UNM Digital Repository. University of New Mexico. Todd Nickerson University of New Mexico

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1 University of New Mexico UNM Digital Repository Doctor of Physical Therapy Capstones Health Sciences Center Student Scholarship 2016 Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease IT band friction (syndrome) and pain more than just pelvic strengthening and stretching alone? Todd Nickerson University of New Mexico Follow this and additional works at: Recommended Citation Nickerson, Todd. "Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease IT band friction (syndrome) and pain more than just pelvic strengthening and stretching alone?." (2016). This Capstone is brought to you for free and open access by the Health Sciences Center Student Scholarship at UNM Digital Repository. It has been accepted for inclusion in Doctor of Physical Therapy Capstones by an authorized administrator of UNM Digital Repository. For more information, please contact

2 1 Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease IT band friction (syndrome) and pain more than just pelvic strengthening and stretching alone? By: Todd Nickerson Doctoral Candidate University of New Mexico School of Medicine Division of Physical Therapy Class of 2016 Advisor: Jodi Schilz, PhD Approved by the Division of Physical Therapy, School of Medicine, University of New Mexico in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy.

3 2 Abstract: Purpose: The purpose of this project is to analyze evidence based research to answer the following PICO question, Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease iliotibial (IT) band friction (syndrome) and pain more than just pelvic strengthening and stretching alone? Background: IT band syndrome is the second most common running injury, and the most common cause of lateral knee pain. Due to large number of variables that can contribute to this condition a specific cause has yet to be found. The most common theories being looked at are: altered gait mechanics (specifically increased hip adduction and knee internal rotation during the stance phase of running), decreased hip strength (particularly hip abduction), and tight lateral hip musculature. There are many different variables that may contribute to the development of IT band syndrome including: shoe type, running surface, running volume, fatigue, and gender. Due to the number of potential variables that contribute to the development of IT band syndrome, it is difficult to design a robust research study correlating specific variables to the onset of IT band syndrome. Case Description: The patient is a 28 year-old male professional runner who presented to therapy with complaints of lateral right knee pain. His pain began during the end of a 12-mile run 10 days prior to evaluation. Outcomes: A review of the literature shows that studies focus on outcomes of hip strengthening, stretching, and/or running mechanics and how improvement in each aspect alters the patient s functional mobility and pain levels. Research reveals that combining all 3, hip strengthening, stretching of lateral hip musculature, and altering gait mechanics during running (with a wider stride and increased cadence) will most likely result in the biggest improvement of functional

4 3 mobility and decreased pain levels during running. Discussion: My case presentation involved a patient that had an acute bout of IT band syndrome who discontinued therapy after 4-weeks to pursue other treatment options. There is a need for continued research on the topic, particularly in studies that combine running gait kinematic management with strengthening and stretching. The uncertain ideology of the syndrome makes it difficult to design a study that is able to control all of the potential variables. Also, patients with IT band syndrome will often have muscular tightness, weakness, and gait abnormalities which make it difficult to figure out which of the three was the primary issue, creating the secondary and tertiary impairments. The fact that some studies are finding conflicting information complicates generalizing therapy programs to the general public. At the end of the day, the best strategy is to perform a solid physical therapy evaluation which includes gait analysis to address any gait asymmetries, functional muscle strength test for pelvic control, and range of motion/muscle length testing.

5 4 Table of Contents: Abstract...2 Background and Purpose of PICO Question....5 Case Description.7 Examination...10 Evaluation.13 Interventions.15 Evidence Based Analysis..16 Reference Summaries...19 Evidence Appraisal Worksheets..33 Table of Articles Discussion..76 Conclusion/Bottom Line...79 References.. 80

6 5 Background and Purpose: The iliotibial band (IT band) is a thickening of fibrous tissue that originates at the distal aspect of the gluteus maximus, gluteus medius, and tensor fascia latae muscles, and is attaches distally at the lateral border of the patella, lateral patellae retinaculum, and Gerdy s tubercle on the anterolateral aspect of the tibia. (Allen, 2014) The most common injury involving the IT band is called IT band syndrome (or IT band friction syndrome). The main theory of the cause is friction of the distal IT band as it moves back and forth over the lateral epicondyle of the femur during repeated knee flexion and extension. (Aderem 2015) The area of impingment/friction is typically around degrees of knee flexion. (Aderem 2015) There is debate on what the cause is, as well as how to most effectively treat it. IT band syndrome is the second most common running injury, and the main cause of lateral knee pain in runners. (Taunton, 2002) As more people are beginning to live a healthier lifestyle, and fitness is becoming more prevalent, there are more people running worldwide now than ever. Due to this, we can expect to see an increase in the number of cases of IT band syndrome in the future. This makes the iliotibial band an important topic to research and attempt to compile the most up to date information on. My case study involves a male professional distance runner that presented to therapy with the signs and symptoms of IT band syndrome. We were unable to improve his function or decrease the pain after four weeks of treatment, and he decided to pursue dry needling at the chiropractor instead. I was perplexed by the injury, and genuinely curious what I could have done differently, and decided to dig deeper into research of IT band syndrome. My PICO question reads, Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease IT band friction (syndrome) and pain more than just pelvic strengthening and stretching alone? I have seen several patients presenting with IT band syndrome in the clinic,

7 6 and after performing an examination, the plan of care usually focuses on hip abductor strengthening and IT band stretching. There are newer studies coming out that look at kinematics of the joints of the lower extremity, attempting to find some sort of correlation of people with IT band syndrome compared to healthy runners. By analyzing the research, my goal is to find the newest evidence based practice that will enable me to help these patients get back to their prior level of function and be able to run without any lateral knee pain.

