Management for ITB friction syndrome

June 16, 2010

Follow up to our last ITB article, we have identified three conditions that contributes to the tightening of the ITB. They are weak outer hip muscles, incorrect training methods and bio-mechanical gait issues. In this edition, we seek to address these three main problems, looking at strengthening those weak hip muscles, rectify those poor training methods and biomechanical issues, outlining the practical management of iliotibial band friction syndrome (ITBFS) associated with running athletes.

Weak outer hip muscles

Early stage of rehabilitation aims to redress muscle weakness in the hip which may be considered as a major factor in the development of this condition. Thus, strength and conditioning exercises should focus on the muscle called gluteus medius. The reason why we target the gluteus medius is because it functions as an important stabilizer to control and decelerate adduction of the thigh during running. Poor endurance and control of the gluteus medius leads to gait alteration and ultimately ITBFS. Furthermore, to decrease tension along the ITB, the use of a foam roll and performing isolated stretches for tight muscles can be particularly effective in releasing myofascial restrictions. Below are some recommended exercises.

ITB Proximal Stretch click for larger view	ITB Proximal Stretch To stretch the IT band of your left leg, stand with your left side facing the wall. Cross your left leg behind your right, while using your left hand to help balance. Put your weight on the right leg and lean against the wall by pushing your left hip towards the wall. You should be able to feel the stretch in your left hip and down the IT band
ITB distal stretch click for larger view	ITB release with Foam Roller Rest the side of the thigh on the foam roller, positioning the foam roller just above the knee. Support yourself with your right arm and right foot to keep your balance. Roll yourself down the mat, rolling the foam roller from the knee up to the hip and then down to the knee. For a trigger point release, you can sustain pressure on the painful spot for 30 seconds.
Clam shell 1 click for larger view Clam shell 2 click for larger view	Clam shell in side lying Lie on left side to work on the right gluteus medius muscle. Keep spine in neutral and not sagging down towards the mat Keep the heels together and the knees at a right angle Lift the right knee up without rotating the pelvis and back. You should feel it on the muscle behind the hip bone
Side Planks click for larger view	Side planks To work on your right, lie on your side with your right hand on the ground or use an exercise mat. Lift your trunk and pelvis up to form a plank Maintain a straight trunk and pelvis alignment Hold for 30 secs

Training methods

Having re-established muscle balance around the hip, you should now be ready to take full bodyweight on the affected leg while maintaining optimal body alignment. To start getting back to running, we recommend running every other day for the first week, starting with easy sprints on level ground. It is important to note that studies have shown that ITBFS occurs mainly at, or at slightly less than, 30 degrees of knee flexion. Thus, it is necessary to avoid downhill running because the knee flexion angle at footstrike is reduced, causing strain on the ITB. Biomechanical studies have also shown that faster-paced running is less likely to aggravate ITBFS. This is because as the foot strikes the ground, the knee is flexed more than 30 degrees, avoiding the range where the strain occurs. Incorrect training practices can also contribute to the condition, such as starting a demanding routine of sport or exercise immediately following a return from injury, or otherwise expanding your training too rapidly.

A gradual increase to your training mileage (e.g. 2-3km per week) cannot be over emphasized. Your body won't get used to running long distances, unless it has run those distances on a regular basis. As the body needs rest between those runs, thus it is recommended that there should be no more than two long runs per week and moderate distance on the other days. Long training runs should be conducted at an aerobic capacity where you can talk and run at the same time. After a run, stretch and then ice the outside of the knee for 5-10 minutes. Last but not least, always train at an appropriate intensity. Training at higher intensities (>80% of Max. Heart rate) will lead to lactic acid production, which will fatigue the muscles and increase the chance of injury. To monitor the level of training intensity, a heart rate monitor may be a useful device.

Biomechanical Gait issues

Always wear appropriate shoes that give you proper support. A wet footprint test is a common method for determining your foot type. Get your feet wet and stand on a flat surface that will allow your footprint to be shown. Compare your footprint to the images below.

foot

Now that you know your foot type, approach a knowledgeable salesperson at a running specialty store and they will be able to help you find the right shoes for you. A semi-rigid orthotic may also be useful for someone who have excessively flat feet or high arches, in bid to improve function by supporting the foot segments during gait. The orthotic is worn in the shoe and it helps by changing the position and time sequences talking place in the foot during running so that no one muscle or group of muscles have to work longer and harder than it should.

