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Getting a Leg Up on Shin Pain

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by Joshua Dubin, DC, CCSP, CSCS, Rachel Dubin, DPT, Gregory Doerr, DC, CCSP

ABSTRACT:

Shin splints is an injury of the lower leg that often afflicts athletes. Generally, symptoms include pain on the anterolateral or posteromedial surfaces of the shin. There is a great deal of research on the treatment and prevention of shin splints, and based on extensive research, several hypotheses have been proposed for its pathophysiology; however, the exact cause of shin splints remains unknown. This paper explains the anatomy of the lower leg and biomechanics of gait. It presents possible etiologies and risk factors for shin splints, and it reviews options for treatment and prevention. Its conclusion, based on extensive literature review, reveals that most cases of shin splints respond favorably to conservative care. Such care generally includes home exercise, training and equipment modifications, and treatment by a skilled practitioner. However, in more advanced cases surgery may be necessary.

Introduction and History:

Shin splints is one of the most common exercise induced lower extremity injuries in athletes participating in activities that require prolonged or quick bursts of running and/or jumping.1 Such activities may include track and field, soccer, basketball, volleyball, basic military training, and long-distance running.7-11

During running each foot strikes the ground approximately 50-70 times per minute, or a total of 800 times per mile, with a force 2-4 times body weight.1,12 The muscles, tendons, and bones that support the lower extremity can usually adapt to such an increased work load if training progresses appropriately. However, the following risk factors may predispose to the development of shin splints by leading to increased ground reactive-forces acting on the lower extremity and/or a compromised musculoskeletal support structure: training errors, foot shape/biomechanics, poor conditioning, high body mass index, poor nutrition, and degenerative changes.1,13-16

Symptoms associated with shin splints may include pain over the anterolateral, or the distal two thirds of the posteromedial aspect of the shin.2-6 Usually, these symptoms are present with activity and alleviated with rest.7 However, if the athlete trains throughout pain and a proper treatment program is not initiated, the symptoms and severity of shin splints may progress.

In the 1900s shin splints was initially defined as any type of pain from the hip to the ankle.14 This broad definition seemed appropriate because treatments for lower extremity injuries were rudimentary and relatively ineffective. Throughout the last four decades medical research has led to advancements in understanding the causes, treatment, and prevention of sports injuries. The exact pathophysiology of shin splints remains unknown; however several possible etiologies have been studied.1,17,18

An understanding of the kinesiology, physiology, and anatomy of the lower leg, risk factors associated with shin splints, and a detailed history and physical examination may aid the practitioner in developing a proper treatment and prevention protocol.3,19,20 Most cases can be effectively treated with conservative care.1,21

Anatomy of the Lower Leg

figure1Long bones, such as the tibia, consist of an outer rigid layer. This external surface consists of several concentric rings of cortical bone that are surrounded by periosteum, a thin layer of dense fibrous connective tissue that is richly supplied by nerves and blood. The periosteum is anchored to the cortical bone by bundles of connective tissue “Sharpey fibers” (figure 1). The periosteum has several functions: it protects the underlying bone, participates in the repair and remodeling process of bone, and is the site of attachment for adjacent muscles. figure2Muscles consist of bundles of individual fibers (fasciculi) that are surrounded by endomysium, a thin delicate layer of connective tissue. The fibrocartilage strands of the periosteum intertwine with the endomysium of abutting musculature, creating an extensive origin of attachment. At these origins of attachment the underlying cortical bone is rough or thickened due to bone remodeling in response to traction exerted by muscles.22,23

figure3The tibia has three potential sites for attachments of muscles: a posterior surface, and anterolateral and medial surfaces that are separated by the anterior tibial crest. The soleus, flexor digitorum longus, and tibialis posterior musculature attach to the posterior surface of the tibia (figures 2A). The tibialis anterior musculature attaches to the anterolateral surface of the tibia (figure 2B). These muscles are contained within the superficial posterior, the deep posterior, or the anterior compartment of the leg (figure 3).3,6,24,25 The muscles surrounding the shin aid in coordinating movements of the foot and ankle and in reducing ground reactive forces.

Biomechanics of the Lower Leg during Ambulation

figure4There are two main phases to a running gait, a stance phaseand a swing phase. During the stance phase the foot contacts and adapts to the ground. The swing phase begins when the stance leg lifts off the ground. Most sport-related injuries can be attributed to repetitive ground reactive forces during the stance phase of gait.26 The stance phase of gait consists of the following sub-phases:

  • initial contact, when the foot of the swing leg initially contacts the ground.
  • loading response, beginning shortly after initial contact as the foot begins to adapt to the ground.
  • early midstance, when the contralateral swing leg is midline with the body and distributes the body weight over the stance leg.
  • late midstance, starting when the foot of the stance leg changes from a mobile adaptor that absorbs ground reactive forces to a more rigid lever that prepares the foot for toe-off.
  • terminal stance, beginning shortly after heel-lift and ending with toe-off (figure 4).27,28,29

figure5Throughout loading response and into early midstance, the foot goes through a series of transformations coined “pronation,” allowing the lower extremity to be more efficient in absorbing ground-reactive forces. Pronation of the foot and ankle consists of the following movements:

  • 1. The heel bone turns outward (everts), and the medial longitudinal arch (instep arch) lowers toward the ground.
  • 2. The tibia approximates to the toes (ground reactive dorsiflexion).
  • 3. The forefoot turns outward (abducts) (figure 5).

Normal range of pronation is four degrees of heel eversion and twenty degrees of ground reactive dorsiflexion. Pronation of the foot and ankle should end before late midstance as the foot prepares for toe-off.27,28,30

figure6Shortly after the foot strikes the ground the muscles attaching to the anterior and posterior aspect of the tibia contract eccentrically; the muscle fibers elongate as tension is produced in an attempt to decelerate a particular motion. The soleus, tibialis posterior, and the flexor digitorum musculature have points of origin on the posterior aspect of the tibia. They contract eccentrically during loading response and into midstance to decelerate pronation. Shortly after initial ground contact, the tibialis anterior muscle contracts eccentrically to decelerate foot slap as the forefoot descends towards the ground (figure 6).24,32

Under normal circumstances, the musculoskeletal support structures of the lower extremity can adapt to these repetitive eccentric loads. However, training errors, structural abnormalities, and other factors may predispose to excessive eccentric loads placed on the lower leg musculature, resulting in anterolateral or posteromedial shin splints. The exact pathophysiology of shin splints is unknown; however, research has come up with several hypothetical causes.

Possible Etiologies of Shin Splints

Traction Periostitis/Periostalgia

Current research supports the hypothesis that posteromedial shin pain in runners may be caused by excessive eccentric contractions of the superficial and deep posterior compartment muscles that originate on the tibia. Training that does not allow for proper adaptation of the musculoskeletal support structures of the lower leg, due to increased workloads, may lead to inflammation or degenerative changes to the surrounding fascia (fasciitis) or to the periosteum (periostitis/ periostalgia).2,6,26 Currently, medial tibial stress syndrome (MTSS) is the most common term to describe posteromedial shin pain thought to be caused by periostitis or periostalgia.1,19

Anterolateral shin pain has been linked to repetitive eccentric contractions of the tibialis anterior musculature. Downhill running accentuates a more pronounced foot slap, predisposing to fatigue of the tibialis anterior musculature, which may result in anterolateral shin pain due to a similar mechanism of injury as MTSS.14 This paper will define this condition as “anterior tibial stress syndrome” (ATSS).

Bone Stress Reaction

Bone remodeling of the tibia in response to increased work loads commences approximately five days after stimulation.2 Two types of cells are active in bone remodeling: osteoblast cells and osteoclast cells. Osteoblast cells produce new bone, while osteoclast cells react to increased stress by reabsorbing bone. Following bone reabsorption, osteoclast cells secrete osteoid, which is uncalcified bone. Osteoid calcifies into new bone after interacting with calcium and phosphate ions. These adaptations should result in a stronger more rigid skeletal support structure. However, it may take ninety days for the reabsorbed bone to be replaced by mature strong bone.14 Overtraining may lead to a higher ratio of bone reabsorption by osteoclast cells as compared to the production of new bone by osteoblast cells. This may result in a compromised porous skeletal support structure, which is susceptible to a bone stress reaction.1,10,11 Bone stress reactions may include microfractures, or in the more advanced stages a stress fracture. The tibia is the most common location of stress fractures in athletes,19,33,34 and most stress fractures occur four to five weeks after the onset of new exercise.12

The treatment of posteromedial or anterolateral shin splints in minor injuries is similar whether the etiology is traction periostitis/periostalgia or bone stress reaction.1,19 The initial history and physical examination should focus on discovering possible risk factors. Treatment and prevention of shin splints should include steps to eliminate or minimize these risk factors.

Risk Factors Associated with Shin Splints

Risk factors for shin splints are intrinsic (within self) and extrinsic (external to self). 6, 36

Table 1

Intrinsic Risk Factors Extrinsic Risk Factors
Lower limb structural abnormalities
• pes planus (flat foot, which may lead to excessive pronation)
• pes cavus (high arch, which may limit pronation and ability to absorb shock)
Training progression
• inappropriate intensity, frequency, or duration of training
• hill training that does not progress gradually
Poor Conditioning
• overweight (body mass index > 30 kg/m2)
• insufficient muscle endurance
• insufficient muscle strength
• limited flexibility
Gear
• unsuitable footwear
Female Triad
• osteoporosis
• amenorrhea
• eating disorder
Training surface
• hard uneven ground
Age related changes
• especially noticeable after 4th decade of life
Type of sport
• activities that involve repetitive running and/or jumping
History
• previous stress fractures

1,2,4,10,11,14-16,19,22,33-36,38

A detailed history and physical examination can aid in discovering risk factors that may have contributed to the development of shin splints. Most risk factors are correctable or can be minimized, aiding in the treatment and prevention of future episodes.

Training Guidelines

Recommendations for frequency, duration and intensity of training runs:1,29,39,40

Aerobic Conditioning, 70-80% maximum heart rate (Max HR=220-age):

This level of training is recommended for gradual adaptation to work loads with both cardiovascular conditioning and connective tissue adaptation. Initially, long-distance runners should establish a training base of 4 miles per run at this low intensity level. A progressive training schedule may include a frequency of 4 runs in a 7-day period, generally consisting of 3 shorter runs (each approximately 4-6 miles) during the week, and 1 longer run during the weekend.41 It is recommended that the weekly training mileage should not be increased by more than 10% per week. Based on marathon training logs and personal experience, the duration of the long run is usually increased by an increment of 2 miles per week or every other week, and he intensity should continue at the aerobic conditioning pace. After a proper training base is established, the short duration training runs can be conducted at an increased intensity level.

Anaerobic Conditioning, 80-90% maximum heart rate:

This training is below lactate threshold, the point after which blood lactate rises rapidly, leading to increased ventilation (speaking to a training partner becomes difficult) and eventual muscle fatigue. Anaerobic conditioning training should include a 5 minute warm up, followed by a 15-20 minute duration at the anaerobic conditioning level, then a 1 mile recovery run at the aerobic conditioning pace, followed by another 15-20 minute run at the 80-90% level. Anaerobic training makes running at a submaximal lactate pace easier over a prolonged duration. Ideally, the marathon pace should be conducted slightly below the lactate threshold. Towards the end of the race, “the last kick,” the pace can be increased.

Aerobic Capacity Training (intervals), 90-95% maximum heart rate:

This training is a vigorous challenge to the athlete’s aerobic and anaerobic capabilities, and stimulates slow twitch and fast twitch muscle fibers. This pace should only be maintained for 6-9 minutes, followed by a 4-5 minute recovery run at a slow pace. Aerobic capacity training runs elevate the lactate threshold and condition the body to deal more efficiently with oxygen debt and muscle fatigue.

Other Training Tips:

Add uphill training gradually. Running uphill should be conducted at a slower pace because of increased energy expenditure due to increased arm and shoulder action, and hipflexor and knee lift. Uphill running also predisposes to an increased eccentric strain on the posterior calf musculature. Downhill running should be limited because of increased risk and limited benefits.40,42

Change running shoes every 300-500 miles (approximately every 3-4 months). A sneaker loses approximately 50% of its ability to absorb ground reactive forces after 300-500 miles.1,19,37,43,44

Modify training. Add exercises such as swimming, bicycling, and using an elliptical machine on non-running days, or while recovering from an injury. For prevention of injury, the older athlete (after 4th decade of life) may limit running on pavement.1,4,11,30,45

Implement an eccentric strength training program for the lower leg musculature. This program can aid in the treatment and prevention of injury.76 Standing and seated calf raises strengthen the gastrocnemius, soleus, and the intrinsic musculature of the foot. A dorsiflexionassisted resistive device, resistive tubing, or a cable machine strengthens the tibialis anterior and extensor musculature of the leg.1,4,30,35,43,46,47 The strength training program should address the whole lower kinetic chain.4 Squats eccentrically strengthen the quadriceps, hamstrings, and gluteal musculature; romanian deadlifts eccentrically strengthen the latter two muscles. Abduction, adduction, and hip extension exercises can be conducted with a cable machine or tubing.48 Based on my training experience, this lower extremity routine should be conducted at a frequency of one time per week, usually on a Tuesday, Wednesday, or Thursday, if the long run is conducted on a Saturday or Sunday.

