Iliotibial Band Syndrome
Runner’s outer knee pain is a common injury. The term used to describe the lateral knee pain is often iliotibial band syndrome (ITBS). Some twelve percent of the running community will experience knee pain felt above the outside of the knee joint. A physiotherapist will need to do an examination of muscles, ligaments and the knee joint. This newsletter will focus on the ITBS.
Where is the Iliotibial Band (ITB)?
The ITB is a thick band of connective tissue that arises at the top of the hip, from the tensor fascia lata and gluteus maximus muscles. It runs down the outer thigh from the pelvis to the shin bone of the lower leg (tibia). The ITB provides lateral stability to the hip and knee joints.
What is Iliotibial Band Syndrome (ITBS)?
The prime cause of ITBS remains debatable. The most accepted theory is when the knee flexes or bends, a tight ITB creates an irritating friction force at the outer femoral condyle, which leads to irritation and pain at the lateral knee. However, current thinking proposes that a layer of fat, with a rich nerve and vascular supply, is compressed between the ITB and outer femoral condyle, causing inflammation and pain. We await further research to confirm this theory.
What causes ITBS?
The classification of ITBS being an overuse injury means training error is often the primary cause of the inflammation and pain. How much you train, how hard you train and how often you train will determine the loading capacity of tissues. When the load on tissues is too great an acute inflammatory response at the outer knee can occur.
Gluteal muscle weakness and poor movement control in the running activity can contribute to further tissue strain. Also if the knee rolls in (valgus) whilst running, greater compression and loading of the ITB at the knee joint will occur. Poor stability at the hip and/or ankle may add to movement control issues around the knee when running.
ITBS Treatment Options with Physiotherapy.
The first option is settling the acute inflammatory response with rest and ice packs. It is important to stop the aggravating activity, such as running, brisk walking or cycling, to allow the healing response to occur. Ice packs to the painful area on the outer knee and thigh can be helpful.
Manual therapy including soft tissue massage, trigger point release, ultrasound, and dry needling may be required to reduce muscle tension in the ITB or quieten areas of pain and inflammation.
When the symptoms have settled, exercising the weak muscle systems efficiently is important. This means your physio will choose exercises for you with progressive, graded loading. These exercises will help to reduce the strain on compromised tissues along the ITB and at the lateral knee when you return to running. The exercises will focus on strengthening core muscles, gluteus maximus, hip abductors (gluteus medius, gluteus minimus and tensor fascia lata) and hip rotators.
Finally, treatment will need to correct movement control in the aggravating activity of running. This can involve movement at the knee, ankle, foot, hip, pelvis and lumbar spine. The physio’s assessment will determine what areas of your body need to be addressed.
Stretching is now not believed to be a reliable, initial treatment approach, as the ITB’s tensile strength is like steel. However, stretching and mobilising the ITBS with a roller may be helpful in self- maintenance, once muscle strength and movement patterns are rehabilitated. A gradual return to running is then advised.
So when pain in the outer knee is debilitating and making it difficult for you to be active, there is hope. ITBS can often be a cause of this lateral knee pain, which must be carefully assessed and then treated according to examination findings. It is good news to realise that this presentation can be effectively treated with a variety of physiotherapy treatment options.
What does Tennis Elbow mean?
Tennis elbow is a painful condition affecting the outside part of the elbow. This area is called the lateral epicondyle and so the medical term for this condition is lateral epicondylitis. Tennis elbow is usually caused by overuse of the forearm. The outer elbow tissues become inflamed. This involves wrist and elbow extensor muscles being overused in repetitive movement and/or sustained postures. Many forearm muscles attach at or around the lateral epicondyle so when they are overused they pull too much on the elbow and make it sore. Patients typically develop this condition in association with activities involving repeated wrist extension against resistance or from activities involving repetitive or forceful gripping of the hand. This includes sporting activities such as tennis and squash, manual work such as gardening, painting, cleaning, sewing and knitting or working at a computer.
