Runners Guide to IT-Band Syndrome: New Movaia Running Podcast Episode

We just published the latest episode of the Movaia running podcast, this time we go deep discussing IT-Band pain, a common scourge of runners.

In this episode, Thomas Butter, our CEO, interviews our trusted physiotherapist JP Gloria and they go deep discussing IT Band Syndrome, a common injury among runners. They cover symptoms, mechanisms, risk factors, and the importance of understanding running form. The conversation emphasizes a phased approach to recovery, focusing on strength training and rehabilitation exercises, while also addressing common misconceptions about foam rolling and stretching. The episode concludes with a few key exercises, insights on recovery timelines and the individual factors that influence rehabilitation.

Find the full episode on Spotify, Apple Podcasts or Youtube (Video below). Or read on after the video for key take aways and the full transcript!

Takeaways

IT Band Syndrome is a common diagnosis for outer knee pain.
Pain is typically felt around the lateral femoral condyle.
The IT band stabilizes side-to-side motion and aids in energy storage.
Recent research suggests IT band pain is more of a compressive injury.
Less experienced runners are at higher risk for IT band syndrome.
Trail running can increase the likelihood of developing IT band pain.
Overstriding can exacerbate IT band issues during running.
Foam rolling may provide temporary relief but won’t solve underlying issues.
Stiffness in tendons is beneficial for running efficiency.
Recovery timelines should be based on individual criteria rather than arbitrary timeframes.

Here’s the full podcast transcript:

Introduction to IT Band Syndrome

Thomas Butter (00:07)
Hello everybody, I’m Thomas. I’m your host and also the founder of AI running forum analysis, startup Movaia.com and today I’m again joined by coach, running forum expert and physiotherapist, JP Gloria. JP, welcome to the show.

JP (00:23)
Thank you for having me.

Thomas Butter (00:25)
Great to have you. Well today we’re going to talk about IT Band Syndrome. So I understand that if you’re a runner and you’re feeling some pain around your knee, there’s a pretty good chance you’re probably dealing with runner’s knee, IT Band Syndrome or maybe patellar tendinopathy. So today we’re going to focus on IT Band Syndrome.

It affects about 8 % of runners. That’s according to a study in 2021 or 2022. And it’s also one of the top four running injuries. So, JP, if you’re a runner and you’re not quite sure what you’re dealing with, what does it feel like if you’re suffering from IT band syndrome?

JP (01:03)
Yeah, I mean that’s part of my job is to figure out if it is IT band pain. Because it ends up being, I like to say, a diagnosis of exclusion rather than inclusion. So basically, long story short, it’s making sure that it actually is IT band syndrome or pain. Because it’s one of the most common diagnoses for outer knee pain, essentially.

However, there’s some things I like to talk about with IT band syndrome specifically. Sometimes I don’t like using the term syndrome. I mean, they use it because it describes complexity, but I like to say all running related injuries are like that, right? They’re complex. There’s a lot of factors involved with all running related injuries.

And I think the other thing about this is I don’t like people to categorize it with genetic disorders. Like, you know, you have your Down syndrome or Marfan syndrome. So that’s why I usually like to categorize it more as IT band pain. Now, when it comes to IT band pain, what is it characterized by? Typically it’s pain on the outer knee.

Understanding IT Band Pain

JP (02:04)
I like to kind of use specifics, it’s specifically pain around, there’s something called the lateral femoral condyle, so it’s just above the joint line, which is very important to know because that’s one of the ways that I differentiate it between, let’s say, something like a lateral meniscus type of pain.

Thomas Butter (02:21)
So the joint Sorry to interrupt, so So

Do I have to think about that as the axis of the knee or what would be the joint line.

JP (02:27)
Right, so the joint line is essentially where the femur and tibia meet, right? But typically that lateral femoral condyle is higher than the joint line. And that’s gonna be important when we’re trying to diagnose it. And then obviously the most common characteristic about IT band pain

is pain is reproduced by 30 degrees of knee bend.

Thomas Butter (02:47)
So we call it IT band syndrome. So I guess the logical question is, what is the IT band? And so what’s the mechanism? Do we know why it causes pain?

