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Exercise Solutions for ITB Syndrome That Treat The Underlying Cause

Written by: Nick Jack
Category: 2014
on 18 February 2020
Hits: 7585

A very common injury with many distance runners and one that can be extremely difficult to get rid of is Iliotibial band friction syndrome. It is often referred to as an overuse injury and is where pain is felt across the lateral part of the knee during exercise like running, hence its nickname, “runners knee”. However overuse is just one factor of many that contributes to the onset of this problem and really is just the straw that breaks the camel’s back. Typical treatments for this involve rest, stretching, massage and foam rolling of the area in pain to reduce the stiffness in the iliotibial band (ITB) and even some VMO strengthening exercises. Unfortunately these remedies are usually ineffective and only short term solutions at best as they fail to address the underlying causes of the injury. In this article we will explain what you need to look for to identify the trigger of your pain, and the various exercise solutions you may require to solve the problem for good. 

What Is The Role Of The ITB?

The prevalence of this injury in runners is staggering. Statistics show that up to 22% of all lower limb injuries in runners are reported as ITB friction syndrome! It also has a similar rate among cyclists around 20%. (Reference: “Knee Injuries in Sporting Athletes” by Sports Injury Bulletin). But like all other knee injuries such as patella femoral pain and ACL tears, the knee itself is not the problem. Read our detailed article for more information on this – Why knee pain is nothing to do with the knee

To fully understand how to treat or prevent ITB friction syndrome it is important to understand the anatomy of the hip and what the function of this muscle actually is.

The iliotibial band is a thick band of fascia that begins at the pelvis and runs down the outside part of the thigh, and crosses the knee to attach into the top part of the tibia or shinbone. It forms from the hip flexor muscle known as tensor fascia lata (TFL) and the gluteal muscles where it stretches across to the knee. The main function of the ITB is to help stabilise the outside part of the knee through its range of motion.

It also is one of the hip abductor muscles that helps to moving the hip away from the mid-line. The iliotibial band also helps with both knee flexion and extension. Notice I underlined the word helps both times and this is important to remember for this muscle is designed to assist much larger and more powerful muscles such as the glutes to perform their role of hip abduction and stabilisation of the hip and knee. It is not powerful or capable of performing this role on its own but due to compensation and muscle imbalance this is exactly what it does.

What Is ITB Friction Syndrome?

Due to the location of this muscle and the precarious positions it ends up in is how this injury is created. It is located behind the femoral epicondyle, which is a small bony protruding part of the femur (thighbone) at the knee joint. Whenever you flex and extend your knee the IT band moves across this condyle. To help make it move smoothly across this bony prominence there is a sac or bursa under the band, however with increased friction from repeatedly rubbing the ITB due to poor movement eventually leads to pain which is felt along the outside part of the knee.

Unfortunately it is very common for many people to ignored the symptoms of this injury in the early stages and continue to train until the inflammation increases to a point where scarring can develop in the bursa. This significantly decreases knee range of motion resulting in more pain and eventual end to all type of training.

What Causes ITB Friction Syndrome?


Many people label it as an overuse injury and while there is merit to overuse being a factor I disagree that it is the main cause. For if this was true you would see almost all marathon runners and professional cyclists crippled with this injury. But you do not as it is only some runners and some cyclists which tells you there is something about the way these people move that is the problem. The training volume just exacerbated the problem much more quickly.

Identifying the trigger and avoiding the pain mechanism is essential to finding solutions to all types of chronic pain. By understanding your pain trigger you can begin to understand how to get rid of it for good or even avoiding more damage to begin with. Corrective exercises have little chance of working if you fail to find the cause or trigger which is why it is always the very first thing I try to do when I see people with injury.

But how do you find your trigger? Where do you look?

Start with looking at any repetitive type activities you undertake and the specific movement the pain is exacerbated with. This will give you several clues as to what joints and movements may be causing the friction. You will begin to see there may be a combination of many factors and not just one single cause meaning your treatment will need a multi-angle approach too.