What are the symptoms of Tennis Elbow?
Symptoms of pain, stiffness and inflammation are common with tennis elbow. Pain can be constant or it just comes and goes with particular wrist and elbow movements. The elbow and forearm pain is often aggravated with grip activities. Even a simple activity of holding a pen and trying to write can be uncomfortable.
Pain and tenderness is usually felt on the outside of your dominant elbow and into the upper forearm. The pain is often aggravated by wrist movements such as gripping, where the use of inflamed forearm muscles and tendon tissues near the outer elbow hurts.
Most cases of tennis elbow settle well with appropriate physiotherapy. This requires careful assessment by the treating physiotherapist to determine which factors have contributed to the development of the condition. The assessment findings determine a treatment plan which will focus on correction of the factors causing the pain.
Physiotherapy Treatment for Tennis Elbow
Physiotherapy treatment for lateral epicondylitis is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Physiotherapy treatment may be a selection of the following:
- Soft tissue massage and myofascial release
- Joint mobilization
- Dry needling
- Ice or heat treatment
- Progressive exercises to improve flexibility and strength
- Activity modification advice
- Technique correction
- Anti-inflammatory advice
- Devising and monitoring an appropriate return to sport or activity plan
How long will my tennis elbow
With appropriate management, most minor cases of tennis elbow that have not been present for long can usually recover within a few weeks. In more severe and chronic cases recovery can be lengthy process and may take up to 6 months in those who have had their condition for a long period of time. Early physiotherapy intervention is therefore vital to hasten recovery and enable you to use your arm in everyday activity with comfort.
Physiotherapy and Gardening Advice
Spring is a special season for all gardeners. Weeds are tugged at and cleared, soil is dug and nurtured, seedlings and seeds are planted. It is so easy for many gardeners to take on too much, resulting in musculoskeletal strains and sprains.
TIPS FOR HEALTHY GARDENING:
- If you have a pre-existing physical problem take extra care. Be mindful of what you are wanting to do in the garden and prepare your body for this with stretches. Pace your activities over time. Always include a rest period between activities to recover
- Do not take on too much. Respect your body by not lifting or carting huge loads that are outside your physical strength zone
- Select appropriate gardening tasks for the required job. Go for comfort versus strain when clipping, digging, sawing and shovelling. Use tools with ergonomic handles and handle lengths that suit your height
- Avoid repetition strain of muscles and joints by mixing up activities during the gardening period
- Use a kneeling pad with handle to protect your knees when weeding, trowelling and mulching. The handle is useful in assisting you to get to a standing position safely
- Avoid bending from your waist, sustained forward lean and activities that place strain on the spine, when raking, leaf blowing and sweeping
- When potting, work at a comfortable bench height
- Keep any load close to you when lifting from your knees, being aware of engaging pelvic floor and deep abdominal muscles before lifting
- If pruning, be careful with arm reaching activities. Ensure you always have a stable footing. Do not over reach and strain neck and shoulder areas with loaded pruning action. Sharp pruning tools are important
- Use your foot to push a spade into the soil when you are digging. Avoid shoving the spade into the soil when you are digging and shoving the spade into the soil with a momentous arm action and back bend
- When lawn mowing walk tall with the mower to minimise forward trunk lean
If you feel tired or there is pain it is time to stop the gardening activity. Seek physiotherapy if your pain continues beyond 24-48 hours. At Physiotherapy for Women our experienced Physiotherapists will assess your issue and select treatment options to promote healing and recovery.
Pregnancy Related Pelvic Girdle Pain and Back Pain
What does pelvic girdle pain in pregnancy mean?
Pelvic girdle pain (PGP) in pregnancy can arise from the three main joints of the pelvis and the muscles, ligaments and nerves associated with these joints. There are two sacroiliac joints (SIJ) at the back of the pelvis. The SIJ exists between the sacrum and the side pelvic bone called the ilium. At the front of the pelvis is the pubic symphysis (PS).
