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Save Yourself from IT Band Syndrome!

All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point

updated (first published 2002)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

illustrations by Paul Ingraham, Gary Lyons, Alexia Tryfon, Lindsay McGee
Picture of a runner

Iliotibial band syndrome (ITBS) — also known as iliotibial band friction syndrome — is a common1 and often maddeningly stubborn repetitive strain injury. It mostly plagues runners, plus a few unlucky cyclists and hapless hikers, and causes pain mainly on the side of the knee.

The side pain is in contrast to the other runner’s knee, patellofemoral pain, which causes pain on the front of the knee and often gets mixed up with ITBS. Another common point of confusion: contrary to popular belief, ITBS is not a hip or thigh problem — that’s something else, more below.

Although IT band syndrome is very common, there are no clearly effective treatment for it, just a mess of options ranging from imperfect to completely bogus, and popular approaches (like stretching) have major problems. ITBS is surprisingly neglected by science, and remains mostly unexplained while several myths about it persist — like the idea that it is a “friction” syndrome, which the limited evidence clearly points away from.

This is a book-length tutorial covering every aspect of IT band syndrome for both patients and professionals: the nature of the beast (etiology), diagnosis and related conditions, prognosis and worst case scenarios, and more than two dozen reviews of treatment methods. It concludes with plenty of specific advice (but there are no miracle cures). Scientific rigour is a high priority, and there are 189 footnotes; many contain substantive additional analysis. This page has been regularly updated for 18 years, and was last updated Sep 22, 2018. I have considerable personal and professional experience with the condition: I had my own severe case, see my own IT band story in Appendix A below (grizzly bears included); I also saw many stubborn cases of it in my own patients.

Bogus ideas about and bad treatments: IT Band syndrome myths are common

Here are some examples of wrong and obsolete IT band treatment that patients constantly encounter. (More support for these points later — this is just a taste of the debunking.)

  1. IT band stretching is the king of the conventional wisdom, in spite of good evidence that stretches don’t work, especially the basic ones usually seen in the wild.
  2. “Elongating” your iliotibial band [InnerBody.com] with intense massage strokes is one of the most popular alternative treatments for ITBS, but it works about as well as it would on a truck tire. Meanwhile, better targets for massage are often neglected.2
  3. Quadriceps training is a therapy for another kind of knee pain, but — weirdly — it often gets prescribed as treatment for ITBS. This is a simple case of mistaken identity.3
  4. Most doctors are barely aware of IT band syndrome,4 and often neglect (or overemphasize) the medical options, like cortisone injections or IT band release surgery, which might help a few people but shouldn’t be your first, second, or even third line of defense. Even specialists — sports medicine doctors and orthopedic specialists — often don’t know enough to guide you in these choices. They are preoccupied with other medical priorities (which is what we want).

This video goes into more detail about some of those points, and introduces several key concepts — all of which can also be found in the text below.

IT band syndrome symptoms

The classic ITBS symptoms are just lateral knee pain when exercising, especially walking or running downhill. That’s enough for a lot of people, but there’s definitely more to know:

  • The epicentre of the pain is mainly sharp or hot pain on the side of the knee. There may be discomfort nearly anywhere else around the entire knee, particularly in severe cases, but the worst spot must be on the side of the knee for an ITBS diagnosis (see the next section for more). That spot will also be sensitive to poking pressure.
  • ITBS is an overuse injury and usually starts with a big workout: a larger-than-usual dose of running, hiking, or walking, especially if there’s a lot of descent (stairs, hills, mountainsides, etc). The classic onset scenario is going down a big hill when you’re already tired.
  • ITBS usually starts quite quickly, often without much warning, within minutes or perhaps an hour or two. Although quite quick, it’s not “sudden” like a sprain.
  • For some people, pain starts after knee surgeries or other knee traumas. For these patients, ITBS can be triggered by much lighter activity than a classic overuse case.
  • Many patients with chronic ITBS feel fine most of the time, but suffer frustrating flare-ups every time they walk or run for more a certain amount. They also learn to beware of going down stairs or hills.
  • Some very severe cases do cause continuous pain, but even those cases are still obviously aggravated by usage.

Later on, I’ll go much further into the topic of diagnosis: whether or not to get an MRI, the role of hip and thigh pain, conditions that get confused with ITBS, some all-too-common misdiagnosis horror stories, and much more.

Are you in the right place? Patellofemoral versus IT band pain

“Runner’s knee” is not one condition. There are two flavours of it (at least). Let’s make sure you’re reading the right tutorial, because ITBS is often confused with the other common runner’s knee injury: patellofemoral pain syndrome. Although the two conditions may seem quite similar, usually you can tell the difference just by the location of the pain.

Iliotibial band pain is truly a side of the knee condition, and the epicentre of the symptoms is always there, by definition. On the other hand, if you have pain that definitely dominates the front of your knee, there’s a good chance that you have patellofemoral pain syndrome, and you should start reading the patellofemoral pain tutorial instead. If you’re not sure which kind of knee pain you have, take the runner’s knee diagnosis test.

Diagram showing the different primary pain locations for iliotibial band syndrome and patellofemoral pain syndrome.

Front or side?

The epicentre of iliotibial band pain is always on the outside of the knee. The pain of patellofemoral pain syndrome is more variable, but usually dominates the kneecap.

There is one other common source of confusion about the location of ITBS. In fact, the number one myth of the condition is that it causes hip and thigh pain. It does not. ITBS is a knee pain condition only.

If you have hip or thigh pain and no knee pain at all, you don’t have IT band syndrome, but this tutorial is probably still useful for you anyway: confusion about IT band pain location is so common that I consider it to be normal part of learning about the condition, and the tutorial offers heaps of advice about common hip and thigh pain as well as knee pain. Whatever it should be called.

An orphan injury: IT band syndrome neglected by science

We can put a man on the moon … but we can’t treat IT band syndrome. This is important basic context for anyone setting out to learn more about their case. Musculoskeletal medicine is a bit of a backwater in medicine.5

No wonder therapy often bombs: it’s just not studied enough,67 and treatment for it is not taught to physical therapists and doctors.8 I have a big sports injuries text that coughs up only a few short sentences, breezily concluding that “the prognosis is good with appropriate treatment”9 — without even saying what the treatment is!

