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Iliotibial Band pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by issy1, Mar 22, 2011.

  1. issy1

    issy1 Active Member


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    I was wanting to pick peoples brains about pain over the iliotibial band region of the knee.

    I have a patient coming in next week who has pain over the iliotibial band region. She has attended a Physio for exercises etc but haven't helped. The physio gave her a pair of OTC devices to wear as he thought "problem may be with her feet," as her pain is exasperated when standing whilst hairdressing. The orthotics haven't helped greatly.

    I have been doing some reading in advance of her appointment regarding pain in this region in relation to foot mechanics and am not coming up with much. All information in relation to IT Band syndrome seems to be in relation to overuse injury in runners. Similarly, not finding much info. regarding relationship of foot and other differential diagnosis in this area.

    I have not seen this patient yet and know nothing of her biomechanics but I do know she is 37 yrs, not a runner or sporty at all and no history of OA. I'm not asking anyone to diagnose here just asking for general advise on the use of orthotics for lateral knee pain around the iliotibial band region.

    Not sure if her problem has been correctly diagnosised or not, but that aside can orthotics be used to relieve stresses in this area??
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Andrew Fryc

    Andrew Fryc Member

    Hi Issy1,

    If during her assessment you still feel the symptoms indicate ITB irritation ask questions regarding flexion of her knee (presume its unilateral). Eg; has she recently moved into two storey living & climbing stairs, or renovating & climbing ladders, or hilly bushwalking or started a program doing lots squats, or quad strengthening or stepper apparatus at her gym etc.. in the absense of any obvious biomechanical issues that may require orthotic therapy then prescribed stretching excercises should go a long way resolving her ITB irritation ...good luck & cheers for now
    :morning:
     
  4. Stephanie C

    Stephanie C Member

  5. Funny evidence seems to point it´s all about the hips and pelvic stability.

    Also Fascia can be stretched everything in the world has an elastic nature so it not completely unstretchable . There is lots of quite definite statements in your Blog going any references ?

     
  6. CamWhite

    CamWhite Active Member

    We have found the Cluffy Wedge (or hallux pad) to be highly effective for IT band pain.
     
  7. issy1

    issy1 Active Member

    Cluffy Wedge brings windlass on quicker. Can you expand on your thinking behind this for IT band pain and also is this always in runners - ever work for none athletes?? Thanks
     
  8. issy1

    issy1 Active Member

    Thanks everyone for info. has been very helpful. From Podiatry point of view I can see that I need to check for things which may cause abnormal stress to IT band eg leg length difference, genu varum, excessive internal rotation of tibia due to excessive pronation, weak hip abductors etc.

    I understand CamWhite's above thinking for cluffy wedge bringing on windlass quicker and slowing internal rotation of tibia - but never been keen on trying these in female shoes due to toe room restrictions. A heel raise does the same thing so could this be used as part of orthotic prescription?

    Anyway will see what the full story is next week - THANKS again for info. Will keep you posted.
     
  9. Griff

    Griff Administrator

    Hi Stephanie,

    Like Mike, I disagree with this. I would say in my clinical experience a far greater percentage of ITB issues are more likely to be associated with pelvic dysfunction/proximal stability issues than they are foot mechanics.

    I saw a textbook example just earlier this week - give me 10 mins and I'll post up some pictures.

    Ian
     
  10. Griff

    Griff Administrator

    Here you go.

    Here's a lass who isn't dissimilar in age or background to issy1's patient.

    Take a punt at which side was symptomatic...
     

    Attached Files:

  11. scott1

    scott1 Member

    my punt would be.... the right side?
     
  12. Griff

    Griff Administrator

    I had a dog... and his name was BINGO!

    Caused by her foot mechanics Stephanie?
     
  13. scott1

    scott1 Member

    i suppose i shouldnt be too proud of myself for getting that one right!
    Just as a slight digression, I have been looking around pod arena for a post I read a while ago regarding ankle and cuboid manipulation and their influence on more proximal structures, particularly those that insert into the fibula e.g. ITB and biceps femoris. Did i dream this, or is there an easy way to search for it?

    Cheers

    ps i was in the vet recently and someone came out carryin two small fat dog called "Jamie" and "Kirsty":wacko:
     
  14. issy1

    issy1 Active Member

    Ian - For those of us with a less trained eye, can you explain what you see here that makes you think right side problematic?
     
  15. Issy which side will put more tension in the Illiotibial Band right or left from Ian´s picture ?
     
  16. issy1

    issy1 Active Member

    O.K. I'm thinking weak hip abductors on left due to dropped hip level which will increase strain on right side? Am I barking up right tree. Also tibial varum on both sides.
     
