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Iliotibial Band Syndrome (ITBS): Symptoms, Treatment and Prevention in Runners and Triathletes

All Ahead Stop!

My next blog was due to be a discussion around the amount of training you actually need to put in to complete an Ironman, and the advantages of taking a midseason break. This will still be my topic, but it has been commuted as I wanted to get a quick blog up about the elephant issue that I have heard coming back from a lot of athletes who have started to get back into training after the off season.

Runner with knee pain from Iliotibial Band Syndrome

What is IT Band Syndrome (ITBS)?

This massive elephant is the wonderfully painful and fantastically frustrating Iliotibial Band (ITB) Syndrome. I myself am an on-and-off sufferer of this ridiculous affliction which ranges from a painful ache at the side of the knee to extreme pain that stops you dead in your tracks, and which can cause pain in your lower back, tensor fasciae latae (TFL), lower or upper quadricep, hip flexor, hamstring, glutes, calf and in the ITB itself. So many muscle groups and tendons? Well yes, they are all interconnected and powered by this massively powerful tendon, and a lot of issues I have come across where athletes think they have a back spasm or an issue relating to their hip flexor or glute, can actually be directly contributed to the IT Band. In fact I would always check this out first before looking at other options as more often than not the ITB is the culprit.

IT Band Topics in this blog:

· What is the Iliotibial Band?

· How can you do a quick test to see if this could be the culprit of your pain?

· What is the main issue that causes ITBS?

· and most importantly, How do you treat ITBS?

Introduction to the Iliotibial Band (ITB)

To start, let’s have a really quick look at the ITB. This tendon is the largest in the body and runs from above your hip flexor going down the outside of your leg to the outside edge of your knee, where it combines into the top of the calf muscle. Part of the ITB also separates off higher up the leg and wraps into the glute muscle. It is an amazing piece of bodily engineering and is responsible not only for flection and contraction, but a huge amount of stabilisation of other muscle groups, as well as keeping muscular skeletal formation in line. The outside of the leg and knee is the direct line of impact for the ITB and it is most commonly associated with pain on the outside of the knee, but due to its significance and size it also plays into muscle groups such as your core, foot flexors, quadriceps and hamstrings, to just throw in a few more for a bit of fun. In fact, if you then place the aforementioned and obvious muscles into the bag of bits (glutes, FTL, hip flexor) then you are left with a lower body array of muscles and connected tendons and ligaments that can all fall foul of any issue with the ITB, creating a buffet of pain in various areas, hence why I said it is always worth checking your ITB out before looking further at a specific area.

Iliotibial Band Anatomy (IT Band)

What does IT Band pain feel like?

Now we have a better understanding of the ITB and its function, how can we test to see whether the ITB is the source of pain and what are the key reasons for the ITB being an issue?

Okay, you’re feeling good. Training has started and you are back in the swing of things and ready to take on the challenges that a new year brings. Kit is on, Garmin is charged and your iPod has your motivational tunes all lined up ready for you to get out there and make this your best season yet. You start your run and feel pretty good and confident about your plan for the year when suddenly, BANG!!! There is an indescribable sharp pain in the side of your knee. ‘Not a problem’ you think, ‘I am sure it’s just the body warming up and I will run this off in a minute’. But as you continue to run the pain starts to become like a vice, gradually tightening up your knee. Maybe you start to get some pain in the front of your hip or lower back and if it all goes completely wrong then your knee may start to loose stability and begin to fold in. Either way you realise this cannot be run through and even walking for a bit with some active stretching doesn’t cure the problem when you start to run again. Well congratulations, you have more than likely entered the world of the IT Band. I say more than likely as this is not gospel and there could be other factors, but I personally would be a wealthy coach if I could put a fiver down on every lower body issue that ends up being caused by the IT Band.

How to test for ITB Pain?

So is there anything we can do to have a quick check to see if the ITB is to blame? Well, there are a few things that are easy to perform and can raise flags to guide you to a self-diagnosis of ITBS, and may help to get you on the right track.

Can I run through ITB pain?

No. The minute you get any kind of pain as mentioned above, or any major niggle or acute pain in the lower part of your body or lower back you need to STOP.

