Iliotibial band syndrome

Is iliotibial tract syndrome (ITS), also called runner's knee, caused by friction or strain on the iliotibial tract? Should we stretch and/or use a foam roller in this case? Or is it all about strengthening the gluteal muscles?

In answering these questions, we would like to dispel several myths associated with this.

SIT is the only source of pain in the lateral aspect of the knee

First, SIT is by far the most common cause of lateral knee pain and is reported to account for 12% of all running overuse injuries. Of course, there are other reasons that can cause such pain. Typical signs and symptoms of SIT include increased pain when running downhill or on narrow trails and a history of sudden increase in training volume. If the patient reports pain at the back of the knee, distal biceps tendinopathy will have to be considered. Unlike SIT, pain from hamstring tendinopathy gets worse when running uphill and also when running at higher speeds, but gets better as you warm up.

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Additionally, you must consider patellofemoral pain, which is very common in runners. Pain from patellofemoral pain syndrome usually worsens when bending the knee under weight, walking up stairs, or after prolonged sitting, also called movie theater sign.

Finally, lateral meniscus pathology or early osteoarthritis may be a cause of pain in runners who regularly run on hard surfaces who report pain when squatting deeply or twisting the knee. This is more common in patients over 40 years of age. There may even be some morning stiffness present in this group.

Iliotibial tract syndrome

Iliotibial band syndrome (ITS) is a common knee injury that is usually accompanied by pain and/or tenderness on the lateral aspect of the knee, above the joint line and below the lateral femoral epicondyle [1]. It is considered a non-traumatic overuse injury often seen in runners and is often accompanied by weakness of the hip abductors [2][3]. The current theory is that this condition is likely caused by compression of innervated local fatty tissue [4]. Research has described a “zone of impingement” occurring at or just below 30° of knee flexion during kicking and early running. During the impingement period of the running cycle, eccentric contraction of the tensor fasciae lata and gluteus maximus muscles causes the leg to decelerate, creating tension (compression) in the iliotibial band [5].

Clinically Relevant Anatomy

The iliotibial tract is a thick band of fascia that runs along the lateral side of the thigh from the iliac crest and inserts at the knee [6]. It is composed of dense fibrous connective tissue that arises from the tensor fascia lata and the gluteus maximus muscle. It descends along the lateral aspect of the femur, between the layers of superficial fascia, and inserts on the lateral plateau of the tibia in a projection known as Gerdy's tubercle [2]. In its distal part, the iliotibial tract covers the lateral epicondyle of the femur and extends to the lateral border of the patella. While the iliotibial tract has no bony attachments as it runs between Gurdy's tubercle and the lateral epicondyle of the femur, this lack of attachment allows it to move forward and backward as the knee flexes and extends.

Histologic and anatomical examination of the iliotibial tract at the lateral femoral epicondyle, gluteus maximus, and tensor fasciae lata suggests a mechanosensory role acting proximally to the anterolateral aspect of the knee. This mechanosensory role may influence the interpretation of the function of the ligaments and tendons of the PTP from the femur to the lateral epicondyle of the femur.

Epidemiology/etiology

SPK is one of the most common injuries in runners, causing lateral knee pain, with an estimated incidence of 5% to 14% [7]. Further research suggests that PTSD is responsible for approximately 22% of all lower extremity injuries [1].

The etiology of SPBT is often multifactorial. Long distance running is a common cause of PTSD, especially when running on a slightly incline, as a small drop on the outside of the foot stretches the PTSD, increasing the risk of injury, and a sudden increase in activity level can also lead to PTSD. Although repeated tissue compression leading to irritation is best supported by recent evidence, there are a number of other hypotheses regarding the development of this condition.

When the knee is in extension, the iliotibial band lies anterior to the lateral femoral epicondyle. When the knee is in 30° of flexion, the tract moves posteriorly to the lateral epicondyle of the femur. It is hypothesized that friction may therefore occur between the posterior edge of the iliotibial band and the underlying lateral femoral epicondyle.

Muscle weakness of the hip abductors may also be associated with iliotibial band syndrome as it causes increased internal rotation of the hip and adduction of the knee. This has been considered a major problem for athletes with iliotibial band syndrome [6][8]. Another proposed etiology is chronic inflammation of the PBT bursa [9].

