Episode 25 | Ask the Expert | Guest: Dr Richard Antbring, Consultant Sports Physician (MBBS, MSc, MRCP, FFSEM)
Few injuries are more frustrating for runners than IT band syndrome. You lace up, head out, and within a mile or two a sharp, burning pain flares up on the outside of your knee – forcing you to stop. Walk home, and it mysteriously disappears. Rest a day or two, try again, and the same thing happens all over again.
In this episode of the London Bridge Sports Medicine podcast, host Lucie is joined by Dr Richard Antbring, Consultant Sports Physician at LBSM, to unpack exactly what’s going on, why it affects so many runners (and cyclists), and – crucially – what you can do about it.
What is the IT band, and what goes wrong?
The iliotibial band (ITB) is a thick, fibrous band of connective tissue that runs from the top of your hip – the bony crest of your pelvis – all the way down the outside of your thigh and inserts into the top of the shin bone, just below your knee. Think of it as a rope running down the outside of your leg. Its job is to stabilise both the hip and the knee when you’re standing, walking, and running.
Because it’s more like a rope than a muscle, the ITB can’t really be stretched – a point worth bearing in mind, as we’ll come back to it.
IT band syndrome was historically thought to be a friction injury, with the band rubbing back and forth across a bony prominence at the outside of the knee. Current understanding has moved on from this. “The pain is most likely generated by nerve endings and a fat pad that sits just underneath the band,” explains Dr Antbring. “It gets compressed as a result of repetitive movement – the thousands of steps we endure when we run.”
That fat pad is essentially an innocent bystander – it’s being compressed because of what’s happening further up the chain.
Who gets it?
ITB syndrome is primarily a runner’s complaint – Dr Antbring sees it across the full spectrum, from someone doing their first Couch to 5K to experienced marathon runners. Cyclists can also be affected, particularly if their saddle height is too high. Rowers and military recruits are also in the firing line.
The single biggest risk factor is a sudden spike in training load. “If you suddenly kick up your weekly kilometres, that will very much multiply your injury risk,” says Dr Antbring. When patients come in, one of the first things he does is review their Strava or Garmin data. The culprit – a big jump in mileage – is usually right there in the numbers.
What does it feel like?
The classic presentation is very specific:
- Sharp, stabbing or burning pain on the outside of the knee, just above the bony prominence
- Pain that comes on during a run, often after a consistent distance
- Pain that disappears when you stop running – only to return on the next run
- Occasionally, pain when walking downstairs (which loads the knee at around 30 degrees of flexion – the same position that compresses the fat pad)
This last point is worth noting: the fact that pain goes away when you stop is actually a key diagnostic clue. It distinguishes ITB syndrome from patellofemoral pain syndrome (another common runner’s complaint), which tends to cause more generalised front-of-knee pain that persists during everyday activities.
How is it diagnosed?
The history alone is usually very telling. In clinic, Dr Antbring will examine the knee to rule out other causes, and will typically find a very localised tender point two to three centimetres above the joint line on the outside of the knee.
But the clinical assessment goes well beyond the knee itself. Functional tests – single leg squats, step-downs, glute bridges – are used to understand why the injury has occurred. “Our job is not only to find out what’s going on, but also why it’s happened,” says Dr Antbring.
And the answer, more often than not, is weakness in the hip.
Why your hip is probably the real problem
Here’s the key insight that surprises many runners: ITB syndrome is rarely just a knee problem. The pain is in your knee, but the root cause is typically much higher up.
When you run, your gluteal muscles – particularly the gluteus medius – are working hard to stabilise your pelvis and control the position of your knee with every stride. As fatigue sets in over longer distances, that control deteriorates. Your knee starts to drift inwards slightly with each footfall, and that fat pad at the outside of the knee starts getting compressed.
“The fat pad is very much a bystander in all of this,” says Dr Antbring. “It’s being compressed and not liking it. But the reason it’s being compressed is because of problems happening further up.”
Studies back this up – runners with ITB syndrome typically show significant gluteus medius weakness compared with healthy runners, along with delayed muscle activation. In clinic, Dr Antbring often sees runners who can comfortably run 20 miles a week but struggle to hold a side plank for 30 seconds. “They’re always quite shocked,” he notes. “They think: I’m really fit, I run for miles – and then they can’t stand on one leg properly.”
Other contributing factors he’ll assess include:
- Ankle mobility – reduced dorsiflexion or over-pronation can create rotational forces up through the shin
- Leg length difference
- Scoliosis – a spinal curve can tilt the pelvis and add stress to the gluteus medius
Rehabilitation: what actually works
1. Manage your training load
Before anything else, get the load under control. For most people, reducing weekly mileage by 30–50% is the starting point. The aim is to find a level you can run at without symptoms, then rebuild gradually from there.