All too often as an athlete the ‘No Pain, No Gain’ mentality, or ‘I can just train through this’ thought pattern, goes through the mind. But please don’t, just stop and let it go. This is hard to do when you want to get a session done, or this is the unwanted start to your season, but trust me I have been there on more than one occasion. All you will do if you try to push through it is cause a bigger issue that will take a lot longer to fix down the road. If it is ITB, it isn’t going to go away because you are giving it a stern talking to, and to be honest you can’t physically get through it even if you want to due to the pain and the power of the tendon once it has started being problematic. So wherever you are when this kicks in (usually at the furthest point from your house because the law of sod dictates it!), just stop and walk back, or call your long triathlon-suffering other half and get them to pick you up. Once you are back home and settled try to give the following three easy stretches a go.

Stretches to test for IT Band pain

1. Standing ITB Stretch

Stand upright and cross one leg over the other. Gradually lean down to touch your toe on the side of the front foot while slowly rotating at the waist so your lower body is still facing completely forward but your hand is flat and pointing towards the outside of your ankle. If you are (like me) about as flexible as a plank of wood then you will probably get to around the midsection of the side of your calves. This is a good point to start. Try to hold this for 30 seconds and every 5 seconds within this count, try to stretch down a little further aiming for your ankle. If you are Reed Richards (the stretchy one from the Fantastic Four), then you will be able to get straight down but it should be uncomfortable in the sense that you will be able to feel a real pull through your ITB and possibly through your glute and lower back. Once you have completed one side, slowly bring yourself back up to a standing position and repeat by crossing the other leg.

Standing Iliotibial Band (ITB) Stretch

2. Seated ITB and Glute Stretch

The principles of this are the same as the standing stretch but I would do it straight after the standing stretch, as going straight in to this one can be seriously uncomfortable if you haven’t done some easier pre-stretching. Remember that the idea of stretching is to gradually draw out the muscle, tendon or ligament, not drag it as hard as you can kicking and screaming to a position where you are tolerating massive amounts of discomfort because you think it’s doing you some good! Little by little and feeding the stretch gradually is the key, even if at first you can hardly get any movement out of the area.

Sit on the floor with your back supported against a wall or sofa. Legs out straight in front of you. Bring one leg up so your knee is vertical and then cross this leg over your other leg (which is still out straight) with your foot flat on the floor. Put your hands around your knee and gently pull it up to bring your foot towards the top of your quadricep. Basically give your knee a big hug. At the same time, rotate the upper half of your body, whilst keeping the lower half steady, and turn your head to look away from the direction of your now cuddled leg. As above try to hold for 30 seconds and (if you can) gradually increase the stretch every 5 seconds by rotating the upper body more while bringing your cuddled leg further in. Once again, repeat this with the other leg.

Seated Iliotibial Band (ITB) and Glute Stretch

3. Seated Hip Opener

Staying in the seated position from your previous stretch put both legs out straight again. This time take one foot and slide it as high up the remaining stretched-out leg as possible. Then (and here comes the hideous bit) use your hand to push the bent knee gently towards the floor whilst keeping your foot in position so that your ankle is flat on your leg. Hold this for 30 seconds and every 5 seconds try to apply a little more pressure. Do take this one very carefully and only push to a tolerance level you can handle and not punish yourself with. If you are tight in the hip flexor and glutes this is going to be seriously uncomfortable and over-doing it could cause issue in itself.

Seated Hip Opener Stretch for Iliotibial Band (ITB)

Once you have done the above three stretches, stand up and shake out and see how things feel by doing some movements like hip-swings, knee-ups, butt-kicks and side-leg raises. If things feel a lot better then you could start thinking that the ITB is your nemesis.

These minor stretches are in no way going to cure your issue, so if they do make you feel a bit looser then don’t think that on your next run it isn’t going to happen again. The issue is that ITBS is a sneaky little git and likes to lull you into a false sense of security before striking again in an attempt to really piss you off and cause pain.

Running Symptoms for Iliotibial Band Syndrome (ITBS)

Here are a few extra tests to see if ITBS is the issue. These are quite easy and are my go-to for a more robust identification of the issue and knowing if my pain is being directly caused by my ITB.

