Move Well, Live Well Newsletter

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1 Move Well, Live Well Newsletter April 11, 2016 Volume 4, Number 4 In This Issue: Physical Therapy Improves Outcomes of Pelvic Surgery Iliotibial Band Pain in Runners: Is Inflammation the cause or a symptom? Trail Running Races Sponsored By Sapphire Physical Therapy Sign up for the Sapphire PT enewsletter at sapphirept.com Links to Related Sites: SapphirePhysicalTherapy.blogspot.com Related Sites: Physical Therapy Improves Outcomes of Pelvic Surgery Rachael Herynk, DPT Women with incontinence and pelvic organ prolapse have been shown to benefit from interventions, including the use of continence products, physical therapy, medications, and surgery. A study conducted in Australia looked at women undergoing corrective surgery for urinary incontinence and pelvic organ prolapse. It compared the role of physical therapy before and after surgery. Half of the women received physical therapy interventions and half received no physical therapy. The study found that women that have pre and post operative physical therapy demonstrated improved outcomes. These outcomes included improved quality of life, reduced urinary symptoms, and increased pelvic floor muscle strength. If you experience urinary incontinence or discomfort associated with pelvic organ prolapse and your doctor has suggested surgery, please consider physical therapy to maximize the benefits received from surgery. Physical therapy treatment of incontinence involves bladder retraining techniques, lifestyle changes, pelvic floor muscle reeducation, and progressive core (abdominal and pelvic floor) and hip strengthening. Your physical therapist may also suggest other treatment options, specific to your symptoms and lifestyle. Please feel free to contact Rachael at Sapphire Physical Therapy with any questions or concerns you may have. Sources: Jarvis Sk, Hallam TK, Lujic S, Abbott JA, Vancaillie TG. Perioperative physiotherapy improves outcomes for women undergoing incontinence and organ prolapse surgery: results of a randomized controlled trial. Australian and New Zealand Journal of Obstetrics and Gynecology (4):

2 The Runners Edge: Missoula s hub for running gear, information, and races Run Wild Missoula membership promotes running, training, and racing in Missoula Missoula s choice for core strengthening and ski conditioning. From beginners to elite athletes, Momentum classes will increase your strength and reduce your injury risk. Find us on Facebook: For more information on the services provided by Sapphire Physical Therapy or to read more related articles, see our website or give us a call at Sign up for the Sapphire PT enewsletter at sapphirept.com Contact Us: (406) Iliotibial Band Pain In Runners: Is Inflammation the Cause or a Symptom? John Fiore, PT As spring and summer mileage increases, lateral knee pain is a common running overuse injury. The iliotibial band (see figure 1), is a large fibrous connective tissue band extending from the tensor fascia latae and gluteal musculature. A commonly known cause of lateral knee pain in runners is iliotibial band friction syndrome (ITBFS). Traditionally, diagnosing ITBFS included assessment of iliotibial band tightness, pain to palpation along the lateral tibia (Gerdy s tubercle), and pain to palpation along the distal IT band fibers. A common (although only partially accurate) explanation for IT band pain in runners is excessive friction of the IT band as it slides in an anteriorposterior direction as the knee moves from an extended to flexed position. i Further anatomical investigation coupled with the relatively poor short-term results in the treatment of IT band pain warrant further discussion regarding the true underlying causes of lateral knee pain and ITBFS. Figure 1: Iliotibial band pain is a familiar injury to me. Following a three-hour trail run in 2013, I experienced the stiffness and sharp pain in my lateral knee characteristic of ITBFS. Conservative treatment and rest helped initially, but I was also tapering for the Bighorn 50-mile race

3 Us: John Fiore, PT: Rachael Herynk, DPT: Jesse Dupre, DPT: Holly Warner, DPT: Jennifer Dreiling: Find Us: Sapphire Physical Therapy 1705 Bow Street * Missoula, MT Map: two-weeks later. Without adequate rest, recovery, or treatment of the underlying causes of my symptoms, I began the race. A net downhill route for the first 18 miles took its toll. By mile 20 I was unable to run and walked the next 16 miles only to drop out of the race at the mile 34 aid station. At mile 20, I felt my proximal tib-fib joint (see figure 2) pop and the tension/pain in the IT band rapidly increased. During the ensuing 16 mile walk to the Dry Fork aid station, I ruminated over the kinematics of the tib-fib joint, hip joint, knee joint (tibia-femoral), ankle joints, and presence/absence of functional strength. If the IT band is the cause, then why does my hip feel tight? If the IT band is the cause, then why does my foot and ankle feel clumsy on rocky trails? Underlying causes of lateral knee pain in the region of the iliotibial band in runners should be included in a comprehensive physical therapy assessment. Traditional treatment techniques are temporary and time consuming. The following contributing causes will facilitate a more effective long-term resolution of symptoms and a return to pain-free running. Figure 2: Our Services: Orthopedic injuries Functional strengthening Pre and post-operative rehabilitation Core strengthening & conditioning programs Back and neck pain Running overuse injury and prevention Running video gait analysis Work related injuries Functional Capacity Evaluations Work Hardening & Functional Conditioning Programs ILIOTIBIAL BAND FRICTION FACT OR FALACY The IT band is not an independent structure which slides freely over the lateral femoral condyle as many believe. The IT band is an extension of the fasciae latae which encases the upper thigh. In addition to its attachment to the tibia (Gerdy s tubercle), the IT band also has fibrous anchors to the femur, making significant movement of the IT band over the femur unlikely. ii A richly innervated layer of fatty tissue beneath the IT band becomes inflamed and painful when tension under load (running) increases through the IT band (Fairclough, it al). The cause of this tension, however, is the key to effectively treating ITBFS.