Dr Antbring’s general guidelines for safe mileage increases:
- If you’re running fewer than 10km per week: increase by no more than 1km per week
- Above 10km per week: 10% increase maximum week on week, and never exceed 20%
- Increases of 30% or more significantly raise injury risk
2. Strengthen the hip
This is the cornerstone of recovery. Dr Antbring recommends two strength sessions per week, aiming for 10–12 sets per session. The key exercises:
Isometrics first (especially if the knee is irritable):
- Side plank – hold for 30 seconds, 3–4 sets with 1–2 minutes rest between
Then progress to strength-based work (8–12 reps, 3–4 sets):
- Single leg Romanian deadlift (RDL) – a favourite of Dr Antbring’s for good reason; brilliant for glute strength and single-leg stability
- Box step-down – stand on a box, lower the opposite foot slowly towards the floor and back up; the slow, controlled movement is the key
Should you stop running entirely?
Rarely necessary. The approach is individualised, but typically:
- First, reduce mileage while starting rehab exercises and see how the knee responds
- If needed, substitute some running with swimming, cycling (with appropriate saddle height), or gym classes to maintain cardiovascular fitness
- Only complete rest is recommended if symptoms are severe and not settling
4. What about foam rolling?
Many runners with ITB pain reach for the foam roller – it does feel tight, after all. Dr Antbring’s honest verdict: “It can make it feel a little better symptomatically, but it doesn’t massively do much to the process of recovery or shorten the time back to full activity.”
The reason goes back to anatomy. The ITB is too thick and rope-like to be stretched or loosened. Foam rolling temporarily inhibits some of the nerve endings causing discomfort, but the relief doesn’t last. “We actually want the ITB to be tense and tight – that’s when it’s doing its job,” says Dr Antbring. “We need to focus on working upstream and improving the strength of those gluteal muscles.”
Medical interventions: when rehab isn’t enough
For runners with a race on the horizon, or when symptoms are proving stubborn, there are two options Dr Antbring may consider:
- Corticosteroid injection – delivered under ultrasound guidance directly to the area of inflammation around the fat pad. Can provide significant relief within a week. Importantly, it doesn’t fix the underlying cause, so rehabilitation must continue alongside it.
- Shockwave therapy – less evidence for ITB syndrome than for conditions like Achilles tendinopathy or plantar fasciitis, but can help by desensitising the painful area. Non-invasive and very safe. A useful option if progress has stalled.
Prevention: what you can do now
If you’re training for an event and want to stay injury-free, Dr Antbring’s advice:
- Prioritise gluteus medius strength – two sessions a week of lower limb work (side planks, single leg RDLs, box step-downs). This is probably the single most impactful thing a runner can do.
- Monitor your training load – use your running watch or app to track weekly mileage and keep increases within the 10% guideline.
- Think about your running cadence – evidence suggests that slightly increasing your cadence (by around 5–7 steps per minute) can reduce the degree of knee collapse during longer runs. Your GPS watch may give a cadence estimate; for a more accurate assessment, a professional running analysis is the gold standard.
- Aim for a mid-foot strike – avoid a heavy heel strike if possible, and be wary of switching to a full forefoot strike too quickly (it places significant load on the Achilles and calf). Any technique changes should be gradual.
- Consider your running surface – running repeatedly on a cambered road or pavement can create uneven load across the two legs. Varying your routes, or reversing direction on a loop, can help.
- Check your footwear – well-cushioned shoes in good condition matter. Old, worn trainers are a silent contributor to many overuse injuries.
The bottom line
ITB syndrome is an overuse injury driven primarily by doing too much too soon, and compounded by hip weakness that most runners don’t know they have. The good news is that it responds well to a structured approach: dial back the load, do the strengthening work consistently, and gradually rebuild.
“Strengthening the gluteus medius is incredibly important,” says Dr Antbring. “It’s probably the biggest influencer of generalised knee pain in runners. If you have strong gluteal muscles, it’s much less likely that your knee will start collapsing through longer distance runs.”
The foam roller can stay – but don’t rely on it. Do the work upstream.
Dr Richard Antbring is a Consultant Sports Physician at London Bridge Sports Medicine (MBBS, MSc, MRCP, FFSEM). He sees patients at London Independent Hospital and Highgate Private Hospital, and works within the academy medical teams at West Ham United and Leyton Orient.
To book an appointment with Dr Antbring or another member of the LBSM team, visit lbsm.co.uk/booking
Listen to the full episode below ↓