8 7 Case Description Reason for Referral: The patient is a 28 year-old male professional distance runner with a diagnosis of right knee pain referred to physical therapy for evaluation and treatment. General Demographics o 6 0 tall, 145 lbs, Caucasian. Lean, athletic body type. History of Current Condition o HPI (history of present illness) The patient s right knee began hurting 10 days prior to the evaluation on the lateral aspect. o MOI (mechanism of injury) The patient did a 12-mile run, and during the last 2 miles he began feeling pain on the outside of his right knee. No trauma reported. o Chief complaint, location, onset, nature/behavior of symptoms, change since onset, better/worse: Moderate to severe pain on the outside of his right knee when he is running. No pain at rest. On a scale from 1-10, the patient reports his pain is at a 7 when he is trying to run. The pain is increasing, and he is able to run less before the onset of the pain begins. The pain is reported as, sharp. He does not have any symptoms when his legs are straight. Past Medical History (PMH) o No prior injuries reported to his right knee. 3 years ago, Achilles tendonitis of the right ankle that prevented him from running for 2months. Past Surgical History (PSH) o No prior surgery

9 8 Medications o Ibuprofen as needed and a daily vitamin. Diagnostic Testing o No X-ray or MRI performed. Precautions/Contraindications o N/A Past History of this Condition o The patient reports never having knee pain before this episode. Prior Level of Function o Running miles per week including interval and tempo workouts. Lifting weights 2X/week. Current Level of Function o Running 0 miles per week. Not able to bike or aqua jog either. Still able to lift weights. Occupation/Employment o Professional long distance runner. Living Environment o 2 steps into house. First floor of an apartment. Lives with fiancé; no pets. Social/Recreational History o Patient enjoys watching movies and hiking with his friends. General Health Status o Excellent Developmental and Family History

10 9 o No significant issues to report. Patient s Goals o The patient s goal is to be able to run again with no knee pain and regain fitness in time for the Olympic Trials this summer.

11 10 Examination Systems Review o No evidence of need to screen for these. Tests and Measurements o Palpation Tender to light pressure on distal right IT band on right side. Bilateral tenderness to moderate pressure on piriformis. No tenderness noted on medial, lateral, superior, or inferior border of right patella. o Special Tests Positive Noble Compression Test on right. (Negative on left) Negative joint line tenderness on right tibial plateau. Negative Thessaly Test on right. Negative McMurray Test on right. o Pain The patient reported no pain with walking during therapy. o Aerobic Capacity/Endurance Resting heart rate: 47 bpm o Gait Mild limp, decreased stride length on left step, decreased mid stance on right step. o Joint Integrity and Mobility Bilateral patella mobility is within functional limits (WFL).

12 11 o Muscle Performance MMT: Right knee flexion: 4/5 Right knee extension: 4/5 Right hip internal rotation (IR): 4/5 Right hip external rotation (ER): 4/5 Right hip abduction: 3+/5 Left knee flexion: 4/5 Left knee extension: 5/5 Left hip IR: 4/5 Left hip ER: 4/5 Left hip abduction: 4/5 o Posture Mildly forward head and rounded shoulders. o Range of Motion Thomas test reveals bilateral decreased muscle length of hip flexors and rectus femoris. Right and left knee active flexion and extension: WFL Right hip active IR: 25 degrees Left hip active IR: 30 degrees Right and left hip active ER: WFL o Work Life

13 12 Professional distance runner; involves running miles per week and lifting weights in the weight room 2X per week. Palpation Tender to light pressure on distal IT band on right side. Bilateral tenderness to moderate pressure on piriformis. No tenderness noted on medial, lateral, superior, or inferior border of right patella. Special Tests Positive Noble Compression Test on the right. (Negative on left) Negative joint line tenderness on right tibial plateau. Negative Thessaly Test on right. Negative McMurray Test on right.

14 13 Evaluation of Clinical Findings Medical Diagnosis: M Right knee pain. PT Diagnosis: M76.3 IT band syndrome. PT Problem List o Decreased functional mobility. o Increased pain in right knee. o Decreased strength in right knee flexion and extension. o Decreased muscle length of bilateral iliopsoas and rectus femoris. o Unable to perform job as professional long distance runner. o Decreased strength in right hip abduction. Narrative Assessment: The patient is a 28 year old male who was referred to physical therapy with lateral right sided knee pain. He presents with decreased right knee strength, decreased right hip strength, decreased length of bilateral hip flexors and knee extensors, and increased pain in his right knee when attempting to run. These impairments are preventing him from performing his job as a professional long distance runner. The signs and symptoms are consistent with right sided iliotibial band syndrome. Skilled physical therapy is recommended to address the above listed impairments, and to improve the patient s gait mechanics to allow him to return to his job as a long distance runner. The patient has a good

15 14 prognosis for recovery due to his healthy lifestyle, motivation to return to running, and the fact that the injury is in an acute phase. Goals o The patient will demonstrate the ability to run 6 miles without any right knee pain in 6 weeks. o The patient will increase the strength of his right hip abduction to 4/5 or greater in order to reduce the pain in his IT band allowing him to return to work as a runner in 5 weeks. o The patient will race in the indoor track National Championships without any knee pain in 8 weeks.

