Part 4-The top 5 causes of ITB ‘Friction’ Syndrome

 In Running

A runner’s guide to the rehabilitation of  ITB ‘Friction’ Syndrome

ITBS is the second leading cause of knee pain in runners and the most common cause of lateral knee pain. Despite its prevalence, few biomechanical studies have been conducted to better understand its aetiology. Because the iliotibial band has both femoral and tibial attachments, it is possible that atypical hip and foot mechanics could result in the development of ITBS.

Overuse Running Injuries

When it comes to overuse running injury development  there are normally five chief contributory categories of contributory factors. These are outlined in the ‘5 steps’ of my book You CAN Run Pain Free! These five key areas are depicted in the below diagram from page 63 of You CAN Run Pain Free!:

ITB Friction Syndrome

A runner suffering from an overuse running injury will typically have several of the above working in concert to cause an injury. Rarely is the causation of a lower limb overuse running injury due to a sole contributory factor.

To get the best momentum with rehabilitation it is important to target the major contributory factors first (to learn more click through HERE>> ITB syndrome Part 3- how to diagnose ITB syndrome). Targeting the major contributory factors first with rehabilitation will allow for the most rapid settling down of symptoms and also the most rapid improvement in function, and return to pain free running.

ITB friction syndrome contributory factors

While the above schematic provides a framework for all overuse running injuries, when it comes specifically to the onset and causation of ITB syndrome in addition to the assessment looking to confirm the diagnosis of ITB syndrome (See ‘How to Diagnose ITB syndrome’) a thorough assessment must be conducted in order to discover the chief contributory factors that coalesced to create the ITB syndrome.

Once identified these contributory factors can then be addressed with the appropriate rehabilitation and guidance.

Over my last 12 years in clinical practice I have observed there to be several common contributory factors for the onset of ITB syndrome in runners. The top 5 contributory factors that can lead to an onset of ITB syndrome are:

1. The running body

When it comes to the contribution of the running body perhaps the best paper to draw upon is the recently (2014) published literature that looked to identify the biomechanical variables involved in the onset of ITB syndrome in distance runners (3).

Biomechanics can be a confusing term, but the definition I find most helpful is the study of the structure and function of biological systems (eg humans). So in this case the researchers were looking to see if there were any statistically significant factors of the runners function and structure that were contributory to ITB syndrome.

An electronic search was conducted using the terms “iliotibial band” and “iliotibial tract”.The results showed that runners with a history of ITBS appear to display:

  • decreased rear foot eversion
  • Increased tibial internal rotation and hip adduction angles at heel strike
  • greater maximum internal rotation angles at the knee
  • decreased total abduction and adduction range of motion at the hip during stance phase
  • greater invertor moments at their feet
  • decreased abduction and flexion velocities at their hips and to reach maximum hip flexion angles earlier than healthy controls.
  • Maximum normalised braking forces seem to be decreased in these athletes.

The researcher’s summary was that the literature is inconclusive with regards to muscle strength deficits in runners with a history of ITBS. They also concluded that Prospective research suggested that greater internal rotation at the knee joint and increased adduction angles of the hip may play a role in the aetiology of ITBS and that the strain rate in the iliotibial bands of these runners may be increased compared to healthy controls.

Their summary was that clear biomechanical cause for ITBS could not be devised due to the lack of prospective research.

Clinically I have over the years observed that there appears to be a greater incidence of ITB syndrome in runners who are genetically more mobile around their joints. Clinically we refer to such runners as being towards the more ‘hypermobile’ end of the mobility spectrum.

Such runners I have observed tend to have more ‘control’ issues relating the movement of their trunk and hips when they run and load through single leg stance. I routinely find that unless the runner is aware of their tendency to move more through their trunk (ie collapse at the hip under load-see below) and thus made a concerted effort to mitigate against the ‘natural’ greater movement with regular strength and conditioning exercise, than they are more at risk of developing ITB syndrome.

Source: You CAN Run Pain Free!

To learn more about how a runner’s mobility status can effect injury risk click HERE>>

2. Running technique

Research has validated that increasing step rate or cadence can have a positive effect on the loading of both the hip and the knee. When 45 runners in a study increased their preferred step rate (natural running gait) by 10% at a constant running speed on a treadmill the researchers reported a substantial reduction in energy absorption at both the hip and knee (4).

The researchers concluded that:

Running with a cadence greater than preferred reduces the biomechanical demands incurred by the hip in the frontal and transverse planes of motion, therefore it may be useful in the clinical management of running injuries.

It should be pointed out that the above mentioned study only looked at asymptomatic runners (ie those who didn’t have lower limb injuries such as ITB syndrome) so it remains unclear if injured runners would have the same biomechanical changes to step rate (cadence)  manipulation.

