SaveYourself.ca •Sensible advice for aches, pains & injuries
 
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Side of your
knee hurt?

IT band syndrome is a common and often persistent knee injury, causing pain mainly on the side of the knee.

Save Yourself from
IT Band Syndrome!

All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point

51,000 words, published 2002, updated Apr 1st, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

illustrations by Paul Ingraham, Gary Lyons, Alexia Tryfon, Lindsay McGee

Welcome to the largest and most scientifically current tutorial about IT band pain available anywhere. This is not just a web page: it’s a detailed book for patients and professionals. Thousands of readers have benefited from it and contributed their stories. If you have a tough case of chronic IT band syndrome, this is the information jackpot you’ve been looking for. What works for IT band syndrome? What doesn’t? Why? You cannot find more, better information about IT band pain.

Iliotibial band syndrome (ITBS) — which is also known as iliotibial band friction syndrome — is a common1 and often persistent injury primarily afflicting runners, as well as some cyclists and hikers, and causing pain mainly on the side of the knee (not the hip, not the thigh — that’s something else).

In the years since I started treating and writing about IT band syndrome, there has been an explosion of free information about it available on the internet. Sadly, this has not resulted in patients or health care professionals being better informed. Quite the opposite, I’m afraid. Most of the information that you can find out there repeats the same oversimplified conventional wisdom … most of which is just wrong.2

I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about IT band syndrome for over a decade. I recovered from my own severe, bilateral case. ~ Paul Ingraham
About footnotes. There are 142 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

Ineffective therapies for IT Band syndrome are common

Back in 2008, Canadian Running magazine featured a story about ITB syndrome. Among other serious errors, the article especially promoted the “hip strengthening” myth — the idea that hip strengthening will prevent and cure ITBS, a theory that is easily debunked in this tutorial.

Cover of Canadian Running with story about ITB syndrome.

Canadian Running magazine gets it wrong

The July 2008 issue completely botches its article on the subject, promoting a half dozen common myths.

Cover of Canadian Running with story about ITB syndrome.

Canadian Running magazine gets it wrong

The July 2008 issue completely botches its article on the subject, promoting a half dozen common myths.

Here are some other examples of wrong and obsolete IT band treatment that patients encounter all too often. Detailed scientific evidence supporting these points will be provided later.

  1. IT band stretching is the king of the conventional wisdom, in spite of good evidence that stretches don’t work … certainly not the simple ones usually seen in the wild.
  2. “Elongating” your iliotibial band with intense massage strokes is one of the most popular alternative treatments for ITBS, but it works about as well as it would on a truck tire. Meanwhile, better targets for massage are often neglected.3
  3. Doctors are generally uninformed about iliotibial band syndrome,4 and may neglect (or overemphasize) medical options like cortisone injections or IT band release surgery, which might actually help — but are not actually the first or even second line of defense. Even many sports medicine doctors and orthopedic specialists simply don’t know enough about IT band syndrome to guide you in these choices — specialists are (quite appropriately) preoccupied with other medical priorities, and puzzles like chronic ITBS tend to fall through the cracks.
  4. Quadriceps training is a therapy for another kind of knee pain, but often gets prescribed as treatment for ITBS as well — probably a simple case of mistaken identity.5

This video goes into greater detail about some of those points, and introduces several key concepts:

An orphan injury: IT band syndrome neglected by science

No wonder therapy often fails: iliotibial band syndrome is not studied enough,67 and treatment for it is not taught.8 I have a seemingly detailed modern sports injuries text on my shelf which offers only a couple of short sentences, concluding that “the prognosis is good with appropriate treatment”9 — without even saying what the treatment is!

I have suffered from IT band syndrome myself (see my own IT band story in Appendix A, below), and I have seen many stubborn cases of it in my own patients, so I know from both personal and professional experience that the prognosis for iliotibial band syndrome isn’t always good, and many accepted treatments are ineffective.10 Many people recover with a little rest, icing, and stretching, but not everyone.

How can you trust this information?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of iliotibial band syndrome. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 150 footnotes here), and I always link to the original sources.

This tutorial is by far the largest and best of its kind. There are no books on this subject anywhere close to this detailed, carefully researched, or well-maintained. In fact, the limited competition has serious “trust issues.”1112

Is there a miracle cure for iliotibial band syndrome?

Of course not! Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But medical science is nowhere close to this for IT band syndrome. So how do you manage the unmanageable — a potentially incurable problem?

What I can do is explain and review all the options, help you to confirm your diagnosis, and debunk bad ideas. After reading this tutorial, certainly some people — with a little effort — will finally enjoy a breakthrough, and get partial or complete relief of their symptoms, sometimes temporary, sometimes lasting. And maybe that is kind of miraculous!

Remember, chances are good that the therapists and doctors you’ve seen so far have not read what little scientific research has been published in the last few years. Even if they have, they probably haven’t studied it carefully. So how can they possibly advise you? Sure, their basic knowledge is fine for basic cases. But when you have a difficult case, you need better information. Even if you just developed IT band syndrome, how long do you want to spend following poor quality advice? Get started on the right foot. Permanent damage is possible in the long term. Get on top of this.

So, no, there are no miracle cures, but maybe this tutorial will get a lot of people a lot closer. Keep reading to find out exactly why most therapy fails. Overhaul your mental approach to the problem. And if you’ve spent a lot of time already trying to solve this problem … you may be shocked and amazed at how much time and money you’ve wasted on strategies that were probably doomed to failure!