16 15 Interventions and Plan o For this patient, our intervention focused on strengthening the hip abductors. The reason for this was: A) this was one of his main impairments, and B) many people believe that hip abductor weakness predisposes somebody to IT band syndrome. We also did gait training to observe pelvic movement and mechanics of the limb. It would be ideal to have him use a gait analysis lab to get specific data for movements. We did this because excess or decreased pelvic motion can lead to decreased lower extremity (LE) function. The final intervention that we did was stretching for his hip flexors, piriformis, rectus femoris, and tensor fasciae latae (TFL). These muscles were all tight, and tightness can lead to dysfunction of the IT band and other issues down the chain. o The importance of compliance of his HEP which included stretching his hip flexors and the lateral musculature, as well as strengthening of the hip abductors and other pelvic girdle musculature was emphasized. o Coordination with other healthcare professionals: Potentially receiving orthotics to put in shoes while running to give more arch support. Information was given about potential dry needling from a certified therapist, which is what he ended up doing after trying more conservative therapy for 3 weeks. Frequency/Duration of Treatment: o 2 times per week for 8 weeks. He ended up postponing physical therapy after 4 weeks to try dry needling from a chiropractor.

17 16 Evidence Based Analysis Search Methodology: The following search methodology sought to answer the following PICO question: Does altering running gait mechanics in addition to pelvic strengthening and stretching in serious runners decrease IT band friction (syndrome) and pain more than just pelvic strengthening and stretching alone? The following databases and journal collections were searched for evaluation of relevant evidence to the above listed PICO question: PubMed, SportDiscuss, and CINAHL. The search terms for each database were identical, and included: IT band syndrome, IT band syndrome and pelvic, iliotibial band and stretching, IT band syndrome running, and lastly iliotibial band syndrome hip strength. Table 1: Systematic Literature Review Process Search Terms Number of Articles Included/Excluded PubMed IT band syndrome 4024 Too many IT band syndrome and pelvic Iliotibial band and stretching 31 2 selected for PICO-relevant study (Aderem 2015, Pavkovich 2015), 1 excluded due to small sample size, 3 excluded after reading abstract, 25 excluded due to title irrelevance selected for PICO-relevant study (Allen 2014, Grau 2011, Falvey 2010) 6 excluded after reading abstract, 43 excluded due to title irrelevance. IT band syndrome running 90 2 selected for PICO-relevant study Noehren 2014, Meardon 2012), 2 duplicates already selected, 12 excluded after reading abstract, 74 excluded due to title irrelevance.

18 17 Iliotibial band syndrome hip strength 22 1 selected for PICO-relevant study (Beers 2008), 1 duplicate already selected, 2 excluded after reading abstract, 18 excluded due to title irrelevance. SportDiscuss IT band syndrome 305 Too many IT band syndrome and pelvic Iliotibial band and stretching 6 1 excluded due to small sample size, 2 excluded after reading abstract, and 3 excluded due to title irrelevance duplicate already selected, 5 excluded after reading abstract, and 58 excluded due to title irrelevance. IT band syndrome running 75 2 duplicates already selected, 7 excluded after reading abstract, 66 excluded due to title irrelevance. Iliotibial band syndrome hip strength 8 1 duplicate already selected, 1 excluded after reading abstract, 6 excluded due to title irrelevance. CINAHL IT band syndrome 208 Too many IT band syndrome and pelvic 8 1 duplicate already selected, 2 excluded after reading abstract, 5 excluded due to Iliotibial band and stretching title irrelevance duplicates already selected, 4 excluded after reading abstract, 24 excluded due to title irrelevance. IT band syndrome running 88 4 duplicates already selected, 9 excluded after reading abstract, 75 excluded due to title irrelevance. Iliotibial band syndrome hip strength 12 1 duplicate already selected, 4 excluded after reading abstract, 7 excluded due to title irrelevance.

