Iliotibial band syndrome

Iliotibial Band Syndrome: Why Does the Outer Side of the Knee Hurt?

Pain on the outer side of the knee may be caused by compression of the tissues located beneath the iliotibial band. This explanation is based in part on an anatomical study; it remains a hypothesis and does not prove the mechanism of the pain.¹ This syndrome particularly affects runners and cyclists.¹

What is iliotibial band syndrome?

Iliotibial band syndrome is characterized by pain on the outer side of the knee. In runners, knee pain in this location may be part of the evaluation. An anatomical study proposes the hypothesis that tissues located beneath the band near the bony prominence on the outer side of the knee are compressed, though this alone does not establish the mechanism of the pain.

Anatomy of the Iliotibial Band

The iliotibial band is a thick strip of connective tissue—a fibrous tissue that connects and supports structures in the body. It runs down the side of the thigh. It attaches at the top to the iliac crest, the bony ridge of the pelvis, and to the tensor fasciae latae, a small muscle located on the front of the hip that keeps the band taut. It runs down to the knee, where it attaches to the tibia, just below the joint.

The ligament connects structures in the hip to the tibia. Its function during movement is complex and cannot, on its own, explain pain. An assessment of knee stability takes into account several structures and their function.

Where does the nickname "windshield wiper syndrome" come from?

This injury is also known as "wiper syndrome," because it was long believed that the ligament moved back and forth over the knee bone like a windshield wiper on a windshield.

An anatomical study proposes the hypothesis that the pain results from compression of the tissues beneath the band rather than from repeated friction against the bone. This study alone does not establish the mechanism of the pain.¹

An anatomical study describes a band attached to the femur and suggests that it may compress a layer of tissue located beneath it rather than rolling over the bone. These observations support an anatomical hypothesis, though they do not, on their own, establish the mechanism of pain.

In this anatomical study, the ligament was compressed against the outer bony prominence of the knee when the knee was bent to approximately 30 degrees.¹

Among a wide range of running injuries, iliotibial band syndrome ranks second among the most common injuries, just behind patellofemoral syndrome.² It is the most common cause of pain on the side of the knee among runners.^{3, 4}

What are the symptoms of iliotibial band syndrome?

The main symptom of iliotibial band syndrome is localized pain on the outer side of the knee, just above the joint, which occurs during physical activity and subsides at rest. It worsens with repetitive movements, and rest usually relieves the symptoms.

Characteristic Location

The pain is very localized. It is located on the lateral femoral condyle, the bony bump on the outer side of the knee. You can often trigger it by pressing on that specific spot.

Typical Course of Pain

Symptoms vary; some people describe one or more of the following:

• Pain develops after running a certain distance
• It gets worse if you continue to run
• It sometimes forces you to stop
• It disappears after a few minutes of rest
• Pain may set in earlier as you go on more outings

Activities that increase pain

Several activities can worsen the symptoms:

• Running, especially on uneven surfaces or downhill
• Cycling, if pedaling triggers the pain
• Going up or down stairs
• Hiking, especially downhill
• Sitting for long periods with your knee bent

Signs to Note During the Evaluation

Please note the following points in particular, as they may affect the assumptions under consideration:

• Visible swelling of the knee
• If your knee locks up or gives out under your weight, get it checked out right away
• Cracking or popping sounds in the knee
• Pain during prolonged rest

If you have these symptoms, an evaluation can help rule out several possible causes. Our comprehensive guide to knee pain and our page on patellofemoral syndrome—which primarily affects the front of the knee—provide additional general information.

What are the causes of iliotibial band syndrome?

The exact causes of iliotibial band syndrome remain unclear. Compression of the tissues beneath the iliotibial band may contribute to the pain, but studies do not point to a single cause. An evaluation may also take into account other running-related injuries, without making assumptions about their cause or the frequency of recurrence.

Training errors

A systematic review of 36 studies concludes that current data do not consistently link running injuries to a specific training parameter or to a recent change in that parameter: the “10% per week” rule therefore does not have the support often attributed to it.⁵ Recent changes in training and recovery between sessions are nevertheless part of the context that needs to be discussed.

Certain changes in training can be discussed on a case-by-case basis, but the observed associations are inconsistent:

• Switching from flat terrain to hills or trails
• Significantly increasing your speed
• Add intervals without adapted progression
• Running twice a day without proper adaptation

Movements Observed During the Race

Certain movements or characteristics may be observed in some runners; they do not indicate a single cause of pain.

