• Good advice for aches, pains & injuries
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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

Paul Ingraham, updated

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 that causes pain mainly on the side of the knee, especially when descending stairs and hills. The injury mostly plagues runners, but it’s not their problem exclusively: a few unlucky cyclists and hapless hikers will get it, and even some relatively inactive people who are more vulnerable in the aftermath of a knee surgery.

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.

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 [] 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:

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.

Runner’s knee without running: post-surgical lateral knee pain

Lateral knee pain seems to develop in people who’ve recently had a total knee replacement. This does not seem to be a widely known fact, and I’ve become aware of it only because so many readers of this page have emailed me to ask: “I am not a runner, but I had surgery and now I seem to have runner’s knee. Is that possible?”

It probably is possible, yes. In the aftermath of surgery, people's knees are so vulnerable that essentially any amount of activity constitutes “overuse.” For a healthy young runner, it takes a bunch of running to do this to their knees. For an older person after knee surgery, normal non-athletic activity will do the same. It is still fundamentally an overuse condition, just with an an absurdly low threshold for the amount of activity required to cause trouble.

Once you have ITBS, how it works and how to treat it are probably quite similar. But not identical. This tutorial probably isn’t ideal for post-surgical cases: it may be relevant to many patients, but misleading/irrelevant for others.

Post-lateral knee pain that is not an IT band problem

It’s also possible that these some or all of these cases are not really a true IT band syndrome. In my experience, many of these patients are diagnosed quite carelessly by their surgeon, with a bit of a shrug, just tossing out a diagnosis that’s a rough fit for lateral knee pain. Most of them probably don’t actually know much about ITBS.

Surgery is notoriously prone to puzzling complications and many patients will suffer from chronic pain with no clear mechanism. Maybe the only post-surgical patients being diagnosed with IT band syndrome are the ones whose symptoms happen to have a superficial resemblance to IT band syndrome. But no one knows. As you’ll learn below, even runner’s knee for runners is poorly understood. For post-surgical patients, the nature of lateral knee pain is even more inscrutable.

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 So basically it's mainly (though not exclusively) an overuse injury.

Homo sapiens may be good at running, but that doesn’t mean it’s easy or risk-free.

Throughout hominid history, if you’re running 26 miles in a day, you’re either very intent on eating someone or someone’s very intent on eating you.

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

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!

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].


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 …

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,

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 12 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…


Unlock access to 62 more chapters for USD$1995 — much less than the cost of any physical therapy, and maybe more useful. Continue reading this page right after purchase. A second book about muscle pain is included free. See the complete table of contents below. Most content on is free.?

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Frequently asked questions

Q. What do I get, exactly? A. Payment unlocks 62 more chapters of a book-length webpage, a total of 73 chapters and 69,000 words. Access is permanent, including several updates per year. An audiobook version is also included. Plus …

  • Free second book! When you buy this tutorial, you will automatically get a second (huge) book all about “trigger points,” because these common sore spots may be an important factor in some cases.more
To unlock all 73 sections, buy this tutorial for $19.95. You’ll receive the full version instantly.
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69,000 words
73 sections
199 footnotes

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

Q. Is there a print version? A. Electronic only, sorry. You can print it yourself, but it’s quite large.

Q. Can I read this offline, like at the beach? A. Yes. Like any webpage, it can be saved for offline reading easily.

Q. Who sells this? A. is a small business in Vancouver, Canada, run by me, Paul Ingraham, sole author and publisher since 2007.

Q. Does the book offer a “cure” for IT band pain? A. No. I sell education about a notoriously tricky condition, not false hope. There’s nothing “too good to be true” here.

Q. Buy more & save 50%! A. Get a “boxed” set of all nine tutorials for great savings.MORE

Q. Ack, what’s with that surprise price tag?! A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here. Of course many people turn away, but 60,900 people have gone for it.?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could. This count is automatically updated once every day or two, and rounded down to the nearest 100. It includes all individual and bundled books for sale on since 2007, and excludes a trickle of earlier sales, donations, and gifts. If money is tight, I offer a 85% financial hardship refund.?Just send me an email after purchase to ask for a money-is-tight refund. I ask people to jump through the hoop of buying first because it’s a nice compromise between “completely free” and “no giveaway at all.” By paying for the book, you take care of the paperwork of becoming a customer. And by holding back 15% — just 3 bucks — I don’t actually lose money on the transaction. Do me one additional favour and tell me your story? Something interesting about your case, perhaps? Anything at all. Note: This offer is for individual books only (the need is greatest), not the boxed set (more of a “want”).

Q. Can I read it on my iPad, Kindle, etc? A. Yes. Any Internet-enabled gadget works fine. (The e-Ink Kindles are not a good choice.)