Potential factors include;

  • Poor training techniques and habits
  • Increasing training volume too fast
  • Incorrect footwear
  • Poor bike set up
  • Poor mobility of the ankle and hip
  • Hip & pelvic weakness
  • Foot instability and weakness
  • Poor neuromuscular coordination

The fact that this injury occurs regularly with long-distance runners, and some cyclists says a lot about the specific training techniques habits with these sports. To understand why this is the case let’s examine these sports more closely.

Potential Running Training Errors

The first thing to address here is if a person is or has been running with pain. This is a no-brainer really but it is amazing how many runners will persist with their training no matter how much it hurts until the day comes when they can barely move. Pain is a signal that something is wrong and needs to be addressed, a bit like a fire alarm warning you of a fire. Before addressing the bio-mechanics and muscular problems associated with running we will look at some of the other contributing factors.

Excessive Hill Training

Excessive hill training and in particular downhill is especially stressful on the IT band as it works hard to stabilize the knee and prevent the femur from sliding over the tibia. Running with knees in constant flexion is a great way to develop this problem and excessive hill training exposes this as a potential problem. Combining excessive hill training with poor running technique is a terrible combination and asking for trouble.

Ignorance to the need for strength training with runners is another big problem here as many feel running provides all the strength they will ever need. Unfortunately it does not provide strength in all areas and it does not develop strength in different patterns of movement meaning you can very easily develop imbalances and compensation. Spending time in the weights room could be all you needed to prevent the onset of small problems that become big problems.

For more information read the article – Why strength training for runners is essential

Uneven road or tracks

Running laps of an oval the same direction every time or on roads or paths that have a camber banking forcing one leg to end up lengthened and out of balance. This is where you often hear that one leg is shorter than the other which is not actually the case as it is the pelvis that is tilted laterally due to the training demands. This leg length discrepancy is often the beginning of the weak glutes and tight TFL imbalance (more on this soon).

Poor footwear

If you are wearing the wrong footwear this could be encouraging excessive pronation or rigidity of the feet, resulting in loss of ankle mobility and altered running mechanics. The feet are a massive component to be considered here and the footwear used can contribute to creating this problem. The foot needs to act like a spring being soft flexible foot to cushion the stress of each step we make, and then instantly become stiff enough to provide enough power to move us forwards or upwards. Problems arise if we lose either one of these two things, and ultimately lose our spring. The modern running shoe with all the extra cushioning allows people to run without changing poor running techniques like heel striking and over-striding and while it saves you in the short term it ruins other joints in the long term.

We will discuss how to assess the feet in more detail in the corrective exercise part of this article but for now I do suggest watching the videos below to gain a better understanding of the relevance of your feet to your ITB friction injury.


Poor Running Technique

This is undoubtedly a big factor and I cannot overstate the importance of getting this right. It is amazing how many people have never had any coaching on their running technique and never spent any time even considering what the best form of running is.

When it comes to evaluating the running technique with the ITB runner I am highly suspicious of two things.

  1. Heel striking
  2. Feet crossing the mid-line

Many people are taught to land with a heel strike and most of us will do that automatically, which is not only very inefficient but very quad and knee dominating. It forces a huge amount of impact to be distributed up through the body and also forces your knees into more flexion making you appear to be sitting down while running. This is destined to create problems at the knee.

The other huge factor is where the feet cross the mid-line and this places the IT band in the position of creating friction. Take a look at the pictures below.

The first picture (A) shows the foot placed in a stable position and the lower limb positioned perfectly to absorb the shock of the impact that transfers directly in the middle of the pelvis and up the kinetic chain. You must appreciate that the stance leg during running takes the entire load of your body and is required to decelerate the joints for efficient movement.

Now, compare this to the second picture (B) which is what I often see with runners with ITB friction syndrome and you will notice the stance leg crossing the mid-line and begin to stress the outer part of the hip and knee. The hip abductors being the glutes and IT band as its helper are now required to absorb huge amount of force and work hard to pull the femur back into alignment. When you consider that the glutes are known as a phasic muscle that is prone to weakness and laziness, and that the IT band is known as a tonic muscle prone to shortness and over-activity you can begin to get the picture of how this running technique is a perfect recipe for pain.

