Condition guide
Pain that starts on the outside of the knee while running, often at the same point in the run and easing when you stop, is often caused by iliotibial band syndrome. It is the most common complaint on the outside of the knee in runners. This guide explains where the pain comes from, why it develops, how it is treated and how you can return to running safely.
The iliotibial band is a thick strip of connective tissue running from the outside of the hip to the outside of the knee. For many years the pain was thought to come from the band rubbing over a bony bump at the knee. Cadaver and MRI studies, however, showed that the band is firmly anchored to the thigh bone and does not really slide over the bone. The pain may instead come from compression of a layer of fat, rich in nerves and blood vessels, beneath the band when the knee is bent at about 30 degrees.
It is an overuse injury, seen most often in runners and cyclists. Evidence on its causes is limited and conflicting, but these factors stand out:
Studies on the treatment of this syndrome are small and generally of low quality. That is why most of the advice relies on load management and hip strengthening, where the evidence is strongest.
Exercises at home
These movements aim to strengthen the muscles that move the hip out to the side and your control of the pelvis and knee while running. The numbers of repetitions are general suggestions. The movements may feel like effort, but they should not increase the pain on the outside of your knee.
Lie on your pain-free side with your lower knee slightly bent. Keeping your top leg straight and slightly behind you, with your toes pointing forwards, slowly lift and lower it. You should feel a burn at the side of your hip.
10–15 repetitions, 3 sets; both sidesLie on your side with your elbow under your shoulder and your knees bent. Lift your hips off the floor to make a straight line from your head to your knees and hold. When it gets easier, straighten your knees and do it on your feet.
20–30 seconds, 3 times; both sidesLie on your back with your knees bent and feet on the floor. Squeeze your buttocks and lift your hips, hold briefly and lower slowly. When it gets easier, do it on one leg.
10–15 repetitions, 3 setsStand on one foot. Keep your pelvis level and do not let your knee drop inwards. If needed, hold on lightly to a worktop; when it gets easier, close your eyes or try it on a soft surface.
30 seconds, 3 times each footStand with your back against a wall and your feet hip-width apart. Bend and straighten your knees to a pain-free depth, with your knees tracking over your second toe. Make sure your knees do not drop inwards.
10–15 repetitions, 3 setsOnce you can walk without pain, start by alternating short bouts of running with walking on flat ground. Stop before the point where the pain starts; leave downhill running until last.
Increase the running bouts a little each session; every other dayTo interpret pain during exercise, see the exercise pain traffic light; for hip and knee control, see balance training.
Usually not, but you need to reduce the load. A UK health provider's information page suggests that if the pain is mild you finish your run before the point where it usually starts, and if it is severe you stop the activity causing it for a while. Meanwhile you can stay fit with swimming or other exercise that does not hurt.
They may feel relieving, but they do not lengthen the iliotibial band. A review of 13 studies found no evidence that stretching changes the band's length. The band is a thick strip of connective tissue firmly anchored to the thigh bone; the most evidence is for programmes based on strengthening the hip muscles.
It may give short-term relief. In a small study of 18 runners with recent-onset symptoms, a steroid injection into the area reduced pain while running in the first two weeks more than an injection of local anaesthetic alone. Its long-term effect is unknown, and an injection does not replace adjusting your load and a strengthening programme. Make this decision together with your doctor.
Most people can return to running within 6–8 weeks. At the end of a 6-week programme focused on strengthening the hip muscles, 22 of 24 runners were back to pain-free running and the problem had not returned 6 months later; however, this was a small study without a control group. If you have had the pain for a long time, recovery may take longer.
Worn-out shoes are listed among the risk factors. Your physiotherapist may look at how you run and suggest changes to your shoes or running technique. Evidence for changing running technique is so far limited to a few case reports.
Rarely. Surgery is considered only for symptoms that persist despite months of appropriate treatment. Studies on treating iliotibial band syndrome in runners are generally of low quality, so load management and exercise are tried first.
For pain at the front of the knee, see the anterior knee pain guide; for pain at the side of the hip, see the lateral hip pain guide.
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