A pregnant woman’s discomfort may come from the front PS and/or the right or left SIJ. It is possible for the pain pattern to shift day to day or week to week, where it may be just one sided, or it alternates, or the pain is only felt at the front or the pain is only at the back of the pelvis.
When only the pubic symphysis is involved the pelvic girdle pain is sometimes referred to as Symphysis Pubis Dysfunction (SPD).
Varying levels of pain can be felt in different areas, which may include the pubic symphysis, groin, lower abdomen, inner thigh, hip, buttock, outer thigh, entire leg or low back.
Pain may be constant or intermittent often described as an ache. Pelvic girdle pain can also be felt as a shooting/stabbing pain in the buttock, down the leg or at the front of the pelvis. Weight bearing on the leg/s may be quite difficult because of this pain experience.
Pregnancy pelvic girdle pain can occur early in the first trimester or at any time during the second and third trimesters.
What causes Pregnancy Pelvic Girdle Pain and Back Pain?
During pregnancy a combination of hormonal changes, altered posture and ineffective muscle support systems of the low back and pelvis may lead to feelings of discomfort and difficulty with walking and general movement. Hormonal softening of joint ligaments and muscle tissue means the joints and tissues of the pelvis and lumbar spine will be easily strained with repetitive activity, poor posture and incorrect exercise. The pain occurs because the pelvic joints have difficulty transferring weight bearing forces through the pelvis due to the physical and hormonal changes in pregnancy.
Unsupportive muscle systems then overwork to try and hold the pelvis together, creating shortened, tight muscles with painful trigger points in the buttock, thigh, hip and lumbar spine. Pregnant women experiencing pelvic girdle pain will often speak of stiffness as well as pain.
What are the Symptoms of Pregnancy Pelvic Girdle Pain?
Symptoms of pelvic girdle pain in pregnancy can be a combination of the following:
- Shuffling gait
- Difficulty weight bearing on one leg
- Difficulty climbing stairs
- Pain turning in bed
- Poor sleep with difficulty getting comfortable because of hip pain
- Inflammation or swelling over the sacrum or pubic bones
- Sciatic type pain down the leg
- Pain with long periods of sitting or standing
- Difficulty going from sit to stand
- Increased discomfort with routine daily activities
- Hip stiffness
- Pelvic floor muscle weakness
Can Pelvic Girdle Pain appear outside of Pregnancy?
Yes, pelvic girdle pain can occur in the postnatal period and is often related to a woman experiencing a small amount of buttock or hip discomfort in the last weeks of her pregnancy. In this scenario, the pregnant woman puts up with the pain in her third trimester, but after delivering the baby her pelvic joints and muscles struggle with the increased lifting, bending and holding movements that are required with baby care.
Injury can produce sacroiliac joint dysfunction and pain at any time in a woman’s life. This SIJ dysfunction has the same symptoms as pelvic girdle pain in pregnancy. The type of injury producing pelvic girdle pain is commonly a fall and landing on one side of the body or buttock. The position of the sacroiliac joint surfaces can be upset in this injury, leading to dysfunction because the transmission of weight bearing forces through the pelvis is upset.
Hormonal changes in the menstrual cycle and at the time of menopause can create muscle imbalances and hip problems that produce a pelvic girdle pain picture.
Overtraining in the gym or in sport may also produce sacroiliac joint dysfunction and pelvic girdle pain, this being related to muscle imbalance and overworking muscle systems that are not supporting the pelvic joints.
What is the Role of Physiotherapy in Treating Pelvic Girdle Pain in Pregnancy?
A physiotherapy assessment is essential to determine the treatment approach and advice for women experiencing PGP. It is recommended that an experienced Physiotherapist treats your presentation. This means a physio who knows the relevance of the musculoskeletal changes occurring in pregnancy. The Physiotherapist must have expert clinical skills in treating pelvic girdle pain with manual therapy and exercise, along with giving the appropriate advice to you.
