Mentoring Minutes: IT Band References

IT Band Syndrome effects up to 12% in Runners and over 50% in cyclists. Learn more about how to treat this pattern with this Mentoring Minutes!

References & VIDEO NOTES:

Gait Posture. 2015 Feb;41(2):706-10. doi: 10.1016/j.gaitpost.2015.01.031. Epub 2015 Feb 7.

Associations between iliotibial band injury status and running biomechanics in women.

Foch E1, Reinbolt JA2, Zhang S3, Fitzhugh EC3, Milner CE3.

- The purpose of this cross-sectional study was to determine if differences in lower extremity and trunk biomechanics during running exist among runners with current ITBS, previous ITBS, and controls.

- Twenty-seven female runners participated in the study.

- Participants were divided into three equal groups: current ITBS, previous ITBS, and controls.

- Over ground running trials, isometric hip abductor strength, and iliotibial band flexibility were recorded for all participants. Discrete joint and segment biomechanics, as well as hip strength and flexibility measures were analyzed using a one-way analysis of variance. 

- Runners with current ITBS exhibited greater trunk ipsilateral flexion less iliotibial band flexibility compared to runners with previous ITBS and controls. 

- Runners with current ITBS may lean their trunk more towards the stance limb which may be associated with decreased iliotibial band flexibility.

Int J Sports Phys Ther. 2017 Feb;12(1):16-24.

DEFORMATION RESPONSE OF THE ILIOTIBIAL BAND-TENSOR FASCIA LATA COMPLEX TO CLINICAL-GRADE LONGITUDINAL TENSION LOADING IN-VITRO.

Wilhelm M1, Matthijs O2, Browne K1, Seeber G3, Matthijs A2, Sizer PS1, Brismée JM1, James CR1, Gilbert KK1.

- Iliotibial Band (ITB) syndrome is a troublesome condition with prevalence as high as 12% in runners. Stretching has been utilized as a conservative treatment. However, there is limited evidence supporting ITB elongation in response to a stretching force.

- The purpose of this study was to describe the iliotibial band tensor fascia lata complex (ITBTFLC) tissue elongation response to a simulated clinical stretch in-vitro.

-  The strain response of six un-embalmed ITBTFLCs to a simulated clinical stretch of 2.75% elongation was assessed. Four sets of array marks were placed along the length of the ITBTFLC. Tissue elongation was compared between proximal, middle, and distal ITBTFLC regions.

- Significant elongation was observed in the proximal, middle, and distal regions during the "stretched" versus the resting condition. The proximal region exhibited significantly greater elongation versus the middle and distal regions.

Arch Phys Med Rehabil. 2002 May;83(5):589-92.

Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches.

Fredericson M1, White JJ, Macmahon JM, Andriacchi TP.

- a compare the relative effectiveness of 3 common standing stretches for the iliotibial band (ITB): arms at side, arms extending overhead, and arms reaching diagonally downward .

- biomechanics was captured as a 3-dimensional image by using a 4-camera gait acquisition system with a forceplate.

- For each stretch, change in ITB tissue length and the force generated within the stretched complex was measured. Data were then combined and analyzed by using kinetic values assessment.

- All 3 stretches created statistically significant changes in ITB length but stretch incorporating overhead arm extension, was consistently most effective both for average ITB length change and average adduction moments at the hip and knee.

BMC Musculoskelet Disord. 2015 Nov 16;16:356. doi: 10.1186/s12891-015-0808-7.

Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review.

Aderem J1, Louw QA2.

- Iliotibial band syndrome is the second most common running injury. A gradual increase in its occurrence has been noted over the past decade. This may be related to the increasing number of runners worldwide. Since the last systematic review, six additional papers have been published, providing an opportunity for this review to explore the previously identified proximal risk factors in more detail.

- The aim of this systematic review is thus to provide an up to date quantitative synthesis of the trunk, pelvis and lower limb biomechanical risk factors associated with Iliotibial band syndrome in runners and to provide an algorithm for future research and clinical guidance.