19 18 Articles Included for Analysis: 1: Aderem, J., & Louw, Q. A. (2015). Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders, 16. 2: Allen, D. J. (2014). Treatment of distal iliotibial band syndrome in a long distance runner with gait re-training emphasizing step rate manipulation. International Journal of Sports Physical Therapy, 9(2), : Beers, A., Ryan, M., Kasubuchi, Z., Fraser, S., & Taunton, J. E. (2008). Effects of multimodal physiotherapy, including hip abductor strengthening, in patients with iliotibial band friction syndrome. Physiotherapy Canada, 60(2), : Falvey, E. C., Clark, R. A., Franklyn-Miller, A., Bryant, A. L., Briggs, C., & McCrory P. R. (2010). Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports, 20(4), : Grau, S., Krauss, I., Maiwald, C., Axmann, D., Horstmann, T., & Best, R. (2011) Kinematic classification of iliotibial band syndrome in runners. Scandinavian Journal of Medicine & Science in Sports, 21(2), : Meardon, S., A., Campbell, S., & Derrick, T. R. Step width alters iliotibial band strain during running. Sports Biomechanics, 11(4), : Noehren, B., Schmitz, A., Hempel, R., Westlake, C., & Black, W. (2014). Assessment of strength, flexibility, and running mechanics in men with iliotibial band syndrome. Journal Of Orthopaedic & Sports Physial Therapy, 44(3) : Pavkovich, R. (2015). The use of dry needling for a subject with chronic lateral hip and thigh pain: a case report. International Journal of Sports Physical Therapy, 10(2)

20 19 Reference #1: Aderem, J., & Louw, Q. A. (2015). Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders, 16. Level of Evidence: 2a Pedro Score: N/A Purpose: The purpose of this systematic review was to provide up-to-date synthesis of lower extremities biomechanical risk factors associated with runners who were suffering from iliotibial band syndrome pain. Methods: The studies that were included for this systematic review tried to determine the differences in lower extremity biomechanics with runners who had iliotibial band syndrome. No animal or cadaver studies were included. The researchers searched: Pubmed, Science direct, Scopus, and Sportdiscuss using the terms, iliotibial band syndrome OR iliotibial band friction syndrome OR iliotibial band strain AND running OR run. The studies included were up through April, There were 2 reviewers who screened the titles and abstracts of all potential papers. An algorithm was used based on data found from each study to determine which articles would be included in the review. Results: The main findings from this review were that female runners with iliotibial band syndrome has an increased peak internal rotation of the knee as well as ipsilateral trunk flexion during the stance phase of the effected side. Peak hip abduction, hip abduction, and contralateral pelvic drop in female runners with iliotibial band syndrome was insignificant. Another study found that male runners with iliotibial band syndrome had significantly increased peak knee internal rotation, while another found that men and women combined had decreased total rearfoot eversion, and rearfoot pronation range of motion. Another study looked at biomechanics of runners pre and post-fatigue, and found that runners

21 20 prone to iliotibial band syndrome use abnormal gait patterns, mostly including hip adduction and tibial internal rotation. Critique/Bottom Line: Many of the studies included did not separate men from women, and due to the differences in pelvic mechanics in particular, this would be a good thing for people to differentiate in future studies. The authors reported that there is a need for much more specific research regarding iliotibial band syndrome, and that footwear should also be taken into account. This paper is a very good tool for gathering the biomechanic aspect of iliotibial band syndrome in gait, but it is also important to look at stride width, vertical displacement, and cadence and I think this is something that at least should have been mentioned.

22 21 Reference #2: Allen, D. J. (2014). Treatment of distal iliotibial band syndrome in a long distance runner with gait re-training emphasizing step rate manipulation. International Journal of Sports Physical Therapy, 9(2), Level of Evidence: 3b Pedro Score: 2c Purpose: To present outcomes of treatment in a runner suffering from iliotibial band syndrome pain by utilizing running gait re-training to increase a rate of stepping above the runner s preferred rate. This was coupled with flexibility and hip abductor strengthening exercises. Methods: Evaluation of the subject (36 year old female recreational runner) included a manual muscle test of bilateral hip abductors, hamstring and piriformis tightness assessment, weight bearing alignment analysis, walking gait analysis, running gait analysis, and functional strength and movement testing. The walking and running gait analysis used slow motion video analysis, looking at hip drop, cadence, initial foot contact, knee angle at initial contact, vertical center of mass displacement, and stride width. The subject was told to run at 176 steps per minute (with auditory feedback from a metronome) 1-2 miles, three times per week. Her normal cadence was 168 steps per minute. She also performed an iliotibial band stretch 3 times per day for 3 sets of 20 seconds each, as well as several exercises for hip abductor strengthening for 1-2 sets of 10, 3 times per week. Results: It took 8 sessions for the subject to assume new running mechanics, where she no longer needed to metronome to achieve 176 steps per minute while running. At the 4-week follow-up, the subject reported running 3.5 miles with no knee pain. Running mechanics had changed as seen in a mid-foot strike pattern, initial foot contact was now directly beneath her shoulder, and decreased vertical displacement. Pelvic drop was now gone

