Fitness & Nutrition

How to treat (and avoid) iliotibial band syndrome

Knee pain when you ride? It could be ITB syndrome - here's what you need to know

One of the most common injuries picked up by cyclists is iliotibial band (ITB) syndrome, which often manifests itself as pain around the outside of the knee.

The iliotibial band extends down the outside of the thigh and over the knee, which it helps to stabilise.  The iliotibial band is just one part of a chain of interacting groups of muscles, tendons and ligaments, each of which can have an influence on one another, and ITB syndrome can be caused by a number of aggravating factors. At best, it will cause discomfort, at worst it could keep you off the bike completely.

But what exactly is ITB syndrome, what causes it, and how can it be treated? We spoke to Nichola Roberts at Velo Physio, a specialist physiotherapy clinic for cyclists and triathletes, to discover exactly that.

ITB syndrome – pain around the outside of the knee – is one of the most common injuries picked up by cyclists (Pic: VeloPhysio)

Before any treatment is attempted, it’s always advisable to visit a specialist physical therapist who will be best placed to confirm whether it is ITB syndrome that you’re suffering from, determine the source of your trouble, and propose interventions that will help your individual weaknesses.

But, for now, let’s take a closer look at the potential causes of ITB syndrome, and present some potential solutions and preventative measures that can help you keep your IT band in shape.

What is iliotibial band syndrome?

First, Roberts explains that iliotibial band syndrome is a coined term to describe pain around the knee. Interestingly, it means the pain we experience when suffering from ITB syndrome isn’t actually felt in the band itself.

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“True iliotibial band pain occurs on the bony outside of the knee as opposed to front of the knee or thigh. The pain is normally reported as ‘sharp and stabbing’ with an epicentre that radiates out,” she explains.

ITB syndrome is caused by excessive friction of the iliotibial band

“It is caused by excessive friction of the distal Iliotibial band as it slides over the lateral femoral condyle of the knee (the bony structure on the outside of knee) during repetitive movements that characterise a pedal stroke.

“This repetitive movement and friction results in irritation of the soft tissue.”

What signs and symptoms can cyclists look for?

Signs and symptoms can vary in type and intensity from person to person, but Roberts says a sharp pain localised to the outside of the knee is often indicative of ITB syndrome. Moreover, if you’re experiencing the beginnings of a “dull ache” in the area, it could be a signifier of a burgeoning problem.

She also points out that pain may be more pronounced some time after you’ve stopped riding.

Pain in the knee may be more noticeable after a rest

“It may be more noticeable after a rest, or when doing something seemingly benign or unrelated like climbing stairs or getting up from sitting,” she says. “If the cause of the pain is left unresolved, eventually it will limit the distance and intensity at which you can ride.”

How do cyclists develop ITB syndrome and why is it common?

“Cyclists develop ITB syndrome in a number of ways, so first it’s important to identify the cause in order to fully resolve the symptoms,” Roberts says.

“Contrary to a popular and fashionable conception, it is certainly not simply a case of foam rolling the ITB and all your problems will be solved.

“The cause(s) may be anything from a change in training load, bike fit changes, shoe or cleat change, or a bio-mechanical issue with strength or flexibility that has become prominent due to increase in riding volume.

“As a result, when assessing clients, one of my first questions is always: ‘What has changed?’”

Many things can cause knee pain, from a change in training load to new shoes/cleats

Roberts explains that the common causes can be anything from the following, and sometimes more than one source can be significant too:

  • Incorrect saddle height
  • Saddle change
  • Cleat adjustments, or cleat change fitted poorly
  • Leg length discrepancies
  • Foot bio-mechanics
  • Poor flexibility around hip and pelvis
  • Poor glute strength
  • Riding a different bike to normal
  • Training volume/intensity increases (commonly called an ‘overuse’ injury)

Why is ITB syndrome potentially debilitating for a cyclist?

“ITB syndrome pain occurs at a 30-degree bend of the knee, under load of the pedal stroke force, which results in stabbing pain as you take the pedal stroke,” Roberts states.

“Due to the repetitive nature of cycling, this can be very limiting, especially as you’re likely fixed to the bike and forced to ride in a specific range of motion.  

“As a result, it’s unsurprising that when pain first occurs it can be so severe that it requires rest from the bike.”

The repetitive nature of cycling, or pedalling at least, means ITB syndrome can be a debilitating injury

Roberts also draws comparisons with other sports, noting that the condition can arise or be exacerbated elsewhere. After all, some of us moonlight with other activities, like running.

“The complaint is often called ‘runner’s knee’ for the likes of runners, triathletes or other high impact sports that involve running,” she explains. “If you are also running, it’s important to examine your running technique as this can often be a precipitating factor. Once the area is inflamed, cycling can serve to aggravate it.”

