As stated in the first blog on this subject Iliotibial Tibial Band Syndrome (ITBS) is a common overuse injury that affects cyclists, triathletes and runners. Overuse injuries, otherwise known as cumulative trauma disorders, are described as tissue damage that results from repetitive demand over the course of time. The condition manifests itself as:

  • A sharp or burning pain on the lateral aspect (outside) of the knee.

  • Pain radiating up the side of the hip or thigh

Many factors can contribute to the development of this problematic condition; it can develop due to either anatomical abnormalities or bike malalignment (improper bike fit).

The demands placed on the ITB during cycling are actually significant and continuous due to the repetitive nature of the pedalling action particularly in demanding training rides, Many keen cyclists, who are often forced due to lifestyle constraints to cram their 7 to 11 hours of training into 2 /3 rides per week (1mid week & 2 at the weekend), run a high risk of developing ITBS should any of the abnormalities or malalignment issues exist.


This blog article will look at some of these issues and offer potential remedies.


Anatomical Issues


As stated a number of factors can contribute to the problem. ITB syndrome can simply be caused by exercise induced muscle imbalance. This situation can arise due to the overworking one muscle group more than another, or simply by a person working a muscle or group of muscles less than optimally during their daily life (poor lifestyle habits)

Muscle imbalances may also develop where some muscle groups, for example the quadriceps and or hip flexors have become too tight, while the hip abductors and extensors have become too weak or fatigued. If this is the case then a rehabilitation regime designed to strengthen the weaker hip extensors, abductors and external rotators muscles is required.

Another cause of ITB inflammation can develop  when the Tensor Fascia Latae (TFL) is overused, causing it to go into a state of spasm thus “shortening” over time. With a stiff and over-dominant TFL, the gluteus medius can be become lengthened and weakened, and can even be inhibited. This again causes issue for the ITB. The rehabilitation process in this case requires the imbalance between the gluteus medius and the TFL to be addressed and this is achieved by strengthening the gluteus medius through glute activation exercises.

As in many scenarios relief from tightness/ pain can be achieved in the early stages through foam rolling and soft tissue mobilization/ recovery stretches.

A mal-aligned pelvis and leg length discrepancies are two major causes of chronic ITB problems; these structural asymmetries can increase the frictional forces through the tract resulting in an inflammatory response; these conditions can be are difficult to correct even with if the person follows a well-structured  programme of strengthening exercises and recovery stretches. If either of these issues are the cause then it may be necessary to seek the help of a health care specialist, such as a physiotherapist.

Problems may also arise because of excessive ankle/forefoot pronation which significantly stresses the shin and outer thigh, despite the foot arch being supported in a fixed position. In severe cases, cyclists may need customised shoe orthotics placed in their cycling shoes.

The condition known as Varus Knee (bow legged) increases the stretch along the outside of the knee thereby potentially causing issues for the ITB. In order to reduce the stress it is advisable to widen the cyclist's stance on the bike. This is achieved by placing spacers between the pedals and the crank arm.

It is not uncommon for people to have a discrepancy in their leg lengths; this condition will cause excessive ITB stretch on the shorter leg again leading to an inflammatory response. If this leg length discrepancy is significant and is deemed to be the cause of ITB issues then shims placed between the cleats and the pedals help to correct this issue. Minor leg length inequalities can be alleviated by moving the cleat of the shorter leg forwards and the longer leg backwards. Functional leg length differences often due to muscle imbalances should not be corrected in a bike fit.


Malalignment Issues


Although anatomical issues can lead to the development of ITB issues the most common cause is the smallest amount of Malalignment between the cyclist and the bike. Common malalignment issues relate to bike set up and the ride position. However some simple adjustments can decrease the strain on the ITB.


The most common issues are:

Poor cleat position; ITBS results when cleats are excessively rotated internally, as this set up increases the tension placed on the ITB. There should be no torsional stress occurring when a person is pedalling, simplistically the feet should feel straight when clipped into the pedals. To eliminate stress on the ITB, the cleats should be adjusted to reflect the cyclist's natural anatomical alignment; alternatively the cleats can be externally rotated to reduce stretch on the ITB.

Incorrect saddle height; The saddle height should be set, so that the optimum range of motion of between 150 ° at full extension to 70 ° of knee flexion is established. A saddle that is too high should be adjusted. Cyclists whose set up creates angles outside of these optimum ranges again significantly increase the likelihood of developing ITB issues.

Incorrect ride stance; again if someone has developed knee issues then it may be worthwhile checking their stance. Stress on the ITB can be reduced by widening the cyclist’s bike stance and by improving both the hip and foot alignment. This can be identified by looking at the knee position in relation to the feet. In essence if the feet are closer than the knees there is an increased chance of ITB issues as the plane of motion at the knees is challenged. This correction can be accomplished by either increasing the size of the pedal axles or by placing spacers between the pedal and the crank arm.

Poor saddle positions; Saddles that are positioned too far back force the cyclist to reach for the pedal with each stroke this action causes a tightening of the ITB thereby increasing the chances of an inflammatory response.

Along with malalignment issues gear ratios and training loads can similarly stress the ITB creating the conditions that may cause a person to develop ITB issues. A high gearing ratio may cause excessive generation of force by the ITB, which obviously can lead to issues. Similarly changes in an individual’s training regime my easily result in the development of this common over use condition. A marked increase in mileage and intensity without an adequate training base or the introduction of excessive hill work naturally increases stress on the ITB.

Whether anatomical or equipment related, malalignment will place significant stress on the distal (away from the bodies centre – in this case near the knee) ITB. As stated it is these stresses, however caused, that lead to the development of this cumulative trauma disorder. Whatever the cause the issues need to be identified and addressed as quickly as possible; as the ITB needs to be realigned to its normal resting position, as this decreases the tension in the tissue and brings about a reduction in inflammation.

As previously stated the development of ITBS can be attributed to a number of factors but in the majority of cases the trigger tends to be a combination of physical issues (imbalances / weaknesses). the actual act of cycling and the basic cycling position. The latter two feed any underlying imbalances thereby contributing significantly to its development.

Regardless of the factors which contribute to the problem ITB pain should be addressed as quickly as possible to avoid the development of a chronic debilitating injury which would probably require time off the bike and in the worst case scenario surgery. In the first instance

  • Temporary decrease or stopping training.

  • An intensive stretching routine.

  • Strengthening of the hip abductors (gluteal muscles esp. the gluteus medius).

  • Gentle foam rolling.

  • Addressing any malalignment issues.

If the above do not help relieve the issues then, ice, non-steroidal anti-inflammatories and treatment by a qualified practitioner may be necessary. ITB pain is certainly preventable and can be quickly eliminated if treated early.



Hopefully you have found this article of interest & value to you. Should you require further information on this subject or wish to find out how we at Cyclissimo can help you realise your cycling aspirations please contact us at or via the contact section found on our website:




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