23 22 bilaterally, and hip abduction increased from 4/5 to 4+/5 on the left side. She was able to now control the dynamic valgus of her left lower extremity better than at evaluation, but continued to have deficits. At 6-week follow-up, all values held the same, with the subject running 7 miles pain free, and increased left hip abduction strength of 5/5. At the 4-month follow-up, the subject reported being able to complete 13.1 miles without any knee pain. Critique/Bottom Line: The bottom line of this study was that in this case, manipulating the gait of a runner by increasing the stride rate by 5%, along with performing strengthening and stretching programs, resulted in the subject returning to full activity pain-free. Another important aspect that I took from this research is that recreational runners are able to alter their mechanics simply with the use of a metronome and the verbal cues of, run quietly or let your feet strike under your body as you fall forward. It is important to not only address impairments, such as decreased flexibility or strength, but the gait mechanics as well or else the issue will likely come back. My main critique of this article is simply the fact that it is only a case study, which is a fairly low level of evidence. I would have also liked to see them compare step rate manipulation only vs. other rehabilitation methods, in order to narrow down what variable may play the most important factor is treatment and recovery from iliotibial band syndrome. Reference #3: Beers A, Ryan M, Kasubuchi Z, Fraser S, Taunton J E. Effects of Multi-modal Physiotherapy, Including Hip Abductor Strengthening, in Patients with Iliotibial Band Friction Syndrome. Physiotherapy Canada, April 2008, 60(2): pgs Level of Evidence: 2c Pedro Score: N/A

24 23 Purpose: Examine hip abductor strength in patients with iliotibial band syndrome, and to determine if strengthening of the hip abductors might play a role in recovery. Methods: Hip abductor strength was measured in 16 patients that were recruited who have been diagnosed with iliotibial band syndrome. This was measured in the side lying position with the hip externally rotated 30 degrees with an isometric contraction against a hand dynamometer with both the healthy and injured legs. The subjects received physical therapy 1-2 times per week for 6 weeks where they were given exercises to improve hip abduction strength. They were also to do these exercises as part of a home program. They were also given 2 stretches to perform. Each subject received ultrasound to the area of discomfort during regular physical therapy visits. Measurements of hip abductor strength were taken at 0, 2, 4, and 6 weeks. Measurements of the patient s functional level as well as their pain were the other outcomes of this study. Results: Of the 16 people that began the study, 13 completed the 6 week program. There was a mean improvement in strength of the injured leg s hip abductors that correlated with decreased pain levels, as well as increased function. The fact that there were only 13 people to complete the study, and there are other variables (running shoes, terrain, stretching, time) that likely played a role in the recovery make it so that you cannot just say that increased hip abduction decreased iliotibial band pain. That being said, you cannot take away from the extrapolation of the data, which shows the coloration as well the fact that hip abductor strength does play a role in iliotibial band pain due to biomechanical changes that it causes. Critique/Bottom Line: This was a good study in the sense that it involved active people who actually were suffering from iliotibial band syndrome, although it was a relatively

25 24 small sample size (16 people). The fact that only 4 of the 16 subjects were completely pain free during physical activity leads you to believe that more than hip strengthening, stretching, and ultrasound might be needed to decrease the pain from iliotibial band syndrome. This rehabilitation routine was successful in improving hip abduction strength but due to the fact that 12 of the 16 were still experiencing pain, it is possible that maybe the hip weakness developed as the person began compensating secondary to the pain on the lateral aspect of their knee. Reference #4: Falvey, E. C., Clark, R. A., Franklyn-Miller, A., Bryant, A. L., Briggs, C., & McCrory P. R. (2010). Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports, 20(4),

26 25 Level of Evidence: 4 Pedro Score: N/A Purpose: The purpose of this research was to determine more accurate anatomical understanding of the iliotibial band, what position of the hip and knee result in the greatest stretch of the iliotibial band, and the amount of strain/lengthening that occurs at the iliotibial band during a hip abduction contraction. Methods: For the anatomical aspect of this research, they used 20 adult cadavers, and dissected to investigate the following: The origin of the iliotibial band and its relationship to the tensor fasciae latae, the location of the insertion of the gluteus maximus into the iliotibial band, the location of the longitudinal attachment of the iliotibial band to the linea aspera on the femur, and the site of attachment of the iliotibial band to the lateral femoral condyle. The second part, to determine what position puts a person in the position to get the best stretch into the iliotibial band, used 5 unembalmed cadavers. They used 3 testing positions: straight leg raise to 30 degrees, a modified Ober s position while side lying and the hip extended behind them, and lastly, the hip flexed/adducted/externally rotated with the knee flexed. A sensor was placed 8 centimeters proximal to the lateral femoral condyle, where it assessed longitudinal strain on the iliotibial band. The final aspect of this experiment measured iliotibial band displacement in 19 professional rugby league players. In the side lying position, the subject abducted their hip, where the weight of their leg was offloaded, and then were instructed to perform a maximum contraction into hip abduction. An ultrasound probe was placed on the skin at the tensor fasciae latae and iliotibial band junction, where excursion was measured. This information was entered into an equation to determine the stretch placed into the iliotibial band. Results: For the anatomical part, they were unable to identify a bursa between the distal

