20 These ﬁndings seem to contradict the commonly asser- ted link between a tight iliotibial band and ITBFS. Furthermore, they would imply that stretching the ITB— insofar as the purpose of stretching would be to increase the distensibility of the band—could accentuate the symptoms of ITBFS. Angle of knee ﬂexion during stance phase? The portion of the knee range of motion at which the ITB is most likely to rub against or compress the underlying structures is with the knee ﬂexed about 20 –30 . Perhaps differences in the degree of knee ﬂexion between individ- ual runners play a role in the onset of ITBFS. The com- monly held association of ITBFS with running downhill [22, 23] may be due to the fact that downhill running results in a higher degree of knee ﬂexion at heel strike, thus increasing the friction of the ITB with the lateral epicon- dyle or the pressure the ITB places on the underlying soft- tissues. However, Orchard et al. found no difference in the angle of knee ﬂexion between runners with or without ITBFS when running on a treadmill [22]. This ﬁnding was echoed by Noehren et al. [17]. An additional subtlety was studied by Miller and others in 2006 [24]. Hypothesizing that a runner’s biomechanics might deteriorate adversely with fatigue, they tested run- ners’ biomechanics at the end of an exhaustive run. Indeed, runners with a history of ITBFS exhibited an increased angle of ﬂexion of the knee at heel strike. Rearfoot eversion? Busseuil et al. found a higher incidence of ITBFS and other lower extremity injuries in athletes who over-pronated [25]. However, Messier et al. and Noehren’s group reached the opposite conclusion, that runners with ITBFS had reduced rearfoot pronation as compared to controls [3, 17]. Other biomechanical factors Other biomechanical factors that have been linked with iliotibial band friction syndrome include: increased landing forces, increased knee internal rotation, low hamstring strength as compared to the quadriceps strength on the same side, and genu recurvatum [3, 8, 17, 25]. What other injuries and conditions are related to ITBFS? Tightness of the ITB may play a role in patellofemoral syndrome [26–28]. Curr Rev Musculoskelet Med (2010) 3:18–22 Vasilevska’s group studied patients with osteoarthritis of the medial compartment of the knee and found a high incidence of iliotibial band friction syndrome. Their model was that reduced medial joint space created a varus knee deformation, thus putting extra tension into the iliotibial band [29]. Greater trochanteric pain syndrome (previously known as trochanteric bursitis) may also reﬂect altered biome- chanics of the ITB. Pelfert and others have reported the occurrence of ITBFS subsequent to repair of the anterior cruciate liga- ment [30]. Costa and others reported having removed a synovial cyst from the lateral knee of a runner diagnosed with ili- otibial band friction syndrome [12]. Hammer reports the common occurrence of various hip and knee problems in those with iliotibial band friction syndrome, though the individual manifestations vary so that no consistent associations can be made between ITBFS and any other speciﬁc syndrome [31]. How is iliotibial band friction syndrome treated? As described by Fredericson and others, the accepted treatment of iliotibial band friction syndrome follows the outline common to the treatment for many connective tis- sue injuries, beginning with treatment of the acute inﬂammatory response and progressing through a correc- tive treatment phase and ultimately to a return to regular activity [32]. Acute phase treatment to limit the inﬂammatory response Care in the acute phase focuses on activity limitation or modiﬁcation, and measures to relieve pain and inﬂamma- tion, such as ice, oral NSAID’s, or corticosteroids delivered via phonophoresis or injection. There is a limited body of research establishing the effectiveness of any of these measures in ITBFS. Ellis et al., in a review of published trials of therapy for ITBFS, found only one prior study of adequate quality that tested the use of NSAIDs, and two other studies that focused on the use of corticosteroids, in one case applied via phono- phoresis and in the other via injection. In all three studies, improvement was demonstrated in both the control group and the treatment group, but the groups receiving anti- inﬂammatory agents showed signiﬁcant improvement compared to those that did not [33]. On the other hand, other research, not speciﬁc to ITBFS, points to the risks of these anti-inﬂammatory measures when treating connective tissue injuries, and raises the