Why Does My Iliotibial-Band (ITB) Hurt When I Run? Considerations for Managing the ITB as a Runner

Sean Rimmer

Running Specialist, Physical Therapist  at Run Potential Rehab & Performance in Colorado Springs, CO. ​

One of the more common running-related injuries I see in recreational runners is pain in the region of the ITB, known as Iliotibial band syndrome (ITBS). If you’ve ever dealt with ITBS, then you’ll know it’s typically accompanied by pain just to the outside of the knee, and it can be exacerbated by spikes in training load and downhill running. For trail runners specifically, managing ITBS can be a very frustrating process due to the nature of the terrain. In this article, I’ll review the anatomy and function of the ITB, why you may be experiencing ITBS as a runner, and some strategies to consider in managing ITBS. ​

​Structure and Function of the ITB:

The ITB consists of a thick fibrous connective tissue with upper attachments at the outer pelvis, glute max muscle, and tensor fascia lata (TFL) muscle near the pelvis; and the ITB spans the outer thigh to insert at the outer femur (thigh bone) and tibia (shin bone) near the knee joint. In the image below, you can get an idea of the ITB anatomy and that it further crosses 2-joints both at the hip and knee.

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The ITB has been proposed to function as a lateral stabilizer to both the hip and knee during the stance phase of running, while also aiding in energy storage and release. An example of the ITB’s function is during the initial contact through loading response phase of our running gait. When our foot first touches the ground, we tend to land slightly on the outside of our foot. Due to this contact, there’s a normal strain to the outer part of the leg. Our ITB functions to reduce excess lateral strain at the knee and hip. Secondarily, this allows the ITB to store some mechanical energy from the initial strain to provide some mechanical return after the loading response phase in our gait. Both of these functions are imperative to us as runners, for both stability and mechanical efficiency.

Cross Over Stride

Why does ITBS occur?

In the past, ITBS was thought to be friction related stress from the lower ITB “rubbing” the lower femur if the ITB was too taught. However, it is now theorized that ITBS is compression related. This compression is thought to occur when the knee is bent past 30 degrees and the ITB compresses against the outer femur at the knee. Though the ITB get’s the rap as the pain source, the pain site is thought to be the highly innervated fat pad between the ITB and femur. 

Now, if you’re reading this you’re probably thinking, well wouldn’t nearly every runner get ITBS if it occurs with only 30 degrees of knee flexion? Unfortunately, the answer is not straight forward, like with most running-related injuries. However, with coming across ITBS frequently, there are some common trends I tend to appreciate in individuals dealing with ITBS:

• Training Error
• Long ground contact times/over-striding
• Narrow step width/cross-over stride
• Reduced pronation mobility/control at the rear-foot

By no means is this an extensive list of causatory reasons to why ITBS comes on, nor is it guaranteed reasons for ITBS to come on. Rather these are patterns I tend to see on the movement and training side of running that have a potential to bring on ITBS.
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Training Error

In previous articles I’ve written, training error tends to come up as a potential contributing factor for running-related injuries. Training error is multifactorial, but in simple terms, it’s excess stress with inadequate recovery. We need both stress and adequate recovery to have a higher potential to remain healthy as runners. With that said, our tissues have capacities before they either fail (major tissue injury), or become sensitized (become irritated or painful). Without discussing altered mechanics or compensation (which I’ll discuss below), if we don’t allow recovery within our training, there’s a higher risk for tissues that are stressed during running to become sensitized or injured. Without going too deep into training error, taking account of your total training load is important. Think of the total training load as the sum of our FDI principle: Frequency, Duration, and Intensity of training, and I would also include terrain, as varying technicality, steepness, and trail surface can have an affect on training load. 

Terrain Factors

For the purpose of this article, I want to highlight terrain as an area of training error. There are two terrain factors that can place a higher level of strain to the ITB and they include downhill running and running on narrow trails. The downhill in general increases the overall load on the musculoskeletal system, where there’s often slight to significant over-striding. If the body isn’t conditioned for this, and or we increase our downhill running rapidly, there’s a potential ITBS could result.

On the other hand, a narrow trail tends to narrow our step width as runners, and this can lead to an increase in lateral strain to the leg. As I previously mentioned, the ITB acts as a lateral stabilizer to the leg during the stance phase of running, and with the ITB being on the lateral portion of the leg, it tends to take on more strain as our step width narrows. Again, this situation can become a problem if our tissue isn’t ready to handle the load of the terrain specifically.