27 26 iliotibial band and the lateral epicondyle of the femur. They also found that a very large portion of the gluteus maximus inserted directly into the iliotibial band. Secondly, they found that hip flexion/adduction/external rotation along with knee flexion while in a supine position resulted in a significantly greater amount of strain put into the iliotibial band than the other two positions. Lastly, they found a very negligible change in iliotibial band displacement with a maximum isometric contraction in healthy rugby athletes. Critique/Bottom Line: This study gave me a few important take home messages. Firstly, using the supine hip adduction/flexion/external rotation with knee flexion might be a more beneficial way to stretch the iliotibial band/tensor fasciae latae then other techniques. One critique that I had with the last section was that the contraction used was isometric. This is important, because the painful range of iliotibial band syndrome is typically around 30 degrees of knee flexion. It is also important to note that the cadavers used were an average age of 79 years-old, therefore, it is not very likely that they were extremely active, and that could account for no bursa being found underneath the distal iliotibial band at the lateral femoral condyle. Nearly all cases of iliotibial band syndrome occurs is active people, because of the fact that it is considered an overuse injury. They did address that loose connective tissue that his richly innervated represents a potential pain generating structure as opposed to a bursa. Reference #5: Grau, S., Krauss, I., Maiwald, C., Axmann, D., Horstmann, T., & Best, R. (2011) Kinematic classification of iliotibial band syndrome in runners. Scandinavian Journal of Medicine & Science in Sports, 21(2), Level of Evidence: 2c Pedro Score: 5/10 Purpose: The purpose was to investigate the differences between healthy runners and

28 27 runners who were experiencing iliotibial band syndrome in terms of their kinematic characteristics. They looked at the biomechanics of the pelvis, knee, ankle, and foot during running. Methods: 18 spherical reflective markers were placed on the subject along the pelvis, femur, tibia, fibula, calcaneus, navicular, metatarsals, and cuniform bones. Kinematic joint angle curves were normalized for each patient, and they then ran barefoot in a laboratory along a 13-meter runway with a soft foam density. They measured range of motion, maximum velocity, knee motion, ankle motion, and rearfoot motion. Results: The group with iliotibial band syndrome demonstrated decreased hip adduction during running throughout the entire rollover process. They also found significantly less hip and knee flexion velocity in the sagittal plane in the subjects with iliotibial band syndrome pain compared to the healthy controls. Critique/Bottom Line: The author discusses one of the main critiques that I had as well. This study reports a different outcome than is traditionally seen with people with iliotibial band syndrome, and that is a decrease of hip adduction. They report that this could possibly be due to this change in gait could be a gait adaptation secondary to the pain. I would like to see these types of biomechanic measurements pre- and post-fatigue, because iliotibial band syndrome pain typically begins after running for a certain amount of time. Reference #6: Meardon, S., A., Campbell, S., & Derrick, T. R. Step width alters iliotibial band strain during running. Sports Biomechanics, 11(4), Level of Evidence: 4 Pedro Score: N/A Purpose: To determine how step width affects strain and rate of strain of the iliotibial band during running.

29 28 Methods: 15 healthy runners had 28 reflective markers placed on each side of the body, and ran along a 30 meter runway. This runway had a force platform to measure ground reaction forces. Step width was measured by taking the mediolateral distance between the left and right heels at its minimum height while running. Measurements were taken at 3 widths : normal, wide, and narrow. Results: Iliotibial band strain as well as iliotibial band strain rate both increased as running strides became more narrow. The subjects of the study were able to maintain the same running velocity and heel strike pattern during all 3 running step widths. From normal to narrow step width, 1.16 times greater strain was observed on the iliotibial band, while 1.33 times greater strain was seen going from wide to narrow. Critique/Bottom Line: The bottom line of this research is that the more narrow the stride when running, the greater force is put through the iliotibial band. Due to its anatomical position on the lateral aspect of the leg, an increase of hip adduction or knee internal rotation will cause an increased tension along the iliotibial band, which could be one of the contributing factors to iliotibial band pain. The number of subjects was relatively low (n=15), and the stress and strain on the iliotibial band was calculated using a software developed model. While the model used statistical analysis of the subjects, it will not capture the exact same strain on each person due to being on a computer. Intra-tissue tests would likely yield more accurate data.

30 29 Reference #7: Noehren B, Schmitz A, Hempel R, Westlake C, Black W. Assessment of Strength, Flexibility, and Running Mechanics in Males with Iliotibial Band Syndrome. Journal of Orthopedic Sports Therapy, March 2014, 44(3): pgs Level of Evidence: 4 Pedro Score: 5/10 Purpose: Determine the differences in iliotibial band length, hip and knee biomechanics while running, and strength of hip musculature between male runners suffering from

31 30 iliotibial band syndrome and healthy controls. Methods: Hip abductor and external rotation strength on the involved side were measures using a dynamometer. The length of the IT band was assessed using the Ober s test. This was followed by a gait analysis, where reflective markers were placed on L4-L5 junction, bilateral iliac crests, ASIS, greater trochanter, medial and lateral femoral epicondyles, tibial plateaus, malleoli, as well as the 1 st and 5 th metatarsal heads. They were then recorded while running to calculate joint angles throughout the running cycle. Results: The males in this study showed a significantly greater hip internal rotation as well as knee adduction angles during the early stance phase of running compared to the healthy control group. There was also a decrease seen in the strength of the hip external rotators, as well as IT band length. There were no differences found in hip abduction strength or hip adduction angle. Critique/Bottom Line: The fact that they found no difference in hip abduction strength between runners with iliotibial band syndrome and healthy controls is in contrast to prior studies that have shown a difference. This could be due to the relatively small sample size, or possibly that the hip abduction weakness develops secondary to the pain, and these subjects were too acute in the process. Reference #8: Pavkovich, R. (2015). The use of dry needling for a subject with chronic lateral hip and thigh pain: a case report. International Journal of Sports Physical Therapy, 10(2) Level of Evidence: 4 Pedro Score: N/A Purpose: The purpose of this case study was to report the outcome for a patient that is being treated with dry needling alone for pain associated with greater trochanteric pain syndrome as well as iliotibial band syndrome.