  1. Get to the bottom of a fairly long hill - gradient to suit, but try to get one that has a bit of a climb on it rather than a gradual slope. Walk or drive there if needed, but don’t jog or run as we need to save this for the test. Once you are at the bottom of the hill start running up it and gradually build into a nice easy sustainable effort. You should, in theory, be able to get to the top without much issue, maybe a slight niggle but not anything that you can’t run with.

  2. When you get to the top keep going but keep it steady (this is absolutely imperative). Quite quickly you should start to get that feeling of tightening across the knee or area of pain. When this starts, speed up rapidly and go from a nice steady jog to around a 5K pace. You should instantly find that the pain subsides or dies back to a mild niggle again. If this happens then stop straight away as it will then come back and bite hard after a while. If you accelerate and the pain is worse, then just stop regardless as this still be a more severe case of ITBS, or there could be another underlying issue.

  3. Once you have stopped then walk back to the top of the hill. Try to run down it nice and easily at about a recovery pace as if you were running hill repeats. The discomfort should be almost instantaneous, and your leg will very quickly start to lock up and the pain will flare faster than before. Again, STOP. Walking down the hill may now also be uncomfortable so go extra cautiously when performing this.

  4. When you get to the bottom (and only if you are able to) try to jog up the hill again a little bit. You may find that for some odd reason the leg begins to unlock again and the pain subsides slightly.

Running uphill to test for Iliotibial Band (ITB) pain

Why does this happen? Well, it’s all about the activation of muscles and how they operate through your system, with varying degrees of load being put through them at different angles. It is also about the amount of stabilising required by the ITB to keep everything in sync during the body’s forward motion, and the angle at which the body is performing these motions in relation to the stabilising effect (simple!).

Is ITB Pain just Runner’s Knee?

ITB pain is not Runner’s Knee. ITBS can be the cause of a multitude of problems so it’s always worth just giving it a quick check to rule it out. If you do the above test and you find any of the mentioned pain responses occur, then I would personally say that at best guess your ITB is the issue. I myself have had ITBS to the point that I couldn’t lift my leg to drive and nearly had to ask my wife to collect me from Tesco’s car park. Even with pain this severe, I found that the above test combined with the stretch tests confirmed an ITB issue, rather than a sciatic nerve issue or a hairline fracture in the hip, which can sometimes be suspected in really bad ITBS conditions.

IT Band Pain in Cyclists

ITBS in cyclists is usually brought on due to weak adductors not holding the leg correctly whilst in a rotational movement. Weak glutes and hamstrings are also a huge factor in this, or underdeveloped/tight quads. Adductors are the counter-balance to the ITB when it comes to supporting the leg during movement. If they are not strong enough then it can cause the leg to fold in slightly, meaning the ITB and supporting muscles have to put in extra work to keep everything level.

Treatment for Iliotibial Band Syndrome Pain (ITBS)

Now you have done the tests you feel fairly confident that your ITB is the issue or is playing a part. Even if you are not 100% sure it’s never a bad idea to work through the ITB and make it as happy as possible. But how can you begin to treat it (and is it actually your ITB that’s to blame)?

Should I Foam Roller my IT Band?

The classic treatment for strains, tears and pulls, along with flexibility and movement restrictions is to hop on the roller and get it rolled out. I absolutely agree with this method and it wields great results. When it comes to the ITB though, DON’T ROLLER IT!!!! Some people reading this will disagree and complain bitterly that I am incorrect, so let me explain.

Reasons why you shouldn’t roller your IT Band

  1. The ITB is a massive band of tendinous tissue, not muscle, and rollering the heck out of it is going to do nothing. All it will do is aggravate a massive chunk of tissue that actually hasn’t got anything to do with the problem, as weird as that may sound.

  2. It’s not the actual ITB that is the problem. Regardless how many people think that it is, trust me it really isn’t. Your problem will lie in the surrounding muscle tissues. Most ITB problems are directly related to having weak or misfiring glutes, a tight lower back, bad hip flexor mobility or tightness through the TFL. This group of troublesome muscles form a pinch-point manoeuvre which overloads the ITB and restricts its ability to do its job correctly. More often than not, the direct force of pressure that these muscles put on the ITB can cause it to shift ever so slightly into an incorrect operational pattern which then will cause the tendon to flick over the anchor points in your body causing a painful flicking effect on your hip or knee.

