Both are common running injuries that build up with training, and both get called runner's knee, which is why runners mix them up. IT band syndrome hurts on the outside of the knee, over the bony bump at the lower end of the thigh bone, and often comes on at about the same distance into each run. Patellofemoral pain is an ache around or behind the kneecap that often shows up away from running too, on stairs, in squats and after sitting with the knees bent. IT band syndrome is irritation at the outer knee, most likely from sensitive tissue being squeezed under the band; patellofemoral pain comes from a kneecap joint that has become sensitive to load.
Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. An in-person exam usually narrows it down, though the two can overlap and some cases need imaging or a second look.
Other ComparisonsThe patterns that separate IT band syndrome from patellofemoral pain in clinic. Read across each row and compare.
| Aspect | IT band syndrome | Patellofemoral pain |
|---|---|---|
| Where it hurts | On the outside of the knee, over or just above the bony bump at the lower end of the thigh bone (the lateral femoral epicondyle). Pressing on that bump is usually tender. | Around or behind the kneecap, at the front of the knee. It is often hard to pin to one spot, and people tend to circle the kneecap with a hand rather than point with one finger. |
| What it feels like | Often sharp, and it can become bad enough to make you stop running. | Usually a dull ache around or under the kneecap, sometimes with a grinding or crackling feeling as the knee bends. |
| How it behaves on a run | Often starts at about the same distance or time into each run, then builds. It settles with rest but comes back on the next run, often at about the same point. | Tends to build the longer or harder you run, and it is often more noticeable during and after running than at rest. |
| Downhill | A classic trigger. Running downhill means the knee is straighter when the foot lands, close to the slightly bent position, around 20 to 30 degrees, where the band presses hardest on the tissue beneath it. | Also a common trigger, along with going down stairs, so downhill pain on its own does not tell the two apart. |
| Stairs, squats and long sitting | Long sitting with the knee bent is not a typical trigger. When it is very irritable, stairs, single-leg tasks or even walking can catch it, and some people walk with a stiffer, straighter knee to avoid the pain. | Classic triggers: stairs (often worse going down), squatting, getting up from a low chair, kneeling, and sitting a long time with the knees bent, such as in a cinema or on a long drive (the theatre sign). |
| What usually sets it off | A sudden jump in distance, more downhill running, sloped (cambered) roads, or running the same way round a track every session. It is common in cyclists as well as runners. | A sudden rise in running, jumping, hills or stair work. Hip and thigh strength is worth building in rehab, though weakness found once the knee hurts does not show that it caused the pain. |
| How long it takes | Some runners improve over several weeks, while others need longer. Return to running and return to full training are separate milestones, guided by symptoms and tolerance. | Many people see meaningful improvement over 6 to 12 weeks of exercise therapy, but recovery times vary, and symptoms can persist or come back even after treatment. |
On the outside of the knee, over or just above the bony bump at the lower end of the thigh bone (the lateral femoral epicondyle). Pressing on that bump is usually tender.
Around or behind the kneecap, at the front of the knee. It is often hard to pin to one spot, and people tend to circle the kneecap with a hand rather than point with one finger.
Often sharp, and it can become bad enough to make you stop running.
Usually a dull ache around or under the kneecap, sometimes with a grinding or crackling feeling as the knee bends.
Often starts at about the same distance or time into each run, then builds. It settles with rest but comes back on the next run, often at about the same point.
Tends to build the longer or harder you run, and it is often more noticeable during and after running than at rest.
A classic trigger. Running downhill means the knee is straighter when the foot lands, close to the slightly bent position, around 20 to 30 degrees, where the band presses hardest on the tissue beneath it.
Also a common trigger, along with going down stairs, so downhill pain on its own does not tell the two apart.
Long sitting with the knee bent is not a typical trigger. When it is very irritable, stairs, single-leg tasks or even walking can catch it, and some people walk with a stiffer, straighter knee to avoid the pain.
Classic triggers: stairs (often worse going down), squatting, getting up from a low chair, kneeling, and sitting a long time with the knees bent, such as in a cinema or on a long drive (the theatre sign).
A sudden jump in distance, more downhill running, sloped (cambered) roads, or running the same way round a track every session. It is common in cyclists as well as runners.