Stretch. Static stretching and ballistic stretching have both been shown to increase flexibility of the lower extremity.49,50 I have found a post-workout stretching routine to be helpful in decreasing cramping and muscle soreness, especially after a long duration training run or bike ride.

Introduce pre-season conditioning. Pre-season conditioning that includes a plyometric program can jump-start the process of bone remodeling and prepare the lower extremity support structures for elevated eccentric work loads.2,6,14,15,26,51,76

It should be emphasized that every athlete needs to be addressed individually. Generic marathon training schedules are helpful, however they may need to be modified for each individual to maximize gains and minimize injury. An experienced trainer may aid the athlete in achieving goals by tailoring a training program and re-assessing progress based on training logs and exertion levels.

Following the above training advice may prevent injury. However, additional treatment and training modification may be necessary for the athlete who experiences shin pain. The discouraged athlete will usually seek care when an injury makes training impossible.

Diagnosing Shin Splints

To properly diagnose the athlete’s condition, the treating physician will take a detailed history and examination to discover the onset and location of pain and attributed risk factors. Palpation may reveal diffuse tenderness over the distal two thirds of the posteromedial aspect of the shin (MTSS) or the anterolateral aspect of the shin (ATSS).16,19,37 However, palpation that reveals the following may be a red flag for bone-stress reaction:

  • focal tenderness localized to bone
  • swelling
  • warmth / redness
  • inability to train due to severe pain at the localized sight.14,17,19

Plain film radiographs (x-rays) are routinely taken of the leg in patients with shin pain. This baseline study may reveal a periosteal reaction, callus formation, or a radiolucent line that are common findings of a bone stress reaction or frank stress fracture. Radiographs may also rule out other pathological conditions such as an osteoid osteoma, osteosarcoma, or Ewing’s sarcoma. However, bone stress reactions are usually not visualized on radiographs until the 2nd to 6th week post injury/initial complaints of symptoms.1,21,35,52 “The sensitivity of early fracture detection by radiography can be as low as 15%, and follow up radiographs may demonstrate diagnostic findings in only 50% cases.”16 More advanced studies may be needed for further evaluation, such as an MRI (magnetic resonance imaging test) or a BS (bone scan). These studies are more sensitive in detecting bone pathology earlier in the stage of injury, and they aid clinical judgment in regards to a gradual return to sport specific training. Such gradual returns may require a longer period of modified rest, immobilization, or corrective surgery for more advanced cases of bone stress reactions.1,10,53

Treatment of shin splints

Goals of therapy include the following:

  • reduce pain and promote healing.
  • incorporate pain-free modified training to maintain fitness.
  • correct or minimize risk factors.
  • gradually re-introduce pain-free activity.
  • develop realistic additional training goals.

Severity of symptoms and level of injury are generally scored on a four-grade system:

Grade 1: Pain is present at the end of the workout but is minimal.

Grade 2: Pain is present during the workout but does not affect performance.

Grade 3: Pain during the workout affects performance but dissipates when the workout ends.

Grade 4: Pain does not allow participation in sport and is present during activities of daily living.1

Usually, the athlete will seek treatment when pain hinders performance. The initial goals of therapy are to promote healing and reduce pain and inflammation. The following initial treatments may be useful:

Inflammation reduction

Use of nonsteroidal anti-inflammatory medications per prescription, and application of a cold pack to the shin for twenty minutes on, one hour off, repeated throughout the day can reduce inflammation. Use of iontophoresis with dexamethasone may also decrease inflammation.1,19,56

Ultrasound and electric muscle stimulation combination therapy

The therapy can restore normal muscle tone, aid in the healing process, and reduce pain.1,10,19,32,57,58

Manual adjustments to the ankle and foot

Adjustments free-up joint motion of the talocrural, subtalar, and midtarsal joint articulations.57,59

Deep tissue procedures, such as the Graston Technique (manual therapy that utilizes specially designed devices) and Active Release Technique (a patented manual therapy technique)

figure7Procedures break up scar tissue and restore soft tissue motion (figures 7A,7B). There is considerable clinical procedures in treatment of strain/sprain injuries.60-63 Myofascial techniques have been shown to stimulate fibroblast proliferation, leading to collagen synthesis that may promote healing by replacing degenerative tissue with a stronger and more functional tissue.45,65

Phototherapy, such as low-level laser therapy or infrared light

Phototherapy decreases inflammation, increases the speed of tissue healing, and decreases pain.58,64

The above treatments may reduce pain and inflammation, and may speed the body’s normal healing response. However, time is a primary factor in recovery: Approximate return to pre-injury strength for bones, ligaments, muscles, and tendons can range from 12 weeks, 40-50 weeks, 6 weeks-6 months, and 40-50 weeks respectively.1,19

During the initial treatment phase – for more severe Grade 2, Grade 3, and Grade 4 injuries – athletes can maintain cardiovascular fitness with modified training. For example, a runner should cycle or swim at a pain-free level.1,12,19

There are no exact studies indicating when to re-introduce sport-specific training; however, the following may be a useful guideline: If there are no time-specific training goals, cease sport specific activity for 2 weeks, and maintain cardiovascular fitness with modified training. After 2 weeks of modified training and conservative therapy, re-introduce pain-free running on a soft track or treadmill, at approximately 50% of the pre-injury intensity and duration. Then, increase the duration of the training runs by 10% each week. It is hopeful that the pre-injury duration can be reached in 5-6 weeks. Athletes should cease running if they experience pain. A brief period of modified training and resumption of pain-free running at a lower intensity and shorter duration may be necessary. The intensity of the training should progress appropriately only after the pre-injury duration is obtained.37,19

Depending on the duration of the athlete’s most recent pre-injury training run, my recommendations for return to activity may vary with the above guidelines. Usually the duration of the initial training run would be 2-4 miles, conducted on a treadmill, at a speed of 10 minute/mile (very slow for most athletes). If the athlete can conduct 2-3 of these traning runs without pain, we would create a program, based on the above guidelines, for achieving time-specific goals.

Before re-introducing sport-specific training, the following methods may reduce the workload placed on the musculoskeletal support structure of the lower leg that are present due to intrinsic risk factors:

  • Buy proper running shoes. A pes cavus foot structure may benefit from a cushioned sneaker. The sneaker liner can be removed and replaced with a cushioned insole. The rearfoot varus, pes planus valgus, and forefoot varus foot structure may benefit from a motion-control sneaker.66
  • Use appropriate arch supports as necessary. A semirigid orthosis with a medial arch support, no higher than five-eighths of an inch, can limit excess or prolonged pronation.1,2,27,28,35,67-70
  • Tape the foot. Taping can limit pronation.57,71,72
  • Temporarily use a quarter-inch or three-quarter inch heel lift.

Temporary use can limit compensatory pronation caused by ankle equinous. As range of motion of the talocrural joint in dorsiflexion improves with therapy, the heel lifts can be removed.1,28,68

  • Apply a shin sleeve or strapping. Sleeves and strappings can add support for leg muscles.
  • Obtain nutritional advice. A dietitian can calculate caloric burn rate and develop a meal plan for healthy weight loss, maintenance, and proper nutrition.19
  • Obtain medical examinations Primary physicians or gynecologists can rule out deficiencies common in athletes, such as low estrogen, ammenorhea, or low bone density.
  • Train for flexibility Increasing flexibility can reduce compensatory pronation due to ankle equinous, and the posterior calf musculature can be stretched.1,35,43,73,74

The treating physician needs to continually re-evaluate the athlete during the course of therapy. If the athlete has time-specific goals, is not responding to conservative care, or symptoms re-appear when sport-specific training is re-initiated, a BS or MRI may be needed. In addition, treatment of slow healing stress fractures may require immobilization with casting or a walking boot for approximately 3-8 weeks.4,10 Pain-free modified training can maintain the athlete’s cardiovascular fitness, and sanity, during this period. Once union of the stress fracture is evident on repeat imaging studies, and pain is not present with ambulation, sport-specific training can be gradually re-introduced.

If non-union of the stress fracture is present on repeat imaging studies after 4-6 months of immobilization and rest, surgery may be necessary. Surgery may include intramedullary nailing, cortical drilling, or excision and bone grafting.1,4,33,75 In recalcitrant cases of MTSS, surgery may include fasciotomy of the posteromedial superficial and the deep fascia of the tibia.1 Posteromedial fasciotomy may aid in alleviating the pull of the soleus and deep posterior calf musculature of the leg on their insertions on the tibia, as well as decreasing pain due to denervation of the periosteum.37,19 Post-fasciotomy studies have indicated good results in regards to reduced shin pain, however many athletes are not able to return to full sport specific training levels.35,75

Conclusion:

Shin splints is one of the most common lower leg sport-related injuries. Risk factors include training errors, foot structure abnormalities, high body-mass index, age-related degenerative changes, poor conditioning, and inadequate calcium intake or estrogen levels. Most cases of shin splints can be treated successfully with conservative care. Conservative treatment includes the following:

  • reduction of pain and inflammation
  • modified training to maintain cardiovascular fitness
  • modifications to gear, such as obtaining new running shoes
  • implementation of a strength and flexibility program
  • correction of training errors
  • a pain-free gradual return to sport-specific activity
  • nutritional counseling or hormonal therapy

If the injury does not respond to conservative care, or there is a time-specific training goal, a BS or MRI may be beneficial in the early detection of stress fractures or other pathologies. Other treatment options for recalcitrant shin splints may include prolonged immobilization with pain-free modified training, surgery to promote bone-union, or a fasciotomy.

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Special thanks to Audrey Mahoney for creating the illustrations.

*To be published in BioMechanics, May/June 2008. ©2008 Dubin Chiropractic

Iliotibial Band Friction Syndrome

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ABSTRACT:

Iliotibial band friction syndrome (ITBFS) is an inflammatory, non-traumatic, overuse injury of the knee affecting predominantly long-distance runners. A home exercise program that includes a flexibility and strength conditioning routine and modified training recommendations can aid in the treatment and prevention of further injury. Most cases of ITBFS can be treated successfully with conservative therapy. Recalcitrant cases of ITBFS may require other interventions such as cortisone injections and/or surgery.

Iliotibial Band Friction Syndrome

Running has increased in popularity for cardiovascular fitness and sport over the last decade (1,2,3,4). It has been estimated that approximately 30 million Americans run for exercise (5). However, it has also been projected that one-half to two-thirds of those runners may sustain a non-traumatic repetitive strain injury at least once (5,6). Iliotibial band friction syndrome (ITBFS) is an inflammatory, repetitive strain injury to the knee that is particularly common in long distance runners (1,7,8,9,10). ITBFS may be caused by a multitude of factors including training errors, worn out running shoes, and/or lower leg misalignments (1,4,11,12,13,14,15,16). The main symptom of ITBFS is a sharp pain on the outer aspect of the knee that can radiate into the outer thigh or calf (17,18,19). Knee pain usually occurs at a particular distance of each training run, probably due to muscle fatigue (1,12), and is more pronounced shortly after the foot contacts the ground surface (20). Attempting to run throughout the pain will intensify the symptoms, eventually causing the athlete to shorten his stride or walk. The frustrated athlete, who may be training for a race, will not be able to progress his mileage appropriately. However, the despondent runner may be unreceptive to advice to temporarily discontinue running and initiate therapy, resulting in a more severe grade of injury. Pain may now be present with walking, exacerbated by walking up or down stairs, and a stiff-legged gait may be acquired to relieve symptoms (21). Based on clinical experience and as a recreational runner, I have identified several reasons why most athletes are unwilling to temporarily discontinue running: it is a time-efficient exercise; genuine friendships are formed in group training; no other cardiovascular exercise can beat the “runner’s high”; and the fear of not attaining his or her training goal. My experience and research studies show conservative therapy to be extremely successful in the treatment of ITBFS (8,22). A proper treatment protocol should include the following: inflammation reduction, pain-free training modification, flexibility and endurance strength training of the muscles surrounding the pelvis and thigh, and correction of faulty training habits (1,2,7,8,9,10,11,12,13,23,24).

