: treatments that seem way more legit than they are

The most prominent problem in musculoskeletal medicine today is the prevalence of what I call “pseudo-quackery”: treatments that are about as sketchy as any old-timey snake oil, but seem modern and scientific and mainstream. A few classic examples: laser therapy, ultrasound, platelet-rich plasma, prolotherapy, nerve and muscle stimulation. But there are many more.

These disguised quackeries are actually based mainly on surprisingly stale tradition, speculation, and authority. They generate more false hopes and wasted time, energy, money, and harm than more traditional quackery because they are vastly more popular and very much part of mainstream medicine, or very friendly with it — even many hardened skeptics aren’t expecting snake oil when they go to see a physical therapist or an orthopaedic surgeon.

So musculoskeletal medicine is a minefield, and a lot of debunking just goes with the territory. But it doesn’t mean there’s no good news at all.

The good news

Despite all the debunking and disappointing evidence, I do indeed have positive things to say about several of the options. I have started this part of the book with a summary of all the options, and I will conclude it with another summary of my recommendations, focusing on the positive as much as possible, and what to actually do. Many things are worth trying, even if they aren’t sure things or sitting on any solid science:

We’re told to strengthen this muscle or stretch that one, or inject this substance into an injury, or zap it with heat or electricity or ultrasound … and sometimes it really works, even though placebo-controlled trials fail to validate the treatment. I’m a big advocate of better science to really understand what causes injuries and how to treat them — but in practice, I also believe that sometimes it’s worth trying something, anything, just in case it successfully ‘reboots’ your injury.

Alex Hutchinson, Sweat Science

An encouraging perspective, but of course it doesn’t mean you should try any old nonsense. And you may save some time and money avoiding several others (or at least re-prioritizing them). You may even avoid the heartbreak of those that can do some harm. Knowing what not to do is half the battle, if not more! Understanding the topic well enough to prioritize the imperfect options is actually a huge win, the best you can realistically hope for.

•

The “negativity” of ratiocination is a surprisingly big topic, often funny, and sometimes profound. I answer the accusation in more detail in a compilation of tales of outrageous hate mail, the ethics and tactics of debunking, what it’s like to (supposedly) be the #1 Public Enemy of Massage (a therapy everyone loves to love), and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.

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A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.

• Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
• Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is strongly modulated by perception. But that only goes so far.
• Placebo is not a magical mind-over-pain superpower and its effects tend to be minor and/or brief. It can’t affect injury and organic pathology; it can only tinker with our experience of them.
• Placebo can also backfire. When a placebo effect wears off — as it usually does — people often fear that they must be really screwed, and then placebo turns to nocebo, placebo’s evil twin: feeling worse because of belief.
• Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
• One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
• Placebo has been hijacked and re-branded for its public relations value to alternative medicine. If your treatment isn’t evidence-based, no worries: you can still sell the power of placebo! “The power of placebo” is widely, weirdly used as a justification for therapy that can’t beat a placebo.
• Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The popular idea of “placebo without deception” is just bullshit, based on an experiment that created a strong expectation effect by inflating the participants’ expectations of placebo. So it was just an odd way of getting to the same phenomenon.
• Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers and caregivers) are definitely not immune to placebo. In fact, with animals there is even more opportunity for an illusion of a treatment effect.

We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”

Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.

And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.

Comic by Loren Fishman, HumoresqueCartoons.com.

What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.

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Corticosteroids are potent anti-inflammatory agents (and not the same thing as the anabolic steroids taken by bodybuilders101).

Oral corticosteroids can be invaluable for management of severe widespread inflammatory conditions — like rheumatoid arthritis, say — but they are overkill for almost any painful “hot spot,” like trying to put out a frying-pan fire by turning on the sprinkler system. If you can avoid exposing other tissues to corticosteroids, you should, because they are a bit of a bull in a biological china shop.102 Injection is preferred for its precision.

But oral corticosteroids certainly kill pain! No doubt about that. The concern is about the side effects, which can be so dire that they should only be tolerated if they are the lesser evil, and only the most desperate patients should consider risking those side effects for IT band pain relief. Few doctors would sign off on it, not with injection as a perfectly good alternative. Injections are popular because oral steroids are a terrible idea for most musculoskeletal conditions.

The rest of this chapter will consider injections only — which have their own problems, but they are at least much more local problems.

Injecting corticosteroids

People avoid needles and knives — we’re funny that way. It’s a sensible impulse, and it is reasonable to be reluctant to try the more invasive medical treatment options of injections and surgery. If you are squeamish about them — or if you simply wish to avoid the expense — then more conservative treatment methods are obviously worth a good try.

However, in the case of IT band syndrome, please do take these more invasive options seriously, particularly if the stakes are high for you, and basic therapy has shown no sign of working after several weeks. In the sections ahead, you’ll learn that ITBS surgery is attractive for a surgery — one of the best of all surgical options for any common repetitive strain injury. And steroid injections are worth considering much earlier in the healing process. In general, the invasive/medical treatments are more worth considering for ITBS than many other conditions.

Wherever pain is caused by inflammation, corticosteroid injections are also likely to produce substantial temporary pain relief — at the cost of a (minimally) invasive procedure with some risks. They can be injected with a needle, or blasted through the skin with an electrical charge (iontophoresis).

It’s limited, but there is half-decent evidence that injecting steroids into the side of the knee can help.103104 The evidence for short-term benefit is particularly decent in the case of tennis elbow (lateral epicondylitis),105 although there is also evidence that the long-term results are much less rosy, or even nasty.106 In some situations, steroid injections don’t seem to do well at all. The notorious rotator cuff of the shoulder is a hotbed of tendinopathy, and one of the most common targets of steroid injections. A 2017 review of 11 studies of 700 patients was scathingly negative.107

If ITBS isn’t acutely inflamed, why would a powerful anti-inflammatory medication be effective at all, even temporarily? Some possibilities:

• Maybe steroids don’t work as well as we are all in the habit of thinking (which seems increasingly likely as the years tick by and we see more reviews like Mohamadi et al). There might not be all that much a treatment effect to explain.
• And maybe cortisteroids are just helping for some other reason altogether — a happy biochemical accident — because steroids have many roles in physiology. For instance, steroids may have an effect on nerve pain, but not inflammation.
• Maybe RSIs cause more immune dys/function than it looks like. In this scenario, RSIs are not un-inflamed, just inflamed differently. And there is recent evidence suggesting exactly this in the context of garden variety tendinitis.

Steroid risks

Steroids in a needle are generally much less risky than steroids in a pill: injection limits your exposure to one spot. But the main risk — and it’s not nothing — is that steroids actually eat connective tissue. Slowly. It’s not like strong acid! Nevertheless, this is a Very Bad Thing, and probably explains the data about long term harm …

It is clear that corticosteroid injection into tendon tissue leads to cell death and tendon atrophy. As tendinosis is not an inflammatory condition, the rationale for using corticosteroids needs reassessment, as corticosteroids inhibit collagen synthesis and decrease load to failure.108

Since the nature of repetitive strain injury is that tissue slowly “rots” and degenerates under stress, steroid corrosion of connective tissue is an ironic hazard — steroids may dangerously exacerbate the basic problem even as they relieve pain. The risk is obviously worst in the case of classic tendinitis, where structurally critical tissue may be weakened. Few people are keen to increase the risk of a rupture just for pain relief! That’s why physicians wisely limit steroid injections to about three (although that may be overly cautious, as we’ll see).

The danger is probably less with ITBS, however — if the injection goes under the IT band as it should, then it will certainly have less impact on the more structurally critical IT band proper, which is in turn an exceptional large, tough structure. It is not clear how functionally important the tissue under the IT band is, so it is equally unclear how dangerous it is to risk further degradation. Steroid degeneration of the contents of the lateral synovial recess may be almost completely harmless (best-case scenario). Or, it could function somewhat like a bursal pad, and while damaging it won’t “blow” your knee, it could be similar to losing the protection of cartilage.

Unfortunately, many doctors are probably not yet aware of the recent evidence showing that it is tissue under the iliotibial band that actually needs the injection, and they will target the band itself — a shallow injection. The distribution of the drug around the point of injection is (hopefully) widespread enough that precise placement doesn’t really matter as far as pain relief goes,109 but we don’t really know, and injecting the IT band directly raises the concern that the steroids will unnecessarily degrade the IT band. It’s almost certainly better to aim under it.

The negative effect of steroids on connective tissue integrity is probably minor with limited dosing — a saving grace for this treatment. However, this is a most awkward and ironic collision of potential benefit with potential risk. There’s just too many variables and uncertainties here still, and no way to make a blanket recommendation for all patients: you have to weigh the pros and cons and decide for yourself whether you want to “go there.”

If three injections do not do the trick, you should probably stop trying, particularly if the pain relief is underwhelming. Some doctors refuse to do it at all because of the risk of harm, but most agree that one to three injections — particularly in this location, where the connective tissue is generally thick and tough — is no cause for concern. The danger is not great, and I suspect that, in the case of the side of the knee, up to twice as many injections are not a ridiculous idea, especially if they are widely spaced. However, there’s also no point in bothering unless they actually seem to make a significant difference: only consider more than three if you face a particularly unholy combination of great need and persistent problems (example110).

Final thought: if you’re going to try injections, be smart about it and use them tactically, coordinating them with other strategies and phases of rehab. For instance, be particularly diligent about resting in the immediate aftermath, so that you are hopefully combining the benefits of both and creating the best possible chance of success. And the corollary of that: don’t waste the injection by carelessly negating its effects with excessive use.

• Worst-case: no benefit, direct worsening of the problem (accelerated degeneration of connective tissue), and a poorer long term result.
• Best-case: significant short term pain relief without any significant adverse effects, and a useful aid in rehab.

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Surgery is generally a poor approach to musculoskeletal problems — many popular orthopedic surgeries have been proven ineffective111 or even much more trouble than they are worth (like the metal-on-metal hip replacement debacle112). But not all surgeries are useless, and, happily, surgery for ITBS may be one of the exceptions to the rule.

The technique of the traditional open surgical approach — opening the skin to get at the IT band with a scalpel — is quite straightforward, although there are many minor variations on the theme. Basically, it involves loosening the IT band at the trouble site by cutting away a small piece of it on the side of the knee — a snip on the edge of the iliotibial band, like cutting a nick in the side of a wide elastic band. This doesn’t loosen the IT band overall, but it does loosen at the side of the knee, and presumably results in a significant reduction in the pressure of the IT band on the underlying irritated tissue — more than can be achieved by any other means (i.e. stretching). As discussed already, loosening the IT band in this way does not necesssarily imply that it was “too tight” to begin with — just that loosening it is a relief for the irritated tissue underneath it.

Again, as with the injections, the procedure is well-supported by the evidence:113114 it seems to work reasonably well for most patients, and complications are not a major concern.

The main downsides to the conventional open surgeries are:

• It fundamentally involves compromising the structural integrity of the IT band. Although this does not seem to present any major difficulty, doing so is generally avoided on principle, and this technique may seem barbaric in the future.
• Recovery takes several weeks, and you’re significantly off your game during that time. Because the IT band itself is cut, and this structure is under tension with every step (especially at this location), it needs plenty of time to heal before it is ready for active duty.
• The standard procedures, unlike the new arthroscopic option, do not provide any opportunity to diagnose and treat any other knee problem. If there is another problem at the knee, the standard surgery will not solve your problem.

As surgeries go, these are not serious disadvantages. For an intractable case of this type of IT band pain, you should not be too discouraged — this surgery helps most people.

But wait for the right moment! Considering surgery is fine, but it does bother me that some people lunge for the option before giving conservative therapy a fair shot. Most patients considering surgery have not yet adequately rested, even though 90% of them think they have. Once you understand what resting really means, it’s usually obvious that your attempts at resting have been inadequate … and then you have to decide whether you want to finally rest properly, or if it’s better to just get the surgery.

The problems with surgery and resting are different in substance, but similar in severity: both involve approximately the same amount of inconvenience. Neither is really an attractive option. Both can fail. Both can succeed. Which option you choose is almost a matter of taste. With surgery there’s a small but real risk of complications, and you know that your knee is going to be next to useless for two to three months afterwards, with greatly limited training for a while after that. To drive home that surgical results are unpredictable, here’s a surgery-gone-wrong story from reader Jill Fowler:

I had IT Band problems on and off for 2 years on both sides. I then had a surgery on the right knee to remove a small portion of the band, but things have not gone well. It’s been a year now. I had swelling that would come and go for months after surgery. For the first 9 months, I had to baby it by icing it after every run, bike ride, and during the day when I could. I also wore a closed neoprene knee brace to discourage swelling. If I ran on an uneven trail today, my knee would probably swell up.

She was told that a cyst was removed, so it’s possible that her case was unusual to begin with. However, finding and removing her cyst obviously did not do the trick (as it may have in other cases, described earlier).