A sudden rise in running, jumping, hills or stair work. Hip and thigh strength is worth building in rehab, though weakness found once the knee hurts does not show that it caused the pain.
Some runners improve over several weeks, while others need longer. Return to running and return to full training are separate milestones, guided by symptoms and tolerance.
Many people see meaningful improvement over 6 to 12 weeks of exercise therapy, but recovery times vary, and symptoms can persist or come back even after treatment.
These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain how an in-person exam narrows them down.
I press over the bony bump on the outside of the knee, along the joint line and around the edges of the kneecap. Tenderness over the bump fits IT band syndrome. Tenderness along the outer joint line, the gap between the thigh bone and the shin bone, points me toward the outer meniscus instead. Patellofemoral pain is often poorly defined, so I rely more on the movements that bring it on.
I press over the bony bump on the outside of the knee while the knee bends and straightens. Pain at around 30 degrees of bend, where the band presses hardest on the tissue beneath it, fits IT band syndrome. Like the other clinical tests for it, it has not been validated in runners, so I read it alongside your history.
The classic test for a 'tight' IT band. In a cadaver study, cutting the band did not change the result, while cutting the hip muscles (gluteus medius and minimus) and the hip joint capsule did, so I treat it as a check of the hip, not as proof of a tight band.
Both bend the knee under load on one leg. What matters is where your familiar pain shows up: around or behind the kneecap fits patellofemoral pain, on the outside of the knee fits IT band syndrome. I also watch whether the pelvis drops or the knee drifts inward, which can be relevant to both.
Pain around the kneecap as you squat supports patellofemoral pain. In a review of clinical tests, squatting showed a trend toward helping the diagnosis, but neither it nor any other single test was accurate enough to confirm patellofemoral pain on its own.
I test the hip muscles that move the leg out to the side and turn it outward and, where it helps, watch you run. Weakness of the muscles on the side of the hip has been found in runners with IT band syndrome in several studies, and weak hip and thigh muscles are common in patellofemoral pain too, but weakness found while you are in pain does not prove it caused the problem. It shows me what rehab can work on.
Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.
Your pattern more likely fits IT band syndrome if the pain sits on the outside of the knee over the bony bump, comes on at about the same distance or time into each run, builds until it is sharp enough to make you stop, and settles between runs, while sitting with the knee bent causes little trouble. It often follows a sudden jump in distance, more downhill running or sloped roads, and it is common in cyclists too.
Read the IT band syndrome pageYour pattern more likely fits patellofemoral pain if the ache sits around or behind the kneecap and is hard to pin to one spot, running makes it build, and it also shows up away from running: going down stairs, squatting, getting up from a low chair, or sitting a long time with the knees bent. It often follows a sudden rise in running, jumping, hills or stair work.
Read the patellofemoral pain pageIt is common to be unsure, especially when the pain sits toward the front and outside of the knee, or when runner's knee is the only label you have been given. I map where it is tender, press over the outer knee as it bends and straightens, watch a single-leg squat and a step-down to see where your familiar pain shows up, test hip strength and, where it helps, watch you run. I also check the outer joint line and the ligaments, because an outer meniscus tear or a ligament sprain can feel similar, and I check the hip and lower back, which can refer pain to the knee. Neither condition usually needs a scan. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or sports medicine physician and refer you. While it is being sorted out, many runners keep going by running less rather than stopping, and by leaving out steep downhills.
The two share a lot. Both are among the most common running injuries, both tend to follow a rise in training, both often flare downhill, and hip strength and running form matter in the rehab for both, so much of the early plan is the same: run less rather than stop, strengthen the hip, and try slightly quicker steps. The difference is in the detail. Patellofemoral pain usually also includes strengthening of the front of the thigh (quadriceps) and changes to how deep and how often you bend the loaded knee, while IT band syndrome leans more on the hip and on how much, and how much downhill, you run. In a 2023 trial of 200 people with kneecap pain, knee-focused and hip-focused programs gave similar, modest improvements, so the starting point can be tailored (Hansen et al., 2023). When a knee shows features of both, I work on both at once rather than one after the other.
