Physical Therapy in Sport 54 (2022) 44e52

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Conservative treatment of iliotibial band syndrome in runners: Are we

targeting the right goals?
Miriam C. Friede a, *, Gunnar Innerhofer b, Christian Fink c, d, Luis M. Alegre e, f,
Robert Csapo g
a
Carinthia University of Applied Sciences, Department of Physiotherapy, Klagenfurt, Austria
b
University of Innsbruck, Department of Sport Science, Innsbruck, Austria
c
Gelenkpunkt Sports and Joint Surgery, Innsbruck, Austria
d
University for Health Sciences, Medical Informatics and Technology, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall, Austria
e
University of Castilla-La Mancha, GENUD Toledo Research Group, Toledo, Spain
f
CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
g
University of Vienna, Department of Sport Science, Vienna, Austria

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Iliotibial band syndrome (ITBS) is presumably caused by excessive tension in the iliotibial band
Received 13 April 2021 (ITB) leading to compression and inflammation of tissues lying beneath it. Usually managed conserva-
Received in revised form tively, there is a lack of scientific evidence supporting the treatment recommendations, and high
23 December 2021
symptom recurrence rates cast doubt on their causal effectiveness. This review discusses the influence of
Accepted 23 December 2021
common physiotherapeutic measures on risk factors contributing to tissue compression beneath the ITB.
Methods: The potential pathogenic factors are presented on the basis of a simple biomechanical model
Keywords:
showing the forces acting on the lateral aspect of the knee. Existent literature on the most commonly
Iliotibial band syndrome
Biomechanical model
prescribed physiotherapeutic interventions is critically discussed against the background of this model.
Etiology Practical recommendations for the optimization of physiotherapy are derived.
Conservative treatment Results: According to biomechanical considerations, ITBS may be promoted by anatomical predisposi-
tion, joint malalignments, aberrant activation of inserting muscles as well as excessive ITB stiffness. Hip
abductor strengthening may correct excessive hip adduction but also increase ITB strain. Intermittent
stretching interventions are unlikely to change the ITB's length or mechanical properties. Running
retraining is a promising yet understudied intervention.
Conclusions: High-quality research directly testing different physiotherapeutic treatment approaches in
randomized controlled trials is needed.
© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

1. Iliotibial band syndrome
The iliotibial band (ITB) is a thickening of the fascia lata on the
lateral thigh that spans out from the iliac crest to the proximal part
of the tibia, and acts as important lateral stabilizer of the pelvis and
knee. It serves as common tendon for the gluteus maximus (GMax)
and tensor fasciae latae (TFL) and transmits their contractile forces
to various insertions on the distal femur, patella, joint capsule of the
knee, and tibia (Flato et al., 2017; Godin et al., 2017). In addition to
GMax and TFL, also the gluteus medius (GMed), the biceps femoris
* Corresponding author. University of Applied Sciences, Dept. of Physiotherapy St.
Veiter Straße 47, 9020, Klagenfurt, Austria.
E-mail address: m.friede@fh-kaernten.at (M.C. Friede).
and vastus lateralis muscles insert into the ITB with some tendinous
components (Baker & Fredericson, 2016; Flato et al., 2017).
One common clinical condition affecting the ITB is the iliotibial
band syndrome (ITBS), also known as runner's knee. ITBS is one of
the most common overuse injuries in runners that affects 12e16%
of athletes (Baker & Fredericson, 2016; Benca et al., 2020; Fields,
2011) and often forces them to suspend their sports activity
temporarily or, in refractory cases, even permanently (Benca et al.,
2020; Mulvad et al., 2018; Ramskov et al., 2018). Clinically, ITBS
mainly presents itself as sharp or burning pain in the region of the
lateral femoral epicondyle. Symptoms typically occur during
physical activity, after a reproducible time or distance of running.
The etiology of ITBS has been a subject of controversial debate.
Traditionally, friction between the ITB and the lateral femoral

https://doi.org/10.1016/j.ptsp.2021.12.006
1466-853X/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.C. Friede, G. Innerhofer, C. Fink et al. Physical Therapy in Sport 54 (2022) 44e52

