Is your IT band really too tight? Or is that just your craving for an elegantly oversimplified biomechanical explanation for pain?

Tight IT bands have a really bad reputation. They are blamed for two common knee conditions: the aptly named “IT band syndrome” (ITBS, pain on the side of the knee) and the less obviously relevant “patellofemoral pain syndrome” (PFPS, anterior pain). But do people with these conditions really have tight IT bands?

This has been studied various ways over time, and it’s a confusing mess.

Perhaps a recent study of patellofemoral pain in Manual Therapy can shed some light on it. This was a tiny study of just a dozen people with patellofemoral pain. The researchers found that they had “highly significant” IT band tightness compared to a dozen people without pain.

Seems like a smoking gun. Painful kneecaps and tight IT bands … slam dunk, right? This is exactly the kind of thing that is used as justification for all kinds of common surgeries and therapies.

But this study is practically microscopic, which makes it about as reliable as a hyper dalmation in a park full of squirrels. Unsurprisingly, it’s contradicted by other evidence, such as Devan et al, in which few female athletes with iliotibial band syndrome or patellofemoral pain syndrome actually had tight IT bands.

Seems like a smoking gun. Painful kneecaps and tight IT bands … slam dunk, right?

The major problem is simple logic, though: If IT band tightness is a critical factor for both conditions, then ITBS and PFPS should go together like double and trouble. And yet that is rarely actually the case.

Although ITBS/PFPS can coexist, they rarely do — certainly no more than they would by chance. ITBS almost invariably involves vividly clear symptoms on the side of the knee only. PFPS has more erratic symptoms, yet it usually does not include the distinctive lateral hot spot of ITBS.

So this logical problem is a key to both conditions: no matter how you slice it, something isn’t adding up: “tightness” is failing to be an meaningful factor in one condition, or the other, and probably both.

This is quite a mess of confusing and contradictory considerations and evidence! Obviously — and this is the point — confident diagnosis of a “tight IT band” as a factor in either condition is completely unjustified. There’s no solid ground here.