Iliotibial Band Syndrome (ITBS): Causes, Symptoms, and Effective Evidence Based Physiotherapy Treatment

Do you feel a sharp pain on the outside of your knee when you run, squat, or descend stairs? You might be dealing with Iliotibial Band Syndrome (ITBS) - a common condition in runners, cyclists, and active individuals.

At Endurance Health Lab, we treat ITBS regularly, helping athletes recover and return to sport with a clear plan.

What Is Iliotibial Band Syndrome?

The iliotibial band is a thick band of connective tissue that runs along the outside of your thigh - from your hip to just below your knee. Its main role is to stabilise the knee and assist with hip movement.

ITBS occurs when this band becomes irritated, often due to repetitive friction against the outer knee (lateral femoral condyle). This results in localised pain and tightness, usually felt about 2–3cm above the outside of the knee.

An anatomical illustration of the iliotibial band (ITB) and surrounding structures, showing its path from the hip to the outer knee. When treating ITBS it is important to consider the surrounding musculature that will influence the tension on the band and thus lead to lateral knee pain.

Why Is ITBS Common in Runners?

Iliotibial Band Syndrome is particularly common in runners, with incidence rates estimated between 5% and 14% of all running-related injuries.

The repetitive flexion-extension cycle of the knee during running creates friction between the ITB and the lateral femoral epicondyle, especially around 30 degrees of knee flexion, which is frequently reached during the stance phase. Over time, this leads to irritation and pain.

A systematic review by Louw and Deary (2015) identified that runners with ITBS typically demonstrate greater hip adduction and knee internal rotation, which increases tension on the ITB. Balachandar et al. (2019) confirmed these biomechanical patterns in their meta-analysis, reinforcing the link between faulty mechanics and ITBS in runners.

Noehren et al. (2014) found that runners with ITBS showed reduced hip muscle strength and neuromuscular control, contributing to altered lower limb kinematics and increased strain on the ITB.

These insights suggest that strengthening the hip abductors, improving neuromuscular control, and modifying gait patterns can significantly reduce the risk of ITBS in runners.

🔗 Want to understand more about what contributes to running injuries like ITBS?

Read our blog on Why Runners Get Injured to see how training errors, biomechanics, and recovery strategies play a role.

Common Symptoms

• Sharp or burning pain on the outside of the knee

• Pain that worsens with running downhill, stairs, or deep squatting

• No swelling or instability, but tightness along the outside thigh

• Pain often starts after a certain distance or load

Diagnosis: How We Assess ITBS

At Endurance Health Lab, we use a combination of:

• Clinical testing (Ober’s test, Thomas Test, Noble compression test, single-leg squat control)

• Movement assessment (running gait, glute control, lumbopelvic stability)

• Palpation for tenderness along the ITB and lateral knee

• In rare cases, imaging may be used to rule out other causes like lateral meniscus or bursitis.

The Ober’s test is commonly used to assess ITB or TFL tightness. However, research by Willett et al. (2016) suggests the test may not isolate the ITB effectively due to potential involvement of the gluteus medius/minimus and hip joint capsule.

The Noble compression test is considered more specific for ITBS, with pain reproduced around 30 degrees of knee flexion when pressure is applied over the lateral femoral condyle.

These findings emphasise the importance of combining clinical tests with a thorough biomechanical and movement assessment to ensure accurate diagnosis.

Treatment: What Really Works

The key to managing ITBS is addressing the cause, not just the symptoms. Research shows that manual therapy alone is rarely enough. 

The best outcomes combine education, load management, and strengthening.

Phase 1: Pain Reduction

• Relative rest or activity modification

• Soft tissue release of the glutes, TFL, and lateral thigh

• Ice and anti-inflammatories (short-term)

• Taping or deload strategies

Phase 2: Rebuild Stability and Control

• Glute med and max strengthening (e.g., side planks, clams, single-leg bridges)

• Lateral step-downs, split squats with control

• Neuromuscular re-education to improve hip and knee alignment

A 2024 systematic review by Sanchez-Alvarado et al. found that hip abductor strengthening led to pain reductions of up to 100% and improved function by up to 57% within 8 weeks.

Phase 3: Return to Load and Performance

• Gradual re-introduction of running or squatting

• Running retraining (cadence, step width, downhill technique)

• Gym integration for long-term prevention

Balachandar et al. (2019) found that runners with ITBS often exhibit increased hip adduction and knee internal rotation, reinforcing the value of biomechanical retraining. Additionally, Gunter & Schwellnus (2004) found that corticosteroid injections may provide short-term pain relief, but active rehabilitation remains essential for sustained improvement.

At Endurance Health Lab we prioritise long-term prevention and thus aim to return to load with the optimal strength and conditioning program specific to your needs.

When to See a Physiotherapist at Endurance Health Lab

If your pain persists longer than 1–2 weeks, or worsens with activity, it’s time to get assessed. Left untreated, ITBS can lead to compensations, training limitations, and reduced performance.

At Endurance Health Lab, we’ll create a plan specific to your goals - whether that’s running your next race, lifting without pain, or just walking stairs comfortably again.

📅 Book an Assessment Today or Email us to address your pain, and enhance your running performance. 

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Located in Chatswood, 2067

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📚 References

Balachandar, V., Hampton, M., Riaz, O., & Woods, S. (2019). Iliotibial Band Friction Syndrome: A Systematic Review and Meta-analysis to evaluate lower-limb biomechanics and conservative treatment. Muscle Ligaments and Tendons Journal, 9(2), 181–193.

Fredericson, M., Cookingham, C. L., Chaudhari, A. M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S. A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3), 169–175.

Gunter, P., & Schwellnus, M. P. (2004). Local corticosteroid injection in iliotibial band friction syndrome in runners: A randomised controlled trial. British Journal of Sports Medicine, 38(3), 269–272.

Louw, M., & Deary, C. (2014). The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners – A systematic review of the literature. Physical Therapy in Sport, 15(1), 64–75.

Noehren, B., Davis, I., & Hamill, J. (2007). ASB clinical biomechanics award winner 2006: Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics, 22(9), 951–956.

Sanchez-Alvarado, A., Bokil, C., Cassel, M., & Engel, T. (2024). Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: A systematic review. Frontiers in Sports and Active Living, 6.