ITB Syndrome: a common cause of knee pain

What is ITB Syndrome?

ITB syndrome (ITBS) is the second most common overuse knee pain amongst athletes, affecting up to 12% of all runners and 15% of all cyclists. ITBS initially presents as a local sharp pain on the outside of the knee when doing activity. However, if it is not addressed early the pain can progress to a deep dull ache even whilst resting.

What causes ITB syndrome?

The Illiotibial band (ITB) is a long thick fibrous band of connective tissue arising from your TFL (tensor fasciae latae) and gluteus maximus muscles at the lateral hip. ITBS occurs with excessive friction of the distal band over the lateral femoral epicondyle from repetitive movements of the knee. The two main causes of ITBS are inappropriate training or excessive training volumes and poor biomechanics.

Although pain is local at the knee, the cause of the pain often comes from higher up in the hip or down lower in the foot due to musculoskeletal imbalances. It is vital to treat the source not just the symptoms. Concentrating on reducing local pain with isolated methods may give short-term relief but the pain will return if the biomechanical issues are not addressed.

Weak or poor activation of the gluteal muscles is one of the most common findings we see with ITBS patients. Weak Gluteals cause an overactivation of your TFL and a rotation of your femur, putting excess stress on your ITB. Gluteal strengthening and activation training are a key component of ITB treatment.

Treating ITB syndrome

Another component many people overlook in their ITBS management is good footwear. Ensuring you have a supportive shoe suited to your foot type prevents excessive pronation at the foot, again helping to offload excessive stress on the ITB.

Things to avoid with ITBS are hills, stairs, uneven surfaces, speed work, heavy squatting and heavy load cycling. If you’re a cyclist, check your positional setup; a saddle too high or far back increases knee extension, irritating the ITB.

A common misconception is the recommendation to stretch the ITB, but recent strong evidence suggests this is not effective. Instead, exercise-based therapy should be tailored to the underlying factors contributing to the pain. That’s why it’s essential to consult a health professional who is trained to identify and treat the root causes of ITB pain—helping to prevent ongoing symptoms and support long-term recovery.