Are you in the right place? Patellofemoral versus IT band

Let’s make sure you’re reading the right tutorial, because ITBS is often confused with patellofemoral pain syndrome, the “other” runner’s knee injury. Although the two conditions can certainly seem quite similar, usually you can tell the difference just by the location of the pain.

Iliotibial band pain is truly a side of the knee condition, and the epicentre of the symptoms is always there, by definition. On the other hand, if you have pain that definitely dominates the front of your knee, there’s a good chance that you have patellofemoral pain syndrome, and you should start reading the patellofemoral pain tutorial instead. If you’re not sure which kind of knee pain you have, take the runner’s knee diagnosis test.

[Diagram showing the different primary pain locations for iliotibial band syndrome and patellofemoral pain syndrome.]

Front or side?

The epicentre of iliotibial band pain is always on the outside of the knee. The pain of patellofemoral pain syndrome is more variable, but usually dominates the kneecap.

[Diagram showing the different primary pain locations for iliotibial band syndrome and patellofemoral pain syndrome.]

Front or side?

The epicentre of iliotibial band pain is always on the outside of the knee. The pain of patellofemoral pain syndrome is more variable, but usually dominates the kneecap.

There is one other common source of confusion about the location of ITBS. In fact, the number one myth of the condition is that it causes hip and thigh pain. It does not. ITBS is a knee pain condition only. If you have hip or thigh pain and no knee pain at all, this tutorial may not be for you: please see Confused about the location of Iliotibial Band Syndrome?. Or just keep reading, because this topic is also covered thoroughly below. Confusion about IT band pain location is so common that I consider it to be normal part of learning about the condition, and the tutorial offers valuable information about hip and thigh pain as well as knee pain.

Part 2

Nature of the Beast

What causes iliotibial band syndrome?

In the next several sections, you will learn that this is not as easy a question to answer as you probably thought. In fact, it turns out that it’s not as easy as anyone thought. Overuse injuries of all kinds are proving to be hard to understand scientifically. Things that therapists and doctors used to consider “obvious” or “common sense” have turned out to be wrong, and researchers have only just begun to try to find out what’s really going on.

On the face of it, iliotibial band syndrome is still a simple condition, “obviously” caused by excessive knee usage and usually treated just by resting. But to anyone who can’t get rid of it just by resting, it is obvious that there must be more to it than that …



The conventional wisdom

Iliotibial band syndrome is primarily known as a running injury, responsible for about one in twenty lower limb injuries in long-distance runners.13 But it is generally common: roughly one in twenty-five people engaged in other kinds of vigorous physical training will get a case of it.1415 I estimate that as many as a quarter or half of all long-distance runners may get the condition eventually. Just to put this in perspective, iliotibial band syndrome is probably not much less common than ankle sprains, which are generally regarded as the most common of all athletic injuries.16

Although primarily a runner’s affliction, iliotibial band syndrome is also prominent in cyclists17 — even though each stroke of the pedals is probably much less irritating to this knee condition than running, sheer repetition can certainly make up for it. Hiking, backpacking, orienteering, and frequent long walks can also cause the syndrome.18

The conventional wisdom says that iliotibial band syndrome (ITBS) is a kind of tendinitis, or at least an irritated tendon. The iliotibial band is a large tendon running down the side of the leg from the hip. If it gets too tight, it rubs painfully over a bump of bone on the side of the knee, the lateral epicondyle. For this reason, it is also commonly called iliotibial band friction syndrome (ITBFS).

Note: “iliotibial” is often mis-spelled as “ilotibial.”

Makes sense. Right? Well, not anymore. It turns out that iliotibial band friction syndrome is probably not a “friction” syndrome after all — not even a tendinitis, in fact. The irritated structure is probably not actually the iliotibial band. Nor is the IT band “too tight,” which particularly fascinates me, given that the world of physical therapy is pretty much obsessed with the tightness of IT bands!

Friction syndrome? So where’s the rub?

In 2007, John Fairclough of University of Wales Institute, with seven coauthors, challenged the definition of iliotibial band syndrome, and even of the iliotibial band itself, in a paper published in the Journal of Science and Medicine in Sport.1920 They present a compelling analysis, concluding that “the perception of movement of the ITB across the epicondyle is an illusion,” in effect suggesting that the function, dysfunction and actual anatomy of the iliotibial band has been misunderstood all along. It’s a charming example of how primitive medical science still is. Can we really still be learning anatomy this late in history? Oh yes!21 Much more on this coming.

“The perception of movement of the ITB across the epicondyle is an illusion.”

And as for the common wisdom that the iliotibial band is “too tight”?

In 2004, a research group at University of Connecticut led by Michelle Devan decided to try to figure out the effect of “structural abnormalities” on overuse knee injuries like iliotibial band syndrome.22 So they measured a bunch of stuff in a group of athletic young women, looking for structural problems that every therapist in the world “knows” are risk factors for various knee problems, including the tightness of iliotibial bands … and then they waited to see who got what kinds of knee injuries. Based on the conventional wisdom, you would fully expect the women with tight iliotibial bands to get more ITB syndrome.

In fact, it’s “obvious”!

But of course that’s not what happened! And that’s what makes IT band syndrome such an interesting subject. Now, here’s what did happen …

Several of these young women athletes did get iliotibial band syndrome that season. Indeed, it was the most common injury in the group.23 But these expert assessors determined that not one of them had tight iliotibial bands. Not even one!

