Does running cause pain on the outside of your knee?

Does your pain occur at the same time or distance (5, 10, 15 minutes etc.) into your run?  If so, you may have an IT band (Iliotibial band) injury.

When people ask me, “What is your favourite band?” my response is the little-known sleeper band called the Iliotibial band (aka IT band or ITB).  Music is clearly not my forte (either is French, or English for that matter).  Ironically, your ITB is what supports your stance and lateral hip and knee when you are enjoying your favourite music band. Jumping up and down, swaying side to side or running because you are late to the show all require use of your ITB.

What is the IT Band?

  • The IT band helps to laterally stabilize the hip and knee as well as the long upper leg bone (femur). In doing so, it helps prevent stress fractures, ankle sprains, knee and hip injuries.
  • Lateral hip and knee stability is essential during running when our foot lands just inside our hip joint. This creates strong forces that push our hip outwards, causing our glute muscles/abductors to respond, contract and stabilize (if strong enough, not injured, stuck, fibrotic etc.).
  • The glutes (abductor portions) function to PREVENT the femur bone (knee at the bottom) from going IN relative to your hip OR prevent your hip from going out relative to your knee. The glutes have a strong fascial connections into your IT Band. This includes the muscular part of the IT Band called the tensor fasciae latae (TFL).  The glutes are therefore triggered to activate (reciprocally to these impact forces during running) to stabilize and prevent lateral collapse of the hip and knee on every step.

Iliotibial Band Syndrome symptoms/signs

  • When the IT band is symptomatic, certain movements of the knee become painful. This discomfort typically occurs during or after running.
  • Pain on the outside of the knee or in a j-shape pattern starting outside of knee to a more central point below the kneecap/top of shin bone.
  • Typically, there is NO locking or clicking sensation of the knee from IT Band injury although some sensation can be felt if /when the IT Band rubs over the lower leg bone (lateral femoral condyle).
  • Usually, there is a painful zone at a particular part of your running mechanics: a certain knee angle especially with impact/weight bearing.
  • Negative imaging with X-ray, although an MRI might show some thickening or swelling around the lateral knee.
  • Pain that starts in about 5 to 20 minutes (or more, but predictable) into a run.

Causes of IT Band injury

Although IT Band (like anything) has some genetic variables that make a runner more susceptible, genetics are typically NOT the difference. 

Causes include training errors/changes such as:

  1. New or excessive running (particularly downhill)
  2. Older shoes and lack of cushioning AND/OR inadequate OR excessive medial support
  3. Too much distance too soon
  4. Running at same pace too much
  5. Always or mostly running on harder surfaces
  6. NOT ENOUGH cross training or other training including quad/glute/core strength and mobility. The 2 biggest weaknesses are glutes and quadriceps insufficiency as they are the main shock absorbing muscles

Biomechanics that may contribute to IT Band injury

  • Ideally, you are landing underneath your hips when you run so have access to your greatest shock absorbers, your quads and glutes. 
  • If you are running on your toes, you may get a shift of forces into your lower leg (calf/achilles/plantar fascia) but this is typically not a long-term solution for most people for distance running
  • Toe running can lead to other injuries (more in the lower leg and foot). 
  • If you are landing under your hip, there are variations of foot strike that are optimal and subconsciously and reflexively determined depending on speed, distance, uphill, downhill, fatigue etc.. 
  • Biomechanics summary: By landing underneath your hip, you are putting all of your joints and muscle/tendons in the best position to shock absorb to support the IT Band and foot contact will be typically irrelevant.

Stages of recovery for IT Band injury

Early and/or mild post-injury stage

  • If it is a mild or a recent tight feeling, awareness or pain then a few off (3-5 days +/- cross training) can be sufficient.
  • Ice or heat – may calm down the short-term symptoms so occasionally helpful as an early and simple intervention
  • Some light stretching and foam rolling your quads (around IT Band), hamstrings and lateral hip/glute muscles can help symptomatically and if minor.  See limitations of stretching and foam rolling below*
  • A newer pair of the same shoes if warn/old OR new shoes with slightly more or less stability (unpredictable).
  • Warm up more gradually before and during your early run. 
  • Start to strengthen with squats (+/- a jump at the top for plyometric/tendon strength), single leg squats, hip thrusts, side planks, glute bridges, lateral crab walks etc. with a focus on the glutes, quads and core (planks).