- Thirteen studies were included (prospective (n = 1), cross-sectional (n = 12)). Overall the methodological score of the studies was moderate.

- Female shod runners who went onto developing Iliotibial band syndrome presented with increased peak hip adduction and increased peak knee internal rotation during stance. Female shod runners with Iliotibial band syndrome presented with increased: peak knee internal rotation and peak trunk ipsilateral during stance.

Sports Med. 2012 Nov 1;42(11):969-92. doi: 10.2165/11635400-000000000-00000.

Iliotibial band syndrome in runners: a systematic review.

van der Worp MP1, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW.

- incidence estimated to be between 5% and 14%.

- a systematic review of the literature on the aetiology, diagnosis and treatment of ITBS in runners.

- The kinetics and kinematics of the hip, knee and/or ankle/foot appear to be considerably different in runners with ITBS to those without

- While the articles were inconsistent regarding the treatment of ITBS, hip/knee coordination and running style appear to be key factors in the treatment of ITBS

J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8. doi: 10.2519/jospt.2010.3028.

Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics.

Ferber R1, Noehren B, Hamill J, Davis IS.

- examine differences in running mechanics between runners who had previously sustained iliotibial band syndrome (ITBS) and runners with no knee-related running injuries.

- Because the iliotibial band has both femoral and tibial attachments, it is possible that atypical hip and foot mechanics could result in the development of ITBS.

- The running mechanics of 35 females who had previously sustained ITBS were compared to 35 healthy age-matched and running distance-matched healthy females. Comparisons of hip, knee, and ankle 3-dimensional kinematics and internal moments during the stance phase of running gait were measured.

-The ITBS group exhibited significantly greater peak rearfoot invertor moment, peak knee internal rotation angle, and peak hip adduction angle compared to controls.

Sports Med. 2011 Jun 1;41(6):463-76. doi: 10.2165/11588740-000000000-00000.

Effects of bicycle saddle height on knee injury risk and cycling performance.

Bini R1, Hume PA, Croft JL.

- Incorrect bicycle configuration may predispose athletes to injury and reduce their cycling performance. This review summarizes literature on methods for determining bicycle saddle height and the effects of bicycle saddle height on measures of cycling performance and lower limb injury risk.

- Increasing saddle height can cause increased shortening of the vastii muscle group, but no change in hamstring length. Length and velocity of contraction in the soleus seems to be more affected by saddle height than that in the gastrocnemius.

- The majority of evidence suggested that a 5% change in saddle height affected knee joint kinematics by 35% and moments by 16%.

- On the basis of the conflicting evidence on the effects of saddle height changes on performance and lower limb injury risk in cycling, we suggest the saddle height may be set using the knee flexion angle method (25-30°) to reduce the risk of knee injuries and to minimize oxygen uptake.

J Sci Med Sport. 2017 Apr;20(4):349-355. doi: 10.1016/j.jsams.2016.09.002. Epub 2016 Sep 20.

Hip abductor strength and lower extremity running related injury in distance runners: A systematic review.

Mucha MD1, Caldwell W1, Schlueter EL1, Walters C1, Hassen A2.

- Determine the association between hip abduction strength and lower extremity running related injury in distance runners.

- Prospective longitudinal and cross sectional studies that quantified hip abduction strength and provided diagnosis of running related injury in distance runners were included and assessed for quality.

- Of the 1841 articles returned in the initial search, 11 studies matched all inclusion criteria. Studies were grouped according to injury: iliotibial band syndrome, patellofemoral pain syndrome, medial tibial stress syndrome, tibial stress fracture, and Achilles tendinopathy, and examined for strength differences between injured and non-injured groups.

-Meaningful differences were found in the studies examining iliotibial band syndrome. Three of five iliotibial band syndrome articles found weakness in runners with iliotibial band syndrome; two were of strong methodological rigor and both of those found a relationship between weakness and injury.

