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Updated: Apr 30, 2020



Iliotibial band friction syndrome (ITBS) is a painful overuse injury usually experienced on the outside of the knee. Its onset is usually gradual over a period of weeks from activity requiring repetitive bending and straightening of the knee such as running &/or cycling. It is said to cause approximately 22% of overuse injuries in runners, whereby symptoms gradually intensify over a period of time due to repetitive movements of the knee. But don’t fear!!! Studies suggest that with a few weeks of conservative physiotherapy management, ITB friction syndrome can be managed very well.

The team at bounceREHAB will have you up and running again in no time!

Before we talk about ITBS, let’s have a quick look at the anatomical structures of the knee…


Your ITB is essentially the tendinous continuation of your Tensor Fascia Lata (TFL) muscle that originates at your hip. The muscle ends at around the same level that

your bottom does. It then merges to form the ITB which travels down the outside of your leg, ending at the lateral shin bone (tibia) and a small portion of fibres anchor on the patella. The image on the right shows you where the TFL starts and where the ITB merges with the TFL.

The TFL muscle helps to stabilise the hip during standing, walking and running by assisting the gluteus minus during hip flexion, abduction and medial rotation. The ITB acts to protect and stabilise the outside of the knee throughout it’s range of motion.


Essentially, ITBS  is the inflammation of the ITB tendon caused by it rubbing forwards and backwards on the lateral condyle of the knee during running or similar repetitive movements. It is most commonly seen in people who train excessively or increase their training load too rapidly. This increases stress on the body resulting in inadequate time for the tendons to repair and heal naturally.

When the knee is flexed (bent) the ITB sits behind the femoral condyle (a bone protrusion of the femur at the knee joint). As the knee is extended (straightened), the ITB moves forward to eventually sit in front of the femoral condyle when the knee is fully extended.


Essentially the chance of developing ITB friction syndrome increases the tighter your ITB gets. When the ITB is under a lot of pressure (stretched/tightened), it rubs more vigorously against the bone on the outside of your knee and hence your chances of developing ITBS increases. Environmental factors such as the type of ground and incline you walk on can cause your ITB to tighten however there are some biomechanical factors that also lead to increased force being placed through your ITB.

(a) Environmental factors:

Normally, your ITB is under its greatest stress during knee flexion of about 20-30 degrees and it is at this bend, pain is at its most severe. Not surprisingly runners tend to feel the greatest amount of pain when their foot first contacts the ground, when their knee is at this angle and the ITB is tightened to stabilise the knee as body weight is put through the joint. Furthermore, running downhill causes the knee to bend further, placing greater pressure through the ITB and hence more pain can be felt.

Contrastingly, running fast and sprinting decreases knee bend and therefore pain can be reduced.

(b) Biomechanical factors:

Underlying muscle imbalances such as weakness, tightness, fatigue and ground impact issues can alter running biomechanics and cause your ITB to be placed under greater tension.

The most common causes include:

  • Poor biomechanics (running technique); particularly inwards rolling knees and hips

  • Weak hip / gluteal muscles

  • Weak hip rotators

  • Weak inner quadriceps VMO/adductors)

  • Weak core muscles of the trunkTight ITB

  • Poor foot arch control (poor orthotic adjustment) 

  • Worn out or unsuitable runners

  • Sudden increase in mileage for training

  • Excessive hill training (particularly downhill)

  • Endurance running (training for ½. and full marathons, ultra-marathons)

Let’s use the image below as an example…

Notice in Image A, the pelvis is straight and the ITB is not under any excessive pressure.

In contrast, the pelvis in image B is tilted. This could be due to many of the factors mentioned above. This tilt, stretches the ITB further and hence more pressure is placed through the tendon causing it to run harder against the lateral epicondyle (outer knee bone).


The severity of ITB can influence the symptoms a person feels however the most common include:

  • Sharp/burning pain just above the outer part of the knee

  • Pain that worsens with continued running or other repetitive activities

  • Swelling over the outside of the knee.

