​The shoulder complex consists of three bones: the collar bone (clavicle), the shoulder blade (scapula) and the upper arm bone (humerus). Acute anterior shoulder dislocation is an injury where the top end of the humerus is pushed out of the shoulder joint socket in a forward direction.  The extent of dislocation varies from partial dislocation (subluxation) to full dislocation where the joint surfaces completely lose contact.

First-time dislocation generally results from trauma (injury), typically during contact sports in adolescents and younger adults. In older adults it may result from a fall from standing height. Traumatic anterior dislocation is the commonest type and accounts for >90% of all shoulder dislocations. Following a shoulder dislocation, the shoulder is generally less stable and, at times, prone to re-dislocation, especially in active young adults.
Initial treatment involves putting the joint back; this is called ‘reduction’. ‘Closed reduction’ refers to cases where this is done without surgery.  Afterwards, treatment is often conservative (non-surgical), and generally involves placing the injured arm in a sling or other immobilising device followed by exercises, which can be supported by a physiotherapist. The period of immobilisation varies. After reduction, and often throughout your rehabilitation, you will be re-evaluated for nerve or blood vessel injuries which can occur in traumatic cases, to ensure anything suspicious is caught early and managed accordingly.

​References
Handoll, H.H., Hanchard, N.C., Goodchild, L.M. and Feary, J., 2006. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database of Systematic Reviews.
Khiami, F., Gérometta, A. and Loriaut, P., 2015. Management of recent first-time anterior shoulder dislocations. Orthopaedics & Traumatology: Surgery & Research, 101(1), pp.S51-S57.

Longo, U.G., Loppini, M., Rizzello, G., Ciuffreda, M., Maffulli, N. and Denaro, V., 2014. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 30(9), pp.1184-1211.

It is common for avid exercise enthusiasts to incorporate hip strengthening exercises into their routines that focus on the hip abductors. There is seemingly a surge in popularity of exercises targeting your glutes, for instance; leg lifts, single leg work, lateral band walks. However, arguably, many people neglect the much needed companion to the abductors, the adductors.

​Hip Adductor Complex

The adductors are a group of muscles on the inside of your thigh. The adductor magnus, adductor longus, adductor brevis, pectineus and gracilis muscles all have involvement in hip adduction (bringing your thighs together). The adductor magnus muscle has a large hip extensor muscle moment arm, which in simple terms, makes it an unappreciated hip extensor, while the other adductors are also hip flexors. Therefore, the adductors play a part in many movements of the hip

​Some believe that the adductor complex does not need specific, targeted exercise, as compound exercises, such as squats, sumo squats, and lunges demonstrate activation of these muscles. However, some evidence would suggest this claim was false. Of course compound exercises are integral to any strengthening exercise programme, but it is advantageous to ensure you make time to consider specific adductor muscle components.
The adductor magnus is a very large and heavy muscle. It is much larger and heavier than the other adductors. By some measures it is the second largest muscle in the body after the gluteus maximus. Ignoring the adductor magnus is therefore likely to lead to a failure to maximize overall muscular hypertrophy (growth and increased size of muscle) in the lower body.
Injury Risk
Just like with the front and back of the leg, where there is a strength relationship between the quadriceps and hamstrings, there is also a relationship between the abductor and the adductor strength. For most, these relationships do not need to be assessed with a fine toothcomb, but these ratios are commonly used within high performance sport. Weakness in the hip adductors compared to the abductors has been shown to be a risk factor for developing groin pain in several sports, such as football and hockey.
 
‘don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme’
 
During rehabilitation, it is important to remember that the adductors may be preferentially activated at different degrees of hip flexion. The adductor magnus is most active between 0 – 45 degrees, the adductor longus and gracilis are most active at 45 degrees, and the pectineus is most active at 90 degrees. Therefore, don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme. Below is an example of an evidence-based exercise for strengthening your adductors.
‘Hands on’ treatment may be used in conjunction with exercise rehabilitation too. A large consensus paper, the DOHA agreement, stated that ‘Multimodal treatment including manual adductor manipulation can result in a faster return to play, but not a higher treatment success, than a partially supervised active physical training programme’.
Copenhagen Adduction Exercise
The Copenhagen adduction exercise (CAE) is a bodyweight, partner-assisted movement popularized by Danish researchers and sports therapists, including one of the leaders in groin injuries, Kristian Thorborg. 