- Hip abduction weakness evaluated by hand held dynamometer may be associated with iliotibial band syndrome in distance runners as suggested by several cross sectional studies

Mentoring Minutes: Patellofemoral Pain Syndrome

REFERENCE & VIDEO NOTES

J Orthop Sports Phys Ther. 2009 Jan;39(1):12-9. doi: 10.2519/jospt.2009.2885.

Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain.

Souza RB1, Powers CM.

            - Twenty-one females with PFP and 20 pain-free controls

-Hip kinematics and activity level of hip musculature were obtained during running, a drop jump, and a step-down maneuver. Isometric hip muscle torque production was quantified using a multimodal dynamometer.

- Runners with PFPS, best predictor of hip IR: isotonic hip extension endurance

J Orthop Sports Phys Ther. 2012 Jun;42(6):491-501. doi: 10.2519/jospt.2012.3987. Epub 2012 Mar 8.

Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single-leg squat in males and females with and without patellofemoral pain syndrome.

Nakagawa TH1, Moriya ET, Maciel CD, Serrão FV.

 - 4 groups: females with PFPS, female controls, males with PFPS and male controls

- Outcomes: trunk, pelvis, hip, and knee kinematics; gluteal muscle activation during SL squat; hip abd+ER eccentric strength

- During SL squat PFPS patients had significantly greater ipsilateral trunk lean, contralateral pelvic drop, hip adduction, and knee abduction with SL squat

- Pts with PFPS had 18% less hip abd and 17% less hip ER strength

- females with PFPS had more hip IR and less glut med activation during SL squat

J Orthop Sports Phys Ther. 2009 Jul;39(7):532-40. doi: 10.2519/jospt.2009.2796.

Gluteal muscle activation during common therapeutic exercises.

Distefano LJ1, Blackburn JT, Marshall SW, Padua DA.

- Which exercise is best for patients with PFPS for glut med and max strengthening

            - Glut med: Side lying hip abd (81% MVIC), Single limb squat: 64%

            - Glut max: Single limb squat and Single limb deadlift (both 59%)

J Orthop Sports Phys Ther. 2013 Feb;43(2):54-64. doi: 10.2519/jospt.2013.4116. Epub 2012 Nov 16.

Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes.

Selkowitz DM1, Beneck GJ, Powers CM.

- Best exercises for activating glut max – bilateral bridging, clam, quadruped hip ext with knee extended, quadruped hip extension with knee flexed, side step, squat, and unilateral bridges

All of these exercises produces 50% higher normalized EMG amplitudes for both gluteal muscles compared to TFL

Clamshells with band– highest glut max normalized EMG amplitude; unilateral bridges – second highest normalized EMG amplitude

Hip abduction in sidelying and hip hike – highest glut med normalized EMG amplitude compared to TFL and glut max

J Orthop Sports Phys Ther. 2012 Jan;42(1):22-9. doi: 10.2519/jospt.2012.3704. Epub 2011 Oct 25.

The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial.

Khayambashi K1, Mohammadkhani Z, Ghaznavi K, Lyle MA, Powers CM.

- Isolated hip abductore and ER strength with PFPS. RCT

- 28 females with PFPS split into 2 groups; 1 group did hip abduction and ER strengthening 3x a week for 8 weeks;

measured pain, womac, strength,

- performed standing abduction and seated Er both with resistance. Starting 3 sets of 20, increasing reps and resistance from TB.. Pain and health status both sustained at 6 month follow up.

- pain, health status, and bilateral hip strength improved in the exercise group following the 8-week intervention but did not change in the control group.

- Improvements in pain and health status were sustained at 6-month follow-up in the exercise group.

J Orthop Sports Phys Ther. 2011 Sep;41(9):625-32. doi: 10.2519/jospt.2011.3470. Epub 2011 Jul 12.

The effect of a hip-strengthening program on mechanics during running and during a single-leg squat.

Willy RW, Davis IS.