See our article about posture for more detail on tonic and phasic muscles.

Other running technique errors associated with this injury and other knee problems is running too upright, over-striding and excessive heel striking. This technique places huge amount of stress through the knee and places the hip in a poor position to absorb shock and be able to use the glutes to effectively provide propulsion. Take a look at the pictures below to give you an idea of what this may look like.

The good news is you can correct this but it will take some time. There are two videos below that give you some basic insights into how to do this. But I highly suggest finding a good running coach who knows the Pose Method. The main emphasis with pose running is to shorten the stride and to land on the mid foot! A good runner should have a very high leg turnover not a long, extended stride length that leads to excessive knee flexion and impact shooting up through the body.

In pose running, the key is to maximise your effort in removing your support foot from the ground; good training is essential to ensure that you don’t over-stride or create excessive vertical oscillation. The runner should fall forwards, changing support from one leg to the other by pulling the foot from the ground, allowing minimum effort and producing minimum braking to this body movement. The idea is to maximise the use of gravity to pull the runner forward.


Okay we have looked very closely at running errors, what about cycling?

Potential Cycling Training Errors

Although ITB pain is less common in cycling than running there is still a significant number of cyclists that develop knee pain. Once again similar problems associated with the runner will affect the cyclist. I myself am a keen cyclist and I love hill training so I am greatly aware of the damage caused to the knees from this type of activity. It is quite funny for at first cycling helps the knee and is a great way to improve some strength into the quads, but too much of it has the negative effect and begins to cause trouble at the knees and hips. Finding a good balance with your training volume is what is required.

Excessive Hill Training


Excessive hill training where the knee is in constant flexion and the quads are taking all the work. There are countless amount of riders who develop knee injuries from too much cycling and developing a muscle imbalance through the hips and quads over the glutes and hamstrings. Quad dominance is very bad for the knee, as it begins to stiffen the joint up, limiting range of motion with everyday movements, in turn inhibiting the glutes from firing and then creating a chain reaction of compensatory movements.

And just like the runner the need for strength training to prevent these imbalances is essential. For more information about cycling read the article – Strength training for cycling

Here is a great story of a client explaining how we helped him get rid of a chronic knee injury that prevented him from riding completely using basic postural and movement retraining

"I was into cycling in a very big way, one day I started having issues with pains in my knees in March 2012. I experienced a great deal of frustration with the injury that stopped my from doing the sport I loved. To try and fix the issue I did a lot of research, spend a lot of time and money trying remedies all for little to no result. It became clear that a quick fix was never going to happen and I gave up trying. Sometime later I found No Regrets while doing some internet searching. They assessed me and put me on a rehab program to correct my movement issues with strength work, massage tools and stretching. I've now been with them for over 9 months and although it's been a slow and sometimes frustrating process, I am very happy to be properly riding again having achieved rides over 100km, rides up into the Dandenong hills and I've just booked my first cycling holiday in 4 years. I still get mild pain but the team have been a great help not only in reducing my pain issues but providing me with the tools and knowledge to be able to build strength, maintain my own issues and stay on the bike. I would recommend No Regrets to anyone with chronic pain. Huge thanks to Elley, Nick and the team for all the help and support they have provided."Matt Sevastopolous

Bike Set Up & Shoe Position

As with the footwear for the runner the shoe set up is a potential factor. ITB inflammation is very likely if the person adopts a "toe in" method when they pedal. This issue may simply be how the toe clips are aligned, forcing the foot to be internally rotated with toes facing in. This can cause the same effect as bowed legs, increasing the angle of the IT band as it crosses the knee and increasing the risk of inflammation. This can be a very simple fix and I suggest you call into your local bike shop for a correct fitting and review of your cleat position with your shoes.

Training Volume

With both running and cycling the amount of training you perform is also a factor. Sometimes the one thing that tips your body over the edge is nothing to do with your technique, training habits or footwear it is simply caused by increasing your training frequency or volume too fast and not allowing enough recovery. With excessive damage and little time to repair it the body remains in a constant state of stress and eventually inflammation becomes so great it forces you to stop. It is not hard to see easily how this can happen when people are rushed in their preparation for an upcoming sporting event or perhaps get a bit excited with their improvement in training they try things never tried before.

