The Top 3 Reasons Why Runners Get Iliotibial Band Syndrome (and Why Foam Rolling Isn’t the Answer)

Iliotibial band syndrome — IT band syndrome, ITBS, whichever name you prefer — is a notoriously common injury that’s plagued the running community for ages.

It can set in quickly, and tends to overstay its welcome like an unwanted guest.

But perhaps, even more frustrating, is trying to search for a solution to ITBS on your own. You can find a whole host of articles easily enough, but all of them fixate on techniques that only yield temporary relief: stretching, strengthening, resting, medication, foam rolling.

That isn’t to say that these methods aren’t helpful with managing the symptoms, but more so that they don’t work towards truly eliminating the problem.

To eliminate ITBS, you have to treat the root cause, not just the symptoms.

In order to find a true, long-term fix for your IT band pain that goes beyond the foam roller and endless stretching, you have to identify the root cause.

How do you do that? Well, the answers lie in your biomechanics, so let’s dive in.

What is Iliotibial Band Syndrome?

First, let’s review the basics.

The iliotibial band (IT band) itself is a long, thick band of tissue that runs from your hip bone down to the outside of your knee. Its primary role is to provide lateral stability to the knee, helping to retain proper leg alignment and shock absorption.

Iliotibial Band Syndrome

When runners experience IT band syndrome, they’re effectively dealing with inflammation or aggravation of the tissue. It most often presents as pain on the outside of the knee, which can sometimes travel up the thigh and to the hip.

As a connective tissue, the IT band consists of muscle fibers from the tensor fasciae latae (TFL) and the gluteus maximus. This means that, in order for the IT band to properly stabilize the knee, both of these muscles have to be at optimal functionality.

So, as you may be able to infer, experiencing painful symptoms in the IT band will often have something to do with deficiencies in either of these muscles…

But there’s a little more nuance than that.

What Causes IT Band Syndrome in Runners?

Unsurprisingly, the most common culprits for ITBS all boil down to biomechanical deficiencies. 

Whether these issues are brought on by impairments in muscular strength, activation, stability, or control, they have a large impact on how you maintain form as you run.

Many of these impairments can occur simultaneously or as a result of each other, so it’s not unusual to see some combination of these problems when identifying the causes for your IT band pain. Here are the three most common errors we’ve encountered:

#1. Femoral Internal Rotation

Alright, this one is less of a specific form error than it is a common biomechanical impairment.

Femoral internal rotation sounds like a mouthful of a term, but it’s quite a straightforward description: it’s when the femur (i.e., your thigh bone) internally rotates, or turns inward. 

It seems like an awkward mechanic when you think of it as an isolated movement, right? But in the context of our everyday movement, it plays a subtler role in combination with other biomechanics. This allows you to maneuver your legs for a whole range of activity, anywhere from putting on your pants to full-on running and squatting.

Femoral Internal Rotation

So clearly, internal rotation itself isn’t a detriment, as it’s a natural piece of our running and movement. It really only becomes a cause for concern when our bodies use it to compensate for other deficient biomechanics.

Take your tensor fascia latae muscle, for instance. Your TFL works with your gluteus maximus as a hip abductor, meaning it helps lift the leg away from the midline of your body. But on its own, it also works as an internal hip rotator. (It sounds contradictory, but both motions can coexist!)

The issue is that your gluteus maximus is essential for hip abduction and hip external rotation, so if that muscle isn’t firing properly or lacks sufficient strength, your TFL is left to compensate for these mechanics.

Which, ultimately, results in excessive hip internal rotation.

This rotation pulls the tissue of the IT band inward, causing it to rub against the femur and joints and become irritated. Then, that irritation is bound to grow worse when your body’s being subjected to the repetitive loading and impact forces of running.

Frustratingly, excessive internal rotation often isn’t the lone culprit behind ITBS. It’s commonly associated with other deficient biomechanics, many of which present in the common form errors below.

#2. Cross-Over

To visualize what cross-over looks like, picture a line going down the middle of your body (or think of straddling a line on the track). If either of your feet (or both) cross over that line as you land each step and move through your stride, you’re running with some degree of cross-over

Most runners don’t realize if they run with cross-over, since you don’t typically stare at your feet to watch where they’re landing. And, even if you tried to look for it, it’s hard to keep track of your body’s midline as you’re running.

Identifying cross-over is easiest if you have some method of tracking your form, whether it be a high-tech pressure treadmill or a simple video recording of your running from behind.

With proper leg alignment and foot landing, your IT band doesn’t experience any excessive pulling or overstretching. But, if your feet land overthat imaginary line, they’re effectively pulling your leg towards the middle of your body, commonly referred to as “hip adduction.” The farther in your leg is pulled, the more strain is placed on your IT band as it stretches to match your compensatory movement.

