If you run regularly, there is a good chance you have felt pain on the outside of your knee at some point. Sometimes it creeps in slowly. Other times it seems to appear out of nowhere and refuses to settle.
ITB syndrome, often referred to as runners knee, is one of the most common running related issues I see in our clinics. Despite how common it is, it is also one of the most misunderstood conditions among runners.
A lot of people come in worried that something is rubbing, damaged, or structurally wrong inside the knee. That concern is understandable. Knee pain has a way of making people think the worst. In most cases though, what is actually happening is far less dramatic and far more manageable once it is properly explained.
I see ITB syndrome regularly at Physio Club, particularly in runners who are increasing mileage, training for events, or changing their routine. With the right approach, most people recover well and return to running with confidence.
In this article, I will walk you through what ITB syndrome actually is, why it happens, who tends to be at risk, and what tends to help, based on what we see day to day in clinic.
If at any point you feel unsure whether this applies to you, you can learn more about how we assess and treat knee pain at our Engadine and Sutherland clinics.
For broader background reading, organisations such as Sports Medicine Australia also provide helpful information on common running injuries
https://sma.org.au
Table of Contents
- What is ITB syndrome
- Why ITB syndrome happens
- Common myths about runners knee
- Who is most at risk
- How ITB syndrome is assessed
- Treatment options for runners knee
- Exercises and load management
- Returning to running safely
- When to seek professional help
Key takeaways
If you are short on time, here are the main things to know about ITB syndrome and runners knee.
- ITB syndrome causes pain on the outside of the knee and is very common in runners
- It is not caused by friction or the ITB rubbing over bone
- Pain usually comes from compression of sensitive tissue under the ITB
- A tight ITB is not the main problem and aggressive stretching is rarely helpful
- Sudden changes in training load are one of the biggest triggers
- With the right approach, most runners recover well and return to running confidently
If you are dealing with ongoing knee pain and want to understand what is driving it, a proper assessment makes a big difference. You can learn more about how we assess and manage knee conditions at Physio Club.
For evidence based information on running related injuries, resources such as Sports Medicine Australia also provide helpful general guidance.
What is ITB syndrome
ITB syndrome stands for iliotibial band syndrome. It is a condition that causes pain on the outside of the knee, most commonly during running but sometimes during walking, cycling, or when going up and down stairs.
The iliotibial band, often shortened to the ITB, is a thick band of connective tissue that runs from the outside of the hip, down the thigh, and attaches just below the knee. Its role is to help stabilise the leg during movement and assist with efficient energy transfer when we run.
For many years, ITB syndrome was described as a friction problem. The common explanation was that the ITB rubbed back and forth over the outside of the knee, creating irritation and pain. This idea became widespread and is still mentioned frequently online and within running communities.
We now know this explanation is outdated.
Current evidence shows that ITB syndrome is best described as a compression related condition, not a friction injury. Pain occurs when the ITB compresses highly sensitive tissue underneath it on the outside of the knee. This compression increases as the knee repeatedly bends and straightens during activities like running.
Importantly, the ITB itself is not inflamed, torn, or damaged in most cases.
This helps explain why stretching or aggressively foam rolling the ITB often does not resolve symptoms. The ITB actually needs to be firm to do its job properly. It plays an important role in storing and releasing energy during running, acting much like a spring.
Research published in the British Journal of Sports Medicine has helped shift our understanding of ITB syndrome away from friction based theories and toward load management and tissue sensitivity.
In clinic, this updated understanding makes a significant difference. When people realise that pain does not automatically mean damage, fear often reduces straight away. From there, treatment can focus on the factors that are actually driving symptoms rather than chasing solutions that do not address the cause.
If you are experiencing pain on the outside of your knee and are unsure whether it is ITB syndrome or something else, a proper assessment is important. Knee pain can have several different causes, and the right diagnosis guides the right plan. You can read more about how knee injuries are assessed and treated at Physio Club.
Why ITB syndrome happens
One of the most frustrating things about ITB syndrome is how suddenly it can appear. Many runners will say that everything felt fine, then over the space of a few runs they start noticing a sharp or nagging pain on the outside of the knee that keeps coming back.
In most cases, this does not happen because something has gone wrong structurally. It happens because the demands being placed on the knee have changed faster than the body has been able to adapt.
The biggest factor we see in clinic is training load.
Load refers to how much stress your body is exposed to. For runners, this includes things like total weekly distance, running speed, hills, terrain, and how often you run. When one or more of these increases too quickly, tissues can become sensitive.