All the athletes with iliotibial band friction syndrome had a negative bilateral Ober test [their iliotibial bands were not tight].

Devan

To be fair, this study involved a small number of athletes, and researchers consider the question to be controversial. But the take-home message is that IT band tightness is not a straightforward thing: you simply cannot assume (or do therapy on the assumption) that a tight ITB is a big deal.

The conventional wisdom was such a nice, straightforward picture of the condition that no one was apparently motivated to question it — after all, ITBS is a relatively minor condition. Most cases of iliotibial band syndrome resolve spontaneously or with conservative treatment, and the others respond pretty well to a simple surgery. Why rock the boat by challenging the very definition of the problem?

Most cases of iliotibial band syndrome resolve spontaneously or with conservative treatment, so why rock the boat?

Because that simple picture is almost certainly wrong! “Minor” or not, many consumer dollars have probably been wasted on therapies based on incorrect information and unsafe assumptions. What little research there is has been largely based on dubious assumptions about how ITBS works. If we understand the condition as it truly is, perhaps someday ITBS can be treated more efficiently and conservatively, without surgery — and perhaps with more effective surgeries as well.

So, what exactly is iliotibial band syndrome? To answer that, we need to talk anatomy. Hang on, you’re about to learn some Latin. You will be able to amaze your running buddies with your knowledge. Your authoritative command of ITB anatomy will blow them away!

So is it a tendon or what? IT bands are special

The iliotibial band is usually described as a tendon, a big tendon. Many times, I myself have called it “the largest tendon in the body.” And that’s sort of true. But it’s clearly not just any tendon, but a rather special and complicated one. Consider this list of surprising differences from ordinary tendons. (Most of these, especially the most critical points, were reported by Fairclough et al in 2006.)

  • The IT band doesn’t really have a discrete point of connection like most tendons, but rather blends seamlessly into the capsule around the knee … which is why your knee seems to “cinch up” during an effective iliotibial band stretch.24
  • Most tendons have clear edges. They could be snipped at either end and then tied in a bow. They are separate from other tissues, except at the ends where they are attached to muscle and bone. The iliotibial band is simply a massive thickened section of the sausage wrapping of connective tissue that envelops the entire thigh — it is more of a reinforced section of the wrapping around the thigh than a tendon.
  • The ITB also manages to meet the definition for a ligament: that is, a connective tissue structure that connects bones. The ITB is partially attached to the pelvis.
  • Most tendons are dwarfed by the muscle they are attached to, but the iliotibial band is much more massive than the tiny tensor fasciae latae muscle — several times longer and much wider.
  • And although the gluteus maximus also partially uses the iliotibial band as a tendon, the connection is at an odd angle: the job of the gluteus maximus is probably not so much to pull along the length of iliotibial band, as with virtually all other muscle-tendon arrangements, but rather to increase the tension on it by pulling on it laterally, like drawing a bowstring.
  • Most importantly of all, it is tightly anchored the full length of the femur, from hip to knee — especially just above the knee.

It’s that last one that’s really important to understand. Most professionals think of the IT band as being free to move relative to the femur, a strap that lies just underneath the skin, separated from the femur by a good thick layer of muscle (the quadriceps). But the iliotibial band is not free to move relative to the femur, or so little that it doesn’t count. It’s attached to it.25 And it’s especially attached to the femur right at the location where it supposedly rubs back and forth. But it can’t do that!

This is why Fairclough et al suggested that “the ITB cannot actually create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee.” The anatomy only creates the illusion of a slide over the side of the knee.

So what’s really going on, if not “rubbing”? As the knee bends, tension on the IT band shifts from the front to the back. That is, it “pops out” a bit, first a little ahead of the knee, then further back — which can look an awful lot like movement. But it’s just parallel fibres tightening in sequence, like a wave, as the knee changes position. Other tendons actually do slide around and snap over other structures, but the IT band is not free to do this.

That mental image of the IT band snapping over the side of the knee is prevalent (almost universal), utterly false, and tragically the basis for a bunch of doomed treatments. This is an advanced anatomy puzzle, very specific, and it might not be reasonable to expect a professional trained 17 years ago might to be aware of the implications of some very specific anatomical research published 7 years ago. On the other hand, a lot of under-trained professionals really need to upgrade their anatomy, or at least stop pretending to know it!26 Regardless, let’s get the accurate anatomy out there.

It’s best to think of the ITB as a large, complex connective tissue structure with some characteristics of a tendon, others of a ligament, and an unusual tension control system consisting of a couple of hip muscles at the upper end.

What’s actually irritated? Not the IT band …

Fairclough et al argued that the iliotibial band itself is not the irritated structure in ITBS. If not, what is? Something under the IT band is the simplest answer at this time…

END OF FREE INTRODUCTION

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Part 2.5

Appendices

Appendix A: My own iliotibial band syndrome story … grizzly bears included

I made a new furry friend the day I was struck down with severe iliotibial band syndrome. (Thanks to www.firstpeople.us for the photo.)

Note: this is the condensed version of this story. If you find me particularly amusing, you can also read a more long-winded version.

I was struck down dramatically by iliotibial band syndrome in both knees at once, on a solo backpacking trip in the Monashee Mountains in the spring of 1998. But that makes me sound more adventurous than I am.

