IT Band and Related Knee Pain

If you are feeling pain on the outside of your knee or on the side of your thigh but you haven’t had a twisting injury or taken a fall to that knee you may well be experiencing IT Band pain.

Typical symptoms with ITB syndrome include pain or tightness on the outside of the knee at or just above the level of the kneecap which can move all the way up the outside of the leg to the hip. Symptoms are typically worse with activity and better with rest, and swelling can occur at the lower tendon if the inflammation is severe enough.

The ITB is a thick fibrous band that runs from the outside of the hip, all the way down the outside of the thigh to insert just below the knee joint on the tibia. More specifically, as you can see in the picture above, it starts from fibers of the Gluteus Medius (GM) + Tensor Fascia Latae (TFL) and inserts onto the Tibia (larger lower leg bone, the smaller is the fibula). As the IT Band inserts below the knee it splays out some sending fibers to the kneecap as well as the hamstring muscles.

We often get this pain where the band attaches to the knee joint because the muscles the band is attached to (white part) has become tight or weak and almost ‘pulling’ at this junction. This results in the band being a) pulled tight over the femur (big upper leg bone), and b) repeatedly dragged back and forth over the bone as it helps bend and straighten the knee. Once this happens, the band is open to injury, especially in the presence of repetitive activities such as running, walking or biking.

So, why does the band tighten in the first place? Well, there are several factors at play:

1) ‘The knee is stuck in the middle with nowhere to go !!’

What we mean by this is that the symptoms you experience here are most likely to be caused by some dysfunction either above the hip or down in the ankle. You must remember that your knee doesn’t just have to straighten and bend when we walk or run. The lower leg bones (fibula and tibia) must be able to rotate on the upper leg bone (femur) and vice versa. And yes, even this needs to happen when we are running and walking in straight lines!

If you picture somebody running with their foot planted fully on the ground during mid stance you must realise there are a lot of forces going through the knee, hip, and ankle joint (pretty much your whole bodyweight). Through the different phases of the gait cycle these forces and rotations above and below the knee are constantly changing, admittedly not as much as when we are twisting and turning, but throw in running on even slightly uneven surfaces and it will happen a lot more. So, we can see our knees take more load through bodies than we give them credit for!

An inability to control these forces and rotations through weak or non-functioning muscles can lead to this type of knee pain. But as we have always said at AON Physiotherapy; your ability to move from one posture to another will often dictate why certain muscles are weak and non-functioning. This is what I will discuss next.

2) Breathing and Posture

We regularly come across people in clinic who have poor breathing patterns. We find many of them are mouth breathers and don’t sufficiently use their diaphragms – this can lead to being stuck in one posture all the time. Most mouth breathers tend to have ribs that flare out quite a bit (see pic).

Unfortunately, this can lead to an increase of lumbar lordosis in the spine increasing the tilt of your pelvis forward (what we call anterior pelvic tilting). Anterior pelvic tilting will lead to lengthened hamstrings, weak glutes, and tightened quads. This will affect your normal propulsion during gait.

The result is that the inner hamstrings and adductors work harder to extend the hip and over time shorten due to the repetitive stress; the knee is pulled in towards the mid-line due to the resulting muscle contracture and the lateral hip muscles can become overloaded.

3) Previous injuries to ankle, hip and shoulder joints

We often talk about the body acting like a spring that will ‘load’ and ‘explode’ with movement (think of landing on one foot and pushing off that same foot when we run). If the loading ability of the hip or ankle is affected or the opposite shoulder cannot rotate efficiently, this can place more load through the knee. Due to this increased load the knee can no longer ‘explode’ and recoil and more muscular effort is required which can lead to your pain! Previous injuries to the hip, ankle and the opposite shoulder can cause your nervous system to alter your gait pattern and your posture. Therefore, it is vital that anyone treating your knee pain is made aware of previous injuries.

What can we do to fix it?

You need to free up and control your pelvis

To do this you need good rib cage mobility. For this to improve you need an efficient working diaphragm. This means doing specific breathing exercises with your pelvis in different positions


Once our pelvis moves efficiently and freely, we can set about ensuring our quads can lengthen and shorten effectively. Again, there are specific exercises that may need to be carried out to achieve this.

Strengthen your Glutes/ hamstrings

The role of the glutes is to primarily extend the femur. This is very hard if you are in an anterior pelvic tilt position. The next step is to maximise the muscles that will give you the greatest control of your pelvis and the muscles that will propel you forward to maximum effect when running and walking.

Get your walking or running gait assessed.

Although the exercises above are all highly effective to help the tissues around your knee joint, the key is to find YOUR specific root cause of the problem. Therefore, we never just prescribe the same exercises for two people with the same symptoms because we are individuals and our postures are all completely different. It is generally a good idea to get a qualified clinician to assess your posture as it will speed up the process and get you out of pain faster.

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