Sports medicine in general is amazingly primitive considering how much potential funding it has. You’d think anything affecting elite athletes with huge audiences would be getting more attention! The situation is improving, but only recently and it still has a long way to go.10

I have suffered from IT band syndrome myself — see my own IT band story in Appendix A below (grizzly bears included). I have also seen many stubborn cases of it in my own patients (I was a massage therapist for a decade). The prognosis for iliotibial band syndrome is not always good, and many common treatments are ineffective.11 Many people recover with a little rest, icing, and stretching, but not everyone. And probably not you, or you wouldn’t be reading this.

Let’s get into it …

Part 2

Nature of the Beast

What causes iliotibial band syndrome?

This is not as easy a question to answer as you probably thought. In fact, it turns out that it’s not as easy as anyone thought. Overuse injuries of all kinds — once seen as basically mechanical, like brake pads wearing out — have proven to be scientifically messy and bizarre. Chronic pain of any kind turns out to be a neurological rabbit hole. Much that was once considered “obvious” or “common sense” has been proven embarrassingly wrong. Researchers have only just begun to try to find out what’s really going on. Maybe.

On the face of it, iliotibial band syndrome is still a simple condition, caused by excessive knee usage and mostly treated by resting. But to anyone who can’t get rid of it just by resting, it is equally obvious that there must be more to it than that …


Humorous graphical definition of “iliotibial band syndrome.” It’s quite difficult to describe this image.

The conventional wisdom

Iliotibial band syndrome is mainly a running injury, responsible for about one in twenty lower limb injuries in long-distance runners.12 Probably at least a quarter of all long-distance runners will be stricken eventually. It is as common as dirt, and roughly one in twenty-five people who do any kind of vigorous physical training will get a case of it.1314 Just to put this in perspective, iliotibial band syndrome is probably not much less common than ankle sprains, which are generally regarded as the most common of all athletic injuries.15

Iliotibial band syndrome is also prominent in cyclists16 — even though each stroke of the pedals is probably much less irritating to this knee condition than running, sheer repetition can certainly make up for it. Hiking, backpacking, orienteering, and frequent long walks can also cause the syndrome.17 Maybe in the future it will be known as Pokémon trainer’s knee.18

The conventional wisdom says that iliotibial band syndrome (ITBS) is a kind of tendinitis. The iliotibial band is a large tendon running down the side of the leg from the hip. If it gets too tight, it rubs painfully over a bump of bone on the side of the knee, the lateral epicondyle. For this reason — the alleged rubbing — it is also commonly called iliotibial band friction syndrome (ITBFS).

Makes sense. Right? Well, not anymore. Iliotibial band friction syndrome is probably not a “friction” syndrome after all — and not even a tendinitis, in fact. The irritated structure is probably not actually the iliotibial band. Nor is the IT band “too tight,” which particularly fascinates me, given that the world of physical therapy is obsessed with trying to loosen tight IT bands!

About footnotes. There are 189 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Friction syndrome? So where’s the rub?

In 2007, John Fairclough of University of Wales Institute, with seven coauthors, issued a major challenge to the classic definition of iliotibial band syndrome, and even of the iliotibial band itself, in a paper published in the Journal of Science and Medicine in Sport.1920 They make a strong case, concluding that “the perception of movement of the ITB across the epicondyle is an illusion.” They’re saying the function, dysfunction and actual anatomy of the IT band has been misunderstood all along.

It’s a charming example of how primitive medical science still is. Can we really still be learning anatomy this late in history? Oh, hell yes!21 Of course.

(Not only still learning, but still arguing about it. A few years later, Jelsing et al. came along and used ultrasound to show that the IT band does move back and forth — even though they agree that the IT band really is firmly anchored to the side of the knee. There is no good solution to this paradox for now, but for a few reasons I still think it’s best to think of friction as an obsolete idea. Much more about Jesling’s fly-in-the-ointment evidence below.)

And as for the common wisdom that the iliotibial band is “too tight”?

In 2004, a research group at University of Connecticut led by Michelle Devan decided to try to figure out the effect of “structural abnormalities” on overuse knee injuries like iliotibial band syndrome.22 So they measured a bunch of stuff in a group of athletic young women, looking for structural problems that every therapist in the world “knows” are risk factors for various knee problems, including the tightness of iliotibial bands … and then they waited to see who got what kinds of knee injuries. Based on the conventional wisdom, you would fully expect the women with tight iliotibial bands to get more ITB syndrome. In fact, it’s “obvious”!

But of course that’s not what happened — and this is what makes IT band syndrome such an interesting subject. Now, here’s what did happen …

Several of these young women athletes did get iliotibial band syndrome that season. It was the most common injury in the group.23 But these expert assessors determined that not one of them had tight iliotibial bands. Not even one!

All the athletes with iliotibial band friction syndrome had a negative bilateral Ober test [their IT bands were not tight].

Devan

It was just a few athletes, and the Ober test isn’t a good test,24 but it doesn’t detract from the main message: it’s not safe to assume that a tight ITB matters.

The conventional wisdom was such a nice, straightforward picture of the condition that no one was apparently motivated to question it — after all, ITBS is a relatively minor problem. Most cases resolve spontaneously or with conservative treatment, and the others respond pretty well to a simple surgery. Why rock the boat by challenging the very definition of the problem?

Because that simple picture is almost certainly wrong! “Minor” or not, many consumer dollars have been wasted on therapies based on that wrong picture. What little research there is has been undertaken under the influence of bogus basic assumptions about how ITBS works. If we understand the condition as it truly is, maybe someday it can be treated more efficiently and conservatively, without surgery (or more effective surgeries).

So, what exactly is iliotibial band syndrome? To answer that, we need to talk anatomy. Hang on, you’re about to learn some Latin. You will be able to amaze your running buddies with your knowledge. Your authoritative command of ITB anatomy will blow them away!