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The treating physician should have an understanding of the anatomy of the iliotibial tract, surrounding musculature of the outer thigh and pelvis, the extrinsic and intrinsic risk factors that predispose long distance runners to ITBFS, and the biomechanics of the ankle, tibia and knee during the stance phase of gait.

Anatomy of the Iliotibial Tract

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Fascia is a sheath-like tissue that surrounds muscles and muscle groups. The fascia lata surrounds the hip and thigh. The iliotibial tract (ITT) is a lateral thickening of the fascia lata, originating from the iliac crest of the pelvis. The ITT continues down the outer third of the thigh, at the femur bone, passing over a protuberance called the greater trochanter. At the level of the greater trochanter, fibers from the gluteus maximus (GM) and Tensor fascia lata (TFL) musculature merge with the ITT posteriorly and anteriorly, respectively. Located between the ITT and greater trochanter is a bursa, a fluid filled sac that functions to decrease friction between two adjacent structures. The ITT attaches superficially to the fascia of the vastus lateralis musculature, and through passage of the intermuscular septum to the linea aspera, a linear ridge on the posterolateral aspect of the femur. As the ITT approaches the knee joint, it passes over a protuberance on the outer aspect of the femur, the lateral femoral epicondyle (LFE). A thin layer of fatty tissue is located between the ITT and LFE. As the ITT approaches the knee joint it splits into two structures, the iliopatellar band and a distal extension of the ITT. The distal extension of the ITT crosses the knee joint and attaches to Gerdy’s tubercle, a bump located on the proximal outer aspect of the tibia. The iliopatellar band migrates medially to join with the lateral retinaculum, a sheath-like tissue that attaches to the outer aspect of the patella (Figure 1,16,19,20,25,26,27,28,29,30,31). The distal extension of the ITT provides lateral stabilization to the knee joint through its attachment to the distal femur and the proximal tibia; the iliopatellar branch of the ITT aids in decelerating medial glide of the patella and leg flexion (32).

To properly diagnose, treat, and prevent ITBFS, a physician should understand the biomechanics of the ankle, tibia, and knee joint that this area undergoes during a typical running gait, and how these movements dynamically affect the ITT.

Lower Leg Biomechanics with Running

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Gait can be separated into two phases: the stance and swing phases. This discussion will focus on the stance phase, as it directly relates to ITBFS. During the stance phase, the foot contacts and adapts to the ground surface; during the swing phase, the leg accelerates forward and prepares for ground contact. The stance phase consists of initial contact, loading response, mid-stance, and terminal stance (33) (Figure 2). The ankle joint, tibia, and knee joint move in synchronicity during the individual stance phases, changing the lower extremity into a rigid lever for initial ground contact and toe-off, or a mobile shock absorber from loading response and into early mid stance (34).

Two tri-planar movements are particular to the ankle joint during the stance phase, supination and pronation. The ankle assumes a supinated position for stability during initial contact and in preparation for toe-off. Supination consists of calcaneal inversion (the heel is turned inwards), plantar flexion (the toes approach the ground surface) and adduction of the forefoot (the toes point toward the midline) (Figure 3). Ankle pronation occurs throughout loading response and into early mid stance, transforming the foot and ankle into a supple mobile adaptor that is efficient in absorbing ground reactive forces. Ankle pronation consists of eversion of the calcaneus (the heel turns outward), ground reactive dorsiflexion (the tibia moves forward over the foot) and abduction of the forefoot (the toes and forefoot turn away from the midline) (Figure 4) (2,35).

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During initial contact the knee is flexed approximately 21 degrees (36), the ITT should be located anterior to the LFE, and the ankle is supinated (Figure 5). Throughout loading response and early midstance, the ankle pronates, the tibia internally rotates, the knee joint flexes beyond 30 degrees, and the ITT translates posterior to the LFE (Figure 6). From early midstance and continuing into terminal stance the ankle re-supinates, the tibia externally rotates and the knee re-extends (33).

It has been proposed that ITBFS is secondary to repetitive knee movement through an impingement zone of 30 degrees of leg flexion (9,10,17). This injury is most common in long distance runners because the activity involves repetitive leg flexion and extension approximately 800 times per mile (37,38). The onset of pain associated with ITBFS will cause an athlete to shorten his stride, thereby limiting leg flexion and minimizing friction of the ITT over the inflamed fatty tissue and periosteal layer of the LFE. This

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altered gait will temporarily allow the athlete to continue running, but may exacerbate the condition. A study performed on athletes who had acute or sub-acute clinical symptoms for ITBFS revealed MRI findings of fluid accumulation in the fatty tissue deep to the ITT (17,39,40). Secondary bursa or thickening of the ITT may be more common in chronic stages of ITBFS (41).

Repetitive flexion and extension of the leg through the 30 degree impingement zone may be one risk factor; however the causes of ITBFS are multifaceted. Other risk factors include training errors and structural misalignments.

Training Errors and Risk Factors for ITBFS

Training errors are contributory to most overuse running injuries. Properly progressed training programs allow the supporting structures of the pelvis and knee to adapt to increased stresses. Inappropriately increasing the intensity, duration, and frequency of the training runs, as well as incorporating hills on the training routes too soon, may overload the supporting structures of the knee, eventually leading to injury (2,8,9,11,12).

Structural misalignments that cause altered movement patterns of the ankle, tibia and knee joint can also be contributory to ITBFS. Knee movement occurs in 3 planes of reference: the sagittal plane, frontal plane, and transverse plane. Flexion and extension of the leg occur in the sagittal plane (Figure 7A). Frontal plane movements include varus (gapping of the lateral aspect of the knee joint) (Figure 7B), as well as adduction of the lower extremity towards the midline. Internal rotation of the tibia on the fixed femur takes place in the transverse plane (Figure 7C). Excessive repetitive movement patterns of the knee occurring in the sagittal, frontal, and transverse planes are risk factors for ITBFS (17,18,20,21).

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Studies have suggested two factors that lead to excessive adduction of the stance leg in the frontal plane, causing increased tension of the ITT: weakness of the muscles that abduct and support the pelvis, and running on cambered (arched) surfaces (20). Contraction of the gluteus medius, GM, and TFL occur predominately during the first 35% of stance (9). Long distance runners with ITBFS have weaker hip abduction strength in the affected leg compared with their unaffected leg (10). Fatigue and weakness of the GM, TFL, and gluteus medius may occur later during a run, resulting in an altered “Trendelenberg gait,” raised ipsilateral hip, and increased frontal plane adduction of the thigh and leg (1,42) (Figure 8). This modified gait has been shown to increase tension on the ITT and is a risk factor for ITBFS (1,20).

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Pronounced adduction of the stance leg due to muscle fatigue leads to increased tension on the ITT that may initiate or exacerbate symptoms related to ITBFS.

Excessive internal rotation of the tibia in the transverse plane can also be caused by structural misalignments and can contribute to ITBFS. Anatomical misalignments such as rearfoot varus, forefoot varus, and pes planus may cause excessive or prolonged pronation of the ankle joint throughout the stance phase of gait. Abnormal pronation of the ankle joint may cause greater than normal internal rotation of the tibia, accompanied by increased tension on the ITT at its insertion point on Gerdy’s tubercle during each foot strike, predisposing to injury (1,12,38,43,44,45) (Figure 9).

Risk Factors for ITBFS

Extrinsic risk factors may include:

  1. Worn out running shoes. A sneaker loses approximately 50% of its ability to absorb ground reactive forces after 300-500 miles (14). The more worn out the shoe, the more ground reactive forces are transferred to the knee.
  2. Training programs that increase mileage or incorporate hills inappropriately. Weekly mileage should not be increased more than 5-10% per week to allow for adaptation of the muscles, tendons, ligaments and bone to increased stress (46,47,48).
  3. Running at an improper pace. Placing too much strain on untrained legs may lead to fatigue and injury. Long runs to improve aerobic conditioning should be slow, at 65-70% maximum heart rate. Anaerobic threshold training can be conducted with shorter runs at 85-100% maximum heart rate (46).
  4. Running on a cambered surface or slippery surface (11).

Intrinsic risk factors may include:

  1. Bow leg/genu varum (49)
  2. IBFS9

    Rearfoot and forefoot varum (50)

  3. Pes cavus/high arch. A pes cavus foot has limited ability in absorbing ground reactive forces, placing more stress on the knee joint.
  4. A prominent LFE and tight IT and TFL.
  5. Weak gluteus medius, GM and TFL (42).
  6. Tightness and weakness in the Quadriceps, ITT and lateral retinaculum. This may lead to excessive lateral tracking of the patella and decreased deceleration forces acting on leg flexion, leading to increased stress on the lateral stabilizing structures of the knee joint (47,51).

Diagnosing ITBFS

A physician can diagnose ITBFS and discover internal and external risk factors for the condition through a detailed history and physical examination. A history should include the following questions: What are your current symptoms? When did you first notice the injury? How have you progressed the frequency, duration and intensity of your weekly training runs? Do your training routes include hills or cambered surfaces? How old are your running sneakers? What are your training goals?

Two orthopedic tests that aid the doctor in diagnosing ITBFS are the Modified Ober’s test (Figure 10) (42,52) and Noble’s test (Figure 11) (15,17,52). The Modified Ober’s test is an assessment tool for evaluating tightness of the ITT and TFL. Initially the patient lies on the non-injured side. The doctor raises the upside hip and thigh into slight abduction, extends the thigh, and then allows the thigh to drop vertically into adduction. The doctor should stabilize the pelvis and thigh with one hand to prevent flexion of the pelvis and internal rotation of the thigh, movements that may lead to false negative findings. The Modified Ober’s test is positive for a tight ITT and TFL if the thigh does not descend to or beyond 10 degrees of the horizontal plane.

Noble’s test can be utilized to differentiate between ITBFS and other conditions that refer pain to the outside of the knee, such as bicipital tendonitis, popliteus tendonitis, lateral collateral ligament strain, lateral meniscal tear or cyst, and osteoarthritis (53,54,55,56,57, 58). The patient is instructed to lie on his back with his leg hanging off the side of the bench and his knee flexed to 90 degrees. The doctor places his thumb over the LFE and instructs the patient to extend his leg. As the patient extends his leg to approximately 30 degrees, the ITT translates anteriorly under the doctor’s thumb. If the patient complains of lateral knee pain that is similar to pain present while running, Noble’s test is positive for ITBFS.

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The Creak test (17) is analogous to Noble’s test. During this orthopaedic test the athlete is standing and instructed to transfer his weight to the fully extended injured leg. He is then instructed to flex the injured leg to approximately 30 degrees. As the leg flexes to 30 degrees, the ITT would track over and posterior to the LFE. If lateral knee pain is present at approximately 30 degrees of leg flexion, the test is positive for ITBFS.

Further examination should include a strength and flexibility assessment of the musculature surrounding the thigh and pelvis, and observation of the athlete’s lower extremity biomechanics with standing and walking.

Therapies

Initial goals of therapy are to reduce swelling and inflammation. Pain-free modified training can then be implemented to improve strength and flexibility of the hip, thigh, and calf musculature, as well as cardiovascular fitness. The end goal is to return the athlete to a pain-free running routine. Grading the injury helps to determine the plan of treatment (7,43).

Grades of Iliotibial Friction Injuries and Phases of Tissue Repair and Treatment
Grade 1

Pain does not occur during normal activity, but generalized pain is felt about 1 to 3 hours after sport-specific training has ended. Tenderness usually resolves within 24 hours without intervention.

Grade 2

Minimal pain is present towards the end of a training run; performance is not affected. Appropriate treatment may be necessary to prevent a grade 3 injury.

Grade 3

Pain is present at an earlier onset of training, and interferes with the speed and duration of a training session. Treatment and training modification are necessary to prevent a grade 3 injury from progressing to a grade 4 injury.

Grade 4

Pain restricts training and is also noticeable during activities of daily living; the athlete can no longer continue sport-specific training. Low-impact training, such as swimming, running in a pool, and biking, can be implemented for cardiovascular fitness and aggressive muscu- loskeletal therapy can reduce the severity of the injury. The goal of therapy is to reduce inflammation and restore strength and flexibility of the hip and thigh musculature, allowing for the athlete to return to pain-free sport-specific training.