  17. Could be a lot of things which Ian may tell us about, but yes as the left side the tension in the ITB should be much less than the right as the distance between origin and insertion of the ITB at the same stage of gait is clearly longer in the right side.

    as to the cause of this Ian ?
     
  18. Griff

    Griff Administrator

    Hi Issy,

    As Mike says it's all about knowing our anatomy, and then identifying if we feel there are any movement patterns which we feel may be potentially 'pathological' (which in this case may increase the tensile loading force in the ITB).

    You are right that there may be increased strain on the right side, but it is actually the right sided hip abductors/gluteii which are likely to be at fault here and not the left. As an easy to remember rule - the leg the person is standing on is the side that is being 'tested', and if they are dysfunctional then the contralateral side will drop. So when our lady is on her left leg you can see her pelvis is level in the frontal plane (i.e. flat like the horizon) --> therefore the left side seems to be functioning ok. However when she is on her right leg the pelvis becomes unstable and we see the left side drop --> therefore the right sided musculature may be dysfunctional. Does this make sense now?

    When I have a bit more time later I will upload a doodle which I do for patients to explain this in very simple terms using a wall, a shelf and a bracket as an analogy.

    As far as stating the muscles are 'weak' I would say they may be, but more often than not the problem is actually with their recruitment or timing characteristics. Making a muscle 'strong' is not usually enough in these cases (no good having a really powerful lightbulb if the switch and electrics are not working is it?). I'll post more on this later too - apologies for being so brief now - patients are limiting my time I can spend on here today.

    IG
     
  19. issy1

    issy1 Active Member

    Yes, this makes sense. If you've time later maybe you could highlight your findings and treatment plan for this lady.

    Many Thanks. Issy
     
  20. Griff

    Griff Administrator

    No problem. I suppose the point I was trying to make was after seeing this comment:

    Ask what exercises she has been doing. Just because they didnt help does not make this a "foot problem" (more a case of an "inappropriate exercise problem" perhaps?)

    Also check her standing position (i.e. when she is at work cutting peoples hair). Bet she favours 'hanging' off of one hip - you never know - you may even be lucky and find its the side that hurts...
     
  21. Griff

    Griff Administrator

    Right, here is the way I explain this to patients (and I make no apologies for its gross over-simplification)

    The main culprits are usually Gluteus Medius, and to a degree Gluteus Maximus also. Their fibres tend to run in a inferior-lateral direction, from the ileum to the greater trochanter of the femur (and the ITB itself for maximus). I describe this like the bracket of a shelf, as in picture below on the right hand side. The shelf itself it the pelvis (i.e. the waistband of their shorts). The wall the shelf is attached to is the leg/femur they are standing on. Still with me?

    If that bracket fails (is dysfunctional) then what happens to the shelf? If falls away from the wall - i.e. the end of the shelf opposite to the bracket falls down towards the earth. So if we take a right sided trendelenberg, as with the lady in the previous video analysis stills, she is on her right leg, the left side of the pelvis is falling towards the earth - therefore it suggests the hip abductors (brackets) on the right side are dysfunctional. Most patients understand this concept once explained to them.

    So why does this happen? Well here is my take on it. As I said earlier in my opinion it is more of a recruitment or timing issue than isolated 'weakness'. This neuromuscular control seems to be lost in individuals who have sedentary jobs (... that'll be most people then). I saw a chap in London today who runs for up to 1 hour a day. Pretty impressive, but sadly still a very small percentage of time compared to the 16 hours a day he spends sitting in front of his 3 computer screens analysing the stock markets.

    Sitting = hip flexion. Gluteal demand = zero. In my experience when these individuals then stand up to walk/run their gluteii just simply don't know what to do or when to do it. Almost like a de-conditioning effect, but more than that - a complete inability of the neuromuscular system to 'switch on' the muscles in this relatively extended hip joint position.
     

    Attached Files:

  22. RobinP

    RobinP Well-Known Member

    I believe it may have been Howard Danenberg who mentioned that particular one. I think he was referring to the link between all of the structures you mention. Ted Jadnik(spelling?)/TedJed mentioned it in this post

    located on this thread.
    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=38213

    If you want to search for anything in PA, put the search terms you are lloking for into google with podiatry arena as the last search term and it is more accurate than using PAs search. There is actually a thread about it.