So is it a tendon or what? IT bands are special

The iliotibial band is usually described as a tendon — a big one. It’s so big that it’s also called the iliotibial tract [Wikipedia]: no other tendon is known as a “tract”! It is often called the largest tendon in the body, which is sort of true, but it’s clearly not just any tendon. It’s a rather special and complicated one …

  • The IT band blends seamlessly into the capsule around the knee (which is why your knee seems to “cinch up” during a good iliotibial band stretch25).
  • Most tendons have clear edges and are well separated from other tissues. The IT band is more of a reinforced section of the connective tissue container for the whole thigh — like a tough part of a sausage wrapping.26
  • This tendon is also technically a ligament: that is, a connective tissue structure that connects bone-to-bone, rather than muscle-to-bone. The ITB is attached to the pelvis as well as the knee. It’s the only major example of a ligament-tendon hybrid in the human body.
  • Most tendons are dwarfed by the muscle they are belong to, but the iliotibial band is much more massive than it’s tiny tensor fasciae latae muscle — several times longer and much wider.
  • Although the gluteus maximus also partially uses the iliotibial band as a tendon, the connection is at an odd angle: the job of the gluteus maximus is probably not to pull directly on the iliotibial band (like most muscle-tendon relationships), but to increase the tension on it by pulling on it laterally (like drawing a bowstring).
  • It’s an energy storage device, a leg battery. It stores some elastic energy during part of our stride, and then releases it to give us a little boost, just like the Achilles tendon. It’s a minor effect, much less than the Achilles tendon, but it’s one of the things that makes it an eccentric bit of anatomy.27
  • In addition to blending with the connective tissue wrappings of the thigh and the knee joint capsule, the IT band is quite well-connected with many discrete deep attachment points (“insertions”) on the femur, the tibia, and the patella.28 A couple of these have been discovered surprisingly recently, and one of them is especially relevant to runner’s knee …
  • Most importantly, the IT band is tightly anchored to the full length of the femur, from hip to knee — especially just above the knee.
  • Oddly, the upper reaches of the IT band also penetrate all the way into the hip, from the bottom of the TFL muscle to the lateral surface of the hip joint, which it entirely covers.29 This feature of the IT band was first clarified in 2017. The feature has no direct relevance to IT band syndrome, but it’s interesting anatomy that’s really at odds with the conventional picture of the IT band as a superficial strap running down the outside of the thigh.

It’s the last three points that are really important to understand—all that anchoring to deep structures. Most people still think of the IT band as being free to move relative to the femur, like any other self-respecting tendon: a strap that lies under the skin, separated from the femur by a thick layer of quadriceps muscle. But the iliotibial band is not free to move relative to the femur, or so little that it doesn’t count. It is anchored to the femur between the big muscles of the front and back; it clings to it like a barnacle to a rock,30 even right where it slides back and forth over the side of the knee.

This is why Fairclough et al suggested that “the ITB cannot actually create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee.” The anatomy only creates the illusion of a slide over the side of the knee.3132

Cartoon of a man taking an “Anatomy and Physiology Final Exam,” the text of which we can see over his shoulder. It reads: “1. Fill in the blank: The blank bone’s connected to the blank bone. The blank bone’s connected to the blank bone.” And it continues like that off the bottom of the page.

Cartoon by Loren Fishman, HumoresqueCartoons.com

That mental image of the IT band snapping over the side of the knee is prevalent and misleading, the reason for some futile treatment strategies. This is an advanced and obscure anatomy puzzle; many pros will never learn more than they did in school, which was probably still wrong even if they graduated this year, even 11 years after Fairclough et al’s paper. The state of anatomical knowledge in general is a cringe-inducingly poor.33

But the truth is out there! The ITB is a unique connective tissue structure with some properties of a tendon, others of a ligament, and an unusual tension control system consisting of a couple of hip muscles at the upper end, and it probably does not slide significantly over the side of the knee.

What’s actually irritated? Not the IT band …

Fairclough et al argued that the iliotibial band itself is not the irritated structure in ITBS. If not, what is? Something under the IT band is the simplest answer at this time…

END OF FREE INTRODUCTION

Purchase full access to this tutorial for USD$1995. Continue reading this page immediately after purchase. A second tutorial about muscle pain is included free. See a complete table of contents below. Most content on PainScience.com is free.?Almost everything on this website is free: about 80% of the site by wordcount (well over a million words), or 95% of the bigger pages (>1000 words). This page is only one of 8 big ones that have a price tag. There are also hundreds of free articles, including several about IT band pain. But this page goes into extreme detail, and selling access to it keeps the lights on and allows me to publish everything else (without ads).


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The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small vendor. My business never actually handles card info (it goes straight from your web browser to Stripe.com, a major payment processor with a great reputation), but …

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

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

Important reminders!

  1. Many confirmation emails are mis-identified as junk email. If you don’t one, please check your spam folder!
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I really appreciate your objectivity. ~ Dr. Bryan Allf, MD, North Carolina

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

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

Other free samples from the book, and closely related articles on PainScience.com:

 TABLE OF CONTENTS PREVIEW
BUY NOW $1995 USD
Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
PayPal logo

The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small vendor. My business never actually handles card info (it goes straight from your web browser to Stripe.com, a major payment processor with a great reputation), but …

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

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

Important reminders!

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

The ITBS misinformation explosion and why this book matters

In the many years since I’ve been writing about IT band syndrome, there has been an explosion of shabby information about it available on the internet. Shockingly, this has not resulted in patients or health care professionals being better informed. Most of the information that you can find out there repeats the same oversimplified conventional wisdom … much of which is just wrong.+If the road to Hell is paved with good intentions, nothing has helped more people drive there than the internet. For many years, if you Googled “iliotibial band syndrome,” the abominable www.itbs.info was the #1 result: an incomplete, scientifically illiterate tour of stale conventional wisdom. Untouched since 2000, it finally dropped off the first page of results sometime in 2013, and then disappeared at last, after at least fifteen years of attracting tens of thousands of readers per year. The demise of itbs.info didn’t improve the Google search results much. Scientists have actually proven that “Dr. Google” is incompetent — just in case you needed any convincing. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al.

I’ve been obsessively updating this tutorial for about 18 years, and it’s the largest and best of its kind as far as I know. The limited competition has serious “trust issues.”+I once noticed a new book about ITBS on Amazon. Had someone finally written something that might compete with this tutorial? Er, no — it contained exactly zero actual information about ITBS, a fraudulent non-book filled with irrelevant advice on things like how to find a doctor and research nutrition. Hilariously, this non-book was actually recommended on www.itbs.info, the awful but high-ranking website I mentioned in the last note. After years of neglect, a tiny update was posted recommending this “book.” That was the “update”! • facepalm •

There is no cure for IT band syndrome. Of course not! Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But we’re nowhere close to this for IT band syndrome. This book wouldn’t need to exist if there were.

