Iliotibial Band (ITB) SyndromeIliotibial Band (ITB) Diagram

Pain and Tightness Along the Thigh

Having pain and tightness along the side of the thigh is quite common, especially for athletes. When the pain encompasses the lower half of the thigh towards the outside area of the knee, it often carries the diagnosis of Iliotibial Band (ITB) Syndrome. For many people it can be persistent or unresponsive to typical treatment. The IT band is a stiff layer of tissue that blends from a broad attachment of muscles from the side and back of the hip. The band becomes narrower as it descends toward the knee where its attachment broadly blends with tissues about the knee cap and into the tibia bone.

Stretch for Tensor Fascia Lata Muscle

Standing stretch for TFL and ITB.

The condition is frequently described as the ITB being ‘tight,’ and typical treatment often includes attempts at ‘stretching’ the ITB.  But when you look at the tissue of the band and how it attaches, it becomes difficult to understand how the band itself could get ‘tight’ in the first place. The tissue is relatively rigid and doesn’t have the quality to length or shorten. Then what could possibly have an effect to cause the band to functionally shorten or cause the pain?

Three Overlooked Components

In these cases, I see three major components that sometimes get overlooked. First, what does have the tendency to tighten up are the muscles that the band directly attaches to; a relatively small muscle coming off of the front and side of the hip called the tensor fascia lata (TFL), and the large gluteus maximus (the outer part of the major muscle of the buttock). These muscles can be stretched effectively with the following technique, among others. First, standing with the right leg crossed behind the left, then side-bending the trunk to the left (this stretches the TFL of the right leg and ITB). Also, lying on your back and pulling your right knee towards your chest would stretch the Gluteus Maximus. In my experience, however, these stretches are often not successful by themselves.

Stretch for Gluteal Muscles

Stretch for gluteus maximus.

A second influencing factor for ITB Syndrome are muscles that attach to the pelvis, spine, and thigh that have shortened. The iliopsoas, gluteus minimus, and deep hip rotators such as the piriformis, once shortened, cause the thigh bone to be rotated on the pelvis. Some signs that this condition may exist may be seen in the following: When standing erect, does one foot’s arch appear noticeably flat compared to the other? When lying flat on your back with legs relaxed, does one leg appear turned out noticeably more than the other? While these situations are not the only reason that may cause an arch to be flat or a leg to be turned out, it is a hallmark of a muscle imbalance that I see regularly in clients who have ITB pain. This condition is quite amenable to targeted stretching. It could include stretching the hip flexors (iliopsoas) as seen in a forward lunge stretch or similar modification, and a deep hip rotator stretch or the “pigeon pose” stretch. (See photos.)

Forward Lunge and Pigeon Pose

Forward Lunge and Pigeon Pose

Finally, there is a large and significant muscle that runs immediately underneath the IT band, the vastus lateralis. It is the outside muscle of the four quadricep muscles in the front of the thigh. This muscle can get irritated and develop trigger points. A trigger point (TP), is a small band of hypersensitive muscle fibers that, when pressed, can give rise to pain in characteristic patterns, in this case along the ITB, and can involve the outside of the knee. This component can be treated effectively with deep tissue mobilization.

Iliopsoas Muscle Group Diagram

Deep Tissue Rolling

Some people perform their own deep tissue mobilization by rolling the side of their thigh with a foam roller or ‘stick.’ (See photos.) For some, this can be quite effective, but I don’t believe it is ‘rolling out the ITB’ that is being effective; it is the muscle underneath. And sometimes deep tissue rolling and massage are not fully effective and the TP requires deactivation with dry needling.

Check out our VIDEO: Foam Rolling Techniques for Runners”

Trigger Point Dry Needling

Dry needling is a technique used by certified clinicians that uses a very thin, solid filament needle that is placed directly into the TP within the muscle. They are the same needles used in acupuncture, though this is only for the purpose of deactivating the TP. (See photo.) Again, the IT band itself does not have the ability to contract or lengthen to any substantial degree. When these deep tissue techniques or dry needling are effective, I believe it is predominantly due to the effect on the vastus lateralis muscle.