Grade 5

Pain interferes with training as well as activities of daily living. Aggressive therapy is required and surgery may be necessary. (Source: 7,43)

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Appropriate treatment of a grade 1 or grade 2 ITBFS injury would consist of:

  • Manual adjustments to the ankle and foot, as well as medial glide mobilization of the patella to free up joint motion and improve tracking of the patella (45).
  • Deep tissue procedures, such as the Graston Technique (manual therapy that utilizes specially designed devices) and Active Release Technique (a patented manual therapy technique), to break up scar tissue and restore soft tissue motion (59). There is considerable clinical evidence to support the effectiveness of deep tissue procedures in treatment of strain/sprain injuries (60,61). A home exercise program for myofascial release therapy can be taught on a foam roller (Figure 12).
  • Ultrasound and electric muscle stimulation combination therapy to restore normal muscle tone, help in the healing process, and reduce pain (50,62). Iontophoresis with dexamethasone is also a useful modality to decrease inflammation (63).
  • Inflammation reduction by taking nonsteroidal anti-inflammatory medications per prescription, and applying a cold pack to the lateral aspect of the knee 20 minutes on/one hour off, repeated throughout the day.
  • Implementation of a strength training program for the gluteus medius, GM, and quadricep musculature. Exercises should include squats, standing hip abduction, and supine floor bridges with alternating leg lifts (Figures 13 A-C). Strengthening the gluteus musculature has been shown to be instrumental in returning athletes to pain-free running (10,51). Strengthening exercises should be progressed with no or little discomfort (64). When pain free training resumes, it is my opinion that a leg workout can be included once a week, with at least 48 hours rest before or after a long run.
  • Stretching routine. I have found that a 15-20 minute flexibility routine with a resistance band helps in decreasing delayed onset muscle soreness, as well as improving flexibility through hysteresis/creep. The flexibility routine should include stretching of the hamstrings, quadriceps, adductors, ITT, and external rotators of the thigh (65,66,67). Longer stretching (30-60 seconds), with short intermittent contractions of the antagonist, has been shown to be one of the best mobilization techniques for a painful muscle/tendon (11).
  • A recommendation to change running shoes every 300-500 miles of use, at which point the shoe loses 50% of its shock absorption capability (8,14).
  • A recommendation to use appropriate arch supports as necessary. A runner with pes planus will usually overpronate, leading to increased internal rotation of the tibia, a risk factor for ITBFS. A good sneaker with a firm heel counter and an inside arch support will help correct overpronation. If necessary a semirigid orthosis with a medial arch support no higher then 5/8 inch can be utilized to further control pronation. A runner with pes cavus has limited pronation and poor shock-absorbing capabilities. The high-arch runner should get a sneaker with good cushioning; if necessary a semirigid orthosis or cushioned liner can be added (1,8).
  • Recommendation for appropriate training limits. For marathon runners, initially a training base of four miles at 65%-75% maximum heart rate needs to be established. Later, a progressive training schedule should be followed that allows for adaptation of the supporting structures of the knee to withstand future increased stress loads. Long training runs, usually done on the weekend, should be limited to a pace that requires 65-75% maximum heart rate to improve aerobic capacity. During the week, a shorter 4-8 mile interval run at 85-90% maximum heart rate is recommended to improve anaerobic capacity. Hill training should be added gradually because of the increased load placed on the knee joint. The average marathon training schedule consists of 3 shorter runs during the week, and 1 longer run on the weekend. Total mileage should not be increased by more then 10% per week (33,46,50).

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Early therapy and intervention (as above) are important to prevent a grade 3 ITBFS injury from progressing to a grade 4 or 5 injury. In the early stages of a grade 3 injury, one week of activity modification from the offending training regimen is recommended, as well as treatment procedures similar to those used to treat a grade 1 or 2 injury. Modified activity with swimming, running in the pool, bicycling, or an elliptical machine would be useful in maintaining aerobic fitness and allow for proper healing. Treating a more advanced grade 3 or grade 4 ITBFS injury would involve a longer bout of modified activity and rest from an offending activity, and a slower progression of weight training and stretching (68,69,70).

Chronic ITBFS may not always resolve with conservative therapy. In recalcitrant ITBFS, other treatment methods may need to be considered, such as steroid injection therapy and surgical procedures. Steroid injections, used judiciously, have been shown to reduce symptoms and inflammation (1,11,12,13). Steroid injection therapy should be followed by a properly progressed strength, flexibility and car- diovascular program to restore function before training resumes. Surgery should only be considered if all other means of therapy fail and the athlete is not willing to give up his sports activity (23). One type of surgery involves lengthening of the ITT at the level where the friction accumulates and typically involves two small incisions. The first incision is in the posterior fibers of the ITT that lie over the LFE when the leg is flexed to 30 degrees. The second incision is placed in the anterior fibers of the ITT proximal to the first incision, and is a “Y” shape to allow for maximal lengthening (1,9). In a study by Holmes et al., open release-excision, a surgical procedure involving removal of an ellipse of tissue that abrades the LFE, was found to be a safe and effective surgical procedure (71).

Conclusion

ITBFS is a common non-traumatic overuse injury that is particularly common in long distance runners. Certain biomechanical malalignments, such as rearfoot varus; forefoot varus; genu varum; pes cavus; a prominent LFE; weak GM, gluteus medius and Quadriceps musculature; and tight TFL, ITT, and lateral retinaculum predispose runners to ITBFS. The risk of ITBFS can be reduced if athletes follow a properly progressed training program that allows for adaptation of the structures supporting the pelvis, thigh and knee. To prevent injury, these athletes should incorporate proper footwear, semirigid orthosis as necessary, a lower body flexibility and strength training routine, and cross training into their workouts.

ITBFS can usually be treated successfully with a conservative rehabilitation program that includes modified training and a flexibility and strength home exercise program. When the athlete can run 3-4 miles pain-free on a treadmill, he can progress his training program carefully to prevent re-injury. Sometimes ITBFS is resistant to conservative therapy and a cortisone injection or surgery may need to be considered as alternative treatment options. Surgery, when necessary, may involve lengthening the ITT and removing a section of the posterior aspect of the ITT that is impinging on the LFE.

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©2006 Dubin Chiropractic

Special thanks to Audrey Mahoney for creating the illustrations.

Achilles Tendinopathies in Runners: Causes, Treatment, and Prevention

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achilles1The Achilles tendon, which runs from the top of the heel to the back of the calf, is a strong, non-elastic, fibrous tissue that attaches the gastrocnemius muscle (Figure 1A) and the soleus muscle (Figure 1B) to the calcaneus (heel bone) (1). Another name for the muscle group sharing the Achilles tendon is the “triceps surae.” The Achilles tendon can effectively absorb ground reactive forces associated with running that can approach 6-8 times body weight with an average of 800 foot strikes per mile (2, 23). Injury to the Achilles tendon or its surrounding sheath, the paratendon, can be the result of overuse, improper training, gait abnormalities, age related degenerative changes, or improper footwear (1-7). Recreational runners who prematurely increase the intensity, duration, and/or frequency of their training sessions are prone to developing Achilles tendon injuries because the Achilles tendon does not have the time to adapt to the increased demand. Improper training may lead to microtears and degenerative changes to the Achilles tendon or the surrounding paratendon, weakening the tendon and predisposing it to further injury. Achilles tendon injuries usually occur gradually, increasing in severity without proper treatment and rehabilitation. Symptoms of Achilles tendon injuries can include one or more of the following:

  • diffuse or localized swelling and tenderness around the tendon
  • pain with the first few steps after getting out of bed in the morning
  • exacerbation of the injury upon walking uphill.

Conservative therapy can aid in the normal reparative processes of Achilles tendon healing, thereby allowing athletes to return to their sport more quickly (4, 8).

There are three classifications of Achilles tendon injuries: tendinosis, tendonitis, and paratenonitis. Achilles tendinosis is a non-inflammatory asymptomatic condition that may lead to abnormal thickening of the tendon or other structural degenerative changes. These degenerative changes compromise the strength and function of the Achilles tendon, predisposing it to further injury. Achilles tendonitis and paratenonitis are painful inflammatory conditions of the Achilles tendon and surrounding paratendon respectively (1, 9, 10, 11).

To develop effective treatments for these injuries, it is necessary to understand the biomechanics of the ankle joint, the function of the triceps surae during a normal running gait, and the conditions that predispose the Achilles tendon to injury.

BIOMECHANICS OF THE ANKLE JOINT AND ACHILLES TENDON WITH RUNNING

A runner’s gait can be separated into two phases: the stance phase and the swing phase. During the stance phase, the foot contacts and adapts to the ground surface; during the swing phase, the leg accelerates forward and prepares for ground contact. The stance phase with walking consists of the following sub-phases: initial contact, loading response, midstance, and terminal stance (Figures 2). During initial contact, the heel contacts the ground surface. The loading response occurs immediately after initial contact, ending when the contralateral foot lifts off of the ground surface. During the loading response, the foot and ankle adapt to the terrain and absorb ground reactive forces. Double limb support occurs during initial contact and the loading response, when both feet are in contact with the ground surface. The midstance phase starts when the contralateral foot lifts off of the ground surface; the contralateral leg is now the swing leg. The midstance phase ends as the forward momentum of the swing leg and the tension on the triceps surae of the stance leg cause the heel to lift off of the ground surface. The terminal stance phase begins when the heel lifts off of the ground and ends when the swing leg contacts the ground. The running stance phase differs from the walking stance phase in that the stride is elongated, the cadence is increased, and double limb support is eliminated (Figures 3) (6, 12, 13).

achilles2

achilles3

achilles4_5There are two types of active muscle contractions: eccentric and concentric. An eccentric contraction involves lengthening of a muscle as it attempts to decelerate a particular movement, while a concentric contraction involves shortening of a muscle as it generates force to produce movement across a joint. Most overuse soft tissue injuries are caused by repetitive eccentric forces that exceed the tensile strength of the tissue that is attempting to decelerate a particular movement. The Achilles tendon is the strongest tendon in the body; normally it does not incur injury when absorbing the eccentric forces exerted on it during running or jumping (1). However certain gait abnormalities, tightness of the calf musculature, improper training, and age-related changes can predispose the Achilles tendon to repetitive microtrauma and injury.

The ankle joint is actually two joints: the talocrural joint and the subtalar joint. The talocrural joint is the articulation between the leg bones (tibia and fibula) and the talus (an ankle bone) (Figure 4). Two types of movements primarily occur at the talocrural joint: plantarflexion and dorsiflexion. Plantarflexion of the talocrural joint involves the toes pointing downwards as the heel lifts off of the ground (Figure 5). Plantarflexion of the ankle joint occurs when conducting a calf raise as the triceps surae contracts concentrically. Dorsiflexion of the ankle joint involves approximation of the leg towards the foot and occurs throughout the midstance phase of gait (Figure 6).

achilles6During the midstance phase of gait, the triceps surae contracts eccentrically, exerting force through the Achilles tendon to decelerate forward movement of the stance leg over the foot (2, 4, 14). Dorsiflexion of the ankle joint is dependent on flexibility of the triceps surae. A tight tricep surae limits dorsiflexion of the ankle joint, placing excessive eccentric strain on the Achilles tendon throughout midstance, predisposing it and the surrounding paratendon to injury.