This is what many people describe as doing too much too soon.
Common examples we see include increasing weekly mileage, adding speed sessions, introducing hills, or returning to running after a break. Even positive changes like feeling fitter or more motivated can lead people to push faster than their body is ready for.
Another important factor is how the hip and thigh control the position of the knee during running. Reduced control through the hip can increase compression on the outside of the knee with each step. On its own this is not usually a problem, but when combined with a spike in load, symptoms often appear.
Running environment also plays a role. Trail running and downhill running tend to place higher demands on the outside of the knee. This helps explain why some runners only notice symptoms when they move off the road or start training on more varied terrain.
Cadence and stance width can also influence how forces move through the leg. Some runners naturally run with a narrow stance or a slower cadence, which can increase compression at the knee. Again, this is not inherently wrong, but it can become relevant when training load changes.
Research discussed in publications such as the British Journal of Sports Medicine highlights that ITB syndrome is best understood as a load related condition rather than a tissue damage problem.
In clinic at Physio Club, this understanding shapes how we approach treatment. Rather than focusing on a single structure, we look at the overall picture. Training history, recent changes, running habits, and strength all matter.
The key takeaway here is that ITB syndrome is rarely caused by one bad run. It is usually the result of repeated exposure to a level of load that the body has not yet adapted to.
Who is most at risk
ITB syndrome can affect any runner, but there are certain patterns we see more often in clinic. Understanding these risk factors is not about labelling people as broken or doing something wrong. It is about recognising situations where the knee may be under more stress than it can currently tolerate.
One of the most consistent risk factors is how long someone has been running.
Newer runners tend to be more at risk than long term runners, particularly in the early months when fitness is improving quickly but tissues are still adapting. Enthusiasm is high, progress feels fast, and it is easy to increase training faster than the body is ready for.
That said, experienced runners are not immune. We often see ITB syndrome in runners who have been training consistently for years but make a sudden change. This might be a new training plan, a jump in mileage, a focus on speed work, or a shift from road running to trails.
Sex differences have also been observed. ITB syndrome is reported more commonly in men than women, although this is likely influenced by differences in training volume, running patterns, and exposure rather than one single factor.
Running terrain plays a role as well. Downhill running increases braking forces through the knee, which can increase compression on the outside of the joint. Trail running adds uneven surfaces and frequent changes in direction, which can further increase load. This helps explain why runners sometimes feel fine on flat roads but develop symptoms when they introduce hills or trails.
Running style can also influence risk. Runners with a narrower stance width or lower cadence may experience higher compression forces at the knee. This does not mean these patterns are wrong or need to be changed in every case. They simply become more relevant when combined with changes in training load.
Educational resources from organisations like Sports Medicine Australia and Runner’s World often highlight that most running injuries are multifactorial. ITB syndrome is no different. It is rarely caused by one single issue.
At Physio Club, we spend time looking at the whole picture rather than ticking boxes. Training history, recent changes, running environment, and individual capacity all matter. Two runners can do the same program and have very different outcomes.
The important thing to remember is that being in a higher risk group does not mean you are destined to get injured. It simply means that being mindful of load, recovery, and gradual progression is even more important.
Common myths about runners knee
Because ITB syndrome has been talked about for so long, there is a lot of outdated or misleading information still floating around. I see this create unnecessary stress for runners, and in some cases it actually slows down recovery.
Let’s clear up a few of the most common myths.
Myth one: ITB syndrome is caused by a tight ITB
The idea that the ITB is too tight and needs to be stretched or loosened sounds logical, but it does not line up with what we now understand about the condition. The ITB is designed to be firm. Its stiffness helps store and release energy during running.
Trying to aggressively stretch or loosen the ITB does not address the real issue and can sometimes irritate symptoms further.
Educational resources from the British Journal of Sports Medicine and the American Physical Therapy Association support the idea that ITB syndrome is related to compression and load rather than tightness.
Myth two: Foam rolling will fix it
Foam rolling can feel good, and in some cases it may help with short term symptom relief. But relying on foam rolling alone rarely solves runners knee.
If load, strength, and movement patterns are not addressed, symptoms usually return once running resumes. Foam rolling should be seen as a small part of a broader plan, not the main solution.
This is something we explain often when runners come in for knee pain assessment at Physio Club.
Myth three: Pain means damage
Pain on the outside of the knee can feel sharp and alarming, which leads many runners to assume something is damaged or wearing out.
