IT Band Syndrome: Why Foam Rolling Isn't the Fix and How We Treat It

You know exactly where it’s going to start. Somewhere around the same point in every run, a sharp pain switches on at the outside of your knee. You push on for a bit, then end up walking home with a stiff, straight leg. A few days later it feels fine, so you try again, and it switches on in the same place.

Plenty of runners who come to us with it have already spent weeks on a foam roller. Here’s why that rarely solves it, and how we treat it instead.

What’s actually going on

The iliotibial band, or IT band, is a thick, tough strip of tissue running down the outside of your thigh from the hip to just below the knee.

For years IT band syndrome was explained as the band rubbing back and forth over the bony point on the outside of the knee. Anatomy research has challenged that. The band is firmly anchored to the thigh bone, including just above the knee, so it can’t really slide back and forth over it. Instead, the pain is thought to come from the band pressing on a layer of fatty tissue underneath it that is packed with blood vessels and nerves (Fairclough et al., 2007).

The same researchers suggest IT band syndrome is linked to how well the hip muscles are working, and that it only properly settles when the hip is addressed (Fairclough et al., 2007). That’s why so much of our focus goes above the knee.

Why it switches on at the same point

A study that filmed runners with IT band syndrome found the irritation happens just after the foot lands, while the knee is only slightly bent (Orchard et al., 1996). Every stride presses on the same spot, so the pain builds over a run until it reaches the point where you have to stop.

The same study explains two things runners often notice:

Downhill makes it worse. Running downhill, your knee is straighter as your foot lands, which keeps it in the range where the band presses hardest (Orchard et al., 1996).
Running faster can feel better. On flat ground, faster running and sprinting were less likely to aggravate it, because the knee is more bent as the foot lands (Orchard et al., 1996).

Why foam rolling isn’t the fix

Rolling the outside of your thigh can feel like it’s doing something, and if you enjoy it you don’t have to stop. But the band itself doesn’t seem to change much.

In a trial of 30 people, researchers measured how stiff the IT band was before and after a session of either foam rolling or stretching. Neither one changed the band’s stiffness (Pepper et al., 2021). A review of IT band treatment in runners also points out that stretching on its own is unlikely to lengthen such a thick, tough band (Friede et al., 2022).

So rather than trying to loosen the band, we look at why it’s pressing on the tissue underneath in the first place.

Why the hip matters

The muscles on the side of your hip, mainly the gluteus medius, keep your pelvis level and stop your thigh drifting inwards each time you land. When they tire or aren’t strong enough, the leg and the band take the strain differently.

In a study of 24 distance runners with IT band syndrome, the hip muscles on the sore side were weaker than on their other leg and weaker than in healthy runners. After a six-week programme focused on those muscles, 22 of the 24 were pain free and back running, and none reported the pain coming back over the next six months (Fredericson et al., 2000).

Treatment and rehab, together

The research supports combining the two. A 2024 review of 13 studies of runners found hip strengthening was the common thread, and concluded that an approach built on it, sometimes with shockwave or hands-on treatment added, eases pain and helps people get back to doing more (Sanchez-Alvarado et al., 2024). That’s how we work: treatment in the clinic to settle the pain, and rehab that builds the strength to keep it away.

Your assessment

We start by finding out what changed, such as distance, hills, shoes, bike set-up or a race build-up. We check your hip strength, assess your hip, knee, foot and lower back and watch how you squat and step down on one leg. If your knee dives inwards or your hip drops, that tells us a lot about where to focus.

Treatment in the clinic

Hands-on treatment, including work on tight muscles around the outside of the thigh and hip, fascial release for the tough layer of tissue that wraps them and gently moving any stiff joints
Shockwave therapy. In a trial of 24 runners, shockwave and hands-on treatment, each given alongside an exercise programme, reduced pain during running by a similar amount (Weckström and Söderström, 2016).
Dry needling. A trial of 40 patients found both dry needling and shockwave eased pain and made everyday movement easier (Maghroori et al., 2021).

