Iliotibial Band Friction Syndrome, also called ITB syndrome is a very common injury among runners who put in a lot of mileage. There are many possible causes for ITB syndrome. The primary symptom of ITB syndrome is pain over the lateral aspect of the knee at the lateral epicondyle. Another painful affliction that happens in runners and rowers is Trochanteric Bursitis, the treatment for both of these injuries are the same. Before I get into the treatment and rehab for the injuries I will explain the function of the structures involved, I will go through some of the causes, and I will explain the best ways to rehab and prevent ITB syndrome and Trochanteric Bursitis.

The Iliotibial Band (ITB) is a long tendon that runs from the iliac crest (the top of the hip) crosses the greater trochanter (the bump at the top of your femur near the neck of the femur at the hip joint) runs all the way down the femur (your thigh bone) crosses the knee at the lateral femoral epicondyle (the bump on the side of your knee) and inserts on the front of the tibia (the big weight bearing bone on the inside of the shin) in a bony protuberance called Gerdy’s Tubercle. The ITB is a tendon for the Tensor Fasciae Lata (TFL). The TFL and the ITB perform several very important functions both at the hip and at the knee.

When the hip is in extension (your foot underneath or behind you) the TFL and ITB act to help the gluteus medius abduct the hip (pull the leg out to the side). The TFL and ITB act to both extend the hip, that is bring the hip backwards. The last function of the TFL and ITB at the hip is to medially rotate the leg (point the toes inwards). At the knee the TFL and ITB act to both extend (straighten) and to flex (bend) the knee. At 30 degrees of flexion, the ITB snaps over the lateral epicondyle to switch its function at the knee. Through these functions the ITB acts as a dynamic stabilizer to both the hip and the knee.

Every time you take a step while walking or a stride while running your TFL and ITB contract to keep your hip from collapsing down on your thigh, keeping you upright. The primary muscle responsible for this is the gluteus medius. Every time you swing your knee forwards during a stride the quadriceps does most of the work, but it is assisted by the Sartorius, which flexes the hip and externally rotates the femur. After 30 degrees the ITB snaps over the lateral epicondyle and acts to extend the knee. When your body is moving over your leg, after your heel has hit the ground, the ITB assists the gluteus medius in keeping the torso upright. It also assists the gluteus medius in extending the hip. As you can see the TFL and ITB get no rest during running.

There are several purported causes of ITB Syndrome and Greater Trochanteric Bursitis. Some of the causes are not best treated with therapeutic exercises and modalities (such as stretching, strengthening and icing). Some biomechanical causes of ITB syndrome include improper footwear (not wearing a show which provides the type of support or cushion your foot needs). For some people an orthotic for their shoe can help. Leg length differences can be a factor, however most people have one leg about ¼ of an inch longer than the other. If the leg length is a factor a heel riser or a lift in a shoe might help. Genu Varum or being bowlegged is a cause because it has the ITB rubbing over the lateral epicondyle to a much greater extent. The most common causes of ITB syndrome which can best be treated with exercise are tight lateral structures; tight ITB most of all, a tight gluteus medius, a tight piriformis and tight hamstrings. Weak quadriceps, weak hip extensors (the gluteus maximus and the hamstrings), and to a great extent weak hip abductors (gluteus medius).

You have two courses of treatment for ITB syndrome. The first takes time and patience, it involves deep tissue massage to the IT band, stretching the IT band, the quads, the hamstrings and the glutes, strengthening all those same muscles, and finally icing. The second option includes all that in the first option, however the second option is used only for track athletes who need to compete in a week. That option has the athlete use a straight leg immobilizer for one week, taking it off only to stretch and ice, so that the symptoms can subside in time for the competition without actually addressing the root cause. No one ever chose the straight leg immobilizer.
And now, the rehab program:

Never start cold, so warm up for 5 minutes in a way that won’t irritate the ITB, if running and biking irritate it, warm your ITB up with a moist hot back for 10-15 minutes.
Second comes stretching; You want to stretch your hamstrings, quads, piriformis and most of all your IT band. I will focus on the Gluteus medius and the IT band stretches. All static stretches should be held for 30 seconds for between 3 and 5 repetitions. Do not bounce, and do not stretch until pain is felt. These stretches can be done 2-3 times per day and should be done every day regardless of type of physical activity on that day.

1-Lie on your back, with a belt around your foot, pull the affected leg up in the air using the belt, leave the other leg flat on the ground. Pull the affected leg across your body until a stretch is felt in the side of the hip and down the leg.

2- Standing, cross your unaffected leg in front of the affected leg. To the side until a stretch is felt along the ITB.

