The Infamous and Irritable Iliotibial Band

The Infamous and Irritable Iliotibial Band

by Dylan Bartley, MSPT, CMP

Iliotibial Band Syndrome (ITBS) is one of the most common overuse injuries among runners, cyclists, and athletes alike. It can manifest in pain on the outside of the knee or hip. Maybe you’ve seen one of the many rollers or massagers on the market designed to loosen up the IT Band. But do you know the anatomy and biomechanics behind the IT Band? Understanding why it can become such a problem helps guide us in treating it comprehensively and making sure we can run and climb stairs well into the golden years.


The IT Band is the body’s largest tendon, connecting the muscles gluteus maximus in the back and the tensor fascia latae in the front of the hip down to the knee. It passes past the outside of the knee to attach on the outside of the upper tibia. As it passes over the outside of the hip near a protrusion called the greater trochanter it can cause friction and irritate the trochanteric bursa. Bursae are designed to reduce friction, but they can only take so much before they get inflamed and become a source of pain. Further down the line, as the IT Band crosses the knee there are more bursae that can become irritated and cause you knee pain.


A big question we ask next is, “Why does it get so tight”?  , If the abdominals, gluts and/or hip flexors are weak and not supporting the body when standing on one leg mid-stride, the IT Band steps in and says, I’ll do it! When there is too much load through the IT band, it can become scarred down and the friction and pain begins. At the knee, when the inner quads are weak, the IT Band has no opposing force. It pulls the patella too far to the outside. This causes breakdown of the cartilage on the outside of the patella. The patella rides like a train moving on one rail. Of course, things aren’t always so simple. Pain in the outside of the thigh may not be from the IT Band at all. A physical therapist can assess the situation and make sure that the pain is not referred from a pinched nerve in your back or a stress fracture. Alternatively, you may have great strength but there may be errors in footwear, the fit of your bike, or just how you have learned to run over the years.
How do we treat it? In the short-term, massaging it with a foam roller or other massage tool will help break up the adhesions and bring some circulation to the tendon. This can often produce immediate relief in knee and hip pain. Long-term, however, you need to strengthen the muscles around the IT Band. Squats, double- or single-leg bridges, side leg lifts, and clamshells are just a few exercises that your physical therapist may recommend to strengthen some of the hip and quadricep muscles. We will do an assessment of your movement patterns and identify areas of specific muscle weakness to help develop a routine that will address your unique deficits.

Sham surgery may be better than Menisectomy for Knee Pain

A partial menisectomy has been one of the most commonly recommended surgeries for people suffering from knee pain. A meniscus tear is likely when there is medial or lateral pain along the joint line, there is pain with twisting, and the knee locks up, gives way or buckles when walking. In December of 2013 a double blinded study from Finland was released in the New England Journal of Medicine that compared a group who had the typical surgery to a group that had a fake surgery where they were arthroscopically probed but the torn meniscus was left as it was. The participants that had the meniscus cleaned up and smoothed out had better results early on, but by 12 months there were no differences between the two groups.


This suggests that maybe you should give a second thought to whether you go under the knife to fix your knee pain. An earlier study by a different group compared physical therapy to arthroscopic surgery and found no difference at 6 and 12 months between the two groups. These two research studies may be pointing more patients towards physical therapy to deal with their knee injuries. It is more cost effective than the $3,000 to $6,000 sticker price for the menisectomy, and also less traumatic to the body. Of course, surgery will always have its place, especially in cases where the meniscus is flapping over on top of itself or ligaments are also torn.

Physical therapy can reduce swelling and pain, strengthen the muscles around the knee and help you to correct any biomechanical faults that may have been the cause of the damage to the meniscus. This is one of the main reasons that the research studies are finding surgery coming up short: it may clean up the injured tissues for a moment, but more damage is likely to occur if one continues to use their knee in the same way.