In reality, I am a big chicken, and being in the woods alone spooked me but good. I got injured because I pushed too hard, too fast, and ended up deep into the mountains late in the day, with the trail ahead lost in snow. I decided to rush back to the trail head even if I had to hike in the dark for a while. So I practically ran down the mountain with a fifty-pound backpack — big mistake! After just an hour, both my knees started to scream.

The rest of the hike was a nightmare, certainly one of my most painful experiences. There were times when I felt certain I couldn’t take another step … yet somehow I did.

The Monashee Mountains: This is where I got iliotibial band syndrome.

The Monashee Mountains

This is where I got iliotibial band syndrome.

The Monashee Mountains: This is where I got iliotibial band syndrome.

The Monashee Mountains

This is where I got iliotibial band syndrome.

I was almost at the trailhead when a momma grizzly found me. I’d seen a warning sign about her before starting the hike. In fact, I had gotten quite paranoid about crossing paths with her as I neared the trailhead!

It didn’t work.

It was deep twilight, and there was nowhere to run, and I couldn’t run anyway, and no one outruns a grizzly anyway. She charged me on the trail, and I heard her before I saw her. I thought the following two thoughts, in this order, I swear:

  1. I guess I’m going to be maimed and killed now. Damn. This is going to hurt.
  2. At least I won’t have to walk any further!

Grizzlies are fast! (Up to 34 mph, 55 kph.) She came at me like I was lying at the bottom of a cliff and she was falling on me. The idea of unlatching my bear spray from its “quick” release, pulling the safety pin, aiming, and firing … absolutely ridiculous! She was simply way too fast and intimidating.

And she did what grizzlies almost always do when they charge people: she veered off at the last second. Grizzlies aren’t particularly predatory, but they certainly take their cubs seriously, and her main goal was to intimidate me … and that she surely did.

And that’s my entertaining bear story! It’s given me years of dinner party material, and it will for the rest of my life. Now, back to iliotibial band syndrome …

The next day, I quite literally could not get down stairs — which was problematic, because I lived in a 3rd-storey walk-up — both due to the worst case of delayed onset (post-exercise) muscle soreness I have had in my life, and the napalm attacks on the sides of my knees. I have seen some nasty cases of iliotibial band syndrome in my career, but I feel comfortable claiming that I’ve had it worse than anyone else I’ve ever met.

I was in school at that time, and we hadn’t learned diddly-squat about iliotibial band syndrome yet, nor did we later — that’s partly how I know just how poorly informed most massage therapists are about this condition. I never would have learned more than the basics if I hadn’t been forced to learn more by my own injury. It took me one year to recover, and to this day I still suffer occasional flare-ups if I run for more than a couple hours … which I do.

That’s me, getting ready to flick the disc.

I am an enthusiastic ultimate player — that’s me there in the picture, getting ready to flick the disc — so the injury was deeply frustrating to me, and, just like every serious runner I’ve ever treated, it was nearly impossible to keep me from re-injuring myself. I simply would not stay off the field. Every return to play was premature. This was where I first made the observation that, in all likelihood, runners (and ultimate players) are more of a problem than their knees. Iliotibial band syndrome isn’t stubborn — we are!

For me, the best treatments were probably rest, megadoses of well-timed icing (controlling inflammation at the times when it was most likely to start), and discovering that one of the taiqi moves I did was particularly good at stretching the iliotibial band and associated musculature (see Iliotibial Band Mobilization). How did I know? Because it hurt like hell! With my ultra-sensitive knees, it was really quite easy to evaluate how strongly different positions pulled on my iliotibial band — given that I was studying anatomy intensively at the time, I was in ideal circumstances to experiment. So this is how I first learned the importance of knee flexion in stretching the iliotibial band, a difference that was as clear to me as flicking a light switch: just add knee flexion to any of the standard stretches, and the iliotibial band pulls much tighter over the side of the knee. To this day, I don’t know if the stretching actually helped, but it certainly felt like a “real” stretch of the IT band, more so than any other stretch I could do.

All of this was good preparation for helping other people with iliotibial band syndrome, of course. Today, I know many things that I really wish I had known when I first hurt myself! And that’s why this very, very long tutorial exists.

Acknowledgements

Thank you to Dr. Michels and his colleagues for their important, evidence-inspired work in pioneering a new surgical treatment for ITBS, with its fascinating implications. Thank you as well to Dr. Fairclough and his research colleagues who also deserve special mention for their seminal 2007 paper on IT band syndrome, which was a game-changer and instantly made this topic much more interesting to continue writing about.

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Warm thanks also to reader John J, who reported more typografic errors and other miner glitches in onelarge batch than I would ever have dreamed posssible so many years into the lyfe of this document. Many readers have helped out with such reporting, but John’s effort was truly the most remarkable yet.

Reader Comments

Here is what some readers have said about the iliotibial band syndrome tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


I owe you many thanks. Your tutorial has given me great hope. I was extremely discouraged and frustrated by the issues I was having, but I experienced more relief in my first session with a trigger point therapist than I did in 12 weeks of physical therapy.

— Ryan Luke, MA, CSCS, Department of Kinesiology and Health, Georgia State University


Thanks for your great work. I’ve read about ITBS for years and everything I’ve ever read did not add up to ½ of the information you provided.

— Kevin Burnett, runner, California


I appreciate your research on this subject, and that you have clearly debunked lots of poor quality “science.”