  3. Arguers for the use of the roller will say that the ITB hasn’t got a great blood supply and so you need to improve this to increase the repair effect. Or they say you may have micro abrasions on the ITB that need to be softened out as they are causing it to operate incorrectly by shortening the tendon slightly. I understand this, but if the ITB is not the problem in the first place then why attack it with a roller? If you do have micro abrasions in a tendon this large, it is not going to react to any kind of breakdown process with a roller. Muscles react well to foam rollers, as there is soft tissue movement that allow the abrasion to be gradually rolled out, like dough on a board. But the ITB tendon is so tight that the abrasion has no soft tissue to allow it to be assimilated into. Going at it with a roller means that you would have to put huge amounts of pressure through the roller and would need to keep this pressure up for a long period of time to gradually wear down the abrasion lump. You will anger the ITB long before you impact the area you are trying to treat. This can cause bigger issues brought on by swelling and irritation of the tendon and can easily make the situation worse. Light rollering (and I mean light) after you have treated your ITB, to increase blood flow to the area is great, but not as a treatment method.

I will come back to abrasions on the ITB later in this article with some advice for what to do instead.

Treatment for IT Band pain

Let’s have a look at what we can do to start to treat Iliotibial Band pain. As I have said, this is not your ITB’s fault, unless you have somehow miraculously managed to actually tear it, which is a whole other bag of issues and you won’t be standing, let alone trying to train on it. Let’s then look at the muscle groups around the ITB, mainly TFL, Glutes and Hip Flexor, taking into consideration Hamstrings, Quads, Lower Back and even to some extent Calves.

We need to get these muscles working properly and lining up so they don’t put pressure on to the ITB and everything syncs up allowing you to perform lower limb motion in a clean and concise way.

Muscle Strength Training for Iliotibial Band Pain

To strengthen these muscle groups it’s about gentle manipulation rather than pure strength. So often I have come across athletes who head straight down the gym and perform some obscene strength work to try to solve the problem. Nope, not going to happen. Movement first, strength later.

These easy to perform movement-based work outs will not only help to resolve the issue but over time should clear it completely.

IT Band Stretches

1. Side poise leg lift

Lie on your side on the floor with one leg on top of the other and support your head in any way that’s comfortable. Lift your top leg up into a scissor position and gradually roll the leg back whilst keeping your hip straight and core taught. Do not flex back or forward at the hip. Your body will want to move at the hip, to help manoeuvre your leg, but this is where you need to engage your glutes to carry the load rather than your core and hip. Hold this out for a couple of seconds and then bring the leg back parallel and lower. Try to repeat this 12 times. If you have weak glutes, you may only be able to do this a couple of times to start with, but this is fine, don’t force it. It’s better to do two or three with great form than try and punch out twelve and do them incorrectly. Once completed lie on your other side and repeat.

Side Poise Leg Lift Stretch for Iliotibial Band (ITB)

2. Kneeling Hip Flexor Activation

Kneel on the floor then bring one leg forward so you are in a position where you feel like you should be knighted in a King-Arthur-styled film. Nice and simply keep your upper body straight and slightly lean into the outward leg whilst trying to pull your glutes tight. Do not bend at the waist, unclench your glutes or let your upper body go floppy. Hold your head high and look straight like a spaniel at Crufts. Hold this for a few seconds and then go back to a straight position. Once again, repeat this about twelve times and then repeat with the other leg/side of your hip.

Kneeling Hip Flexor Activation Stretch for Iliotibial Band (ITB)

3. Seated clamshells with a band

This one you can go to the gym for if needs be, but stretch cords and bands can be purchased pretty cheaply. I actually sell Dynabands through Neuff Athletic (blatant advertising there!). If you are using a flat band such as a Dynaband, then tie it into a loop at the top. Sit on a chair or bench with your knees hip-width apart. Bring the band under your legs so it is anchored on your hamstrings about midway up your leg. Twist the top end of the band and bring this end down under your feet and stand on it to secure it in place. Now, slowly open your legs whilst keeping your feet flat in position, and once you are out as far as you can go (or as far as the band will let you), slowly bring them back in again. Repeat this up to twenty times, or as much as you can do and then perform the exercise again, but this time leaning forward to increase the power of the stretch and redirect the area that is being worked.

