I remember the moment I examined her knee. It was swollen, sore to touch, and everything about it pointed to ITB friction syndrome. This is a common overuse injury that affects runners and cyclists, especially those increasing their training volume quickly. We ran some clinical tests and all signs lined up. To be sure, we sent her for an MRI.

When the results came back, I knew this was going to be a challenge. I forwarded the scans to a knee consultant and his response said it all. If ten was the worst ITB friction syndrome he had ever seen, this was a ten.

We realised straight away that this was not a simple rehab case and the question was whether we could help her recover in time for the race without needing surgery.

Many people think the IT band itself is the root of the problem with this injury. But in most cases, the real issue starts higher up at the hip. Muscles like the TFL, or tensor fasciae latae, pull on the IT band and make it overly tight. That tightness causes the band to rub against the outside of the knee during repetitive movements like running and cycling. Over time, this friction causes inflammation and pain.

In Anna’s case, we decided to try injection therapy as a final attempt before going down the surgical route. She received two injections. The first was a steroid to reduce the inflammation at the knee. The second was Botox into the TFL to reduce muscle tone at the hip and relieve some of the pull on the IT band.

It worked well at first. The pain eased quickly and Anna got back into light training. Unfortunately, within just a few weeks, the pain came back just as strong. With only a short time left before race day, she made the difficult decision to pull out.

Anna went ahead with an ITB lengthening procedure. It was a straightforward surgery that gave her the relief we had all been hoping for. Within eight weeks, she was completely pain free. and she returned to running and cycling without a hint of the old pain.

But that was only part of the solution. Surgery removed the inflammation and pressure at the knee, but it did not address the cause of the injury. That is where our real work began.

We spent time strengthening the muscles around her hips and glutes, correcting her movement patterns, and improving her control through the pelvis. We worked together on mobility, balance, and posture so she could move better and more efficiently.

Now she is back to doing what she loves. She runs, cycles, swims, and is already planning her next race. And most importantly, she is doing it all without pain.

There are two big takeaways from Anna’s journey that I always share with others.

First, if you are a runner or cyclist and you start to feel a nagging pain on the outside of your knee, especially if it shows up around the same distance or intensity each time, get it checked. ITB friction syndrome can start small but escalate quickly. Anna’s pain began as a little niggle, but over time it became a major setback that needed surgery. If we had caught it earlier, we could have likely resolved it with physio alone.

Second, recovery is not just about treating the pain. Whether the approach involves rest, injections, or even surgery, that only addresses the symptoms. The long-term fix comes from identifying and correcting the underlying cause. That means looking at how you move, building strength in the right areas, and creating better habits. That is what prevents injuries from coming back.

Joe Sharp

BSc (Hons) Physiotherapy