With such a determined focus on progression and performance you can quickly fall into the trap of pushing too hard for train too long and simply doing way too much. It is in our nature to strive for perfection and often we are led to set goals that may be out of reach. While we can work to achieve our potential, we must always consider our abilities and our limitations and avoid the danger of over-training which can be a serious problem to your health.


We must acknowledge that rest is just as important as the training itself and it is during rest that our body becomes stronger and fitter. I suggest to read the two articles below with a detailed explanation behind the science of over-training and recovery for more detail on this.

Okay, now that we have covered all the potential causes of poor training habits, footwear, or excessive training what we must look at now is the possible biomechanical causes of your injury. There are many people who never run or cycle who also suffer from this injury and this will be due to several dysfunctions and muscle imbalance. In this next section we will give you several things you will need to assess and also the possible exercises and strategies you can use to correct your injury for good.

How to Treat ITB Friction Syndrome Using Corrective Exercises

Before you jump into any corrective exercise, foam rolling or stretching you must complete a thorough postural and movement assessment. Following a template or a series of exercises that worked for someone else is the worst thing you can ever do for any injury as you may be aggravating things instead of correcting them. We are all very unique and differ in so many ways that it is critical to assess your body to find the appropriate starting point specific to you. I regularly get emails asking me what is the best exercise or best stretch to do and my answer always is, it is impossible for me to give you the exact correction for it will differ from person to person. I can only know for sure once I have completed an assessment.

You can see how our assessment process for knee pain is completed in the detailed article – How to complete a knee pain assessment

The main thing you must understand with corrective exercise it will always come back to HOW YOU MOVE. Trying to isolate muscles with stretching or strengthening may help to some degree but will never change the motor programs that you use to move. And it is always within these programs that the big problems exist.

Now having said all that I am going to give you some areas to look at that are very common to people with ITB problems.

Foot Stability and Ankle Mobility

I briefly touched on this earlier when discussing running technique and it makes sense to start at the feet as they are the first part of the body to touch the ground when we move. Any problems found at our feet will result in problems up the entire kinetic chain. The feet have a tendency to being lazy, and easily losing strength and motor control and are designed to withstand incredibly high forces and should provide more in terms of shock absorption than perhaps any other body part. I have seen countless ACL injuries that all began with poor foot stability and there is no doubting that it is a huge contributor with ITB friction.

Three simple tests I use to identify weakness here are.

  1. Can you SPREAD your toes? This drill is so simple to do and very important in mobilising all the bones and muscles in your feet to provide you with a wider base to stabilise. It is amazing how difficult this can be to do if you have weak feet, and you will most likely need to use your fingers to do this.
  2. Can you LIFT the BIG TOE ONLY?
  3. Can you LIFT all the toes except the big toe?

Failing to do any one of these simple tests indicates you have some degree of foot instability.

If the foot is prone laziness and weakness the ankle is almost the opposite as it attempts to make up the lost stability of the feet. It tends to develop stiffness very easily and needs more focus on mobility and flexibility. The ankle is very similar to the hip in that its main purpose is to provide mobility and our ability to complete multi-directional movements. Any loss of mobility at this joint will create compensatory movement at the next joint to make up for it. And what joint do you think follows the ankle? That’s right it is the knee! Unfortunately the knee is not designed for mobility like the ankle and the hip so if it is forced into excessive rotation or lateral flexion huge problems are not far away.

Great videos to watch for assessing and correcting the feet and the ankle are shown below.


Hip Mobility & Glute Function

I have skipped assessing the knee itself and gone straight to the hip and this is where many people will assume the problem is all to do with weak glutes. They may be right but, it is never wise to assume this, and it is even more foolish to blame all of your trouble on a single muscle. Some muscles are more concerned with stability and deceleration, while others are focused on locomotion and acceleration and all of this happens in a blink of an eye. While it may appear for a certain muscle to be weak or tight, addressing it individually ignores how this muscle is truly used and the interaction it has with its synergistic partners.