The well-known, FIFA promoted, FIFA 11+ injury prevention and warm-up programme was disseminated worldwide in 2009. More recent research has suggested adding the Copenhagen Adduction exercise to the FIFA 11+ to potentially prevent groin problems.
Thorborg and colleagues also investigated other exercises using elastic bands in adductor muscle strengthening research. Here, a hip adduction movement was performed over full range of motion with 3 seconds in, 2 seconds hold, and 3 seconds out. The participants performed 3 sets of exercise with both legs during each session. 

Good luck strengthening your adductors and keep active!

​

References
Harøy, J., Thorborg, K., Serner, A., Bjørkheim, A., Rolstad, L.E., Hölmich, P., Bahr, R. and Andersen, T.E., 2017. Including the copenhagen adduction exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players: A randomized controlled trial. The American journal of sports medicine, 45(13), pp.3052-3059.
 
Ishøi L, Sørensen CN, Kaae NM, et al. Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomized controlled trial. Scand J Med Sci Sports. 2016 Nov;26(11):1334-1342.
Jackie L Whittaker, et al. (2015) Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med;49,pp.803-809
Jensen, J., Hölmich, P., Bandholm, T., Zebis, M.K., Andersen, L.L. and Thorborg, K., 2012. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. Br J Sports Med, pp.bjsports-2012.
 
Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J. and Paajanen, H., 2015. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med, 49(12), pp.768-774.

​Over the past few years, the popularity of recreational road cycling has significantly increased. I should know as I finally got on a road bike this year and absolutely love it! Cycling is low impact and non-weight bearing which results in fewer injuries when compared to other sports, and this may play a role in the attractiveness of cycling at any age. The sport includes long-distance endurance cycling and high intensity efforts when sprinting or hill climbing. As a result, cyclists need to train both aerobically (“with oxygen”) and anaerobically (“without oxygen”).
 
The main energy currency used all over the body is Adenosine triphosphate (ATP). ATP is broken down to adenosine diphosphate (ADP) which releases energy. ATP is produced along an energy continuum involving three key energy systems: the phosphocreatine (ATP-PC) system, which produces ATP during extremely high-intensity activity lasting up to 30-seconds; anaerobic glycolysis which produces ATP during high-intensity activities from 6-120-seconds; and aerobic metabolism which produces ATP during low-intensity activities, from 120 seconds onwards. Note that there is an overlap in the activation of the energy systems meaning that ATP production occurs with at least two energy systems at one time. Given that road cyclists require both anaerobic and aerobic power, all three of these systems need to be trained.
 
Interestingly, analysis of cycling grand tours such as The Tour de France, reveal that cyclists can spend approximately 20-minutes per day over the individual anaerobic threshold, and when on hilly stages they are riding at high intensities of between 70-90% of their VO2max (the measurement of the maximum amount of oxygen a person can utilise during intense exercise), hence this group of athletes need to be able to tolerate high workloads over long periods of time. They also need to be able to produce brief episodes of high-power outputs, for example when steep climbing or sprinting at the race finish.
 
The pedal cycle consists of the power phase and the recovery phase. During the pushing action of the power phase, the hip and knee joints extend at the same time powered by the hip extensors (gluteal and hamstring muscles) to initiate the movement and the knee extensors (quadriceps muscles) to move the crank forward, and then together they work to gain momentum on the crank to apply a substantial driving force onto the pedals. The plantarflexors of the foot (the calf muscles) contract for a short period following this. During the recovery (upstroke) phase the tibialis anterior engages to dorsiflex the ankle, and the knee and hip flexors contract to draw the pedal back to the top centre of the crank cycle. Overall the quadriceps contraction is almost twice that of the hamstrings. Cycling also requires core, upper back, and upper limb strength to maintain good posture on the bike for prolonged periods.

​Aerobic training involves longer duration rides at 60-80% maximum effort. Aside from cardiovascular benefits, this type of training develops type I slow-twitch muscle fibre types, which are very resistant to fatigue.
 