In 2016 a systematic review of clinical and biomechanical findings related to the effect of running retraining interventions on running biomechanics and injury development. The study also incorporated interviews with sixteen international experts, who recommended running retraining for runners suffering from: ITB friction syndrome, plantar fasciitis (fasciopathy), achilles, patellar, and proximal hamstring and gluteal tendinopathies, calf pain, and medial tibial stress syndrome (shin splints).

Forty-six studies validated the effect of running technique retraining on biomechanics such as: step rate, foot strike pattern and manipulation, proximal (lumbo-pelvic/hip) kinematics, and cues to reduce impact loading.  The experts recommended a tailored approach to each injury and runner was required for optimal rehabilitation outcomes to occur.

Clinically I have observed that the over-striding runner (ie the runner with too low of step rate) landing with their foot out in front of their centre of mass (see below) tend to be more predisposed to the onset of lower limb running injuries including ITB syndrome.

ITB Friction Syndrome

For this reason and the above referenced research I tend to coach runners to increase their cadence both as part of rehabilitation of ITB syndrome and also to be preventative against the onset of lower limb running related injuries.

To learn more about my preferred approach to working with runners on their cadence click HERE>>  (Running Technique Principle 1: Cadence).

3. Running shoes

There exists no direct link in the research between a runner’s shoes and their risk of developing ITB syndrome.

Clinically I have observed that runners who have continued to run in shoes beyond their ‘use by’ date tend to be more prone to the onset of not only ITB syndrome but lower limb running injuries in general.

I believe ‘old’ shoes to be far more of a potential contributory factor to the onset of ITB syndrome than runner’s selecting the ‘wrong’ pair of running shoes. In fact research has found that runner’s selecting their shoes on ‘comfort’ as opposed to foot type tend to have a lower injury risk.

In 2010 a published paper based on 6 years of previous research, established that it was not possible to accurately match a shoe to a foot, based on arch profile. Furthermore, they were able to demonstrate that when a low arched (or “pronated”) foot was matched to a motion control shoe, per the manufacturer’s recommendations, there was zero positive outcome in relation to overuse running injury.(5) This was a major research finding which contraindicated the popularised method of fitting a runner to a shoe based on their ‘foot type’ eg high arch, low arch, neutral foot etc.

In tandem with the above research finding Nigg et al (2015) proposed that a runner intuitively selects a comfortable product using their own ‘comfort filter’ that allows them to remain in their preferred movement path. This may automatically reduce the injury risk and may explain why there does not seem to be an overall reduction in the running injury rates we see today compared to 40 years ago despite purported shoe technology advances (6).

The beauty of the above research finding is that it takes the ‘pressure’ of trying to ‘pick’ or find the exact right shoe. Many injured runners place far too much emphasis on the quest for the right shoes and neglect the importance of running body, technique, and training errors as this blog post outlines.

4. A deficit in hip strength and control

A deficit of hip strength tends to be the greatest contributory factor for runners I see who are suffering from ITB syndrome.

Specifically there can exist weaknesses in the glute max, glute medius, or deep hip external rotators. Runners may have deficits in all of these muscle groups, or more isolated weaknesses. Of note also is that runners who tend to be more hypermobile tend to have greater hip strength deficits. Click HERE>> to read more about genetic mobility status (Runners know your genetic mobility status).

See the image below illustrating the deep hip rotatores and the glute medius musculature, with the glute max being resected or cut away.

The effect of a deficit in hip strength is a collapsing of the thigh (femur) in towards the midline of the body as depicted above. This is termed hip adduction. Hip adduction in the frontal plane had been shown to be contributory for a combination of lower limb running injuries including: patello-femoral knee pain (1), tibial stress fractures, and also ITB syndrome.

Davis et al in 2003 measured hip abduction (glute medius) and hip external rotation isometric strength scores for the injured side of 15 female subjects with patellofemoral pain. These scores were compared to age matched female control subject scores.  The subjects with patellofemoral pain demonstrated 26% less hip abduction strength and 36% less hip external rotation strength than their matched controls (1).

In 2010 Ferber et al. (2) published the results of a trial that looked at the differences in mechanics of 35 healthy female runners who sustained ITB syndrome compared to matched runners who had no history of running related knee injuries.

The iliotibial group exhibited significantly greater peak rearfoot invertor moment, peak knee internal rotation angle, and peak hip adduction angle compared to controls. No significant differences in peak rearfoot eversion angle, peak knee flexion angle, peak knee external rotator moment, or peak hip abductor moments were observed between groups. That is runners with a history of ITB syndrome demonstrated knee mechanics that would suggest increased stress on the IT band.

