Iliotibial band syndrome Iliotibial band syndrome is a common cause of lateral knee pain in runners. The iliotibial band (ITB) is the distal fascial continuation of three muscles: the tensor fascia lata, gluteus medius, and gluteus maximus. The ITB runs along the lateral aspect of the knee and inserts into Gerdy’s tubercle of the lateral tibial plateau with some insertion also into the lateral supracondylar ridge of the femur. The ITB also has an extension that attaches to the lateral patella (Hadeed & Tapscott, 2023). As such, the ITB can influence patellar mechanics. Etiology Like patellofemoral pain, the cause of iliotibial band syndrome is thought of as multifactorial. One theory is that friction of the ITB occurs as it rubs on the lateral epicondyle of the femur. As the knee moves through flexion and extension range of motion, the ITB makes contact with femur at 30 degrees, an angle that correlates roughly with foot strike. Anatomical studies have not supported this idea. Two other possible sources of pain for iliotibial band syndrome the highly innervated fat pad that is deep to the distal ITB and the ITB bursa that lies between ITB band and the lateral epicondyle of the femur (Hadeed & Tapscott, 2023). Symptoms Runners presenting with iliotibial band syndrome will typically identify a recent increase in training load. They will describe lateral knee pain that is located between the femoral epicondyle and Gerdy’s tubercle. Pain is typically worse with hill running, running with longer strides, and with running on a cambered road (Hadeed & Tapscott, 2023). Physical examination The knee should be observed for genu varus/valgus alignment. Palpation typically reveals tenderness at the distal ITB about 2 to 3 cm proximal to the tibiofemoral joint line (Hutchinson et al., 2022). Crepitus may be felt in this area with knee flexion/extension (Hadeed & Tapscott, 2023). Strength testing of the hip and knee muscles, especially the hip abductors should be completed (Hutchinson et al., 2022). For this test, the patient is supine while the examiner applies firm pressure over the lateral femoral epicondyle with the palm of hand. The examiner grasps the patient’s ankle with the other hand and moves the knee from full extension to 90 degrees of flexion. The test is positive if pain and/ or crepitus is noted at approximately 30 degrees of knee flexion (Noble’s Test, 2022). Self-Assessment Quiz Question #3 The Noble’s test looks for tenderness of the ITB at approximately 30 degrees of knee flexion as that is the position where the ITB comes in contact with the femur. What phase of the running gait cycle does this correlate with? a. Push-off. Special tests Noble’s test
Ober’s test For this test, the patient lies on the uninvolved side. The examiner stands behind the patient. One hand is used to support the knee and the other hand is placed to the iliac crest for stabilization. The hip is abducted and brought into extension. From this extended position, the hip is now adducted. The test is positive if pain and/or tightness in the ITB is noted in position of hip adduction/extension (Hadeed & Tapscott, 2023). The utility of Ober’s test has been recently questioned (Geisler, 2021). Biomechanical factors Genu varus is a biomechanical factor that can predispose the iliotibial band to increased stress or tension. Increased hip internal rotation and hip adduction during stance phase have been shown to be present in runners with iliotibial band syndrome compared to control subjects without this condition. Increased rearfoot eversion may also play a role (Friede et al., 2022). Treatment Soft tissue techniques Soft tissue techniques such as trigger point therapy, myofascial release, and instrument-assisted techniques such as the Graston technique and foam rolling can be applied to the ITB itself as well as the vastus lateralis, biceps femoris, and tensor fascia latae muscles. The goal is to reduce ITB strain and pain by releasing myofascial restrictions. Although no studies have looked at the effectiveness of soft tissue techniques alone in treating iliotibial band syndrome, they have been shown to increase flexibility and decrease muscle Strengthening the hip stabilizing muscles, especially the hip abductors, is considered a key part of rehabilitation for iliotibial band friction syndrome. The rationale for this is that a weak gluteus medius increases demand on the tensor fascia lata, resulting in greater tensile force in the ITB. At present, the evidence to support strength training in runners is considered low (Friede et al., 2022). Friede et al. (2022) recommend that hip muscle strengthening should focus on neuromuscular control and strength endurance. Stretching The goal of stretching is to relieve tension in the ITB in order to decrease compression on the underlying tissues. Typically, ITB focuses on side bending of the trunk with adduction of the lower extremity as this lengthens the ITB. Stretching has been shown to decrease stiffness and neuromuscular activity in the short term. In addition, stretching may decrease nociceptor input (Friede et al., 2022). Friede et al. (2022) recommended that static ITB should be performed for a minimum of 3 minutes, such as three repetitions with a 1-minute hold, and that stretching be incorporated into a regular routine. Extracorporeal shock wave therapy and dry needling Both extracorporeal shock wave therapy and dry needling have been shown to improve pain and function in patients with iliotibial band syndrome (Razie et al., 2021). tone (Friede et al., 2022). Strengthening exercises
b. Foot strike. c. Propulsion. d. Pre-swing.
Stress fractures Stress fractures are the result of repeated mechanical stress to the bone that exceeds the bone’s capacity for remodeling, resulting in microfractures. If activity persists, stress fractures can lead to fractures (May & Marappa- Ganeshan, 2023).
Etiology The most common risk factor for stress fractures is an abrupt increase in training volume. Intrinsic risk factors include poor physical conditioning, female, menstrual disorder, poor bone density, and reduced muscle mass (May &
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