Technical FAQ: How to address and resolve IT band pain

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Dear Lennard,
I’m 70 years old, six-foot-two, 240 pounds, and riding a Lynsey XL bike. I ride three days per week, 20-30 miles each day. I’ve had a professional bike fit, but I’m having problems with an IT band that continues to be painful. The fitter has put extensions on my pedals to widen my base. Do you have any other thoughts to provide relief to my IT band problem?
— Bob

Dear Bob,
Yes. Try getting rid of the pedal extension on the sore side.

I have had my share of debilitating IT-band pain and can offer some advice, as I have managed to completely heal from it and be largely symptom-free for many decades. I never assume it won’t come back again or is something I have permanently alleviated, however.

For those yet unfamiliar with the iliotibial (IT) band, it is a broad tendon (a thick band of elastic tissue that connects muscle to bone) on the lateral side of the upper leg that narrows down as it passes by the knee. It runs from the top of the pelvic bone (the iliac crest) to just below the knee, where it connects to the top of the tibia.

When the IT band flares up, the symptom is pain on the lateral side of the knee due to friction between the iliotibial band and a bump (epicondyle) on the lateral side of the lower end of the femur. With every pedal stroke, the narrow section of the IT band alongside the knee strums back and forth across this bony protuberance. It should be obvious that if this huge tendon is very tight, it will push hard against the bone, and this strumming of it across the epicondyle with every rotation of the pedals could bring on inflammation.

There are two main ways I addressed IT-band pain, and resolved it. Because it is so painful, I don’t ever want another recurrence, and I have been religious about doing these two therapies regularly ever since.

The first methodology I always employ if I have an IT band flare-up is one that PTs and orthopedists often recommend, namely IT-band stretching and, once it stops hurting, foam rolling. I have a few different IT-band stretching techniques I use, and I won’t go into the details here, since you can find lots of instructions online for stretching the IT band, with illustrations and photos. Be aware that stretching the IT band requires close attention to form during the stretch, since improper hip rotation will let the IT band slip away, unstretched.

Foam-rolling the IT band is not something you can or should do when you are experiencing the sharp lateral knee pain of a sore IT band; it is simply too irritated and inflamed for this to do anything other than further inflame it. However, I do roll the lateral side of my legs from my hip bone down to my calf on a foam roller at least once a month when it is asymptomatic. It feels better when I do so and feels like it softens the band. I recognize that there is some disagreement about whether foam rolling actually loosens the IT band. It feels good to me, so I do it.

The more important immediate thing I do is to reduce the tension in the IT band with my shoe setup. I wedge up (raise) the lateral side of the foot on the affected side so that it won’t pull as hard on that big tendon with each pedal stroke. I came upon this because the first time my IT bands flared up was when I naively switched to shoes that intentionally supinated my feet (rolled them to the outside). This was a design feature of the original Time shoes, which were introduced along with the original Time pedals, in the late 1980s. All it took was a long ride or two in those shoes, and I was in agony like somebody was stabbing me with an icepick on the lateral side of both knees. I then realized that, prior to clip-in (a.k.a., “clipless”) pedals, of which the Times were one of the first I tried, my feet always tended to pronate (roll to the medial side) on the bike. Prior to that, with toeclips and straps on Campagnolo road pedals with leather-soled shoes, my first metatarsal deformed the medial shoe sole in the metatarsal area down into the cage of the pedal, pronating the foot; this is no longer possible with hard-soled shoes and clip-in pedals. Even with a flat clip-in system, my feet are less pronated than they had been through all of the years of my racing career at an elite level, and their supination with those early Time shoes pulled tension on my IT bands.

To proactively wedge my foot so it pronates to alleviate IT-band pain, I stack up shims under the lateral side of my insole. I save the stock insoles that come with any cycling shoes I get, and when I have IT-band pain, I remove my custom orthotics and use a stock insole that I have modified to cant my foot to the medial side (i.e., I cause the foot to pronate by stacking up shims under its lateral edge). I trim progressively narrower strips off of the lateral edge of insoles and glue a stack of 2-4 of them (I use more if the pain is more extreme, fewer if the pain is mild), decreasing in width, under the lateral side of an untrimmed insole so that it is shaped like a wedge in cross-section. Then I put it in my shoe and ride with it like that. It immediately reduces or eliminates the pain in my IT band where it strums past the lateral femoral epicondyle.

After a week or two of riding pain-free that way, I peel off the bottom, narrowest layer I have glued to the insole, and then ride with my foot less pronated. If that is pain-free for a week or more, then I remove the next layer, etc., until I am back to only the bare insole, at which time I return my normal custom orthotic to the shoe. This has always relieved the pain and gotten me back to a pain-free setup.

Specialized BG shoes used to intentionally supinate the feet, as did the “Big Meat” cleat shims that canted the cleat and were popular in the 1990s. All I had to do was ride a few days with either of those setups and I was back in the IT-band-pain cave. Now, I make sure I only ride in shoes whose soles have constant thickness across the metatarsal area, and I add a thin Specialized BG wedge under the orthotic in my left shoe to lift the lateral edge of that foot. This keeps my IT bands happy.

In your case, Bob, you should be aware that increasing your pedaling stance with those pedal extensions (or longer pedal spindles) will have the same effect of increasing tension on the IT bands as tipping your feet to the outside would have. Widening the pedaling stance is a common adjustment made by fitters if the knees flare out at the top of the pedal stroke. The idea is to bring the feet under the knees and cause the knees to track more straight up and down, but it may be that doing so causes more tension in your IT bands than your body can handle.

Analogously, and the reason that early Time and Specialized BG shoes and Big Meat cleat wedges canted the feet to the outside, wedging the medial side of the foot is often used by fitters if the knee is perceived to fall in on the downstroke and track inward of the foot during pedaling. Supinating the feet props the knees out more, thus better aligning them over the feet throughout the pedal stroke; at the same time, it puts greater tension on the IT bands.

Save for rare flare-ups and thanks to regular IT-band stretching and my shoe setup, I have been pain-free in the IT bands since at least the last time I rode over 200 miles in a day or did over 15,000 feet of climbing in a day. Super-long, super-hard rides like that often brought on IT-band tenderness and required my immediate attention to canting my feet, or the pain would become chronic. I no longer do rides like that anymore, and I avoid any shoe/cleat setup that would supinate my feet. Perhaps sharp pains in my IT bands are a thing of the past for me.
― Lennard

Lennard Zinn, our longtime technical writer, joined VeloNews in 1987. He is also a custom frame builder (www.zinncycles.com) and purveyor of non-custom huge bikes (bikeclydesdale.com), a former U.S. national team rider, co-author of “The Haywire Heart,” and author of many bicycle books including “Zinn and the Art of Road Bike Maintenance,” “DVD,” as well as “Zinn and the Art of Triathlon Bikes” and “Zinn’s Cycling Primer: Maintenance Tips and Skill Building for Cyclists.” He holds a bachelor’s in physics from Colorado College.

Follow @lennardzinn on Twitter.