Characteristics/clinical picture

In many cases, subjective assessment will already provide an excellent basis for suspecting this syndrome. Activities that require repetitive knee flexion and extension are commonly reported, along with burning pain at (or just below) the lateral epicondyle of the femur. The diagnosis of patients with this syndrome is based on various symptoms [10].

The main symptom of PTSD is acute pain on the outside of the knee, especially when the heel hits the floor, which may extend to the outside of the thigh or calf [11]. The pain tends to get worse when running or going down stairs. An audible clicking sensation may occur as the knee bends due to the tract sliding over the bony tubercle. There may also be some swelling on the outside of the knee.

Characteristics include exercise-related tenderness over the lateral femoral epicondyle [10]. The patient may regularly experience sharp, burning pain when pressing on the lateral epicondyle of the femur when flexing and extending the knee [3]. Signs of inflammation may also be detected [1][10]. During running, pain occurs in the lateral aspect of the knee, which is worse when going down a hill or going down stairs, and the pain is usually worse when running long distances [12].

The first well-documented cases of SPBT were conducted by Lieutenant Commander James Renne, a Medical Corps officer who documented 16 cases of SPBT out of 1,000 recruits. Onset most often occurred in the lateral aspect of the knee after 2 miles of running or walking more than 10 miles. Walking with the knee extended relieved the symptoms. All patients had focal tenderness over the lateral femoral epicondyle at 300 flexion, and 5 patients had unusual palpation described as “rubbing the finger against a wet balloon” [13].

The prevalence of PTSD in women is estimated to range from 16% to 50%, and in men from 50% to 81% [7].

Differential diagnosis

• Biceps tendinopathy
• Degenerative joint disease
• Damage to the lateral collateral ligament (LCL)
• Meniscus dysfunction or injury
• Myofascial pain
• Patellofemoral stress syndrome
• Popliteal tendinopathy
• radiating pain in the lumbar spine, stress fractures and sprains of the upper tibiofibular joint [14].
• Osteochondritis dissecans of the knee joint
• Overuse injury
• Peroneal mononeuropathy
• Acetabular bursitis [15].

Diagnostic procedures

There are various provocative tests:

• Renne test
• Noble test
• Ober test

Survey

• Hip abduction strength:

The strength of the hip abductors may be reduced. Therefore, these muscles should be tested [10].

• Treadmill test:

This test has been described in several studies as a valid, effective and sensitive method for assessing the effects of treatments for running-related pain and is used to measure the amount of pain subjects experience during normal running. If this includes pain in the lateral aspect of the knee, the test is considered positive [16].

• Noble compression test:

This test begins in the supine position with the knee flexed 90 degrees. As the patient extends the knee, the examiner applies pressure to the lateral femoral epicondyle. If it causes pain over the lateral epicondyle of the femur at 30-40 degrees of flexion, the test is considered positive [3]. A goniometer is used to ensure correct knee angle [16].

• Ober test:

The patient lies on his side with the injured limb facing upward. The knee is flexed 90 degrees, and the hip is kept in line with the torso during abduction and extension. The patient is asked to abduct the hip as far as possible. The test is considered positive if the patient cannot abduct further than the edge of the couch. A positive Ober test indicates a short/tight iliotibial band or tensor fascia lata, which is often associated with friction syndrome [1][17].

Both the Noble compression test and the Ober compression test can be used to evaluate a patient with suspected iliotibial band syndrome. The result will be more obvious if you combine them into one special test. To do this, the Ober test position is adopted and compression is applied to the lateral epicondyle during passive extension and flexion of the knee. Moving the knee can place more stress on the damaged structures and may help reproduce the patient's symptoms if the combination does not. Medial sliding of the patella can also increase symptoms and may reveal the exact location, while lateral sliding reduces them. Internal rotation of the tibia, where the knee moves from flexion to extension, can also cause symptoms. A combination of the Noble and Ober tests with the knee unweighted or in a weight-bearing position can also be performed to reproduce symptoms [3].

