ITB Lower Back Pain: Why Your Back Makes Your ITB Hurt

About two-thirds of the back pain patients on whom I perform an exam have a fired-up and tender ITB. In addition, I’ve seen through the years that treating the issues in the back as well as the ITB works much better than just treating the back. Why? Because the ITB is the canary in the coal mine for back problems. Let me explain ITB lower back pain.

What Is the ITB?

The acronym ITB stands for iliotibial band. It’s basically the thickening in the fascia at the side of your thigh. In fact, you see people in the gym rolling out the side of their thigh all the time. So we all know that the ITB is an issue in many people.

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A Little Deeper into Understanding the ITB

OK, so you know that the ITB is on the side of your thigh and that it hurts in many people. You also know that people roll it out to help with the pain. However, to really understand this bad boy, you need to know more.

The ITB acts as a lateral stabilizer of the hip and knee. As you can see in the image below, the butt muscles (gluteus maximus—g max) and TFL muscles anchor the ITB as it runs down the side of the leg to the knee. So as you step on that leg with the other foot off the ground as you walk, these muscles and the ITB support your body. Without this support, your pelvis would collapse toward the foot off the ground.

medical illustration of the gluteus maximus, TFL, and ITB.

What happens if these muscles at the side of the hip get weak? The tension on the ITB that’s there to hold your body up as you walk or run lessens. Hence, your ITB begins to get trashed as it gets yanked on repeatedly as you walk.

Given that nerves supply these muscles, if you have low-level nerve irritation in your low back (which you may not notice as back pain), the ITB muscles can begin to misfire and get slightly weak. The nerves that come from the lower part of the low back and go to these muscles are L4, L5, and S1. For more information on how this works, see my video below:

ITB Lower Back Pain: The ITB Is the Canary in the Low Back Coal Mine

In my experience, whenever these lower lumbar nerves are irritated, we see an issue in the ITB. It starts out as side-of-the-hip pain, and this area is extremely tender to palpation. In a few patients, it gets bad enough that they can’t sleep on their side at night.

So while this covers the lower nerves in the lumbar spine, what about other nerves in the low back? Can the upper low back nerves (L2, L3, L4) cause ITB issues too? Let’s explore that a bit.

The Vastus Lateralis and ITB

My personal trainer is a great student of anatomy, and we often banter back and forth. One of the things he relayed the other day is that he read a nice article on the relationship between the ITB and vastus lateralis (VL). This threw me for a second, but then I realized that he was right. The weird thing? I could find very little about this relationship online. Hence this blog.

What Is the Vastus Lateralis?

The VL is the outside-most muscle of the four muscles that make up the quadriceps. These muscles make up the big “thigh” muscle that you can see in the front. The muscle originates from the top of the femur bone and then passes down below the knee. The job of these muscles is to extend the knee.

Photo of a person's torso and thighs with overlapping illustrations showing the anatomy of the thigh

Perhaps the more “famous” of these four muscles is the VMO, which is the vastus medialis. This is one of the muscles that physical therapists strengthen when someone has kneecap pain. It’s located on the far inside while the VL is on the far outside.

Why Few People Understand the Relationship Between the ITB and Vastus Lateralis

For the most part, medical providers tend to think that the muscle that underlies the ITB is the outside part of the hamstrings muscle, called the biceps femoris. It’s not. In fact, the ITB is simply a thickening of the VL fascial covering. What does that mean, and why is it critically important to why all of those people keep rolling their ITBs and why my patients have ITB issues?

Take a look at the diagram below. It shows that the muscle on the very outside part of your thigh is the vastus lateralis and that the biceps femoris is located behind the ITB. In order to really understand why all of this is important, you need to know more about how muscles work.

medical illustration of cross section of thigh showing the Iliotibial band and vastus lateralis

Muscles are surrounded by fascia. This holds them tightly contained and improves their ability to contract more strongly. In addition, the fascia around one muscle connects to the fascia around other muscles.

So What Does All of this Have to Do with the Vastus Lateralis?

The ITB is nothing more than a thickening in the fascia that surrounds the VL. If this muscle is not working well, the ITB will be impacted. In fact, looking at the cross-sectional design above, since muscles get larger as they contract, simply firing this muscle will cause the ITB to tighten. Hence, controlling the tension on the ITB happens through the two muscles described above (glutes and TFL) but also through the VL.

So what happens if the nerves that come from the low back are a problem? Meaning, if they’re irritated (with or without this patient having back pain)? The L2, L3, and L4 nerves go to the VL muscle, so the ITB will be impacted. You see what I’m describing here? The ITB is jacked into every nerve in the low back! So it doesn’t matter which low back nerve you have irritated, your ITB is likely impacted. Hence, the ITB is truly is the canary of low back problems! Meaning if you can’t get rid of ITB problems, then you need to get your back checked whether you have back pain or not!

Can This Type of ITB Problem Be Fixed?

Yes! While rolling the ITB and VL muscle can help your pain temporarily, if it persists, you need treatment. What works? First is an extensive hands-on exam and review of your low back MRIs. Once the culprit irritated back nerve is identified, we use our advanced fourth-generation platelet lysate precisely injected around the nerve using fluoroscopy guidance. See my video below for more information on that type of treatment:

The other thing that needs to be treated is the ITB and VL. We inject our high-dose platelet-rich plasma into these areas. On why that’s different, see my video below:

The upshot? If you have ITB pain, it’s likely ITB lower back pain, originating from your low back, even if you don’t have much day-to-day back pain. So take the hint from your body! If you need to roll out your ITBs more than occasionally, then see a Regenexx provider and get it fixed.

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.