With resting, there’s virtually no risk except to your time … but it’s also somewhat less likely to solve the problem, and it can take quite a long time of being very careful with your knee before you find out one way or the other. When it works, it’s fabulous — it’s always better to solve a knee problem without knives, if you can. But sometimes no amount of rest relieves the irritation under the IT band, and it can take months to really be sure one way or the other if it works.

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As discussed above (starting in What’s actually irritated?), Michels et al and Hariri et al have demonstrated that it may be possible to treat iliotibial band syndrome not by loosening the IT band, but by removing irritated tissue in a pocket underneath it. Sounds great, right? Bring on the magic bullets! However, at least a little caution and patience is called for.

To recap, Michels et al, a group of Belgian surgeons, performed “resection of the lateral synovial recess”: they scraped out some thin, loose, irritated fatty tissue from around a little bursa-like pocket of tissue around the attachments of the IT band to the femur at the side of the knee, right down to the bone.115 The study was conducted primarily to test a principle, to try to prove exactly which tissues are the real source of pain. They did not cut the IT band. The results have been extremely promising. In an updated report in 2011, they reported 38 of 40 knees having “good” or “excellent” results — weighted towards the excellent116 — with all patients going back to sports within three months — and every single one of them started out with a serious, chronic case of ITBS. These results compare very favorably with the conventional surgery!

Similarly, Hariri et al experimented with bursectomy: they removed inflamed bursae or bursa-like tissues from immediately under the IT band. Like the Belgians, they got good results without actually cutting the IT band, although with far fewer patients: “Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied.”

But the surgeons performed these procedures on only a small number of knees — 40 and 12. That’s not a lot of knees! Despite the promising results, these techniques have not yet been established as effective or safe, and they certainly must still be thought of as experimental. It is possible, for instance, that the effect was a placebo. That may seem unlikely — and it probably is unlikely — but a placebo is often a surprisingly powerful thing, and several prominent scientific studies have shown that sham knee surgeries can fool people into “healing”!117

Despite these concerns, another reason to at least consider discussing this surgery with your surgeon is that it is an arthroscopic procedure — inserting a tiny camera through a tiny incision — so it is minimally invasive, plus the surgeon can easily see and correct other minor knee problems at the same time. In the 35 knees described in their 2009 report, Michels et al also found one case of femoral cartilage damage, two mensical tears, and a lateral recess with some “gravel” in it — a “calcified loose body.” That last example is quite a fascinating finding and yet another interesting, unconventional explanation for the existence of IT band syndrome in the first place, and why nonsurgical techniques might fail. That person literally had something bumpy stuck under the IT band! Remember the “rock in shoe” analogy? It might be an especially good description of some cases! These other problems were corrected, which is a major advantage to the procedure.

Best of all, though, it’s less destructive and recovery is much quicker than snipping the IT band. Faster recovery is a major benefit, particularly for an athlete.

A reader talks to three surgeons

Reader Conor G., an ITBS sufferer for several years, visited three surgeons in 2021, and their views represented the full range of views on surgery for ITBS. I thought it would be useful to share this real-world experience with asking surgeons about these procedures for a very stubborn case. Conor writes:

1. One surgeon (apparently one of the best in the country here in the UK) was cavalier and said outright that they’d stick with the “newer-older” methodology involving a small 2cm incision into the side of the knee, which is apparently day surgery.
2. Another fancy surgeon in London looked over the Michels paper and thanked me for directing his attention to it, and seemed to have an open mind about the approach. Ultimately, he was cautious and argued the case for the better-known methods, and that’s as far as we spoke.
3. The final surgeon, who is the one I have mainly been working with to understand my particular case, is very cautious about proposing any surgery for ITBS. He flat out told me that he would never personally opt for surgery in that area of the knee himself, and so he’d urge his patients not to either. He’s sympathetic to why someone might want surgery, but he thinks that one small mistake in that area of the knee could easily make things worse, in terms of scar tissue build up, or even risk someone’s leg if they were to develop lateral compartment syndrome. As he put it, “we might not be able to make you better, but we can definitely make you worse.”

I thought the latter case was particularly interesting and might be important to highlight to readers that not all surgeons think there’s enough evidence to support knifing into the side of the knee.

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Most drugs work on only about a third of the population, they do no damage to another third, and the final third can have negative consequences.

Craig Venter, extremely famous and spooky smart geneticist (public lecture, Vancouver, May 3, 2011)

Vitamin “I” — ibuprofen, the main ingredient in drugs like Advil and Motrin — is an almost universal treatment choice for iliotibial band syndrome (and, of course, every other repetitive strain injury). The drugs ease inflammation and fever, and the injury seems to be inflamed, so it’s a perfect match! Or people just take them because it’s a pain-killer and they have pain to kill. For one reason or another, nearly every patient and professional assumes that NSAIDs are at least somewhat helpful, though few are foolish enough to think it’s any kind of a cure.

In fact, the NSAIDS are probably one of the weakest treatment options — because of course repetitive strain injuries are not actually very “inflamed,” per se.

Scientific evidence on this topic has always been scarce and discouraging,118 and even the anecdotal evidence for ibuprofen is weak. I’m sure there are some testimonials for ibuprofen — there are testimonials for anything. But consider: even though ibuprofen is probably the first or second line of defense for virtually every case, the world is clearly still full of serious, chronic iliotibial band syndrome … that ibuprofen could not stop.

(Many athletes, especially runners, swear by ibuprofen as a prophylactic to prevent soreness during competition, but that’s quite a different usage, and it definitely doesn’t work.119)

So, NSAID chemistry is laughably irrelevant to the chemistry of IT band pain,120 but it gets worse: they may actually interfere with recovery from the connective tissue degeneration that actually is the problem, because NSAIDs may actually retard soft-tissue healing121 (and hard-tissue healing too, for the record122) Just what every RSI victim needs! (Fortunately, they don’t actually damage connective tissue, like steroid injections. Probably.) There’s no direct evidence that NSAID use will impede recovery from IT band pain, but it’s possible.

And it gets even worse! NSAIDs are also well-known as “gut burners” for their disagreeable and common effects on the gastrointestinal tract, which is a deal-breaker for many patients. And they can, paradoxically, actually cause headaches.123 Oh, and one more thing: they increase the risk of strokes and heart attacks, even in healthy people, at any dose. (Diclofenac [Wikipedia], a popular oral NSAID almost everywhere on Earth but North America, has even worse cardiovascular side effects than the others.124 Oral diclofenac specifically should probably be banned.) Lovely!

A drug is a poison with potentially beneficial side effects.

Dale Favier, Massage Therapist, poet

I know some readers are thinking right now, “Yeah, well, okay … but I’m still going to take my Vitamin I.” With dosing caution — small doses, short-term use — I have no serious objection. If there’s any reason to take them, it’s that they might relieve some pain by unknown mechanisms (the inflammation question is not exactly simple).

Or — and this seems almost crazy, I know — you could just actually heed the science, ignore the conventional “wisdom,” and never bother popping another NSAID unless you’ve got some uncomfortable classic inflammation to take an edge off. Imagine two NSAID scenarios …

• The (not-unlikely) worst-case scenario: slowed healing, aggravated pain, GI tract upset, increased chance of a stroke or heart attack, headaches, waste of valuable seconds popping pills.
• Best-case scenario: temporary modest pain relief, no side effects.

Speaking of dosing caution …

Voltaren Gel — not exactly a magic bullet, but probably safe, reasonable & worth a shot.

Voltaren is basically another NSAID (diclofenac) in a tube, and a relative newcomer to the range of options. Because you smear it on and it’s absorbed through the skin, you don’t have to carpet bomb your entire digestive tract and circulatory system with the stuff to get it to the problem. This significantly reduces your overall exposure to the risk of side effects125 — which is important, because the same stuff (diclofenac) taken by mouth has some serious problems126 — but you still get an adequate dose into the tissue with the issue.

Another reason that Voltaren is interesting and well worth bringing up here: it would never have been approved for sale if it didn’t have some genuinely persuasive evidence attached to it. The stuff actually seems to do something for arthritis pain — pain that probably has much more in common biologically with RSIs. So we’ve got something like a shred of a reason for optimism here and greatly reduced risk. Yahtzee!

• Worst-case: It could be just as much of a chemical clean miss as any other medication, in which case you’re basically just smearing expensive Vaseline on yourself.
• Best-case: It could actually provide some real pain relief, with a very low risk of side effects.

To wrap this up, here’s comedian Louis CK satirizing a doctor talking about the painkiller dilemma: “Oh, it’ll do some intestinal damage after a while. But you’ve just got to weigh that against how much you like your ankle not hurting!” This is a short excerpt from his 2008 stand-up show, Chewed Up.

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The apparent value of icing for seemingly “hot” and allegedly inflamed pain like IT band pain is mostly the poetic, non-medical mental imagery of cooling. The problem is not heat, of course, and it can’t be fixed by cooling.

That said, I once went down a mountain with acute IT band syndrome, and I may not have made it without ice (or snow, in that case). It may have “only” been a case of timely and extremely short-term pain control from numbing … but that counts when you’re trying to get off a mountain safely.

If ice can help a repetitive strain injury in any way beyond brief numbing, no one has ever actually proven it or shown how it might work127 — an ordinary, common home remedy that science has almost totally ignored. There’s little doubt that it’s relieving in the short term, and maybe it stimulates miscellaneous minor tissue healing processes as well. Virtually any stimulatory input to the body, up to a point, can provoke a healthy response, because of the use-it-or-lose-it principle. Stress a tissue, and it will probably get tougher (adapt) in some way. That’s the only plausible therapeutic mechanism of icing. Ice may simply be one of the easiest delivery systems for a bit of stimulation — a way to stimulate tissue without overloading it, while simultaneously getting some temporary pain relief from numbing.

It almost certainly isn’t “anti-inflammatory” in any meaningful sense for IT band syndrome.

The great advantage of ice as a treatment is not its impressive biological effects, but its thrift, ease, and safety: treatment options simply don’t get any more innocuous while still having some plausible mechanism of benefit. Therefore ice remains firmly on my “worth a shot” list for RSIs. Keep your expectations low, but there are virtually no risks, other than ice burn (which takes at least a couple minutes — probably even twice that — of raw ice application).

Used properly and safely — with a little caution not to “burn” yourself — there’s really no limit to how much icing you can do, and more of this good thing might be better. If ice works at all, particularly via the stimulation of tissue healing, then the benefits could be cumulative — even if the effect is minor.

Power icing. For these reasons, I have experimented with recommending a lot of icing for IT band pain — many times per day, as much as thirty brief doses (a minute or two) of raw ice, way more than the recommendation you would receive from most health care professionals — and some of them have seemed to enjoy excellent results. That is a nearly useless statement — it’s far too small a group to draw any serious conclusions about this approach — but the concept makes some sense and has virtually no downside. Try power icing for a few days, and see what happens.

Ice gel packs are not the best choice; instead, use “raw” ice, bare ice, ice-to-skin contact. An ice cube held in a dish towel will do in a pinch, but use an ice cup if you intend to spend any real time at it: fill a styrofoam cup with water, freeze it, cut the top inch off, and you have a large ice cube with an insulated handle. (Handy commercial ice cup products are now available as well.) Apply ice in slow circles to irritated tissues for about two minutes maximum, or until you’re numb, whichever comes first. You can do this as often as you like, as long your tissues have a chance to warm up between applications.

Note that icing is going to be effective only where the problem tissue is superficial — which it is, in the case of IT band pain. Please see Icing for Injuries, Tendinitis, and Inflammation for more detailed information.

Precision icing timing

It is possible/plausible that timing could be important, and again this is a refinement that can be implemented with basically no risk: if it’s worth trying to ice your knee, it’s worth trying to do it at times that make sense. Try icing when your knee hurts — or when you suspect that it might start to hurt but before it actually does. In other words, “head it off at the pass.” As pure pain control, of course it makes sense to apply ice at the time you need to control pain. For runners, this could be a way of adding time to your run more aggressively with minimal risk. But there might also be some tissue benefit to icing at the times when the strain is greatest, or immediately after a walk, hike, or run.

Extra tip for hikers: if you are struggling with iliotibial band syndrome on your way down a mountain — a common scenario — do not hesitate to pour icy stream water over your knee every chance you get! Very helpful — and icy stream water is more common than snow.

Don’t worry about aggravating trigger points. Astute readers will note that, elsewhere on the website, I warn that ice has the potential to make trigger points worse. Don’t worry much about that in this context.128

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If it’s worth icing, it’s worth contrasting. Ice packs and heating pads are familiar rehabilitation tools, but many people have never heard of therapeutic contrasting: quickly changing tissue temperature from hot to cold and back again. This is usually achieved with hot and cold water, either dunking a limb or even immersing the whole body.

Contrasting is a tremendously good, simple idea, and I promise that it feels better than it sounds when it’s done right. The point is to force your tissues to adapt to the sudden changes, which are stimulatory and require a lot of metabolic activity and circulatory gymnastics. Basically, contrasting constitutes an extremely gentle tissue workout: stimulation without stress and strong sensations without movement, which may be quite helpful for a body part that badly needs some rest while it heals.