Treatment

Treatment of acute inflammatory response

Modifying activity to prevent further deterioration of the patient's symptoms should be the first area to address in treatment. Encouraging periods of active rest or significantly reducing the intensity of aggravated activities would be a good starting point. Patients should be encouraged to participate in other physical activities, such as swimming, that do not aggravate their symptoms, in order to maintain fitness. It is important to work with the patient to find a level of activity that allows them to feel confident in their ability to rehabilitate and have a clear understanding of why this reduction in activity is necessary, and to exercise within a pain-free range [4]. Some authors [1][3] suggest complete rest from sports for at least 3 weeks; other authors [2] suggest that it is best to rest for 1 week to 2 months, but this period of rest is highly dependent on the specific clinical case of each person.

Other methods that may provide pain relief include ice (cryotherapy) or heat [1][9], taping and stretching according to objective results.

If symptoms do not improve and inflammation persists, the following treatments may be considered:

• Ultrasound therapy [9], providing thermal or non-thermal treatment of damaged tissue in the frequency range from 0.75 to 3 MHz (depending on the depth of the soft tissue being treated) [18]
• Muscle stimulation [9]
• Iontophoresis or phonophoresis [9], methods in which a drug is introduced into damaged tissue through the distribution of ions controlled by an electric field, or passed through the skin using ultrasonic waves, respectively. Iontophoresis with dexamethasone may be useful as an anti-inflammatory agent [6].  

Phonophoresis has been used in an attempt to enhance the absorption of topically applied analgesics and anti-inflammatory drugs through the therapeutic application of ultrasound. One study assessed the effectiveness of two methods of treating PTSD: phonophoresis using ultrasound to transfer 10% hydrocortisone into the subcutaneous tissue and immobilize the knee; the result suggests that the use of phonophoresis is a better treatment than simple knee immobilization [19].

An alternative treatment strategy is radial shock wave therapy. RSVT is considered safe because it results in minor side effects, including worsening of symptoms over a short period of time, reversible local swelling, redness, and hematoma. RUWT is thought to stimulate soft tissue healing and inhibit nociceptors. Thus, it increases the diffusion of cytokines through the vessel walls into the painful area and stimulates the tendon healing response. Shock waves also reduce unmyelinated sensory nerve fibers and significantly reduce calcitonin-gene-related peptide, and substance-P release. Finally, shock wave treatment can stimulate neovascularization at the tendon-bone junction, thereby promoting healing.

Shockwave therapy uses energy generated when a projectile in a handpiece is accelerated by compressed air and fired into a 15mm diameter metal applicator. The energy is then transferred from the applicator through the ultrasound gel to the skin, where the shock wave is dispersed radially into the treated tissue.

Radial shock wave therapy has been shown to be indeed effective as a rehabilitation program for runners with iliotibial band syndrome [16].

Physiotherapy

Treatment for SPBT is usually non-operative, and physical therapy should be considered the first and best line of treatment.

• iliotibial band stretching exercises are no longer considered a strictly valid treatment approach. The best exercises to start with will depend on causal factors derived from subjective and objective assessment. If the gluteal lateral muscles are found to be weak or malfunctioning, this will result in compensatory muscle adaptations that may result in excessive contraction of the iliotibial band [12]. If the gluteal groups are too short, external rotation of the leg can occur and create abnormal tension in the iliotibial band [20][7].
• Myofacial treatment can be effective in reducing pain in the acute phase when pain and inflammation are felt at the insertion site. Trigger points in the biceps femoris, vastus lateralis, gluteus maximus, and tensor fasciae lata will be addressed with myofascial treatment [6].
• Using a foam roller on tight muscles can also be helpful [12]. The patient can also perform exercises using a foam roller at home to create deep lateral friction, self-myofascial release (massage), and muscle stretching. A possible exercise is to lie on your side with a foam roller placed perpendicular to your lower leg, just below your hip bone. The top foot should be positioned in front for balance. Using your hands for support, roll up and down on the roller [21].
• Exercises to strengthen the abductors and stabilize the hip may be useful when clinically indicated. Because PTSD can often be associated with hip abductor weakness, hip strengthening and stabilization will be beneficial in the treatment of PTSD [2]. Some examples of useful exercises: Stand on the edge of a step with most of your body weight on the unaffected side. Lower the hip of the involved leg and return it to a neutral position [10]. Another example is the hip abduction exercise in a side decubitus position with the back pressed against the wall and the leg held at approximately a 30° angle to hip abduction with slight external rotation of the hip and neutral hip extension. This exercise can be made more strenuous by placing a 1 meter long band between your ankles [2].