Rehab we set and progress with you

Alongside treatment, we’ll give you a hip strengthening programme matched to what we found, such as side-lying leg raises, side planks and step-downs. We’ll check your form at each visit and make the exercises harder as you get stronger, so they keep matching what your hip and knee can handle.

Changes to your running

You usually don’t have to stop completely. While treatment and rehab do their work, a few changes can take pressure off the knee:

Stop before it starts. If the pain switches on at 6 km, keep your runs to around 4 or 5 km for now and build up gradually from there.
Stick to the flat for a while. Downhill running keeps the knee in the position that aggravates it (Orchard et al., 1996), so avoid long descents until it has settled.
Take slightly shorter, quicker steps. In a study of 45 runners, taking about 10% more steps per minute at the same speed reduced the strain on the hip and knee and reduced how far the thigh drifted inwards (Heiderscheit et al., 2011). Most running watches show your step rate, also called cadence, so it’s easy to check.
Mix it up. Swapping some runs for swimming or other training that doesn’t bring on the pain keeps your fitness up.

We’ll plan your training with you, so you know what to keep, what to change and when it’s safe to build back up.

If you’re a cyclist

Cyclists get IT band syndrome too, often after a jump in distance or a change to the bike. The same combination of treatment and hip rehab applies. We’ll also look at how your riding has built up, and if your position on the bike may be playing a part, a professional bike fit can be worth considering.

When it might be something else

Pain on the outside of the knee isn’t always the IT band. Get it seen promptly if:

It started with a fall, twist or knock and is very painful or swollen
After an injury your knee feels unstable or won’t take your weight
It’s red and swollen, you can’t fully bend or straighten it, or you have a fever

These can point to a different problem (Bunt et al., 2018). We’ll examine it and, if needed, refer you for an X-ray, ultrasound or specialist opinion.

How we can help

If the outside of your knee keeps cutting your runs or rides short, we’ll find out why and build a plan that combines treatment and rehab around your training. You can book directly without a referral.

Read more on our IT band syndrome and knee pain pages, try our 60-second running injury screen or book an appointment at our Sandton practice.

Frequently Asked Questions

Should I foam roll my IT band?

If you enjoy it, you don't have to stop, but don't expect it to fix the problem. In a trial of 30 people, a session of foam rolling or stretching made no difference to how stiff the IT band was (Pepper et al., 2021). The research on treatment points to strengthening the side of the hip, with shockwave or hands-on treatment added (Sanchez-Alvarado et al., 2024).

Why does IT band pain start at the same point in every run?

The irritation happens just after your foot lands, while the knee is only slightly bent (Orchard et al., 1996). Each stride presses on the same sensitive spot, so the pain builds over a run until it switches on, often at a similar distance each time.

Why does running downhill make IT band syndrome worse?

When you run downhill your knee is straighter as your foot lands, which keeps it in the position where the band presses hardest on the tissue underneath (Orchard et al., 1996). The same study found faster running on the flat was less likely to aggravate it, because the knee is more bent at foot strike.

How long does IT band syndrome take to get better?

It varies with how long you've had it and how much you're training. In one study of distance runners, 22 of 24 were pain free and back running after a six-week programme focused on their hip muscles (Fredericson et al., 2000). Once we've assessed you, we can give you a clearer idea of your own timeline.

Can a chiropractor help with IT band syndrome?

Yes. We combine hands-on treatment, shockwave therapy or dry needling with a hip strengthening programme that we set and progress with you. A 2024 review concluded that this kind of combined approach eases pain and helps runners get back to doing more (Sanchez-Alvarado et al., 2024).

Can I keep running with IT band syndrome?

Usually, yes, with some changes. We look to keep runs shorter than the point where the pain switches on, stick to flatter routes for a while and build back up as your hip strength improves.

References