What is iliotibial band (ITB) syndrome as a running injury?

The following is a guest blog from a colleague of mine practicing in Miami. Iliotibial band syndrome often presents as a result of gluteal inhibition or weakness.  This post adds further explanation to my previous blog posts.   Please read the post by Bruce Wilk and Annmarie Garis.

http://postinjuryrunning.com/Blog/?p=210

“Where does it hurt?”; “On the outside part of your knee?”; “Oh, you must have ITB syndrome!”  This is a classic example of the “point-to-it” diagnosis.

 How many times have you been to a health care professional, told to point where it hurts, and immediately you’re given a diagnosis without so much as a simple physical examination? It seems so clear cut, right? Well, actually it isn’t that simple. All too often patients are quickly “diagnosed” without ever being properly examined, which can actually result in a misdiagnosis. We can’t just point to where we perceive pain and make a proper diagnosis. The pain needs to be put into context with the rest of the runner’s symptoms.  The dysfunctional running must be linked to actual physical impairments in order to fully understand and treat the true culprit of the problem being presented.  All of this must be accompanied by actually examining the runner and taking a good history.

In musculoskeletal injuries, the area where we perceive pain is often similar for different types of running injuries, so we cannot make a diagnosis based on pain alone. For example, a common area in which runners experience pain is along the outside of their knee. This knee pain is most often diagnosed as iliotibial band (ITB) syndrome, but in fact, the symptoms could actually be emanating from the calf or hamstring muscle.

ITB syndrome, calf strains, and hamstring strains (HS) can produce similar symptoms. And while the perceived area of pain may be similar for ITB, HS, and the calf, the actual source of the impairment and the rehab process itself are essentially very different.

So with so many running injuries being cursorily examined and potentially misdiagnosed, what do we do?  In the following section, I’ve provided you with some basic tests to help you identify your problem area and begin to get control of your running injury as soon as possible. To better assess your specific area of tenderness, stiffness/inflexibility, weakness, and gait dysfunction try each test on both legs and note any differences between your injured leg and your non-injured leg.

 ITB-

Tenderness: Use your hands to find specific points of tenderness and pain along the band on the outside of your leg anywhere from your hip to just below the knee. Note any specific areas of significant pain.

 Stiffness: Lie on your back with your leg straight. Use a belt or a rope wrapped around the foot to pull your leg across your body, over the opposite leg. Be sure to keep your hips and pelvis down on the floor. Repeat on the opposite leg. Notice if you feel a greater restriction in movement or inability to pull one leg over compared to the other.

 Weakness: Lie on your side, with the affected leg towards the ceiling and in line with the rest of your body. With a straightened leg, lift your top leg up towards the ceiling. Repeat 10 times. Now repeat with the other leg. Do you notice greater difficulty lifting one leg in comparison to the other?

 Gait dysfunction: Try this: Hold onto your hips with both hands and run. Feel for any wobble or excessive movement in one hip compared to the other.

 Calf-

Tenderness: Press into your calf muscle. Assess the entire muscle from behind the knee all the way down to the back of your ankle. Take note of any localized pain or specific stiffness.

 Stiffness: Lay on your back. Hold your leg behind the knee with both hands.  With your leg straight up in the air and knee straightened, flex your ankle (toes toward your nose).  Note if one side is more limited or painful than the other.

 Weakness:  Stand and balance on one leg.  Do a “calf raise” by pushing up through your toes and lifting your heel off the ground 20 times.  Did you experience pain or weakness in the affected leg?

 Gait dysfunction: Emphasize pushing off through your 1st toe (the big toe) when you run. Do you have more difficulty pushing off with one leg versus the other?

 Hamstring-

Tenderness:  Tenderness can be either on the outside or inside part of the back of your thigh, anywhere from behind your knee to your buttocks. 

 Stiffness:  Lying on your back, pull your leg up towards your nose and straighten the leg (knee locked out).  Do you feel more tightness or pain in one leg than the other? 

 Weakness:  Lie on your stomach, bend your knee and kick toward your butt 20 times. Is there a difference in how far you can kick your leg? Is it more difficult to kick the injured leg back versus the unaffected leg?

 Gait dysfunction: Try running and see if you feel a difference or difficulty with kicking back, a shorter kick back on one side than the other or a kick back that is not in line with the rest of your leg (i.e. is not straight).

 In reality, running injuries don’t manifest as a particular diagnosis but instead as an injured body part(s).Most running injuries are a result of repetitive wear and tear that results from a problem within our running technique, form or training habits. The factors disposing us to running injuries are both intrinsic and extrinsic and can certainly be more complex than a simple muscle strain, which is why it is important to properly examine the injured area. The first step to overcoming any running injury is properly identifying what is injured.  Once you are able to identify the specific problem, then you are ready to move on to recovery.