So what can I do for you?

What I can do is explain and review all the imperfect options so that you can prioritize them. I can help you confirm your diagnosis and debunk bad ideas. Some people will finally enjoy a breakthrough after reading this tutorial, and get partial or complete relief of their symptoms, sometimes temporary, sometimes lasting. And maybe that is kind of miraculous!

Basic knowledge is fine for basic cases, but better information is important for the tough ones. And even if you only recently developed IT band pain for the first time, how long do you want to spend following poor quality advice or muddling about with partial understanding? Get started on the right foot.


BUY NOW $1995 USD
Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
PayPal logo

The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small vendor. My business never actually handles card info (it goes straight from your web browser to Stripe.com, a major payment processor with a great reputation), but …

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

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

Important reminders!

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

Part 2.5

Appendices

Appendix A: My own iliotibial band syndrome story … grizzly bears included

I made a new furry friend the day I was struck down with severe iliotibial band syndrome. (Thanks to www.firstpeople.us for the photo.)

Note: this is the condensed version of this story. If you find me particularly amusing, you can also read a more long-winded version.

I was struck down dramatically by iliotibial band syndrome in both knees at once, on a solo backpacking trip in the Monashee Mountains in the spring of 1998. But that makes me sound more adventurous than I am.

In reality, I am a big chicken, and being in the woods alone spooked me but good. I got injured because I pushed too hard, too fast, and ended up deep into the mountains late in the day, with the trail ahead lost in snow. I decided to rush back to the trail head even if I had to hike in the dark for a while. So I practically ran down the mountain with a fifty-pound backpack — big mistake! After just an hour, both my knees started to scream.

The rest of the hike was a nightmare, certainly one of my most painful experiences. There were times when I felt certain I couldn’t take another step … yet somehow I did.

The Monashee Mountains: This is where I got iliotibial band syndrome.

The Monashee Mountains

This is where I got iliotibial band syndrome.

I was almost at the trailhead when a momma grizzly found me. I’d seen a warning sign about her before starting the hike. In fact, I had gotten quite paranoid about crossing paths with her as I neared the trailhead!

It didn’t work.

It was deep twilight, and there was nowhere to run, and I couldn’t run anyway, and no one outruns a grizzly anyway. She charged me on the trail, and I heard her before I saw her. I thought the following two thoughts, in this order, I swear:

  1. I guess I’m going to be maimed and killed now. Damn. This is going to hurt.
  2. At least I won’t have to walk any further!

Grizzlies are fast! (Up to 34 mph, 55 kph.) She came at me like I was lying at the bottom of a cliff and she was falling on me. The idea of unlatching my bear spray from its “quick” release, pulling the safety pin, aiming, and firing … absolutely ridiculous! She was simply way too fast and intimidating.

And she did what grizzlies almost always do when they charge people: she veered off at the last second. Grizzlies aren’t particularly predatory, but they certainly take their cubs seriously, and her main goal was to intimidate me … and that she surely did.

And that’s my entertaining bear story! It’s given me years of dinner party material, and it will for the rest of my life. Now, back to iliotibial band syndrome …

The next day, I quite literally could not get down stairs — which was problematic, because I lived in a 3rd-storey walk-up — both due to the worst case of delayed onset (post-exercise) muscle soreness I have had in my life, and the napalm attacks on the sides of my knees. I have seen some nasty cases of iliotibial band syndrome in my career, but I feel comfortable claiming that I’ve had it worse than anyone else I’ve ever met.

I was in school at that time, and we hadn’t learned diddly-squat about iliotibial band syndrome yet, nor did we later — that’s partly how I know just how poorly informed most massage therapists are about this condition. I never would have learned more than the basics if I hadn’t been forced to learn more by my own injury. It took me one year to recover, and to this day I still suffer occasional flare-ups if I run for more than a couple hours … which I do.

That’s me, getting ready to flick the disc.

I am an enthusiastic ultimate player — that’s me there in the picture, getting ready to flick the disc — so the injury was deeply frustrating to me, and, just like every serious runner I’ve ever treated, it was nearly impossible to keep me from re-injuring myself. I simply would not stay off the field. Every return to play was premature. This was where I first made the observation that, in all likelihood, runners (and ultimate players) are more of a problem than their knees. Iliotibial band syndrome isn’t stubborn — we are!

For me, the best treatments were probably rest, megadoses of well-timed icing (controlling inflammation at the times when it was most likely to start), and discovering that one of the taiqi moves I did was particularly good at stretching the iliotibial band and associated musculature (see Iliotibial Band Mobilization). How did I know? Because it hurt like hell! With my ultra-sensitive knees, it was really quite easy to evaluate how strongly different positions pulled on my iliotibial band — given that I was studying anatomy intensively at the time, I was in ideal circumstances to experiment. So this is how I first learned the importance of knee flexion in stretching the iliotibial band, a difference that was as clear to me as flicking a light switch: just add knee flexion to any of the standard stretches, and the iliotibial band pulls much tighter over the side of the knee. To this day, I don’t know if the stretching actually helped, but it certainly felt like a “real” stretch of the IT band, more so than any other stretch I could do.

All of this was good preparation for helping other people with iliotibial band syndrome, of course. Today, I know many things that I really wish I had known when I first hurt myself! And that’s why this very, very long tutorial exists.

Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

I really appreciate your objectivity.

~Dr. Bryan Allf, MD, North Carolina


I love your IT band tutorial. Is there any way that I can keep it forever, or maybe order a hard copy? This information is very valuable to me — I would like to be able to refer to it permanently.

~Marilyn Anderson, Aspen, Colorado

Of course I hope it will be a book someday! Meanwhile, customers are welcome to electronically preserve and/or print my tutorials. ~ Paul

It’s hard to work out what causes the trouble in the first place, and different strategies work for different people, but thanks to your advice and recommendations I’m running, and a lot less grumpy! Thank you!

~Debbie Bridgland, mid-distance runner, Atwell, Australia


Thanks for your great work. I’ve read about ITBS for years and everything I’ve ever read did not add up to ½ of the information you provided.