Other exercises that are recommended based on the relationship between single-leg weight loss and neuromuscular control are the single-leg step-down, the single-leg squat, and the single-leg raise [17].

• Hip/knee coordination and modification of running/cycling style by enhancing neuromuscular control of gait [1][12].
• Cyclists are also at risk of developing PTSD if they tend to pedal with their toes turned, so using optimal technique can minimize the risk of developing symptoms [12].

Surgery

In rare cases, surgery may be recommended. During the operation, a small piece of the posterior portion of the iliotibial band, which covers the lateral epicondyle of the femur, will be removed [9]. There is also some low-level evidence [1] supporting the resolution of SBST by surgical excision of the bursa, cyst, or part of the lateral synovial recess. Surgery is not indicated for SPBT, except in rare cases where long-term conservative treatment has neither relieved the patient's symptoms nor eliminated SPBT.

Sources

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2. Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy, 2006; 208(3): 309-316
3. Michael D. Clinical Testing for Extra-Articular Lateral Knee Pain: A Modification and Combination of Traditional Tests. North American Journal of Sports Physical Therapy, 2008; 3: 107–109.
4. Lazenby, T & Geisler, P (2017). Iliotibial Band Impingement Syndrome: An Updated Evidence-Informed Clinical Paradigm. Published 2017/03/06 DOI: 10.13140/RG.2.2.22882.53448
5. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial Band Syndrome in Runners. Sport Medicine, 2012; 42(11):969-92
6. Baker RL, Fredericson M. Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Physical medicine and rehabilitation clinics of North America, 2016; 27(1):53-77
7. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial Band Syndrome in Runners. Sport Medicine 2012;42(11):969-92.
8. Mucha MD, Caldwell W, Schlueter EL, Walters C, Hassen A, Hip abductor strength and lower extremity running related injury in distance runners: A systematic review., Journal of Science Medicine in Sports, 2017;20(4):349-355 .
9. Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. Journal of the American Academy of Orthopedic Conditions. 2011;19(12):728-36.
10. Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport, 2007; 10:74-76
11. Physical Medicine and Rehabilitation for Iliotibial Band Syndrome Differential Diagnoses. 2016.https://emedicine.medscape.com/article/307850 (accessed on 26th of Jul 2018)
12. Wong M. Pocket Orthopedics, Evidence-Based survival guide. Jones and Bartlett Publishers, 2009.
13. Seijas R, Sallent R, Galán M, Alvarez-Diaz P, Ares O, Cugat R. Iliotibial Band Syndrome Following Hip Arthroscopy: An unreported complication, Indian Journal of Orthopedics, 2016; 50(5): 486–491. doi: 10.4103/0019-5413.18959.
14. Khaund R, Flynn SH. Iliotibial band syndrome: a common source of knee pain. American Family Physician. 2005;71(8):1545-1550.
15. Bischoff C, Prusaczyk WK, Sopchick TL, Pratt NC, Goforth HW. Comparison of phonophoresis and knee immobilization in treating iliotibial band syndrome, Journal of Sports Medicine, Training and Rehabilitation, 1995, 6(1):1-6. https://doi.org/10.1080/15438629509512030
16. Weckström K, Söderström J. Radial extracorporeal shockwave therapy compared with manual therapy in runners with iliotibial band syndrome, Journal of Back and Musculoskeletal Rehabilitation, 2016; 29(1):161-70. doi: 10.3233/BMR-150612.
17. Gajdosik RL, Sandler MM, Marr HL. Influence of knee positions and gender on the Ober test for length of the iliotibial band. Clin Biomech (Bristol, Avon), 2003;18(1):77-9
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19. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: A randomized controlled trial. British Journal of Sports Medicine, 2004; 38(3):269-72;
20. Krista Simon; Iliotibial Band Syndrome; NYsportsmed, 2015.
21. Jerold M. Stirling et al., Iliotibial Band Syndrome Treatment & Management. Sports Medicine, 2015. https://emedicine.medscape.com/article/91129 Accessed on 30 Jul 2018

SIT is caused by friction against the bursa at the lateral epicondyle of the femur

The original idea behind SIT was that the iliotibial tract rubs against the lateral epicondyle of the femur. This occurs at approximately 30 degrees of flexion when the iliotibial tract changes its force vector from knee extension to flexion or vice versa.