— Sukey Jacobsen, Sukey Design Studio, Mount Vernon, Washington — fine art, tiles and functional art


When investigating my IT band injury online, the information I found was superficial. That changed when I came upon your well-researched report. I teach scientific writing as part of my class and as I read your report I kept thinking that I'd love for my students to read it and see that well-researched work can be fun to write and read as well. Your plan is the only one I have seen based on peer-reviewed research, evidence, and professional and personal experience. No doubt, it'll take a healthy dose of patience, self-restraint, diligence, and positive attitude on my part, but what you wrote and the runner testimonials showed me that ITB injuries are not something to mess around with. Thanks for the great work, Paul!

— Cortney Martin, PhD, Virginia Tech


I really appreciate your objectivity.

— Dr. Bryan Allf, MD, North Carolina


On May 21st, 2008, Dr. M. Gilbart released my IT band and now all is well. This is 2 years and 5 months after the first diagnosis. Thank you again for all your encouragement. I re-read your iliotibial band syndrome tutorial several times over the last few months, and each time I found new nuggets of advice.

— Rosemaree Gentles, recovered iliotibial band syndrome sufferer



One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.


What’s new in this tutorial?

This document was originally published as a much simpler article in 2002. It was expanded and republished as a book-length tutorial in April of 2007, and has been updated and revised regularly since then. An unusually large batch of improvements were made in mid-2012 in preparation for recording an audiobook.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 62 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Updated (Apr 1 '14, section #3.1)Added good news story from a reader about a case with a cyst, and improved the information about cysts at the same time. See section #3.1, Should you get an MRI?

Major update (Jan 30 '14)The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.

Science update (Nov 21 '13, section #5.20)Added a bad-news citation. Sorry about that. See section #5.20, Soft knee straps (and/or Kinesio Taping) are worth a shot.

New case study (Oct 3 '13, section #2.8)Added a fascinating and extreme example of the effect of running style from a case study of an ultra-runner. See section #2.8, Why does IT band pain gets so nasty so fast? A vicious cycle related to running pace.

Science update (Jul 9 '13, section #2.10)A particularly “good news” science update about how running is, counterintuitively, actually pretty good for joints — not hard on them. See section #2.10, “Maybe you’re just not built for running”.

Update (Jun 13 '13, section #2.10)A new introduction for the chapter about the trend of anti-running “science.” See section #2.10, “Maybe you’re just not built for running”.

Updated (May 29 '13, section #2.14)Added more detail and a couple examples. See section #2.14, When ITBS isn’t a repetitive strain injury.

Minor update (Apr 10 '13, section #2.10)Minor but nice: a really good new quote adds some entertaining and genuinely fascinating perspective to this section. See section #2.10, “Maybe you’re just not built for running”.

Minor update (Mar 29 '13, section #5.5)Upgraded risk and safety information about Voltaren Gel. See section #5.5, Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.

Product upgrade (Feb 4 '13)Audiobook version now available. See the announcement for more information.

Minor update (Dec 7 '12, section #2.3)Added some fun stuff and context about bad anatomy. See section #2.3, So is it a tendon or what? IT bands are special.

Expanded (Nov 29 '12, section #5.14)Added much more detailed self-help information for trigger points. See section #5.14, Trigger point massage for your hips, glutes & quads.

Science update (Nov 20 '12, section #5.22)Weak but interesting new evidence on natural running and injury prevention. See section #5.22, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Science update (Nov 13 '12, section #5.12)Added evidence from the first foam rolling research ever done. See section #5.12, IT band massage, foam rollers, and Graston Technique® — a big fat waste of time and/or money.

Major update (Nov 9 '12, section #5.15)Numerous significant clarifications, revisions, and new references, and a generally stronger recommendation. See section #5.15, Deep transverse friction massage.

Rewritten (Oct 18 '12, section #6)Now about four times more detailed than before and much more strongly focussed on the positive, what my final recommendations are, and how to “put it all together.” See section #6, Now what?: An action-oriented summary of recommendations.

Nice upgrade (Oct 17 '12, section #5.18)After years of procrastination, I have finally created a video demonstration of a tricky ITBS stretch! About time! See section #5.18, Some stretching hope: a better iliotibial stretch?

New section (Oct 17 '12, section #5.1)New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. See section #5.1, So what’s the plan?

New diagram (Jun 30 '12, section #5.14)Nice new diagram, “Key locations for massage treatment of ITBS.” See section #5.14, Trigger point massage for your hips, glutes & quads.

Minor update (May 4 '12, section #5.9)Very simple swimming tip added. Hat tip to reader Eric C. See section #5.9, The fear of rest, and relative resting: how to maintain fitness while protecting your knees.

Major update (Mar 12 '12, section #5.21)Rewritten and expanded, much clearer and more detailed. Not much new science, though — ITBS+orthotics science is pretty scarce! See section #5.21, Orthotics for IT band syndrome: a worthwhile long shot.

Minor update (Mar 8 '12, section #5.9)Added a paragraph about elliptical machines. See section #5.9, The fear of rest, and relative resting: how to maintain fitness while protecting your knees.

Minor update (Mar 8 '12, section #5.3)Added an example of surgery gone wrong. See section #5.3, The old surgery: snipping the band.

New section (Mar 8 '12, section #2.14)No notes. Just a new section. See section #2.14, When ITBS isn’t a repetitive strain injury.