Take a look at the picture below and decide what you think is causing the poor form shown on the left.

  • Is the problem really the weak gluteus medius?
  • Is it a problem at the foot and ankle? 
  • Is the problem more to do with coordination and the fact that they don’t know what good movement even is?
  • Is it just a problem with this particular movement pattern?
  • Or is it all of the above?

As you can see it is impossible to lay the blame on one muscle in a movement pattern that requires multiple joints and muscles all firing within a blink of an eye. When I begin looking at the hip I always start with looking for mobility restrictions first as tight muscles will inhibit weak muscles otherwise known as muscle inhibition. This means that there may in fact be weak glutes present in the single leg squat, not due to the glutes being weak and lazy but due to the fact the hips are stealing their work. This faulty mechanism has been researched and explained in great detail by Dr Vladimir Janda in his book “Assessment & Treatment of Muscle Imbalance”.

A simple test I like to use to help me identify this is shown in the video below.


I will also need to look carefully at any loss of mobility at the muscles around the hip, in particular the TFL. Excessive tightness in this muscle creates more anterior pull of the ITB over the lateral condyle which results in more friction. Releasing the TFL is crucial in restoring optimal hip function.

How do you do this?

Most people believe it is all about foam rolling and trying to release the tight ITB. Others say you should never do this as it only damages the ITB as it is not the same as other muscles. I myself prefer to use the roller to mobilize the glutes and hips. Any stretching of the ITB is useless. But really the underlying problem in nearly all cases comes backs to weakness and poor stability. We already looked at how the feet can be causing this and if you have ruled this out or are working on correcting this if there was a problem you are up to the next step.

Videos of mobilizing the hips are shown below.


Glute Strengthening Exercises

There are tons of exercises shown on social media of how to build strong glutes and unfortunately many of these lead to creating serious troubles for hip function and the lower back.  Once again the very first thing you need to do is perform some simple tests to identify if there is a weakness and where. Possibly the easiest test to do is the single leg hip extension shown in the video below and we use this often for clients with severe hip or back pain in our initial assessment. It is very simple with no risk of pain, but very effective at revealing the hip compensation often seen with this injury when the person stands.


If you found this test easy which many people do you can move to more progressive exercises that utilise Swissballs and resistance bands, making sure you keep the exercises to floor based positions to begin with. I suggest to check out the articles below for more ideas on isolated and regressions of exercises you can use for the hip and pelvic region.

However, the two best exercises for developing true gluteal strength with hip and pelvic stability that is specific to the problem with ITB friction syndrome is the deadlift and the single leg squat. I will always start with deadlifts before squats to ensure the person can control the pelvis and optimally position their body to gain gluteal control. The squat will be much more difficult to do when knee pain is present so I will tackle that movement last.

As this article includes a stack of information I have provided you with a FREE checklist you can download that has links to all the relevant information all on one page so you can implement the steps more easily. Click the image below to download your free PDF checklist.

Learn How to Activate the Glutes in the Standing Position

We know the glutes are vital for providing a bulk of the workload with all leg movements but the way they are trained can have a dramatic effect on how they work. Making sure you keep the anterior tilt of the pelvis is the secret and this is where we really see where everything comes undone if the person loses this position during movements like running. And the best way to correct this is with the deadlift exercise, in particular, the Romanian deadlift where the hips are predominately used. Once the two leg version is mastered we must move to the single leg version and this is where we may see pain kick in as the weakness is exposed.

The video below shows you what to look for with the deadlift and the single leg deadlift.


Once the deadlifts are mastered I need to address other movement patterns like the lunge and the squat. As stated earlier I will leave the squat to last as it is the movement most likely to aggravate the condition for it demands incredible knee control. The lunge is a nice stepping stone to the squat as we can provide great challenges to the knee without forcing huge flexion that can set off the ITB. The freedom in the hips that the lunge provides makes it possible to build strength in combination with the deadlift that will enable people to be pain free.