However, Fairclough et al. (2006) showed that in fact there is no bursa of its own under the iliotibial tract. In addition, the same authors (2007) showed that the iliotibial tract is attached to the distal femur by fibrous threads, which makes friction in this part of the knee impossible. The “click” sensation that runners report is more of an illusion of movement that is created by changes in tension in the anterior and posterior fibers of the iliotibial tract during knee flexion.

Main symptoms

In most cases, the onset of the syndrome is characterized by the appearance of mild pain on the outside of the knee joint, distributed on the side of the knee. Pain appears two to three minutes after the start of a run, often intensifying while running on an inclined plane. After rest, the pain usually disappears, although if the injury is neglected, it may persist during rest.

Iliotibial band syndrome can be diagnosed when examined by a doctor using a series of tests. To exclude other possible causes of pain in the knee joint, X-ray examinations, computed tomography and MRI of the knee joint are also often prescribed.

Stretching and foam rolling are effective treatments for SIT.

A study by Seeber (2020) examined iliotibial tract stiffness. Scientists have concluded that the iliotibial tract can withstand significant forces and is largely nonextensible. What's more, they found that it actually ruptured at about 80 kilograms of stress. For this reason, the authors concluded that clinical stretching is not likely to result in any lengthening of the iliotibial tract. At the same time, many gyms around the world actively engage in stretching and rolling of the iliotibial tract. The expectation that this will disrupt adhesions or lengthen the iliotibial tract is unreasonable.

What may be possible is to stretch the muscles that attach to the iliotibial tract. However, what stretching likely achieves is increased pain tolerance when stretched in the short term. A study by Wilhelm (2017) showed that tensor fascia lata is in fact capable of some lengthening in response to clinical stretch (unlike the iliotibial tract), but the durability of the effect is poor.

Finally, if we assume that SIT is caused by excessive compression rather than friction, then all of these approaches will simply result in further irritation of the fat pad under the iliotibial tract. So all these procedures are likely to make the problem worse.

Runner's Knee Treatment

To treat runner's knee, the so-called “conservative method” is mainly used, which involves rest, relieving inflammation, a complex of physical therapy, massage, stretching, strengthening individual muscle groups with a gradual return to exercise. It is also important to eliminate factors predisposing to injury.

Depending on the “negligence” of the symptom, training is stopped for 2-3 weeks or stopped altogether, or reoriented to those that provide minimal stress on the problem area (swimming, for example).

At the first stage, it is necessary to relieve the inflammatory process. Rest alone may often not be enough, so ice compresses and non-steroidal anti-inflammatory drugs in the form of tablets or ointments ( paracetamol, diclofenac, celecoxib, etc. ) are used. In some cases, ultrasound and phonophoresis are used for physiotherapy.

At the next stage, physical therapy exercises are used, including both stretching the iliotibial tract itself and strengthening various muscle groups of the leg. Next, move on to light training on a flat, non-rigid surface. At first, you can use a pressure bandage (orthosis), which is worn at the level of the epicondyle of the femur to reduce friction of the tract during movement.

You can also use kinesio taping with cotton tapes; they can quite successfully replace a bandage, fixing the joint well and not interfering with its movements.

Surgical intervention for symptoms of the iliotibial tract is used quite rarely in particularly severe cases. Its effectiveness is more than 80%.

Gluteal muscle training

The general recommendation is to strengthen the gluteal muscles to reduce hip adduction and thus reduce stress on the iliotibial tract.

This is very patient dependent: while there are patients with increased valgus alignment who would certainly benefit from strengthening the hip abductors. The second group demonstrating SIT is typically men with knee varus alignment. In this group, hip abductor training may not be as effective as in the first group. In addition, a study by Willy et al. (2012) showed that training the gluteal muscles did not change biomechanics.

For runners, it ultimately comes down to a combination of addressing running biomechanics, training errors, and neuromuscular deficits.

