Iliotibial band friction syndrome Knee pain in Runners

There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone) which causes the irritation and inflammation of the tissue. It is this location that also gives IT Band Syndrome, and it may be easier to understand the name “Runner’s Knee.” There are two distinct problems labeled “runner’s knee.” For problems that relate to Chondromalacia Patella – Patellofemoral Pain Syndrome please see that article.

But in the simplest terms, Iliotibial Band Syndrome is a problem of a damaged ligament.

Like many sports injuries, doctors tend to manage symptoms as opposed to fixing the problem of Iliotibial Band Syndrome

We see many patients in our clinic with problems of “Runner’s Knee,” or “Iliotibial Band Syndrome.” We typically see these people after they have tried many treatments with little to no success. In our description of the challenges these people face, you will probably see yourself as having tried the same treatments. You may even see some that you have not tried.

You started experiencing outer knee pain

What was the first thing you did? Search for remedies online. What did you come across?

Step 1: Anti-inflammatory programs and medications:

  • RICE
    • The RICE Protocol is Rest, Ice, Compression, and Elevation: For many athletes, a doctor’s recommendation of the RICE protocol for healing their sports related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism as the components of the therapy are somewhat “anti-circulation.” Soft tissue needs blood pumping into it so it can heal. Rest, Ice, Compression, Elevation do the exact opposite. They send the blood away.
    • Please see our article for why we do not typically recommend RICE or PRICE.
  • NSAIDs
    • NSAIDs are also something we would not typically recommend as chronic non-steroidal anti-inflammatory drugs (NSAIDs) usage can make the pain worse in the long-term. We just said soft tissue needs blood to heal. Blood carries inflammatory factors that repair damage. Inflammation is only bad when it is always there.

Let’s stop here for a second and realize you are probably reading this article because these treatments did not repair your injury. They only made it feel better for a short time.

Step 2: Foam rollers, stretching, and massage

Foam rollers, stretching exercises, and massage are effective pain relief methods for many people. But they are not fixing the problem of a damaged ligament. They are fixing the problem of a spasming muscle. The muscle is in spasm because you have a damaged ligament.

Like most runners, you kind of get use to nagging injuries and you always manage to work your way through them. Injuries do not become “real” injuries for most runners until such time that it becomes too difficult and painful to run. At some point, you decide that you can no longer manage this pain on your own with over-the-counter pain relief medications and ace bandages so you go to a health care provider.


Hip and Knee Dynamics – Runners

Studies comparing female distance runners and female recreational runners with ITBS to healthy controls, found that the ITBS group exhibited significantly greater hip adduction and knee internal rotation (the knee hip complex rotating inwards) than control groups. The theory is that these combined motions created excessive strain to the ITB as it attempted to decelerate hip adduction and knee internal rotation causing compression and the ITBS lowest connection points to the bottom of the femur/thigh bone.(2)

Supporting this is a recent case history from the Cleveland Clinic Rehabilitation and Sports Therapy suggesting that problems of Iliotibial band syndrome were connected to the dynamic between increased hip rotation and knee internal rotation.[3]

Dutch researchers also supported this idea of rotation by suggesting that female runners demonstrate a greater internal rotation angle while running than male counterparts, which is why they are more likely to develop iliotibial band syndrome. [4]

As with the friction theory, the hip-knee rotation dynamic involves the tendons and irritation and inflammation in the tissue.

The issue of muscle strength and weakness

Some studies concentrate on changing the running style, or length of stride to help to alleviate the symptoms of ITBS. However, a literature review of many studies conducted by the University of Brighton in the United Kingdom concluded:

  • “It appears unlikely that abnormal biomechanics at the foot or tibia is responsible for increasing tension in the ITB.”
  • “There is currently no evidence to suggest that reduced muscle strength plays a role in the etiology of ITBS.”[5]
  • And another, “Weakness of hip abductors does not seem to play a role in the etiology of Iliotibial Band Syndrome in runners, since dynamic and static strength measurements did not differ between 10 healthy runners and 10 runners with Iliotibial Band Syndrome, and differences between hip abduction and adduction were the same. Strengthening of hip abductors seems to have little effect on the prevention of Iliotibial Band Syndrome in runners.”[6

Symptoms and traditional treatment of iliotibial band syndrome

Hip Joint Instability

ITBS symptoms vary from patient to patient and may range from a:

  • Stinging sensation just above the knee to swelling or thickening of the tissue in the area where the band moves over the femur.
  • The stinging sensation just above the knee joint is typically felt on the outside of the knee or along the entire length of the IT band. This severe excruciating pain in the lateral knee makes running very difficult.
  • Sometimes there is a crunching or grating sound where the iliotibial band rubs over the femur.
  • Pain may not occur immediately during activity, but may intensify over time, or at the end of a run.
  • Pain is most commonly felt when the foot strikes the ground, and pain often persists even after the patient has stopped running.
  • Pain may also be present above and below the knee, where the IT band and the tibia attach.

