Runner's Knee/ Iliotibial (IT) Band syndrome

Runner's Knee/ Iliotibial (IT) Band syndrome

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Doctor's Edition

The main cause of IT band syndrome is overuse. Please be careful when you have much running time and distance.

Disease Overview


Runner's knee is the general term for running sports injuries around the knee joint, including a variety of conditions. Using the term runner's knee in a narrow sense, I would like to mention IT band syndrome, in which the iliotibial ligament rubs lateral to the knee and causes pain.

Cause and mechanism of onset

IT band syndrome is representative example of knee disorders caused by running. Repeated flexion and extension exercises of the knee can cause the iliotibial ligament to touch (rub) the femoral lateral condyle, causing inflammation (synovitis) and pain. It is particularly common among long-distance runners, such as marathoners (as well as in basketball, swimming, cycling, aerobics, and ballet).
The cause is overuse. A variety of factors have been identified, including excessive running time and distance, lack of flexibility (lack of warm-up), lack of rest, hard road surfaces and downhill, hard sole shoes, and leg alignment (genu varum).


Tenderness exists only around the femoral lateral condyle (Figure.). IT band apparently increases tension and sometimes radiates pain along the course of the ligament.
Initially, pain appears after running but disappears after rest. However, as the person continues to run, the pain gradually increases and does not disappear easily.

Iliotibial ligament inflammation 1
Iliotibial ligament inflammation 2

Iliotibial ligament (circled area)


Lateral knee tenderness and pain on motion. A pain-inducing grasping test is helpful when the knee is flexed 90 degrees and the iliotibial ligament is pressed against the lateral condyle before the knees are extended (manual examination).

X-rays show no marked changes. Magnetic resonance imaging (MRI) shows no characteristic findings.

Differential diagnosis

It must be distinguished from lateral meniscus injuries, which are characterized by pain in the lateral knee joint.

Similar disease

The same symptoms may be caused by running on the inside of the knee. It is called the pes anserine bursitis and is also caused by overuse.

Runner's knee is more likely to occur in marathon

Treatment and rehabilitation


Conservative treatment is principle for overuse. First, to rest a local, i.e., a running pause, is important. Next, to strengthen stretching, mainly in the outer part of the hip joint, such as tensor fasciae latae (see Trainer Edition), and to perform icing thoroughly. Furthermore, the administration of anti-inflammatory analgesics and physical therapy, such as ultrasound, can be done if needed. Once symptoms appear, they do not disappear easily, so early decision-making and appropriate rest periods are important. To reduce the strain on the knee on the same side, occasionally track running in the opposite direction is recommended. Surgical treatment has been reported, but is less common. Finally, check the body's flexibility, leg alignment, and shoes condition and track surfaces.

Yasuhiro Nakajima

Yasuhiro Nakajima

Head coach of Shonan Bellmares Sports Club Triathlon Team, Head coach of Triathlon Team of Nippon Sport Science University, and Chairman of the Japan Triathlon Union Multi-sports Committee

Trainer's Editon


Iliotibial ligament inflammation is an overuse syndrome. The amount of running (speed, distance) can be stressful and painful when current strength becomes intolerable, when fatigue recovery is inadequate, when running form [Does this revision reflect your intended meaning?] is habituated, when road surfaces are hard, or when shoes are inadequate. There is not just one cause. Therefore, it is necessary to consider a training program that takes into account all factors comprehensively and aims to return to competition.
The effects of training begin after full recovery from fatigue. As training increases, preventive measures include stretching to recover from fatigue, eating nutritionally, and allowing more time for recovery, such as sleep.

On-site evaluation and first aid

Runner's knees are painful on the outside of the knee during and after running. Initially, the pain is mild and uncomfortable, but the pain is worse if the person continues to be trained without response. (Figure 2) It is characterized by aching when running at a certain distance.
Reduce training if iliotibial band [Does this revision reflect your intended meaning?] inflammation is suspected. Alternatively, stop and continue the icing.