In the case where the pain is only in a small, local spot where the ITB attaches just to the side of the knee, ice can help reduce the pain temporarily. But the source of the problem is usually elsewhere, like the some of the faulty biomechanics described above, and it can include how and where a person might train. For example, the curved elements of a track will increase the strain on the left leg if you are running clockwise. Indoor tracks have tighter turns, and increase loading further if the turns are not banked. Even if you routinely jog on the road, always facing traffic results in an asymmetrical strain on the left and right legs due to the crown design for roads to shed water.

Deep Tissue Rolling

Deep Tissue Rolling

Customized Orthotics and Kinesiology Taping

Orthotics, or inserts for shoes that customize the arch for the individual, as well as specialty elastic tape (Kinesiotape or Rock Tape®) can be helpful components for selective individuals. I recommend you consult a professional trained in orthotics or taping application.

Note that while I have described the IT band condition as it presents on only one leg, it is possible that some folks have the pain on both legs, though the same principles apply.

Finally, the challenging part of ‘persistent’ IT Band Syndrome is in knowing how many of these components are contributing to the individual’s condition, and which ones are the predominating factors. The good news is that clinicians well trained in these conditions can help you if needed.

I hope you have found the information helpful.

Billy Cioffredi, PT/founder

Cioffredi & Associates

Trigger Point Dry Needling

Trigger Point Dry Needling


Overview of the Knee

Runner’s Knee (Patellofemoral Pain Syndrome)

Common Running Injuries

Trigger Point Dry Needling: Applications & Evidence

Piriformis Syndrome: That Pain in the Butt



Bill Cioffredi, PT - Founder

In the bodywork and exercises that we use in our work, I often feel we are simply undoing what people have done to themselves. Most of our clients didn’t have an accident. Rather, they developed a painful condition gradually, often times without a known reason. Postural pain, as well as joint and muscle pain, are often the result of unknowingly tensing or activating muscles that don’t need to be working or are working too much for the demand. Herniated discs, sciatica, arthritis pain, and rotator cuff problems are all just examples that are influenced by this issue. To a large degree, our work in helping people to restore pain-free movement involves freeing up stiff tissues in joints. But then we need to teach people how to “relax” their muscles. “Release” may be a better term, as we want our clients to release the excessive tension and muscle activation—not have muscles go totally soft.

“Good posture” is not a held position; it is free of excessive tension. You can see this kind of freedom in action in a master glassblower. They move smoothly and effortlessly, free of excessive tension as they work with the glass. We are often involved in teaching people to “release” their excessive muscle tension and “get out of their own way.” It can be learned. To that end, we have added a Qigong movement class on the weekends taught by Peter Payne, who is a master at teaching people how to “get out of their own way.” Check out the videos at

Best Wishes,
Billy Cioffredi, PT

Related Articles

Pain and Resilience: What I’ve Learned
Treating the Cause of Tension Headaches
Why Qigong?


Back on the Job: Hanover Firefighter Jack Emerson

Jack Emerson, Hanover Firefighter and Cioffredi Client

“When I hurt my back at work I was unsure if I would ever be able to return to work at the firehouse. The staff here was so encouraging and motivating. I had to put the hard work in, but Zac kept me focused and on track. The entire staff knows your name, it feels like they are all in your corner. I had heard I might be out for 4-6 months, at best, but 2 ½ months later I’m back on shift working full duty.” –Lieutenant Jack Emerson, Hanover FD



Did You Know?

Low Back Pain is Responsible for 33% of Workers’ Comp Claim Costs

Low back pain is one of the most frequent and disabling conditions affecting workers in their productive years. Quality of life and job selection are limited, and recurrence is a major reason for early retirement and disability claims. Low back pain is responsible for 16% of workers’ compensation claims, and a disproportionate 33% of total claim costs.
-Garg et al. BMC Musculoskeletal Disorders 2013, 14:84

How Can We Help?

Learn more about the benefits of physical therapy for low back pain.


Dawn Famiglietti: A Story of ResilienceDawn Famiglietti: A Picture of Resilience

When Dawn Famiglietti of Sunapee reached out suddenly to break someone’s fall one day in late 2011, she was acting on instinct. She had no idea that this quick action would change her life forever, sending her on a journey of pain and healing that would test her to the core. Today, with rods and cages fusing together seven vertebrae in her lower back, Dawn shares inspiration and encouragement with everyone she meets.  Her message: “Don’t stop moving!”