epicondyle was believed to be the reason for the irritation of the where RH and RV represent the horizontal and vertical compo-
tendon e an explanation that has received some empirical support nents of R. Geometrical considerations dictate that RH and RV are
by an imaging-based study showing anterior-posterior movement contingent upon a1 and a2 , i.e., the angles enclosed by the hori-
of the ITB relative to the lateral femoral epicondyle during knee zontal and the proximal and distal section of the ITB, respectively:
flexion and extension (Jelsing et al., 2013). A cadaveric study by
Fairclough and colleagues, by contrast, found the ITB to be firmly 2) RH ¼ F,cosða1 Þ þ FR ,cosða2 Þ; RV ¼ F,sinða1 Þ þ FR ,sinða2 Þ.
attached to the lateral femoral epicondyle by fibrous strands that
preclude shearing between the ITB and bone in the anterior-to- Since
posterior direction (Fairclough et al., 2006). The authors, there-

fore, proposed that excessive tension in the ITB might lead to RH > 0; a1 þ a2 < 180
3) ,
compression of underlying fat tissue or bursae, ultimately causing RH < 0; a1 þ a2 > 180
inflammation and pain (Ekman et al., 1994; Fairclough et al., 2006;
Muhle et al., 1999). Confirmatively, edema between the ITB and the the sum of a1 þ a2 determines whether RH acts to compress or
lateral femoral condyle are more typically seen than pathological relieve the fat pad positioned between the lateral femoral epi-
alterations of the ITB itself (Flato et al., 2017; Arend 2014). However, condyle and the ITB. The activity of the TFL undulates during the
direct and robust evidence in support of the compression hypoth- gait cycle, with peak activities recorded during the stance as well as
esis is missing. early- and mid-swing phase (Montgomery et al., 1994). Assuming
ITBS is usually managed conservatively through a combination that a1 þ a2 < 180 , the force compressing the fat pad beneath the
of rest, stretching and strength training as well as a modification of ITB may, therefore, be expected to fluctuate between the times of
the running technique e therapy options that have mostly been initial swing (iSw) and terminal stance (tSt), with the mean being
recommended based on expert opinions (Baker & Fredericson, given by
2016; McKay, Maffulli, Aicale, & Taunton, 2020; Mellinger &
Neurohr, 2019). The success of treatment is modest, with report-
edly only 44% of patients fully recovering during 8 weeks of therapy
(Beals and Flanigan, 2013). Symptoms often persist or recur despite
treatment (Beals & Flanigan, 2013; Friede, Klauser, Fink, & Csapo,
2020; Mulvad, Nielsen, Lind, & Ramskov, 2018). This unsatisfac-
tory outcome suggests that the most common treatment ap-
proaches are not sufficiently effective, but the prescription of better
interventions is complicated by the paucity of high-quality studies
evaluating their effectiveness (Balachandar, Hampton, Riaz, &
Woods, 2019; Ellis, Hing, & Reid, 2007; McKay, Maffulli, Aicale, &
Taunton, 2020; Mellinger & Neurohr, 2019). The few available
studies were uncontrolled and reported solely the patients' sub-
jective perception of pain and functional outcome measures (Beers,
Ryan, Kasubuchi, Fraser, & Taunton, 2008; Fredericson et al., 2000;
McKay, Maffulli, Aicale, & Taunton, 2020; Weckstro €m &
So€ derstro
€m, 2016; Zemadanis & Betsos, 2017). Based on this evi-
dence it is not possible to evaluate the treatments’ causal
effectiveness.
Against this background, the goal of the present review was to
discuss the plausibility of the treatment strategies mainly recom-
mended for the management of ITBS, under the assumptions that
the compression hypothesis is correct and the syndrome is truly
related to excessive ITB tension. For this purpose, a simple biome-
chanical model will be used to illustrate the factors theoretically
contributing to the compression of tissues lying beneath the ITB.

2. Pathogenic factors

Considering the simplified knee model shown in Fig. 1, the ITB is

a distal continuation of the TFL and GMax muscles (GMax not
shown for simplicity). It is linked to the femur through the lateral
intermuscular septum and fibrous tissue strands, and finally at-
taches to the tibia at Gerdy's tubercle. A highly vascularized and
innervated fat pad just proximal to the lateral epicondyle separates
the ITB from bone (Fairclough et al., 2006). Muscular contraction of
!
TFL (and GMax) exerts a pulling force F , which acts to tauten the
! !
ITB. As per Newton's third law, F is resisted by Fr . At the lateral
!
epicondyle, which acts as a pulley, the contractile force F also in-
!
duces a resultant force R , the magnitude of which is given by Fig. 1. Biomechanical model of the knee. SIAS¼ Spina iliaca anterior superior, TFL ¼ M.
tensor fasciae latae, MTJ ¼ Muscle-tendon-junction, EL ¼ Epicondylus lateralis,
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi GT ¼ Gerdy's tubercle, F ¼ force, R ¼ resultant force, RVert ¼ vertical force,
1) R ¼ RH 2 þ RV 2 , RHoriz ¼ horizontal force, a1 ¼ angle of proximal force, a2 ¼ angle of distal force.