Painful site of enterotibial ligament inflammation

Figure: Pain site

Doctors suspect IT band syndrome when a person sits with a bent knee as shown in the picture and feels pain when the knee is straightened while the person presses on the knee. Please seek a doctor to determine your severity and how long it takes to recover.

Early treatment is needed because IT band syndrome often takes long time to recover if you have severe case.


With consultation of a doctor, a patient is trained to return to competition while checking for pain.
Start with no landing impact, such as underwater walking, swimming, or cycling, moving from walking to short jogging to increase the distance of jogging.
After those training, perform adequate icing and stretching are essential.
Continue stretching to reduce the burden on the affected area. The IT band connects the lateral side of the tibia and the pelvis. The gluteus maximus (the large muscle in the buttocks) and the tensor fasciae latae (the muscle located around the pockets of trousers) are attached to the area near the pelvis, and those two muscles have much burden and become less flexible, making the IT band firm and more inflamed. It is recommended to stretch the whole body, such as the quadriceps muscle, hamstrings and waist because accumulation of fatigue can cause posture to collapse and can adversely affect various parts of the body.

Iliotibial ginseng band stretching

Stretching of iliotibial band

Buttock stretching 1

Buttock stretching 2

Stretching the quadriceps muscle 1

Stretching the quadriceps muscle 2

Stretching the quadriceps muscle 2

Stretching of waist and buttocks

Environmental factors

Avoid hard roads and hillsides during training to return to competition. In particular, you should pay attention to setting the course, because downhill increases the burden to the lower extremities. Run on grass and soil in a wide a park as possible. Swimming, walking under water, or cycling are recommended for training to keep your physical strength.
As mentioned above, the iliotibial ligament lies on the outside of the leg. Stress that causes the body to swing outward causes the femur on the knee to rub and become painful. Paved roads are designed with the outside of the road lower for rainwater drainage. During running, the lower side, the outside of the road, is more likely to bend outward. That is, if you always run on the right side of the road, you will always run with your body tilted to the right. The athlete should try to run on the left side as well.
Tracks in the onshore athletic field are also stressful on the outside of the corner. People who are not accustomed to track training should gradually increase their practice on the track and, if possible, try running to the opposite direction of the track.
They also say that they have pain soon after the shoes were changed. Choose shoes with cushioning soles that fits your strength. Do not choose less cushioned items only by pursuing lightness. Some shoes soften part of the sole to improve stability. For some people, this may be burdensome, so you should consult with shop staff when you purchase shoes.
Soccer, basketball and volleyball athletes run as part of their training without using shoes, causing pain. Shoes should be worn as much as possible when you are starting running training.
For example, the bow leg may be stressed less by using a plantar plate that raises the side of the shoe sole slightly to reduce stress on the iliotibial ligament.


Acquisition of an ideal running form can reduce the burden on the body. It is important to keep the center of gravity high at all times and be aware that there is no shaking in the wrong direction.
At first, please stabilize standing position. A balanced disk or balance board is used to obtain a stable condition in one leg and to walk with the center of gravity elevated with awareness. Walking also ensures that the body does not sway from side to side between landing the foot and leaving the ground. Acquire a stable walking form while checking with a teammate, coach, or trainer so that the toes of the feet do not turn inward or the knees turn outward.
Landing is more vigorous than walking, and the shaking motions are larger. So, first of all, please get the ideal form in walking. The foot and head should be as straight as possible. If the hips break outward when landing, they are stressed externally. Please be aware that the leg opposite the landing should be swung forward and raised so that the person does not fall down.
Once the walking form has stabilized, a single-leg jump to land softly on the other leg, and the other as well, is performed to confirm the appropriate form. In doing so, the patient should be aware that the body can move in a linear position without less shaking from side to side.
Rather than simply considering the amount and intensity of training, it is important to consider the correct running form and appropriate environment to prevent recurrence.

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