~Kevin Burnett, runner, California


I went to a sports medicine “specialist” for my iliotibial band syndrome, and he wasn’t very special. It was actually a complete waste of my time, all he did was diagnose me and tell me to take it easy and slow my pace down (which turns out to be exactly wrong, which I now know, thanks to you). You gave me easily a half dozen new ideas about how to take care of my knee. I would have paid triple for this, seriously, you should raise your prices.

~Christine Corey, triathlete, Seattle


Your iliotibial syndrome tutorial has been helpful in understanding the issues. After reading your full version, it all made sense. I would suggest that anyone wanting to do research in this area needs to read your tutorial first.  Your hypotheses seem very much worthy of testing. My running experience combined with your article has given me a sound course of action that I suspect will clear things up. Thanks for the insights.

~Scot G. Dollinger, Attorney at Law, distance runner, Texas


I thought I had my Ph.D. in the iliotibial band. I thought I had spoken with everyone and read everything out there, but somehow I managed to miss what you’ve done here. I already knew everything in your admirable ebook ... but I might be the only one, because you have published a lot of good information!

~Jeremy Friedman, triathlete, New York


On May 21st, 2008, Dr. M. Gilbart released my IT band and now all is well. This is 2 years and 5 months after the first diagnosis. Thank you again for all your encouragement. I re-read your iliotibial band syndrome tutorial several times over the last few months, and each time I found new nuggets of advice.

~Rosemaree Gentles, recovered iliotibial band syndrome sufferer


One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

  • Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
  • Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.
  • Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
  • Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

Acknowledgements

Thank you to Dr. Michels and his colleagues for their important, evidence-inspired work in pioneering a new surgical treatment for ITBS, with its fascinating implications. Thank you as well to Dr. Fairclough and his research colleagues who also deserve special mention for their seminal 2007 paper on IT band syndrome, which was a game-changer and instantly made this topic much more interesting to continue writing about.

Thanks first and most of all to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is a much bigger project. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, and actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, Dr. Ravensara Travillian, Dr. Neil O’Connell, Tony Ingram, Dr. Jim Eubanks … oh dear, there’s so many more still …

I work “alone,” but not really thanks to all these people.

Warm thanks also to reader John J, who reported more typografic errors and other miner glitches in onelarge batch than I would ever have dreamed posssible so many years into the lyfe of this document. Many readers have helped out with such reporting, but John’s effort was truly the most remarkable yet.

What’s new in this tutorial?

This document was originally published as a much simpler article in 2002. It was expanded and republished as a book-length tutorial in April of 2007, and has been updated and revised regularly since then. An unusually large batch of improvements were made in mid-2012 in preparation for recording an audiobook.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 86 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

SeptemberNew section: Not an important new section, but definitely some interesting extra colur. [Section: INTERLUDE: “I have a lot of money for you” if you would just lie to me about what works”.]

JulyNew section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

JuneScience update: Added some minor but interesting new points and citations about IT band anatomy. [Section: So is it a tendon or what? IT bands are special.]

JuneNew section: Although this book goes into great detail about diagnosis, strangely it was missing a simple thorough list of symptoms. A reader brought this to my attention, and I’ve corrected it. It’s a strange loose end to be tying up more than a decade into the project, but there you have it. [Section: IT band syndrome symptoms.]

AprilImprovements: Basically a continuation of the February reboot of this chapter, tying up some loose ends, adding some colour and detail. [Section: Hip strengthening is badly over-hyped.]

FebruaryMajor science update: After a long delay, I finally came back to the topic of hip weakness and just started over, reviewing the evidence from scratch. No change to the bottom line, but now more persuasive, thorough, and fully up-to-date. [Section: Hip strengthening is badly over-hyped.]

FebruaryNew section: No notes. Just a new section. [Section: ITBS and leg length.]

2017Science update: Cited and discussed the implications of Eng 2015, which purports to show that the IT band uses elastic energy to enhance running efficiency. [Section: The trouble with stretching the IT band in particular.]

2017Science update: Added important discussion of the implications of Willett et al. [Section: Stretching to prevent or treat IT band syndrome.]

2017Upgraded: Made a few changes and added a few new paragraphs exploring the implications of Willett et al. [Section: Like a rock in your shoe: the mechanism of irritation and the red herring of tightness.]

2017Rewritten: Six years after the last re-write, another major renovation of the topic of hard-surface running and shock absorption: new ideas and advice spelled out and supported much more thoroughly. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2017Minor upgrade: Added evidence from a new dissection study and edited the whole section for currency and clarity. Time flies: it’s been a long time since I last looked at this topic! [Section: The trouble with stretching the IT band in particular.]

2017Science update: Cited a useful new review of studies of instrument-assisted soft tissue mobilization (IASTM) — scraping massage — plus some general cleanup and clarifications about IASTM. [Section: IT band massage, foam rollers, and Graston Technique® — a big fat waste of time and/or money.]

2017Minor addition: Added peroneus longus to the list of muscles to massage, because of evidence that it contributes to IT band tension. [Section: Trigger point therapy for your hips, glutes, quads, and calves.]

2017New topic: A much more encouraging new conclusion to this section, endorsing simple massage for a simple reason. [Section: IT band massage, foam rollers, and Graston Technique® — a big fat waste of time and/or money.]

2016Science update: Added information about the Ober test, finally — and the brand new evidence that it doesn’t measure IT band tightness after all. [Section: Like a rock in your shoe: the mechanism of irritation and the red herring of tightness.]

2016Minor update: Added general perspective on the efficacy and safety of orthopedic surgeries. [Section: The old surgery: snipping the band.]

2016New section: Important new evidence that undermines my own debunking, thoroughly acknowledged and analyzed. [Section: Does the iliotibial band move after all?]

2016Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2016Update: Careful and thorough editing/update of NSAID recommendations, especially with regards to safety. [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2015Science update: Discussed the implications of some (weak but noteworthy) evidence about screening for the risk of lower limb injuries in athletes. [Section: What are the root causes of iliotibial band syndrome?]

2015Minor science update: Added citation to shore up evidence that taping tinkers with knee sensation. [Section: Soft knee straps (and/or Kinesio Taping) are worth a shot.]

2015Minor science update: Citation of Collins 2008, a review of icing evidence (or the lack of it), plus a few related edits. [Section: Icing: more is better?]

2015Expanded: Added several items that might cause diagnostic confusion. [Section: Other possible diagnoses and sources of diagnostic confusion.]

