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Brought to your knees by pain? (1/2)

The gray has many names - tract syndrome, tract chafing, tractus iliotibialis syndrome, iliotibial band syndrome, or ITBS for short. Unfortunately, it not only has many names, but it is also a widespread plague in sports. Basketball players, handball players and hikers, but especially endurance athletes are affected. Almost every fourth runner has suffered or suffers from pain on the outside of the knee, so that the best-known and simplest name for this complaint is no coincidence: runner's knee.

No other joint in the human body has such a complex structure and size as the knee joint. All of its elements, from bone to cartilage, tendons, ligaments, muscles, capsules and menisci, must be as precisely coordinated as possible for it to fulfill its function. As an articulated connection between the upper and lower leg, it is responsible for flexion and extension of the knee on the one hand, and transfers the weight of the trunk to the lower extremities on the other. Forces of up to 3000 Newtons per step can act on the joint. In runner's knee, the center of pain is usually on the outside of the thigh, where the tractus iliotibialis runs. With its strong longitudinal collagen fibers, it is woven into a very large connective tissue sheath (fascia lata) of tight, braided connective tissue and envelops the entire thigh musculature.

More specifically, the tractus iliotibialis originates in the lateral gluteal/hip region from the end tendon of the hamstring tensor (Musculus tensor fasciae latae) and the gluteal fascia (Fascia glutealis), which comes from the iliac crest. It slides along the outside of the quadriceps femoris muscle and connects broadly with the tibial fascia below the lateral tibial plateau. The most important task of the tractus iliotibialis is to remove bending stress from the thigh bone (femur) during the stance phase of the same leg by counter-bending. To do this, the tractus iliotibialis is tightened by the hamstring tensioner during each step.

The following article provides information on symptoms, cause, physiology, diagnosis, therapy and prevention of runner's knee.



Characteristic symptoms of runner's knee manifest as burning or stabbing pain on the outside of the affected knee joint, occasionally also below the kneecap. As a rule, these first appear directly after running or brisk walking, especially downhill, and initially lose much of their intensity during periods of rest. Later, the pain develops already during the running load or appears from a certain distance and then increases continuously, so that a break must be taken. Other sports, such as soccer or tennis, which generally place a greater strain on the knee joint, can usually be performed without pain. If these complaints remain untreated, the symptoms intensify and can also occur when walking uphill, running on flat surfaces, merely touching the kneecap or sitting with the legs bent. Although the problems are due to local inflammation in the attachment area of the tractus iliotibialis tendon plate, this rarely manifests as swelling, redness or overheating of the tissue. Occasionally, acoustic signals also indicate a tractus syndrome, as the knee makes a perceptible crunching sound during movement.


The knee joint must withstand enormous forces when walking and is therefore naturally predisposed to overuse injuries. Until now, pain during running was thought to be caused by the tractus iliotibialis rubbing against the outer bony prominence of the femur at the knee (epicondylus lateralis femoris); however, more recent studies indicate that the tendon plate presses against the bony prominence. In addition, problems at the hip can trigger the symptoms. Due to the complexity of the knee and various external factors, there is not only one specific cause for runner's knee, but diverse reasons can be present, alone or combined.



The characteristic pain in the corresponding situations (walking downhill or running) gives the affected person an initial indication, but this should be confirmed by a thorough orthopedic examination. In the anamnesis (questioning of the patient), the previous course of the complaint is determined and documented. A direct physical examination provides further information about possible damage to the connective tissue structures around the knee joint.

Since complaints that at first glance indicate iliotibial band syndrome may also signal other knee diseases, a differential diagnosis should precede the final findings. In this way, alternative pain triggers can be ruled out by the rule-out principle. Redness and swelling of the knee joint indicates bursitis. Pain sensitivity (nociception) during certain movements, such as external rotation of the knee joint or outward pressure when the leg is extended, suggest ligament or meniscus damage. Specially trained examiners can also detect altered tissue structures by palpation, for example hardening (Taut band) or nodules with pressure pain (tender nodules). For a diagnosis by palpation, the pain should also be repeatable (recognition) and characteristic (referred pain).

For an exact diagnosis, the orthopedist should also use modern examination methods such as ultrasound, X-ray or magnetic resonance imaging, which can reveal possible fractures, arthritic changes or cartilage damage, in order to eliminate the last doubts about the diagnosis of runner's knee. A special diagnostic method is the biomechanical gait analysis. Here, a high-speed camera records the patient's walking and running movements, which are then analyzed in detail for the smallest errors in the movement sequence in order to draw conclusions about possible imbalances or malpositions.