However, being pain free does not mean the job is done. We still have to address the squat technique and more specifically the single leg squat. And it is at this time we discuss the role of the VMO muscle for the very first time. This may surprise many people that it took all this time for us to finally look at the VMO as for many therapists it is the first thing they usually give to someone. Most of these isolated exercises a complete waste of time for they fail to address the reasons it became weak in the first place. Remember it is more to do with the feet and the hips causing faulty alignment of the femur that is the problem and the VMO has no influence over this. The ITB is simply reacting with tightness to further stabilise a faulty alignment and the VMO is therefore inhibited by the ITB. Any strength you gain from isolating the muscle is lost the minute you stand up and move with the same faulty alignment and control you had before. Until you change these faulty movements and positions you will never develop strength in the VMO.

Watch the video below to see more on this.


Why the Single Leg Squat Is the Key

If you have done everything correctly to this point you will definitely feel stronger and almost ready to go back to sports. But the problem with all the exercises up to this point is we have yet to effectively place all the muscles involved in moving and stabilising the knee in the exact position to cause pain. This means we have not yet trained them to work together. This is why so many programs fail for they forget to teach integrated patterns and change the faulty motor program that is causing the pain.

With many the glute isolation exercises they only focus on one part of the glutes role. When in fact there are three parts that are used simultaneously in a movement like walking and running.

  1. The posterior fibers - These fibers contract at early stance phase to lock the ball into the hip socket. The posterior fibres therefore essentially perform a stabilising or compressing function for the hip joint.
  2. The middle/anterior fibers - These run in a vertical direction, help to initiate hip abduction, this is where the clam comes in which is then completed by a hip flexor muscle known as the TFL. The glutes work in tandem with TFL in stabilising the pelvis on the femur, to prevent the other side dropping down.
  3. The anterior fibers - These allow the femur to internally rotate in relation to the hip joint at mid-to-end stance phase. This is essential for pelvic rotation, so that the opposite side leg can swing forward during gait. The anterior fibres perform this role with TFL.

Basically we need an exercise that performs these three key functions in order to restore optimal movement and strengthen correctly. The exercise needs to stabilise the hip, act as a hip rotator, and lock the head of the femur into the socket, creating a very tight and stable hip joint during gait. This prevents the ball and socket joint from rattling around during walking and running.

The single leg deadlift did a great job of this earlier but unfortunately we did not require much work from the knee as it is a hip dominated movement. We need an exercise that uses all three functions of the glutes is the single leg squat, but even better than that it teaches the VMO and ITB how to work together as a team during the pattern of walking.

That brings us to the single leg squat. The two videos below give you tons of ideas to work with here. The video on the left is how to use it as an assessment tool and the video to the right shows you to correct various faults with three different exercises.


There is a lot of stuff to cover with this exercise and I suggest to read the detailed article - How to use the single leg squat as an assessment to pinpoint your weakness to see more.

Do You Need More Help?

Even though we have covered a lot of information you can see how messy this program can get. If you are really struggling with knee pain I highly recommend getting a copy of our online program that comes as a 60 minute video and PDF report. This was put together several years ago to show you how to implement the assessment process to identify mobility & stability restrictions along with movement pattern dysfunction creating your knee pain. These programs provide over 70 exercises and teach you how to design your own program based on your test results to correct your weakness.

Click here to go straight to the online shop and download the video or click on the images below to see more about these programs.



This was definitely one of the longest articles I have ever put together and took me over a month to write this as I constantly kept going back and adding things that I thought were important to address. It just shows you how complicated things can get and why so many people struggle to find answers to their pain for they may be ignoring the signals of why they are in pain in the first place and just treating their symptoms. Half of this article I spent talking about the potential cause of ITB friction syndrome and you can see how often it kept coming back to the feet and the hips. Remember, you must assess your body before applying any of the exercises shown in this article for every person is different. Even though the pain symptoms may be the same the reason for the pain could be for completely different reasons. Find the source of your trouble and you will find the answer to your injury once and for all.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you live in Melbourne and feel you need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.


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