    Regards,

    Robin
     
  23. RobinP

    RobinP Well-Known Member

    Nice way of explaining it Ian. I'll have to take people to my house and explain to them that their gluteals are functioning in much the same way as the bracket for the "floating shelf" that I bought from B&Q. That is ....not at all.

    I have the only "floating shelf" that is bracketed on to the wall.

    Regards,

    Heath Robinson
     
  24. efuller

    efuller MVP

    Another way of explaining. Right leg stance phase. Body weight (gravity) acts on center of mass of trunk downward. Femur applies an upward force to keep the trunk in the air. These two forces are not directly in line so they will create a force couple that will cause the trunk to rotate to the left. Something has to prevent that rotation. The right hip abductor muscles will rotate the trunk to the right, which is the same as saying they will create a moment in the opposite direction as gravity. In the picture, the muscles are not holding the pelvis level and the pelvis rotates to the left. When the pelvis rotates far enough to the left the right iliotibial band will become tight and create downward force on the pelvis at a point that is lateral to the upward force from the femur. In other words the IT band creates a moment that wants to rotate the pelvis to the right.

    Eric
     
  25. Ian:

    It would be more accurate to model the gluteus medius as being rubber bands or a cord that are attached, by a nail, for example, to the top surface of the shelf and then extending to the top surface of the table, that is "superior" to the "joint axis" and creating a tension force to hold the shelf up. Your current model, unfortunately, uses compression force on the "inferior" side of the joint axis, a type of force which muscles, ligaments and tendons do not use to accomplish such tasks.

    Thought that this point should be made before others start using this same model without understanding it's limitations.
     

    Attached Files:

  26. Griff

    Griff Administrator

    Thanks for this Kevin. I only devised this model/description as an illustration for my patients (i.e. lay people). In my experience what confuses most people regarding a trendelenberg is the fact that the side which drops is actually the contralateral side to the dysfunctional side. To this end, my analogy has been very easily understood by all I have explained it to, and therefore I regard it as useful (despite it's limitations that you have highlighted). The reason I posted it here was that I felt it may help some people in the same way.
     
  27. Ian:

    I like your idea of the folding shelf on a desk for explaining the Trendelenburg sign. I thought the cord on top of the table and shelf made more sense from a modelling sense.
     
  28. footdrcb

    footdrcb Active Member

    Well put ...I agree with you on that one....kevin
     
  29. HansMassage

    HansMassage Active Member

    Ian: I really like your wall grids.
    There is another muscle imbalance/recruitment-timing that I find is often involved. It is the Psoas Minor. It balances the anterior tilt of the pelvis above the contact leg while the other is lifting. Often there is a locked rotation and uneven enervation at T11/12 as the source.
     
  30. issy1

    issy1 Active Member

    Saw patient today. She suffers from pain along course of iliotibial band and at insertion into knee and hip of LEFT side mostly but occasionally right too. Pain is always there when weightbearing but worse when climbing stairs etc. She does no form of exercise. She attended Physio who did acupuncture and gave her some stretching exercises but she has not been doing them!

    When walking the pelvis does dip slightly on right side when weightbearing on left so probable weakness of left hip abductors.

    When walking she has externally rotated knees (a little more internal rotation can be acheived when supine with hip flexed than extended), and just before contact she has a sudden adduction action happens which is probably the key moment in the irritation of the IT Band. Leg Length same. She looks like she is going to strike the ground in a very varus position but then just at last moment before strike she has a very sudden adduction moment and actually hits ground on horizontal heel.

    She does have forefoot supinatus with plantarflexed 1st Ray which she loads heavily but as this adduction action is mostly happening before heel strike I assume that Orthotic treatment would not help IT Band pain much?? I have printed off some stretching and strength exercises for Hip abductors and Piriformis and have advised of importance of doing these. Have also advised her to ice areas when painful. Also she does admit to 'hanging of one hip' when hair dressing but constantly changes from foot to foot trying to ease pain. Have advised her to stand with even weight on both feet and with unflexed knees whilst hair dressing. Will review in 1 month.

    Would people agree that this is not a foot problem as orthotics are not going to stop this sudden adduction moment before heel strike or is their anything else I can do?
     
  31. efuller

    efuller MVP

    I'm a little confused by the terminology. Are you looking from behind, as she walks, and seeing that the heel is inverted during swing. Then just before contact you see the heel evert?

    What happens during swing is an unconscious choice made by the patient. The question is why is the patient making that choice. If it is related to the foot then an orthotic may effect that choice. For example, if the patient was laterally unstable then choosing to evert before heel strike may help prevent inversion injuries.