The subtalar joint of the ankle consists of the articulation between the talus and the underlying calcaneus (Figure 7). Two primary movements occur at the subtalar joint: inversion and eversion. Subtalar joint inversion involves the calcaneus turning inward (Figure 8). The ankle joint is stabilized in subtalar inversion as the ligaments and surrounding structures on the outside of the ankle become taut. Inversion of the calcaneus occurs during the initial contact phase to prepare for ground contact, and later in the terminal stance phase to provide a rigid platform for toe-off. Subtalar joint eversion involves the calcaneus turning outward (Figure 9). Eversion of the calcaneus occurs during the loading response and continues into the beginning of midstance. From loading response to midstance the foot and ankle change from a rigid lever into a mobile shock absorber and adapt to the terrain.

achilles7achilles8_9

Initially, when the foot strikes the ground, it is in supination; the talocrural joint is neutral and plantarflexing, the subtalar joint is inverted, and the forefoot is adducted – toes are directed towards the midline (Figure 10). The supinated position maintains stability of the ankle joint during initial contact with the ground. After initial contact the ankle pronates, the talocrural joint dorsiflexes, the subtalar joint everts, and the forefoot abducts – toes are pointed away from the midline (Figure 11). The ankle pronates during the loading response and into the beginning of midstance, allowing the ankle and foot to absorb compressive forces and become a mobile adaptor to the ground. During pronation the triceps surae contracts eccentrically to decelerate eversion and dorsiflexion at the ankle joint. The ankle re-supinates during midstance to create a rigid lever for effective toe-off.

achilles10During initial contact the calcaneus is normally in 2-3 degrees of inversion. However, certain structural abnormalities can change normal inversion. One such structural abnormality, rearfoot varus, involves excessive inversion of the calcaneus during initial surface contact. To compensate for rearfoot varus, the subtalar joint pronates excessively and at a faster speed than normal to allow for the medial aspect of the calcaneus to contact and adapt to the terrain. The excessive pronation of the subtalar joint, which occurs at an increased velocity from initial contact to midstance, places an increased eccentric load on the Achilles tendon, predisposing the tendon to injury.

achilles11Forefoot varum is another structural abnormality that predisposes the Achilles tendon to injury. In this condition the forefoot has an increased inversion tilt as compared to the rearfoot. Forefoot varum leads to prolonged pronation through midstance and into terminal stance to allow for the inside of the forefoot to contact the ground surface. During the beginning of midstance and into terminal stance of a normal running gait, the subtalar joint re-supinates to change the foot into an effective rigid lever for toe-off. However, a runner’s gait with forefoot varum may exhibit prolonged pronation throughout midstance causing the subtalar joint to rapidly re-supinate and create a rigid lever for toe-off. Prolonged pronation into midstance followed by an attempt of the subtalar joint to re-supinate causes a bowstring effect on the Achilles tendon (Figure 12). The bowstring effect places an increased eccentric load on the medial side of the Achilles tendon, predisposing it to injury (5, 15, 23, 24).

achilles12The subtalar joint in a runner with a flat inside arch (pes planus) tends to overpronate, causing an increased eccentric strain on the Achilles tendon. The subtalar joint in a runner with a rigid high inside arch (pes cavus) has limited pronation. Limited pronation decreases the ability of the foot and ankle to absorb ground forces, leading to transmission of excessive forces through the Achilles tendon and other adjacent structures.

Runners in their 30s and 40s have an increased risk of developing Achilles tendon injury because the collagen (supportive subunits of muscles, tendons, and ligaments) of the triceps surae degrades with age (16). Without adequate time to rest and heal between bouts of exercise the tricep surae of these athletes are predisposed to injury. To prevent injury older athletes should train on softer surfaces and cross-train with exercises such as cycling, swimming, cross country skiing, rollerblading, and use of a quality elliptical machine.

Factors predisposing an athlete to developing Achilles tendon injuries include tight gastrocnemius and soleus musculature, overpronation and increased velocity of pronation from initial contact through the beginning of midstance, prolonged pronation during midstance, age-related degenerative processes of the Achilles tendon, and training programs that do not allow for adaptation of the Achilles tendon. Initial training programs that incorporate too many uphills or downhills, high intensity interval training, and excessive mileage, lead to injury because the Achilles tendon is not allowed to adapt.

GRADES OF TENDON INJURIES AND PHASES OF TISSUE REPAIR AND TREATMENT

There are five grades of tendon injuries:

Grade 1 – Pain does not occur during normal activity, but generalized pain is felt in the Achilles tendon about 1 to 3 hours after sport-specific training has ended. Tenderness in the Achilles tendon usually resolves within 24 hours without intervention.

Grade 2 – Minimal pain is present in the Achilles tendon towards the end of the sport-specific training session, but performance is not affected. Appropriate treatment may be necessary to prevent a Grade 3 injury.

Grade 3 – Pain is present in the Achilles tendon at the onset of training, and interferes with the speed and duration of a training session. Treatment and training modification are necessary to prevent a grade 3 injury from progressing to a grade 4 injury.

Grade 4 – Pain in the Achilles tendon restricts training and is also noticeable during activities of daily living; the athlete can no longer continue sport-specific training. Low impact training, such as swimming and biking, can be implemented for cardiovascular fitness and aggressive musculoskeletal therapy can decrease the severity of the injury. The goal of therapy is to restore structural integrity of the tissues allowing for the athlete to return to pain-free sport-specific training.

Grade 5 – Pain in the Achilles tendon interferes with training as well as activities of daily living. The Achilles tendon becomes deformed and there is a loss of function of the triceps surae (5). Aggressive therapy is required and surgery may be necessary.

Conservative therapy is usually successful for treatment of Achilles tendon injury. A thorough history and examination will help find the cause of the Achilles tendon injury. Was the injury caused by improper training techniques, age related degenerative changes, a tight tricep surae or biomechanical dysfunction of the rear or forefoot? Initial goals of therapy are to reduce swelling and inflammation of the tendon and paratendon to alleviate acute tendon injury or chronic flare-ups so the patient can perform activities of daily living with less pain. Pain-free modified training can then be implemented to improve strength and flexibility of the triceps surae, as well as cardiovascular fitness. The end goal is to return the athlete to pain free running. However, even if the pain dissipates, the athlete should be made aware that it takes time for the Achilles tendon to regain full strength and function. With fewer blood vessels then muscles, tendons have a limited oxygen and nutrient supply. Faced with this shortage, tendons take a longer time to heal than muscles.

There are three phases of tissue repair: the reactive phase, the regenerative phase, and the remodeling phase. The reactive phase is the initial inflammatory response to microtrauma. Vasodilation of the blood vessels surrounding the injured tendon or muscle occurs, causing swelling, pain, and loss of function. To limit the immobilizing effects of the reactive phase, RICE (rest, ice, compression, and elevation) should be applied to the injured region. During the regenerative phase dead cells are cleared out, tiny blood vessels are restructured to help supply oxygen to the damaged tissue, and collagen is laid down for repair. The reparative collagen is initially weak, but with time its strength improves. After 7-14 days, damaged muscle regains approximately 50% of its strength; tendons may take a longer time to regain their strength. During the remodeling phase, the reparative collagen matures. After completing a proper medical treatment program and complying with a home strength-training and flexibility routine, the athlete may regain 100% strength. The remodeling phase can take up to six months for muscle repair and even longer for tendon repair, depending on the severity of the injury (11, 17, 18).

Appropriate treatment of a grade 1 or a grade 2 Achilles tendon injury consists of:

1. Manual adjustments to the ankle and foot to free up joint motion (25).

2. Deep tissue procedures, such as Graston Technique and Active Release Technique, to break up scar tissue in the affected tendon or paratenon and restore soft tissue motion and glide (19).

3. Ultrasound and electric muscle stimulation are useful modalities to restore normal muscle tone, help in the healing process, and decrease pain (17, 20).

achilles134. Inflammation reduction by icing the Achilles tendon for 20 minutes on, 1 hour off, repeating throughout the day, and use of NSAIDs (non-steroidal anti-inflammatory drugs) per primary doctor recommendation. Iontophoresis with dexamethasone is also a useful modality to decrease inflammation.

5. A strength training program for the gastrocnemius and soleus musculature, including standing and seated calf raises (Figure 13A and 13B). Studies have indicated that emphasizing eccentric strength training of the triceps surae has been beneficial in treatment and prevention of future Achilles tendon injuries (26, 27). Dorsiflexion strengthening exercises should also be implemented to increase the strength of the tibialis anterior and extensor musculature (Figure 14). Strengthening exercises should progress appropriately with no or little discomfort.

6. Use of a step or slant board to stretch the triceps surae (Figure 15A and 15B). A stretching and strengthening routine for the lower extremities, using a resistive band, can be implemented to improve strength of the dorsiflexors and evertors and flexibility of the hamstring and calf musculature.

achilles147. A recommendation to replace running sneakers after 250-400 miles of use, at which point the shoe loses 40% of its shock absorption abilities.

8. The possible recommendation of appropriate arch supports. A runner with a flat inside arch, pes planus, will usually overpronate, placing an increased strain on the Achilles tendon. A good sneaker with a firm heal counter and an inside arch support will aid in correcting overpronation and help in preventing Achilles tendon injury. If the Achilles tendon injury does not resolve with sneaker adjustment, a semi-rigid orthotic with no more than 5/8” medial arch support is useful. A temporary 1/8” heel lift can also be added to the orthotic to limit dorsiflexion of the foot; this takes pressure off of the injured Achilles tendon. A runner with a high inside arch has limited pronation and poor shock absorption. The high arch runner should get a sneaker with good cushioning; if necessary a semi-rigid orthotic or cushioned liner can be added (3, 4, 8, 13, 28).

achilles159. A night splint that maintains the ankle and foot in slight dorsiflexion can help to alleviate morning stiffness in the Achilles tendon (23). For more advanced cases of Achilles tendon injury a walking splint can alleviate stress on the slowly healing tendon.

10. Recommendations for appropriate training limits. For marathon runners, an initial training base of four miles at 65%-75% maximum heart rate. A gradual progressive training schedule should follow. A proper warm-up, consisting of a slow jog, increases the blood supply to the muscles and tendons, making them more efficient in absorbing loads. Hill training should be added gradually to a training route because uphill running increases the eccentric load on the Achilles tendon.

Early therapy and intervention are important to prevent a grade 3 tendon injury from progressing to a grade 4 or a grade 5 tendon injury. In the early stages of a grade 3 tendon injury, one week of modified activity is recommended, along with treatments similar to those administered for grade 1 and grade 2 injuries. Modified activity with swimming, running in the pool, bicycling, or using a quality elliptical machine maintains aerobic fitness and allows the triceps surae to heal properly before the athlete resumes full training. Treatment of a more advanced grade 3 or grade 4 tendon injury involves a longer bout of modified activity, rest from the offending activity, and a slower progression of weight training and stretching (3, 4, 18).

Chronic Achilles tendon injuries may not always resolve with conservative therapy. Initially, microscopic tears in the Achilles tendon or paratendon repair naturally with Type III collagen. Type III collagen is immature, disorganized scar tissue that temporarily binds the damaged tendon fibers. Type III collagen is later replaced by Type I collagen, mature scar tissue that has a similar parallel arrangement of fibers as the normal tendon tissue. With time and a properly progressed rehabilitation program the Type I collagen scar regains the tensile strength of the normal tendon tissue. However, sometimes the type III collagen is not always replaced by type I collagen in the later stages of healing. The immature scar tissue remains a chronically inflamed and weakened structure that may be palpated as a tender nodule, usually located on the medial side of the Achilles tendon. The degenerative scar tissue may be resistant to conservative care, and attempting to train on the injured tendon may cause further injury. An athlete who wants to return to running without pain may need to consider surgery. Magnetic Resonance Imaging has been shown to be extremely sensitive to pathological changes in the Achilles tendon and may be a useful tool for the surgeon in discovering degenerative tissue that needs debridement. Surgery usually involves excision of the degenerative intratendinous lesion, followed by rehabilitation. In cases of chronic paratenonitis “brisement” – distension of the paratenon-tendon-interface may help to resolve paratenonitis (23, 29, 30, 31).

CONCLUSION

Athletes participating in sports involving repetitive jumping and running are predisposed to developing Achilles tendon injury. Achilles tendon injuries can be reduced by following a properly progressed training program that allows for adaptation of the Achilles tendon to adapt to increased eccentric loads. Certain biomechanical dysfunction, such as, rearfoot varus, forefoot varus, pes cavus, tight and weak triceps surae, and age-related degenerative changes, also predispose an athlete to Achilles tendon injury. To prevent injury athletes with these dysfunctions should incorporate proper sneaker wear – if necessary semi-rigid orthotics – as well as lower body flexibility, strength and cross training. Achilles tendon injuries can usually be treated successfully with a conservative rehabilitation program that includes modified training and incorporates eccentric strength training of the triceps surae. The athlete must be made aware that it takes time for the Achilles tendon to heal even with rehabilitation. After the Achilles tendon regains function and becomes pain free, the athlete should implement an appropriate training program to prevent re-injury. Sometimes Achilles tendon injuries are resistant to conservative therapy. In such cases surgery and proper rehabilitation may be necessary to remove the degenerative tissue from the tendon or paratendon to allow for proper healing and restoration of strength and function.

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25. Menetrey J, Fritschy D. Subtalar Subluxation in Ballet Dancers. The American Journal of Sports Medicine. 1999; 27(2): 143-149.

26. Shalabi A, Wilberg MK, Svennson L, Aspelin P, Movin T. Eccentric Training of the Gastrocnemius- Soleus Complex in Chronic Achilles Tendinopathy Results in Decreased Tendon Volume and Intratendinous Signal as Evaluated by MRI. The American Journal of Sports Medicine. 2004; 32(5): 1286-1296.

27. Fahlstrom M, Lorentzon R, Alfredson H. Painful Conditions in the Achilles Tendon Region in Elite Badminton Players. The American Journal of Sports Medicine. 2002; 20 (1): 51-54.

28. Gross ML, Davlin L, Evanski PM. Effectiveness of Orthotic Shoe Inserts in the Long-Distance Runner. 1991; 19: 409-412.