As we alluded to above and in the medical journal Arthroscopic Therapies doctors write, “Conservative management including rest from activity, equipment modification, oral nonsteroidal anti-inflammatory drug (NSAID) use, and physical therapy is the mainstay of treatment initially, refractory cases do exist. Surgical options include percutaneous release, open release, ITB Z-lengthening, and an arthroscopic technique.”[7 These are procedures that cut the IT Band to “release” tension. “Assuming the inflammation in the tissue connecting the ITB band to the lateral femoral epicondyle is the culprit of ITB pain, this tissue can be removed with an arthroscopic shaver.”

Difficulty in treating and diagnosing Iliotibial Band Injury

University researchers in the Netherlands, publishing in the journal Sports Medicine suggest to treat IT Band injury, doctors need to know what its causes are and to be able to diagnose it. “Iliotibial band syndrome is the most common injury of the lateral [outer] side of the knee in runners, with an incidence estimated to be between 5% and 14%. In order to facilitate the evidence-based management of Iliotibial band syndrome in runners, more needs to be learned about the etiology, diagnosis, and treatment of this injury. . . The methodological quality of research into the management of Iliotibial Band Syndrome in runners is poor and the results are highly conflicting.”[8]

Doctors at the University of California Irvine also wrote of the problems of unresolved iliotibial band syndrome misdiagnosis. They suggest that when orthotic devices failed to deliver favorable results in IT Band Syndrome, it may be suggesting a different diagnosis – potentially popliteal tendinitis or lateral meniscus tear.[9]  It is important that the runner has a physical examination and discusses with the doctor a detailed history to reach an accurate diagnosis.

Prolotherapy for Iliotibial Band Syndrome

Since the iliotibial band goes from the hip area across the knee area, it traverses two joints. If either of these two joints is weakened or has ligament laxity, the tibia and/or femur will move excessively. This will put extra stress on the iliotibial band. In runners with iliotibial band syndrome, Prolotherapy would be recommended into and around their knees and hips.

If the hip is evaluated and considered stable, then an athlete with iliotibial band syndrome will get Prolotherapy to the area on the tibia where the iliotibial band attaches. If there are other parts of the iliotibial band that are tender on the athlete besides the attachments, then these areas are treated with the components of Comprehensive Prolotherapy, including Neurofascial Prolotherapy, and/or Platelet Rich Plasma to increase healing to the area. Typically 3-6 visits of Prolotherapy are needed. The treatments can be done weekly, if necessary. Generally after two treatments the athlete starts working out again.

The safest and most effective natural medicine treatment for repairing tendon, ligament, and cartilage damage is Prolotherapy. For the athlete with chronic lateral knee pain, an evaluation by a Prolotherapist is warranted. We have treated many cases of iliotibial band syndrome in athletes (mostly runners) successfully with Prolotherapy.

1 Pandit SR, Solomon DJ, Gross DJ, Golijanin P, Provencher MT. Isolated iliotibial band rupture after corticosteroid injection as a cause of subjective instability and knee pain in a military special warfare trainee. Mil Med. 2014 Apr;179(4):e469-72. doi: 10.7205/MILMED-D-13-00438. [Google Scholar]
2. Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskelet Disord. 2015 Nov 16;16(1):356.  [Google Scholar]
3. Allen DJ. Treatment of distal iliotibial band syndrome in a long distance runner with gait re-training emphasizing step rate manipulation. Int J Sports Phys Ther. 2014; 9(2): 222–231.  [Google Scholar]
4. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012; 42(11):969-92.[Google Scholar]
5. Louw M, Deary C. The biomechanical variables involved in the etiology of iliotibial band syndrome in distance runners: A systematic review of the literature. Physical Therapy in Sport. 2013; 1-12. [Google Scholar]
6. Grau S , Krauss I, Maiwald C, Best R, Horstmann T. Hip abductor weakness is not the cause for iliotibial band syndrome. Int J Sports Med. 2008; 29(7): 579-583. [Google Scholar]
7. Cowden CH. Barber FA. Arthroscopic treatment of iliotibial band syndrome. Arthrosc Tech. 2014; 3(1): e57–e60. doi: 10.1016/j.eats.2013.08.015 [Google Scholar]
8. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW.  Iliotibial band syndrome in runners: a systematic review. Sports Medicine 2012; 42(11): 969-992 [Google Scholar]
9. English S, Perret D. Posterior knee pain. Current Reviews in Musculoskeletal Medicine. 2010;3(1-4):3-10. doi:10.1007/s12178-010-9057-4. [Google Scholar]


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