- evaluate a simple gait retraining technique, using a full-length mirror, in female runners with patellofemoral pain and abnormal hip mechanics.

- Had them just practice running in front of a mirror with verbal cues… slowly deceasing the feedback Transfer of the new motor skill to the untrained tasks of single leg squat and step descent was also evaluated.

- significant changes in only 2 weeks, (8 sessions)  with improved mechanics and decrease in pain, with feedback decreasing after 4, also recheck at 1 month and 3 months after.  Were shown their video of running to see faults- that transferred over to other tasks (SL squat) and was sustained up to 3 months later

-Subjects reduced peaks of hip adduction, contralateral pelvic drop, and hip abduction moment during running

- Skill transfer to single leg squatting and step descent was noted, and maintained through 3 months post retraining.

Mentoring Minutes: Hip OA

Today's #MentoringMinutes covers Hip OA diagnostics along with manual therapy & therapeutic exercise options in treatment.

***Hip pain with mobility deficits:
For Diagnosis (new changes form 2017 guideline revisions
o Moderate anterior or lateral hip pain during WB
o AM stiffness < 1 hour
o Hip IR ROM < 24 deg
o or < 15 deg opp side
o or painful PROM hip IR
o Hip Flexion < 15 deg from opp side

Important to look at functional activity and make objective
o 6 min walk test, 30 sec STS (ave 12, arms across chest), Step test (15 cm step, 15 sec, mean 14, MDIC 3)

For Assessment:
o ROM: Flexion, IR/ER supine or prone; hip ext — change with lateral distraction
o MMT: Hip abd, Ext, IR/ER in sitting (HHD 5cm ablve malleolus)

Interventions: multiple studies that show a combination of manual therapy, exercise and education, better than just exercise, or manual therapy alone) 
o Distraction thrust
o MWM flexion, and IR with lateral glide (12 deg increased flex, 4 deg increased IR)- 2016 study comparing to sham
o Supine cross over post glide
o Ext PA

Therapeutic exercise
o Rock back with belt
o Supine SKTC with belt (foot or distraction)
o Ext stretch (kneeling or standing)

Patient education
o Activity modification, unloading with assistive decvices and weight loss (loss 5% BMI and 3.3% body fat had improved womac 17% and pain levels 25% improves at 8 months)

Poor prognosis: mod to severe OA, increased joint space 0.3-0.7 mm per year: total rot 42 deg or less, and sx’s longer than 36 months- no change after PT

***REFERENCES***
Holla JF, Steultjens MP, van der Leeden M, et al. Determinants of range of joint motion in patients with early symptomatic osteoarthritis of the hip and/or knee: an exploratory study in the CHECK cohort. Osteoarthritis Cartilage. 2011;19:411-419. https://doi.org/10.1016/j.joca.2011.01.013

French HP, Cusack T, Brennan A, et al. Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2013;94:302-314. https://doi.org/10.1016/j.apmr.2012.09.03

Wright AA, Cook C, Abbott JH. Variables associated with the progression of hip osteoarthritis: a systematic review. Arthritis Rheum. 2009;61:925- 936. https://doi.org/10.1002/art.24641

Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351:h5983. https://doi.org/10.1136/bmj.h5983

Bieler T, Magnusson SP, Kjaer M, Beyer N. Intra-rater reliability and agree- ment of muscle strength, power and functional performance measures in patients with hip osteoarthritis. J Rehabil Med. 2014;46:997-1005. https:// doi.org/10.2340/16501977-1864

Choi YM, Dobson F, Martin J, Bennell KL, Hinman RS. Interrater and intra- rater reliability of common clinical standing balance tests for people with hip osteoarthritis. Phys Ther. 2014;94:696-704. https://doi.org/10.2522/ ptj.20130266

Pua YH, Wrigley TV, Cowan SM, Bennell KL. Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in per- sons with hip osteoarthritis. Arch Phys Med Rehabil. 2008;89:1146-1154. https://doi.org/10.1016/j.apmr.2007.10.028

Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014;311:1987-1997. https://doi.org/10.1001/jama.2014.4591 
Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-

Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-85. https://doi.org/10.1016/j.math.2015.10.007

Paans N, van den Akker-Scheek I, Dilling RG, et al. Effect of exercise and weight loss in people who have hip osteoarthritis and are overweight or obese: a prospective cohort study. Phys Ther. 2013;93:137-146. https:// doi.org/10.2522/ptj.20110418

Mentoring Minutes on Piriformis Syndrome

Also, check out our Patient Education on PIRIFORMIS SYNDROME CAN BE A PAIN IN THE BUTT

*** CASE NOTES & REFERENCES ***

- Treatment of an Individual with Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation: A Case Report
- Typical treatment: STM, stretching, nerve gliding; 
- 2 year history buttock and post thigh pain
- Movement analysis: Step down (excessive hip add/IR), which had ROS
- MMT : weakness if hip abd and ER muscles
- Treatment: hip strengthening and movement re-education; 
- Outcomes: 0/10 pain with all ADLs’s; 80/80 LEFS improved LE kinematics for peak hip adduction and IR; 
- So instead of pirifmoris being short, its possible to be over lengthened
- Phase 1 (0-4): Bridge with TB; Clam with TB; 
- Phase 2 (4-9): squat with TB; side steps with TB; SL STS; Step down
- Phase 3: functional training: (9-14): forward lunge, lunge at 45 deg, DL jumps, DL to SL lands

Published: Journal of Orthopaedic & Sports Physical Therapy, 2010 Volume:40 Issue:2 Pages:103–111 DOI:10.2519/jospt.2010.3108

Mentoring Minutes: Patellar Tendinopathy

References and notes:

J Sport Rehabil. 2017 Nov 15:1-22. doi: 10.1123/jsr.2017-0196. [Epub ahead of print]

Clinical Measures and Their Contribution to Dysfunction in Individuals With Patellar Tendinopathy.

Jeon H1, McGrath ML2, Grandgenett N3, Rosen AB4.

• 30 participants with patellar tendinopathy
• Purpose of this investigation was to determine if strength, flexibility, and various lower extremity static alignments contributed to self-reported function and influence the severity of patellartendinopathy.
• Isometric knee extension and flexion strength, hamstring flexibility and alignment measures of rearfoot angle, navicular drop, tibial torsion, q angle, genu recurvatum, pelvic tilt, and leg length differences were assessed. 
• Significant relationships between questionnaires and BMI, normalized knee extension and flexion strength, q angle and pelvic tilt . Regression models identified thigh musculature strength and supine q angle to have greatest predictability for severity in patient-reported outcomes.

Br J Sports Med. 2015 Oct;49(19):1277-83. doi: 10.1136/bjsports-2014-094386. Epub 2015 May 15.

Isometric exercise induces analgesia and reduces inhibition in patellartendinopathy.

Rio E1, Kidgell D2, Purdam C3, Gaida J4, Moseley GL5, Pearce AJ6, Cook J1.

• Single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms. Isometric contractions can be completed without pain for people with PT. The clinical implications are that isometric muscle contractions may be used to reduce pain in people with PT without a reduction in muscle strength.

Br J Sports Med. 2007 Apr;41(4):217-23. Epub 2007 Jan 29.

The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes.

Visnes H1, Bahr R.

• 7 articles with a total of 162 patients 
• Most studies suggest that eccentric training may have a positive effect, but our ability to recommend a specific protocol is limited. The studies available indicate that the treatment programme should include a decline board and should be performed with some level of discomfort, and that athletes should be removed from sports activity. 
• Most were home-based programmes with twice daily training for 12 weeks
• Drop squats or slow eccentric movement, squatting on a decline board or level ground, exercising into tendon pain or short of pain, loading the eccentric phase only or both phases, and progressing with speed then loading or simply loading.