JP (02:56)
yeah, that’s a really good question. what does it do? Cause that’s a common question. Do we need it? And it’s an interesting thing cause if you think about just animals in general, a lot of them don’t have IT bands. So what does it do for us? Well, it does two things. One, it helps stabilize side to side motion, but it also helps to prevent the knee from dislocating inward or medially. It works really well because there is a very rare occurrence of dislocations happening medially. They typically happen more laterally or more out.

So stability is one of them. Two is a lesser known thing, which is it’s responsible for energy storage and release. It’s roughly like when we’re running it, it contributes to roughly 10 % of that. It’s only second to the Achilles tendon, which is roughly, around 30 % energy storage. So that’s what it does.

Mechanism and Causes of IT Band Syndrome

I think I forgot the second part of your question now that I’m thinking about it, which was the mechanism, right? I guess talking about mechanism, it’s interesting actually, because before we used to think that the pain that you experience with IT band, happens more as a friction injury, where like the end of the band essentially is kind of rubbing on the structures underneath it, particularly that femoral condyle. So we thought it was that friction that causes the pain. However, recently rather than thinking of it as more of a friction injury, we think about it more as a compressive injury. So actually, there’s the band itself, then there’s the lateral femoral condyle, then right in between that it’s like adipose, it’s like a highly innervated tissue. And it’s that compression that causes the pain.

Thomas Butter (04:42)
Highly innvoated means that…? Lots of nerves,

JP (04:44)
sensitive. Yeah.

Just a very sensitive area.

Thomas Butter (04:47)
So that explains why it is so painful if you have it,

JP (04:50)
yeah, I mean, that’s where pain comes from. So that’s important because that kind of changes the way that we would approach it. You asked about factors, right?

Thomas Butter (04:58)
next… Exactly.

JP (05:00)
Yeah.

Thomas Butter (05:00)
So what makes you more likely to suffer from IT band syndrome? And then, of course, what are the factors that we can influence to maybe avoid getting IT band syndrome and suffering from that pain?

Risk Factors for IT Band Syndrome

JP (05:15)
Yeah, so, factors are interesting. Very fascinating. I guess one of the things that I think about with risk factors is it typically happens with less experienced runners. This is important to understand, when I’m working with a runner in front of me, because…

You know, typically it happens with less experienced runners, but if I have someone coming in with what they think is IT band pain, but they’re more of an experienced or an elite runner, because I work with some elites and pros, that raises a little bit of a flag for me, because it might not be IT band pain. The thing that I get very curious about is something like a bone stress injury on that, let’s say femur area, you know, the distal femur, essentially.

So that’s me rambling a little bit, but that’s, I guess one risk factor is less experience, right? The second one is being a guy. It’s predominantly seen in males. which is the opposite of,

We did talk about this in earlier episode about like patella femoral pain and that’s predominantly women Other risk factors, Another that’s interesting is you know, the idea of trail runners It’s more likely to develop in people who run trails for a couple of reasons one of them being you’re working a lot with hills, right? So hill work, particularly downhill work can irritate the IT band. Also, what does happen with trail running, is that you know, sometimes when, there’s like a a narrow path, a single track. And what ends up happening with that is, you know, you have to get your steps a lot closer to this. So have to take a lot more of a narrow step or do more of a crossover type gait pattern. And that can increase a little bit of stress on that area and can cause pain too.

Thomas Butter (06:57)
was thinking crossover gate, That’s something that can be caused by a single track trail, a very narrow trail. But in some runners, it also appears as a running form issue that they naturally tend to have this narrower gait.

Running Form and Its Impact

Would there be any other running form related things that might make it more likely you’ll get IT band pain. Are there issues like overstriding or so that would impact it or is crossover gait the main one to worry about for IT band syndrome?

JP (07:28)
That’s a good question. this goes into like murky waters with how we approach this. So it comes to running technique is it might be hard to predict injuries that happen based off someone’s gait pattern. However, changing gait pattern or running technique can be helpful when navigating an injury. So let’s say someone’s dealing with IT band pain. What are things we could do to help reduce stress on that area so it’s less painful and that person can return to running a little quicker? So one of the things you mentioned was overstriding, right? If someone’s taking too big of a step forward, essentially, you know, that’s putting a lot of stress on essentially the whole leg.