2015New item: Added IT band plungering. No really! If it’s stuck, suck it! [Section: Brief debunkery of several therapies that you should be particularly skeptical of.]

2014New item: A brief but very well-researched review of platelet-rich plasma injection. [Section: Brief debunkery of several therapies that you should be particularly skeptical of.]

2014Updated: Added good news story from a reader about a case with a cyst, and improved the information about cysts at the same time. [Section: Should you get an MRI?]

2014Major update: The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.

2013Science update: Added a bad-news citation. Sorry about that. [Section: Soft knee straps (and/or Kinesio Taping) are worth a shot.]

2013New case study: Added a fascinating and extreme example of the effect of running style from a case study of an ultra-runner. [Section: Why does IT band pain gets so nasty so fast? A vicious cycle related to running pace.]

2013Science update: A particularly “good news” science update about how running is, counterintuitively, actually pretty good for joints — not hard on them. [Section: “Maybe you’re just not built for running”.]

2013Update: A new introduction for the chapter about the trend of anti-running “science.” [Section: “Maybe you’re just not built for running”.]

2013Updated: Added more detail and a couple examples. [Section: When ITBS isn’t a repetitive strain injury.]

2013Minor update: Minor but nice: a really good new quote adds some entertaining and genuinely fascinating perspective to this section. [Section: “Maybe you’re just not built for running”.]

2013Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2013Product upgrade: Audiobook version now available. See the announcement for more information.

2012Minor update: Added some fun stuff and context about IT band anatomy. [Section: So is it a tendon or what? IT bands are special.]

2012Expanded: Added much more detailed self-help information for trigger points. [Section: Trigger point therapy for your hips, glutes, quads, and calves.]

2012Science update: Weak but interesting new evidence on natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2012Science update: Added evidence from the first foam rolling research ever done. [Section: IT band massage, foam rollers, and Graston Technique® — a big fat waste of time and/or money.]

2012Major update: Numerous significant clarifications, revisions, and new references, and a generally stronger recommendation. [Section: Deep transverse friction massage.]

2012Rewritten: Now about four times more detailed than before and much more strongly focused on the positive, what my final recommendations are, and how to “put it all together.” [Section: Now what?: An action-oriented summary of recommendations.]

2012Nice upgrade: After years of procrastination, I have finally created a video demonstration of a tricky ITBS stretch! About time! [Section: Some stretching hope: a better iliotibial stretch?]

2012New section: New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. [Section: So what’s the plan?]

2012New diagram: Nice new diagram, “Key locations for massage treatment of ITBS.” [Section: Trigger point therapy for your hips, glutes, quads, and calves.]

2012Minor update: Very simple swimming tip added. Hat tip to reader Eric C. [Section: The fear of rest, and relative resting: how to maintain fitness while protecting your knees.]

2012Major update: Rewritten and expanded, much clearer and more detailed. Not much new science, though — ITBS+orthotics science is pretty scarce! [Section: Orthotics for IT band syndrome: a worthwhile long shot.]

2012Minor update: Added a paragraph about elliptical machines. [Section: The fear of rest, and relative resting: how to maintain fitness while protecting your knees.]

2012Minor update: Added an example of surgery gone wrong. [Section: The old surgery: snipping the band.]

2012New section: No notes. Just a new section. [Section: When ITBS isn’t a repetitive strain injury.]

2012Revised: Some modernization and clarifications. Now also discusses the notion of “just rubbing” the hot spot. [Section: Deep transverse friction massage.]

2012Rewritten: Another “like new” rewrite: this section now offers much more detailed resting advice, perspective, and troubleshooting. [Section: The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.]

2012Rewritten: This section is “like new” and much beefier, and links to an upgraded main contrasting article as well. [Section: Contrast hydrotherapy: exercising tissues with quick temperature changes.]

2012Rewritten: Major changes: new science, new recommendations, more detail, and some explanation of the (very difficult) problem of why anti-inflammatory injections might work despite the fact that IT band syndrome doesn’t involve much inflammation. [Section: Steroid injections: a complicated mix of certain risks and uncertain rewards.]

2012Rewritten: Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” [Section: Icing: more is better?]

2012Rewritten: Completely revised to reflect new science and new understanding of the interaction of NSAIDs with “inflammation.” [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2012Major Update: Expanded and revised summary of treatment options, with emphasis on new and better recommendations about “anti-inflammatory” treatments. [Section: Treatment: What can you do about iliotibial band syndrome?]

2012Updated: Advice on “running through” has changed, with more emphasis on the unknown but plausible risk of permanent damage. [Section: Can you “run through” iliotibial band syndrome?]

2012Major revision: Extensive editing and re-writing concerning the nature of inflammation. The main point of the section remains unchanged, but the section now does a much better job of explaining why ITBS isn’t really inflamed, and why it matters. Although not cited, this update drew heavily on some new scientific papers. [Section: Where’s the fire? The inflammation myth.]

2011Updated: Added new information and some pie charts about the success rate of arthroscopic surgery for ITBS. [Section: The new surgery: excision of tissue from under the IT band.]

2011Minor update: Addressed some common fears about the threat of getting out of shape while resting. [Section: The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.]

2011Major update: Clearer and more thorough content throughout several sections about the “Nature of the Beast” and “Diagnosis,” especially from the discussion of root causes and onwards. I am producing the audio version of this tutorial, and I am revising and improving content significantly as I go. Information about trigger points was completely re-written, and there’s a whole new section about hip and thigh pain.

2011Updated: Modernization and revision for clarity. [Section: Mobilize and stretch the hip musculature.]

2011New section: Stretching is such a hot topic that I decided to break the discussion up with a new section focused on stretching the IT band itself. It was inspired by important new scientific evidence: researchers have found that IT band stretching is not a very moving experience … [Section: The trouble with stretching the IT band in particular.]

2011Major update: Significant modernization and clarifications. Much better description of why this kind of stretch might be worth trying. [Section: Some stretching hope: a better iliotibial stretch?]

2011New science: Added more anatomical evidence that the IT band is particularly impossible to stretch or even move. [Section: So is it a tendon or what? IT bands are special.]

2011New section: No notes. Just a new section. [Section: Hip and thigh pain: part of the problem, or red herring?]

2011Minor update: Clarifications about the location of IT band syndrome pain. [Section: Are you in the right place? Patellofemoral versus IT band pain.]