Strength training is advocated because of potential improvements in speed, anaerobic capacity and movement economy, and in postponing the effects of fatigue. Strength training is an anaerobic training modality which can lead to improvements in both the ATP-PC and anaerobic systems.  A further benefit of strength training is that it increases the size and strength of muscles fibres, particularly type II fast-twitch fibres.  Type II muscle fibres use anaerobic metabolism and provide short bursts of power. These adaptations can result in higher peak power output during cycling and thus an improved power to weight ratio, which is advantageous to cycling performance. High-intensity training for 30-40 seconds followed by a recovery period can also help to influence the ATP-PC system.
 
The pedalling motion and power during cycling is created by the cyclists’ legs, however a strong core is important, particularly when riders are in the saddle for many hours. Many postural muscles contain type I muscle fibres as they need to have endurance capabilities, and core stability training can help to strengthen this group of muscles. Core stability has been described as three co-dependent subsystems: passive (skeleton), active (muscles), and neural control (nerves). Constant communication between all subsystems is required for the maintenance of stability, and exercise programs should aim to incorporate these different aspects.
 
Sports medicine literature describes core stability as the neuromuscular control required to allow the “production, transfer, and control of force and motion to distal segments of the kinetic chain”. In a cyclist, a stable core could help to prevent energy loss by reducing trunk rotation and shoulder movements. Improved core stability also increases pelvic stability and balance in the saddle, which in turn helps to ensure sound lower limb alignment and greater force transmission from the torso to the legs. Core strength and stability also allows for highly coordinated muscle activation patterns to change continually, depending on the demands of the task at hand. Core stability exercises should be aimed at strengthening the scapula-thoracic region and the abdominal, lumbar spine and hip muscles.
 
Our clinic can help you with core stability training, strength and conditioning training, bike fits to ensure optimum positioning on the bike, as well as assistance with any cycling musculoskeletal injuries or problems. Stay safe and happy cycling!

 
What is fascia?
 
Fascia is tough connective tissue which spreads throughout the body in a three-dimensional web from head to toe. The fascia is ubiquitous, surrounding every muscle, bone, nerve, blood vessel and organ all the way down to the cellular level, hence the fascial system is not segmented or divided structurally. However, the tissue quality within this single system varies in terms of density and function according to local tensional demands.
 
Fascia is composed of an elasto-collagenous complex with elastin fibers and collagen fibers (both of these are types of proteins), embedded in a gelatinous ground-substance which allows fibers and cells to move without restriction. Ground substance is a gel like consistency of raw egg white. It reduces friction between muscle fibers creating ease of motion. These single collagen molecules line up side by side overlapping in a staggered pattern akin to a brick wall, and they attach together to form a tough stable fabric. Scar tissue is new collagen that is secreted by ground substance, but the viscosity or density of the ground substance can vary from very thick to watery. The thicker the ground substance, the thicker and less mobile the tissue is.

 
The fascia can be simply described as consisting of three layers.

• Superficial fascia 

• Deep fascia 

• Subserous fascia 


 
The superficial fascia lays directly under the skin. With long term muscle tightness, the superficial layer loses its mobility and becomes taut. Muscles are embedded in deep fascia; when in the healthy state, this fascia is soft and pliable allowing the muscle fibers to contract and lengthen efficiently. Subserous fascia lines the body cavities and surrounds the organs. It also surrounds blood vessels and nerves, and forms the dural tube which surrounds and supports the central nervous system (brain and spinal cord).
 
What are myofascial restrictions?
 
The moving body depends on connective tissue for support and biomechanically efficient movement. Connective tissues make a major contribution to the dynamic properties of the body. Movement depends on connective tissue being functional and properly distributed.
Research has suggested that inflammation, injury, postural stress, and overuse syndromes can cause the fascial tissue to become tighter or denser. In an attempt to support the body, the system contracts and bonds to neighbouring structures forming adhesions which can impair their ability to slide freely over one another. The unwanted bonding can create excessive deposits of tissue resulting in thick bandaging around joints and fibrous masses in the muscle bellies.
 