Revised (Feb 27 '12, section #5.15)Some modernization and clarifications. Now also discusses the notion of “just rubbing” the hot spot. See section #5.15, Deep transverse friction massage.

Rewritten (Feb 18 '12, section #5.8)Another “like new” rewrite: this section now offers much more detailed resting advice, perspective, and troubleshooting. See section #5.8, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Rewritten (Feb 16 '12, section #5.7)This section is “like new” and much beefier, and links to an upgraded main contrasting article as well. See section #5.7, Contrast hydrotherapy: exercising tissues with quick temperature changes.

Rewritten (Jan 23 '12, section #5.2)Major changes: new science, new recommendations, more detail, and some explanation of the (very difficult) problem of why anti-inflammatory injections might work despite the fact that IT band syndrome doesn’t involve much inflammation. See section #5.2, Steroid injections: a complicated mix of certain risks and uncertain rewards.

Rewritten (Jan 16 '12, section #5.6)Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” See section #5.6, Icing: more is better?

Rewritten (Jan 16 '12, section #5.5)Completely revised to reflect new science and new understanding of the interaction of NSAIDs with “inflammation.” See section #5.5, Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.

Major Update (Jan 13 '12, section #5)Expanded and revised summary of treatment options, with emphasis on new and better recommendations about “anti-inflammatory” treatments. See section #5, Treatment: What can you do about iliotibial band syndrome?

Updated (Jan 11 '12, section #4.3)Advice on “running through” has changed, with more emphasis on the unknown but plausible risk of permanent damage. See section #4.3, Can you “run through” iliotibial band syndrome?

Major revision (Jan 11 '12, section #2.11)Extensive editing and re-writing concerning the nature of inflammation. The main point of the section remains unchanged, but the section now does a much better job of explaining why ITBS isn’t really inflamed, and why it matters. Although not cited, this update drew heavily on some new scientific papers. See section #2.11, Where’s the fire? The inflammation myth.

Updated (Dec 29 '11, section #5.4)Added new information and some pie charts about the success rate of arthroscopic surgery for ITBS. See section #5.4, The new surgery: excision of tissue from under the IT band.

Minor update (Dec 13 '11, section #5.8)Addressed some common fears about the threat of getting out of shape while resting. See section #5.8, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Trivial update (Nov 25 '11, section #1.3)Added an example of unusually bad ITBS information, made widely available. See section #1.3, How can you trust this information?

Major update (Nov 23 '11)Clearer and more thorough content throughout several sections about the “Nature of the Beast” and “Diagnosis,” especially from the discussion of root causes and onwards. I am producing the audio version of this tutorial, and I am revising and improving content significantly as I go. Information about trigger points was completely re-written, and there’s a whole new section about hip and thigh pain.

Updated (Nov 16 '11, section #5.19)Modernization and revision for clarity. See section #5.19, Mobilize and stretch the hip musculature.

New section (Nov 16 '11, section #5.17)Stretching is such a hot topic that I decided to break the discussion up with a new section focussed on stretching the IT band itself. It was inspired by important new scientific evidence: researchers have found that IT band stretching is not a very moving experience… See section #5.17, The trouble with stretching the IT band in particular.

Major update (Nov 15 '11, section #5.18)Significant modernization and clarifications. Much better description of why this kind of stretch might be worth trying. See section #5.18, Some stretching hope: a better iliotibial stretch?

New science (Nov 15 '11, section #2.3)Added more anatomical evidence that the IT band is particularly impossible to stretch or even move. See section #2.3, So is it a tendon or what? IT bands are special.

New section (Nov 10 '11, section #2.13)No notes. Just a new section. See section #2.13, Hip and thigh pain: part of the problem, or red herring?

Minor update (Nov 10 '11, section #1.5)Clarifications about the location of IT band syndrome pain. See section #1.5, Are you in the right place? Patellofemoral versus IT band.

Updated (Nov 2 '11, section #5.16)Added new research evidence that stretching doesn’t prevent injuries, including (of course) ITBS. See section #5.16, Stretching to prevent or treat IT band syndrome.

New video (Oct 14 '11, section #1.1)Section now includes a new video, summarizing myths and treatment mistakes. See section #1.1, Ineffective therapies for IT Band syndrome are common.

Minor update (Sep 28 '11, section #5.23)Added reference to Kong et al, about the effect of shoe wear. See section #5.23, Running softly and the impact of impact.

Minor update (Jul 29 '11, section #1)Added a reference about the poor overall quality of online information about common injuries. See Starman. See section #1, Introduction.

Rewritten (Jun 17 '11, section #5.23)Evidence about the real but surprisingly weak connection between impact forces and injury from Zadpoor et al has prompted a bunch of revision and new recommendations for runners. See section #5.23, Running softly and the impact of impact.

Major update (Jun 15 '11)Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

New section (Apr 28 '11, section #5.13)No notes. Just a new section. See section #5.13, Mis-treatment horror story: intense massage on an obviously inflamed thigh.

New section (Feb 20 '11, section #5.22)Finally, long overdue, a new section on this topic. See section #5.22, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Important new info (Feb 8 '11)Where’s the fire? Recently I published a major new article about repetitive strain injuries (like IT band pain), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

New section (Dec 2 '10, section #3.10)New short section for both this book and the patellofemoral pain book covering potentially confusing alternative diagnoses, such as politeal artery entrapment syndrome (PAES). See section #3.10, Other possible diagnoses and sources of diagnostic confusion.