Equipment and Environment

The comfort and condition of your shoes can be discussed during the evaluation, without assuming that they are the cause of the pain. If running on a specific side of a curved road triggers your symptoms, vary your route and observe the response. The surface alone is not enough to determine the cause. Long downhill sections can trigger symptoms in some people. If this applies to you, you may want to temporarily limit such runs.

How is iliotibial band syndrome diagnosed?

The clinical evaluation may take into account the history of symptoms, their location, and the physical examination. No single test can confirm the syndrome; the use of imaging depends on the clinical situation.

Clinical evaluation

During the physical therapy evaluation, your physical therapist will assess:

• A precise history of your symptoms and training
• Locating the pain through palpation, that is, applying pressure with the fingers to identify the sensitive area.
• The mobility of your hip, knee, and ankle
• The strength of your gluteal and stabilizing muscles
• Your running style, if necessary

Clinical Tests

The Noble test may be part of the examination: the therapist applies pressure to the outer side of the knee as it is flexed and extended. The reproduction of pain is one clinical observation among others; it does not confirm either the diagnosis or its mechanism.¹

During the Ober test, the healthcare professional moves your leg while you remain relaxed and observes the movement of your hip. It may be part of the evaluation, but on its own, it does not confirm either the diagnosis or the tension of the band.

In a study of 53 college athletes, overuse injuries of the knee were no more common among those who tested positive on the Ober test, when considered in isolation. The study included several types of injuries; this result does not support the conclusion that tension in the ligament explains this syndrome.⁶

Role of imaging

The healthcare professional may order imaging if the diagnosis remains unclear or if the examination suggests another cause of pain. Depending on the situation, these tests can help identify:

• An injury to the lateral meniscus, a cartilage pad in the knee
• Osteoarthritis in the outer part of the joint
• Meniscal cyst, a small sac of fluid near the meniscus.

The appropriateness of imaging is determined on a case-by-case basis based on the patient's history, physical examination, and other possible diagnoses.

How does physiotherapy treat iliotibial band syndrome?

The physical therapy plan may include activity modifications, exercises, or movement assessments. These components are selected and reassessed based on symptoms, function, and goals. In sports physical therapy, the plan takes into account the specific sport and activities involved.

Temporarily adjust the activity

Activity may be temporarily adjusted based on symptoms, function, and recovery. Possible options include:

• Reduce distance to your pain threshold
• Temporarily reduce downhill runs and side-sloping terrain if they increase pain
• Prefer flat and even surfaces
• Alternate running and walking if necessary

If you'd like to mix up your routine, here are some options you can try based on how well you tolerate them:

• Swimming
• Cycling (if not painful, with an adjusted seat)
• Elliptical
• Exercises in water

Explore options for strengthening

Strengthening the gluteal muscles can be part of the program. A small case series observed improvement following a rehabilitation program that included these exercises, although it was not possible to isolate their specific effect.⁷ Another study found no difference in hip muscle strength between runners with and without the syndrome; it did not test a treatment.⁸

Based on the assessment and your goals, possible exercises include:

• Shells with elastic
• Lift your top leg while lying on your side
• Side-stepping with a resistance band

• Glute bridge with progression
• One-Legged Deadlift: Lean your torso forward while keeping one leg on the ground.
• Lunges with knee control

• Single-leg balance
• Step down one step slowly, controlling the movement of your knee.
• Single-leg half-squat in front of a mirror.

Planning Your Return to Running

Returning to running can be a gradual process, just like any return to sports after an injury. Walk-run intervals should be tailored to the individual; the following examples do not constitute a validated protocol:

• Alternate between short periods of running and walking, for a manageable duration
• Gradually increase the duration of the runs if the response is acceptable
• Shorten walking periods when the exercise is well tolerated
• Return to continuous running for a duration appropriate to the goal and the body's response

Progress is assessed based on the severity and progression of symptoms, as well as function and recovery between sessions.

Technical Corrections

Running analysis can be used to observe movement, without automatically identifying a factor that needs to be corrected:

• Monitor the stride length without assuming that a change will improve symptoms
• Observe the foot's response without assuming that a change will improve the symptoms

Make these changes gradually to allow your body to adapt.

What to do at home for iliotibial band syndrome?

At home, you can temporarily adjust the range of motion and choose exercises suited to your ability. The amount, frequency, and progression are determined based on how your body responds.