  • Pain during early knee bending

  • Gradual onset of symptoms


In order to get a comprehensive understanding of your symptoms and make an accurate diagnosis, the physiotherapists at bounceREHAB will perform a thorough assessment. There are some key factors that they will be looking for that may suggest you do in fact have ITBFS.

  • Aggravating factors – running downhill and gets worse with activity, usually after a pain-free start.

  • Area of pain during activities – outside of the knee

  • Palpation – tenderness on the outside aspect of the knee over the ITB insertion

  • Active movements – pain is felt during bending and straightening of the knee, especially at around 20 degrees knee flexion.

  • Tightness – restricted hip adduction due to tight TFL and ITB.

  • Tight hip flexors may also be present.

  • Weakness – usually presents in the hip abductors, specifically the gluteus medius.

The following provocative tests may be used:

Ober’s Test Noble test Thomas test


The main treatments are to reduce inflammation, modify activities or rest and to correct the underlying problem. Once pain is reduced, flexibility and strengthening exercises of the muscles around the hip are initiated. It is only when you are pain free, that it is recommended to return to activity. If the ITB has not been fully rehabilitated, there is a risk that the ITBFS will become a more long term, chronic problem. Surgery is available however more commonly used as a ‘last resort’ and not recommended to be effective v’s conservative treatments.


Conservative treatment has a very good outcome for ITBFS. These treatments are performed by a physiotherapist.

In the initial acute phase, pain and anti-inflammatory medication can be taken to reduce the pain and swelling. Corticosteroids can also be injected to the outside of the knee for patients who do not respond well to these medications. During this period, it is also strongly recommended that people should avoid participating in any physical activity that causes pain.

Once pain has been controlled, a stretching program and ROM exercises are prescribed and activity levels can increase gradually. The main muscles that should be targeted at this stage are:

  • Hip flexors

  • Hip extensors

  • Hip adductors

  • Hip abductors

  • Lumbar Spine flexors/extensors

Myofascial “active release” massage and dry needling “western acupuncture” treatment can also be done by your physiotherapist to abolish any trigger points that may be causing the ITB to tighten or become hypertonic (overactive at rest).

Following this, a progressive exercise program should be started to increase leg strength and resolve muscle imbalances. Compression garments for the ITB are also extremely effective in altering ITB strain by “hugging” the quadricep-hamstrings-ITB lessening the friction of the the distal 1/3 ITB of the lateral femur bone.

In order to return to sport safely, you must be able to perform the stretching and strengthening exercises well and pain free. The usual return to sport occurs 4-6 weeks post injury.

  • Identifying the cause of the ITB friction syndrome and contributing factors.

  • Reduce acute pain and inflammation.

  • Unload your IT band.

  • Assist you with modifying your exercise or training regime to reduce pain and prevent recurrence.

  • Normalise joint range of motion of the hip.

  • Strengthen the knee, hip and leg muscles

  • Normalise lower limb muscle lengths and core conditioning.

  • Improve proprioception, agility and balance.

  • Correct running and landing techniques and function.


Actively stretching your ITB and other muscles around the knee and hip should be included in every training session (see examples below). A foam roller can also be used to release trigger points in tight muscles or in the ITB itself. Here’s a few basic and safe stretch options below…Please note, bounceREHAB goes beyond the simple outline below, our physio team has developed an ITB 4 week conditioning protocol for elite and social return to sports.

Lateral stretch , Quads stretch, ITB foam roller, Glutes Stretch, Calf stretch

You should ensure the strength of muscles surrounding the lumbar spine, hip and knee is maintained and that any aspects of training that results in ITB pain is avoided.


ITBFS is a very common condition in athletes who run long distances or along hard surfaces. Although it can cause a lot of pain and may result in a reduced training load, with the right help from a physiotherapist, you will be back on your feet in no time and walk (or run) away with strategies to prevent recurrence.


Check us out at:

I hope you found our blog on ITBFS useful, i tried to make it informative and relevant to a sufferer of this condition.

Sydney University School of Physiotherapy Clinical educators @ bouncerehab are Matt and Paul


Brukner, Peter & Khan, Karim (2012). Brukner & Khan’s clinical sports medicine (4th ed). North Ryde, N.S.W. McGraw-Hill


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