Not exactly. Runner's knee is a general label rather than a diagnosis. It is often used for patellofemoral pain, pain around or behind the kneecap, but some people use it for IT band syndrome or patellar tendinopathy (jumper's knee) too. The pattern tells me more than the label: where it hurts, when in a run it comes on, and what else in your day sets it off. Sorting out which one is present changes the rehab plan, so it is worth knowing before you build a routine around one of them.
Stretching and rolling are fine if they feel good, but they are unlikely to change the band itself. The IT band is a thickened part of the sheet of tissue that wraps the thigh, firmly attached along the thigh bone, and researchers who studied it in cadavers questioned the reasoning behind treatments built on stretching it. The usual tightness test, the Ober test, mostly reflects the hip muscles and the hip joint capsule rather than the band. In a study of 34 men, runners with IT band syndrome were only very slightly tighter on that test than healthy men, by less than the smallest difference the measurement can reliably detect; the clearer differences were in how the hip and knee moved while running. Rolling may briefly reduce sensitivity, but it does not meaningfully lengthen the band, so I put most of the effort into hip strengthening and adjusting how much you run.
Probably not in the way the old explanation suggests. Kneecap pain does not usually mean the kneecap needs pulling back into line; the tracking explanation has not held up well for most cases. In a review of 18 studies that followed 4,818 people to see who went on to develop kneecap pain, fixed measures such as the Q angle (how the thigh and shin line up through the kneecap), height, weight and body mass index did not predict who did. How the kneecap moves is a separate question, looked at alongside strength, load and your familiar symptoms. Scans are usually normal or show changes that are also common in people without pain. Strength, control and training load are things rehab can change, so that is where the plan focuses.
Partly. With both, I usually start by cutting running back rather than stopping, and taking slightly quicker steps may help with either. For IT band syndrome, the main work is strengthening the hip muscles that move the leg out to the side, turn it outward and extend it, and leaving out hard downhill running and steeply sloped roads early on. If it is slow to improve, shockwave is an option alongside the exercise program: in one small trial of 24 runners, shockwave and hands-on treatment, each added to exercise, reduced running pain by similar amounts over 8 weeks, although with no group that had neither, it cannot show how much either added. For patellofemoral pain, the plan strengthens the front of the thigh (quadriceps) as well as the hip, and adjusts how deep and how often you bend the loaded knee on stairs and in squats. Tailored kneecap taping can give short-term relief alongside the exercises; braces, sleeves and straps are not recommended, and the 2019 guideline advises against them.
Often yes, in a reduced form. With IT band syndrome, cutting how much you run by roughly half at first lets many runners keep running while rehab progresses; leave out hard downhills and steeply sloped roads early on, and when you build back up, keep weekly increases small, with about 10 percent as a rough guide. Complete rest often feels good short term, but symptoms tend to return within the first few runs because nothing has changed in what the knee can handle. With patellofemoral pain, run less for now, avoid steep downhills, and aim to keep pain at or below 3 out of 10 during the run and settled within 24 hours; if it is getting worse week over week, cut back until it turns around. Taking slightly quicker steps, about 5 to 10 percent more steps per minute, is worth trying with either.
Yes. Tenderness along the joint line rather than over the bony bump, with catching or locking and often a twist with weight on the leg, points to the outer meniscus. An injury that forced the knee outward points to the ligament on the outer side of the knee (the lateral collateral ligament). Pain at the top of the thin outer shin bone (the fibular head) can come from the outer hamstring tendon or from the joint where that bone meets the shin bone. At the front of the knee, pain in a small spot just below the kneecap points to the patellar tendon instead. Numbness or tingling in the lower leg or foot can be checked at your physiotherapy assessment; a new foot drop or weakness that is getting worse needs a same-day medical assessment, and sudden unexplained weakness means calling 911. And if the knee locks and will not straighten, get it assessed the same day by your family doctor, urgent care or emergency; it needs an urgent orthopaedic referral.
Sources I lean on when separating these two conditions in clinic.
In 2,002 running injuries recorded by doctors over two years at a primary care sports medicine clinic in Vancouver, patellofemoral pain was the most common injury and IT band syndrome the second most common.
Taunton JE, Ryan MB, Clement DB, et al. "A retrospective case-control analysis of 2002 running injuries." Br J Sports Med 2002; 36(2): 95-101.