4 Cycling injuries & biomechanical bike fitting Women s health All insurance accepted & billed Cash payment option Figure 3: MUSCULAR IMBALANCE AND WEAKNESS Deep cross friction massage or aggressive ASTM or IASTM treatments may further irritate the painful region by irritating the highly innervated lateral knee region. Releasing the proximal IT band, hip musculature, gluteal musculature, and lateral hamstring musculature through manual therapy techniques (active release techniques, contract-relax, muscle energy, integrated dry needling) and deep tissue mobilization will decrease tension through the painful distal IT band by restoring tissue mobility proximally in the leg. Muscular weakness in the gluteus medius muscle results in overuse or over-compensation of the tensor fascia latae muscle (TFL). The TFL extends distally to the lateral knee via the iliotibial band. Overuse of the TFL leads to increased IT band tension and compression. Similarly, our sedentary, seated lifestyles cause hip flexor muscle shortening (psoas, iliacus, rectus femoris) lead to an anterior tilt of the pelvis resulting in ineffective gluteal muscle activation and function. Without adequate proximal stabilization via the gluteus medius and gluteus maximus musculature, foot strike will result in an internal rotation of the femur, inward motion of the knee, and increased lateral leg and IT band tension (see Figure 3). HIP JOINT STIFFNESS Hip joint stiffness decreases the efficiency with which the hip absorbs torsional forces and impact associated with running. Limited hip mobility results in increased joint compression and lateral knee tension. Chronic hip weakness and degenerative changes contribute to hip joint stiffness. Assessing the full range of motion of the hip joint may reveal an asymmetry worthy of treatment for IT band pain. ANKLE AND KNEE JOINT (TIB-FIB) STIFFNESS The more I study the kinematics of the ankle the more I realize how underappreciated the ankle is. Pronation (controlled lowering of the arch with weight bearing) is an intrinsic means to absorb shock and transfer tension and stress associated with running toward the more

5 muscular hip and knee. Ankle pronation with weight bearing results in a medial (inward) rotation of the tibia relative to the femur when the knee is flexed, and a lateral (outward) rotation of the tibia relative to the femur when the knee is extended. The fibula (lateral lower leg bone) has a proximal and distal joint attachment to the tibia. Anteriorposterior and rotational motion must occur during running in the proximal and distal tib-fib joints to effectively transfer tension through the knee and to the hip where muscle stability absorbs the impact of running. Stiffness in the proximal and/or distal tib-fib joints transfers stress and tension associated with running in the lateral knee. STRESS FRACTURE Pain in the area of the lateral knee and proximal tib-fib joint which does not respond to conservative treatment or assessment of the secondary causes of lateral knee pain warrants medical diagnostic testing. Second only to metatarsal stress fractures, stress fractures in the tibia and fibula are common due to the torsional stress through the long tibia and fibula while running. An X-ray may show a stress fracture, but the fracture may not show up on an X-ray prior to the formation of a bone callous later in the healing phase. Magnetic Resonance Imaging (MRI) may more accurately show a stress fracture but the cost is much higher. Treatment techniques, therefore, must address each of the possible contributing factors, to bring about a comprehensive, effective, longterm solution. A physical therapist skilled in exercise and manual therapy techniques specific to runners can be a source of information and treatment knowledge to get you back to your favorite running routes and and trails. John Fiore, PT john@sapphirept.com

6 Trail Running Races Sponsored By Sapphire Physical Therapy John Fiore, PT Sapphire Physical Therapy will support the Missoula running community through our trail running race sponsorship of the Runners Edge Events races as well as a few Run Wild Missoula races. Sponsoring local races helps bring high quality racing experiences to runners of all ages and abilities. Promoting healthy lifestyle choices and fitness through race participation fits well with the Sapphire Physical Therapy philosophy. We hope you will join us in participating in the below races and in supporting our local running specialty store (Runners Edge) and local running club (Run Wild Missoula)! 2016 Runners Edge Events sponsored races: -Bitterroot Runoff Races: April 30, Miles to Paradise: May 15, Striped Pig Wine Runs: June 2, Mount Sentinel Hillclimb: July 24, Snowbowl 15k: August 6, The Run Mountain Runs: September 2-4, Blue Mountain 30k: October 5, Run Wild Missoula sponsored races: -Pengelly Double Dip Races: June 4, Elk Ramble 15k: Date TBA i Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med, 1992;14(2): ii Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat, March 2006;208(3):