The scope of Dawn’s back injury did not become fully apparent for several months after the incident. During that time her life became a waking nightmare of unbearable pain. “We tried everything at first: steroid injections, chiropractic adjustments, massage, the pool,” but relief just wouldn’t come without increasing doses of narcotic pain medication—and then with greater frequency.  She suffered headaches, couldn’t sleep, and the pain that shot down her leg like an electric current was unrelenting. She found herself constantly lying on the floor, and away from her loved ones. “Standing was difficult, driving was almost impossible, and I couldn’t sit long enough to even have dinner with my family.”


To hear her explain it, Dawn fought hard against the idea of being disabled, but the pain and the growing distance between living and merely existing took their toll. “I tried to stay positive in front of my family, but when they were gone I had panic attacks and anxiety. I was depressed.” Like so many people, Dawn found it hard to share her pain or ask for help, but it became too much. “I reached a point where I stopped caring, and I felt very desperate.” When the Christmas decorations didn’t even come out of storage in 2012, she knew she had hit bottom.

SURGERY AND REHABSeven-Vertebrae Lumbar Fusion X-Ray

A surgeon in Boston was finally able to repair Dawn’s severely damaged spine with a multilevel lumbar fusion, a procedure that took two days to complete. Then more than a year since her injury, he challenged her to take charge of her own care. “You can do anything you want,” he told her, “the question is only whether you want to do it.” Right away she knew that her top priority was to get back to normal living, and to move as pain free as possible with minimal use of medications.

Dawn arrived at Cioffredi  & Associates with a limp and still hurting from her initial recovery rehab, but determined to get back her life and her sense of herself.

“When you have back pain, people can’t see it. It’s not like there’s something obviously wrong with you. I had a hard time when I went back to work, because I think I felt like people wouldn’t believe that I was really injured—that they would think I was soaking the system.”


Physical Therapists Marsha Wykes and Anna Hinman worked with Dawn during her rehabilitation. “They were wonderful,” Dawn reported. “They made me feel important, and that I wasn’t there for no reason. They gave me good information to follow; they educated me, and when I didn’t do my exercises the way I was supposed to,” she explained sheepishly, “I was gently prodded. I almost didn’t want to leave.”


Dawn’s PT experience helped her to be constantly thinking about her posture and the way she does things, and even today she misses no opportunity to stretch or move. Most of her coworkers have no idea of the ordeal she has gone through since 2011, but they might just notice how energetic and positive she is. She always takes the stairs, often two at a time, and sometimes takes an extra set just to push herself. In her office, which is equipped with both a standing desk and a yoga mat, she’ll take a break and do a few stretches. If her door is open and someone sees her bending over in a forward fold, “l just tell them I’m looking for my contact lens. I don’t want anyone to say ‘Poor Dawn,’ I just know that I’ve got to keep moving, just keep those muscles moving.”

POSITIVE OUTLOOKDawn Famiglietti Back on Her Horse

While Dawn’s outcomes are remarkable, she will likely always have good days and “not-so-good days,” when back pain intrudes. She’s determined to keep her positive outlook, but on the tough days she allows herself a break—and occasionally even some Tylenol—and acknowledges that there are things she will always need to approach differently. There won’t be any sit-ups or back bends in her daily fitness routine, for example, but her doctors have cleared her for “everything but skydiving.” Mostly she just wants to keep on gardening, caring for her horses, taking her dog for longs walks, and filling the wood box.

“I set goals for myself that aren’t huge. I look at my behavior and I try not to get down on myself; to go easier for the big things and just always keep moving.”

Her next big goal has to do with her daughter’s wedding in September 2017, she explains bashfully, pointing to her feet. “I want to be able to wear shoes with a little heel.”

LEARN MORE about the kind of excellent physical therapy care that Dawn received at Cioffredi & Associates.

This article appeared in the Cioffredi & Associates July 2017 newsletter. View the entire issue online.

George Merrill’s Total Approach to Movement

Cioffredi & Associates is grateful to serve so many outstanding members of the Upper Valley community, and for the trust they place in us to restore and enhance movement and to get them back to doing the things they love. George Merrill took full advantage of our continuum of care services, and he was kind enough to share his “Movement for Life” experience…

George Merrill's Total Approach to Movement
Continue reading

Introducing Two New Members of the Cioffredi & Associates Team

Cioffredi & Associates | The Institute for Health & Human Performance is growing to better serve your needs, with the addition of a physical therapy clinician and an integrative health coach to our team.