Such as a knee with IT band pain.

What does the science say? Not much about this, unfortunately — just a handful of studies, all about using contrast to accelerate recovery from exercise, and notable for failing to turn up anything promising .129 Contrasting for recovery from injury is definitely unproven too, but also more reasonable and plausible, costs nothing, and is almost perfectly risk-free.

Contrasting knees is a bit mechanically awkward: they are just not anatomically convenient to heat up and cool down. (Hands and feet are much more convenient for dunking.) Your Mission: Difficult, should you choose to accept it, is to thoroughly heat the knee up for about two minutes, then cool it rapidly for about one minute. Do that three to six times. Use enough heat so that the cold feels refreshing, not alarming, and finish with cold.

1. about 2 minutes of heating: comfortably hot
2. about 1 minute of cooling: cool, not cold (unless you’re tough)
3. about 2 minutes of heating: hotter!
4. about 1 minute of cooling: colder!
5. about 2 minutes of heating: hot as you can handle
6. about 1 minute of cooling: cold as you can handle

But how? There are several options, none of which are ideal:

• Pouring. The easiest method, but probably not the best, is to simply sit on the edge of the tub in your shorts and repeatedly fill a medium sized-container with water and pour it over your knee.
• Big bucket immersion. The premium method would be full immersion in extremely deep buckets — if you have them, and if you’re short enough to submerge your entire calves and knees. However, the right buckets may be hard to come by, and would take quite a while to fill.
• Detachable shower head. Just get into the shower and start sprayin’. This is so much more convenient than other methods that I recommend actually going out and buying a shower head for this purpose, which is probably the maximum possible expense for this self-treatment method (and of course it’s also useful for actual showering). However, the effect of spraying is not as good as immersion, and a low-flow model may not cut it. An advantage to the detachable shower head is that you can easily include the entire leg, thigh, and hip, on the off-chance that stimulating the whole region is more useful than just the knee. However, beware of spreading your spray too thin and inadequately contrasting the knee itself.
• Wrapping in sopping wet towels. Get yourself a pair of medium sized buckets of hot and cold water and four good absorbent hand towels. Put a couple towels in each bucket, and put everything in the tub. Wrap a hot wet towel around your knee, then a cold one, then a hot one. This is fussy to set up, but it works quite well.

Contrasting the calf at the same time as the knee is a good idea, if you can do it. For example, immersing the legs in smaller buckets is more convenient, and you can sit with your legs in buckets while also pouring water over your knees. The more tissue south of the knee that you can heat, the better: it will force greater changes in circulation that have to go through the knee.

Be creative! And be safe. The sole hazard of knee contrasting is a low, low risk of burning, if you are particularly careless and self-abusive — so don’t burn yourself! For more detailed information and many more tips and ideas, see:

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This is not about ITBS treatment per se, even though it concerns an all-too-real email from a real person with real knee pain. He was an extremely dissatisfied customer, and basically his problem was the “negativity” of the treatment reviews. However, he spells out an unusually self-destructive attitude that I can usually only see between the lines.

This desperate knee pain patient actually says point blank that he wants me to lie to him, to tell him what he wants to hear, to give him a miracle cure that does not exist …and, if I would only supply that, he told me: “I have a lot of money for you.”

But he clearly does not want education, nuance, or any discouraging forays into fact. Here’s the highlights of the email (reproducing all errors), with some of my snarky fantasy responses (my actual responses were kinder and gentler):

Can’t do my job anymore as an electrician. Can’t stand without the sensation of a hot iron on outside of knee along with weakness and shaking. I’ve seen four physio therapists. Shockwave therapy. Laser therapy. Acupuncture with deep muscle stimulation (pulsed DC).

“Well, there’s your problem.” That’s three particularly terrible treatment methods in a row. I’ve linked to critical analysis of each. And as for “four physiotherapists,” it really depends on who you get: it can go well, but there’s still a lot of pseudo-quackery in that profession.

Over 120 minutes a day of exercises which you say are useless.

I do not say that exercise is “useless.” I don’t secretly believe it. I don’t even imply it. If that’s what you’re getting from my book, you’re reading it wrong. Unless you’re trying to fix IT band syndrome by stretching for 120 minutes per day, I don’t think your attempts to exercise are “useless.”

Please stop writing pages upon pages of how everything I and my physiotherapists, naturopaths, doctors, etc are doing is wrong. I don’t want to read a book explaining opinions and your experience and the research you went through.

I want a protocol. Tell me what to do to fix this. I am happy to put in the work. I am happy to pay money. But your literature seems to be a dissertation on why the typical things don’t work. I don’t care.

You should care! You could save yourself a lot of time and money.

Write a panflet [sic] called “how to get out of debilitating chronic pain from it band syndrome by following this protocol guaranteed” and I have a lot of money for you.

That would be fraud, because there is no such thing.

Wish I could buy more of yiur [sic] stuff because I am desperate. But you are failing yourself and those of us in pain with what you are presenting.

Mister, the only thing I’ve failed to do is bullshit you. If you really want to pay someone to just tell you what you want to hear, you won’t have any trouble finding someone to do that for you. But you can’t buy that here.

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It’s hard to stop using your knees: this is basically why iliotibial band syndrome is hard to treat. Most of the common overuse injuries afflict anatomy that we rely on heavily, of course. But you’re going to have to try!

The basic template for all injury rehab is to “calm shit down” and then “build shit up.”130 Resting properly is about taking that calm-shit-down phase more seriously than most people do, and then working your way back up to normal physical stresses more cautiously than most people do. When I talk about “resting,” this is what I mean: much more than just taking it easy for a while, but a logistically challenging process of eliminating knee stresses and then gradually re-introducing them.

It’s all trickier and more important than most people realize. It is often underestimated or simply ignored as a factor in healing, yet it is the most important part of therapy for any repetitive strain injury — perhaps more important than all other treatment options combined. It is usually what people who think they’ve tried everything have not actually tried — not well enough.

Resting will not work for everyone, but it’s very important to make the effort. A rest-test should be your “plan A.”

Obviously, if you don’t exercise at all, it is not good for you. Exercise improves your health. And a lot of exercise improves your health a lot. But that doesn’t mean that insanely large amounts of exercise are insanely good for your body. At some point, too much begins to damage various physiological systems. Everything in physiology follows the rule that too much can be as bad as too little. There are optimal points of allostatic balance.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 123

Runners are their own worst enemies

Runners often think that iliotibial band syndrome is stubborn. It is, of course, but runners are probably even more stubborn! The runners most likely to get injured in the first place — serious long-distance runners — are the same runners most likely to keep running through the pain or never rest enough to make a difference. They don’t take the injury seriously enough.

ITBS may be a relatively minor injury, but it is an injury, and it will probably not just magically go away if you keep pissing it off.

The importance of rest: the cheek-biting analogy

When you bite the inside of your cheek, the tissue is damaged and becomes inflamed: hot, red, and swollen. The swelling, of course, makes it exasperatingly easy to bite it again … and again, and again. The physiology of cheek bites is different, but it’s a lot like a repetitive strain injury in its sensitivity to reinjury and the resting required to recover.

Ask yourself: if you were trying to recover from biting the inside of your cheek, would any amount of cheek-biting be acceptable? Absolutely not. And it’s the same with this. Keep this useful image in mind as you go through recovery. Don’t keep “biting your cheek”!

How does resting fail?

Most people reading these words have already tried either “taking it easy for a while” or more of a break from the most aggravating activities (running) for a longer period. It’s common for me to hear from runners who have stopped running or reduced their training volume for long periods, only to have the pain come roaring back when they try to ramp up again. Some cases are immune to rest, but in many cases the resting simply wasn’t done well enough. There are several ways these seemingly earnest, worthwhile resting efforts can be inadequate for the tough cases:

• “A while” just wasn’t long enough. (People often say “a while” when what they really mean is “I took a week off.” A week is not enough.)
• It also usually isn’t enough to just “take it easy.” (Ironically, in the case of running, taking it easy often means a slower pace … which might actually make ITBS worse, as discussed earlier.)
• Even if running is dropped completely, many other activities can easily continue to generate low-grade knee stress — not necessarily enough to be obviously uncomfortable, but enough that you’re not really “resting,” enough to prevent or slow down recovery.
• The rest may not have been well-supported and coordinated with other treatment efforts. Rest alone is not enough in most cases. In addition to removing stressors, you also need to do what you can to support recovery.
• Ending rest too abruptly. Like a lot of medications, you can’t just suddenly stop resting and go back to normal activity. It’s important to baby-step your way back to normal knee stresses. That tedious progression is the soul of rehab.

So how much rest exactly?

Some stubborn cases might yield to as little as a couple weeks of really good quality resting. Most will take at least twice that. The worst cases could take three to six months — mine did — though you should never invest that much time in a serious resting without some obvious progress131 (or if it’s not that big a deal to you132).

• For a mild new case, three days of good rest, followed by a couple weeks of taking it easy, could be enough to resolve it.
• For the average case, you probably need about one week of good rest, followed by a couple months of gradually getting back to normal.
• For more severe and entrenched cases, a month of near total knee rest might be required, and it could take a full year of cautiously training the knee to tolerate athletic stresses again. Runners are often horrified when I tell them that the “rest” period is just the beginning, and they may have to go back to running like a beginner — but that’s how it goes when you’re injured.

There’s no way to know in advance how long your case might take … and it can be hard to tell if it’s working without testing it out and going for a walk or run — which could re-irritate the problem just as you’re finally making headway. There are two basic strategies for dealing with that dilemma, and which you choose is a matter of personal style.

1. The overkill method — get it all over with a single mighty resting effort, possibly much more (and more inconvenient) than you actually need. But it will either work … or you can scratch it off the list and honestly claim to have really tried the heck out of resting.
2. The escalation method — make the minimum investment in resting that might work. If it doesn’t work, you up the ante and try again. If you’re lucky, your first or second attempt will do the trick. If you’re unlucky, you’ll try longer, deeper phases of resting several times in a row — a long process — and still fail. (I was an escalator with my own ITBS.133)

Total rest? Should I use a wheelchair, or what? Crutches, maybe? Just how much should I avoid knee stress?

Truly total rest/immobilization is rarely a good idea for any kind of rehab; we even avoid casting fractures these days, whenever possible. However, for anyone who can swing it logistically, it can be a good idea to temporarily go to extraordinary measures to reduce knee stress. To “calm shit down” more aggressively than you probably ever imagine when you started this book.

A wheelchair is a big step, a complicated thing to adapt to. I wouldn’t recommend it for any case except the most extreme.

Crutches, similarly, are probably overkill for most cases. They also have their own risks — they are extremely awkward. However, they are quite accessible, and you might consider using them part-time for a few days.

Canes and walking sticks, however, are truly excellent options: easy, effective, and practical. They significantly reduce knee stresses without cramping your style too much. It’s a really good idea to integrate one of these into your resting plan.

Is it possible to heal without resting?

Probably not, no — at least some rest is required. I am not aware of any case of iliotibial band syndrome actually resolving while someone was still running and progressing with training. I’m not saying it’s impossible, but it must be difficult and rare. Someone out there with a mild-to-moderate case of iliotibial band syndrome might manage to heal without really slowing down. But that person is probably not you.

I have occasionally seen cases resolve while running at a significantly reduced intensity. If you diligently take care of your iliotibial band syndrome in every other way, and if you slowly increase your running over a month or two, you might recover from iliotibial band syndrome while still running. But that’s a riskier road to take.

And yet rest alone may not be enough to make ITBS go away. There’s no way to know for sure, but who seems more likely to recover: the person who just rests, or the one who rests and uses every other rational treatment option available at the same time?

Is there any science about how well resting works, or the best way to do it?

Not really, no. We have no evidence-based guidance on how much resting is effective, or exactly what tactics work best. The importance of resting seems to be too obvious for science to bother testing directly.

We really know nothing about exercise dosage for any kind of chronic pain, and exercise dosage is just a mirror image of resting dosage: less exercise is the same as more resting.134

One of the main conclusions of a major review of “How much is too much?” is that there’s not enough research, and what we do know is mostly from limited data about a few specific sports.135 There’s enough science to be confident that “load management” is definitely important overall, but not enough to know how to optimize it. Although it’s well-known that spikes in training load in sport are a major risk factor for injuries of many kinds, even in 2018 “there is an urgent need” for testing how quickly athletes can actually ramp up load without breaking themselves.136 It’s astonishing that we don’t know that already, but even that research — surely one of the highest specific priorities! — still wouldn’t constitute a direct test of resting as a treatment strategy (even though it would have obvious relevance137).

I really wish someone would do a nice controlled test comparing “extreme” resting for runner’s knee (avoiding most knee stress from any source) to ordinary resting (avoiding obvious sources of knee stress from running or workouts, but otherwise carrying on as normal).