So if we could cue that leg to land a little bit closer to the body, that can help reduce stress on the leg, which would therefore maybe hopefully decrease pain in the area so they can continue running. That’s one. Having the person, you know, if someone’s landing too far ahead of the body, have them land a little closer. A second one is the one that you mentioned first actually, which would have been the crossover gait pattern. And I think you could check that with your analysis software too, right? So, essentially, if someone’s having, has a narrow gait pattern, this goes back to what I mentioned about the mechanism being a compressive type of injury. Because if you take a narrow step width, or you know, you’re crossing over, essentially that’s causing more compression

around that distal IT band. That’s further irritating the area. So something that I look at is trying to widening out that person’s running pattern. We talked about taking steps close to the body, but also widening it out, getting the feet a little bit away from each other.

Thomas Butter (09:10)
So I think there’s some mental cues to help you with that pattern or some tricks. Can you share anything about that?

JP (09:16)
we’ll start with overstriding. I mean, since we’re talking about the two, right? With overstriding in particular, what’s one very effective way to do that? I mean, you could say, you know, try to land underneath the body, right?

You can’t actually land under the body. I think we’ve talked about this before. You can’t actually land under the body, again, but landing close to the body. Again, cues don’t always have to mirror the actual movement that’s happening, right? So that’s one way. The second way for overstriding is using a metronome to manipulate one’s cadence, which is how quickly to take steps.

What you would do with that is, you you find that person’s preferred cadence or step rate, so let’s say it’s 160, and then, you know, if they’re overstriding, you would set the metronome to something like 170 steps per minute, and essentially they have to match their step to the beat. That makes them increase their cadence, and in order to do that, that’ll probably naturally have them land more closer to the body, a little bit more subconsciously.

So those are kind of two ways to work on over-striding. Second one we talked about was the crossover pattern. One of the ways, you kind of talked about it already, which was a cue that I would use, which is imagine that there’s like, a line that’s dissecting you, like that’s right at the midline of the road, don’t let your feet cross over that line. So essentially that’s reducing that crossover pattern. What I like to do most of the time though, is just giving them visual feedback of what’s going on. You could do that with a mirror. You could project it from like a camera. And essentially they could just see it as they’re running and they’ll try to, you know, fix it themselves.

Thomas Butter (10:59)
I think we also talked about it that most runners actually don’t look exactly like they think they look like. So in our running from analysis, we actually show people what they look like. And that always leads to some surprises there.

Training Load and Nutrition

JP (11:14)
Right, I mean, that’s like, you you ever like take pictures during a race and you think you’re running so smoothly and nice and then you see the photos at the end of the race and it’s like, I was running, like it just looks way different than you imagine it to be.

Thomas Butter (11:29)
Yeah, for sure. So we covered a few risk factors, like trail running, the characteristics of the path, running form. What about other things? One that we always mentioned is previous injuries, that also an issue here? What about training load, training volume, anything else?

JP (11:44)
We talked about, you know, increase in training loads, particularly speed work or hills. Then there’s always the thing about, you know, nutrition and under fueling or not, you know, essentially eating enough. But that’s like not necessarily specific to IT band pain.

Thomas Butter (11:59)
So under fueling can also increase your risk for injury. How would that be related?

JP (12:06)
Well, this is something I’m particularly careful with, especially when working with endurance athletes in general, is the chance that there’s under-fueling happening. Because the thing about running, it uses fuel essentially, right? But then the thing is, what needs to happen is you need to build up your body.

But if someone’s under fueling, let’s say, you know, cause sometimes with runners, you know, they’re not happy with their body, is they’ll tend to do a lot of running, but they won’t eat too much.

This also happens with a lot of runners when they’re approaching, let’s say, a race. They feel like, I need to lose weight because if I lose some of this weight, it’s less that I have to carry and I’ll be able to run faster. And then they get injured because there are quite few studies now let’s say, significant weight loss, is actually a risk factor for getting injured, especially with running.

Rehabilitation Phases for IT Band Pain

Thomas Butter (12:56)
That’s fascinating. So once you figure it out, okay, you’re dealing with IT band syndrome.

Is it all about exercises or is it also about foam rolling or stretching? And I guess also following up on our last episode, can you actually keep on running or I say better to stop if you’re feeling that kind of pain.

JP (13:17)
Yeah, it depends. Let’s say someone is working with IT band, first of all, we have to differentiate it, right?