As if that wasn’t enough to aggravate a runner, cross-over also makes it more difficult for you to properly recruit the gluteus maximus. This limits the amount of knee and hip stability as you run, and, consequently, increases the degree of that pesky internal rotation discussed in error #1.

#3. Pelvic Drop

Pelvic or hip drop is an incredibly common form error that’s also named quite descriptively: it occurs when one hip drops lower than the other. As you’re bearing your weight on your stance leg, the other side will be noticeably lower.

You can typically notice hip drop with the naked eye — whether it’s a coach telling you to pick up your hip, or just a simple video of you running from behind. (Some runners place white tape at their hips for an easier visual of whether or not their pelvis is level.)

Pelvic Drop

Excessive pelvic drop is most commonly caused by weakness in the glutes, particularly the gluteus medius. This muscle attaches to the top of your hip bone to the top end of your femur, so it plays a big role in hip stability and preventing pelvic drop.

The thing about hip drop is that it’s not just one side that dips lower than the other; your pelvis is one large bone, so when one hip goes down, the entire structure tilts and the other hip moves upwards.

And since your IT band attaches to the pelvis, you can imagine how this change in level directly affects the tissue during movement. When the hip of your stance leg tilts up, even only slightly, it stretches your IT band and lengthens it more than usual. That general pulling sensation will naturally lead to some pain or aggravation at the hip.

Plus, if your knee or thigh moves toward the midline of your body, this will pull at the bottom end of your IT band too, so the tissue is getting stretched in both directions.

How to Fix IT Band Syndrome

Now, if you’ve been dealing with (or have dealt with) ITBS before, you’ve probably read all about the quick-fix solutions: rest more, stretch it out, try to foam roll, the whole shebang.

But if the solution is meant to be a “quick fix,” it’s probably not an actual solution.

Rather than using these methods as the solution to your IT band pain, they should be used as tools to supplement your actual treatment and training plan. Foam rolling and resting can be beneficial for mitigating the symptoms, but addressing the root cause of the issue takes a more in-depth analysis and approach…

It’s all in your biomechanics and running form.

(Or, as we like to say in our clinic, it’s “form over foam.”)

You may have noticed that the 3 main causes for ITBS shared quite a few similarities. In particular, there was 1 major thread that tied them all together:

Each is caused by — or associated with — gluteal weakness.

The real fix to ITBS is to combat that weakness by practicing glute-specific strengthening exercises. Of course, it’s a little more nuanced than that (if only we could just tell runners to “strengthen their glutes” and have it all magically go away!).

While your recovery needs are unique to your training, you’ll typically find yourself practicing exercises like clamshells, single-leg raises, lateral band walks, squats, and hip hikes to help strengthen the glutes muscles. As you develop strength, you’ll start progressing to more single-leg drills to better emulate running mechanics, particularly with glute activation and leg alignment.

Throughout your training, it’s extremely beneficial to work with a running specialist. They’re able to evaluate your form and provide solutions to incorporate sufficient glute activation into your movement.

EMG Activation

Utilizing specific technology, like our electromyography (EMG) sensors or dynamometer, is an excellent way to solidify your training in data. This equipment can measure how well (or poorly) your muscles are activating, as well as how much strength they can generate, respectively. Not only does this give you hard evidence of your current glute activation and strength, but it also allows you to see what kind of improvements you’re making through your training plan.

Once you’ve established a decent foundation of strength and activation in the glutes, you’ll also  benefit greatly from pairing your training with running retraining drills.

The type of drill you practice will vary case-by-case, as there’s a wide variety of potential cues that could benefit ITBS rehabilitation. (But that just means it’s an opportunity for you to visit our in-person gait lab and experience the full analysis yourself!)

Eliminate ITBS for Good

Remember: every athlete can present ITBS differently, and for different reasons.

The basics of your training will boil down to establishing a proper foundation, ensuring muscle activation and strength, and maintaining sufficient alignment. What you identify in your biomechanics — and how you approach it — will be unique to your running needs.

And with data-backed, expert care, you’ll be able to put an end to your IT band pain for good.

Originally published on January 2, 2017; updated on April 13, 2022.

By Dr. Kevin Vandi DPT OCS CSCS

Dr. Vandi is the founder of Competitive EDGE Physical Therapy — with his background in physical therapy, orthopedics, and biomechanics, he is a highly educated, compassionate specialist. Using state-of-the-art motion analysis technology and data-driven methodologies, Kevin has assisted a wide range of clients, from post-surgery patients to youth and professional athletes. When he isn’t busy working or reading research, he spends his time with his wife Chrissy and their five wonderful children, often enjoying the outdoors and staying committed to an active lifestyle.

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