Myofascial restrictions can create abnormal strain patterns and hold the skeleton in an inefficient alignment, potentially leading to poor muscular biomechanics, altered structural/bony alignment, and pain. Neural and vascular structures can also become entrapped in these restrictions, causing neurologic symptoms or ischaemic conditions.
 
What is myofascial release?
 
The goal of myofascial release is to elongate and soften the connective tissue relieving soft tissue from an abnormal hold of a tight fascia.
 
Myofascial release is a hands-on soft tissue technique that facilitates a stretch into the restricted fascia. A sustained pressure is applied into the restricted tissue barrier; after 90-120 seconds the tissue will undergo histological (microscopic) length changes allowing the first release to be felt. The therapist follows the release into a new tissue barrier and holds. After a few treatments, the tissues can become softer and more pliable, which can help to reduce pain and tissue tenderness, and restore alignment and joint mobility.
 
Self-myofascial release is when an individual uses an object to provide myofascial release under their own power, usually in the form of foam roller, ball or massage stick. An individual rests their body weight over the piece of equipment and uses gravity to induce pressure along the length of the specific muscle or muscle groups, allowing for the fascia to be massaged. There is an array of kit out there, which can be very helpful if used correctly and safely. If it is appropriate, your therapist will recommend products that could help you.
 
Myofascial release is often used in conjunction with other manual therapies and acupuncture, but also with various strengthening and stretching exercises. Interestingly, fascia is also influenced by temperature and emotion so the use of heat and relaxation-techniques may also be recommended by your therapist.
 
As with many musculoskeletal health issues, it is important to identify, treat and then manage the underlying causes of your problem. For example, if you have long-standing neck pain caused by poor posture sitting as your desk, hands-on treatment can help to relive your pain and restore normal movement, however it is also important to address your desk ergonomics; increase your postural awareness; partake in exercises that stretch the compressed tissues and strengthen the muscles to support better posture; and implement strategies that you can do yourself to manage any symptoms you may experience.
 
Having an awareness about fascial tissue can also help in your understanding of how a problem or injury in one area of the body can have a ‘knock-on’ effect onto another area. So many patients comment that they have problems ‘down one side of their body’, or that for example, since they twisted their ankle they are having issues with their lower back. Fascia can be one of the reasons for this, though a thorough assessment will help to identify all contributory factors. This also highlights the importance of rehabilitating properly from an injury or painful condition in order to minimise future problems.
 
Should you wish to discuss this further, please do not hesitate to contact the clinic (01225 683007) or email Renu who has a particular interest in this area (Renu.khosla@physioimupulse.co.uk)
 

References: 
 
Barnes, M. F. 1997. The basic science of myofascial release: morphologic change in connective tissue. Journal of Bodywork and Movement Therapies 1(4), pp. 231-238. doi: https://doi.org/10.1016/S1360-8592(97)80051-4
 
Gordon, C.-M. et al. 2016. Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach. Journal of Bodywork and Movement Therapies 20(3), pp. 614-622. doi: https://doi.org/10.1016/j.jbmt.2016.01.009
 
Grieve, R. et al. 2015. The immediate effect of bilateral self myofascial release on the plantar surface of the feet on hamstring and lumbar spine flexibility: A pilot randomised controlled trial. Journal of Bodywork and Movement Therapies 19(3), pp. 544-552. doi: 10.1016/j.jbmt.2014.12.004
 
Shah, S. and Bhalara, A. 2012. Myofascial Release. International Journal of Health Sciences & Research 2(2), pp. 69-77.
 
Wong, K.-K. et al. 2017. Mechanical deformation of posterior thoracolumbar fascia after myofascial release in healthy men: A study of dynamic ultrasound imaging. Musculoskeletal Science and Practice 27, pp. 124-130. doi: https://doi.org/10.1016/j.math.2016.10.011
​

What is it?
 
The plantar fascia is the flat band of tissue (ligament) that connects your heel bone to your toes. It supports the arch of your foot. If you strain your plantar fascia, it can get weak, swollen, and irritated (inflamed) which can lead to changes in the tissue structure leading to plantar fasciitis/fasciosis.

​Physiotherapy:
If these simple tips do not rectify your problem our team here at Physioimpulse will be able to help you on your way to recovery with a full assesment, hands on treatment and a tailor made exercise programme. Please call if you would like an appointment: 01225 683007 or you can simply book online. 