Formthotics

Written by Admin · Filed Under Hip, Injury Management, Injury Prevention, Knee, Running, Treatment Option | View Comments

Running Economy

May 7, 2010

Can you run faster AND easier? Yes you can, by improving your running economy.

BOB FOY
click for larger view

What is Running economy?

Running economy is about how efficiently you run. A runner that uses less oxygen to run at a certain pace is said to be more economical or efficient.

One method to improve running economy is to minimise energy loss; by releasing stored potential energy to help propel your body forward.

Your body have several such potential energy stores that may not be fully utilised. To minimise energy wastage, you should make full use of

your Achilles tendon as a trampoline,
your core muscles as a winding mechanism,
your legs as a pendulum and
your body’s flight trajectory like the flight of a javelin.

Achilles tendon

Bouncing on a trampoline pushes the body upwards via the stored potential energy from the elastic fabric. If the trampoline is too soft or elastic, you will not get a good bounce up because energy is lost by the shock absorbing effect of a soft surface. If the trampoline is too stiff or inelastic, a lot of impact forces go through the legs and body, you also will not get a good bounce and put yourself at a higher risk of impact injuries. Once you “catch” the rhythm of bouncing on the trampoline, it is almost effortless to remain bouncing. This rhythm is known as the resonant frequency, a phase where stored potential energy is easily transferred to kinetic energy with no loss of energy. In reality, there will be some loss of energy and the key is to minimise this loss.

Our Achilles tendon stores energy and transfers it to push the foot off via a stretch-shorten cycle similar to a trampoline. Like the trampoline, the Achilles tendon should not be too flexible or there will be too much dampening or shock absorption. In addition, the calf muscles should be strong enough to stiffen the Achilles tendon and withstand the impact of landing on the foot; at the same time, pushing off with the recycled energy.

Core muscle

Imagine wringing a thick elastic band in a clockwise direction and then releasing it. The elastic band will unwind in the opposite direction and then get wound up again before unwinding again. The rotation and counter rotation will carry on until all the energy is lost. The core muscles of our trunk act just like this elastic band as they wind up to store energy, and release it by unwinding and rotating the trunk in the opposite direction. Unwinding of a "wound" up set of core muscles is easier if the core muscles is stiff, like a stiff spring coil. In contrast, a soft coil of rope doesn't explosively uncoil when released. This trunk winding-unwinding movement helps swing your pelvis forward, making it easier to take longer strides, covering longer distances with each same step.

Foot

As your foot swings in mid air during the flight phase, it acts like a pendulum to swing the foot further forward. Ideally, the leg should not go pass beyond the horizontal. If your foot is kicked up higher pass the horizontal, the pendulum effect will not be as effective because of energy lost. The foot tends to go higher either because of your running style or tight hamstrings.

Body

A common running fault often observed is where the body moves excessively in the vertical plane, thus not maximising energy moving forward in the horizontal plane instead. Like a javelin thrown too high, it covers a long travel distance but doesn't travel very far forward..

Have someone look at your running technique and look out for the above faults. Stretch your hamstrings (hypelink to article) and strengthen your core and calf muscles to run faster with less effort.

Written by chyetuan.chng · Filed Under Running, Sports Performance | View Comments

Tips to Run Pain Free

January 10, 2010

Recently our physiotherapist, Lenia, was featured in Shape magazine Jan 2010. Here is an excerpt from the article.

Shin splints are caused by weak shin muscles or faulty running biomechanics while plantar fasciitisis the result of tight calf muscles that reduce the foot's ability to absorb shock. Here are some tips to stay on track. Read more

Written by chyetuan.chng · Filed Under Exercises/Tools, Injury Prevention, Running, Sports Injury | View Comments

Osteoarthritis Knee

December 25, 2009

Osteoarthritis (OA) of the knee is a degenerative condition where the cartilages of the knee wear away. Pain, stiffness and swelling are common symptoms of an OA knee. In this article, we look at the three factors that lead to the development of OA knee – Aging, Physical Attributes and Muscular Causes. Of which two of these factors, Physical Attributes and Muscular Causes, can be addressed with physiotherapy management. We will focus more in detail on the exercises and treatment for OA knee in a follow-up article.

Aging

OA Knee

OA knee usually afflicts the older population as our cartilage thin naturally as we age. If you have a past history of knee injury or long history of activities that overloads the knee joint, degeneration may set in much earlier. Unfortunately, these events are irreversible, so it is important that we look after our knees during our early adult life.