2011Updated: Added new research evidence that stretching doesn’t prevent injuries, including (of course) ITBS. [Section: Stretching to prevent or treat IT band syndrome.]

2011New video: Section now includes a new video, summarizing myths and treatment mistakes. [Section: Bogus ideas about and bad treatments: IT Band syndrome myths are common.]

2011Minor update: Added reference to Kong et al, about the effect of shoe wear. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman. [Section: Introduction.]

2011Rewritten: Evidence about the real but surprisingly weak connection between impact forces and injury from Zadpoor et al has prompted a bunch of revision and new recommendations for runners. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011New section: No notes. Just a new section. [Section: Mis-treatment horror story: intense massage on an obviously inflamed thigh.]

2011New section: Finally, long overdue, a new section on this topic. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2011Important new info: Where’s the fire? Recently I published a major new article about repetitive strain injuries, in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

2010New section: New short section for both this book and the patellofemoral pain book covering potentially confusing alternative diagnoses, such as politeal artery entrapment syndrome (PAES). [Section: Other possible diagnoses and sources of diagnostic confusion.]

2010Overhauled: Rewrote section to accommodate some new science. The new evidence is interesting, but not particularly illuminating: it mostly just emphasizes how we really (still) don’t know if IT band tightness is actually a problem. [Section: Like a rock in your shoe: the mechanism of irritation and the red herring of tightness.]

2010New cover: At last! E-book finally has a “cover.”

2010Minor update: Updated the nutraceuticals item with information about a new study of glucosamine for knee pain. [Section: Brief debunkery of several therapies that you should be particularly skeptical of.]

2010New section: One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). [Section: The new surgery: excision of tissue from under the IT band.]

2010Major update: One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). [Section: The old surgery: snipping the band.]

2010New section: One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). [Section: The bursitis possibility.]

2010Major update: One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). [Section: A new surgery works without loosening anything tight.]

2010Major update: One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). [Section: What’s actually irritated? Not the IT band ….]

And many more (May '07 – Dec '09) — Thirty-five older updates are listed in a separate document, for anyone who cares to take a look.

Notes

  1. “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.” And many of those are IT band syndrome cases. That quote is from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame. BACK TO TEXT
  2. The muscles that actually control the tension on the iliotibial band, such as the tensor fasciae latae and gluteus maximus. BACK TO TEXT
  3. Quadriceps strengthening is a standard treatment option for patellofemoral pain syndrome — a similar but different kind of overuse injury of the knee (more on this below). It doesn’t necessarily work even for that condition, or not for the reasons people think it does, but it is a nearly universal rehab choice for that condition, for better or worse. Not for ITBS, though! Although strengthening some muscles (hip and gluteals) has been proposed as a treatment for ITBS, and might work, quadriceps training has almost no relevance to ITBS. I assume that it gets prescribed anyway simply because these two knee pain conditions are often confused, even by pros who should know better — a simple case of mistaken identity. BACK TO TEXT
  4. As they are of most musculoskeletal problems. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman, HumoresqueCartoons.com

    BACK TO TEXT
  5. PS Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. PainScience.com. 2723 words. BACK TO TEXT
  6. As of 2015, only just over 200 search results in PubMed! Compare that to 5200 for adhesive capsulitis (frozen shoulder), or 9000 for carpal tunnel syndrome. Also, more so in the case of iliotibial band syndrome than other conditions, a great number of those papers are tutorials for professionals, not primary research. To an amazing degree, they all tend to repeat conventional wisdom and reference each other and clinical experience instead of actual science. BACK TO TEXT
  7. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome — A systematic review. Man Ther. 2007. PubMed #17208506.

    This 2007 scientific review paper makes it extremely clear that there is a “paucity in quantity and quality of research” about iliotibial band syndrome. They also conclude that what information exists is not particularly helpful! “There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.” Yet it is absolutely routine for therapists and doctors, and even so-called experts, to make claims of therapeutic effectiveness! What are they basing that optimism on? The truth is, they simply don’t really know what they are talking about. They can’t — no one does!

    BACK TO TEXT
  8. In my own 3000 hours of training — three full years of nothing but studying aches and pains and how to treat them — it was barely even mentioned. Unless a massage therapist has gone out of his or her way to study the condition, he or she knows no more than anyone else who spends twenty minutes looking it up on the internet … and perhaps less! BACK TO TEXT
  9. This is not a joke. It’s a good, new sports injury text book — but its inadequate coverage of ITB syndrome is typical for the subject. The text is Clinical Guide to Sports Injuries. BACK TO TEXT
  10. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781.

    Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …

    BACK TO TEXT
  11. Falvey EC, Clark RA, Franklyn-Miller A, et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010 Aug;20(4):580–7. PubMed #19706004. “Our results challenge the reasoning behind a number of accepted means of treating ITBS.” BACK TO TEXT
  12. Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band syndrome in distance runners. Sports Med. 1985;2(6):447–451. BACK TO TEXT
  13. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999 Aug;31(8):1176–82. PubMed #10449021. PainSci #56967.

    In a study of 1300 US Marine Corp recruits in training, nearly 40% got hurt, and 78% of them got repetitive strain injuries, and those injuries tended to happen during the weeks with the most training. “The most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%), iliotibial band syndrome (5.3%), and stress fractures (4.0%) were the most common diagnoses.” The findings suggest that “[vigorous] training, particularly running, and abrupt increases in training volume may further contribute to injury risk.”

    BACK TO TEXT
  14. In Clinical Guide to Sports Injuries, on p340, iliotibial band syndrome is listed as a “less common” cause of knee pain, after the “most common” conditions of patellofemoral syndrome, patellar and quadriceps tendinopathy, meniscus injuries and knee instability … all of which contradicts my own experience. I have seen more iliotibial band syndrome in my practice than all of those other “more common” conditions combined. This may reflect the nature of my practice more than reality for the rest of the world, but I’m just sayin’. BACK TO TEXT
  15. This is surprisingly hard to prove, because the vast majority of ankle sprains are minor and go unreported and untreated. However, clinical experience and many years of personal experience playing ultimate (a Frisbee team sport with an intensity like soccer) indicates that ankle sprains are probably more common than any other significant injury. BACK TO TEXT
  16. Some papers that mention cycling: Ellis, Fairclough, Fredericson, Martens, Farrell. BACK TO TEXT
  17. Linde F. Injuries in orienteering. Br J Sports Med. 1986;20(3):125–127.