Julie earned her Doctorate in PT in 2007, as well as a BS in Psychology in 2004, from Sacred Heart University. She has been practicing orthopaedic and sports rehabilitation therapy since 2007, with a special interest in adolescent athletes.

Julie loves all things “active and outdoors.” As a college athlete she captained her field hockey team, achieving second team All-American recognition, and served as assistant coach as a graduate student. She has experienced many areas of the country including Alaska and Washington state as a travel therapist, and enjoys snowboarding, biking, hiking, kayaking, and “playing with her pups!”

Learn more about how Julie can help you live a happier and healthier life.

MICHELE BOUTIN, Integrative Health Coach and Client Care RepresentativeMichele Boutin, Integrative Health Coach

Michele has been practicing as an Integrative Health Coach in the Upper Valley for the past 10 years, specializing in immune system and GI wellness and has, recently, added Personal Cheffing to her services. As a Freelance Writer in the field of Integrative Health, Michele’s pieces have been published in: Upper Upper Valley Parents Paper, HEAL, Kids Stuff, Kearsarge, and Upper Valley Life Magazine.

As the Client Care Representative, Michele ensures that all clients of Cioffredi & Associates get what they need and want from their care and that their experience with us is of the highest quality.



Humanities and Health

Do you know someone who exercises regularly, but it’s almost a compulsive activity to “manage stress?” Controlling their weight is a constant “battle.” Going to their physician is a source of stress, as they wait to see what their numbers are going to be; worrying about their blood pressure, cholesterol, or other lab values they’re monitoring.William Cioffredi, PT

Then there’s the person for whom exercise and activity are enjoyments. They seem to eat sensibly, and you don’t hear them describing things that they should or shouldn’t be eating. They just generally seem to be happy, laugh easily, and seem confident without being cocky. They get sad in appropriate situations, but the sadness doesn’t persist. They don’t seem to be “battling” anything in their life. If they have a health problem, it doesn’t seem to dominate their life.

At a time when technology seems to be advancing at the speed of light, research is delving deeper and deeper into our own biology for the answers to better health. Yet our country is one of the largest consumers of pain and psychotropic medication, as well as alcohol and other drugs that help us to interface with life.

Could it be that one of the challenges with our health is that our understanding of the humanities and human behavior has not kept up with the pace of technology in the natural sciences? If it piques your interest, consider attending our Speaker Series event in May.

Learn More about our Spring 2017 Speaker Series

Featuring Dr. Cathleen Beaver and Dr. Dominic Candido, founders of Enhance Health.


5:15-7:00 p.m.

Cioffredi & Associates | The Institute for Health & Human Performance

112 Etna Road, Lebanon, New Hampshire

Happy, Healthy New Year

The Pursuit of Happiness

“The pursuit of happiness…” Our forefathers thought it important enough to include it the Declaration of Independence, and yet I’m struck by how we, here in New England at least, seem to talk more about improving our health—and our healthcare—than we talk about our happiness (maybe happiness is more a West Coast thing?). Despite continuous advances in medicine, people are expressing more anxiety about their health to me than at any previous time in my career. As this New Year begins, my wish is that we can all achieve both.

Competence and Confidence

Like healthcare, the pursuit of happiness is big business in the United States. For me, it’s important to realize that they are not the same, although they can overlap. I’m talking about the condition of happiness, not that temporary emotion whose opposite is “sadness.” The condition of happiness can include appropriate periods of feeling sad, at the loss of a friend or a pet, for example, but the condition of happiness persists. There are two elements I’ve observed that seem to be fundamental to people enjoying the condition of happiness: competence and confidence. Whether it’s in a skill or within a relationship, feeling competent and confident seems vital to success. What if you felt this way about your health?

Health and Relationships

The subtitle of Ruth Whippman’s recent book, “America the Anxious,” explains “How Our Pursuit of Happiness Is Creating a Nation of Nervous Wrecks.” If that is so, we are a less healthy nation, since there is clear biological evidence that chronic stress negatively affects our basic physiology. Whippman found evidence that yoga, meditation, and mindfulness show positive physiological effects, but her research revealed that the strongest indicator of happiness was connected to relationships.

Helping People

In our practice, people come to us primarily because they have a painful condition. I believe our greatest success is demonstrated when we can help them achieve confidence and competence in taking care of that aspect of their health. Strong relationships are fundamental to delivering on this success.

