Chronic Knee Pain: A Study of Female Triathletes

By Massage Therapy Foundation Contributor

Chronic Knee Pain: A Study of Female Triathletes

By Massage Therapy Foundation Contributor

Contributed by Derek R. Austin, PT, DPT, MS, BCTMB, CSCS; MK Brennan, MS, RN, LMBT; Drew A. Rowe, LMT, BGs, BCTMB

Little research has been performed on treating triathletes, but anecdotally many athletes find massage to be an integral part of their recovery. Triathletes, in particular, are vulnerable to overuse injuries, especially knee injuries, due to the demands of training for multiple sports simultaneously.

Knee pain can originate from several sources and manual therapies can be utilized to treat soft-tissue restrictions and myofascial trigger points in surrounding tissue including the iliotibial band (ITB), hamstrings and quadriceps.

Long gliding strokes, firm pressure and myofascial techniques are often used to treat these dysfunctions. This study examines the efficacy of those techniques. While this article reports on the treatment of lateral knee pain as performed by a physical therapist, the techniques used are familiar to massage therapists.

Lateral Knee Pain

The question is whether massage techniques can reduce chronic knee pain resulting from the demands of a triathlon training regimen. The study was titled "Treatment of Lateral Knee Pain Using Soft Tissue Mobilization in Four Female Triathletes" and was published in the International Journal of Massage and Bodywork in 2014.

The study design was a prospective case series, meaning a review of the treatment and results of four female triathletes who had a similar presentation of lateral knee pain. Notably, all the athletes had been dealing with chronic pain making them unable to train for at least seven months and had already completed at least six weeks of physical therapy.

The four athletes were all female and ranged in age from 27-43. All athletes experienced pain in a similar location of the lateral knee around the lateral femoral condyle that originally resulted from a change in their training routine. All athletes had consulted with an orthopedic surgeon, were immobilized or restricted from physical therapy for at least two weeks, and had normal MRI results.

The author hypothesized that soft-tissue mobilization would be effective, as immobilization and inactivity frequently lead to soft-tissue restrictions and dysfunction. The author performed a complete physical examination including special tests for meniscal and ligament injuries.

Knee Extension Angle

As outcome measures to assess change over time, the author measured hamstring and ITB flexibility. For hamstring flexibility, the author used a test called knee extension angle (KEA, commonly referred to as hamstring 90-90 flexibility). In the KEA test, the client's hip is flexed to 90 degrees and then the knee is stretched from 90 degrees of flexion into extension; the KEA is the angle of knee flexion at which hamstring inflexibility allows no further extension.

The author identified a cut-off of 20 degrees for the KEA test; if the knee was able to extend to an angle less than 20 degrees of flexion, then the hamstring flexibility was considered normal. The author also measured the flexibility of the ITB using Ober's test, whereby the client is positioned side-lying while the examiner identifies if the patient is able to adduct the leg with the knee bent.

A positive finding on the Ober's test is noted if the pelvis drops or the leg is unable to adduct, and this is considered to be a sign of ITB inflexibility. No specific standard was given as a cut-off for ITB flexibility in this study, although the author did measure the angle of hip adduction using a bubble inclinometer in order to assess change in the Ober's test result.

Treatment Model

Each athlete received three weekly sessions for three weeks consisting of soft-tissue mobilization for 40 minutes at a time. The techniques used included stroking the anterior and posterior borders of the iliotibial band (ITB) for 5 minutes each using distal-to-proximal strokes.

The ITB mobilization technique was followed by "muscle bending," a myofascial technique involving broad, shearing force performed through the palms along the entire extent of the vastus lateralis muscle for 10 minutes. Next, the biceps femoris was stroked in a similar manner to the ITB for 5 minutes.

Following stroking, 10 minutes of muscle bending was performed along the biceps femoris and gastrocnemius muscles. Finally, passive knee and hip flexion and extension were performed for 5 minutes, but it is not noted if static or prolonged stretching was performed during this time period. Four weeks after the initial assessment, three of the four athletes had nearly complete resolution of their knee pain and were able to resume triathlon training.

The fourth athlete showed no improvement and later underwent arthroscopic surgery to treat a lateral meniscus tear in the affected knee. All four athletes showed improvement in hamstring flexibility and ITB flexibility (per the Ober's test).

On the Flip Side: STudy Limitations

The study's limitations are based on having only four female athletes throughout the duration of the study, indicating the results may not be applicable to other triathletes with lateral knee pain.

It could be further critiqued for the choice in limiting massage modalities to the utilization of myofascial and soft-tissue techniques instead of trigger-point release, Swedish massage, Thai massage, or many other possible techniques. Since the treatments were performed by a physical therapist and were observed to have a positive effect on the athletes, there may be an opportunity for a massage therapist to consider a study of this population using some of the massage techniques mentioned here.

The study makes a contribution to the field of massage research by examining a unique population, specifically female triathletes with knee pain. This case series shows some individuals who receive a high frequency of soft-tissue treatment (40 minutes, three times weekly, for three weeks) may experience reduced knee pain.

The study also highlights the importance of correctly identifying intra-articular pathology and the need for massage therapists to refer out individuals whose pain does not improve with treatment.


  1. Winslow J. Treatment of Lateral Knee Pain Using Soft Tissue Mobilization in Four Female Triathletes. International Journal of Therapeutic Massage & Bodywork. 2014;7(3):25-31.

Editor's Note: The preceding research synopsis is authored by volunteers from the MTF's Writing Workgroup. To learn more please visit their columnist page.