In most cases of ITB syndrome, pain reflects tissue sensitivity rather than structural damage. Understanding this is important because fear and avoidance can sometimes make recovery harder.
Organisations like Pain Australia and Sports Medicine Australia emphasise that pain does not always equal damage, especially in overuse injuries.
Myth four: You must stop running completely
Complete rest is rarely the best long term solution.
While some short term modification may be needed, most runners benefit more from adjusting training load rather than stopping altogether. With the right guidance, many people can continue running in a controlled way while recovering.
This is where individual assessment and planning matters. What works for one runner may not be appropriate for another.
The key message here is that runners knee is not caused by one simple problem and it is not fixed by one simple solution. Understanding what actually drives symptoms allows treatment to be targeted, realistic, and far less frustrating.
Exercises and load management
When runners ask about exercises for ITB syndrome, they are often hoping for a short list they can tick off and be done with. In reality, exercises only work when they are paired with appropriate load management.
These two always go together.
Exercises are not about fixing a weak muscle in isolation. They are about improving how the body handles load during running.
Most rehabilitation programs for runners knee focus on improving control through the hip and thigh, as these areas influence how much compression occurs on the outside of the knee. Exercises are selected based on what challenges the runner currently struggles with, not just what looks good on paper.
Early on, this might involve slower, controlled strength work. As symptoms improve, exercises usually progress toward more dynamic and running specific movements. This often includes single leg loading, step downs, split squats, and eventually plyometric based exercises once the knee is tolerating higher forces.
For endurance runners, this type of progression is particularly important. Programs need to respect the demands of long distance running rather than rushing straight back to speed or volume. This is something we commonly manage through our endurance athlete physiotherapy services.
Load management sits alongside this.
Load does not just mean how far you run. It includes how often you run, how fast you run, the terrain you choose, and how much recovery you allow between sessions. A small change across several of these variables at once can be enough to provoke symptoms.
One of the most common mistakes we see is increasing multiple things at the same time. For example, adding mileage, introducing hills, and increasing pace all within the same few weeks. Even if each change seems reasonable on its own, together they can overwhelm the knee.
This is where structured planning and guidance make a difference. Working with a physiotherapist who understands running demands can help ensure progression is gradual and realistic. This is a key part of how we approach care through our sports physiotherapy services at Physio Club.
In some cases, additional tools may be considered as part of a broader plan. This might include gait assessment or temporary support strategies if there are clear mechanical contributors. These are never a standalone fix, but they can be useful when used appropriately alongside strength and load management.
Ultimately, the goal of exercises and load management is not just to reduce pain. It is to rebuild confidence in movement so that running feels predictable and enjoyable again.
Returning to running safely
One of the most common questions runners ask is when they can start running again. The honest answer is that there is no single timeline that applies to everyone. What matters more than the date is how well the knee is tolerating load.
Returning to running works best when it is planned and progressive, rather than rushed.
In most cases, we look for a few key signs before increasing running load. Pain should be settling more quickly after runs, symptoms should not be escalating week to week, and everyday activities like walking and stairs should feel comfortable.
Rather than jumping straight back into normal training, most runners benefit from a staged return. This often starts with shorter runs on flatter terrain, keeping pace comfortable and avoiding hills or trails initially. As tolerance improves, distance, speed, and terrain can be layered back in gradually.
A common guideline is to increase overall running load by around ten percent per week. This is not a strict rule, but it provides a useful framework to prevent sudden spikes. Some runners may need to progress more slowly, while others can tolerate slightly faster increases depending on their history and capacity.
For runners training for longer events, return to running needs to consider cumulative fatigue. This is where endurance specific planning becomes important. We often support this process through our endurance athlete physiotherapy services, particularly for runners preparing for half marathons, marathons, or trail events.
It is also important to understand that some mild discomfort during the return phase does not automatically mean you are doing damage. What matters is how symptoms behave over time. Pain that settles within twenty four hours and does not progressively worsen is often acceptable. Pain that escalates or lingers longer usually signals that load needs to be adjusted.
This is where guidance can make a big difference. Having someone help you interpret symptoms, adjust training, and stay confident often prevents the cycle of stopping and restarting that many runners fall into.
At Physio Club, return to running plans are built around the individual rather than a generic template. The aim is not just to get you running again, but to help you train consistently without fear.
If you are unsure how to safely return to running or feel stuck in the cycle of flare ups, booking a review can help clarify the next step. Appointments can be made through our online booking page.