Overhauled (Sep 15 '10, section #2.7)Rewrote section to accommodate some new science. The new evidence is interesting, but not particularly illuminating: it mostly just emphasizes how we really (still) don’t know if IT band tightness is actually a problem. See section #2.7, Like a rock in your shoe: the mechanism of irritation and the red herring of tightness.

New cover (Aug 6 '10)At last! This e-book finally has a “cover.” SHOW

Minor update (Jul 27 '10, section #5.26)Updated the nutraceuticals item with information about a new study of glucosamine for knee pain. See section #5.26, Brief debunkery of several therapies that you should be particularly skeptical of.

New section (Feb 12 '10, section #7.2)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #7.2, Appendix B: List of surgeons offering arthroscopic repair of iliotibial band syndrome.

New section (Feb 12 '10, section #5.4)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #5.4, The new surgery: excision of tissue from under the IT band.

Major update (Feb 12 '10, section #5.3)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #5.3, The old surgery: snipping the band.

New section (Feb 12 '10, section #2.6)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #2.6, The bursitis possibility.

Major update (Feb 12 '10, section #2.5)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #2.5, A new surgery works without loosening anything tight.

Major update (Feb 12 '10, section #2.4)One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #2.4, What’s actually irritated? Not the IT band ….

And many more (May '07 – Dec '09) — Thirty-five older updates are listed in a separate document, for anyone who cares to take a look.

Notes

  1. “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.” And many of those are IT band syndrome cases. That quote is from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame. BACK TO TEXT
  2. If the road to Hell is paved with good intentions, nothing has helped more people drive there than the internet. For many years, if you Googled “iliotibial band syndrome,” the abominable www.itbs.info was the #1 result: a shabby, shallow, stale website by a well-intentioned amateur. Barely updated since 2000, it finally dropped off the first page of results sometime in 2013, but it had been at the top for about fifteen years, even though there was hardly even anything there: a hilariously incomplete snapshot of wilted conventional wisdom posing as a useful resource for people who actually need help. (Apparently a hundred thousand of them between 1997 and 2002, while I was writing the first version of this book.) Sadly, even with the fading of itbs.info, there is not much improvement in the first few pages of Google’s search results: a lot of it is basic, poorly written, full of myths and old, dead ideas, and so on. It’s just a mess! And that opinion is backed up by experts: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  3. The muscles that actually control the tension on the iliotibial band, such as the tensor fasciae latae and gluteus maximus. BACK TO TEXT
  4. As they are of most musculoskeletal problems. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See Medical Blind Spot for Aches and Pains: Most doctors are unqualified to care for many common pain and injury problems. Especially the stubborn ones. BACK TO TEXT
  5. Quadriceps strengthening is a conventional treatment of dubious value for patellofemoral pain syndrome. Although strengthening some muscles (hip and gluteals) has been proposed as a treatment for ITBS, quadriceps training is not even really on the table as an option. I assume that it gets prescribed anyway simply because these two knee pain conditions are often confused — a simple case of mistaken identity. BACK TO TEXT
  6. As of Jan 2009, only 125 search results in PubMed! Compare that to 4200 for adhesive capsulitis (frozen shoulder), or 6900 for carpal tunnel syndrome. Also, more so in the case of iliotibial band syndrome than other conditions, a great number of those papers are tutorial papers, not primary research. To an amazing degree, they all tend to repeat conventional wisdom and reference each other and clinical experience instead of actual science. BACK TO TEXT
  7. Ellis et al. Iliotibial band friction syndrome — A systematic review. Manual Therapy. 2007. PubMed #17208506.

    This 2007 scientific review paper makes it extremely clear that there is a “paucity in quantity and quality of research” about iliotibial band syndrome. They also conclude that what information exists is not particularly helpful! “There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.” Yet it is absolutely routine for therapists and doctors, and even so-called experts, to make claims of therapeutic effectiveness! What are they basing that optimism on? The truth is, they simply don’t really know what they are talking about. They can’t — no one does!

    BACK TO TEXT
  8. In my own 3000 hours of training — three full years of nothing but studying aches and pains and how to treat them — it was barely discussed. Unless a massage therapist has gone out of his or her way to study the condition, he or she knows no more than anyone else who spends twenty minutes looking it up on the internet … and perhaps less! BACK TO TEXT
  9. This is not a joke. It’s a good, new sports injury text book — but its inadequate coverage of ITB syndrome is typical for the subject. The text is Clinical guide to sports injuries. BACK TO TEXT
  10. Falvey et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports. 2010. PubMed #19706004. “Our results challenge the reasoning behind a number of accepted means of treating ITBS.” BACK TO TEXT
  11. A while ago I noticed that a new book about iliotibial band syndrome had appeared on Amazon, The Official Patient's Sourcebook on Iliotibial Band Syndrome. I made a note to myself read it, and hopefully learn something — had someone finally written something that might compete with this tutorial? When I returned recently to buy it, I found the following review:
    Complete ripoff. This is not a book about Iliotibial Band Syndrome, even tho the title would lead you to believe it is. The book contains a few sentences about IBS, and then chapter after chapter of boilerplate about things like how to find a doctor, or how to research nutrition, how to use a library. I am astonished that the publishers had the gall to publish such a ripoff.
    I didn’t waste my money verifying this: the world is already awash in scammy, useless information about this problem and all the others. I have no doubt the “book” is just as empty and pointless as the reviewer says it is. BACK TO TEXT
  12. Amusing addendum to the previous note. Just a little ways back here, I had a long note about a really terrible website, www.itbs.info, which tragically dominated Google search results for 15 years. Back in 2004, the author “updated” www.itbs.info by recommending the not-actually-a-book Sourcebook. That was his update! The mind boggles. BACK TO TEXT
  13. Sutker et al. Iliotibial band syndrome in distance runners. Sports Medicine. 1985. BACK TO TEXT
  14. Almeida et al. Epidemiological patterns of musculoskeletal injuries and physical training. Medicine & Science in Sports & Exercise. 1999.