What rehabilitation techniques can cyclists use to recover from ITB syndrome?

If you suspect you have ITB syndrome, Roberts repeats with fervour that visiting a physiotherapist with a specialism in cycling is very important so the root cause can be identified.  

“Without this, it’s very difficult to treat correctly,” she says. “A good specialist will be able to look at you on the bike as well as off it in order to identify the driving problem. They can then focus on a bespoke program challenging the weakness or weaknesses.”

Indeed, we know such screenings to assess your bio-mechanics, range of motion and outlying factors are commonplace in bike fits, and Roberts explains it can form a key part of ongoing recovery from and future prevention of ITB syndrome.

If you have knee pain, a specialist will be able to identify the specific problem

However, the following interventions for treatment of the ITB syndrome are common.

“As a general rule I would usually recommend using a foam roller to provide myofascial release around the origin of the ITB at the top and side of the hip, the quads and the glute [IMAGES 1a & 1b],” Roberts says.


(Image 1a) Focus on foam rolling the front and outside third of the quad, all the way to the top of the hip (Pic: VeloPhysio)
(Image 1b) Foam roll to target the glute to release tension on the outside of the hip and through the top of the iliotibial band as shown (Pic: VeloPhysio)

“A lacrosse ball can be effective in releasing the outside of the hip and glute specifically – but make sure a professional shows you how, otherwise you could cause more damage.

“Also, I often recommend an individual-specific strengthening programme that targets the glutes and leg muscles.

(Image 2) Single leg bridges aregood for focusing on the gluteus maximus. which inserts into the ITB (Pic: VeloPhysio)

“Exercises can include single leg bridges [IMAGE 2], squats, and Bulgarian split squats with good form, among others.”

Single leg bridges are good for focusing on the gluteus maximus activity, Roberts says. As the gluteus maximus inserts into the ITB it is key in balancing the down stroke when pedaling. For this exercise, bring the heel close to the bottom to favour activation of the glutes over the hamstrings. Aim to keep the pelvis level as you lift. Lift quickly, and slowly lower down. Do three sets of three reps, then repeat on the opposite side. Raise your arms to increase the difficulty.

“This can be accompanied by stretching exercises that target the hamstrings [IMAGE 3], hip flexors and the glutes/ITB itself [IMAGE 4],” Roberts adds.

(Image 3) Lying on your back using a band to release hamstrings is a good way to isolate the hamstring muscle as opposed to stretching through the sciatic nerve (Pic: VeloPhysio)
(Image 4) Start on all fours. Poke your foot through between hand and opposite knee, sink back through hip and drop down to elbows. You should feel the stretch on the outside of the hip/glute. If you feel discomfort in the knee, adjust your position to reduce the rotation through the knee. Hold for 30-60 seconds (Pic: VeloPhysio)

How can cyclists avoid developing ITB syndrome in the first place?

As with any injury, avoiding ITB syndrome is always preferable to recovering from it – hence the slightly contrived but often-used term, ‘prehabilitation’. As a result, a good conditioning regime that supplements your cycling can be help when it comes to avoiding ITB syndrome.

“Maintaining good flexibility through your hips, glutes and hip flexors is essential,” says Roberts. “Also, it’s good to maintain good spinal mobility through an exercise class such as yoga.

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“Additionally, strength training off the bike that targets your glutes and the muscle chains associated with cycling will help to fortify the muscles against ITB syndrome.”

Roberts also explains that maintaining good posture at work, instead of slouching or leaning, can affect the suppleness of the ITB, as well as your general position on the bike. “Rotation at your desk tends to lead to rotation when sat on the bike; this imbalance through the pelvis can be a cause of the pain,” she says.

Maintaining good flexibility is key to avoiding injury

When it comes to training, Roberts also recommends getting a bike fit as a preventative measure, rather than a reactive one, to make sure that your position isn’t either too ambitious or too conservative when riding.

This can be especially important when increasing training load, which itself can highlight previously undiscovered issues. Ensuring that your training load is increased gradually is also a key factor in avoiding injuries linked to overtraining, of which ITB syndrome can be one.

While a bike fits sometimes include a bio-mechanical assessment as part of the service, Roberts says it’s worth having a separate assessment with a physiotherapist to identify any imbalances if you’re not willing to go down the bike fit route, which can be expensive, or find out if one is necessary.

Finally, Roberts says paying attention to detail when it comes to servicing your bike, or changing equipment, can really pay dividends.

“For example, when you travel with your bike and take it apart and put it back together, or even when changing cleats, be meticulous,” she concludes. “Even little unintentional changes can make a big difference to your body.”

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