45
M.C. Friede, G. Innerhofer, C. Fink et al. Physical Therapy in Sport 54 (2022) 44e52

R
iSw Harrison, 2018; Lieberman, Raichlen, Pontzer, Bramble, &
4) RH ¼ RH ðtÞdt=ðtSt  iSwÞ. Cutright-Smith, 2006; Mann & Hagy, 1980; Mann, Moran, &
tSt
Dougherty, 1986; Montgomery, Pink, & Perry, 1994). Particularly
If the ITB was perfectly stiff, increases in contractile forces would the contractile forces generated by the TFL and GMax are critical for
be instantaneously translated into increased resultant forces R. As a the forces F acting along the ITB as well as the resultant forces R.
collagenous tissue, however, it is a viscoelastic material that Only two studies published to date have compared these muscles’
dampens the increases in force during contraction and dissipates activation patterns during running between patients suffering from
ITBS and healthy controls. Baker et al. (2018) found the TFL activity
stored elastic energy as heat during relaxation. Thus, RH will also be
during the deceleration phase of stance to be significantly greater in
influenced by the ITB's mechanical properties.
ITBS patients at the beginning of a treadmill-based run. However, a
Based on the above biomechanical considerations, it is possible
later conducted meta-analysis, classified the overall standardized
to contemplate factors potentially contributing to increased tissue
mean difference found in this study as minor and non-significant
compression at the lateral aspect of the knee. One non-modifiable
(Besomi et al., 2020). Another study by Brown et al. (2019)
factor is small pelvic width, which might contribute to increased
compared the timing of TFL and GMax activity onset during the
compressive forces by decreasing a1 and, thereby, the a1 þ a2 sum
terminal swing phase in both the fatigued and rested state and
of angles. In confirmation of this hypothesis, a recent study in
found no differences between ITBS patients and controls (Brown
college athletes found smaller distances between femoral heads,
et al., 2019). Thus, although both the timing and degree of muscle
greater trochanters and anterior superior iliac spines to be associ-
activity may influence the resultant forces R at the lateral knee,
ated with a smaller base of gait during running (Heiderscheit et al.,
there is no clear evidence to suggest that the activity of muscles
2020), which, in turn, has been suggested to favor the development
inserting into the ITB would be either excessive or mistimed in
of ITBS (Meardon et al., 2012). At the knee, more prominent lateral
patients suffering from ITBS.
femoral epicondyles would move the point of ITB deflection further
As indicated above, the compression of tissues lying beneath the
laterally, which would equally result in more acute a1 and a2 an-
ITB may also be influenced by its mechanical properties. Under the
gles. Support for this notion comes from a recent MRI-based study,
simplified assumption that the ITB acts as a spring placed in series
in which the height of lateral femoral epicondyles was compared
with the muscles inserting into it, its stiffness may be defined as the
between subjects suffering from ITBS and age-, gender- and height-
ITB elongation in relation to the (contractile) force acting on it.
matched controls, and found to be significantly greater in patients
Theoretically, a perfectly stiff ITB would be fully resilient to defor-
(Everhart et al., 2019). However, it should be noted that, in this
mation and transmit the contractile forces F directly to its bony
study, the difference between groups was only 0.9 mm, so the
insertions. Any fluctuations in F would cause instantaneous
biomechanical effect was likely small.
changes in the resultant force R and, thus, the compression of tis-
In addition to predisposing shapes of bones, joint malalign-
sues lying beneath the ITB. However, collagenous tissues exhibit
ments, such as excessive hip adduction (lowering a1 ) or varus
viscoelastic properties (Sopakayang and Vita, 2011), which implies
alignment of the knee (lowering a2 ), would equally be expected to