But that’s a pipe dream. I doubt I will see it in my lifetime.

There are scraps of relevant research here and there, but mostly we have to read between the lines of research on the risks of excessive loading in sport. If too much loading, too fast, is the major risk factor for injury, that strongly suggests that less and slower loading — “resting” — is probably effective injury prevention… and what prevents ITBS often also treats it. So I am not exactly going too far out on a science limb recommending good rest.

Bottom line: my resting advice is based on scientific plausibility, relatively low-cost, and virtually no harm. But not, unfortunately, not a stitch of directly applicable research — not even close.

For (quite a lot) more about how and why you should rest, see The Art of Rest.

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A major part of the art of resting is finding ways to stay active and fit without placing stress on injured or severely fatigued tissues. Like rest in general, relative rest is a neglected concept in rehabilitation. The challenge can and should be tackled with precision and creativity.

For many athletes, the prospect of resting for weeks while recovering from ITBS seems like a shocking training setback. One of my readers emphatically told me that she would lose her edge in a matter of days if she couldn’t keep training, throwing off months of carefully timed preparation for the next marathon.

This fear of resting is a very common, nervous objection to resting: the fear that you will “go to pot” or get critically out of shape. It’s true, you can lose your athletic edge pretty quickly. Optimal, competitive fitness takes hard, constant maintenance. But you lost your shot at maintaining optimal fitness the moment your knee started hurting … and you aren’t going to get it back until it stops. And your next marathon was a lost cause the moment your knee started to hurt, so blowing the training schedule is pretty much a moot point.

The only thing worse for an athlete than having to take a break is failing to heal entirely.

For highly motivated individuals, it is often emotionally vital — sanity preserving, even — to find a way to continue training anyway (and there is always the marathon after the next one). So we look for alternative forms of exercise, ways of training without pissing off the bad knee.

If you rest, you certainly won’t “go to pot” in a month. Or two. Or even six. But you certainly will go to pot if you never heal! Long-term pain is a much greater threat to your fitness than short-term resting. And nothing will keep an overuse injury going like more use! So, first things first. It takes what it takes. In general, you must be healed before you can maintain or develop fitness, let alone optimize it.

One simple way to stay in shape while protecting your knee is to switch to cycling or swimming … unless you’re already a cyclist or a swimmer, in which case you have to come up with something even less stressful.

Swimming is intensely aerobic and relatively “knee neutral.” You can improve the knee protection substantially by using a pull buoy.139 Unfortunately, swimming is not a practical or desirable option for many athletes. Not everyone’s a swimmer. Cycling is a more popular backup exercise.

Cycling. So for a long time, I particularly recommended cycling as an alternative form of exercise to runners who were recovering from iliotibial band syndrome. On the one hand, cycling is probably not as hard on ITBS as running, because “the foot-pedal forces during cycling are only 18% of those occurring during running while the ITB is in the impingement zone.”140 But, yikes, do you really want to be irritating your iliotibial band syndrome 18% as much as usual?

For some athletes, the answer is yes: an 82% reduction in irritation of the knee — while still being able to train aerobically — is an absolutely acceptable risk. For a triathlete, shifting the focus of training to the bike is actually productive instead of a frustrating distraction. But for a pure marathoner who has no particular interest in cycling, enjoys swimming, and lives near a pool, it would make much more sense to switch to swimming rather than risk the irritation of cycling.

How about elliptical machines? Probably okay for most people, but it depends, and they have one obvious disadvantage compared to cycling: less control over loading. On an elliptical machine, you’re always bearing your full body weight. On a bike, you can dial the resistance down much lower. And yet they have their place. They are clearly not as hard on the knee as running for most people.

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Judy Baloo is a Toronto native formerly from my own home of Vancouver. She has been running for about 15 years. Her first half marathon was in 2011, on her 40th birthday, and in 2016 she decided to commit to training for a marathon. Her first was in 2017 in Ottawa, followed by the Scotiabank Waterfront in Toronto in September 2017, and then Boston Marathon in April 2018. She was looking forward to a summer of training for the New York marathon that fall.

Things were looking great. But that was an awful lot of mileage, without any injuries, so maybe it’s not surprising that her number came up.

Phase One: Judy realizes she’s got a problem

On June 17, about 7 kilometres in to a run, she noticed some strange discomfort — “not really pain, just odd” — on the outside of her left knee. This is an example of a slow onset; many runners are in agony within minutes.

The next day, while out for an easier, slower run with a friend, it came back again, and this time there was some pain, but it was still trivial. She knew enough to suspect that it was IT band related, but it didn’t seem bad enough to abort the run. After that, though, she took a few days off and did all the conventional stretching and icing, taking the advice that you can get from 10,000 articles and videos.

But she didn’t take a real break. She was back to training soon, and right into a longer run. The pain started around 12 kilometres.

That’s where I should have stopped! But I decided to run the last part of my husband’s run with him. He is a slower runner, and it was during those couple of slow kilometres that my knee became really painful and there was no denying that full-blown ITBS had arrived. As the day progressed even walking became painful.

Notice that twice now in this story her symptoms have flared during slower running. Just sayin’.

Phase Two: Things get more serious

For three months she battled the pain: massage, acupuncture, ice, stretching, and more. Everything except solid rest, of course. Initially she switched to cycling and it was a week before she realized that cycling was actually contributing to the problem. She began a run/walk regime, and soon found that 5 minutes of running were too much and so she eventually settled on 3:1.

Things looked up for a while. She found that running at a faster pace didn’t set off nearly the discomfort of running at a slower pace. Things were starting to feel less bad, and she was starting to get optimistic. Relatively minor flare-ups could be tamed with ice. But in retrospect, she was simply avoiding most of the problem with a less demanding training regimen. And when she tried to get serious with the running again… boom, her knee flared right up like nothing had ever improved, and it could not be soothed. Her summer of training was looking like a bust.

That should have been the clue to take New York off the schedule. But nope! As you say in your tutorial, I was ready to do anything to keep running — except stop running.

That’s when she discovered this tutorial, which she claims to have devoured in a single sitting, seeing herself reflected in the words again and again, nodding furiously at almost everything. “It all made such sense! Except, of course, the part about resting. I just flat out ignored that part, because I didn’t like it. Real Runners Keep Running!”

And there were only 7 weeks left to ramp up to the marathon distance.

Phase Three: Acceptance

But the next time she ran, it was bad, and the light finally went on as she ran. “I couldn’t hide from it for long. I couldn’t seriously believe, after everything I’d been through, that it was was wise to impair the healing process even further by pouring on the intensity until a marathon that fall.” It took her the rest of that run to come to terms with it, but she did.

She withdrew from New York — always a tough choice for any marathoner. And she gave her knee a thorough resting, and then resumed training very cautiously. “Probably not as cautiously as I should have,” she says, “but a lot more cautiously than before. Baby steps!”

And then she ran the Boston Marathon the next year. And a few more since then.

Rest is never guaranteed to work, and anecdotes aren’t evidence of efficacy, but this is a nice story of apparently successful load management. It seems like Judy was a runner who just had to come to terms with not running for a little while — and then she could get back to it without much difficulty. Sometimes it’s that “easy.” Though even with a clear cut success story like this, which went just about as well as any determined runner could dare to hope for, it wasn’t actually easy or quick at all, and it cost her a marathon and lots of frustration and uncertainty.

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Over the years, a handful of readers have reported a simple way to achieve short-term relief from ITBS: the duck-footed posture, turning your feet outwards while you walk (or just the affected side), also known as slue-footed (the odd official term). In the midst of an acute flare-up, people have claimed, this significantly reduces the severity of the pain.

This is not a difficult or risky thing to experiment with, and it’s well within almost everyone’s movement repertoire. Pointing the toes outward comes almost entirely from external rotation of the hip, and the hip can certainly handle it.

The minor cost of this gait is that it’s a bit inefficient. (Please ignore the zillions of articles online that go way overboard and demonize this alleged movement “defect.” It’s not biomechanically important unless it’s quite extreme.) We normally keep our feet aimed in the direction we’re going because we use our toes in walking and running. If you try to run with highly exaggerated external rotation, you’ll quickly discover that it’s not something you want to do for all that long.

But it might be handy in a pinch. If it reduces the pain. If it works, it has three main interesting implications:

1. It suggests something about the nature of the beast, though I am not sure what. My first guess would be that it reduces tension on the IT band, primarily by the mechanism of making it harder for the gluteal max to pull on the IT band — because it is both a major external rotator of the hip and partially responsible for IT band tension.
2. It might be a way to help you get home if you get stuck with strong ITBS pain. If you get into trouble on a run, and you can’t get a ride home, you might be able to duck-foot it home more comfortably — and limit the severity of the flare up.
3. It might be an effective tactic you could use to assist with load management throughout rehab. If it’s a way to walk with less irritation, by all means, every time you have to walk (or descend hills/stairs) during rehab… maybe a little external rotation to reduce its impact.

Some ducking doubts

It seems a little bit unlikely to me that this will relieve pain in the majority of sufferers, simply because it doesn’t seem like a hard solution to stumble on. Surely more people would know about it?

I did not stumble on it during my own severe bout of ITBS in the late 90s. And — importantly — I already swing my right foot way out to the side. I have a slightly gimpy foot. Specifically, I have a “fixed forefoot varus,” meaning that the front of the foot is twisted away from the midline, just because the bones are shaped like that.

My foot does not look deformed at all, but it does have an effect on my foot position and gait. It’s minor and subtle, but unambiguous. As soon as I could walk, I did so with my right foot turned out. The first time my parents took me cross-country skiing, when I was just a tiny lad about three years old, I had trouble keeping my right ski in the track! It just kept popping out. I tell the story of my funky foot in more detail in my plantar fasciitis tutorial, where it’s most relevant.

For our purposes here, suffice to say that my chronically ducky foot position obviously did not protect me from ITBS. Not only that, I had always assumed that it was probably part of the reason I was vulnerable to ITBS in the first place! Not that I actually know, but it always seemed like a reasonable hypothesis.

Maybe slue-footed posture is only helpful for ITBS when the external rotation is particularly extreme. And maybe that explains why most people don’t stumble on it. But, if “particularly extreme” is what it takes, it’s also proportionately less useful as a load management tactic.

And maybe it only works if the external rotation is relative to your normal posture — which is why my normal duck-footing was irrelevant. Perhaps I would have noticed an effect if I’d made a point of swinging my foot further out.

Try it and let me know!

Having added this chapter to the book, I hope I can collect some reports from readers. At least half the people who buy this book are patients with serious ITBS cases. If that’s you, please try this, contact me, and report your experience. With any luck, I can update this chapter with better anecdata. 😜

Here’s the only example I’ve received so far (the absence of reports being noteworthy in itself). From reader Eugene Zolenko (attributed with permission, of course):

Just read about duck-footing relieving ITBS and want to add my own case — it totally does. I got my ITBS after a 14-hour hike going up and down two peaks in the same day and then descending in a dry creek bed with lots of boulders. Up a boulder, down a boulder, up and down!

Anyway, since then I often get flare-ups when going down a mountain (or a long walk with a kid on my back). Rotating the foot outwards helps when going down a reasonably steep slope, as well as not bending the knee when possible.

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The buzz began in 2000, when Fredericson et al reported in the Clinical Journal of Sports Medicine that “long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners.”141 Better yet, they found (or seemed to) that “symptom improvement … parallels improvement in hip abductor strength.”

This wasn’t a perfect study. It didn’t prove that weak hip muscles actually cause iliotibial band syndrome, or that strengthening them will cure it. The researchers showed only that — maybe — these things tend to go together: ITBS and hip weakness, sitting in a tree, kay-eye-es-es-eye-en-gee.

It was intriguing.

Beware! People, including scientists, are too easily impressed by correlations like this. Rather than causing iliotibial band syndrome, it’s possible — downright likely, in fact — that hip weakness could be a minor symptom of iliotibial band syndrome, collateral damage.142 But there was a lot of excitement about it anyway, and in 2005, drunk on his own Kool-Aid, Fredericson made the correlation mistake, publishing the indefensible opinion that hip strength does indeed cause ITBS,143 even though his original study had proven no such thing, and he hadn’t done any other research on the subject since then, and neither had anyone else.

Phase 2: The Hypening

A month later, someone else finally did: Niemuth et al published “Hip muscle weakness and overuse injuries in recreational runners.”144 Although they found the same association as Fredericson et al, that really was all they were looking for, the sample size was small, and they didn’t prove a causal relationship, which they freely and specifically admitted (“ … no cause-and-effect relationship has been established”).

In 2006, Lori Bolgla and a team at the University of Kentucky joined the fray. They studied various muscle strength and function measurements in relationship to patellofemoral pain syndrome,145 finding only a “moderate” association between that condition and weakness in one minor hip movement (external rotation), but conspicuously did not find a significant difference in the “main” hip strength movement: hip abduction.146 The authors clearly state — and no surprise here — that “we were unable to determine if hip weakness was a cause or a result.”