​Possible causes for low back pain can be endless, and as a patient you may have seen a number of different clinicians providing different diagnoses as to what is causing your low back pain. Many low back pain cases I see as a Chiropractor will be caused by the sacroiliac joint (SIJ). This joint, which basically connects your spine to your pelvis, assists the body with every-day movements such as walking, bending forward or hip flexion when walking or running.
 
SIJ pain can be caused by twisting at an awkward angle (usually combined with bending forward), leaning to one side when sat on the sofa for a long period of time or missing a step when descending the stairs. Anyone can suffer from this common condition, including desk workers, athletes or during pregnancy when  a hormone called relaxin causes the pelvic ligaments to relax.

In many cases, this joint when restricted does not cause pain initially but over time muscle tension can  build after shifting our weight to the other side to compensate for the lack of movement in the joint that has now become irritated. This can lead to irritation of the sciatic nerve, leading to pain radiating down the legs and around the hips.

 When a patient presents with this complaint in the clinic, manipulation of the restricted joint is really effective in promoting more movement and less pain in the affected joint. Manipulation involves a safe, often gentle impulse encouraging movement in the joint, which can be combined with soft tissue massage to free up the surrounding area. The immediate results are usually fantastic, with further follow up treatments providing a permanent basis for the joint to continue moving freely and effectively, as well as reducing the increased muscle tone. In addition to the hands-on manipulation, strengthening exercises and lifestyle advice are provided to prevent these problems reoccurring.

Watch this video explaining how a manipulation is carried out to the lumbar spine or SIJ. Below that is a great strengthening exercise for the gluts to support the SIJ.

​The PFJ is the joint at the front of the knee connecting the patella (knee cap) and the femur (thigh bone). Pain can emanate from many structures, most commonly the bony surfaces and associated tendons.

Risk factors

• Activities that frequently aggravate symptoms include running (particularly longer runs, downhill running or running on cambered surfaces)
• walking (particularly up and down stairs or hills)
• Muscular tightness/weakness (particularly quads, hamstrings, TFL core and glutes).
• Excessive or inappropriate training load (mileage, intensity)
• Abnormal biomechanics or poor running technique.
• Recent changes or inappropriate footwear or surfaces                                                                                                              

 Signs and symptoms
Patients with PFJ pain experience pain on the anterior aspect (front) of the knee. Patients usually experience an ache that may increase to a sharper pain with activity. Pain is typically experienced during activities that bend or straighten the knee repetitively particularly whilst weight bearing, such as running or squatting in the gym. Pain may be worse first thing in the morning or following activity (once the body has cooled down). This may be associated with knee stiffness and can sometimes cause the patient to limp.

​Clinical signs
Patients with PFJP typically experience pain when firmly touching the distal aspect of the patella and the patellar tendon and also mobilising the patella. In more severe cases, swelling may be present at the anterior aspect of the knee along with an associated grinding sound when bending or straightening the knee. Occasionally, patients may also experience episodes of the knee giving way or collapsing due to pain.

Investigations
A thorough subjective and objective examination from a physiotherapist is sufficient to diagnose PFJP. Investigations such as an ultrasound or MRI may be used to assist with diagnosis.

Management options
Physiotherapy treatment for PFJ is vital to speed up the recovery process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment options include:

• soft tissue massage (particularly to the quads)
• mobilisation of the patella
• dry needling
• electrotherapy
• ice or heat treatment
• progressive exercises to improve flexibility, strength and balance
• activity modification advice
• biomechanical correction (see our biomechanics page)
• anti-inflammatory advice
• Clinical Pilates and core stability exercises
• footwear advice

​Did you know?

• The average office worker is likely to spend 65,000 hours in a office chair from leaving full time education until retirement .
• 33% of long term sickness is due to work related musculoskeletal disorders such as back and neck pain.
• 31 million working days are lost in UK (approx £100billion/year) due to MSK disorders, neck and back pain.