that they are not merely elastic (i.e., they may be deformed by
rotate the resultant force R in the lateromedial direction. Moreover,
distorting influences and resume their original shape during
joint malalignments may also affect the degree of ITB strain and
unloading) but also dissipate a part of the absorbed elastic energy
tensile stress. As an example, knee varus and internal rotation shift
during unloading in the form of heat (viscous properties). Hence,
Gerdy's tubercle in the medial direction, which increases ITB strain
viscoelastic tissues, such as the ITB and other tendons (Kubo et al.,
(Baker et al., 2018; Ferber et al., 2010; Hamill et al., 2008; Kim et al.,
2002) fulfill two important functional roles: Firstly, they rhythmi-
2020; Meardon et al., 2012; Stickley et al., 2018). Such tensioning
cally store and release elastic energy to economize cyclic move-
might limit the tendon's capacity to dampen force peaks by storing
ments. Using a modeling study, Eng and colleagues estimated that
elastic energy. Although studies providing robust mechanistic ex-
the total energy stored in the ITB was 7 J per stride during running
planations are missing, cross-sectional studies comparing the
at 5 m/s, which equates to roughly 14% of the energy stored in the
running kinematics indeed suggest that during the stance phase
Achilles tendon (Eng et al., 2015). Secondly, they act as shock ab-
the peak hip adduction and knee internal rotation are greater in
sorbers that protect tissues by dampening force peaks and lowering
runners with ITBS (or those who go on to developing the syn-
impulse (Konow and Roberts, 2015). An overly compliant ITB,
drome) as compared to healthy controls (Mousavi et al., 2019).
however, might be ineffective in laterally stabilizing the knee and
Consistent with these observations, several studies found hip
hip in the frontal plane (Gottschalk et al., 1989). Due to the inherent
abductor weakness to be associated with ITBS, although the notion
difficulties in measuring the mechanical properties of the ITB
is not undisputed (Mucha et al., 2017). Improper lower limb
in vivo, the optimal values of stiffness and hysteresis are unknown.
alignments at the ankle or foot, such as increased rearfoot eversion
Otsuka and colleagues recently published a study in which they
(Balachandar et al., 2019), might coincide with malalignments and
used the ultrasound-based shear wave elastography (SWE) method
increased stresses at the knee, although further research is required
to measure the propagation velocity of tissue perturbations
to confirm the role of ankle or foot malpositions in the etiology of
induced by sound beams as a proxy of ITB stiffness (Otsuka et al.,
ITBS (Ferber et al., 2010; Noehren et al., 2007; Sua rez Luginick et al.,
2020). They included twelve healthy males with no history of
2018).
knee pain and found that the ITB was stiffer at its distal sites, in
While the shape and alignment of lower limb bones influence
particular at the superior aspect of the patella. Moreover, the au-
the orientation of the resultant force R that acts on the lateral
thors reported that ITB stiffness increased with hip extension and
aspect of the knee, it is the activity of muscles inserting into the ITB
concomitant knee flexion, which may partly be explained by the
(GMax, TFL, GMed, vastus lateralis, biceps femoris) that determines
stretch this posture exerts on the irradiating vastus lateralis muscle.
its magnitude. All ITB-associated muscles are active during the
A recent study by our group used the same technique to test the
stance phase, with secondary peaks at different time points of the
hypothesis that, as compared to healthy controls, the ITB stiffness
gait cycle (the activity of the TFL precedes that of other muscles).
would be greater in runners with ITBS (Friede et al., 2020). Against
With increasing gait speed (jogging, running, sprinting), the dura-
expectations, no significant differences in ITB stiffness were found.
tion of the stance phase diminishes while muscle activity increases