The therapy of a runner's knee is divided into the reaction to the acute pain phase as well as a long-term and sustainable treatment to alleviate the pain. There are various therapeutic approaches and courses, which are described below.

Initial measures in the acute phase:
- To reduce the initial pain, the affected knee joint should be cooled immediately (cryotherapy), for example with an ice pack.
- Another immediate measure is treatment with anti-inflammatory (antiphlogistic) and analgesic (analgesic) ointments or even anesthetics if the pain is particularly severe. For the latter, however, it is essential to consult a doctor first.
- If acute knee problems occur, the patient should also reduce or even completely stop walking. In some cases, more frequent training at a lower intensity or faster running can help. In general, however, an increase in pain is to be expected when training with the same intensity under discomfort, and thus an extension of the required running break by several weeks. Sports that are easy on the joints, such as swimming or aqua jogging, should be able to be performed without any problems as an alternative.
- Consistent sparing is the key to a quick recovery. If this rule of thumb is not followed, there is a risk of a chronic condition that can cause irreparable damage and lifelong discomfort.
- Bandages or kinesio tapes can be used to stabilize the knee.
- Pain is always a warning and signals that something is wrong. Microtrauma due to exercise often occurs in the tissues in conjunction with inflammation. If left untreated, these not infrequently end in protracted and painful overuse injuries. Therefore, (micro) injuries must be treated as early as possible. Enzyme therapy used at the first sign of pain, for example with the pharmacy-only enzyme combination preparation Wobenzym® plus, tracks down inflammation, activates the body's self-healing powers and accelerates the healing process.
"Wobenzym® plus can help provide relief and faster healing for runner's knee! Especially the enzymes trypsin and bromelain, which are contained in Wobenzym® plus, contribute to improved healing through their edema relief! The antioxidant mode of action of the ingredient rutoside (rutin) has also been proven." (Steffen Wittmann, physiotherapist and marathon runner)

Long-term therapy approaches

Regardless of the course of treatment after the acute phase, an orthopedist should be contacted for sustained freedom from symptoms. The further course of treatment then depends on the diagnosis and the cause.
- Cold and heat applications (alternating baths, ice rubs, etc.) should be performed independently, as these stimulate the metabolism at the affected site and promote the healing process.
- Furthermore, injections (infiltration treatment) into the myofascial structures of the knee can support the healing process, although in principle only biological medications should be used. Cortisone treatment is only appropriate in the case of acute inflammation and only in individual cases.
- Painkillers such as diclofenac or ibuprofen can also lead to an attenuation of the pain. However, possible side effects in the gastrointestinal and cardiovascular area must be observed extremely carefully.
- Enzyme therapy: enzymes, unlike common painkillers, do not suppress inflammation but promote faster healing. In the case of overuse injuries and traumatic sports injuries, it is therefore advisable to take an enzyme combination preparation such as Wobenzym® plus. These drugs contain high concentrations of the anti-inflammatory enzymes bromelain and trypsin and the flavonoid rutoside. Studies show that enzyme combination preparations have an equivalent effect to classical painkillers. However, they are significantly better tolerated - an important indication for long-term use in chronic diseases.

"The use of Wobenzym as a complementary therapeutic agent is recommended. Due to its anti-inflammatory and decongestant effect, Wobenzym relieves pain, because less swelling means less pressure in the tissue and thus less pain." (Steffen Wittmann, physiotherapist and marathon runner)

- Professional physiotherapy in conjunction with cross-frictions, electrotherapy, physiotherapy and local massages can optimize the metabolic situation at the fasciae and thus support the recovery process. In addition, targeted physiotherapy should compensate for muscular imbalances and accompany independent stretching.
- If the causes of runner's knee lie in a leg length difference, this must be compensated for according to its nature:

Anatomical: Depending on the length of the difference, the spectrum of measures here ranges from increasing the heel of the shoes with sole compensation and insoles to custom-made shoes to orthotics or, in the last step, a surgical intervention.
Functional: Before resorting to mostly more cost-intensive compensation options in this regard, one should first try to correct the difference through targeted stretching of the shortened tendons, ligaments, fasciae or muscles under the guidance of a trained physiotherapist. (See suitable exercises under point 7)
- In general, targeted stretching of various muscles can often alleviate the symptoms. (See suitable exercises under point 7)
- Movement always involves the interaction of complex muscular structures (antagonist principle), consisting of agonists, synergists and antagonists. A disturbed balance of forces can lead to complaints, so that in individual cases a strengthening of individual muscle groups is indicated as therapy. (See suitable exercises under point 7)
- If conservative treatment remains unsuccessful, surgery is a last possible option. In a surgical procedure, the tractus iliotibialis is lengthened by means of a z-shaped incision and thus relieved.