So I need to, first of all, differentiate, you know, is it actually IT Band pain? And if we find that it is, how would we approach that? Well, I like to keep this simple.

When I look at it, I kind of separate things not into necessarily timelines, but I like to be very criteria based. Like I set a criteria for runners. So depending on where we’re at, you know, if you could meet this criteria, we’ll move on to the next phase. I’ve seen people in pretty bad shape people are like, man, I want to get back running again.

But actually that person can’t walk or do stairs. Like we have to put this in perspective where you can’t run, but you also can’t do daily life. And that leads to what I talked about with the first phase, which is typically if I’m dealing with a full blown, you know, IT band irritability, the first step is just calming it down. And my objectives during this phase, the focus isn’t necessarily running.

I need you to be able to get comfortable with just your daily movements, like no pain with walking and honestly having no significant pain with something like stairs.

I’m not really focused on strength yet. I just want to calm it down. And typically I’ll do that through certain isometric type or think they’re just exercises that don’t irritate it, that can load the area gently enough where we’re loading it, but not causing or inflicting pain.

But that’s the big thing. I’m not really focused about progressive strengthening quite yet. I mean, if they could handle it, great. But it’s not my main focus. During this time though, yeah.

Thomas Butter (14:53)
So generally focusing on isometric exercises, right? I would be using a pain scale to figure out when it’s time to move on or?

JP (15:02)
Yeah, I mean, there’s the pain scale. you know, a typical rule of thumb with a lot of pain in general is, you know, between zero and 10, we want it to be under like a, you know, under a four out of 10. Never really works very well with endurance athletes because they like to modify based off what you say.

So there’s navigating that. But I really don’t want the person to have that much pain or discomfort with daily activities. Again, running, contrary to what people think, you know, people think about running as like a low load activity. No, it’s a pretty stressful activity.

and we need to be prepared for it. So if people think about, you know, I need to get fit and they do it through running, but you also have to be prepared for the demands of running as well. That’s something to think about. So with that in mind, during that first phase, if they already have pain with walking and stairs, maybe running is not my priority yet, right? However, can we do something during that time? And I’d say yes, right? You could do something like,

uphill walking, like walking up a treadmill with a bit of incline. Because if you’re walking up an incline, essentially that decreases stress around that IT band area and it puts it more into the posterior chain, so more like your calf and glute area. So that could be one way to continue conditioning without irritating the area. we’re talking about that first phase.

You could do elliptical, could do cycling, swimming could be okay. So things that are more partial weight bearing or just activities that they can almost train without irritating the knee.

Thomas Butter (16:38)
Okay, so maybe do some cross training, isometric exercises to stay fit until it calms down and then you are moving on to phase two, right?

JP (16:49)
So if they don’t really have pain with, let’s say, walking stairs and, some basic daily life activities, we could move on to phase two, which is the focus now is instead of calming down, it’s already calm, let’s build strength. You know, I like to say like, you don’t build a house on fire, right? If you’re trying to build a house that’s on fire, it’s just going to burn too. So now that we’ve doused the flame in phase one,

we’re gonna move to phase two, which is now building the foundation. So this is where with exercises, I start to incorporate progressive strengthening. And I mean not just body weight exercises, I mean like getting them to do some heavier lifting.

Thomas Butter (17:33)
What are the muscles you’d be targeting in this case for these exercises?

JP (17:37)
This gets interesting. Because I would say like the whole leg to be quite honest. Obviously there’s a particular interest around the hip region with this. However, contrary to what people think, hip strength is not a risk factor for IT band pain. People think, oh, because you have weak hips, that’s why you have IT band pain. But there has been very weak research to support that type of thought process. And actually, it might be the opposite, Having IT band pain can cause hip weakness. So instead of thinking about hip weakness being the cause, rather it could be an effect of the IT band pain. Yeah, but anyway, we build strength.

Thomas Butter (18:23)
Interesting

Got it. So you mentioned lifting with some weights. Any go-to exercise you would like to mention there?

Exercises and Strengthening Strategies

JP (18:34)
Some of my go-tos is like building the hip up. So I’m thinking like single leg bridges are a great starting point, but I really like moving onto this like standing clam shell on a wall where it almost works that, you know, the lateral hip stabilizers, in a manner specific to running. So that means, you know, working that muscle in a loaded position. Because that’s actually, you know, when those hip stabilizing needs to work the most is in that loaded position when you run. I would incorporate some common ones. You know, that Bulgarian split squats would be helpful to incorporate, Romanian deadlifts, single leg Romanian deadlifts.