    From the abstract: “Medial shin pain, Achilles peritendinitis, peroneal tenosynovitis and iliotibial band friction syndrome were the most frequent overuse injuries [in 42 orienteers].”

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  18. Sound ridiculous? Pokémon Go is one of the most successful video games in history, and the first super successful gameification of exercise: to play, you have to get outside and walk, run, or ride. In the summer of 2016, several tens of millions of players were out and about every month — which is actually similar the number of recreational runners. Those stats have continued in 2017, with an estimated 65 million monthly active players. BACK TO TEXT
  19. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309–316. PubMed #16533314. PainSci #56738.

    ABSTRACT


    Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and 'rolls over') the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30 degrees of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.

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  20. Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science & Medicine in Sport. 2007 Apr;10(2):74–76. PubMed #16996312.

    ABSTRACT


    Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present, but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.

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  21. The science of anatomy was surprisingly slow to develop historically, and remains surprisingly incomplete. An excellent example from 2015 is the somewhat embarrassing discovery of lymphatic vessels in the central nervous system. Oops, how’d we miss that?

    My Heart Will Go On, by Robert Krulwich & Adam Cole, explores the goofiness of historical beliefs about anatomy, especially the heart. For example, the influential Roman physician Galen made many declarations about human anatomy without ever doing a human dissection, and then no one else checked his work for another 1000 years, and so everyone thought that the liver was a pump just like the heart. Those crazy Romans!

    Don’t be too quick to laugh, though. Are you sure that you’re own mental anatomy text is accurate? Modern people still have many odd misconceptions about anatomy. People are often “great believers in” treatments based on ideas that are literally anatomically impossible … and wrong IT band anatomy is actually one of the best examples.

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  22. Devan MR, Pescatello LS, Faghri P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. J Athl Train. 2004;39:263–267. PubMed #15496997. PainSci #56601. For a more detailed analysis of this research, see Iliotibial Band & Patellofemoral Pain Defy Biomechanical Expectations. BACK TO TEXT
  23. Followed, predictably, by patellofemoral pain syndrome. BACK TO TEXT
  24. I’ll cover this in more detail below, but basically there’s good evidence that the Obert test is not a good way to judge the tightness of IT bands (see Willett). BACK TO TEXT
  25. Anyone who has felt that knows exactly what I mean, but the sensation eludes many people, because it’s difficult to apply enough tension to the IT band to achieve it. Many people will simply never feel it. More about this in the stretching section. BACK TO TEXT
  26. More detail: most tendons could be snipped at either end and then tied in a bow. They are mostly disconnected from other tissues, except at the ends where they are attached to muscle and bone. In contrast, the iliotibial band is simply a massive thickened section of the sausage wrapping of connective tissue that surrounds the whole thigh. BACK TO TEXT
  27. Eng CM, Arnold AS, Lieberman DE, Biewener AA. The capacity of the human iliotibial band to store elastic energy during running. J Biomech. 2015 Sep;48(12):3341–8. PubMed #26162548. This paper presents the abstract and speculative “results” of a thought experiment aided by a fancy model of the leg, so it can’t be taken too seriously, and in particular it has no clear clinical implications. But it is interesting! Mostly it purports to show that the IT band stores elastic energy, much like the achilles tendon, just a lot less: “1J of energy per stride during slow running and 7J during fast running,” which is “approximately 14% of the energy stored in the Achilles tendon at a comparable speed.” If that’s how it actually works, it’s a handy biological adaptation that makes running a little more efficient: more evidence that we are “born to run.” BACK TO TEXT
  28. Vieira EL, Vieira EA, da Silva RT, et al. An anatomic study of the iliotibial tract. Arthroscopy. 2007;23(3):269–274. BACK TO TEXT
  29. Putzer D, Haselbacher M, Hörmann R, Klima G, Nogler M. The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study. Arch Orthop Trauma Surg. 2017 Dec;137(12):1755–1760. PubMed #29032422. PainSci #53147. BACK TO TEXT
  30. How is this possible? Fairclough et al explain that “our cadaveric dissections confirm that the ITB is simply a thickened, lateral part of the fascia lata. It completely surrounds the thigh, is anchored to the femoral shaft by the lateral intermuscular septum.” In general, muscle sheaths are no more free to move relative to the muscle they contain than a sausage wrapper is free to move relative to the sausage. In this case, the wrapping is even stronger, because it actually penetrates to the bone, attaching to the femur along most of the length of the femur (on the linea aspera). This was backed up by another dissection study in 2009, which also found that the IT band is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the thigh. This thing does not slide around. BACK TO TEXT
  31. As the knee bends, tension on the IT band shifts from the front to the back. That is, it “pops out” a bit, first a little ahead of the knee, then further back — which can look an awful lot like movement. But it’s just parallel fibres tightening in sequence, like a wave, as the knee changes position. Other tendons actually do slide around and snap over other structures, but the IT band is not free to do this. BACK TO TEXT
  32. Although this has been contradicted by other evidence — Jelsing 2013 — for now I’m working with the assumption that any movement is probably trivial and not a sliding at all, like the slight swaying of seaweed anchored to rocks in shallow water. That is, it’s not “rubbing” back and forth so much as flexing to and fro. BACK TO TEXT
  33. I often hear athletes, trainers, and therapists talking about the anatomy of injuries with great ignorance and confidence — a nasty combination. They believe pain is coming from a part of them that literally doesn’t exist, or not in that neck of their woods.

    Many lesser-trained professionals make so many mistakes that it’s clear that they could not pass an anatomy exam … like the massage therapist I saw once who tried to base his treatment of me on a completely imaginary muscle — a weird hybrid of two or three others, like the quadriglutator or the sternobiceptoid. (I would have laughed, if he hadn’t been carelessly handling my fairly badly injured shoulder at the time, trying to find my … whatever he thought he was looking for.) It may sound absurd, but we live in a world where some people believe that ketchup is a vegetable — and anatomy is much harder than food identification. It’s one thing to be wrong, but the overconfidence of these anatomical fantasies really tickles my funny bone.

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There are 156 more footnotes in the full version of this book. I like footnotes & I try to have fun with them whenever possible.


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