Moreover, TFL stiffness was significantly lower in ITBS patients.
(Eng, Arnold, Lieberman, & Biewener, 2015; Howard, Conway, &
While the reasons for the decreased muscle stiffness are unclear, it
46
M.C. Friede, G. Innerhofer, C. Fink et al.
Table 1
Factors potentially promoting iliotibial band syndrome.
Factor
Small pelvic width
Greater lateral femoral epicondyle prominence
Excessive hip adduction
Knee varus
Knee internal rotation
Increased or mistimed activity of TFL and/or GMax
ITB stiffness
may be speculated that in ITBS patients the neural drive to the TFL
would be involuntarily reduced in an attempt to lower its resting
tone and, thus, the compression of tissues beneath the ITB.
Table 1 summarizes the factors theoretically promoting ITBS
discussed in this section. It should be noted that kinematic factors
as well as alterations in TFL activity in athletes suffering from ITBS
are discussed controversially.
! applied during massage may act on mechanoreceptors like Ruffini
ITB is the iliotibial band. R is the vector of the resultant force R
that is induced by contraction of the muscles inserting into the ITB
and has a horizontal component acting in the medio-lateral
direction.
Most likely, the etiology of ITBS is defined by the interplay of
multiple contributing factors that increase the compressive forces
between the ITB and femur just proximal to the lateral epicondyle.
The following section discusses the effects of physiotherapeutic
interventions commonly prescribed for the treatment of ITBS on
the above factors.
3. Plausibility of conservative treatment approaches
The first goal in the conservative management of ITBS is to
counter the acute inflammation and alleviate symptoms. Measures
typically prescribed in this phase include non-steroidal anti-in-
flammatory drugs (which may be administered locally or system-
ically), the application of ice and rest and, in particular, the
avoidance of painful activities (Gunter and Schwellnus, 2004;
Schwellnus et al., 1991; McKay et al., 2020). Albeit a necessity, these
interventions are not causally effective. As per the considerations
above, the compression of nociceptive tissues beneath the iliotibial
tract must be relieved to ensure the long-term efficacy of treat-
ment. Towards this aim, soft tissue techniques, stretching,
strengthening of the hip muscles, and running retraining are most
commonly applied.
3.1. Soft tissue techniques
The soft tissue techniques used in the early stage of ITBS (Baker
& Fredericson, 2016; Fredericson et al., 2000; Fredericson & Wolf,
2005; McKay, Maffulli, Aicale, & Taunton, 2020; Strauss, Kim,
Calcei, & Park, 2011) may incorporate treatment modalities
deployed by a therapist, such as Western massage, trigger point
techniques or myofascial release as well as patient-conducted
techniques like self-massage, sometimes assisted by the use of
special instruments (e.g., Graston Technique®, foam rolling). With
the intention to release myofascial restrictions and, thus, reduce ITB
strain and symptoms, they are applied on the ITB itself as well as on
adjacent muscles like the vastus lateralis, biceps femoris or TFL
(Fredericson and Wolf, 2005). No studies performed to date have
investigated the effects of isolated soft tissue mobilization on ITBS,
but evidence acquired in healthy cohorts suggests it may promote
increased flexibility as well as reduced muscle tone. These
47
Physical Therapy in Sport 54 (2022) 44e52
Assumed influence
!
Medially rotating the orientation of R
!
Medially rotating the orientation of R
!
Medially rotating the orientation of R and ITB strain
!
Medially rotating the orientation of R
!
Medially rotating the orientation of R
!
Increasing the magnitude of R through ITB strain
!
Increasing the magnitude of R
beneficial effects are most likely driven by neurophysiological
mechanisms: On the one hand, the application of pressure acts to
stretch the tissue which stimulates Golgi tendon organs located at
the myotendinous junction to provide afferent feedback to the
spinal cord. This reduces motor unit firing rate and lowers muscle