So ensuring you have the right desk and seating set up could be vital in helping to try and minimise work-related Musculoskeletal disorders…
The Chartered Society of Physiotherapy have come up with some top tips to help with your desk environment:

Recent debate has argued that there is no perfect posture and that frequent breaks and regular exercise is the key:

• Moving more throughout the day can help keep your weight at a healthy level and limit your chances of developing a number of serious illnesses.
• UK exercise guidelines recommends adults aged 19-64 take at least 150 minutes of moderate to vigorous intensity physical activity each week, aiming to be active every day. 

These simple stretches can help ease the aches and pains associated with sitting for long periods combined with regular physical activity:

​

If you try all these exercise and continue to suffer work related aches and pains then give us a call for some extra input from our physio team.

​The hamstrings are formed by three muscles and their tendons. The hamstrings arise from the ischial tuberosity, or sitting bones, at the bottom of your pelvis. They run down the back of your thigh and their tendons cross the knee joint and attach onto each side of the shin bone (tibia). The hamstrings are involved in hip extension (moving the leg backwards) and knee flexion (bending the knee).
Acute hamstring injuries are common and generally present with localised pain following rapid acceleration or deceleration movements, such as when sprinting, and frequently occur in sports such as football, skiing, and hockey, to name a few. Acute injuries can also occur when the muscle is stretched too far Whereas chronic/persistent hamstring injuries present with a stealthy onset of unrelenting pain made worse with sports activities and sitting – often found in runners.
It is very important to treat and rehabilitate hamstring injuries correctly; incorrect or improper healing makes re-injury more likely. For the first 3 to 5 days (in the acute phase), the general consensus is to control swelling, pain and bleeding. The POLICE method is often used. POLICE stands for Protection, Optimal Loading, Ice, Compression and Elevation.
Following this acute phase, there was previously some ambiguity among treatment protocols until the introduction of Askling and colleagues’ 2013 research.  In this paper, Carl Askling and colleagues used 75 elite Swedish football players to compare two different hamstring rehabilitation protocols called the C-Protocol and L-Protocol. They then assessed outcomes of return to play and re-injury. The L-Protocol focused on eccentric loading of the hamstrings while the C-protocol consisted of conventional hamstring rehabilitation exercises. Participants in the L-protocol (outlined below) were able to return to sport significantly faster than those in the conventional group (mean 28 days vs 52 days). Their research into which protocol was best for chronic injuries was inconclusive, but the researchers were able to surmise that rehabilitation protocols consisting of eccentric exercises are more effective in returning athletes to their sports following hamstring injury.
Additionally, it is recommended that hamstring injury rehabilitation protocols should be preferentially based on strength and flexibility exercises that primarily involve exercises with high loads at long muscle–tendon lengths.

​The L- Protocol Exercises

• L1 - The Extender
  • The athlete lays in the position shown then slowly extends the knee
  • The knee is straightened as much as possible, not through pain
  • Three sets of 12 repetitions, twice per day

​

• L2 - The Diver
  • The athlete stands on the injured leg in the position shown. Both hands are then reached forward slowly whilst the leg is reached backwards
  • Three sets of 6 repetitions are performed every other day at a slow tempo

​

• L3 - The Glider
  • The athlete starts with one hand holding onto a railing or support and 90% of the weight on the injured leg with a slight knee bend
  • The uninjured leg is then glided backwards, stopping before pain on the injured leg
  • The arms are then used to return the athlete to the starting position
  • Three sets of 4 repetitions every third day
  • Progress this exercise by increasing the range of motion and speed at which it is performed

​These exercises are a great starting point. Head over to our clinics for this and much more in the way of hamstring treatment, rehabilitation and general advice. We can also use hands on manual therapy of the hip and spine in combination with exercise therapy to help you recover and rehabilitate fully.
Good luck and keep active!
Chris, PhysioImpulse

​Iliotibial band syndrome (ITBS) has been reported as the second most common running injury and most common reason for lateral (outer) knee pain in runners. In case you were wondering, a large research study reported patellofemoral pain syndrome to be the most common running-related injury.
 
What is your ITB?
 
The iliotibial band is a thick band of fascia that runs on the outer side of the thigh. It is a dynamic and multidimensional structure with relationships that span the lumbar spine (lower back) to the anterolateral (front and outer) aspect of the knee.
 