Q. Satisfaction guaranteed, right? A. Of course—and no time limit.

Q. Can I buy this anywhere else? Amazon? A. Not yet. Maybe someday.

Q. Can I lend it? A. Yes, with a 3-person limit.

Q. Can I give it to my clients? A. I have a generous lending policy, but not that generous. 😉 Please recommend buying it, or consider my bulk purchase program.

Q. Why do you want my postal code? A. To prevent fraud (strongly recommended by my payment processor), and to identify customers for login and repeat business.

Q. Are you going to send me e-mail? A.  Just a receipt.

Q. Why should I trust you with my credit card? A. I will never see it: it goes straight from your screen to Stripe, a payment processing service with a great reputation for Doing Things Right. They handle all the high-tech security.

You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on

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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 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 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 19 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, 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!

It’s also actually evidence-based, at least a little. Online tutorials may actually be able to help people with chronic pain.+Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. 

Researchers tested a series of web-based pain management tutorials on people who had been suffering for more than six months. No matter how much (or little) help they had from doctors and therapists, they all experienced significant reductions in disability, anxiety, and average pain levels, for at least three months.
Basic knowledge is fine for basic cases, but more and 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.

All of that is hopefully worth more than several sessions of physical therapy, at a fraction of the cost.

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Part 2.5


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 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 t’ai chi 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.

Thank you for the clear, well-written, highly researched, and logical information you provide. I’ve read an awful lot about knee injuries and about sensitization. Much of it seems to fall into one of two camps: anti-science praise for alternative therapies, or dismissive “it’s all in your head” claims from doctors who aren’t sure what’s wrong. I deeply appreciate the time you’ve taken to explain what is known, what is not known, and how standard therapies have evolved (sometimes even in opposition to scientific evidence). Your writing resonates with my own experience of injury and pain as well as my experience of doctors who are guessing, trying things that don’t work, and then trying those same things again while hoping for better results.One more thing: I’m a fellow writer/editor type, and I appreciate your style. It’s straightforward, clear and light, skimmable but rewarding to dive into, smart and funny--everything that this type of writing should be.

~Livia Neale

First off, I previously purchased two of your e-books for my wife and I. Thank you for your diligent research. Thank you for taking the initiative to get this information out there. I have suffered with a chronic case of runner’s knee that the physical therapists & orthopaedists couldn’t fix. After reading your book, it’s no wonder - these ‘experts’ know very little about the situation to begin with. After researching relevant material, including your e-book, I am finally on the road to recovery.

~Dainton Sears

I purchased your ITBS book and just wanted to say thank you: every other word of advice I had gotten about the injury either didn’t help, or made things worse. Your tutorial was the only guide to the injury that was consistent with my experience and symptoms. It’s helped me understand the issue better, and I hope, a few weeks after having read through the tutorial thoroughly, that I’m on my way to recovering fully.

~Dennis Tower, Boston

I appreciate what appears to be a well-researched, sobering, humble but hopeful approach to this complex condition.

~Frankie Koch

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

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 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:


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 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 actually a much bigger project than a book. 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, plus 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. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

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

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

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 remarkable.

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 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 91 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

AugustNew section: No notes. Just a new section. [Section: Runner’s knee without running: post-surgical lateral knee pain.]

AugustMinor improvement: Added more detailed explanation of testing popliteal tendon. [Section: Other possible diagnoses and sources of diagnostic confusion.]

MayNew section: No notes. Just a new section. [Section: The noise, noise, noise! The significance of knee snaps, crackles, and pops.]

MarchEdited and expanded: Added a new basic concept to the introduction, added discussion and recommendations about total rest, and clarified several other points. [Section: The art of rest: the biggest challenge and opportunity for patients who have supposedly “tried everything”.]

2018Science update: Explored evidence-base and scientific plausibility of resting recommendations. [Section: The art of rest: the biggest challenge and opportunity for patients who have supposedly “tried everything”.]

2018New section: Not an important new section, just some interesting extra colour. [Section: INTERLUDE: “I have a lot of money for you if you would just lie to me about what works”.]

2018New section: A new standard chapter for most tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

2018Science 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.]

2018New 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.]

2018Improvements: 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.]

2018Major 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.]

2018New 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?]

Older updates — Many older updates are listed in a separate document, for anyone who cares to take a look.


  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,

  5. PS Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. 3120 words. BACK TO TEXT
  6. As of 2015, only just over 200 search results in PubMed! Compare that to 5200 for 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!

  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 …

  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.”

  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].”

  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. 


    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.

  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. 


    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.

  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 your 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.

  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 IT Band & Patellofemoral Pain Defy Common Sense. 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.


There are 166 more footnotes in the full version of the book. I really like footnotes (and I try to have fun with them).

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