tone (Beardsley and Skarabot, 2015; Huang et al., 2010; Chalmers,
2004; Khan and Burne, 2009). On the other hand, the pressure
and Pacini corpuscles leading to a decrease of neural excitability
(Behm et al., 2013; Goldberg et al., 1992; Huang et al., 2010; Young
et al., 2018). Similar effects have been documented for different
massage techniques as well as for self-myofascial release through
foam rolling or roller massage, respectively (Behm et al., 2013;

Huang et al., 2010; Beardsley & Skarabot, 2015; Behm & Wilke,
2019).
The reduction of the resting tone of muscles through massage
would be expected to facilitate the relaxation of the respective
muscle-tendon units. The studies testing this hypothesis have
applied different techniques examining the stiffness of muscles
through SWE or myotonometry, joint ranges of motion or torques
measured during passive joint rotation. The results of these in-
vestigations are inconsistent. While some studies observed signif-
icant reductions in muscle or muscle-tendon unit stiffness
(Baumgart et al., 2019; Eriksson Crommert et al., 2015; Morales-
Artacho et al., 2017; Wilke et al., 2019), others failed to demon-
strate similar effects (Akazawa et al., 2016; Ikeda et al., 2019; Krause
et al., 2019). Irrespective of whether soft tissue techniques may
provoke measurable muscle-tendon unit relaxation, it is important
to note that their effects are transient and most likely very short-
term. As an example, Young and colleagues found roller-massage
induced reductions in spinal excitability to abate within 3 min af-
ter cessation of the intervention (Young et al., 2018). Hence, soft
tissue techniques must be understood as a symptomatically effec-
tive first line of treatment that may reduce pain perception (Behm
and Wilke, 2019) and, thus, prepare patients for subsequent
treatments.
3.1.1. Practical recommendations
 Soft tissue techniques should focus on hypertonic muscles
adjacent to ITB
 Soft tissue techniques are effective in reducing symptoms and
can, therefore, be applied in acute phases
3.2. Hip muscle strengthening
Since some authors consider excessive hip adduction a risk
factor in the development of ITBS in runners (Bramah et al., 2018;
Ferber et al., 2010; Noehren et al., 2007), strengthening of the hip
stabilizing muscles (especially the hip abductors) is usually rec-
ommended as integral component of the treatment of the
M.C. Friede, G. Innerhofer, C. Fink et al.
syndrome (Baker & Fredericson, 2016; McKay, Maffulli, Aicale, &
Taunton, 2020; Mellinger & Neurohr, 2019; Strauss, Kim, Calcei, &
Park, 2011; Weckstro €m & So € derstro
€m, 2016). Little interventional
research testing the effectiveness of strength training in runners
with ITBS has been conducted, and the level of evidence of studies
published to date is mostly low. Additionally, the therapies tested in
studies are usually multi-modal and consist of different treatment
measures like strength training and stretching, which renders the
evaluation of single measures very complicated. One recent ran-
domized controlled trial compared the effects of conventional ITBS
rehabilitation to physiotherapy emphasizing strength training and
another group performing isolated stretching (McKay et al., 2020).
The results of this study suggest that neither of the interventions
tested was significantly superior to the others.
The rationale for strengthening the hip abductor muscles is
based on Janda's classification of muscle imbalance (Janda, 1983)
according to which GMed weakness may trigger a compensatory
increase in TFL activity, which results in greater tensile forces acting
on the ITB. Exercises like pelvic drop or one-legged squats are
recommended in the rehabilitation of ITBS to correct the alleged
muscular imbalance. However, recently performed studies
measuring the muscle activities in patients suffering from ITBS
during running found no evidence of abnormal TFL activation
patterns, although the changes in the electromyography power
spectrum observed during a prolonged run pointed to a reduced
fatigue resistance of the GMed muscle (Baker et al., 2018; Brown
et al., 2019). The heavy and slow strengthening exercises typically
performed might be unsuitable to correct potential deficits in
gluteus medius fatigue resistance (incorporation of measures to
improve muscular endurance would appear more appropriate). It is
also questionable whether gains in the maximum strength of the
hip abductor muscles would help prevent pelvic drop in dynamic
and complex activities like running. In fact, a study by Willy and
Davis (Willy and Davis, 2011) found a 6-week hip-strengthening
training program not to affect hip or knee mechanics during
running, suggesting that abnormal running mechanics may not be
corrected by strengthening measures alone. Moreover, it should be
noted that it is not possible to target the GMed in isolation and that
hip abductor strength training will also affect the TFL and GMax
(Selkowitz et al., 2013). While their activation patterns during
running yet need to be more thoroughly studied in patients
suffering from ITBS (see section Pathogenic factors), stronger TFL
and GMax muscles have the potential to exert greater forces on the
ITB. With the above biomechanical considerations in mind (see
Fig. 1), it is, therefore, necessary to weigh the benefits of improved
pelvic stabilization against the potential cost of increased resultant
! Commonly applied stretching interventions consist of static ITB
forces R compressing soft tissues beneath the ITB.
Another point to consider when discussing the usefulness of
strength training in the context of ITBS rehabilitation is its effect on
