Iliotibial Band (ITB) Friction Syndrome – Not just a painful knee ?

Iliotibial Band (ITB) Friction Syndrome – Not just a painful knee ?

With the HBF run for a reason in May and the city to surf in August 2013, one of the most commonly occurring injury we see in the Physiotherapy clinic is Iliotibial Band (ITB) Friction Syndrome (ITBFS).

What is it?

The ITB is the connective tissue band that runs down the lateral side of the thigh and attaches on the lateral surface of the tibial condyle). The ITB originates from the Tensor Fascia Latae (TFL) muscle that originates on the outer third of the antero-lateral iliac crest.

ITBFS is an overuse injury that produces pain on the lateral knee during running and, occasionally, cycling. Pain is generally caused by an unusually tight ITB, the undersurface of which frictions over the lateral femoral condyle. This occurs during knee flexion and extension at approximately 30 degrees knee flexion when running and cycling, when the ITB flicks over the lateral femoral condyle. This process leads to friction, microtrauma, inflammation – and hence pain develops.

What causes it?

The two most common predisposing factors that lead to ITBFS in runners are anterior hip inflexibility and poor rotational control of the lower limb.

First, one of the reasons that this pattern of inflexibility is frequently observed in runners is because of poor lumbar-pelvic position and control while running. This prolonged activity in hip flexion can lead to muscle sarcomere shortening – and hence iliopsoas/TFL muscle tightness develops over time. This increased tension in the TFL that is in turn transferred to the ITB, can cause increased friction and pathology.

This same flexed positioning or lumbar pelvic control (tilt) can also lead to the development of reduced rotational control in the lower limb. This can occur if the TFL muscle becomes overactive in the shortened hip-flexed position described above. The TFL internally rotates the hip and is also a synergistic hip abductor with the Gluteus Medius muscle during stance phase, preventing lateral pelvic tilt. Therefore, if the TFL develops over activity, the Gluteus Medius can potentially become inhibited. This can lead to the lower limb being forced into internal rotation and uncontrolled pronation through the stance phase via the action of the TFL. ITB friction can then increase over the lateral femoral condyle due to this movement.


One strategy essential for preventing this pattern from developing and potentially causing injury is regular hip flexor and quadriceps stretching.

• The muscle groups should be stretched daily and before and after activity to optimally prevent the development of ITB symptoms.

• Self-massage to the outer side of the thigh between the knee and the hip can also assist in reducing tightness in the ITB. Icing the distal ITB is essential after running and cycling for 20 minutes.

• Lower-limb stability, strength and balance exercises are crucial in rectifying ITBFS predisposing factors. Single leg squats and lunges can remarkably improve lower-limb control if performed in front of a mirror with good alignment where the knee flexes over the middle toe. This ensures that the Gluteus Medius activates effectively and that the TFL remains underactive.

Assessing biomechanics

Another strategy used in the prevention and assessment of ITB friction syndrome is to assess the running biomechanics.

At On the Go Physiotherapy, we can assess your running and cycling biomechanics and prescribe various drills and strategies to aim to rectify any biomechanical flaws.

In conclusion, ITBFS is a complex over-use injury that can be easily treated symptomatically but has numerous predisposing factors that, if not addressed, will lead to persistence and/or recurrence of symptoms.

Happy Running


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