    In a study of almost 1300 Marine recruits in training, “the most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%, N = 1,143), iliotibial band syndrome (5.3%, N = 1,143), and stress fractures (4.0%, N = 1,296) were the most common diagnoses. The findings also suggest that “[vigorous] training, particularly running, and abrupt increases in training volume may further contribute to injury risk.”

    BACK TO TEXT
  15. In Clinical guide to sports injuries, on p340, iliotibial band syndrome is listed as a “less common” cause of knee pain, after the “most common” conditions of patellofemoral syndrome, patellar and quadriceps tendinopathy, meniscus injuries and knee instability … all of which contradicts my own experience. I have seen more iliotibial band syndrome in my practice than all of those other “more common” conditions combined. This may reflect the nature of my practice more than reality for the rest of the world, but I’m just sayin’. BACK TO TEXT
  16. This is surprisingly hard to prove, because the vast majority of ankle sprains are minor and go unreported and untreated. However, clinical experience and many years of personal experience playing ultimate (a Frisbee team sport with an intensity like soccer) indicates that ankle sprains are probably more common than any other significant injury. BACK TO TEXT
  17. Some papers that mention cycling: Ellis, Fairclough, Fredericson, Martens, Farrell. BACK TO TEXT
  18. Linde. Injuries in orienteering. British Journal of Sports Medicine. 1986.

    From the abstract: “Medial shin pain, Achilles peritendinitis, peroneal tenosynovitis and iliotibial band friction syndrome were the most frequent overuse injuries [in 42 orienteers].”

    BACK TO TEXT
  19. Fairclough et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy. 2006. PubMed #16533314.

    Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and 'rolls over') the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30 degrees of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.

    BACK TO TEXT
  20. Fairclough et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science & Medicine in Sport. 2007. PubMed #16996312.

    Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present, but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.

    BACK TO TEXT
  21. The science of anatomy was surprisingly slow to develop historically, and remains surprisingly incomplete. My Heart Will Go On, by Robert Krulwich & Adam Cole, explores the goofiness of historical beliefs about anatomy, especially the heart. For example, the influential Roman physician Galen made many declarations about human anatomy without ever doing a human dissection, and then no one else checked his work for another 1000 years, and so everyone thought that the liver was a pump just like the heart. Those crazy Romans! Don’t be too quick to laugh, though. Are you sure that you’re own mental anatomy text is accurate? Modern people still have many odd misconceptions about anatomy. People are often “great believers in” treatments based on ideas that are literally anatomically impossible … and wrong IT band anatomy is actually one of the best examples.

    BACK TO TEXT
  22. Devan et al. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. Journal of Athletic Training. 2004. PubMed #15496997. For a more detailed analysis of this research, see Iliotibial band syndrome and patellofemoral pain syndrome aren’t as simple as they seem. BACK TO TEXT
  23. Followed, predictably, by patellofemoral pain syndrome. BACK TO TEXT
  24. Anyone who has felt that knows exactly what I mean, but the sensation eludes many people, because it’s difficult to apply enough tension to the IT band to achieve it. Many people will simply never feel it. More about this in the stretching section. BACK TO TEXT
  25. How is this possible? Fairclough et al explain that “our cadaveric dissections confirm that the ITB is simply a thickened, lateral part of the fascia lata. It completely surrounds the thigh, is anchored to the femoral shaft by the lateral intermuscular septum.” In general, muscle sheaths are no more free to move relative to the muscle they contain than a sausage wrapper is free to move relative to the sausage. In this case, the wrapping is even stronger, because it actually penetrates to the bone, attaching to the femur along most of the length of the femur (on the linea aspera). This was backed up by another dissection study in 2009, which also found that the IT band is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the thigh. This thing does not slide around. BACK TO TEXT
  26. I often hear athletes, trainers, and therapists talking about the anatomy of injuries with great ignorance and confidence — a nasty combination. They believe pain is coming from a part of them that literally doesn’t exist, or not in that neck of their woods. Many lesser-trained professionals make so many mistakes that it’s clear that they could not pass an anatomy exam … like the massage therapist I saw once who tried to base his treatment of me on a completely imaginary muscle — a weird hybrid of two or three others, like the quadriglutator or the sternobiceptoid. (I would have laughed, if he hadn’t been carelessly handling my fairly badly injured shoulder at the time, trying to find my … whatever he thought he was looking for.) It may sound absurd, but we live in a world where some people believe that ketchup is a vegetable — and anatomy is much harder than food identification. It’s one thing to be wrong, but the overconfidence of these anatomical fantasies really tickles my funny bone. BACK TO TEXT

There are 116 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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