Seated Clamshell Stretch with a Band.  For Iliotibial Band (ITB) Pain

4. Use the test stretches above (Standing ITB Stretch, seated ITB and Glute Stretch and Seated Hip Opener)

Also add in quad, hamstring, calf and lower back stretches, to make sure you are keeping all adjoining tissues nice and supple. Keep persevering with this and don’t expect it to clear the issue overnight, but over a relatively short space of time you should get back to full mobility with no ITB pain.

Can you run with IT Band Syndrome?

Once you are experiencing ITB improvements through stretches, the next thing is to test progress by running. Try getting out the door and build up slowly.

  1. Start running for around twenty minutes built as two minutes run, one minute walk.

  2. Over the course of a couple of weeks, gradually increase the time running and the duration you are out for, but as you get to around the eight minute mark for continuous running, increase the walk time to ninety seconds.

  3. Once you are able to train as around ten minute run, ninety seconds walk for about forty-five to fifty minutes then you are good to try to take on a thirty minute straight through run and increase from there, but slowly.

  4. Do not rush this and keep up the stretching and exercises even if you feel that everything is fine, as ITBS can sneak up again pretty quickly. When you get to about fifty minutes to one hour of clean running with no irritation or pain then you are pretty well good to go.

  5. If possible, do not do these runs on a treadmill. Due to the way a treadmill operates, you can find that you run well, you then go outside with the increased downward/upward load through your leg and a different gait to your run and, BANG!!!!, back to square one.

Preventing Iliotibial Band Pain

To help prevent ITB Pain from re-occurring, there are a few maintenance areas that can be done to keep everything in check.

  1. Keep going as much as you can with the previously outlined stretches and try to throw in the strength exercises once a week at least.

  2. Other movements that will help are:

    1. Weighted lunges and clock lunges,

    2. Weighted squats with flat feet and with your heels slightly raised on a 5kg weight plate.

    3. Box weighted step ups, placing a weight bar on your shoulder, and then stepping up onto a box or bench around twenty times with one leg and then the other, and repeating for three reps.

    4. Walking weighted lunges, holding a dumbbell in each hand and literally walking across the gym, but as squats. Do ten and then go back the same way to your starting position.

    5. Really importantly, try to use an abductor/adductor machine or do anything to strengthen your inner/outer thighs. This is particularly important when ITBS is affecting cyclists.

Improving blood flow to the ITB

Finally, let’s get back to that blood flow/potential abrasions/legions issue, that may have formed on the ITB due to micro tears that have then healed over and could cause a slight tightening or shortening of the tendon. Well despite the knocking I will get from the roller hounds, as pointed out, this won’t work, as much as you would want it to and as much as a muscle-bound guy called Larry tells you it will on his YouTube channel. The only way to deal with this effectively (if you think it is something that needs to be addressed, or if you have never had it done) is to go to a good sports physio and have a beautiful process called ITB stripping done. The physio uses a tool to apply pressure and literally strips it down the ITB, much like planeing a piece of wood. A word to the wise on this, co-codamol or two paracetamol and two ibuprofen taken twenty minutes before hand will go some way to alleviate the need to scream profanities as loud as you possibly can (and upsetting all the other clients waiting to go in for a session). ITB stripping really does help to smooth things out and increase the blood flow but do not try it yourself. Make sure you see a good physio and a regular trip to the physio for general work, in my book, is always the best way to keep everything moving regardless of what you can do at home.

Cautions about self-treating ITBS

I hope this helps you if you are a plighted athlete who is suffering from, or keeps getting bouts of, ITBS. I have a huge amount of experience with injuries and rehab from injuries and illness having suffered from nearly everything in the triathlete’s book of problems, and having worked closely with an amazing physio for years. But I am not a medical expert and so if you are seriously concerned or if the pain and discomfort is not easing or is causing you serious issues then please consult a GP or specialist as soon as possible.

Woman running to train for a triathlon


Next blog is on how much you need to train for an Ironman and the advantages of a midseason break…………. Hopefully!!!!

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