Clinically I have also found that there is not only a need for a runner who has strength deficits of the hip to get strong in the above mentioned hip musculature, but it is also (with distance running) an imperative that the runner develops endurance in the muscle groups.

A significant or even relatively minor deficit of hip musculature activation, strength, and endurance is the greatest risk factor for the onset of ITB friction syndrome. Depicted below is the 3 stages all lumbo-pelvic muscles must progress through in order to develop hip musculature that is fully activated, has strength, combined with the all important endurance of the muscles (noting that if a runner was to run at say 90steps/min, this equals 5,400 repetitions that the hip musculature must deal across an hour of running).

ITB Friction Syndrome

In the final blog post of this series I will outline the best specific exercises to target hip muscle weakness that contributes to ITB syndrome onset.

5. Training Errors

In almost all cases of ITB syndrome I have seen runners present with over my last 12 years of physiotherapy, the runner had made some kind of training error, and this error has contributed to the onset of the ITB syndrome.

Common training errors include:

  • Suddenly increasing running volume or mileage-well above the average weekly volume
  • Suddenly increasing the running intensity -above the average or standard intensity of training sessions
  • Increasing the amount of hills (downhill and uphill) in the training program
  • Failing to schedule adequate rest or active recovery days or sessions

In recent times load management has been closely assessed in the scientific literature. One way that the literature supports in terms of runners (and athletes) monitoring their training loads and avoiding injury is to monitor the Acute on Chronic Workload Ratio (ACWR). The beauty of the ACWR is that it detects sudden ‘spikes’ or increases in training loads that will be likely partly causative of a lower limb running injury such as ITB syndrome.

To read more about avoiding training errors read the below:

  1. Finding your optimal training load: reaching peak performance and minimising injury risk  HERE>>
  2. Finding the sweet spot: training hard vs injury HERE>>

In rehabilitating ITB syndrome one of the immediate treatment principles I recommend and implement is a reduction in training load, until the irritability of the ITB syndrome reduces. I will then work with the runner to ensure a successful return to full running volume occurs over the required and appropriate time frame.

Next ITB syndrome Post

In the next and final instalment of this ITB syndrome blog series I will outline the 5 best exercises I prescribe for the rehabilitation of ITB syndrome.

If you know a runner who can benefit from this article please forward it and spread the #runpainfree message.

Physio With a Finish Line™,

Brad Beer physiotherapist gold coast

Brad Beer (APAM)

Physiotherapist (APAM)
Author ‘You CAN Run Pain Free!
Founder POGO Physio
Host The Physical Performance Show

Featured in the Top 50 Physical Therapy Blog


  1. Davis, I et al (2003). Hip strength in females with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy, 2003 Volume:33 Issue:11 Pages:671–676 DOI:10.2519/jospt.2003.33.11.671
  2. Ferber, Reed, et al. “Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics.” journal of orthopaedic & sports physical therapy 40.2 (2010): 52-58.
  3. Louw, Maryke, and Clare Deary. “The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners–A systematic review of the literature.” Physical Therapy in sport 15.1 (2014): 64-75.
  4. Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. Effects of Step Rate Manipulation on Joint Mechanics during Running. Medicine and science in sports and exercise. 2011;43(2):296-302. doi:10.1249/MSS.0b013e3181ebedf4.
  5. Joseph J. Knapik, ScD, Daniel W.Trone, PhD(c), David I. Swedler, MPH, Adriana Villasenor, MPH, Steve H. Bullock, DPT, EmilySchmied, MPH, TimothyBockelman, BEd, Peggy Han, MPH, Bruce H. Jones, MPH, MD (2010).  Injury Reduction Effectiveness of Assigning Running Shoes Based on Plantar Shape in Marine Corps Basic Training.The American Journal of Sports Medicine Vol 38, Issue 9, pp. 1759 – 1767.
  6. Nigg B, Baltich J, Hoerzer S, et al Running shoes and running injuries: mythbusting and a proposal for two new paradigms: ‘preferred movement path’ and ‘comfort filter’Br J Sports Med Published Online First: 28 July 2015. doi: 10.1136/bjsports-2015-095054
  7. Barton CJ, Bonanno DR, Carr J, Neal BS, Malliaras P, Franklyn-Miller A, Menz, HB. ‘Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesized with expert opinion’. B J Sports Med. 2016 Br J Sports Med doi:10.1136/bjsports-2015-095278



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  • Dave

    As someone who used to do a lot of running years ago, but essentially had to give it away due to ITB pain in both legs. I can think back to when I first gained this injury and see what I maybe did to bring it on. These posts are a great read, can’t wait for the final installment.

    • Brad Beer

      Glad you have been finding the ITB syndrome posts helpful Dave.

      Regards Brad Beer

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