Manage Your Training Load

Volume, terrain, and descents can be temporarily adjusted based on symptoms, function, and recovery, with no universal thresholds or guidelines.

Examples of exercises to adapt

Lie on your back with your knees bent and your feet flat on the floor. Lift your hips, then lower them slowly. Choose a comfortable range of motion and adjust it based on how your body responds.

Lie on your side with your knees bent and the resistance band positioned above your knees. Open the top knee while keeping your feet together, then control the return. Choose a comfortable resistance level and adjust it based on how you respond.

Stand with the resistance band above your knees or around your ankles. Take a few steps to each side, keeping your knees slightly bent and your core stable. Adjust the distance and the number of repetitions based on your response.

What to Avoid

• Aggressively stretch the painful area; the specific clinical benefit of stretching the band has not been established
• Use a massage roller directly on the painful area, without assuming that pain means it's working.
• Continue despite a noticeable increase in symptoms rather than adjusting the output
• Standing for a long time on one leg, if this position triggers your pain (try switching legs regularly)

What are the specific tips for runners?

For a runner, the run can be adjusted based on symptoms: shortening the distance, temporarily altering the downhill sections, or trying a shorter stride. Advice on what to do when dealing with a running injury offers other options to try, though it does not guarantee a full recovery or prevent a recurrence.

When symptoms have just appeared or are getting worse

• You can try splitting up your workouts into segments with durations that suit your response
• Try taking slightly shorter, faster steps. If this change reduces your symptoms, stick with it; there’s no specific number to aim for.
• Avoid long downhill stretches
• Try running on flat terrain with no side slopes, and see how it affects your symptoms
• You can try cycling or swimming to stay active, as long as the activity doesn't make your symptoms worse

For Returning to Running

• According to a systematic review, the 10% rule is not supported by current data.⁵
• Gradually adjust the volume and intensity based on symptoms, function, and recovery
• Keep a log of your symptoms after each run
• Vary your running surfaces

Preventing Recurrence

Measures to prevent recurrence should be tailored to your training and symptoms. One study examined running mechanics before the onset of the syndrome, but it did not assess recurrences.⁴ The following measures can be discussed with your physical therapist; their effect on recurrences remains uncertain.

• You can continue to strengthen your glutes if it aligns with your goals, without a set regimen or any guarantee that it will prevent a recurrence
• Follow the principles of progression
• Replace your shoes when they lose their shape or when they start to feel different, rather than after a set number of kilometers: there is no specific mileage figure that has been conclusively proven.
• Vary your routes and surfaces

Among more than 1,000 military recruits whose training load was increasing, a program focusing on strength, flexibility, and coordination did not reduce overuse injuries of the knee compared with a placebo program. This trial did not address iliotibial band syndrome. In this population, this trial merely shows that this generic program did not reduce knee overuse injuries. It does not allow for conclusions regarding the prevention of iliotibial band syndrome in runners.⁹

When should you consult a professional?

See a physical therapist if your symptoms persist despite rest and basic exercises. The timing of your visit alone does not predict how quickly you will improve or whether your symptoms will persist. Learn more about what physical therapy for knee pain involves.

Signs that an assessment is necessary

• Persistent pain that limits running or other activities
• Pain that appears earlier and earlier during your runs
• Symptoms that do not respond to basic measures
• Difficulties with daily activities (stairs, walking)

Signs to Have Evaluated

• Persistent pain at rest; this should be discussed during a clinical evaluation.
• Visible swelling of the knee; this should be discussed during a clinical evaluation.
• If your knee locks up or gives out under your weight, seek medical evaluation right away.
• Pain that wakes you up at night; this should be discussed during a clinical evaluation.

These symptoms warrant an evaluation to determine the cause. Seek medical attention promptly if your knee remains locked, if you cannot put weight on it, if it is severely swollen, or if you have a fever along with a red, warm knee.

How long does it take to recover?

Recovery from iliotibial band syndrome can take several weeks, but the timeframe varies from person to person. The recovery plan is tailored to your symptoms, the activities you can do, and your goals.

Items to Document During Follow-Up

• Duration of symptoms at the time of evaluation
• Regular participation in drills
• Absence of major risk factors
• First episode

• Symptoms present for several months
• Recurrence of a previous episode
• Observations regarding gait or movement should be discussed based on symptoms, function, and context.
• Recent changes in exercise regimen should be discussed based on symptoms, function, and context.