To Kegel or not to Kegel?

     Without fail, whenever I explain to people that I treat people with incontinence and pelvic pain issues they say, "You mean like doing Kegels?"   The answer is usually no, at least initially.  The idea that kegels are the ultimate answer to incontinence and pelvic pain issues is a dangerous misconception. 

     Most people are somewhat familiar with the Kegel pelvic floor exercise.  A Kegel is an exercise where one voluntarily contracts the pelvic floor as if trying to stop the urine stream.  If there is TRUE WEAKNESS in the pelvic floor, performing Kegel exercises is a place to start, but just because you have some urinary incontinence doesn't mean you have isolated weakness in your pelvic floor.  Also, in my practice I have found that many people think they are performing Kegels and they are really contracting their abdominals, or their hip muscles, or simply holding their breath. 

    What I find most commonly when someone has pelvic pain or incontinence issues is that there is some spasm or areas of trigger points in muscles of the pelvic floor.  This Mayo Clinic article does a great job of explaining this phenomenon, how it can present, and how physical therapy can help:

 http://www.mayoclinicproceedings.org/article/S0025-6196%2811%2900024-3/fulltext

    The Nonrelaxing Pelvic Floor

The pelvic floor could be in spasm for a number of reasons. This is often seen after childbirth with tearing or episiotomy.  It's also seen after a pelvic or abdominal surgery or any medical issue with the pelvic organs.   In response to these irritations or traumas the pelvic floor responds by tightening up, just like other muscles in the body respond to pain.  Some issues that can result in pelvic floor spasm include fibroids, interstitial cystitis, kidney or bladder infections, constipation, endometriosis, pelvic inflammatory disease, and polycystic ovarian syndrome.  Likewise, many pelvic or gynecological diagnoses are actually primarily or partly due to pelvic floor spasm.  These include vaginismus, dyspareunia, vestibulitis, vulvodynia, coccygodyia or tailbone pain, and pudendal neuralgia.  Incontinence and pelvic organ prolapse can occur as a result of the weakness associated with a spastic pelvic floor as well. 

Unfortunately, the public and even the medical community is still quite unaware of this issue.  As a result, the spasm or tightening in the pelvic floor often goes unaddressed, resulting in sometimes years of pain or incontinence.  Patients often go through unnecessary surgeries with poor results.  And more surgeries can result in even more pelvic floor tightening, ultimately worsening the pain or urinary incontinence. 

The thing NOT to do in these situations is the first thing that comes to the mind of many medical professionals and much of the public - KEGELS.   The pelvic floor is a muscle and behaves much like any other muscle in the body.  When a muscle is in spasm it is weak.  If you had a spasm in any other muscle that was causing you pain, what do you think would happen if you went around contracting that muscle several times a day?  The spasm would get worse.  The pain would get worse.   And the weakness would get worse, which would result in any incontinence to worsen as well.  

What a pelvic or women's health physical therapist would do is assess the pelvic floor muscle to check it's tone.  If the tone is too high, or the muscle is in spasm, we would do gentle massage and instruct in relaxation techniques to first normalize the tone.  We would also address any other muscle imbalances in the hips, legs, and trunk.  Weakness and limited mobility in these related areas often results in overuse and spasm of the pelvic floor.  In this way we are addressing the ultimate cause of the pain, not just the source of the pain.  If this rings true for you or someone you know, please refer them to a women's health or pelvic physical therapist.  Please feel free to contact me with any questions as well.  I can't tell you how many patients I have seen who get relief quickly after finally having physical therapy for these issues after years of unnecessary pain and embarrassing incontinence.

Conley Physical Therapy in Decatur, Georgia can help!   
www.conleyphysicaltherapy.com
info@conleyphysicaltherapy.com

I hope this post will help to bring awareness to a very common problem and that people will find the help they need!

Warmest Regards,

Kelly Conley, PT, DPT, OCS

Exercises for activating gluts and progession to single leg squat

Hello again,

Are you ready to get your gluts firing?  As you recall in a recent post - Are your gluts working when you work out - we discussed the single leg squat and how to learn if you are performing a single leg squat correctly and whether you can self correct to have the proper form.   Today I will be discussing some exercises to try if you are unable to perform a single leg squat properly.

To review, a proper single leg squat should look like the figure on the left and not like the figure on the right.  The center of your knee cap should be aligned over your second toe, and your pelvis should be level, not tilted or rotated.  Also your trunk should be straight, not rotated or with your trunk leaning forward.   Knowing how this activity should look, you can try to perform it correctly.  If you aren't able to do so, you shouldn't be running or jumping or stair climbing for exercise.  If you don't hurt already, you will eventually due to uneven forces and wear and tear on your system.