32 31 Methods: The patient underwent treatment 2 times per week for 8 weeks, receiving dry needling to target the: gluteus maximus, gluteus medius, lateral piriformis, greater trochanteric bursa, and 4 points along the lateral thigh into the iliotibial band and vastus lateralis. The therapist used a fast in/out movement technique. The needles were then wound clockwise, and left in place for 15 minutes. No electrical stimulation was used during this experiment. Results: The subject in this case study demonstrated decreased pain and improved function at the end of the 8 week dry needling treatment. Her score in the lower extremity function scale improved from 24/80 to 54/80. While her pain and function improved, she did continue to have some pain along her lateral thigh. She also had an increase of strength in her pelvic musculature as measured by MMT, which was not an initial hypothesis of the researcher. Critique/Bottom Line: My major critique of this study is that it was done using a 78-year old woman as the subject. The issue with this is that she is most likely not as active as somebody that is younger than her, which is usually the demographic who suffers from iliotibial band syndrome pain. This being said, there is virtually no research for dry needling for iliotibial band pain, and this is still something to use as a baseline. The author agrees that dry needling should not be used as a stand-alone treatment for iliotibial band syndrome, it is important to know that it does not worsen the symptoms (at least in this case.) The author also predicts that the strength gains seen in this patient could be secondary to the fact that she is in less pain, and therefore be able to functionally strengthen through activities of her daily living.

33 32 Reference # 1 Systematic Review Evidence Appraisal Worksheet Citation: Aderem, J., & Louw, Q. A. (2015). Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders, 16. Level of Evidence (Oxford scale): 2a Does the design follow the Cochrane method? Step 1 formulating the question Do the authors identify the focus of The focus of this review is to provide up to the review date quantitative synthesis of the pelvis, trunk, A clearly defined question should and lower extremity risk factors in runners specify the types of: with IT band syndrome. They are also people (participants), attempting to design an algorithm for future interventions or exposures, research, and for clinicians to find and use the outcomes that are of interest best current evidence. studies that are relevant to answering the question Step 2 locating studies Should identify ALL relevant literature Did they include multiple databases? Was the search strategy defined and include: o Bibliographic databases used as well as hand searching o Terms (key words and index terms) o Citation searching: reference lists o Contact with experts to identify grey literature (body of materials that cannot be found easily through conventional channels such as publishers) o Sources for grey literature Part 3:Critical Appraisal/Criteria for Inclusion Were criteria for selection specified? The authors included studies if they were conducted to look at lower extremity biomechanical differences between runners with IT band syndrome and healthy runners. They searched from PubMed, Science Direct, Scopus, and SPORTDiscuss. The terms used were: ((Iliotibial band syndrome OR Iliotibial band friction syndrome OR Iliotibial band strain) AND (running OR run)). There were 2 reviewers for this study. They used the Critical Appraisal Form for

34 33 Did more than one author assess the relevance of each report Were decisions concerning relevance described; completed by non-experts, or both? Did the people assessing the relevance of studies know the names of the authors, institutions, journal of publication and results when they apply the inclusion criteria? Or is it blind? Part 3 Critically appraise for bias: Selection Were the groups in the study selected differently? Random? Concealed? Performance- Did the groups in the study receive different treatment? Was there blinding? Attrition Were the groups similar at the end of the study? Account for drop outs? Detection Did the study selectively report the results? Is there missing data? Part 4 Collection of the data Was a collection data form used and is it included? Are the studies coded and is the data coding easy to follow? Were studies identified that were excluded & did they give reasons why (i.e., which criteria they failed). Quantitative Studies to appraise the quality of the papers. The researchers developed a checklist to determine inclusion and exclusion criteria. Any studies conducted on animals or human cadavers were excluded. They did not address whether or not the names of the authors or journals were blinded to the reviews, so we have to assume that they were not. None of the subjects were random or concealed for any of the studies included in this systematic review. There were observational studies, cross-sectional studies, and prospective cohort studies. Due to there being a high volume of studies, they did not comment on performance, attrition, or detection but more on the results and outcomes of each article. Two customized excel spreadsheets were used for data extraction. The subject demographics, study aims, gait analysis tool used, running conditions, speed, and phase of gait cycle analyzed were all included. They were not included. The results of each study are easy to follow, but the data collection spreadsheet was not available. They did not identify which studies were excluded and simply states that they did not meet the inclusion criteria.