29. Maffulli N, Ewen SB.W., Waterston SW, Reaper J, Barrass V. Tenocytes from Ruptured and Tendinopathic Achilles Tendons Produce Greater Quantities of Type III Collagen than Tenocytes from Normal Achilles Tendons. The American Journal of Sports Medicine. 2000; 28(4): 499-505.

30. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long Term Prognosis of Patients with Achilles Tendinopathy. The American Journal of Sports Medicine. 2000; 28(5): 634-642.

31. Maffulli N, Testa V, Capasso G, Sullo A. Calcific Insertional Achilles Tendinopathy. The American Journal of Sports Medicine. 2004; 32(1): 174-182.

Special thanks to Audrey Mahoney for creating the illustrations.

Medial Epicondylitis / Pitcher’s Elbow

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Prolonged repetitive throwing motions such as those familiar to baseball pitchers are a risk for developing repetitive strain injuries to the muscles, ligaments, and tendons supporting the inside of the elbow. These injuries are also common in athletes participating in overhead activities like tennis, badminton, and javelin throwing. The main symptom of this so-called “pitcher’s elbow” is a gradual onset of pain on the inside of the elbow that may travel down the inside of the forearm. Such high-velocity throwing motions place a lot of strain on the structures on the inside of the elbow, leading to microtears and possibly to the development of a repetitive strain injury. Ongoing sport participation without proper treatment may lead to an increase in the severity of the elbow pain, elbow swelling, and eventually decreased performance, like a slower fastball or a compromised tennis serve. This injury is known as medial epicondylitis. Prolonged injury without treatment may lead to an inability to compete.

Understanding which muscles, tendons, and ligaments are contracting, being pre-stretched, or are stabilizing the elbow joint in each of the five phases will help in developing a proper treatment and prevention program for medial epicondylitis.

Evaluation of the Pitching Motion

An effective pitching delivery (or overhead serve) involves rotation of the hips and torso in coordination with movement of the shoulder, elbow, and wrist. Two very successful professional pitchers, Nolan Ryan and Roger Clemens, were able to pitch effectively and relatively injury-free during their careers due to their regimented strength and conditioning programs and proper pitching mechanics. On the other hand, many pitchers with great arm strength but poor biomechanics have seen a premature end to their careers due to shoulder and elbow injuries. This article will focus on the biomechanics of pitching and stress placed on the elbow joint, which may lead to the development of medial epicondylitis.

There are 5 main pitching phases: the wind-up phase, stride/cocking phase, acceleration 1 phase, acceleration 2 phase, and follow-through phase (Figs. 1A-1H).

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During the wind-up phase (Fig. 1A), the opposite knee of the pitching hand (the stride leg) is lifted to about waist level, the torso is extended slightly, and the hips are rotated towards the batter. The main purpose of the wind-up is to generate energy that will be transferred from the hips and torso to the arm during the later phases of throwing. Another purpose of the wind-up is to hide the style of pitch from the batter before it is delivered to the plate.

During the stride/cocking phase (Figs 1B-C), the pitching arm extends behind the head as the hand goes down, back, and up into the cocked position. Also during this phase the stride leg moves down and forward and the foot lands flatly on the ground. This pitching phase prepares the body to transfer the stored energy from the hips and torso to the shoulder and arm.

During the acceleration 1 phase (Fig. 1D), the body rotates towards home plate over the stride leg as the pitcher’s chest and shoulder come forward. The pitching arm is placed in extreme external rotation and there as an increased “valgus strain” placed on the structures supporting the inside of the elbow. Stabilization of the elbow joint during the acceleration 1 phase is dependent on the integrity of the muscles surrounding the elbow joint (Figs. 2A-B) and of the medial collateral ligaments, located on the inside of the elbow (Fig. 3). Injury to the medial collateral ligament will decrease performance and cause pain on the inside of the elbow. If this problem goes untreated, further tearing of the ligament may occur, possibly necessitating surgery to correct the problem.

pitcher2The power of the pitch is transferred from the torso and lower trunk to the shoulder, arm, and hand during acceleration 2 (Figs. 1E-F). During this phase, the trunk springs from extension (stretching out) to flexion (bending in) and rotates towards home plate over the planted stride leg. At the same time, the shoulder rotates internally and the arm and hand accelerate towards the plate until the baseball is released from the hand.

The follow-through phase (Figs. 1G-H) is the last phase of pitching and involves deceleration of the arm and hand after the baseball is released. The pitching arm, elbow, and hand should go down, over, and outside the lead leg while the other leg swings forward in line with the stride leg. The purpose of the follow-through is two-fold: arm deceleration (where the legs and back muscles aid the muscles, ligaments, and tendons of the shoulder, elbow, and arm); and preparation (placing the pitcher in a fielding position ready to field a ball hit in his direction).

pitcher3During the cocking and acceleration 1 phases, the wrist is slightly extended, stretching the flexor muscles of the forearm-the flexor digitorum superficialis, flexor carpi radialis, and flexor carpi ulnaris (Fig. 2A)-and an increased “valgus strain” is placed on the medial collateral ligament. From acceleration 1 to acceleration 2, the wrist goes from a slightly extended position to a flexed position, causing a forceful contraction of the forearm flexors. The tendons attached to these forearm flexors have a common insertion point on the medial epicondyle, an outgrowth of bone found on the inside and bottom of the humerus (arm bone). When these muscles are under-prepared and stretched in this way, tension develops in the tendons at the insertion point on the medial epicondyle. Overuse may cause microtears in these structures, causing pain at the medial epicondyle in the elbow.

Improper pitching technique, including failure to utilize the trunk and torso effectively during the pitching phases, will place an increased workload onto the muscles, tendons, and ligaments of the arm, forearm, and hand, leading to overuse injuries. If the athlete does not improve pitching technique and/or fails to treat the condition appropriately, further injury will ensue, leading to the development of medial epicondylitis.

The overhead tennis or badminton swing would be similar to the cocking and acceleration 2 phases of the pitching motion. These athletes would benefit from exercises similar to those recommended for baseball pitchers.

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Treatment and Prevention of Medial Epicondylitis/ Pitcher’s Elbow

Repetitive strain injuries in the elbow region are directly related to the strength of the muscles as compared to the force acting on the muscles, and also to the number of repetitions performed. Strength training exercises consisting of reverse curls, pronation exercises, wrist flexors, wrist extensions, tricep extensions, and bicep curls (Figs. 4A-4F) will increase the strength of the muscles surrounding the elbow, allowing them to sustain more tension before injury. Such exercises also decrease the strain sustained by the medial collateral ligament during the pitching phases. Strength and flexibility training of the shoulder, abdominal, and leg muscles should also be included. Consult with a doctor before starting these exercises.

Off-season and pre-season conditioning should include pitching technique drills focusing on balance during the leg kick, proper stride technique, and coordinated hip rotation/trunk flexion combined with shoulder, arm and hand movements. A pitch count should be planned, limiting the number of pitches thrown until a base is established, and the velocity of the pitches should be increased at an appropriate rate during practice and pre-season games. After pitching, ice should be applied to the shoulder and elbow immediately, or as soon as possible, to decrease inflammation. After strenuous outings or workouts, an experienced sports therapist should be consulted to help relax the musculature surrounding the shoulder and elbow to assist in the prevention of injury.

Treatment of Pitcher’s Elbow at Dr. Dubin’s office would consist of:

  • Deep tissue procedures to the muscles surrounding the shoulder, arm, and forearm to free up soft tissue motion
  • Chiropractic adjustments of the wrist and elbow joints to free up joint motion
  • Ultrasound and electric muscle stimulation combotherapy applied to the structures on the inside of the elbow to restore normal muscle tone, decrease pain, and absorb scar tissue
  • Implementation of a personalized home strength program (Figs. 4A-4F), noting the importance of increasing strength and flexibility of the trunk musculature and the shoulder musculature
  • Ice therapy applied to the elbow, 20 minutes on and one hour off after competition
  • Recommendation to meet with a pro to improve pitching or swing technique.

Note: Consult with a doctor or certified strength conditioning specialist before starting these exercises.

Patellofemoral Syndrome/Pain on the Front of the Knee

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knee1Patellofemoral Syndrome (PFS), pain in the front of the knee, is one of the most common complaints of athletes and active people. PFS is typically caused by a repetitive strain injury or a single traumatic event. Repetitive strain injuries occur when micro-tears in the muscles, tendons and ligaments surrounding the knee joint occur faster then tissue repair, while a single event is often a fall or other athletic impact. PFS is usually characterized by a dull aching pain on the front, bottom, or top of the knee, sometimes accompanied by swelling of the knee joint. Failure to treat this injury appropriately may lead to increased pain symptoms, further damage to the structures stabilizing the knee joint, and eventually an inability of the injured knee to support body weight. This syndrome commonly occurs in athletes or the “weekend warrior” participating in sports such as basketball, football, soccer, triathlons, or track and field events. These sports involve repetitive running, jumping and sometimes kicking, placing a lot of tension on the structures supporting the knee joint.

An understanding of the anatomy and the biomechanics of the knee joint during flexion (bending) and extension (straightening) of the leg will make it easier to comprehend how to effectively treat and prevent Patellofemoral Syndrome.

Anatomy of the Knee Joint

knee2The patella, or kneecap, is a conical shaped bone lying between the femur (thigh) bone and the tibia (lower leg) bone (Fig.1). The undersurface of the patella glides over the trochlea, a groove located at the bottom and front of the femur bone. The quadricep muscle group, which plays a vital role in the stability of the knee, is located on the front of the thigh and consists of four muscles, the vastus lateralis, vastus intermedius, vastus medialis and the overlying rectus femoris (Fig. 2). The quadricep muscles share a common tendon, the quadricep tendon, which anchors these muscles onto the top of the patella. The patella ligament acts as a downward continuation of the quadricep tendon, originating from the bottom of the patella and inserting onto the tibial tuberosity, an outgrowth of bone on the front of the tibia.

The two retinacula, sheath-like structures located on the front of the knee, are also important in knee stabilization. The lateral retinaculum attaches to the vastus lateralis and iliotibial band superiorly and descends to attach to the lateral aspect of the patella ligament. The medial retinaculum attaches to the lower part of the vastus medialis and descends to attach to the inside area of the patella ligament (Fig.2).

Biomechanics of the Knee Joint

The patella acts as a pulley system by supporting the mechanical work of the quadricep musculature during leg extension and also during deceleration of leg flexion. Proper function of this pulley system depends on the ability of the patella to track properly during leg extension and flexion. Muscle tightness in the outer knee area and muscle weakness in the inner knee area may compromise this tracking, and are often a root cause of knee injury. The structures that are often tight include those on the outside of the knee, such as the lateral retinaculum, vastus lateralis and iliotibial band (Fig. 3) while structures that are often weak include those on the inside of the knee, such as the vastus medialis and adductor magnus. In this situation, the patella may track too far laterally (towards the outside of the knee). Excess lateral tracking of the patella will decrease the efficiency of this pulley system during leg flexion and leg extension, predisposing these tissues to injury. A stretching program with the Flexband© and strengthening program incorporating squats and ball squeezes (Fig. 4A & 4B) will aid in tracking the patella properly and decreasing the risk of injury.

knee3There are three main types of muscle contractions: concentric, eccentric, and isometric. Each of these contractions may contribute to PFS in different ways. During a concentric contraction, a muscle shortens to perform a particular motion. The patella, quadricep muscle, quadricep tendon, and patella ligament create the “extensor mechanism” of the knee. When the quadricep muscles concentrically contract, they pull on the quadricep tendon, causing tension on the patella and patella ligament, leading to extension of the leg (Figure 4C). An athlete’s ability to kick a soccer ball or football is dependent on the concentric strength of the quadricep muscles and also on the flexibility of the hamstring musculature. The hamstring muscle group acts to decelerate extension of the leg. Inadequate flexibility of the hamstring musculature will place an increased strain on the quadricep muscles during leg extension, predisposing the athlete to the development of PFS.

During an eccentric contraction, a muscle will slowly elongate to decelerate a particular motion. While doing a squat (Fig. 4A) or during heel strike and mid-stance of the running gait cycle, the quadricep muscles, tendon, and patella ligament slowly elongate to decelerate leg flexion. Excessive eccentric loads (e.g. doing a squat with weights that are too heavy, or landing from a high jump) or repetitive eccentric motions (e.g. landing from frequent jumping, as in basketball) may lead to injury of the above structures and to the development of PFS.