tendon mechanical properties. Training-induced gains in muscle
strength are typically accompanied by an increase in the stiffness of
their in-series tendons (Bohm et al., 2015; Maganaris et al., 2017;
Svensson et al., 2016; Wiesinger et al., 2015). Initially, this me-
chanical strengthening is mostly driven by changes in the tendons'
intrinsic material properties, which are mostly related to collagen
density, composition and cross-linking (Couppe  et al., 2009;
Samiric et al., 2009; Thorpe & Screen, 2016), and reflected by
Young's modulus. Although the notion is not undisputed (Massey
et al., 2018), chronic training is generally assumed to later result
in tendon hypertrophy, which would help to lower the increased
tendon stresses caused by greater muscular forces (Wiesinger et al.,
2015). The examination of stiffness requires the concomitant
measurement of tendon forces and resultant elongation. While in
some lower limb tendons, such as the Achilles and patellar tendon,
48
Physical Therapy in Sport 54 (2022) 44e52
these parameters may be assessed in vivo using a combination of
dynamometry and ultrasound imaging (Seynnes et al., 2015), the
same technique is not readily applicable to the study of the ITB. For
this reason, we recently used SWE (a technique that estimates
stiffness based on the propagation velocity of tissue perturbations
induced by an ultrasound beam) and found that ITB stiffness at the
lateral knee was indeed significantly increased following a 6-week
period of physical therapy (Friede et al., 2020). Although the
intervention was multi-modal, the exercises performed to
strengthen the hip abductor muscles may safely be assumed to
have been the driving force underlying the observed increases in
ITB stiffness. As per the reasons given in section Pathogenic factors,
an increase in stiffness not only limits a tendon's capacity to
rhythmically store and release elastic energy, but also lowers its
capacity to act as shock absorber that dampens force peaks. Hence,
the risk of irritations of tissues lying beneath the ITB might actually
increase as a consequence of tendon stiffening.
In conclusion, measures to strengthen the hip abductor muscles
are typically incorporated into ITBS rehabilitation routines with the
aim to correct assumed muscular imbalances that are characterized
by GMed weakness and a compensatory, excessive activation of the
TFL. At present, it is unclear whether these measures are indicated
since no robust body evidence to demonstrate abnormal TFL acti-
vation in ITBS patients exists. Moreover, it is questionable whether
increased hip abductor strength alone would truly correct
abnormal running mechanics (i.e., pelvic drop). Hip abductor
strengthening measures may also have undesired side effects,
including inadvertent strengthening of TFL and GMax as well as ITB
stiffening. While adequate hip abductor strength is a prerequisite
for hip stabilization during running, measures aiming to increase
maximum strength are neither fully supported by current scientific
evidence nor by biomechanical considerations.
3.2.1. Practical recommendations
 Hip muscle exercises should focus on neuromuscular control
and strength endurance rather than maximum strength
 To prevent undesired side effects, strength training should be
followed by measures to reduce muscle tone
3.3. Stretching
Another crucial component of the conservative treatment of
ITBS is stretching. Already recommended in the early stages of
rehabilitation, stretching aims to relieve the tension in the ITB and
decrease the compressive forces acting on underlying tissues.
stretches through trunk side bends and thigh adductions which are
held for approximately 30 s and typically repeated 3 times
(Fredericson et al., 2002). A large number of interventional studies
have demonstrated that stretching performed for as little as 3e8
weeks (short-term stretching) may significantly improve the range
of motion in various joints (Freitas et al., 2018; Lempke, Wilkinson,
Murray, & Stanek, 2018; Medeiros & Martini, 2018). Theoretically,
the observed gains in flexibility might be caused by lengthening or
improved relaxation of stretched muscles, lengthening or a
decrease in the stiffness of their in-series tendons as well as
neurophysiological adaptations leading to desensitization and
improved stretch tolerance (Blazevich, 2019; Freitas et al., 2018;
Medeiros & Martini, 2018). Although not undisputed, several
studies indicate acute changes in muscle stiffness and tone
following static stretching of the plantarflexor and hamstring
muscles (Fowles, Sale, & MacDougall, 2000; Herda, Cramer, Ryan,
McHugh, & Stout, 2008; Kay & Blazevich, 2009; Magnusson et al.,
1996; Morse, Degens, Seynnes, Maganaris, & Jones, 2008).
M.C. Friede, G. Innerhofer, C. Fink et al.
Significant reductions in stiffness and neuromuscular activity
(measured by EMG), observed immediately after stretching, would
be beneficial in ITB muscle-tendon unit relaxation. This, in turn,
! ported significant improvements in pain and function, but larger-
would relieve the compressive force R acting on soft tissues
beneath the ITB (see Fig. 1). However, effects have been shown to be
transient and abate within 30 min (Fowles, Sale, & MacDougall,
2000; Kay & Blazevich, 2009).With regards to the ITB, no studies
investigating the potential structural adaptations induced by short-
term stretching interventions (3e8 weeks) exist. Evidence obtained
in other lower limb muscle-tendon units suggests that stretching,
irrespective of the technique used, does not induce lasting signifi-
cant changes in tendon mechanical properties and only very minor
reductions in muscle stiffness. Gains in passive ranges of motion
