IT Band (ITB) pain is a common source of knee pain, especially among runners. It presents as pain on the outside of the knee that occurs during running and can be exacerbated by going downhill or navigating stairs. Many people find that when they start to experience this pain they have to stop running. The most common reason for ITB pain in runners is a rapid change in their running distance or intensity. If exercise load increases faster than the body can adapt, pain is more likely to occur.
ITB pain was previously described as a “friction syndrome,” where it was believed that the pain was due to the ITB rubbing on the outside of the knee. However, research has shown that the ITB has many solid connections where it attaches to the knee, so it doesn’t actually slide back and forth. Instead, ITB pain appears to be caused by compression of fat tissue on the outside of the knee1. This fat tissue has a large amount of nerve innervation, making it a particularly sensitive area.
The ITB serves as a type of “spring” in the body, absorbing force as you land and then helping to propel you forward on the next step. While foam rolling and stretching are often prescribed to treat ITB pain, this is likely not the most effective treatment. Research using ultrasound has shown that ITB tightness does not differ between people with and without ITB pain and that as ITB pain improves, ITB tightness actually increases!2 This makes sense if we think about the ITB as a spring; a looser spring would make running harder as it would not store and return energy efficiently. Furthermore, the ITB is made up of thickened fascia. Computer modeling has shown that the forces applied by rolling or scraping only deform fascia by less than 1%3. Therefore, it is unlikely that this treatment will cause any lasting change in the tissue and may not be beneficial if it did. Throughout this blog, we will discuss treatment options that may be more effective in reducing ITB pain.
One of the easiest places to start when dealing with ITB pain is to adjust the running environment and mechanics to reduce stress on the ITB. ITB pain is frequently aggravated by downhill running, so if your running involves frequent hill work, it may be better to stick to flat ground or even slightly inclined treadmill walking to decrease compression at the lateral knee. Research has shown that a more narrow step width increases force on the lateral knee. Trail running often causes a more narrow step width due to path size so it may be advisable to avoid trail running while the ITB is irritated. If you naturally run with a narrow step width, it may be helpful to videotape and evaluate this to determine if conscious changes to your step width could improve your pain levels. Running cadence, or the number of steps per minute you take, can also impact pain levels. Increasing your cadence by 5-10% can increase step width and reduce the force placed on the ITB. The easiest way to monitor and change cadence is by using a watch that tracks it.
While many runners shy away from strength training, it is important to build strength due to the high forces runners experience every time they hit the ground. When experiencing ITB pain, strength training is important for multiple reasons. The ITB is responsible for absorbing high levels of force during running so if we avoid all activity and stress to this area, pain may resolve but will quickly return once running is resumed. Building capacity in this area is key to preparing it for the forces involved in running. Additionally, maintaining strength throughout the lower body is important to prevent subsequent injuries due to detraining while running is not possible.
One primary exercise to work on is the Bulgarian split squat, as this helps load the ITB while also strengthening the glutes and quads. Aim for 3 sets of 8-12 reps, leaving 2-5 reps in reserve. This can be done 2-3 times per week. Other exercises to maintain lower body strength include squats, deadlifts, lunges, leg extensions, leg curls, leg press, and calf raises.
Since the ITB acts as a spring for energy absorption and release, it is important to prepare it and the rest of your body for the high forces associated with running. After establishing a base level of strength, it is a good idea to add plyometric exercises that involve jumping, especially lateral jumping, as this specifically loads the ITB. Examples include skater hops, where you jump side to side, focusing on pushing off as aggressively as possible. You can also add resistance with a band or weights. Lateral box jumps are another good option. These should be done with lower reps, around 3 sets of 5 reps, ensuring you stay fresh throughout the exercises for maximum power output.
If you can complete all of the exercises mentioned over a few weeks without an increase in pain, it may be time to start working on returning to running. It is important not to jump back to your previous intensity and volume, as your body needs time to adjust to the load of running. Options to ease back in include walk/jog intervals, alternating every 0.25 miles. You can also start at 25-50% of your previous running distance and as well as decrease your speed. These modifications will help decrease the load on your legs and body as you return to running. It is also a good idea to start running with the initial modifications, such as running on a slight incline and increasing cadence slightly to decrease stress on the ITB. As time goes on and symptoms do not return, you can gradually reintroduce downhill and trail running.
The ITB acts as a spring in our bodies, allowing us to be more efficient when running. When it becomes painful, focus on activity modification, running form adjustments, heavy resistance training, and plyometric exercises until symptoms improve. If you are dealing with ITB pain, you can make an appointment with one of our physical therapists to have it further evaluated and create a personalized plan for you.
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