During an isometric contraction, the muscle generates force but neither elongates or shortens, so such movement will not lead to injury. For example, the quadricep muscles isometrically contract when conducting a straight leg raising exercise (Fig. 4D). Isometric exercises are useful in the initial stages of rehabilitation by restoring strength of the “extensor mechanism” without compromising the structure or integrity of the joint.

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Checklist for the prevention of Patellofemoral Syndrome:

  • Conduct a lower body strength training program (see Fig. 4A-4E). In addition to these movements, the program should include strengthening of the calf musculature, tibialis anterior, and core abdominal musculature.
  • After exercise, stretch with the Flexband and ice both knees for 20 minutes.
  • Cross train, rather than repeating one activity over and over. Substitute biking, cycling, and swimming for running, for example.
  • Slowly increase the duration or intensity of the training program; use the 10% increase in mileage per week rule.
  • Change sneakers every 250-400 miles, run on softer surfaces, and avoid hill training before a base of training is established.

Treatment of Patellofemoral Syndrome at Dr. Dubin’s office would consist of:

  • Deep tissue procedures to the quadricep musculature and surrounding knee structures to free up soft tissue motion
  • Mobilization of the patella and adjustments of the ankle and foot to free up joint motion
  • Ultrasound and electric muscle stimulation combo-therapy to restore normal muscle tone, decrease pain, and absorb scar tissue
  • Implementation of a personalized home strengthening and flexibility program
  • Possible recommendation of a semi-rigid orthotic
  • Ice therapy (20 minutes on and 1 hour off)
  • Possible recommendation of prescribed or over-the-counter anti-inflammatory medications (taken with food)
  • Temporary use of an elastic sleeve with a lateral stabilizing pad for the knee.

For more information on Patellofemoral Syndrome, or to schedule an appointment with Dr. Dubin, call 617-471-2444.

Note: Consult with a doctor before conducting the above exercise routines.

Hamstring Injury

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One of the most common sport-related injuries is a hamstring pull or strain. The hamstring, a group of four muscles in the back of the thigh, can be felt stretched as you bend forward to touch your toes. Three of the four hamstring muscles, the semitendinosis, semimembranosis, and the long head of the bicep femoris, cross both the hip and knee joint and are the true hamstring muscles. At the top, these muscles have a common attachment to the ischial tuberosity (a bone at the bottom of the pelvis), and at the bottom, the tendons of these muscles then attach to the tibia and fibula (bones below the knee) (Figure 1). The other hamstring muscle, the short head of the bicep femoris, only crosses the knee joint.

There are two main types of hamstring injuries, and each affects a different part of the hamstring musculature. The first hamstring injury is most common in younger athletes and is caused by a sudden motion, such as an explosive sprint, a jump, or a kick. In this type of injury, the strain occurs at the muscular portion of the hamstring, resulting in pain in the middle of the back of the thigh. Swelling and later bruising may be present in the back of the thigh, and the athlete may limp or utilize crutches to take weight off of the injured leg.

Training errors in activities such as cycling and running usually causes the second type of hamstring injury. In this case, the hamstring strain occurs at the tendinous insertion on the ischial tuberosity of the pelvis. Tri-athletes, duathletes, and marathon runners are common sufferers of this injury, and will complain of pain in the lower buttock region that increases in severity as the foot of the injured leg strikes the ground.

By understanding the biomechanics of running and some concepts of cycling, it becomes easier to understand why hamstring injuries occur and how to prevent them. With both types of hamstring strains, chiropractic treatment and re-injury prevention exercises are effective management techniques.

Biomechanics of Running

There are two phases of running: the stance phase and the swing phase. The stance phase consists of foot-strike, mid-stance, and toe-off (Figure 2); and the swing phase consists of follow through, hip flexion and leg descent (Figure 3). During an eccentric contraction, muscle fibers will slowly elongate to slow down a particular motion, while a concentric contraction involves shortening of the muscle fibers to lift an object or move a limb in a particular direction. During leg descent and foot-strike, the pelvis flexes forward and the leg extends, the hamstring muscles are eccentrically contracting to slow down both of these particular movements (Figure 4). When the eccentric load exceeds the strength of the muscle fibers, tearing of the hamstring fibers occurs, resulting in a strain injury.

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hammy4Flexibility and strength training of the hamstring musculature and the nearby muscles surrounding the pelvis and thigh will reduce the risk of injury. Strengthening the abdominal and gluteus maximus musculature is important in the prevention of a hamstring strain because these muscles aid the hamstrings in decelerating flexion of the pelvis during heel strike. Flexibility of the hip flexors and low back musculature is also important in the prevention of a hamstring strain injury. Tight hip flexors and low back musculature causes excessive flexion of the pelvis during foot-strike placing an increased strain on the hamstrings. Tightness in these muscles also inhibits strengthening of the gluteus maximus and abdominal musculature.

Strength training and Flexibility Training

See the following diagrams for examples of exercises to help strengthen and increase flexibility of the hamstring and surrounding muscles.

  1. Core training- chops, abdominal crunches, Russian twist (Figures 5, 6, 7)
  2. Straight leg deadlifts and squats- eccentrically strengthen the hamstring musculature
    (Figures 8,9)
  3. Flexibility training with the flexband

Talk to a doctor or certified strength conditioning specialist before attempting this or any new exercise program.

hammyexercises

Training Protocols for Running

The initial training phase should consist of establishing a good aerobic base, a comfortable slow pace where oxygen is plentiful, allowing the body to convert stored fats and glucose for energy. A heart rate monitor can be a useful tool in training at the appropriate pace. Aerobic conditioning should be conducted at approximately 70-80% of maximum heart rate (MHR), expressed in number of beats per minute. To determine your MHR, subtract your age from 220, or by looking at your heart rate monitor after a fast all-out run up a hill. After establishing a good aerobic base, pace can be increased to 85-90% maximum heart rate, a point called anaerobic threshold training. The anaerobic threshold is the point immediately before oxygen debt occurs, and will eventually become the race pace. With proper training, the anaerobic threshold will increase — allowing the athlete to run at a faster pace before reaching oxygen debt.

Competitive and elite athletes will conduct short distance interval anaerobic training runs at 95% maximum heart rate to increase their body’s ability to deal with muscle fatigue. At this fast pace, oxygen debt ensues and energy is now produced by the breakdown of glucose to lactate, with the byproduct of hydrogen ions. In order for muscle contraction to occur, calcium needs to bind to a particular protein in the muscle fibers. Hydrogen ions compete with calcium for these binding spots, eventually inhibiting muscle contraction. The body can only function for approximately two to three minutes at this faster pace, however maintaining this pace may mean the difference between an elite runner finishing first or third at the end of a race.

Progressing training runs appropriately will reduce the risk of developing a hamstring injury by preparing these muscles for an elongated stride, as well as allowing the body to function at faster speeds before muscle fatigue and eventual muscle failure may occur.

Biomechanics of Biking

Bike racers assume a racing position that is the most aerodynamic (least wind resistant) and that is conducive to the greatest strength through pedal stroke. A racing position that satisfies these two conditions allows racers to maximize their speed. Unfortunately, this racing position places an increased eccentric strain on the hamstring and erector spinae musculature, increasing the risk of a hamstring injury. Proper flexibility and strength training, as well as bicycle conditioning and correct bike fitting, are important in attaining this strategic position while decreasing risk of injury. For more information on proper bike fitting, provided by FitWerx, click here.

Case History

Leiha came to Dr. Dubin’s office with complaints of pain in the lower left buttock region. She stated that after running the Boston Marathon she had no pain. However, soon after the marathon she started to run with a friend to train for a 5k race; that’s when she began to experience pain. It is important to note that she had run the Boston Marathon at a slow pace and with a short stride, but trained for the 5k race at a faster pace and a longer stride. Leiha had not included squats or straight leg deadlifts in her strength training routine. The pain increased to where she could no longer train.

Examination revealed extreme tenderness in the left buttock region, where the hamstrings attach to the pelvis. Tightness was evident in the left hamstrings and iliotibial band. Dr. Dubin explained to Leiha that due to her sudden increase in pace of training, her hamstring musculature was not prepared for the eccentric load placed on them. This led to her injury.

With proper treatment (see below), Leiha’s condition was resolved after 5 visits. To prevent re-injury, she was instructed on a proper strength and flexibility routine and was instructed on a strategic plan to slowly progress the pace of her training runs.

Treatment at this office

  • Deep tissue procedures (Active Release Technique) to free up soft tissue motion of the hamstrings and surrounding musculature
  • Adjustments to free up joint motion of the lumbar spine
  • Ultrasound and electric muscle stimulation combo-therapy applied to the proximal hamstring tendons to break up scar tissue, restore normal muscle tone, and decrease pain.
  • Implementation of a proper strength and flexibility program
  • Advice on how to progress training runs more appropriately

For more information, or to set up an appointment with Dr. Dubin, please call 617-471-2444.

Low Back Pain

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lowback2Most people suffer from low back pain at some time in their lives. Common cases of low back pain include people who work in a prolonged flexed posture while sitting at a computer, or the “weekend warriors” who attempt to participate in activities such as golf, biking, and basketball without a proper training program.

Understanding the biomechanics of the lumbar spine and pelvis while bending forward and returning to the neutral position will illustrate why the loss of strength and flexibility in particular muscles predispose individuals to the development of low back pain.

Movement 1: Anterior Flexion of the Lower Back

The low back consists of five functional units. A functional unit (Fig. 1) consists of two vertebra, an adjoining disc, facet joints, and the surrounding musculature, ligaments and fascia.

Ligaments attach bone to bone, and fascia is a sheath of fibrous tissue that encloses muscles and muscle groups. There is approximately 9 degrees of flexion at each functional unit, allowing up to 45 degrees of forward flexion (Fig. 2A & 2B).

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At 45 degrees, the fascia, muscles, and ligaments of the low back are taut and no more flexion is allowed without forward rotation of the pelvis. An endpoint of motion in forward flexion of the low back is the point at which a person bends forward and can go no further pain. If the ligaments, fascia, muscles of the low back are not flexible, this endpoint of motion will be decreased and will result in a strain/ injury of the low back when attempting to bend forward to 45 degrees. In order to bend forward past 45 degrees, the pelvis has to rotate forward (Fig. 3).

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The anterior motion of the pelvis is dependent on the flexibility of the hamstrings and the gluteus maximus musculature. If the hamstrings and gluteus maximus musculature are not flexible, the pelvis will be limited in anterior flexion (Fig. 4). When this limited endpoint of forward flexion is exceeded, one will usually suffer from an acute onset of low back pain.

Movement 2: Return to Neutral Position from Flexion of the Low Back

When returning from a flexed low back posture, the gluteus maximus muscle (Fig. 5) will contract, derotating the pelvis from its anteriorly rotated. At the same time, the abdominal musculature contracts, tightening the fascia surrounding the low musculature, adding more stability to the lumbar spine.

Movement 1 and Movement 2 illustrate why flexibility of the lower back and hamstring musculature and proper strength training of the gluteus maximus and abdominal musculature are important in the prevention of low back pain. Having flexibility of the hip and external rotators of the hip, as well as strength in the quadracep can also aid in the prevention of low back pain.

Case Study

Bob came to Dr. Dubin’s office for care with complaints of low back pain. He stated that he worked as a stockbroker and sat looking at a computer screen all day. His low back pain came on gradually and became more severe with time. He did not belong to a gym, nor did he do a strength and flexibility training program at home.

Dr. Dubin conducted a thorough exam on Bob’s lower back to diagnose his condition. The treatment techniques utilized by Dr. Dubin at his office included: specific deep tissue procedures (active release technique) applied to the muscles in the low back to free up soft tissue motion; adjustments to free up joint motion; and combotherapy to help to relax the muscles, restore normal muscle tone, and break up scar tissue. Dr. Dubin tailored a home flexibility program for Bob involving the FlexBand® and a proper strength training program. Bob was also instructed on how to ergonomically correct his workstation to help alleviate the repetitive strain on his low back. Bob now does stretching exercises with the FlexBand® for 15 minutes a day (see below) and a regular (1-2 times a week) strengthening program for his low back. Bob’s low back pain has resolved, and his ongoing workout routine will continue to help in the prevention of future low back episodes.

How to Relieve Low Back Pain

Repeated, prolonged stress to the back and shoulders can lead to a multitude of injuries down the road. Most jobs require a prolonged (sitting or standing) slumped forward position, which results in a postural overstretch and eventual low back pain. Decrease and prevent lower back pain by doing a 15 to 20 minute daily stretching routine using a FlexBand®. These exercises will help prevent your low back pain.

Stretching Techniques

Carpal Tunnel

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carpal1Carpal tunnel syndrome is a common occupational injury resulting from tasks that involve repetitive extension and flexion of the fingers, such as typing on a computer keyboard (Fig. 1).