3- Standing, cross your unaffected leg in front of the affected leg. Reach down to touch the toes of the affected leg while keeping your back straight until a stretch is felt.

4- Lie on your back with both knees bent. Cross the ankle of the affected leg onto the unaffected knee. Grab your unaffected leg just above the knee and pull it toward your chest until a stretch is felt.

5- Standing in front of something that can support your weight, stand on the unaffected leg, place the affected leg behind your unaffected leg, and underneath your body. Squat down until you feel a stretch.

The following are links that have pictures and descriptions of various stretching techniques in case my instructions are confusing.
http://www.runnersworld.com/article/0,7120,s6-241-285--11642-0,00.html
http://www.runnersworld.com/article/0,7120,s6-241-285--11555-0,00.html
http://www.runningtimes.com/Article.aspx?ArticleID=6099
http://www.rice.edu/~jenky/sports/itband.html
http://www.rice.edu/~jenky/images/piriformis.stretch.gif
http://www.rice.edu/~jenky/sports/itband_str.html

Strengthening is the next aspect of the rehab involved in ITB Syndrome. As with many resistance training programs for best results you should have 48 hours between strength training sessions. These should be done 2-3 times per week after warming up and stretching. The strengthening exercises will probably be fairly simple and also somewhat silly.

1- Leg press: Use a leg press machine for quadriceps and gluteus maximus strengthening. Make sure your knees stay behind your toes and your knees neither bow in or out. Standard strength trainng 3 reps of 10 sets scheme.
http://www.youtube.com/watch?v=Yt7pYIjEFo4

2- Squat: If you know how to properly perform the squat, this is the gold standard for quadriceps and gluteus maximus strengthening. Do 3 sets of 10 reps.
http://www.youtube.com/watch?v=dbxxs1PErLQ

4- Romanian Deadlift (RDL): This exercise, also known as the Stiff Leg or Straight Leg Dead Lift is the gold standard for hamstring and gluteus maximus strengthening. It is performed by keeping the knees in an extended position, holding the barbell in front of you, keeping your back straight, and lowering the barbell as low as you can bending from the hip and keeping the barbell close to your body. Do 3 sets of 10 reps.
http://www.youtube.com/watch?v=IHWIC0cxhp4

5- Theraband Side Step: This is an exercise for the gluteus medius, it requires an elastic band tied in a loop (as this type of exercise is becoming more popular you can buy the elastic bands in any sporting goods store and no longer need to order from sports medicine suppliers). You start with the band around your ankles, feet shoulder width apart with the band on tension, then you step out to one side. Keep going for about 10 meters, then reverse direction keeping the band on tension all the time. Do 3-5 laps.

6- Monster Walks: This exercise strengthens the gluteus medius and gluteus maximus, it requires an elastic band tied in a loop. You start the exercise standing upright, then you extend one leg backwards at a 45 degree angle, place your leg down. Pick up the front leg, bring it even with the planted leg without taking tension off of the band, then extend the unplanted leg backwards at a 45 degree angle. This should be done for about 10 meters, then reverse direction. Do 3-5 laps.

7- Contrakicks: This requires an elastic band tied in a loop and strengthens the hip flexors, the hip extensors and the hip abductors as well as provides a cognitive balance challenge. You start standing upright on the affected leg with the elastic band around your ankles. You should be standing on a slightly elevated surface so that your planted leg can have a bent knee but your unaffected leg has a straight knee. Kick forwards 20 times, kick backwards 20 times, kick to the side 20 times, do 3 sets, and switch legs.
http://www.youtube.com/watch?v=CD6qzbfVJZo
This video is not exact, you can also do this on a cable column if you can have the resistance down at your ankle. It can be done on an unstable surface as well to add additional balance challenge.

7- Pistol Squat or Single Leg Squat: This exercise requires all of the muscles to be both strong and coordinated, so I expect everyone will try to do this exercise first, but it is the most advanced of the group. You begin standing on the affected leg, with the unaffected leg either held up in front of you, or hanging off the side of the bench/box you are standing on. Sit back, bending at the hip and the knee, keeping your knee behind the toes, then stand up. Switch Legs. This should also be done on a 3 set scheme. Dumbbells can be held if it becomes too easy with just bodyweight. It can also be done on an unstable surface to add additional balance challenge.
http://www.youtube.com/watch?v=MLBAbqEZIeU

Deep Tissue Massage/The Foam Roller is the third step in the rehab program. It can be done every day. It basically involves lying on the affected side and rolling the length of your femur from the insertion of the ITB to the origin of the ITB. The first several times it can be a somewhat uncomfortable exercise as it truly is a deep tissue massage. The key here is that you control how much of your bodyweight is on the foam roll. You can do the foam roll for 3 sets of 1 minute of rolling at least once a day.
http://www.youtube.com/watch?v=c9aJtO0VCqw

Stretching: Repeat the stretching done at the beginning to maximize flexibility gains and ensure the ITB did not become tight during the strengthening exercises.