Now, what can you do if you aren't able to properly perform the single leg squat?  
You look at your double leg squat.   First let's look at the proper form of the squat.

The alignment of the legs should be similar to that of the single leg squat.  The center of the knee cap should be in line with the second toe.  I tell my patients that if you look down, you should be able to see your big toe on the INSIDE of your knee.  In the image above, this would be true on the squat being performed on the left. In the squat being performed on the right, the knees are inside of the foot completely.  If he were to look down, his toes would either be on the outside of his knees or he wouldn't be able to see his toes at all because his knees would be blocking them.  This type of squat puts unequal and dangerous forces throughout the foot, ankle, knees and hips.  If someone who could only squat like this were to try to run, these dangerous forces would likely not only result in knee, hip, and ankle issues, but they would translate up the body to the back, shoulders and neck causing pain and injury in any of these areas as well.  

SO, how can we correct this and reinforce gluteal activity? 
There are some squatting type exercises to help activate your gluts where your weight is on both legs.   Let's look at a few of these.  


For this exercise you take a loop of resistance band and fold it in half or double it.  Then put it around your legs or step inside it.  Position one part of the resistance band below the knees and one part above the knees.  Pull the knees out into the band as you do your squat with proper form, with the center of the knee cap aiming towards the second toe.  The toes should point straight ahead and not out to the side.  Within a few repetitions you will feel your gluteal muscles working.  Try not to lean your upper body forward.  It should remain fairly upright or vertical.  A very slight forward lean at the hips is ok, as is shown in the picture.  Also, make sure your lower back isn't rounding out.  There should have a slight arch, or lordosis, in the lower back.  Sometimes to maintain this it feels like you are "sticking your butt out."

Often times it is difficult for people to keep their trunk upright.  If that is the case, I would recommend the ball wall squat, keeping a resistance band just above the knees to pull against in order to recruit the gluteal muscles.  The same alignment of the leg is correct - middle of the knee cap over the second toe, so that you can see your big toe on the inside of your knee.  The toes still point straight ahead.

 If you did find that you had a lot of difficulty keeping your trunk upright in the regular squat and your shoulders wanted to move forward - your core and back muscles may be weak or inhibited.  If that's the case, I would move to another exercise seen below. 






This exercise is an over head squat.  The resistance band helps to activate the back muscles and keep your upper body vertical.   The alignment of the legs is similar - although you can move the feet slightly wider than the hips and point the toes slightly outward.   Be sure the knees don't go inside of the toes.  Also, you should only bend or squat as low as you can WITH PROPER FORM.  As soon as the hands and trunk move forward in front of your hips - stop bending and return to upright.  As you get stronger and/or the inhibited muscles become activated, you will be able to squat lower.

Remember, no exercise should cause you any pain.   The only discomfort you should feel with any of these activities is the burn of the muscle working and fatiguing.   If you do experience any pain, you should consult a health professional to help you with your problem.

I hope this has helped you to understand how to progress to be able to perform a proper double leg squat and to activate your gluteal muscles during your exercise and weight bearing activity.  Remember, Conley Physical Therapy in Decatur, Georgia can help! Feel free to contact us with any questions.

www.conleyphysicaltherapy.com
info@conleyphysicaltherapy.com

Now go and get those gluts firing!
Kelly Conley, PT, DPT, OCS 

Conley Physical Therapy at New St. Festival in Decatur

This weekend Dr. Kelly Conley, PT, DPT, OCS was spreading the word about Conley Physical Therapy at the New Street Festival in Decatur, GA.  It was a great day to tell people how physical therapy can help eliminate their pain!  

Are your gluts working when you workout?

Today I will be talking about the Glorious Gluteal muscle group and I will show you how you can tell whether yours are working properly during your workout.   The gluts have been a buzz word for quite a while now and there is good reason.   Research has told us that hip muscle weakness is associated with knee pain and injuries. 

One thing that always amazes me is the body's ability to compensate or adjust to it's faults or weaknesses.   I have worked with professional Ironman athletes, football players, and marathon runners who have come to me because of pain or difficulty performing due to glut weakness or inhibition.  How crazy is it that someone can run a marathon but can barely raise their leg off the table against gravity?!

So, how can you tell if your gluts are working? 
The Single Leg Squat.   What I want you to do is stand in front of a mirror.   Now stand on one leg and bend your knee to do a single leg squat.   
Does your squat look more like the image on the left or the image on the right?  If you look more like the image on the left, that is the correct form.  It is safe for your knee, hip, back, ankle and foot and your gluts are activated.  I tell my patients that they should be able to look down and see their big toe on the inside of their knee.  If you can't see your big toe, then your leg is not aligned properly.

