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transferred to the bone. In time, this higher stress load overwhelms the bone's capability to respond to the stress and small stress fractures develop. Stress fractures are a serious problem in the military because they take a long time to heal and require significant time away from activities. One important way to reduce the frequency of stress fractures is to decrease the stress transferred to the bone by keeping the muscles and other soft tissues in their optimum functioning capacity. Massage treatment of the tibialis posterior and other deep compartment muscles is highly valuable in achieving this goal. One of the most effective methods for addressing the tibialis posterior and other deep compartment muscles is through active engagement. These techniques are especially helpful because the tibialis posterior is difficult to access with other treatment methods, and consequently the muscle is often ignored. This technique is, of course, highly valuable for Gluteus maximus Tensor fasciae latae Iliotibial band 2 108 A side view of the tensor fasciae latae and gluteus maximus in relation to the iliotibial band. 3D anatomy images. Copyright of Primal Pictures Ltd. www.primalpictures.com. massage & bodywork march/april 2013 many individuals doing repetitive lower-extremity activities, like running, that put significant repeated loads on the lower extremity. Iliotibial Band Friction Syndrome Any repetitive movement of a lower extremity is likely to involve frequent flexion and extension of the knee. The weight of the equipment or packs carried by military personnel puts greater load on the tissues performing these motions. Lateral knee pain routinely occurs for individuals doing repetitive lower-extremity motions. Historically, this condition has been referred to as iliotibial band friction syndrome because the primary pathology was suspected to be the iliotibial band rubbing back and forth across the lateral condyle of the femur (Image 1, page 107). Several years ago, a study published in the Journal of Anatomy seriously challenged the traditional understanding of this condition, as well as our common treatment approach.5 The study notes that the iliotibial band is actually fibrously connected to the femur, and is not truly capable of rubbing back and forth across the lateral femoral condyle. Instead, the apparent friction is most likely due to changes in tension between the anterior and posterior aspects of the band as the knee moves in flexion and extension. The pain of this condition is most likely due to compression of a fat pad lying under the iliotibial band. Traditionally, massage treatments for this condition have encouraged friction of the fibers in the distal iliotibial band directly over the lateral condyle with the idea of encouraging fibroblast proliferation and reducing fibrous adhesions that result from fraying and friction of the iliotibial band. However, based on our new understanding of anatomical relationships in this region, that treatment may not be very helpful. Instead, as the study notes, ideal treatment for iliotibial band friction syndrome should focus on reducing excessive tensile forces within the band. The gluteus maximus and tensor fasciae latae are the primary muscles that pull on the iliotibial band. When they become hypertonic, they pull even more. Consequently, our key goal is to reduce tightness in these muscles. The gluteus maximus is broad and thick, and is effectively treated with simple, deep, stripping techniques directly along the length of its fibers. It is also valuable to address the gluteus medius and gluteus minimus muscles to make sure tightness is reduced in all of the primary gluteal muscles. The tensor fasciae latae is significantly smaller and more challenging to treat (Image 2). Due to the position and size of the tensor fasciae latae, there is not a great deal of room or muscle length for stripping methods. However, active engagement methods allow longitudinal stripping techniques and are highly effective on this muscle.