At Physiotherapy for Women a research based Pelvic Girdle Questionnaire is given to each pregnant woman presenting with PGP. This assists in giving the physio a picture of the level of pelvic girdle pain and dysfunction the client is experiencing. The response to the questionnaire becomes a clinical measure for the effectiveness of the physiotherapy treatment approach over several treatment sessions.
The physiotherapy evaluation is important to determine what pelvic joint, ligament and muscle tissue is not working properly with specific movement testing. This will determine the cause of your pain, stiffness or loss of movement. Specialised clinical tests will be performed to rule out any problems that may require further medical intervention.
Listening to your goals and what is important to you will determine the direction of the treatment program. Physiotherapy treatment for pregnancy pelvic girdle pain may include:
- Manual therapy Massage, soft tissue and trigger point release for tight, sore muscle groups is a part of manual therapy. Correcting pelvic joint or SIJ alignment requires specific manual therapy skills, including muscle energy techniques.
- Core activation Training of pelvic floor and transversus abdominis muscle activation is important in resetting a background of core muscle support around your pelvis and lumbar spine. Selecting the right positions for core exercise is necessary. Then progression of the exercise can occur with graded loading that is safe and appropriate for you.
- Strengthening exercises Reducing ligament sprain and pain in your pregnant pelvis requires strengthening of weak gluteal, lower abdominal and pelvic floor muscles to improve stability of the sacroiliac, pubic symphysis and spinal joints.
- Flexibility exercises Tight muscles often need to be stretched to improve your flexibility, but selection and timing of when these stretches start requires the skills of the physio. If an overworking muscle system is stretched too soon before a background of core muscle support is happening in the pregnant woman’s body, pelvic joint pain can increase.
- Modalities To alleviate pain or to soften tight muscles prior to treatment or exercise, hot or cold treatments are often prescribed. Electrical treatments can also be a choice of treatment. Small ice packs placed over a painful pubic symphysis may be instructed by the physio as a home treatment.
- Bracing Your physio may recommend wearing a pregnancy pelvic belt that needs to be correctly fitted to support the pelvic ring. Specific taping with either rigid tape or kinesiology tape may be chosen to better support the SIJ’s and dampen trigger point activity in muscles. Wearing pregnancy support shorts, such as SRC or Solidea, may be suggested to provide necessary pelvic and low back support in daily activities and at work.
- Education Your physio will teach you postural correction, back support in sitting, how to improve your general movement approaches in daily activity and how to carry or lift light objects safely. This information will assist in making you feel more comfortable. Being encouraged to have a daily rest may also be advised.
The earlier you seek physiotherapy treatment for pelvic girdle pain symptoms the better it is for you. Treating the pelvic joint niggle or slight buttock/hip muscle ache is preferred, as you can take the physios advice home with you and make your pregnancy a happier time in general. Thinking pelvic girdle pain is simply a part of pregnancy and nothing can be done for this condition is incorrect. However, it is true that in severe cases of PGP in pregnancy women are unable to walk short distances without using crutches or a walking frame. So please be wise and take the healthy approach by seeking out the skills of Physiotherapists working with pregnant women.
Lower Body Warm Up – Air Squats
Before heading off on a walk, run or other sporting activity, air squats are useful to warm the lower and upper body. It is also a useful morning stretch exercise that can be done before rushing out the door to work, or even whilst waiting at the bus stop.
1) Stand comfortably with your arms by your side and your legs shoulder width apart.
2) As you slowly bend your hips and knees to lower you buttocks toward the floor/ground, raise your arms to shoulder level. Keep your knees in line with your feet.
3) Allow your spine to be neutral as you squat with your chest lifted.
4) Once your thighs are level with the floor/ground, reverse the motion and return to standing with arms by your side.
5) Repeat 10 to 15 times.