Typical Recovery Stages

• Temporarily adjust the stroke based on symptoms, function, and recovery.
• Strength exercises: to be considered based on the assessment, objectives, and response.
• Gradually increase the stroke volume
• Increase the intensity and return to your normal workout routine

Progress is determined based on the response to the activities, physical function, and recovery between sessions; the pace varies from person to person.

The level of recovery and the time it takes to recover vary; the small number of cases cited does not allow us to estimate the proportion of runners who return to their previous level.⁷

Frequently Asked Questions

Frequently asked questions cover running, stretching, foam rollers, shoes, and cortisone.

Should I stop running completely?

Some people may be able to continue running with some adjustments; others may need to reduce their running or take a temporary break, depending on their symptoms and physical condition. A return to running should be approached gradually.

Are IT band stretches helpful?

One study measured slight deformation of the strip during stretching exercises, without assessing their effects on pain, function, or return to running.¹⁰ The clinical benefit of stretching for this syndrome therefore remains uncertain.

Does the massage roller help?

A comfortable sensation from the massage roller does not prove that the band changes. In a trial conducted among people without this syndrome, a single session did not alter their stiffness in the short term.¹¹ This result does not support the conclusion that there is an effect on pain or the return to running in people with the syndrome.

Should I change my shoes?

A professional can assess whether your type of shoe is suitable for your foot and your running style.

A critical review of studies on foot orthoses concludes that there is insufficient evidence to recommend them—whether custom-made or off-the-shelf—as a treatment for lower-limb overuse injuries. These studies do not specifically address iliotibial band syndrome.¹² If you have flat feet, find out what to do about flat feet when running.

Is cortisone helpful?

In a small controlled trial involving runners with recent symptoms, a cortisone injection reduced pain while running during the first two weeks.¹³ The study does not allow for conclusions regarding persistent cases or longer-term outcomes.

Sources

The sources for this article include anatomical studies, clinical studies, and reviews on iliotibial band syndrome.

Links open in a new tab.

1. Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006;208(3):309-16. (Back to sections: 1, 2, 3, 4, 5)
2. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of running injuries in 2002. Br J Sports Med. 2002;36(2):95-101. (Back to section: 1)
3. 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. (Back to section: 1)
4. Noehren B, Davis I, Hamill J. 2006 ASB Clinical Biomechanics Award Winner: A Prospective Study of the Biomechanical Factors Associated with Iliotibial Band Syndrome. Clin Biomech (Bristol). 2007;22(9):951-6. (Back to sections: 1, 2)
5. Fredette A, Roy JS, Perreault K, Dupuis F, Napier C, Esculier JF. The Association Between Running Injuries and Training Parameters: A Systematic Review. J Athl Train. 2022;57(7):650-671. (Back to sections: 1, 2)
6. Devan MR, Pescatello LS, Faghri P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. J Athl Train. 2004;39(3):263-267. (Back to section: 1)
7. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10(3):169-75. (Back to sections: 1, 2)
8. Grau S, Krauss I, Maiwald C, Best R, Horstmann T. Hip abductor weakness is not the cause of iliotibial band syndrome. Int J Sports Med. 2008;29(7):579-83. (Back to section: 1)
9. Brushøj C, Larsen K, Albrecht-Beste E, Nielsen MB, Løye F, Hölmich P. Prevention of overuse injuries through a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1,020 army recruits. Am J Sports Med. 2008;36(4):663-70. (Back to section: 1)
10. Falvey EC, Clark RA, Franklyn-Miller A, Bryant AL, Briggs C, McCrory PR. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010;20(4):580-7. (Back to section: 1)
11. Pepper TM, Brismée JM, Sizer PS, Kapila J, Seeber GH, Huggins CA, et al. The Immediate Effects of Foam Rolling and Stretching on Iliotibial Band Stiffness: A Randomized Controlled Trial. Int J Sports Phys Ther. 2021;16(3):651-661. (Back to section: 1)
12. Richter RR, Austin TM, Reinking MF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis—critical appraisal and commentary. J Athl Train. 2011;46(1):103-6. (Back to section: 1)
13. Gunter P, Schwellnus MP. Local corticosteroid injection for iliotibial band friction syndrome in runners: a randomized controlled trial. Br J Sports Med. 2004;38(3):269-72; discussion 272. (Back to section: 1)