Physical Attributes

The three key physical attributes are:

Obesity - A heavier person will load their knee joints more, wearing out their cartilages faster than a lighter person.
Knee alignment – A bow legged or knock-knee appearance will cause an uneven compression of the knee. Either the outer or inner compartment knee respectively will take up most of the load upon weight bearing and cause more wear and tear.
Foot type -
- People with flat feet or whose feet over pronate tend to roll their knee inwards upon weight bearing similar to a knock-knee above.
- A person with high foot arch or whose feet under-pronate absorbs less impact with each foot fall. More impact goes up through the leg and the knee will have to work harder to cushion the impact.

Muscular Causes

When the muscles around the knee do not contract strong and fast enough in a coordinated fashion to absorb the impact of walking or running, the knee joint takes up the remaining forces of the impact.

Tight muscles pull joints closer to each other.In an OA knee where the joint space is already reduced, tight muscles will increase the compression of the joint space. Muscles with reduced flexibility are also less coordinated and slower in reaction time. The muscles that tend to be tight are the quadriceps, hamstrings and calves.
Weak muscles. The quadriceps muscles is the main muscle group that help to support the weight of the body and off loads the knee joint. It is very common for this muscle to atrophy because of disuse. The knee pain deters the patient from loading the knee and this will gradually lead to weakness of the knee which will affect the ability to cushion the impact. This pain, disuse, weakness cycle will continue without treatment.
Weak gluteus medius muscle can aggravate the degeneration of knee cartilage because its function is to keep the hip joint stable, especially in walking. This is often seen as a waddling gait where the hip sway with big movements side to side. The thigh muscle have to work a lot harder to stabilise the wobbly hip and if they are unstable, the knee joints will have to bear the weight.

The management of these factors are summarised in the following table. In our upcoming article, we will further discuss the specific exercises and treatment for OA knee.

Physical Attributes	Management
Weight	Weight loss programme
knee alignment	- training of muscles – orthotics
foot type	- orthotics

Muscular Causes	Management
Tightness	Stretch Quadriceps, Hamstring and Calves
Weak	Strengthen Quadriceps and Gluteus Medius

Written by chyetuan.chng · Filed Under Knee, Knee (NonSport), Running | View Comments

Q angle and knee pain

November 25, 2009

What is Q angle?

The Q angle describes the angle of the knee from a frontal view. The Q angle gives an idea how the thigh muscles functions to move the knee and also how the knee cap (patella) tracks in the groove of the knee joint. A normal knee cap should move up and down within the groove with flexion and extension of the knee. When the Q angle is excessive, the knee cap tends to track out of alignment and hence causes wear and tear (degeneration) of the cartilage behind the knee cap.

What is the normal Q angle? The normal Q angle measured in standing is about 15 degrees and anything more than that is considered a risk factor for knee injuries. Ladies tend to have a wider Q angle due to their wider pelvis compared to their males.

Q-angle

How to measure Q angle? The Q angle is an intersection of two lines. First line joins the ASIS (bony protrusion in the front of the pelvis) to the middle of the patella. Second line runs from the protrusion on the top of the shin bone (tibial tuberosity) below the patella and upwards through the middle of the knee cap.

Common injuries related to a wide Q angle:

Iliotibial band friction syndrome (ITBFS)
Anterior knee pain or Patella Femoral Pain Syndrome (PFPS)
Anterior cruciate ligament injury (ACL)

Injuries because of an excessive Q angle can be categorised into 3 main reasons.

1. Muscle imbalance :

A large Q angle pulls the knee cap outwards due to the stronger lateral pull from the quadriceps and tight ITB. Coupled with a weakness of the inner aspect of the quadriceps (Vastus Medialis Oblique, VMO) the knee cap will track laterally instead of smoothly up and down within the knee groove. This maltracking causes the cartilage behind the knee to wear off or degenerate and hence the pain.

2. Biomechanical compensation:

An excessive Q angle can alter the movement pattern especially in the foot. The knee will tend to point inwards (valgus or knock-knee appearance) which encourages the foot to roll inwards (pronates). Over-pronation can lead to a number of injuries especially in runners.

3. Joint laxity/instability:

When the knee point inwards, the ligaments on the inner aspect of the knee gets overstretched and lax, therefore compromising the stability of the knee joint. The Anterior Cruciate Ligament (ACL) also undergoes a lot of stress in this position. Interestingly the larger Q angle in females has been attributed as a main reason why females are at a higher risk of sustaining an ACL injury.

How to manage a wide Q-angle?