Still no smoking gun here. A definite absence of gunsmoke.

In 2007, Ferber et al completed another study.147 Despite never being published, both the researchers and media made way too much of the results — a damning example of science-by-news-release. “I think this is a good news study for people who are living with chronic running pain,” said Dr. Ferber. “You can do something about it.” Such optimism! Reporting on it for the Calgary Herald, Trent Edwards wrote (no longer available online): “While most running injuries happen in the knees and lower legs, it turns out their root cause is almost always weak hip muscles.” The whole thing has a weird eureka tone, as though a great mystery had been officially solved. But Dr. Ferber was clearly ahead of himself. Everyone loves a root cause!

Patients bring such media reports to me in a tizzy of optimism, and I have to be the wet blanket. I have to explain that — just like with every other Holy Grail of biomechanical theorizing — the jury is not just “out,” the trial had hardly even begun. A dozen necessary studies were still missing in 2007. Reaching a conclusion based on the evidence back then wasn’t just difficult, it was impossible in principle.

Not much else happened for three more years, while the hype marched on and the researchers continue to promote their hypothesis.148149 The promotion is obvious in a general review of running injury mechanisms in 2009,150 and then again in 2010, in a paper which did not even present good evidence of correlation, let alone causation.151 Those were paltry scientific contributions, and I dropped the topic in a bit of disgust at that point. And so could you. Skip this next bit if you’re already convinced/disappointed, because there’s very little to add, and what little there is mostly just confirms that this is a dead end. But I am obliged to be thorough, because that’s what you paid for.

Like cold fusion, but with smaller press conferences

When there are signs that a scientist may be just a little too fond of their own exciting hypothesis, eventually other scientists come along and try to find the same thing … and usually fail. Like cold fusion, but with smaller press conferences.

The first example of failed replication of the hip weakness hypothesis was in 2007, just as the hype was really surging. Grau et al said everything I’ve already said above, but more formally, with a paper titled, “Hip abductor weakness is not the cause for iliotibial band syndrome.”153 They did a tiny test of strengthening to see if it would help, comparing hip strength in ten runners with and ten without IT band syndrome. There were no meaningful differences, and “strengthening of hip abductors seems to have little effect.”

Which was followed by years of scientific silence. During which time tens of thousands of runners were told by well-intentioned clinicians to strengthen their hips to prevent/treat ITBS. They all thought they were practicing not just evidence-based medicine, but bleeding edge EBM. Ruh roh, Raggy!

Fast forward all the way to 2014: a small paper reported only one minor part of hip strength was detectably weak in injured runners — internal rotation — and it was hardly a big difference.154 “Teensy” is the technical term for that kind of difference. And while internal rotation is indeed part of the biomechanical equation, it’s hardly what people are thinking of when they think of hip strength. “Obscure” is the next adjective that comes to my mind.155

There’s only one more scrap of science I know of, in 2015, yet another small one (of course), reporting a modest weakness in hip strength — the more familiar kind, abduction — but only in runners with previous IT band syndrome.156 Runners with current ITBS … well, that was just a big fat nothing burger. No link at all. And the link with previous cases hints that what little weakness they found might well be a long-term consequence of being injured, not a cause.

There’s no other science to report on except a few review papers, formally trying to make sense of the same inadequate evidence I’ve been weighing here, some of them concluding that there may or might or could be a link possibly, perhaps. But others, like Louw et al, have more honestly concluded that, duh:

The literature is inconclusive with regards to muscle strength deficits in runners with a history of ITBS.157

So the whole thing just reeks of “pet theory” syndrome, and it’s extremely unlikely that hip weakness causes IT band syndrome. And therefore it is also extremely unlikely that strengthening hips will prevent or treat it.

Why not strengthen your hips anyway? Who doesn’t want stronger hips?

You probably have better things to do than progressively load obscure muscles that probably have nothing to do with ITBS. But I suppose if it was me, if my own case of ITBS made a comeback and got really stubborn, I might do it anyway. It’s certainly not going to hurt anything. I can’t endorse it, but I don’t object to it either.

Just go in with your eyes wide open. You might be wasting your time. Just like five hundred soldiers who already tried it on your behalf …

Here’s one more bit of discouraging science I held back for a punchline. This was not a small experiment: it was a huge test of a thousand soldiers that failed to show any (injury prevention) benefit to hip strengthening. Although one study is never enough to settle an issue, this one almost could. The results were published in 2008 in the American Journal of Sports Medicine.158 500 soldiers did both stretching and strengthening exercises chosen to try to prevent overuse knee injuries. Hip abduction was included, specifically because of the hype about hip strengthening: because of the prominent papers pushing it as a possible risk factor. 500 more soldiers did no exercises for comparison.

Results: the injury rates in the two groups were … almost identical. And what difference there was between them was (slightly) different in the wrong direction. The group that did no exercises actually had slightly fewer injures: 48 injuries instead of 50.

Generic hip strengthening is definitely not preventing IT band syndrome. And if it’s not preventing it, it’s not going to treat it either.

A scrap of data about hips tiring out faster in ITBS patients

In 2019, Brown et al reported on the results of a teensy little trial, contributing just a little bit of indirectly relevant data.159 They took some measurements of a couple hip muscles, gluteus medius and tensor fascia latae, before and after running on a treadmill until they were worn out. They were mainly trying to determine the effect of running on the strength and responsiveness of hip muscles, which is kind of an oblique take on the central question.

Unsurprisingly, hip muscles got weaker after hitting the treadmill so hard, and equally so in both groups. Despite that, the authors conclude — on the basis of one other single metric — that the gluteus medius “does demonstrate less resistance to fatigue,” slightly. In other words, they found one subtle and technical sign, in just 12 injured runners, that was more “suggestive of fatigue” than the other signs. Scraps of evidence don’t get much thinner.

They wrap up by recommending strengthening of the gluteus medius, as though their data demonstrated a need for that. It does not. If gluteus medius actually does have poor fatigue resistance in runners with IT band syndrome, there’s no specific reason to think it isn’t just a trivial symptom of the condition — rather than a defect that needs correcting.

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There are several different kinds of therapeutic massage and self-massage options for iliotibial band syndrome. None are based on any scientific evidence. A couple approaches are sensible enough, and their value might be confirmed by research someday. Several other massage therapies for IT band syndrome are probably a bad idea. The next three sections discuss the three primary popular options: IT band massage (long strokes on the side of the thigh), trigger point therapy (primarily for the hip musculature, but not exclusively), and transverse friction massage.

Direct massage of the IT band — pressure on the band itself and the underlying quadriceps muscle — is by far the most common kind of massage therapy offered for IT band syndrome. It’s also probably the most simplistic and useless. If you are a manual therapist who has employed these methods, please forgive my particularly intense disdain for them.160

Typically, strong Swedish massage is used to “lengthen” the IT band and/or “unstick” it from the underlying quadriceps, and the intention of this treatment is rarely any more complicated than that. These approaches to ITBS have a cave-man level of therapeutic sophistication: “IT band hurt, ugh! Therapist Thag must rub IT band!” Patients are routinely instructed to perform the same massage treatment on themselves using a foam roller at home. It’s a painful place to massage strongly. In this section, I’ll show that it’s also pointless.

Some therapists may also claim that the underlying quadriceps (vastus lateralis) muscle is an additional target of the treatment, but they’re unlikely to have a clear idea how quadriceps massage is supposed to help, and the focus of the treatment will still be on the IT band itself, which is probably futile.

Graston Technique® or Astym® (or the Chinese gua sha) are variants of IT band massage that are quite savage, using wicked-looking stainless steel “scraping” tools to allegedly break down tissue adhesions. They are not as common as the other methods, but I pick on them because they are painful and costly and so focused on the dubious idea of treating the IT band itself.

So what’s the problem with these treatments? They are all based on poor understanding of the condition, the anatomy, and of connective tissue.

The iliotibial band is a massive structure, the largest tendon in the body, made of a bio-rope stuff that is slightly elastic but with a greater tensile strength than steel cable. Collagen is an extremely tough protein. It cannot be elongated beyond its natural elasticity by any known method short of surgery, and certainly not by rubbing it or (even sillier) rolling over it. Here’s an absurd little thought experiment to demonstrate how silly it is:

1. Measure a leather belt.
2. Lay the belt out on the edge of a table.
3. Grease up your elbow with some lubricant.
4. Slide your elbow along the length of the leather belt. This patient feels no pain: be as brutal as you like!
5. Re-measure the belt. How’d you do? Make much progress?

Now consider that leather is actually much less strong than tendon. Leather is cow skin — remarkably tough, but with a lower tensile strength than tendon, and much easier to tear. Tendons are so tough that they basically don’t tear at all, ever.161 Yet even if you halved the thickness of that belt, hung it from a strong hook in the ceiling, and pulled on it with all of your body weight, it would probably still hold you.

So … good luck trying to “elongate” the IT band with massage.

Even if you could elongate the IT band by rubbing it, this would surely not be the smartest way of doing so. This is a tendon we’re talking about here: tendons tie muscles to bones. If you want to change the tension on a tendon, change the behaviour of the muscle. Changing muscle tone is not exactly easy either, but it’s certainly more plausible than beating the IT band itself into shape. Consider this: if you want to loosen your hamstring tendons, should you massage the tendons, or the hamstring muscles? The muscles, of course!

There’s a dead giveaway that therapists who do this treatment are really not thinking it through: they usually ignore or minimize the hip muscles, the same muscles that actually control the tension on the iliotibial band.162 In my many years working as a massage therapist, I asked many clients, “Did your previous massage therapist work on muscles in your hip at all?” They routinely replied, “Nope, just the side of the thigh.”

What about thixotropic effect? Some therapists might try to argue that “thixotropic effect” is the method behind their madness. This is just a straightforward abuse of the concept — it doesn’t mean what they think it means. Thixotropic effect in physiology is the tendency of certain tissues to become a little softer when kneaded or stressed. This is a real thing.163

However, thixotropic softening is a minor and transient response with no effect at all on the length of the IT band, only its pliability; and, whatever effect thixotropy has, the IT band rapidly reverts to its previous state after treatment, like a piece of warm plastic thrown into a snowbank.

What about breaking adhesions?

Some therapists justify IT band massage by arguing that the IT band is literally “stuck” (adhered) to the underlying quadriceps, and that this accounts for IT band tightness. This is a popular concept. While thixotropy is obscure, adhesions are downright popular — you’d have trouble finding a therapist who didn’t bring them up in this context. But discussing adhesions here hopelessly mixes up the ideas of elasticity, tightness, and freedom to slide.

Like thixotropy, adhesions are a real thing — tissues can become stuck together by a slight chemical bonding of hydrogen atoms that protrude from the surfaces of connective tissues like the hooks and loops of Velcro. But the elasticity of tendon is determined entirely by the molecular structure of the protein molecules that make it up164 ... not on the ability of layers of connective tissue to slide over each other.

Unfortunately, the adhesions justification is particularly wrong because it ignores the normal anatomy of the IT band, which is actually anchored to the femur for most of its length — it’s not free to slide in the first place, so it can hardly be deprived of that power by adhesions! You can’t “free” what was never pathologically stuck to begin with. Short of quite a bit of messy work with a scalpel and cutting the IT band free of its moorings, you can’t make the IT band available for sliding.

And, equally important, even if you could “free” the IT band, you wouldn’t really be “loosening” the IT band, not in the sense of making it more slack, which is clearly what IT band massage is supposed to achieve. A tight IT band could, in principle, slide just fine — if it were free to slide. Muscles and tendons generally do slide over underlying structures, tight or not. “Freedom to slide” and “tightness” are simply not the same thing.

As if it weren’t bad enough already, the adhesions justification gets sillier still: adhesions probably don’t even exist under the IT band to any significant degree anyway. Such adhesions are a clinical problem only in people who are significantly immobilized due to paralysis, and even then adhesions can be broken up relatively easily — this is just stickiness, not scarring. In active people — like virtually all patients with IT band syndrome — it is basically impossible to develop any significant adhesions anywhere in the body.

So, adhesions probably don’t exist in this location, have nothing to do with IT band tightness at all, and can’t prevent sliding powers the IT band never possessed in the first place. It’s therefore a good mystery why therapists are so busily trying to break them.

What about the quadriceps muscles?

Some therapists may argue that long, deep strokes up and down the length of the iliotibial band are actually intended to massage and treat the quadriceps. Foam rolling is often recommended as a delivery system for those strokes. It’s a popular self-treatment for the thighs, regardless of IT band problems. A 2012 trial of foam rolling is the first of its kind: Macdonald et al measured its effect on knee range of motion in healthy men and reported a small, temporary boost, but that sure doesn’t prove much — and the study was small and inconclusive in any event,165 the tip of a research iceberg that doesn’t exist yet.

Trigger points in the quadriceps might contribute to pain and feelings of stiffness and dead heaviness in the thigh and knee. To the extent that typical Swedish massage of the quadriceps relieves those possible trigger points — which it might, though not so well as deliberate trigger point therapy — it might provide some temporary symptom relief only.