    If this happens in swing, before contact, then it is hard to see how this causes the IT band pain. You might go with how she stands as she works as a better explanation. There still might be something to treat in the foot.

    Eric
     
  32. issy1

    issy1 Active Member

    Yes I am looking from behind but I am referring to an abducted knee and foot position throughout swing and then a sudden internal rotation of femur and knee just before heel strike which adducts her foot and makes her heel strike vertical and foot position no longer abducted. The heel goes from an inverted position during swing to a vertical position just before heel contact. As she moves on into midstance their is a very slight eversion of heels but very little change from heel contact. Although she has a cavus foot type it is not rigid and she has no history of lateral instability.
     
  33. Griff

    Griff Administrator

    You originally said pain was only exacerbated by standing/hairdressing. If this is the case then personally I would be focusing mostly on postural re-education. The question then becomes - do you feel orthoses have a role to play in this?

    I may be wrong, (and of course have not seen the patient) but I'd still be surprised if this was primarily a 'foot problem'. Here's what I think has happened:

    1. Patient attends Physio who diagnoses ITB pathology
    2. Physio performs acupuncture and prescribes stretches
    3. Patient doesn't get better
    4. Physio 'palms off' to Podiatry saying it 'may be a foot issue'

    I'm pretty sure step 2 is where the problem is here - inappropriate treatment. Assuming it is a case of increased tensile forces in the ITB secondary to dysfunctional pelvic musculature, then what the devil is acupuncture and a stretching program going to do? Foxtrot Alpha....

    Do you work privately Issy? If so, and you have a good working relationship with said Physio then send a letter explaining your thoughts on what may be required proximally to get the best results for your patient. (Or refer onto another Physio who you know is good/better with their neuromuscular rehabilitation).

    And remember this may not be a strength/weakness issue. It may be a recruitment issue. Management has to planned according to this.

    Keep us posted!

    IG
     
  34. issy1

    issy1 Active Member

    No I said problem is exacerbated when hairdressing not only when hair dressing. But yes I do work privately so abit out on a limb of my own. I do have a Physio I refer to now and again but more because he is a friend of the family - not sure what his strong points are! I still feel that the IT Band is being aggravated when this sudden adduction of leg occurs just before heel strike - is this sign of weak hip abductors??
     
  35. Griff

    Griff Administrator

    Personally I wouldn't be worrying too much about anything I saw dynamically if standing was the primary exacerbating factor. As a hairdresser she stands a hell of a lot more than she walks over the course of an average day. And how do we know its not just hurting when she walks as a direct result of standing all day anyway?

    I'm surprised you say you feel 'out on a limb of your own' due to being in private practice. It is far easier to nourish good relationships with other professionals and to engage in multidisciplinary teamwork privately than it is in the NHS! Maybe if you let us know where you are based someone can give you a recommendation - I'm still of the belief this will settle with some appropriate Physiotherapy.
     
  36. efuller

    efuller MVP

    The IT band runs vertically, so the forces it applies will be mostly vertical. So, for that reason it is unlikely that the IT band is the cause of the transverse plane motion that you see. The IT band is mostly a passive structure so if it did casuse knee motion by becoming tight at the end of swing and the medial hamstrings were not tight, you would expect to see external rotation, not internal, in the transverse plane.

    Your observation is of an unusual gait, but just because it is unusual mean that it the cause of the patient's pain.

    Eric
     
  37. RobinP

    RobinP Well-Known Member

    Ian,

    Thanks for that breakdown and logic workthrough, a good lesson for folks like me in identifying tissue stress causes and filtering out extraneous information.

    If recruitment is the problem - what type of work does the physio actually do to improve recruitment?

    Thanks

    RP
     
  38. Griff

    Griff Administrator

    Will email you some exercise sheets to show you birthday boy
     
  39. footdrcb

    footdrcb Active Member




    Interesting you mention that . I treat a patient a while ago that had ITB syndrome , but interestingly enough he had quite major testicular and general groin pain which he had thougoughly investigated without a remarkable result.

    His neuro surgeon found a compression at T12 , even though the primary innervation along the dermatome for the groin area is L5/S1.

    Im not sure on the mechanism IE How? the Psoas minor can balance the anterior tilt of the pelvis, please forgive my ignorance. As I understood it, p minor is partially responsible "for" anterior rotation. Im not sure what the antagonistic muscle group is ?? Erector spinae???

    I would be grateful if you could explain this a little more .

    Kind regards

    FDCB
    Craig :bang:
     
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