You can reduce the risk of injuries by targeting the reasons above.

Muscle imbalance: Stretching on the ITB, strengthening the VMO and Glut medius to enable proper tracking of the knee cap.

Biomechanics: Get a customised orthotics to control excessive pronation and reduce the stress to the knee.

Joint Laxity/Stability: Balancing exercises to train knee proprioception and stability.

Written by lenia.teo · Filed Under Featured, Injury Prevention, Knee, Netball, Running, Soccer, Sports Injury, Women & Sports | View Comments

ITB friction animation

November 20, 2009

Iliotibial band friction (ITB) syndrome is a common running injury due to a tight ITB. In a previous article, we explained the reasons why the ITB tightens up. To make it easier to understand how a tight ITB causes friction and inflammation, click here to see an animation of ITBS.

Written by chyetuan.chng · Filed Under Injury Management, Knee, Running, Video | View Comments

Different Compensation Strategies During Jogging by Low Back Pain Sufferers

November 2, 2009

I am sure all athletes have experienced the effects of muscle fatigue. You will use your body differently, trying to compensate by moving your limbs in a more comfortable way. Try going down stairs right after a marathon and you get the picture.

running form

An interesting question is, do everyone compensate using the same strategy? Apparently not. A recent study¹ shows people with recurrent low back pain jogs with a different compensation strategy compared to healthy individuals after a set of fatiguing lower back muscle endurance exercise.

The exercise was to hold the lower back in an extended position until their muscles shows signs of fatigue on surface electromyography (EMG).

The low back pain group was found to jog with a more extended or arched lower back and had more hip movements whereas the normal healthy group runs with a more forward flexed trunk. This may be why it is a common for people with chronic low back pain to complain of hip muscle soreness and fatigue after endurance exercises.

It is a known fact that chronic low back pain sufferers have poor core muscle function. This adaptation of running with an extended back may be a strategy to stabilise the lower back without the need to use core muscles and yet able to continue running. On the other hand, healthy individuals are able to use their core muscles as a natural trunk stabiliser and prevent unnecessary movements.

Parallels can be drawn with long hours of sitting where the body requires muscle endurance to sustain in a single position. When fatigue sets in, the body may adopt a different strategy to try to protect the back and inadvertently creates a wrong movement pattern or mal-adaptation. Therefore, correcting wrong movement patterns and strengthening of the core muscles are important aspects of treating chonic low back pain.

Reference:

1. Hart JM, Kerrigan DC, Fritz JM, Ingersoll CD. Jogging Kinematics After Lumbar Paraspinal Muscle Fatigue Journal of Athletic Training. 2009; 44(5):475–481

Picture: www.amercianrunning.org

Written by chyetuan.chng · Filed Under Latest Research Findings, News on the Spine, Running | View Comments

What can i do for a hamstring “pull”

August 31, 2009

Pulling one’s hamstring is one of the most common soccer injuries and the most common cause is the lack of proper stretching before playing. When one says that they pull their hamstring, what it means is that one has strained or slightly torn their hamstring. Most soccer players think that by just resting for about 2-4 weeks without playing is all that is required to recover. However, this is not true. If you do nothing about the strain, you are at a higher risk of sustaining the same injury.
Read more

Written by MCR · Filed Under Exercises/Tools, Injury Prevention, Rugby, Running, Soccer, Sports Injury, Thigh, Treatment Option | View Comments

Anterior Knee Pain in Runners

July 22, 2009

Do you feel pain in your knee on climbing stairs or even squatting after your run? Feeling weird that it doesn’t hurt while you run? Then, chances are, you might be suffering from anterior knee pain. Knee pain is the most common running injury, occurring in approximately 55% of recreational runners. Of this number, 65% will have severity of symptoms that will require them to seek medical attention or contemplate cessation of running. Anterior Knee Pain (AKP), otherwise known as Patellar Femoral Pain, has been found to be one of the most common condition resulting in knee pain. It has been estimated to have an incidence of 25% of all knee injuries.

Written by MCR · Filed Under Injury Management, Knee, Running, Sports Injury | View Comments

The Ten Most Common Mistakes Made By Triathletes

December 18, 2008

Wayne Goldsmith got it down nicely in this article. With triathlons becoming an increasingly popular sport in Singapore and around the region, we at Back2Sports are also seeing a corresponding rise in injuries with triathletes and biathletes. Wayne has some good advice for us.

Written by MCR · Filed Under Cycling, Running, Swimming | View Comments