“Happier” quadriceps musculature could also lead to slightly altered hip and knee function, and this could conceivably result in changes in IT band syndrome — but would those changes be beneficial? Lasting? Or significant? No one knows any of that, but perhaps. I will devote a separate section to this approach shortly, though, because it’s at least promising. Alas, happy quads are rarely the actual goal of professional massage therapy — the fantasy of IT band lengthening is much more likely to be the focus of treatment.

Graston Technique® and Astym®: Scraping the IT band with hard edges

Instrument-assisted soft tissue mobilization (IASTM) techniques (best known as brands like Graston Technique® and Astym®) are the coup de grâce of this parade of inanities. IASTM is mainly intended to break down scar tissue and adhesions, and/or to force tissue adaptation with an intense, mildly damaging stimulus (provocation therapy).

GTindy, CC BY-SA 3.0 | upscaled, cropped

The steel massage tools of
Graston Technique® & other IASTM brands. for ITBS involves intense scraping the thigh musculature & IT band.

This rationale is appealing to many patients — “We are going to tenderize the IT band!” — but meaningless. IASTM is scientifically bankrupt.166 A systematic review of several studies of it in 2016 concluded that it produces only “insignificant results which challenges the efficacy of IASTM as a treatment for common musculoskeletal pathology.”167 That evidence is incomplete and does not rule out the possibility that it could work on IT bands, which are obviously a bit of a special case, but it is quite damning. It’s not the last nail in the coffin for IASTM, but it’s probably one of the last.

And the IT band may be a special case, but if anything it’s less likely to respond meaningfully to scraping than other structures.

I explained above the IT band is so incredibly tough that it’s a complete fantasy that it can be lengthened with massage. If you wanted to try, though, maybe the steel tools of Graston Technique would do the trick? Not likely! Consider the leather belt analogy again: I don’t think any amount of force (that the patient could tolerate) would do the trick, and possibly no amount of force at all would work.

“Scar tissue” is a bogeyman that has absolutely no place in this discussion. No one is scarred without an injury. So why would anyone’s ITB in particular be scarred without an injury? Therapists who talk about scar tissue where there has been no injury have simply wandered away from physiology and into marketing language. Unfortunately, this is common.

Adhesions are sometimes imprecisely portrayed as a type of scarring, but that’s misleading: they are fundamentally different. And adhesions, as discussed above, are not clinically relevant to ITBS in any case.

There is just no rationale for IASTM that is consistent with what is actually known about the nature of connective tissue or iliotibial band syndrome. Furthermore, it is such an aggressive approach that there are several ways in which it may simply add injury to injury.

Finally, some good news

This has been a long section about a lot of things that don’t make much sense and probably don’t work. Fortunately, we can end it on a simple, positive note: a perfectly good reason to try “elongating” massage, even foam-rolling … just not focused on the IT band itself, but on the muscles that control tension on the IT band.

Massage literally loosens muscles, a little bit, temporarily, probably. A few firm massage strokes along the length of a muscle — parallel to the fibres — increases the flexibility of the muscle.168 It’s almost certainly a neurological effect. It’s not breaking up adhesions. It’s not melting anything. It’s probably just temporarily changing the behaviour of the muscle with some sensory input.

Do this to the right muscles, and it probably can reduce tension on the IT band. It’s not a big deal, but at the right intensity it feels nice and it may provide some (much needed) temporary relief. Bringing up the rock-in-shoe analogy yet again, loosening your laces doesn’t exactly solve the problem, but you probably still want to loosen your laces.

The muscles that cinch up the IT band are:

• gluteus maximus
• the tensor fascia latae
• the peroneus longus (a little known curveball)

All of these are worth massaging in the context of trigger point therapy as well, so I’ll defer detailed instructions to that section, which is not far below.

Massaging the IT band itself, even though it may have no mechanical effect, might have a sensory effect. In other words, because it’s essentially a giant tendon for the gluteus maximus and tensor fascia latae, it’s possible that massaging it has at least some of the same effect as massaging the muscles themselves. This might even be why so many people swear by foam rolling of the IT band. But they would probably get better results if they focused on the muscles rather than their big tendon.

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A reader reported a craaaazy example of dangerously unwise therapeutic advice — an instant classic for my files. Extreme medical incompetence always makes for a good story … and a teachable moment. I think it’s important for readers to see just how far wrong therapy can go, how illogical and unreasonable it can be. This story will give you a disturbingly clear sense of how irrational and foolish the devotion to conventional wisdom can be!

It all started with a steroid injection for knee pain. As you read above, steroid injections are a reasonable treatment option, worth a shot in tough cases. Unfortunately, no treatment is risk free, and she demonstrated this in spades, with a rare and particularly severe negative reaction to the shot: a phenomenon sometimes called “steroid flare.” The result was an evil welt running up the side of her thigh: “super red, hot to touch, swollen, hard” and so painful she could barely touch it.

She was understandably alarmed, and she returned to the doctor’s office. Stunningly, she was told on the spot to go home and “roll it” — an intense massage technique, pointless and ineffective at the best of times, but actually awful and dangerous in these circumstances. He might as well have told her to massage an open wound, or to treat a fracture with a hammer — a few good whacks should help!

She didn’t do it, of course. She was horrified, and promptly moved on to another doctor, who immediately declared the prescription to be the stuff of malpractice. Obviously!

It’s always frustrating and morbidly amusing how illogical treatments persist in health care. As I mentioned, I have seen many cases over the years of rolling and other intense IT band massage being prescribed in inappropriate circumstances. For instance, patients often mention that foam rolling had been prescribed to them for other knee conditions that have nothing to do with the IT band whatsoever, and couldn’t possibly be treated by rolling even if rolling did work for IT band syndrome — multi-dimensional wrongness!

But this?

Was this professional blind? Or sadistic? How is it possible to be that incompetent? It’s hard to know what to make of it. And it’s disturbing that people like that can get through our schools and get certified.

The cherry on top of this story is that the patient had read this book and was well aware that rolling is not much of a therapy, and she said so. The doctor’s bizarre emotional response was to evade the obvious issue — the insanity of massaging a severely inflamed welt — and to double-down with an emotional, stubborn lie. He blustered, “The evidence does support foam rolling.” That was nothing but a clueless bluff. There is no such evidence.

Bad treatments are often recommended for incredibly bad reasons, but this is definitely one of the best examples of it I’ve ever seen.

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We’ve already established that trigger points (muscle knots) might be partially relevant to iliotibial band syndrome, because they could cause shortening of the muscles that increase tension on the IT band and/or because they may screw up hip function a bit (causing weakness, poor coordination). We have some credible reasons to believe that trigger point therapy might be an effective treatment — no hard evidence, but certainly much better reasons than we have for massaging the IT band directly (which is commonly done). Just as the problem can be treated with a loosening surgical snip on the side of the IT band, it might also be loosened a little with thumbs instead of knives. And if there is any truth to the theory that hip weakness matters, then it might be worth trying to help those muscles.

Conveniently, trigger point therapy also overlaps with simple longitudinal massage, which I cautiously endorsed above. You can do both at the same time! Indeed, it’s hard not to. And both techniques may help loosen things up in different ways. Even if one is bunk, the other may not be. Each concept is “Plan B” for the other.

Optimism must be tempered by the knowledge that “tightness” per se is probably not the problem, that the need for hip strengthening is mostly hype so far, and even the science of trigger points itself isn’t exactly rock solid either — it’s just a label for the murky phenomenon of focal muscle pain. While I think that trigger point release in the IT band muscles is probably a little relevant to ITBS, in practice I think it yields only a minor benefit to the condition. Trigger point release is an uncertain business, and hip trigger points in particular have an unusually stubborn character, nearly impossible to get rid of completely. People’s hips tend to be full of sensitive spots, no matter how much therapy you do.

If you can pull it off, will a small amount of temporary IT band loosening — compared to surgery, say — even help IT band syndrome? Recall that IT band loosening as a treatment is analogous to loosening your shoelaces to try to deal with a rock in your shoe. If the rock is still there, a looser shoe is indeed better than a tight one, but the problem isn’t solved. IT band tightness may be relevant to ITBS and may be affected by massage of the hip muscles, but it’s unclear whether even a successful massage can loosen the IT band at all, let alone enough to make a difference.

Go pro? Although it would certainly be ideal to try trigger point therapy applied by a skillful and experienced therapist, it’s expensive — especially for a therapy that may not work no matter how competently it is performed. Therefore, self-treatment using your own thumbs and simple tools is a surprisingly good option — cheap, safe, and probably nearly as effective as professional therapy, especially with a little practice. Plus, it also has other benefits.169

Despite its many uncertainties, trigger point therapy is easy to try: it’s really just a matter of applying pressure to key locations in muscle tissue … and it’s hard to do something wrong when nobody really knows how it’s supposed to be done. That leaves you free to experiment!

Basic trigger point massage

This is a basic introduction to trigger point therapy. But much more information is available to you, such as my more general introduction to the topic for all site visitors. And for readers who want to learn a lot more about muscle pain, the largest e-book I publish is all about trigger point therapy:

The Complete Guide to Trigger Points & Myofascial Pain: An extremely detailed guide to the unfinished science of muscle pain, with reviews of every theory and treatment option

To treat trigger points, first feel around for unusually sensitive and aching spots in your muscles. For basic trigger point massage, don’t worry about trying to find lumps or bumps — just judge by the sensation alone. Choose three to five spots to work on for a few days. Return to each of them each day.

Gently knead the tender spots for a few seconds with fingers or thumbs, or press firmly until the sensitivity eases. Your goal is not to manipulate meat in any particular way, but simply to create sensation, to “scratch the itch.” Err on the side of gentler — most people tend to be too brutal with their own trigger points, especially at first. Give a little more attention to spots that produce “good pain,” and be more cautious with those that simply feel nasty.

Spend five to twenty minutes on a massage session. Do one to three sessions per day for up to a week or so. There’s only so much time most people should spend below the knee on this challenge. Success feels like clearly reduced sensitivity over a period of days, and/or reduced IT band pain symptoms. If it’s not reasonably obvious that you’re making progress, you probably aren’t making progress.

Almost anything can happen, and — strangely — failure means nothing in particular. It could mean that you have no meaningful trigger points at all and it’s not worth your time to continue. Or it could mean that you have unusually severe and stubborn trigger points, and you need to learn much more about muscle pain and try much more advanced self-treatment strategies. (And there's a big guide for that.)

If massage does not work, how hard and long should you try? Who should consider getting more serious about trying to treat trigger points? For many patients, IT band pain and other primary chronic pain problems are tips of icebergs. If you’ve suffered from many body pain problems over the years, and IT band pain just happens to be the one that’s bugging you the most at the moment, then it’s probably a good idea to learn more about muscle. Or if the soft tissue in your lateral thigh and hip seems to be quite rotten with sensitive spots, that too is probably a good excuse for delving deeper.

Sensitivity in muscle tissue is poorly understood and sometimes will not respond to anything you can do to the muscles. And it may or may not matter to IT band pain. (I promised to keep my enthusiasm in check, remember?) But it is worth trying.

Five key locations to explore with trigger point therapy

1. Tensor fasciae latae (TFL). The IT band is the tendon of the TFL muscle. It is a short muscle descending from the front of the hip. For more about the tensor fasciae latae, see below.
2. Gluteus maximus. In a curious arrangement unique in the body, the gluteus maximus attaches to the side of the IT band, pulling on it the same way that an archer pulls on a bowstring — except that it’s pulling on one end of the string. For directions on self-treating the primary gluteus maximus trigger point, see Perfect Spot No. 12.
3. Gluteus medius and minimus. These two almost identical muscles are on the side of the hip. They do not control IT band tension. However, they are a significant part of a common pattern of muscle crankiness in the region. Arguably, you cannot successfully relieve gluteus maximus and tensor fasciae latae trigger points if you do not also relieve them in the gluteus medius and minimus as well. To some extent, that is true of every muscle in the region — however, I suspect the gluteus medius and minimus are the most important. For more information about treating these muscles, see Perfect Spot No. 6.

Click to embiggen. The gluteus minimus & medius muscles are shaped like slices of pizza. (The minimus is hidden here: it is the same shape as the medius, but smaller & lying directly under it.) Perfect Spot No. 6 is usually found half way down the lateral edge, right on the side of the hip, in the “soft” area between the ridge of the pelvis & the big bone on the side of the hip (greater trochanter). But rather than being “soft,” the edge of the gluteus medius is usually quite rigid — almost as hard as the bones above & below!