are, therefore, mostly attributed to increased stretch tolerance
(Blazevich, 2019; Freitas et al., 2018; Medeiros & Martini, 2018).
Although the mechanisms underlying the changes in the percep-
tion of stretch-related stress are not clearly understood, altered
nociceptor signaling may have a role. In addition, reports of non-
local stretching effects (Behm et al., 2021) suggest adaptations in
the central processing of afferent feedback.
While the responses to stretching may differ in dependency of
the muscle group examined (Guissard & Duchateau, 2004;
Nakamura, Ikezoe, Takeno, & Ichihashi, 2012) and the effects on
the ITB and associated muscles yet need to be directly tested, it
appears unlikely that intermittent interventions as performed
during rehabilitation may cause biomechanically effective elonga-
tions and/or relaxations of tissues and, thus, significant reductions
of compressive forces at the lateral femoral epicondyle.
3.3.1. Practical recommendations
 Static ITB stretches should be performed for a total of at least
3 min (e.g. 3  1 min stretching) to reduce muscle tone,
particularly after hip and thigh muscle strengthening measures
 Lasting effects may only be expected when stretching exercises
are incorporated into training routines and repeated on a reg-
ular basis
3.4. Running retraining
Joint malalignments or altered lower limb kinematics during
running are expected to be factors promoting the development of
various injuries including ITBS (Bramah et al., 2018; Barton et al.,
2016; Mousavi et al., 2019). Evidence from cross-sectional studies
comparing the running kinematics between athletes with ITBS and
healthy controls suggests that (particularly female) patients feature
altered lower limb mechanics characterized by increased peak hip
adduction as well as greater hip and knee internal rotation (Ferber,
Noehren, Hamill, & Davis, 2010; Hamstra-Wright et al., 2020;
Noehren, Schmitz, Hempel, Westlake, & Black, 2014). Although it is
unclear whether these patterns are causative for or rather a result
of ITBS, they may aggravate the syndrome by increasing ITB strain.
This is because the alignment and kinematics of the lower ex-
!
tremity influence the orientation of R e the vectorial component of
the contractile force generated by the muscles inserting into the ITB
that acts to compress tissues lying beneath the ITB (see Fig. 1 and
Table 1). As mentioned above, hip muscle strengthening is typically
recommended to address the altered lower limb kinematics but the
efficacy of this measure, when performed in isolation, in correcting
abnormal running patterns is questionable (Willy and Davis, 2011).
Running retraining, by contrast, might have the potential to effec-
tively improve running mechanics which explains why it is rec-
ommended by leading authorities in the field of ITBS rehabilitation
(Baker & Fredericson, 2016; Barton et al., 2016). Yet, scientific
49
Physical Therapy in Sport 54 (2022) 44e52
research on the effects of running retraining in patients suffering
from ITBS is scarce, with only two single-case reports published to
date (Allen, 2014; Hunter et al., 2014). Both of these studies re-
scale controlled trials are needed to test whether treatment
regimen focusing on running retraining indeed yield superior
outcomes.
3.4.1. Practical recommendations
 Running retraining should be based on the individual assess-
ment of running mechanics
 Real-time feedback should mostly be given in the early phases of
rehabilitation to correct aberrant movement patterns, but then
be gradually reduced through the course of treatment
4. Conclusion
Based on the assumptions that the compression hypothesis is
correct and ITBS is related to excessive ITB tension, the compression
of tissues lying beneath the ITB may be promoted by anatomical
predisposition (small pelvic width, prominent lateral femoral epi-
condyles), joint malalignments (excessive hip adduction, knee
varus or internal rotation), excessive or mistimed activity of mus-
cles inserting into the ITB or increased ITB stiffness. Conservative
treatment approaches typically include hip abductor strengthening
exercises, which may have undesired side effects, including inad-
vertent strengthening of TFL or ITB stiffening. Based on current
evidence, it is also unclear to what extent increased hip abduction
strength would benefit pelvic stabilization during running. Against
this background, we propose that (i) hip strengthening exercises
should be tailored to improve muscular endurance rather than
build maximum strength, and (ii) be accompanied by measures to
improve running technique. ITB stretching, representing another
integral component of physiotherapeutic treatment, is performed
to reduce the tension in the ITB and associated muscles. However,
evidence obtained in other muscle-tendon units challenges the
notion that intermittent physiotherapy would have a significant
effect on tissue length or stiffness. Thus, lasting effects may only be
expected when stretching routines are incorporated into training
routines and performed on a regular basis. High-quality research
directly investigating the causal effectiveness of conservative ITBS
treatment measures in randomized controlled trials is urgently
needed.
Ethical statement
Ethical Approval was not required.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
Declaration of interest: none
Acknowledgements
We thank Ryan Hoyme for his picture of the skeleton and Bojan
Makivic for his support with the preparation of the graph.
M.C. Friede, G. Innerhofer, C. Fink et al. Physical Therapy in Sport 54 (2022) 44e52

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