In 15 cadavers, the IT band was anchored to the thigh bone by fibrous strands over a layer of fat rich in nerves and blood vessels, and no fluid-filled sac (bursa) was found in the cadavers, in six people scanned without pain or in two athletes with IT band syndrome. The scans showed the band pressed against the bony bump on the outer knee at about 30 degrees of knee bend, and the athletes' scan changes sat in the fat layer, so the authors suggest the pain is more likely to come from compression of that fat than from repeated rubbing.
Fairclough J, Hayashi K, Toumi H, et al. "The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome." J Anat 2006; 208(3): 309-316.
In lightly embalmed cadaver legs, cutting the IT band did not change the result of either version of the Ober test, the usual test for a tight band, while cutting the gluteus medius and minimus muscles and then the hip joint capsule did. The authors concluded that the test reflects tightness of structures around the hip rather than of the band.
Willett GM, Keim SA, Shostrom VK, Lomneth CS. "An Anatomic Investigation of the Ober Test." Am J Sports Med 2016; 44(3): 696-701.
A review of 65 randomised trials in people with patellofemoral pain found that exercise aimed at the knee reduced pain and improved function compared with sham, placebo or wait-and-see groups, and that exercise aimed at both the hip and the knee did better than knee exercise alone, at up to 3 months. No treatment had been adequately tested beyond 3 months.
Neal BS, Bartholomew C, Barton CJ, et al. "Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis." J Orthop Sports Phys Ther 2022; 52(11): 750-768.
A review of 13 studies in 201 adult runners with IT band syndrome, five of them randomised trials and six of them case reports or case series, found hip strengthening a common part of treatment, sometimes combined with shockwave or hands-on treatment, with pain and function improving over 2 to 8 weeks. The studies differed too much to be pooled, and running retraining still needs proper trials.
Sanchez-Alvarado A, Bokil C, Cassel M, Engel T. "Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review." Front Sports Act Living 2024; 6: 1386456.
In 34 men, 17 with IT band syndrome and 17 without, those with the condition were only very slightly tighter on the Ober test (1.2 degrees), had weaker hip outward rotators, and showed more hip inward rotation and more inward angling of the knee while running. A one-time comparison cannot show which came first.
Noehren B, Schmitz A, Hempel R, et al. "Assessment of strength, flexibility, and running mechanics in men with iliotibial band syndrome." J Orthop Sports Phys Ther 2014; 44(3): 217-222.
A review of 18 prospective studies following 4,818 people found that the Q angle, height, weight and body mass index did not predict who went on to develop kneecap pain.
Neal BS, Lack SD, Lankhorst NE, et al. "Risk factors for patellofemoral pain: a systematic review and meta-analysis." Br J Sports Med 2019; 53(5): 270-281.
In 24 runners with IT band syndrome, shockwave and hands-on treatment, each added to an exercise program, reduced pain during running by similar amounts over 8 weeks. With no group that had neither, the trial cannot show how much either added.
Weckström K, Söderström J. "Radial extracorporeal shockwave therapy compared with manual therapy in runners with iliotibial band syndrome." J Back Musculoskelet Rehabil 2016; 29(1): 161-170.
A review of clinical tests for kneecap pain found that squatting showed a trend toward helping the diagnosis, but no single test was accurate enough to confirm it on its own.
Nunes GS, Stapait EL, Kirsten MH, et al. "Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis." Phys Ther Sport 2013; 14(1): 54-59.
The 2019 clinical practice guideline for patellofemoral pain supports tailored kneecap taping alongside exercise for short-term relief, and advises against knee braces, sleeves and straps.
Willy RW, Hoglund LT, Barton CJ, et al. "Patellofemoral Pain." J Orthop Sports Phys Ther 2019; 49(9): CPG1-CPG95.
200 people with kneecap pain were randomised to 12 weeks of quadriceps-focused or hip-focused exercise. The two programs gave equivalent improvements, though neither group's average gain reached the level judged clinically important.
Hansen R, Brushøj C, Rathleff MS, et al. "Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial." Br J Sports Med 2023; 57(20): 1287-1294.
If this page has helped you narrow things down, or if it has left you wanting a proper exam, I see patients at Endorphins Health & Wellness Centre in Burlington. Direct insurance billing is available, and a physician referral is not required.
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