And so…to those professionals with whom we have had the pleasure to work, and to those individuals whom we’ve had the privilege to treat, I wish you a healthy and happy New Year.


William Cioffredi, PT

View  & Read the Entire Winter 2017 Newsletter Online!

Cioffredi Newsletter January 2017 Cover



Cioffredi & Associates Recognized Nationally with PRACTICE OF THE YEAR 2016 Honorable Mention

Cioffredi Recognized Nationally Top 4 PT Practice


December 2016

Cioffredi & Associates was named recipient of one of three national 2016 Honorable Mentions for ADVANCE magazine’s Practice of the Year award. Read on for an excerpt from the full article in the December 2016 edition of ADVANCE for Physical Therapy & Rehab Medicine.


Second Consecutive Year

For the second consecutive year, Cioffredi & Associates|The Institute for Health and Human Performance, located in Lebanon, NH, has earned a “top 4” designation in the Advance Healthcare Network’s ADVANCE Magazine’s Physical Therapy Practice of the Year award competition.

Now in its 15th year, the ADVANCE Practice of the Year Contest tallies anonymous entries from across the country and scores them on a range of success metrics. The contest is free to enter and is never connected with advertising contracts or incentives.

Other recipients of the top 4 honors included Foothills Sports Medicine Physical Therapy, a practice with 22 clinic location headquartered in Phoenix, Arizona, and Synergy Physical Therapy & Sports Medicine based in Jacksonville, North Carolina.

We continue to be grateful for the opportunity to work with wonderful people here in the Upper Valley!

About Cioffredi & Associates, Lebanon, N.H. 

Cioffredi & Associates is located in Lebanon, N.H., near Dartmouth College, Dartmouth Hitchcock Medical Center, and Alice Peck Day Memorial Hospital. Founder Bill Cioffredi, PT, grew up in Rutland, Vt., graduated from the University of Pennsylvania in 1979, and began his professional career at Dartmouth-Hitchcock Medical Center right out of school. While at DHMC he met Ruth Curtis, an OT specializing in hand rehabilitation.

In 1985 Bill and Ruth married, and established the Cioffredi Orthopaedic & Sports Therapy Center. Originally, the practice was open part-time, with Bill as sole provider. As the caseload grew, he brought on additional staff to meet demand and to maintain his policy of immediate therapist access. The organization moved four times since its inception, each time to a larger and more efficient space. Today the practice has 23 staff members offering a full complement of therapy services.

“In 2014, we moved to new location and developed the Institute for Health and Human Performance,” said CEO Amy Hayward. “The vision of the institute was to provide adjunctive and complementary services, which include medically based personal training, nutrition counseling, massage therapy, and health coaching to our existing rehabilitation services. It also allowed us the ability to provide educational forums and programming on a variety of healthcare topics to the general public. The institute is now viewed as a resource of knowledge for in the community.”Cioffredi Award Winning Practice

Their patient-first customer service philosophy includes immediate therapist access, a warm and welcoming therapy environment, inspiring open floor plan complete with cathedral ceilings, natural light, and views of the surrounding woods, and a client care representative who meets with all new patients.

Pillars of maintaining a committed therapy team include a mentorship program, a continuing education allowance, regular 1:1 meetings with supervisors, opportunity to participate in a speaker series, and a fun working environment that often features free breakfast and lunch, staff contests, and regular outings for pizza and bowling. Cioffredi & Associates regularly hosts DPT students as a clinical affiliation site.

Newer offerings include a corporate wellness program and occupational health services. “We are currently working with two local banks that, combined, employ over 350 people, as well as a large accounting firm,” Hayward said. “In our occupational health services we are currently piloting a program working with 36 glass blowers for a nationally recognized company.”

balance workoutAdditional services include a balance and vestibular program that offers free fall prevention screens to people ages 65 and older, and a pediatric therapy program that fills a void in the community for outpatient pediatric services. A speaker series, single-topic seminars, presentations at schools and senior centers, physician meetings, and regular e-mail and social media communication top the list of community engagement.

“In addition to highly competent clinical care, we believe there are other aspects that make up the total patient experience,” Hayward said. “Not only quality of care and clinical outcomes, but a highly satisfied client that has formed a relationship with our office.”