And something that I do like to say, even though, you know, we could focus around the hip and knee, but I mentioned focus on the whole leg. And again, it’s not being lazy because actually the whole leg does affect, you know, each part of the body. You know, when you run, everything works together. So I like to say also, don’t forget about the calf ankle complex. Because that’s primarily involved in propulsion.

Because if that’s the weak link, that can cause compensations up the chain too. So maybe that might be one of the underlying compensations that we do need to address.

Thomas Butter (19:42)
That’s important, I guess, this message to not focus too narrowly, right? It’s all connected, So in this phase two, is this the phase where I then can slowly reintroduce running? Or do we have to wait for another phase for that?

JP (19:47)
Mm-hmm. I mean, I try to introduce it as soon as possible. This is not all like set in stone and, you know, I’ll make, you know, I’ll make certain calls. Let’s say, they’re feeling really good with the progressive strengthening and they can handle those heavier loads. Maybe we could start to talk about the return to run process. Now, when it comes to running, a lot of it, essentially it’s like single leg hopping. I mean, that’s how some people characterize running, but it’s true. It’s an energy storage and release that’s happening on one leg.

So maybe you should be able to tolerate something like plyometrics or single leg plyometrics, like hopping on one leg, for instance. Anyway, that moves us to phase three, which is going from strength to plyometrics. So when it comes to that, I typically want that person to tolerate lower load plyometrics like pogo jumps into gentle pogo hop, single leg hops, be able to tolerate, you know, skaters, because we can’t just think about the forward-backward, or just the forward movement, but we have to think that it’s a side-to-side stabilizer. So we should work on things that involve that type of demand, like the skaters, or skater jumps.

If someone can start to tolerate kind of those, that’s when typically during this phase, I also try to return someone to running.

Thomas Butter (21:18)
Yeah, so if I understand correctly, so if you look across all three phases, they are progressive in terms of the demands, of course, on the exercises, starting with things that are not running related, like cross training. You mentioned the uphill treadmill, for example, or cycling or some isometric exercises. Then you build to strength in phase two. And once you feel you can do that without significant pain, then you move on to phase three, where it’s about plyometric exercises and returning to running. Would that be a fair summary?

JP (21:52)
Oh yeah, that’s a fair summary. I mean, calm it down, build it up. let’s build, let’s sequence back in the running. And we typically will start with plyometrics. I think that’s something that’s underutilized too. I mean, everyone really gets focused on strength, but plyometrics is something important that we need to consider, especially in the rehab process for running.

The Role of Foam Rolling and Stretching

Thomas Butter (22:11)
So I have question for you, because one of the things I really dislike to do after running is to foam roll my IT band, because it’s not particularly comfortable. is that something that is actually important, or is that just something that runners do to make themselves feel better?

JP (22:18)
Yeah, it’s the second one. We could talk all about this, right? There’s, I mean, I could rant about it. I’ll rant a tiny bit. But with the IT band, it’s incredibly strong, like incredibly strong. Like people think, let me rub it out with a foam roller and try to break up the IT band. You can’t do that. Like, you know, it takes like a ton of force, literally, to even cause deformation on that.

So your foam roller is not going to create any structural changes there. So if it’s not causing structural changes, can it still be helpful? Yeah. Like it could temporarily, you know, temporarily decrease the pain, which can help you keep moving. But is it going to solve the problem? Typically not.

Maybe with like, you know, slight IT band pain, maybe just more so tightness, that might help with that. But for some people who have like that full blown, like the IT band’s really limiting their ability to move, foam rolling’s not gonna, typically not gonna solve the whole issue.

Thomas Butter (23:27)
What about things like stretching or flexibility work? Would that serve any purpose for IT band? Or is it more about strength really that we’re looking at here?

JP (23:38)
Stretching is interesting. I mean everything is interesting. So stretching, guess that’s another little bit of a myth or misconception behind it. When it comes to the IT band, he was like, you know got this because you’re not mobile or you’re too stiff. And I have a few things to say about that, which is decreased flexibility doesn’t increase your chances of getting IT band pain. And two, actually you do want stiffness inside the tendon around the IT band because that stiffness helps you store and release, you actually want like stiff tendons, because that’ll help you actually be more of an efficient runner. That’s why stretching is not really something that I prioritize.