“Maybe my non-running friends are right that running is bad for me” stage

  • If thickening or fibrosis/scar tissue has developed within or between IT Band and other hip or quadriceps muscles (that often can’t be stretched or strengthened out), a trained therapist can find and release this with more specific treatments. (I treat this on a daily basis with Active Release, Graston, Shockwave etc.)
  • Correct imbalances and strengthen/activate supporting to take more strain off the IT Band.
  • More of Stage 1

“I quit” or “Is there surgery for this?” stage

  • Although traditional medical treatments can be somewhat effective, they typically do NOT address the root causes (weakness, scar tissue/adhesion build-up, biomechanics, alignment, training, footwear etc.). For example, cortisone injections or topical cortisone can help temporarily/quickly but can also permanently weaken (if used in excess or relied on) ligaments and/or tendons and inhibit natural healing mechanisms.
  • The last resort to treating IT band syndrome is surgery to cut/release the fascia/soft tissues in and around the IT band, but this is rarely necessary and can permanently disrupt the fascial/functional chain of stability and support.
  • Solution: More of Stage 1 and 2.

Summary of solutions for IT Band injuries

  • No running for a short period of time (3-5 days) can seem magical to calm down a simple overuse/inflammatory version of ITB syndrome. For a bad case 4-5 weeks with treatment is sometimes required.
  • While you’re backing off on your mileage and pursuing treatment, considering cross training to keep up your cardiovascular fitness such as swimming, pool running, cycling and rowing.
  • Treatment such as Shockwave therapy, Graston Instruments, Active Release Techniques that break down scar tissue and adhesions in fascia muscles and tendons to help separate muscle/tendons/fascia in a more permanent way.
  • Stretches for the glutes, hip flexors, quads, hamstrings and lower back can help to get the hips and legs in more neutral alignment. However, the root cause has more to do with controlling your current (or new) range of motion. Flexibility that is not stabilized or controlled with strength can actually be a detriment and contribute to running (and other sport) injuries.
  • Strength based mobility exercises (in addition to passive flexibility) for hips and core and your shock absorbers are the best long-term way to take strain off of the ITB. It does this by sharing and taking some of the load, impact and forces OFF of the ITB. These exercises include glute bridges, squats (double and single leg), lateral crab walks, clam shells (for early activation) ALL with an exercise band around just above your knees (or ankles for lateral crab walks).


*Limitations of stretching and foam rolling for IT band injury

  • Foam rolling: can help as a short-term intervention especially if recent or mild, but if the foam roller is needed regularly this typically indicates a training error (overuse, imbalance, weakness, biomechanics). Muscles should tighten slightly after harder, newer, faster, longer workouts due to the microtears in the muscles and connective tissues protecting themselves while they heal to avoid further injury. They should loosen up naturally over 1-3 days with (or without) gentle stretching, active mobility and/or warming up for your next workout or run.
  • Although stretching may contribute to short term symptomatic relief, it is typically NOT a solution either. The reason runners feel tight is often due to the necessary protection of our joints and to prevent further damage or injury to the tendon (or just a short-term recovery position to heal and prevent overtraining).
  • Our bodies do not care about flexibility, they care about and assess risk for survival and performance purposes. Constant feedback loops coming to and from our joints and muscles/tendons (slower feedback) through our nervous system interprets this RISK and then ONLY allows the mobility (useful range of motion) that we are stabile in.
  • Extra flexibility without strength and stability can INCREASE your chance of injury. In other words, extra flexibility can put you in more extreme positions (ranges of motion) that are more vulnerable to strain/sprains/dislocations/ITB syndrome.