The ITB connects through the gluteus maximus to the lumbar fascial tissue; and down to the femur (thigh bone), the outer quadriceps muscle (vastus lateralis), the outer hamstring muscle (biceps femoris), and anterolateral tibia (shin bone). The interactions of the ITB suggest an interactive relationship between these different structures.

​Diagnosis and Typical Symptoms
 
The diagnosis of ITBS is based on clinical examination – patients typically present with tenderness over the lateral femoral epicondyle and report a sharp, burning pain when the practitioner presses on the lateral epicondyle during knee flexion and extension. The pain is particularly acute when the knee is at 30° of flexion. The onset often occurs at the lateral knee after a few miles of running, or hiking long distances. Walking with the knee extended can relieve the symptoms, and downhill walking or running can aggravate symptoms.
 
Theories and Causes
 
There are two main theories behind ITBS: the compression model and the friction model.  The ITB inserts in the region of the femoral epicondyle and it glides over the lateral femoral epicondyle when the knee bends. It is thought that due to biomechanical imbalances, the ITB can either become compressed or there is increased frictioning (rubbing) which causes pain and inflammation. Scientific literature often suggests there is there an overlap between these two models.
 
There is no one single cause of ITBS in runners, however, research has shown that biomechanical factors such as increased hip adduction (movement towards your mid-line), knee internal rotation, and femur (thigh bone) external rotation can contribute. Muscle weakness in the hip abductor and/or external rotators can be involved, as well altered neuromuscular control, or poor running technique leading to pelvic drop or rotation.
 
This highlights how ITBS is actually preceded by numerous biomechanical issues, and that the lateral knee pain itself is often the end symptom that you become aware of. On a positive note, these biomechanical issues have the potential to be corrected with physiotherapy, and this also emphasises the importance of sound biomechanics in the first place, which can help to prevent these types of running injuries. Your physiotherapist can help to reduce your injury risk by assessing your movement control and providing you with a plan to improve your biomechanics.
 
Management
 
One key biomechanical goal is to reduce strain related to excessive lengthening of the ITB and stress related to the insertion at the lateral femoral epicondyle.  In the initial stages (up to 2-weeks), anti-inflammatory medication and ice is recommended, along with a reduction in your running volume and intensity, and avoid downhill running.
 
Physiotherapy manual treatment for ITBS may include myofascial treatment addressing trigger points in the biceps femoris, vastus lateralis, gluteus maximus, and tensor fasciae latae muscles. In addition, acupuncture/dry needling techniques can prove helpful. Physiotherapy will also aim to address walking and running re-training, particularly looking to correct pelvic drop, pelvic rise, and trunk deviation if present.
 
ITB stretches can be useful, but you may also need to stretch various muscle groups around the hip and pelvis, such as the quadriceps, gluteals or hamstrings (if appropriate). Core strengthening exercises (particularly gluteus medius exercises) and progressive resistance exercises will be given to improve biomechanics and motor control. Movement control tests such as the single leg squat, the step down test, and single leg dead lift can help to provide baseline measures from which to improve.
 
If localised pain persists at the lateral femoral epicondyle, an ultrasound-guided corticosteroid injection could be considered. You can discuss this further with your physiotherapist.
 
Return to Running
 
When your exercises are pain-free and you can achieve them with good form, this is a good indication that running can be recommenced. A guideline for this is 6-weeks though the range is variable based on successful completion of the earlier phases of recovery. Graded progression is achieved by running every other day with emphasis on good running form, and initially may include easy sprints on level ground. Downhill running is not recommended in the first 2-weeks, and an emphasis on movement control is recommended to focus on pelvic control, forward trunk, and softer landing.
 
Should you wish to discuss any aspects of this or book an appointment with one of our therapists please get in touch.

References
 
Baker, R. L. and Fredericson, M. 2016. Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Phys Med Rehabil Clin N Am 27(1), pp. 53-77. doi: https://doi.org/10.1016/j.pmr.2015.08.001
 
Fairclough, J. et al. 2006. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 208(3), pp. 309-316. doi: 10.1111/j.1469-7580.2006.00531.x
 
Taunton, J. E. et al. 2002. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 36(2), pp. 95-101. doi: 10.1136/bjsm.36.2.95
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