Symptoms of carpal tunnel syndrome are weakness in grip strength; pain and stiffness in the forearm, wrist, hand; and numbness/tingling traveling from the front of the forearm into the thumb, index finger, middle finger, and one-half of the ring finger. The carpal tunnel is located at the wrist. Passing through this tunnel are nine tendons and one nerve: four tendons of the flexor digitorum superficialis, four tendons of the flexor digitorum profundus, the tendon of the flexor pollicis longus, and the median nerve. The floor and walls of the carpal tunnel are made up of eight wrist bones, and the roof of this tunnel is comprised of the transverse carpal ligament. The transverse carpal ligament runs across the wrist bones, attaching to the trapezium and scaphoid, two carpal bones located below the thumb; and to the hamate and pisiform, two bones located below the pinky finger (Fig. 2).carpal2

Carpal tunnel syndrome occurs when the space in the tunnel decreases or the contents in the tunnel enlarge. Daily repetitive typing tasks or prolonged gripping of a vibratory tool such as a jackhammer can cause swelling of the flexor tendons or the synovium lining surrounding these tendons. Swelling of the above structures in the carpal tunnel may cause pressure on the median nerve, leading to the development of carpal tunnel syndrome. Entrapment of the median nerve can also occur at the elbow region between the two heads of the pronator teres and underneath the flexor digitorum superficialis musculature (Fig. 3A). This condition is also common in pregnant woman because of hormonal changes (accounting for fluid retention in the tunnel) and swelling of the synovium of the flexor tendons, both of which will cause pressure on the median nerve.

Case Study

Anita worked as an administrative assistant in a busy healthcare environment. From the moment Anita arrived to the moment she departed work each day, she was at her computer terminal, typing forms, letters, updates, and related material.

She had been working with the company for two years when she began to experience severe pain each day in her wrists, shoulders, and neck. Her wrists would “seize up” just prior to lunch, prohibiting her from continuing her work. At first, she could continue with the help of an Ibuprofen pain reliever. However, after several days of discomfort, even the pain reliever could not provide enough relief to enable her to make it until 5:00 pm. Anita visited her physician, who, to her dismay, informed her that she had carpal tunnel syndrome. Anita was very concerned about the diagnosis and feared she would no longer be able to continue at full capacity in her chosen career. Fortunately, through therapy, medication, and ergonomic adjustments of her work station, she was able to return to work.

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Anita’s case is not uncommon. The advancement of technology today allows for a large number of people to be at risk for computer/keyboard-related injuries. Not only is the threat of computer-related injury in the workplace, but also in the home office. The ergonomics of the home office should be adjusted accordingly in order to avoid injury to all family members working with the computer.

Reducing the risk of injury through ergonomics

The best way to avoid injury is to take preventive measures. The following are some preventive tips to assist in the avoidance of computer/keyboard-related injuries: carpal4

  • Have a wide desk that allows the keyboard to be in line with the computer A narrow desk results in the computer screen being put to the right or left of the keyboard, which can result in neck pain opposite the side where the employee is turning his or her head.
  • Be sure the computer screen is adjusted to eye level. The eye should contact the middle of the screen. If the computer is too high or low, it can lead to a repetitive strain injury of the neck.
  • The desk should be high enough to allow room for knees underneath; otherwise, posture will be slumped.
  • Use a chair that is adjustable, es- pecially in the home office, where it can be specifically adjusted to each user. A 95-degree back tilt will help to prevent a forward slumped posture.
  • Use an inclined board for writing. This will ensure comfort and minimal strain.
  • Arms should be relaxed and at a 90-degree angle. A wrist pad may also be used to add comfort to the wrists. Use a chair with an armrest, which will help ensure that wrists and elbows do not drop below the 90-degree angle.
  • Avoid using traditional telephones while typing, as there is a tendency to bend the head towards the shoulder to hold the telephone in place, causing a repetitive strain injury to the neck muscles. Telephone headsets can help to alleviate this common injury.
  • Feet should touch the ground while typing, and legs should be at a 90-degree angle with thighs resting upon the chair.
  • The bottom of the chair should not press on the back of knees, as this can cause pain in this area.

Fortunately, Anita did not have to make a career change as a result of her injuries. Now, she works in an ergonomically correct environment, and has greatly reduced her risk of recurring pain and injury. Take the preventive steps in the workplace and at home. You will feel better and it will decrease the likelihood for the development of long-term problems.

Conservative therapy at Dr. Dubin’s office to treat carpal tunnel syndrome would consist of:

  • A thorough occupational/recreational history to determine the cause of the injury
  • Specific deep tissue work to relax the flexor and extensor musculature of the forearm and thenar musculature of the hand (Fig. 3A & 3B)
  • Adjustments to free up joint motion of the carpal bones and elbow region
  • Ultrasound/electric muscle stimulation to relax the musculature and restore normal muscle tone
  • A specific exercise/stretching routine targeting the forearm musculature (Fig. 4A & 4B)
  • Correction of the workstation and/or activity to limit the repetitive strain injury
  • Use of a hand splint, which may be helpful in limiting wrist flexion while typing on a keyboard or when sleeping
  • Instructions to ice 20 minutes on, 1 hour off, after the stressful activity in order to decrease inflammation of the tendon sheath and muscles.

Plantar Fasciitis / Heel & Arch Pain

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Plantar fasciitis is a common injury in people whose activities involve a lot of running, jumping, standing, or walking. The main symptom of plantar fasciitis is pain on the bottom inside arch of the foot. When we examine the biomechanics of a foot step, it becomes clear why this repetitive strain injury occurs, how to treat it, and how to prevent it.

plantar2Each step can be broken down into two phases: the stance phase and the swing phase. The stance phase occurs when the foot is making contact with the ground surface. This phase can be divided into three periods: the contact period, mid stance period, and propulsive period (Fig. 1). The second phase is the swing phase, which occurs after toe off and before heel strike, when the leg is not in contact with the ground surface.

During heel strike, muscles on the front of the leg decelerate the foot and soften the impact with the ground surface. The outside of the foot initially makes contact with the ground, and as the foot adapts to the terrain, the inside of the foot then makes contact, marking the beginning of the mid stance phase. During the early mid stance phase, the muscles on the bottom of the foot are active in stabilizing the lower limb as it adapts to the ground surface. In the later stage of mid stance and the beginning of the propulsive period, when the heel lifts off the ground, the big toe is dorsiflexed (bent upwards) by the ground surface. This dorsiflexion of the big toe stretches the musculature and fascia on the bottom of the foot (Fig. 2). Fascia is a sheath of fibrous tissue that encloses muscles and muscle groups. Strain to the fascia and musculature on the bottom of the foot can be caused by excessive standing, walking, or running, and is complicated by flat feet, high arches, and improper footwear.

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Case Study

Walter came to Dr. Dubin’s office with complaints of chronic pain on the bottom/instep of his right foot, which was most severe when he took his first few steps in the morning. He was frustrated because the treatments he had received for his foot over the last three years had proven ineffective. The numerous orthotic devices that were custom molded for his feet did not improve his condition. X-rays taken of his feet revealed bone spurs at the bottom of the heel of both feet, and a podiatrist convinced Walter that this was the cause of his heel pain. Dr. Dubin explained to Walter that studies have shown that these bone spurs may be coincidental findings, and pointed out that he had no pain in his left foot, where bone spurs were also present.

Walter explained that his work required a lot of standing and walking. His shoes were worn down and not well padded, and observation of Walter’s gait with his shoes and socks off revealed that he had flat feet and favored his right side. After conducting an examination of Walter’s right foot, Dr. Dubin diagnosed him with plantar fasciitis.

plantar3Treatment of Walter’s plantar fasciitis consisted of specialized muscle work to free up soft tissue motion of the foot and surrounding musculature. Adjustments were utilized to free up joint motion in the foot and ankle, and ultrasound and electric stimulation were utilized to relax the musculature and restore normal muscle tone. Walter was advised to follow this plan: a stretching and strengthening exercise routine for the lower extremity using the Flex-Band®; rolling a golf ball under the medial arch of his foot (for ischemic compression therapy of the plantar musculature and fascia [Fig. 3]); and application of ice 20 minutes on, 1 hour off, to decrease inflammation. Dr. Dubin also recommended that he invest in a new pair of running sneakers for good shock absorption and comfort, since sneakers lose about 40% of their shock absorption capabilities after approximately 250 miles; they should be replaced every four to six months.

Walter’s plantar fasciitis improved after 4 to 5 visits, and was resolved in 12 visits. Walter continues his exercise routine, and is relieved that he is finally pain-free.

Iliotibial Band Friction Syndrome

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it1Iliotibial band friction syndrome is a common knee injury afflicting athletes who participate in sports that involve repetitive flexion (knee bends) and extension (knee straightens out), such as cycling and running. The first symptom of iliotibial band friction syndrome is a mild ache on the outside of the knee. Typically this ache does not hinder training, and the discomfort disappears before the next training session. If training continues without proper treatment, the mild ache the outside of the knee may progress to an intense burning or stabbing sensation, which can then radiate to the outside of the thigh and calf. At this later stage of the injury, the speed and distance of the training runs are decreased because of extreme discomfort with flexion of the knee, and the intensity of the pain may eventually force the athlete to stop training.

The iliotibial band (also called the “I.T. band”) is located on the outside of the thigh. It is a lateral thickening of the fascia that surrounds the thigh. (Fascia is a sheath-like tissue that surrounds muscles and muscle groups). The I.T. band travels from the outside of the hip, thigh, and knee, and inserts below the knee on a bump on the leg bone called Gerdy’s tubercle. The gluteus maximus muscle (buttocks muscle) and the tensor fascia lata muscle (just outside the pelvis) attach to the back and front of the iliotibial band respectively (Fig. 1). The gluteus maximus and tensor fascia lata muscles contract and increase tension on the iliotibial band, aiding in stabilization of the hip and knee joint.

Iliotibial band friction syndrome can be explained by describing what goes on with the surrounding muscles when the knee flexes and extends. When the knee flexes approximately 30 degrees, tension acts on the I.T. band, causing it to be pulled backwards over the lateral femoral condyle (an outgrowth of the thigh bone on the outside of the knee) (Fig. 2). Conversely, when the knee extends, tension on the I.T. band causes the band to move forward over the lateral femoral condyle (Fig. 3). A thin bursa, or a fluid filled sac, separates the iliotibial band from the lateral femoral condyle, acting to decrease friction between these neighboring structures. Repetitive flexion and extension of the knee will cause inflammation of the bursa and iliotibial band or irritation of the periosteum of the lateral femoral condyle, resulting in iliotibial band friction syndrome.

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Checklist for the Prevention of Iliotibial Band Friction Syndrome:

  • Avoid training on uneven surfaces, as the down leg would be predisposed to the development of iliotibial band friction syndrome.
  • Avoid adding many down hills to training runs. Downhill running will fatigue the quadricep musculature, muscles on the front of the thigh, which are the main stabilizers of the knee. The repetitive flexion and extension of the knee, combined with overstrain of the iliotibial band due to fatigued quadricep musculature, will predispose a runner to the development of iliotibial band friction syndrome.
  • Change sneakers every 250-400 miles, approximately every 3-4 months, when they have lost 40% of their shock absorbing abilities. Marathon runners should alternate two pair of sneakers during their training program.
  • Slowly increase training mileage.
  • Train at an appropriate intensity. Long training runs should be conducted at an aerobic capacity where you can talk and run at the same time. Training at higher intensities will lead to lactic acid production, which will fatigue the muscles and increase the chance of injury. A heart rate monitor may be a useful training device.
  • A semi-rigid orthotic may be useful for athletes who have excessively flat feet or high arches, both of which can increase the risk of developing iliotibial band friction syndrome.
  • After a run, stretch and then ice the outside of the knee for 20 minutes.
  • Include a proper strength training program to improve stabilization of the knee joint.
  • For runners, cross training with swimming, biking and the elliptical machine will maintain aerobic capacity and help in the prevention of iliotibial band friction syndrome.

Treatment of iliotibial band friction syndrome at Dr. Dubin’s office would consist of:

  • Specific deep tissue procedures to the muscles of the thigh and leg to free up soft tissue motion
  • Adjustments of the low back, hip, knee and foot to free up joint motion
  • Ultrasound and electric muscle stimulation combotherapy to restore normal muscle tone, decrease pain, and absorb scar tissue
  • Implementation of a personalized home strengthening and flexibility program
  • Recommendation of a semi-rigid orthotic for individuals with flat feet or high arches.