35 34 Are the results of this SR valid? 1. Is this a SR of randomized trials? Did they limit this to high quality studies at the top of the hierarchies a. If not, what types of studies were included? b. What are the potential consequences of including these studies for this review s results? 2. Did this study follow the Cochrane methods selection process and did it identify all relevant trials? a. If not, what are the consequences for this review s results? 3. Do the methods describe the processes and tools used to assess the quality of individual studies? a. If not, what are the consequences for this review s results? 4. What was the quality of the individual studies included? Were the results consistent from study to study? Did the investigators provide details about the research validity or quality of the studies included in review? 5. Did the investigators address publication bias Are the valid results of this SR important? 6. Were the results homogenous from study to study? a. If not, what are the 12 of the 13 studies were cross-sectional studies, while the final study was a prospective cohort. There were no randomized trials. The potential consequence of this would that be the results with have less validity, and therefore not as applicable. The authors could have different people diagnosing the IT band syndrome then the ones who are placing the markers and analyzing gait for those types of studies. It introduces the possibility of bias into the study. No, they did not follow the Cochrane method selection process. The consequence of this is simply that the results as less valid in terms of generalization to the public. There is still significant clinical relevance in this systematic review. Yes, the authors used a 16-question formula to appraise the quality of each study included in the systematic review. The studies ranged from 9/16 to 11/16. The studies were low quality being prospective cohort and cross-sectional. The investigators discussed the quality of studies based on their 16-question appraisal form. This included questions about reliability, validity, sample sizes, clinical importance, and study design, amongst others. The investigators report that there is a language bias, because only articles that were published in English were considered. The diagnostic criteria varied in the studies, which introduced heterogeneity into the results. No, the results were heterogeneous, because the authors used different diagnostic criteria for

36 35 consequences for this review s results? 7. If the paper is a meta-analysis did they report the statistical results? Did they include a forest plat? What other statistics do they include? Are there CIs? 8. From the findings, is it apparent what the cumulative weight of the evidence is? IT band syndrome. This results in the study having a lower quality, giving no sure answers to potential ways to handle a patient that presents to the clinic with IT band syndrome. The authors performed meta-analysis within the studies where possible. They included forest plots, as well as confidence intervals. They found no statistical difference between female runners with IT band syndrome and controls in terms of peak hip adduction and peak hip abductor moment. They also found peak knee internal rotation and peak trunk ipsilateral flexion was significantly higher in female runners with IT band syndrome compared to healthy controls. No, but the authors give good recommendations on where they found limitations throughout their systematic review. These include studies using more homogeneous outcome measures, and to attempt to find a consensus on diagnostic criteria for IT band syndrome. Can you apply this valid, important evidence from this SR in caring for your patient/client? What is the external validity? 9. Is your patient different from those in this SR? 10. Is the treatment feasible in your setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 11. Does the intervention fit within your patient/client s stated values or expectations? Most of the subjects that were involved in this study were runners, because that is the population who typically develops IT band syndrome. My patient is a professional runner, so it is safe to assume that he is likely running at a higher volume and intensity than the typical person from these studies. They also do not address the ages of the patients in their studies, but it is safe to assume that they are young/middle aged because people with high activity levels develop this overuse injury. Yes. Using gait analysis, strengthening, and stretching is both possible and reimbursable through insurance. This article looks at diagnostic and correlative aspects of IT band syndrome. This could lead

37 36 a. If not, what will you do now? to developing an intervention plan of gait retraining, strengthening, and stretching. What is the bottom line? Summarize your findings and relate this back to clinical significance The findings were that female runners with IT band syndrome have an increased knee internal rotation as well as increased trunk ipsilateral flexion compared to healthy control subjects. The differences between hip adduction were statistically insignificant, but this could be due to the fact that the testing was not done on runners that were fatigued. While it is hard to screen for, looking at the knee and hip during gait analysis is an appropriate evaluation tool in the clinic.

38 37 Reference # 2 Prognostic Study Evidence Appraisal Worksheet Citation: Allen, D. J. (2014). Treatment of distal iliotibial band syndrome in a long distance runner with gait re-training emphasizing step rate manipulation. International Journal of Sports Physical Therapy, 9(2), Level of Evidence (Oxford scale): 3b Is the purpose and background information sufficient? Study Purpose Stated clearly? The purpose of this case report is to analyze Usually stated briefly in abstract and in greater treatment outcomes in a 36-year-old female detail in introduction. May be phrased as a runner by using running gait re-training by question or hypothesis. simply increasing the step rate. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Describe the justification of the need for this study This study was performed because of the high prevalence of IT band syndrome, and the lack of clear ideology. The authors reference several studies that have found gait abnormalities such as increased hip adduction and internal knee rotation in people with IT band pain. They also mention that treatment interventions for specific runners have been lacking, but there was one study that described a 3-phase approach to treat these runners: acute, sub acute, and strengthening. There is also a nonspecific phase where running gait changes. They also discuss the amount of research on gait re-training that is not specific to IT band syndrome, and how increasing cadence can decrease heel strike, braking impulse, step length, and vertical excursion. These factors all reduce impact forces and a decrease of mechanical work performed at the knee.