The final step in the rehab program is Ice. Always ice at the end of a training session to decrease inflammation and decrease any possible pain that may have been caused. For the most effective type of cryotherapy use an ice cup massage.
To make an ice cup is very simple: Fill a paper cup with water, place that cup in the freezer. Once the water is frozen solid, it is an ice cup ready for use. To use the cup, peal away the top of the cup so ½ inch of ice is exposed, place the exposed ice side down on the ITB and massage the painful and inflamed area with firm but gentle pressure for 5-7 minutes. If you are a conservationist, you can re-use the cup, and simpy stick a tongue depressor or popsicle stick halfway in the cup, so once it is frozen you can pull the ice popsicle out of the cup, and use the re-useable popsicle handle to apply the ice massage. Commercial ice cup kits are available, but they are a waste of money when you can re-use a cup and tongue depressor in my opinion.
http://www.my-physical-therapy-coach.com/ice-massage.html

The stretching, strengthening program provided here should help to alleviate the symptoms of ITB syndrome, and once it is incorporated into a regular training program should also prevent the initial onset or return. I hope this advice helps everyone.

Dan, first of all, great post. Truly awesome info. I have a question for ya though. I have been having a hard time figuring out if I have ITB syndrome or something else. Right now I know I have bilateral runners knee. I have the pinpoint pain with soreness in the knees if they are bent in any position for a long time. But in my left leg, I have an achy type pain on the lateral lower leg right on the midaxilary line. It is about 4 fingers below the joint and seems to be below where the LCL terminates at the fibula from the pictures I've looked at. It is worsened by pronation (weight on the big toe and lifting the pinky toe side of the foot in the air right?) I can pin point the pain. It is usually most prominent during finning when I am extending my foot and pushing against that extension. Any ideas if this is the lowest part of the ITB acting up or if it is something else? My PT consists of the crossfit Workouts posted here aka the SOPWOD.

Also if I extend my foot and straighten my leg, the pain becomes constant and at its worst.

FLA, I'm sorry to hear about your knees. Unfortunately I can't tell you what your other injury is from a brief description over the internet, it would require a physical exam to give me an idea of what type of injury you have. The good news is that the ITB Syndrome rehab should help some with your patellofemoral pain syndrome since PTFPS is frequently exacerbated by tight lateral structures (the ITB has fascial ties to the patellar tendon that pull the patella laterally and can cause poor tracking when the ITB is tight).

I know this is kind of an old post but maybe someone can help me before I go to the doctor. really do not want to. I ran a half marathon about a month ago. The next day I was sore abviously. After the muscle soreness dwindled away I still had a pain on my knee cap. It is on my left knee exactly on the point of the inner knee cap (the spot where the pain is is about the size of my finger tip to the touch. And when I bend my knee. sitting, walking if I bend it too far etc..). I took two and a half weeks off I felt my knee feeling a little better so I ran a couple of miles. The next day was as if I ran that half marathon all over again. Its been about 2 weeks again and My knee is feeling a little better in that spot on the knee cap. I can sit and bend my knee but its still sore and I can feel the tightness in my whole left knee when bent. I have to bend it slowly to bend it. Also today while sitting When I pull the muscle right at the top of my knee cap towards my body it hurts. Now I did some research on google on all of these knee syndromes and I have some kind of symptom for all of them but not one of them do I have all symptoms. So I am lost at what I have. But if someone can give it a shot please do so. I am gonna rest it for about another month which is killing me cause I want to run and swim so bad. But I do not want to go see a doctor because I fear all I will be told is: Here take these NSAIDs, Rest and Ice. something I can do on my own with out it on my record. I have this fear because I work in a MTF and is what most of the docs do in the facility I work in. But if this persist I will have no chioce. Sorry for the LOOOOONG post any thoughts would be appreciated by anyone

I will dig up some info a guy sent about it. More importantly, one should not try to hide something like this! I did the same thing for 26 years and it makes it much harder to get a proper VA rating if/when you retire. Bottom line, IF you plan on making the military a career and do go into a ST type job, the more documentation the better...if it's not documented, it didn't happen...it's not being weak, it's not trying to get out of something...it's the right thing to do and will pay dividends a few years down the road.

Very wise words I'm not retired yet but a lot of retirees will tell you the same thing. Make sure you get yourself checked out cause if you go most of your career with the pain and it never gets documented then you will have major problems when you go before the VA board.

LeviathanDan has the info at the beginning of this thread. Get it checked and documented.