4. Vastus lateralis. The vastus lateralis muscle is the most lateral of four big sections of the quadriceps group. It lies partially under the IT band: while the IT band is right on the side of the thigh, the quadriceps is larger and extends further around towards the front. It has no control over the tightness of the IT band. However, massaging it may still relieve some symptoms in the thigh and knee. ITBS patients often have diffuse aching pain throughout the thigh. It’s not the main pain, but it can still be annoying. Vastus lateralis massage may relieve some of that discomfort, and that might in turn have some modest (and pretty unpredictable) effect on the function of the hip and knee. See Perfect Spot No. 8.
5. Peroneus longus. This is a long, thin muscle on the outside edge of the calf. Just like the IT band runs down the side of the thigh like a stripe on a cop’s pants, so does the peroneus longus. Its main job is to point the toes (plantarflexion) and evert the foot (lifting the outside edge of the foot, an awkward little motion), but in its spare time it also applies some tension to the IT band — a minor contribution, but measurable.170 It is undoubtedly the least important listed here, but it’s a surprisingly nice muscle to massage, and you might as well be thorough. And there’s something aesthetically pleasing about extending the massage down the entire side of the leg — it seems right, for whatever that’s worth. Common trigger points in the peroneus longus are high and low in the muscle, a couple of finger widths below the knee, and 3–4 finger widths above the ankle bone.

Key locations for massage treatment of ITBS

More about the tensor fasciae latae muscle. Trigger points in the tensor fasciae latae are arguably the most important of the above, because it is the muscle that most directly controls the tension on the ITB. However, self-massaging it is a little tricky — it’s small — so I’ve never written an article just about that. And I never will — it’s just not an easy enough target for self-massage for the average person.

But for a motivated patient with ITBS? I think it is worth the effort.

Find the point of bone on the front of your hip. This is the “ASIS” (anterior superior iliac spine). Imagine the TFL hanging straight down towards your toes from that point: a span of 6-10 centimetres (2–4 inches) of muscle before it turns into the IT band. It’s not hanging off the front of that point, but more on the side of it, so if you try to come at it directly underneath the ASIS, it’s easy to miss. Instead, come at it from the side.

The key location is usually about 5 cm (2 in) below the ASIS.

On your own. Solo treatment of the TFL is best accomplished by trapping a ball between the side of your hip and the wall or floor. I recommend the wall at first, for better control.

With a buddy. If you have help, then treat this muscle while you are lying down, face up. Your buddy’s elbow comes at it from the side of the hip, pushing the TFL towards the center from its lateral edge, with a little bit of angling towards the floor as well, sort of trapping it against the femur.

Foam rollers. In the previous sections, I strongly criticized all massage of the IT band, which is generally what foam rollers are used for. However, foam rollers are certainly a good self-massage tool for the hip musculature, especially the gluteus medius and minimus on the side of the hip. And to the extent that vastus lateralis (quadriceps) massage is helpful for you, foam rollers are also quite handy for that.

Massage for the hip musculature may or may not have the desired effect on IT band syndrome, but it is definitely helpful for relieving stiffness and aching throughout hips (much the way we think stretching should be but often isn’t). Trigger point therapy has many benefits, so you may decide that it’s worth learning more and experimenting thoroughly, even if it does not help your knee.

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Frictioning is a specific self-massage technique applicable mainly to tendinitis. It is another method (like icing) of stimulating tissue when actually using the tendon will probably just irritate it. The technique is simple: rub back and forth across the most painful spot on the tendon for five minutes, increasing the intensity a little bit whenever the sensitivity fades. If it doesn’t fade, stop for safety.

Frictions are generally not an evidence-based treatment: they haven’t been studied enough, and what little research has been done is not persuasive enough. Despite that, there’s strong expert consensus that the technique makes sense.171

Unfortunately, much less so for iliotibial band syndrome.

This popular tendinitis treatment — and convenient self-treatment — is a bit off the mark for ITBS simply because ITB syndrome is not a tendinitis.

The main idea of frictioning is that it’s a different kind of stimulation — rolling across the parallel fibres of the tendon instead of pulling on them, which is what got the tendon into trouble in the first place. This traditional rationale for friction massage simply doesn’t make sense if you don’t have a clear tendon fibre direction to rub across.

As discussed early in this tutorial, recent anatomical and biomechanical studies have showed that the ITB does not work much like any other tendinitis, and that it’s not even the tendon itself that is suffering. Instead, the pain is more likely caused by compression of the tissue underneath the tendon, just above the lateral epicondyle. If so, frictions on the tendon itself are probably barking up the wrong tree. And the evidence for frictioning ITBS is indeed pretty underwhelming: Loew et al found that studies of frictions for ITB syndrome showed “no benefit of deep transverse friction massage,” but they were also so flawed that “no conclusions can be drawn.”172

But all is not lost! Perhaps gentle provocation of the sore spot could still constitute a Goldlilocks-just-right degree of stimulation, regardless of fibre direction. If we embrace that, we’re abandoning the notion of “friction” and simply resorting to “gentle massage” of the side of the knee, which sounds like a pretty weak option to me — but it’s on the table.

And friction massage might actually work some magic in other ways, too. For instance, there are plausible neurological mechanisms for temporary pain reduction, or even more lasting reduction of pain. In some cases, where pain itself has made the knee more sensitive, frictions may be a way of training the sensitized area to tolerate stress again — another unproven but reasonable theory.

In any case, you can experiment with this technique with just a few minutes per day, so why not do it, just in case? No obvious reason I can think of, other than a low risk of simply irritating it, which is certainly not serious if you exercise a modicum of caution.

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Nearly every ITBS sufferer tries to stretch their way clear of the condition. Stretching is a hot topic and a major part of the conventional wisdom, so I will really get into this in detail over the next three sections:

• A general introduction to the issues, especially the general scientific evidence
• The challenge of stretching the IT band specifically
• A suggestion for a better kind of IT band stretch

Stretching is over-rated as an exercise ritual,173 and there is definitely no good, direct evidence that any kind of stretching will prevent or treat iliotibial band syndrome. Try to find some — I dare you! The jury is out. No one has studied the problem well, and no one is likely to anytime soon. Meanwhile, the indirect evidence and expert opinion that is available on this topic is underwhelming and discouraging … at best.174175

There is a lot of evidence that generally trying to keep limber by stretching before workouts does not prevent injuries in general, including iliotibial band syndrome (which is, of course, one of the most common of all athletic injuries).176 The evidence is thoroughly described in the injury prevention section of my main stretching article, Quite a Stretch, but I’d like to describe one research example here in some detail: a 2008 study by American Journal of Sports Medicine that showed “no significant differences in incidence of injury” in soldiers doing preventative exercises for common overuse knee injuries, especially iliotibial band syndrome and patellofemoral pain syndrome.177

Half of the 1000 soldiers studied participated in an exercise program including five exercises for strength, flexibility, and coordination of the lower limbs, and 50 of those soldiers sustained overuse injuries in the lower leg, either knee pain or shin splints. The other 500 soldiers were doing nothing at all to prevent injury in the lower limbs — no specific stretching, strengthening or coordination exercises — and only 48 of them had similar injuries. There were “no significant differences in incidence of injury between the prevention group and the placebo group,” and the authors concluded that the exercises “did not influence the risk of developing overuse knee injuries … in subjects undergoing an increase in physical activity.”

The tested exercise regimen certainly did not work any prevention miracles for iliotibial band syndrome! This is what I meant above by results that are “underwhelming and discouraging at best.” Although better and more specific testing of IT band stretching can and certainly should be done, it’s reasonable to expect that benefits of IT band stretching should have shown up in this experiment … if the benefits exist. If 500 people can diligently do miscellaneous basic stretching and still get hurt just as much (a little more!) as 500 guys not doing the stretching … well, how good can it possibly be?

Not only is the IT band an extremely difficult structure to stretch (see next section), but it is debatable whether ITB “tightness” is even a basic problem (see way above).

Nor is it safe to assume that stretching works based on the say-so of your physiotherapist, or your fellow runners who swear by it, or because it’s recommended by almost every article on the internet about iliotibial band syndrome. Stretching enjoys an absurdly inflated and unjustified popularity in our culture, but there are many problems with it, and it might very well be a waste of your time.

Don’t believe me yet? That’s okay — we’re just getting started on this.

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by Gary Lyons

How much does the standard IT band stretch actually “elongate” your IT band?

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.178 There are biomechanical difficulties with stretching some anatomy:

• The hip joint and shorter hip muscles are the structures that limit range of motion in an idealized stretch of the iliotibial band. This was competently demonstrated in 2016 by Willett et al,179 discussed above in the tightness section. Their point was to test a test. Specifically, they were testing “the Ober test,” which is a test that supposedly measures the tightness of the IT band. What they found was that it did no such thing. Instead, it was measuring the “tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule.”

  If you can’t test the tightness of the IT band that way, then you can’t stretch it therapeutically either. The Ober test is a theoretically ideal stretch, and it’s not actually stretching the IT band (or not primarily). Other structures get in the way, and the structures we want to stretch — the IT band and the muscles that pull on it — are hard to apply tension to …

• The iliotibial band itself is just too tough to be stretched, even if you could pull on it very hard indeed. Smaller tendons that are easy to pull on are extremely difficult to elongate, requiring long hours of painful stretching such as dancers and gymnasts do. But the ITB is the longest and most massive tendon in the human body. It’s also not free to move like most tendons: it’s anchored along the length of the femur.180 How can you “stretch” a tendon like that? Imagine bolting a two-foot strip of thick tire rubber to a plank of wood in several places. Now try to “stretch” it! You might be able to apply some tension to it, but it’s certainly not going to elongate significantly.
• In addition to its extraordinary toughness, the IT band is also probably more elastic than most tendons, as a functional feature.181 This is not a contradiction: things can be both extremely tough and elastic (like these super rubber bands — unbreakable, but still elastic). Whatever elongation you can get out of an IT band is only what it allows by nature — you can’t stretch it past that point, and by nature it will snap back to its resting length effortlessly, as though you never did anything.
• The tensor fasciae latae, the muscle that most directly controls tension on the iliotibial band, is the most promising target for stretch. It is a hip abducting muscle, so to stretch it you primarily have to adduct the hip: that is, the leg must move towards the midline. But there is not much movement available in that direction: the other leg is in the way. The best that anyone can do is to cross the (stretch-side) leg over the other leg, and push the pelvis out. It is possible to stretch the TFL and IT band in this manner … but not strongly.
• The gluteus maximus is mostly unstretchable: a surprisingly long muscle, it is just impossible to flex the hip enough to apply much tension to it, because the thigh meets the belly too early … even in a skinny person. In someone with a bit of belly fat, it’s hopeless.

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. It is rarely prescribed or taught correctly.182

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.183 An iliotibial band stretch without knee flexion is just not much of an iliotibial band stretch.

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 tighten the broad thoracolumbar fascia like a girdle, also helping to anchor the pelvis.184

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.

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 the beginning of the chapter) 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!185186 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.187

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.

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If there is any hope for any kind of stretching for ITBS, obviously we need to let go of the idea of actually changing the IT band. Instead, it may be smarter to aim for changing its behaviour — how it responds to usage and stress. This might be achieved with a dynamic stretch or mobilization that tries to put as much tension on the IT band as possible in a functional context — to “stretch” it while moving. What kind of stretch includes knee flexion and anchors the pelvis while we’re moving? The best solution I have found for this challenge comes straight out of taijiquan.

I discovered this IT band stretch by accident, and only later worked out why it works biomechanically. Trying to do t’ai chi when I had acute ITBS, I learned the hard way that this particular movement was by far the most painful thing I could do to my own knees. It produced an extremely clear sensation of “cinching up” around the knee,188 and it was obvious that no other movement was so challenging and provocative to the lateral knee.

I have no idea if this dynamic stretch actually works, and I’m not even sure that it is even safe. I am suggesting it primarily as a theoretical “ideal stretch” for readers determined to try stretching. All I know for sure is that it certainly creates tension in the IT band, and that it forces the IT band to do its “job” in a big way — that is, it pushes the IT band to do what IT bands do (stabilize the lateral knee).

Ironically, that also means that the exercise maximizes stress on the IT band, which could be bad news — and is probably completely at odds with the need to rest an overuse injury. Although your goal is to “loosen” the band, you are actually trying to tighten it when you stretch. If the side of your knee is unusually irritated, than any successful stretch should in principle irritate the problem! And by adding knee movement as in the mobilization exercise described here, the risk of aggravation is even greater, because you are applying a stress repeatedly. So you should use this stretch with some caution and only as your symptoms allow. I do not recommend doing it at all in the first few weeks of ITBS. It is probably much safer in the later stages of recovery, when there is less risk of re-irritating the knee.

Numerous readers have asked me to clarify exactly what I mean when I say things like “as your symptoms allow” or “the first few weeks.” Of course, I’ve been imprecise because it is a difficult thing to be precise about! Telling someone at exactly what stage of recovery to try something risky is somewhat like trying to tell an investor whether to go for the glory with volatile stocks, or stick to bonds and mutual funds. However, here are a couple ideas:

1. To help determine how much of a problem early stretching might be for you, stretch early! Stretch while your symptoms are acute with the deliberate intention of provoking an aggravation, just so that you can determine how much stretching affects you. Then use that reaction as a guideline for future action. If stretching clearly aggravates your symptoms, then you should avoid it for longer. If it doesn’t seem to have much effect even when your symptoms are acute, then you can re-introduce stretching as a therapy sooner.
2. Or, avoid stretching entirely until you reach an arbitrary “safe” point in your rehabilitation (i.e. one hour of running with no pain), and then re-introduce it slowly … but try doing it after runs so that you can tell if it causes any problems.