​Long Ground Contact Time/Over-Striding

Another pattern I’ll often visualize when assessing someone with ITBS, is a longer ground contact time (GCT) and/or over-striding. To define these two terms: GCT is the amount of time our foot is on the ground from initial contact through the push off phase of running, and over-striding is when the shin angle increases past perpendicular; or a better example to conceptualize this would be when the foot lands in front of the knee at initial contact. There’s no clear evidence or patterns I’ve appreciated that speak to the degree of over-striding or GCT as a cause of ITBS, but often intervening to improve on either or both areas can be helpful in reducing symptoms in the long-term for ITBS. 

Narrow Step Width/Cross-Over Stride

Both a narrow step width and a cross-over stride have the potential to lead to ITBS. This is due to an increase in ITB strain as the foot moves closer to midline during the stance phase of running. A cross-over stride is when the foot lands past the center point of the pelvis in the horizontal plane (past midline). We’ll discuss some simple, yet effective intervention strategies for step width in the management section.

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Increased Step Width

Reduced Pronatory Mobility/Control at the Rear-Foot

The mobility and control in the foot and ankle are imperative during the stance phase of running. The motion in these joints dictate what may occur up the kinetic chain, whether it’s complimentary or compensatory movement. Pronation is when the foot and ankle are in a state of storing energy and/or absorbing load. The motions that occur within pronation are ankle dorsiflexion, rear-foot eversion, and abduction of the foot. If our foot and ankle can’t manage loading optimally, compensatory motion can occur both locally or up the kinetic chain. 

One of the compensations I’ll often see is someone narrowing their step width to increase the relative pronation at the foot and ankle. When the step width becomes increasingly narrow, the body has a higher leverage to increase rear-foot eversion torque which aids in pronation. Though this correction aids in one issue, it can potentially lead to another problem, that of ITBS. 

Management Strategies for ITBS: 

Early Phase

In the early stage of managing ITBS, it’s important to encourage movement as tolerated, to address the underlying training error or potential biomechanical compensation, and early loading to the ITB specifically. We want to treat ITBS like a tendinopathy (pain within a tendon), as the ITB responds to treatment in a similar fashion. What this often means, is that we can have some minor discomfort with movement, while we’re improving the tissue loading capacity and tolerance to the activity, ie. running. Here are a few examples of what a treatment could look like for someone dealing with ITBS in the early stage or when the ITB is irritable:

Activity/Running Progression

Uphill treadmill walking → Progressing to uphill treadmill run/walk

Running Biomechanical Changes

Cues to “widen” the step width (this can be practiced by jogging on a track while straddling the line and not stepping on the line). 
Or increasing step rate (cadence) as this tends to shorten our stride length and potentially reduce over-striding/cross-over step.

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Loading the ITB in Non-Weight Bearing (R Leg)

Loading the ITB

Initially, this can be done in non-weight bearing if the ITB is highly irritable, but should ultimately be progressed to weight bearing. I like to use a lunge or split squat pattern as a movement to load the ITB as it lengthens the tissue at the hip and the knee when the knee is bent and hip is in extension. A progression could start with someone lying on their back on a PT table or bed with their ITBS leg hanging off the side of the table. If they then slowly work the bending portion of the knee, this can slowly begin to load the ITB in a lengthened state. If this is tolerable, and non-symptomatic, someone may be able to tolerate a lunge isometric (hold) at bodyweight, the depth can be modified based on symptoms. The leg that is back is the leg we are focusing on loading for the ITB. 

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Rear-Foot Elevated Split Squat

Management Strategies for ITBS:
 
Late Phase

In the late stages of managing ITBS we want to progress tissue loading in weightbearing with the addition of external load, add plyometrics with a lateral component to increase loading demand to the ITB, and progress run training via FDI principle and gradual exposure to the terrain that may have contributed to the ITBS.

Activity/Running Progression (Terrain)

Uphill running→ Flat running → Gradual downhill →Steep downhill → More technical steep downhill & single-track trail (narrow)

Loading the ITB

Lunge in place —> Rear-foot elevated split squat → Adding external load through a larger range of motion

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Skater Hops

Plyometrics

Hopping with both feet side to side → Skater hops side to side → Lateral single leg hops at a higher amplitude

Again, it’s important to state that by no means is this a “cookie cutter” approach to managing ITBS as everyone’s situation is unique to them. The intent of this article was to educate on the anatomy and function of the ITB, considerations for why ITBS can come on in runners, and some management options and progressions if dealing with ITBS.

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