If you look more like the picture on the right, try to correct your form and pull your knee out to the side until you see your big toe or the inside of your shoe on the inside of your knee.  If you can do this without rotating your pelvis or twisting your back and shoulders you should practice.  Practice, practice, practice. This way you will be reinforcing the proper pattern.  It's also best to do 20 or 30 single leg squats right before your workout in order to rewire your nervous system to perform this motion in the proper pattern and to keep the gluts activated.   If the single leg squat causes you any pain then you aren't ready for it.   Don't do it if it hurts.  Your exercises and workout should not hurt.  The only discomfort you should feel is the aching or burning of muscle fatigue.  

What if you can't correct yourself?   If you aren't able to perform a single leg squat with the proper form you shouldn't be running or jumping for exercise without the instruction and guidance of a professional.  You need to break down these activities so that you have the proper form and muscle activation.  Running places more than 10 times the forces on your leg - including your muscles.  If your gluts can't handle the single leg squat, they certainly can't handle an activity that places 10 times the force on those muscles.   What will result is a slow breakdown of the joints, ligaments, and tendons until you end up with pain that won't resolve.   


In my next blog post I will discuss some double leg squatting activities that will help you progress to the single leg squat.

Please visit my website at http://www.conleyphysicaltherapy.com to see more information about my physical therapy practice in Decatur, Georgia!

Have a great day and activate your gluts!
Kelly Conley, PT, DPT, OCS

Teaching at Emory University Orthopedic Residency

This weekend I had the pleasure of teaching for Emory University Doctor of Physical Therapy's Orthopedic Residency Program.   I love giving back to the physical therapy community and I always learn something in return!  Zach and Sam are very sharp and have a wonderful career ahead of them!  I look forward to watching them continue to grow and succeed in their career! 

I taught about evaluating and treating knee conditions along with a very detailed anatomy and functional anatomy lecture.   The biggest clinical pearl to come out of the day was the coordination of core, hip and knee muscles during weight bearing exercises!  If we strengthen and train these muscles independently, it simply won't carry over into function and performance.   Contact me at Conley Physical Therapy in Decatur, Georgia for help!   http://www.conleyphysicaltherapy.com

What is a Concierge Physical Therapy Practice?

You may have noticed an increasing number of concierge doctor offices popping up in the Atlanta area over the last few years.   Likewise, there have been an increasing number of concierge or out of network physical therapy practices in the area.  This is in part due to the decreasing insurance payments for medical services which results in increased difficulty in providing the highest quality of care for our patients. In order to make ends meet, healthcare providers need to see more patients.

Undoubtedly, when you are looking for a healthcare provider you usually look for one in your insurance network. I mean, that’s why you pay for your health insurance!  Why, then, is Conley Physical Therapy an out of network practice?  In order to be in network with an insurance company, the therapist must take their negotiated rate for treatment.   Often times this rate is between $50 and $80.  In order to cover all costs (insurance, liability, rent, taxes, billing), in network practices must see 18 to 20 patients every day.  Many of you reading this have been to these types of physical therapy clinics.  The therapist must spread themselves between 3 or more patients at any given moment.  All while keeping up with their paperwork, phone calls, and any other interruptions.  This type of setting doesn’t allow me to utilize the skills that will help you, the client in pain, get better as quickly as possible.

By being out of network with insurance, I am able to provide one on one treatments with my clients for their entire session, every session.  Your therapy sessions will be more efficient because I am able to spend as much time doing the most hands on and individualized treatment techniques to match your needs.   This means you will get better quicker, requiring fewer physical therapy visits.
Treatment with Conley Physical Therapy will often be LESS EXPENSIVE than with an in network practice.  I’m sure you’ve noticed your insurance deductible increasing each year.  This means you will pay the cash rate for an IN NETWORK physical therapy practice until your deductible is met.  So you may be a similar amount for a physical therapy session where you only receive 15 minutes of the therapists time, even though you are there for 60 to  90 minutes.   This will go on until you meet your often $3000 to $5000 deductible.  With Conley Physical Therapy, you will have your therapists undivided attention and care for the entire session.

To answer the question at hand, Conley Physical Therapy is an out of network practice so that we can provide you with the highest level of skill and hands on treatment to address the cause of your pain and dysfunction.  I’ve always said I want to make the world a better place.  The sooner I can get you to feel better and back to doing what you love, the better of our world will be.  I have spent many years advancing my treatment skills in order to get the best results for my patients.  This setting allows me to use those skills as effectively as possible.  Please feel free to contact me with any questions you may have about your condition or your insurance benefits.

Kelly@conleyphysicaltherapy.com

770-769-5098

Enjoy your beautiful day.

Dr. Kelly Conley, PT, DPT, OCS