Curr Rev Musculoskelet Med (2010) 3:18–22 possibility that the pharmaceutical limitation of the inﬂammatory stage in connective tissue injury actually leads to a delay in healing or to poorer healing [34, 35]. Stretching of the iliotibial band and related structures Stretching of the iliotibial band, lateral fascia, gluteus medius, and other muscles is frequently recommended as part of the treatment plan for ITBFS. A variety of stretching protocols have been suggested. Fredericson measured the change in length of the iliotibial band while athletes performed variations of ITB stretches, and found that a particular stretch—with the athlete standing, placing the affected foot adducted and behind the other, and laterally ﬂexing away from the affected side with the arms stretched overhead—created the greatest lengthening of the band [36]. On the other hand, Falvey et al. found that the optimal stretch varied considerably from individual to individual [37]. Neither study documents a link between short term distension of the iliotibial band, such as during a stretching routine, and longer-term changes in the tissue’s mechanical response, in improved running mechanics, or in relief of ITBFS. In addition, in light of the discussion above on the questionable role of iliotibial band tightness on the etiology of the disease, there may be reason to question the rationale for attempting to stretch the ITB. Connective tissue manipulation Manual therapy techniques to release myofascial restric- tions in the iliotibial band and related structures are also frequently recommended. Pedowitz reported on a single case that he treated effectively with strain–counterstrain technique [38]. Hammer emphasizes the use of connective tissue treatment methods to release restrictions not only in the ITB but in the gluteal muscles and any other areas found to be restricted in the hip area, thigh, or lower extremity [31]. Fredericson agrees that treatment of trigger points in the band can help signiﬁcantly [20]. On the other hand, of the scarce published data that has tested the efﬁcacy of these measures, Ellis et al. found a single trial of deep transverse friction massage used in the treatment of ITBFS. It was not found to confer any added beneﬁt [33]. Strengthening of the hip abductors Though no trials have been published on the efﬁcacy of strengthening exercises in the treatment of ITBFS, strength- ening of hip abductors is often recommended [32]. 21 Improved neuromuscular coordination Improving neuromuscular control of gait is also frequently mentioned as a useful approach in the treatment of ITBFS. Fredericson et al. depicted a number of exercises to train complex multidimensional movement patterns involving weight shift and other aspects of hip abductor function [32]. Pettit and Dolski also described the successful application of a multi-dimensional corrective therapeutic exercise program combined with stretching, massage, soft tissue mobilization, shoe modiﬁcation, and electrical stimulation [39]. Surgical excision of a cyst, bursa, or lateral synovial recess Practitioners utilizing conservative means report a satis- factorily high rate of positive response, so that few patients should require surgical intervention [2, 40–42]. Yet a number of case series reporting resolution of ITBFS from the surgical excision of a bursa, cyst, or portion of a lateral synovial recess have been published [11–13, 43]. Summary Iliotibial band friction syndrome is a common occurrence among physically active individuals, causing pain in the lateral knee. There is much to be learned about the etiology, pathology, and optimal treatment of the condition. Many published studies seem to approach the problem from differing and hard-to-reconcile viewpoints. Despite these limitations, and despite the fact that few outcome studies have been done to establish a consensus clinical approach, most practitioners are conﬁdent in their ability to diagnose ITBFS based on the case history and physical examination, and most are satisﬁed with the treat- ment results they get with conservative measures that include methods to control the inﬂammatory reaction, strengthening, stretching, modiﬁcation of neuromuscular control of gait, and connective tissue therapy. Corticosteroids and NSAID’s have documented beneﬁts in the short term. In those few cases that do not respond to a conservative regimen, surgical excision of tissues deep to the band also has an established track record of effectiveness. References 1. Orava S. Iliotibial tract friction syndrome in athletes-an uncom- mon exertion syndrome on the lateral side of the knee. Br J Sports Med. 1978;12:69–73. 2. McNicol K, Taunton J, Clement D. Iliotibial tract friction syn- drome in athletes. Can J Appl Sport Sci. 1981;6(2):76–80.