In any case, when you do try stretching, just bear in mind that there is risk.

Summary: This is a complex “walking” stretch derived from taijiquan , which I think is much more effective than conventional iliotibial band stretches (for whatever ITB stretching is worth).

The iliotibial band mobilization is a dynamic stretch that occurs as you are moving, teaching the muscles that control the tension on the ITB to be responsive, shortening and lengthening as needed. By “freezing” the movement in the right place, you can also stretch the ITB more powerfully than by any other method I know of.

Begin by standing. Step forward the distance of a normal stride, placing your front foot in line with your back foot or even slightly across the midline. The toe of the forward foot should be pointed outwards. The forward leg is not the leg you’re stretching—the back leg gets the stretch.

Crouch deeply, lowering the knee of the back leg almost to the ground. As you do so, push your hip (of the back leg) out to the same side, and your knee (of the back leg) to the far side. Then stand up, step forward with your other leg, and repeat on the other side.

Another important element of this mobilization is arm movement (not shown in diagram). It may take some practice to integrate this step, especially while moving. However, the stretch is strengthened significantly by reaching up and away from the stretch side. That is, when dropping the right knee and stretching the right ITB, reach upwards, backwards and to the left, leaning away from the front right corner of the pelvis.

Here’s a video of the stretch being doing mobilization-style (continuously moving in and out of the stretch, rather than holding it).

That picture gives you a basic idea, but it’s not enough. And so now, after much procrastinating … I finally — it took me literally many years to get around to this — produced a demonstration video of this tricky exercise! It’s even kind of funny.

When the time comes to stretch, how much is right? If it’s feeling good, do a set of about a dozen before running and perhaps another set afterwards and maybe even a third set at some other time of the day. If it continues to feel good, great … you could probably go up to twice that many.

And one reader asked “How fast?” You should probably start slow, but speed and intensity can increase along with frequency.189

So, that is a reasonably effective way of “stretching” the iliotibial band — plus it’s a dynamic stretch, which means that the IT band is doing something, that you are challenging that tissue to do what it does best. Although you can freeze the motion at the peak tension on the ITB for a theoretically ideal static stretch, the movement involved has a lot going for it.

In fact, the concept of mobilizations is quite important …

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In the previous section, I introduced a method of stretching that is probably the best possible way to pull on your IT band, for whatever that is worth, but it was also a dynamic or moving stretch — technically a different beast than just stretching — known as a “mobilization” or “dynamic joint mobility drill.”

Another promising alternative to the usual ITB stretches is to stretch and mobilize the lateral hip musculature specifically, especially the gluteus medius and gluteus minimus. As discussed above, weakness of these muscles is implicated in iliotibial band syndrome by some evidence, even though it’s not particularly persuasive evidence. And they may be weak because they are full of muscle knots, and muscle knots may make strength training difficult or even cause it to backfire.

Stretching, mobilizing, and massage (discussed separately) could help. The rhythmic, repeated movements of mobilizations alternately stretch and contract musculature and other soft tissue — massaging your tissues with movement. I generally recommend mobilizations in preference to stretching because they are more neurologically interesting than stretching, and they stimulate more metabolic activity in the tissue. They are more practical and efficient than stretching in many ways, especially because they can affect more tissues more quickly, and because they constitute both a better warm up and a better warm down for more intense activity. See Mobilize! for more information.

Stretching is not a reliable treatment for trigger points, but it is generally worth trying — sometimes it relieves muscle pain and stiffness. Although stretching is the first thing everyone tries to do for stiff, sore muscle, in practice results are erratic and usually minor at best. If trigger points are “mini cramps,” stretching might help some of them — or it might be more like trying to untie knots in a bungie cord by pulling on them. This topic is covered more thoroughly in the PainSci trigger points guide, and it’s also summarized in my main stretching article: Quite a Stretch.

Yet again, we have no proof — or really any direct evidence at all — that this will work. In fact, if anything, there is evidence that it won’t! As already discussed in the sections above, we know that stretching is generally a proven loser when it comes to preventing injuries, so it’s implausible that these refinements are going to change that.

On the other hand, perhaps this is more than just a “refinement.” There is a big difference between conventional IT band stretching and typical leg stretches versus a more thorough program of mobilizing and stretching with more skill and different intentions. Combined with other treatments for the hip musculature, like actual massage in addition to “massage with movement,” it might all add up to something genuinely better than standard IT band stretching. It’s all probably worth a shot if you’re frustrated with a stubborn case of iliotibial band syndrome. Let me put it this way: it may not be proven, but stretching and mobilizing the hip muscles generally makes more sense than conventional IT band stretching … which isn’t proven either. So if nothing else, this approach at least constitutes a sensible substitute for the kind of stretching you were probably determined to do before you started reading this tutorial.

Call it an “upgrade,” then.

So, how do you do mobilize the hip muscles?

Certainly you could do worse than the dynamic stretch of the IT band described above. However, it is not actually ideal, as it is primarily focused on maximizing tension on the IT band. That means that it’s about as good as you can get for pulling on the tensor fasciae latae muscle as well … but it will only partially achieve the goal of mobilization of the hips. For the gluteus medius and minimus, you need to be more specific.

Unfortunately, just as with the iliotibial band and the gluteus maximus and tensor fasciae latae muscles, it is not easy to elongate the gluteus medius and minimus muscles. They are primarily abductors of the hip, so hip adduction has the “running into the other leg” problem.

However, the gluteus medius and minimus are always hip rotators: that is, they grab onto the femur and “spin” it in its socket. And rotation is something we can do with the femur more easily. The following mobilization isn’t a perfect solution, but it’s probably the best there is — a “one stop shop” for all your hip muscle stretching/mobilizing needs. It also has the added benefit of being quite a pleasant stretch. There are only a handful of stretches and mobilizations that I ever bother with personally, and this is one of them.

Deep Gluteal Mobilization

Summary: Sit, cross one leg over the other, and lean forward. Then spread the feet and push the knees in and down. Far superior to a common physiotherapy stretch prescribed for sciatica and piriformis syndrome.

Starting from a seated position, place your ankle on the stretch side over your knee on the other side. Let your lifted knee relax downwards for a moment, and then begin to lean forward from your pelvis. Avoid simply slumping forward, which is useless. Visualize pushing your belly button between your legs. Now do this on the other side, to even yourself out, even if you have symptoms only on one side. Now, to complete the mobilization for both sides, place your feet widely on the floor, and drop your knees straight down towards the floor.

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Soft knee straps with velcro closures, to be worn just above the knee,190 are often recommended for iliotibial band syndrome — like an extremely minimal soft brace. Let’s do this one Q&A style. Reader Karen McCullough bought the book before I’d added this section. She wrote in to ask:

After reading your tutorial, I thought the strap idea was probably crap. But another health care professional just told me that she’d done some research, and that the idea behind the strap was to loosen the iliotibial band on the pad of fat tissue by tightening the ITBS right above it. What do you think?

I’m such a debunker that I usually don’t have much nice to say about products like this, and that’s probably why Karen thought it was “probably crap” after reading this tutorial. And that’s usually a safe guess!

But in fact I think the strap has potential — just definitely not for the biomechanical reasons usually given. I’ve seen many such rationalizations for these products, so it’s worth addressing here; clearly there is some confusion about just what exactly this product is supposed to do. Even the people who sell them tend not to understand why they might actually work. Whatever the mechanism of action might be, I am quite confident it is not mechanical in any sense. The answer Karen got was incorrect in my opinion, in at least two ways:

• Straps for ITBS are not tight enough to have any significant effect on the tough iliotibial band or the powerful and complex action of the knee. They are soft and secured only with a velcro patch. They are not designed to be worn tightly. Since the iliotibial band is not only extremely strong, but also flush with the thigh, it would require a very tight strap to have any effect on its shape, position, or movement — so tight that it would be like a tourniquet, and you would quickly turn blue below the knee!
• The idea that pressing on the iliotibial band proximal to the lateral epicondyle can somehow relieve pressure on the fat pad is quite strange. Imagine a tight watch strap. How will pressing on it in one spot relieve pressure anywhere else along its length? It just doesn’t work. No, if anything, quite the opposite would happen: press on any part of the iliotibial band, and you are increasing the tension on it (albeit very slightly), just as pressing on any part of a bow string will increase the tension along the length of the entire bow string. As you can see in my (rather lame) diagram to the right, putting a tight strap above the bulge of the knee is only going to increase the impingement of the fat pad.

It’s always about sensation

Despite the implausibility of a mechanical effect, there is decent (albeit indirect) evidence that a strap can help. If so, how is it doing it?

All joint function depends on complex sensory input and motor output equations. Exactly how we use our knee depends heavily on how our knee feels. The “feeling” of knee use is based on the “6th sense” of proprioception (see Proprioception, the True Sixth Sense), and involves a great deal of that sensory data.

Wearing the strap alters proprioception in the knee which often seems to have a benefit for any kind of knee pain, including iliotibial band syndrome. This has been suggested by some experimental results.191192193194

All kinds of therapeutic taping products — like the colourful tapes that were so popular at the 2012 Summer Olympics — probably exploit the same principle. To the extent that they work, they probably work for the same reason. But they do not work to a great extent: according to the British Journal of Sports Medicine, “Kinesio taping does not appear to have a beneficial effect on pain when compared with sham treatment,”195 which isn’t encouraging for IT band syndrome. For a more detailed review of taping and its cousins, see The Dubious Science of Kinesiology Tape.

Anecdotally, I have seen some signs that the strap is helpful, although your mileage will definitely vary. Some people get absolutely no results from it, while others seem quite strongly affected. But remember, this is a cheap and easy and risk-free intervention … which means that if there is the slightest evidence that it works, it is firmly in the “worth a shot” category of treatments! There is really no reason not to try it.

I recommend that you drop in on FootSmart.com and pick their Pro-Tec Iliotibial Band strap for just $15 (USD). “One size fits most,” and they have a 120-day satisfaction guarantee, so you can return it if it doesn’t do the trick for you.

But there are many different types of straps, and in general I would recommend more robust versions — wider, tougher straps. If you’re going to tinker with how the knee feels, tinker more. In fact, I think probably there’s a strong case to be made for a full soft brace...

Soft bracing

A more complete neoprene sleeve for the knee is also an option — just not one that IT band patients seem to favour. It’s not “popular” like the straps, which I guess are cheaper and easier and have a bit of gimmicky mystique.196 But a soft brace is just a boring old brace! Ho hum. ITBS doesn’t seem like a knee condition that needs stabilizing, so it’s usually not on the radar.

Here’s the thing though: if it works, it probably works on the same principle as taping/strapping, only more so. If a strap “comforts” the joint, makes it feel different and a little safer, then a soft-brace probably does that same thing better.

A soft brace also probably has some genuine biomechanical effect, because — unlike the strap — it’s large and stiff enough to actually start to physically tinker with the equation of IT band and knee function. And where there is change there is hope.

A brace might even mimic and support some of the function of the IT band itself. As previously discussed, the IT band has a dynamic lateral stabilization role, tightening and loosening as needed to support (brace!) the ligaments on the side of the knee. Adding a bit of a “dumb” neoprene reinforcement might be quite useful: it might persuade your nervous system that there’s less work for your IT band to do.

I’m speculating, obviously, because there’s little else one can do on this sub-topic. But personally, if I am ever stricken by another case of ITBS, I’d definitely try a soft-brace — not a “gimmicky” little scrap of tape or a thin strap.

Hard bracing seems like a bad idea for ITBS

A reader asked about a treatment idea I’ve never heard of before: “Can the use of a knee brace locked at 20º be useful?” He was referring to using a hard brace, the kind of mechanical contrivance designed to strongly limit movement.

Definitely not recommended! But I get why it was of interest, and it’s worth explaining why it’s not such a great idea.

Immobilization is a rather extreme form of “rest.” In fact, it’s so extreme that it’s more likely to just be a new source of stress. Good quality “rest” in a rehab context is an absence of stressors. Eliminating most movement and loading is restful, but completely immobilizing the knee is likely just irritating. The human body does not seem to like immobilization, even for short periods.

Hard bracing is only useful in rehab when the alternative is dangerous instability, as with a serious fracture — but even in those cases it’s often surprisingly ineffective, either less effective at actually reducing motion and/or less necessary than we hope. Doctors avoid hard casts whenever possible these days. There’s even legitimate controversy and uncertainty about whether bracing severe spinal injuries is worthwhile — something I learned entirely too much about when my wife broke her back rather badly in 2010.

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