Ober test

One of the indicative tests to confirm iliotibial tract syndrome is the Ober test. During the procedure, the victim is placed on his side (opposite to the injured leg), bending the healthy leg at the knee and hip joints at almost an angle of 90 degrees. Next, the doctor, fixing the patient’s pelvis, moves the injured leg back along the patient’s body with his hand. After this, he straightens the abducted leg and lowers it down.

If the iliotibial tract is inflamed, the leg will either not lower completely due to the tension of the tract, or such movement will cause pain in the knee area. If pain appears at the top of the thigh in the pelvic area, this indicates the presence of spindle bursitis.

To confirm the suspected diagnosis, additional tests may be performed, such as the Nobel test, jumping on the affected leg with a bent knee.

How to diagnose inflammation in the knee joint

To determine whether you are developing a serious syndrome, monitor yourself closely during and after training.

The inflammatory process with “runner’s knee” persists for a long time – from one and a half to six months. Having discovered characteristic symptoms, it is necessary to immediately begin treatment. First of all, you need to give up stress for a while and ensure peace. During the first day, it is recommended to periodically apply cold to the injured knee until the pain subsides.

Runner's knee can be diagnosed using an X-ray, MRI or ultrasound of the joint, as well as through consultation with an orthopedic traumatologist.

What are the preventive measures

With the right approach, an athlete can avoid recurrence of the syndrome in the future. But you should not try to treat the syndrome yourself, otherwise you will only worsen the process. Consultation with a doctor will help determine an effective rehabilitation strategy.

After recovering from an injury, a runner should begin working on strengthening the muscles of the lower legs and thighs. Exercises during rehabilitation:

• Walking on a flat surface, using a treadmill is acceptable, BUT not running.
• Exercise bike (with a high seat position to reduce the load on the knee joint).
• The ellipse is a universal trainer for all muscle groups (set to low resistance).
• Swimming, including water aerobics classes.

Be sure to do stretching exercises for all muscle groups.

During rehabilitation, it is necessary to exclude physical exercises with axial load on the knee joint. Care should be taken to master proper running technique in order to optimize the load on joints and tendons. Especially if in the near future the athlete will have to actively train and prepare for competitions.

During training, your doctor may recommend using knee braces (orthoses) to prevent injuries or special insoles that reduce the load on the knee joint.

How to treat PBT syndrome?

If there was a quick fix for PBT pain, life would be nice and easy, but unfortunately there isn't. The best way to relieve pain from PTS is to adjust your running technique.

PBT syndrome is a classic biomechanical problem.

Muscle weakness and dysfunction lead to predictable and repeatable changes in running mechanics, which increases the load on the RTP and causes damage.

Why does my knee hurt when running?

Runner's knee is a very common sports injury that is characterized by the development of chondromalacia of the patella (softening and deformation of the cartilage of the patella) or inflammation of the iliotibial tract.

Iliotibial syndrome is especially common among runners, cyclists, and people who engage in frequent long-distance walking.

source: pectrumhealthcare.com.au

Runner's knee can be considered an occupational injury for long-distance runners. But this syndrome also occurs in other sports, for example, among football players.

With high and prolonged loads, an athlete can develop pathological conditions - an inflammatory process in the iliotibial or iliotibial tract and chondromalacia of the patella. The latter is pathological changes in the cartilage, in which a loss of elasticity occurs. During this process, the joint formations are deformed. It is immediately worth noting that the pathology most often does not require surgical intervention.

What does it mean?

Although the pain is localized to the outer part of the knee, the real problem lies higher up.

While icing, stretching, and deep massage with a foam roller (just don't massage the PBT directly or you'll make it worse!) certainly helps, a biomechanical problem ultimately needs a biomechanical solution.

And for this there are exercises that strengthen the muscles responsible for hip abduction.

The most effective protocol to date for the treatment of PBT syndrome was described in 2000 by Michael Frederickson of Stanford University.

This fairly simple program consists of 2 stretching exercises and 2 strength exercises.

Stretching exercises are performed 3 times a day, holding the position of greatest stretch for 15 seconds for both legs. Strength exercises are initially performed in 1 set of 15 repetitions every day, and gradually the volume of work increases to 3 sets of 30 repetitions.

Classes in this program should last 6 weeks. The athletes in Frederickson's study abstained from running during this 6-week period, and 92% of them made a full recovery.