I will say there are like maybe a couple stretches that I would include maybe in that phase one to, not necessarily stretch, but to gently load that IT band So I would approach it in that capacity, but stretching is not going to solve it.

Timeline for Recovery and Return to Running

Thomas Butter (24:33)
So is there like a typical timeline that we’re looking at here? I imagine there’s some variability, But is it like anywhere between a day and a week? Or are we looking at longer timeframes here?

JP (24:46)
Yeah, I’m very criteria based oriented. Because the amount of time you wait, sometimes, you know, you could rest all you want, but the pain’s not getting any better. But hey, four weeks went by, it should be clear to do this. Like it doesn’t make any sense. That’s why I based them off of the criteria that I mentioned, which is typically, you know, first phase, my first criteria is getting comfortable with daily movements like walking and stairs. Second one, second phase to pass that one, I do want you to be comfortable with being able to do heavy lifting and it doesn’t flare up the IT band. Also, I want you to be comfortable with like level walking, let’s say, or in hiking. If that’s tolerated, you move on to phase three, right? Phase three is plyometrics. Now,

I would say like the next phase after that, you know, I would say that’s gentle plyometrics. It’ll probably incorporate in future phases, but I would say introduction to plyometrics to be more exact. But if they could tolerate that for, let’s say, I don’t know, two, three weeks of consistently incorporating plyometric work in all angles. Yeah. Then there’s, you know, there’s return to running and then there’s actually training.

Because just beginning to run and training are very different. Now, so I like to be criteria based. I could give timelines, but I feel like sometimes that’s arbitrary. Like, you know, I could say like, yeah, it’ll phase one, you know, it’ll take roughly three to four weeks. Strength, it’ll take, I don’t know, four to eight weeks. Plyometrics, I don’t know, four to eight weeks.

But again, I feel like time is arbitrary when, you know, yeah, you’ve, you’re eight weeks out, but you can barely walk. Like you’re not going into the plyometric phase.

Thomas Butter (26:25)
Is the timeline driven by compliance to the program or how bad it was to begin with? Would this be two major factors or does it also have to do with genetics, age, things like that?

JP (26:38)
I mean, all of those things matter. And that’s why I don’t really like giving arbitrary numbers like using time to do it. Because yeah, age can certainly play a factor. Genetics could play a factor too. You know, your prior activity level matters as well. And what you’re returning to matters too. I think people don’t think about that part, but there’s, again, there’s a difference between return to running and actually training. So.

Like I say that, especially when working with elite athletes and pros, they don’t need, you know, 30 minutes of running is not enough to compete at a high level, right? You see the volumes of training that they do. It’s like at least 50, 60, some go in 80 to a hundred miles a week, especially for distance runners or even ultra runners. That’s kind of right, right where it is. So the rehab process looks significantly different based off of the individual.

Final Thoughts

Thomas Butter (27:33)
We covered a lot of topics. We talked about what it is, the mechanism of how it causes pain, risk factors and we talked about treatment and timelines. So I think we covered all the basics. Or did we?

JP (27:44)
I think we covered a lot of different things. I mean, I’m just enjoying the conversation. I’m all good. I could talk for hours. So I feel like we did cover a lot of great things You know, with the audience, if they have any questions, they can always reach out, right?

Thomas Butter (27:58)
That’s a great bridge to our next segment. If you’re listening and if you have more questions that we didn’t answer today, or you even want to talk about some other injuries that we haven’t covered so far, then please send us a message to community at movaia.com. That’s M-O-V-A-I-A dot com.

If you’re unsure whether your running form is a factor in this, then get your running form analysis again at Movaia.com. And if you want to learn more about JP and the amazing work that he’s doing, then check out the show notes for a link to his YouTube channel and how to get in touch with him. All right. Thank you so much, JP. It’s always a pleasure and very insightful to talk to you.

JP (28:39)
Yeah, no, that was great chatting with you. I hope you guys have a nice night.

Thomas Butter (28:43)
I enjoyed it. Thanks a lot. You too. Bye bye.