RECOVERING FROM ILIOTIBIAL BAND SYNDROME IN FEMALE RUNNERS

RECOVERING FROM ILIOTIBIAL BAND SYNDROME IN FEMALE RUNNERS Huibri Schalkwyk November 2017 Course Date: 25 January 2017 Pretoria, South Africa

This research paper addresses the benefits of an ongoing BASI Pilates program that assists in prevention and recovery of Iliotibial Band Syndrome also known as ITBS or ITB, in female runners. Iliotibial Band Syndrome is most common in cyclists and runners - especially in female runner s - due to the overuse of the connective tissues that are located on the outer knee and thigh. I was first diagnosed with Iliotibial Band Syndrome after completing the Soweto Marathon. A reoccurring pain on the outside of my knee continued to worsen throughout my training and completion of this 42.2km race. Rest was prescribed by my physio at the time. I took a year of running while pregnant. However, my Iliotibial Band Syndrome continued to worsen through my pregnancy and through the first 2 years of my daughter s life. After attempting to train for the 2017 Two Ocean marathon the injury worsened and I was forced to stop running and start Pilates to prevent any further long-term damage to my knees. This is where my Pilates journey started and contributed to reduced pain in my knees, making it possible to pick up and carry my toddler pain free. 2

TABLE OF CONTENTS PAGE NUMBER WHAT IS THE ILIOTIBIAL BAND? 4 WHAT IS ILIOTIBIAL BAND SYNDROME? 5 SYMPTOMS 6 ILIOTIBIAL BAND SYNDROME TREATMENT 7 CASE STUDY 9 RECOMMENDED BASI PILATES PROGRAM 10 OUTCOME 16 BIBLIOGRAPHY 17 3

WHAT IS THE ILIOTIBIAL BAND? The Iliotibial Band is the fascia (also known as connective tissue) that runs down the outside of the thigh from the pelvis, across both the hip and the knee and is attached at the top of the Tibia also known as the shinbone. If starts from the Tensor Fascia Lata and you Gluteal Medius and Gluteus Minimus muscles. The purpose of the Iliotibial Band is to assist in stabilizing as well as move the joint through its range of motions. The Iliotibial Band forms part of one of the hip abductor muscles that is used to move the hip away from the midline. It also assists in both knee flexion as well as knee extension. 4

WHAT IS ILIOTIBIAL BAND SYNDROME? Iliotibial Band Syndrome is one of the top 5 injuries experienced in runners over 30 years of age and woman are more at risk to develop Iliotibial Band Syndrome. Iliotibial Band Syndrome is inflammation of the Iliotibial Band that is considered an overuse injury of the fascia that is located on the outer part of the thigh and knee. It is caused by the rubbing of the of the Iliotibial Band on the outside of the knee as it rubs against the outside of the knee joint. Athletes with a genetically wider Iliotibial Band or naturally tight band will have a higher chance of developing Iliotibial Band Syndrome. Another significant factor is weak hip abductors, particularly the gluteus medius and tensor fascia latae that assists in preventing the inward movement of the knee when running. A bursa found on the Condyle assists the Iliotibial Band to glide smoothly across the knee joint when the knee is extended. However, should inflammation occur in this area, then the movement when flexing and extending the knee can cause increased friction from repeatedly rubbing the Iliotibial Band against the outside of the knee joint. This can cause pain on the lateral part of the knee joint. The pain might not be too severe in the beginning and runners tend to continue to run through the pain. When ignoring the symptoms, the inflammation will continue and scarring might develop in the bursa or sac that will increase the pain, decrease activity and 5

decrease the knees full range of motion. The pain will progress over time until the runner will be forced to stop running and seek medical attention. SYMPTOMS The most common sign of Iliotibial Band is pain on the outside of the knee. More specifically around the lateral epicondyle of the femur. This can be accompanied by swelling and even slight bruising that is tender to touch in the same area. This can cause runners to believe that they have a knee injury and prevent them from treating the source of the pain. A way to test if you might have Iliotibial Band Syndrome is to bend your knee to 45 degrees, if you experience pain on the outside of your knee then the chances are high that you have an Iliotibial Band problem. A tightness in the Iliotibial band is another symptom of Iliotibial Band Syndrome. Weakness during hip abduction can also be a common sign of Iliotibial Band Syndrome. Some runners also experience tender trigger points in the gluteal muscles. The pain will gradually increase over time and tends to start at a certain time or distance during a run and gradually gets worse. The pain can be aggravated by running downhill, running on the same side of a cambered road, running too many laps in the same distance around a track or simply running too many kilometers too quickly. Unlike many running injuries, seasoned runner s chances of afflicting of Iliotibial Band pain are almost as high as with beginner runners. 6

If any of these symptoms are present then it is recommended to stop running or drastically reduce your mileage until you consult with a doctor or physiotherapist. Other parts of the legs like the Quadriceps, Hamstrings and even the Calves can experience tightness while trying to over compensate for the tightness and pain experienced in the Iliotibial band. ILIOTIBIAL BAND SYNDROME TREATMENT If Iliotibial Band Syndrome has been diagnosed then rest will bel the first step on the road to recovery. Rest is recommended to allow the inflammation in the tendon to heal. When runners decide to not rest but continue to train then the inflammation will most likely increase. This can also cause chronic Iliotibial Band Syndrome. Initially complete rest is recommended but cross training and other exercise is recommended at a later stage to maintain fitness and muscle strength. Sport massaging or dry needling can also assist, if resting does not reduce the pain, in loosening or relaxing the tightness in the Iliotibial band and assist in pain management. Recovery can take weeks to months to full activity without pain. Patience is a key ingredient in your Iliotibial Band Syndrome recovery plan. It is recommended to introduce stretching, strengthening and foam roller exercises into your recovery plan after a few weeks. 7

Stretching of the hip in particular is important to reduce the tightness and reduce the friction on the side of the knee. Keeping muscles stretched is important in preventing and reducing musculoskeletal injuries such as I Iliotibial Band Syndrome. Foam roller exercises on the gluteal muscles down the of Iliotibial Band can assist in stretching the Iliotibial Band while removing any tight knots and spots and reducing friction on the side of the knee. Strengthening exercises will improve the muscles on the outside of the hip that assists in abduction of the leg. This will assist in preventing the knee from turning inwards when walking or running and therefore reduce the friction causing Iliotibial Band Syndrome. Strengthening exercises of the Gluteus Medius are crucial. Pilates is recommended for the recovery and prevention of the return of Iliotibial Band Syndrome. It can also be used to identify and correct errors in training and running techniques to prevent Iliotibial Band Syndrome in the future. Maintaining flexibility and strength of the lower back, hips, knees and leg muscles is important to avoid recurrence. 8

CASE STUDY Subject Huibri Schalkwyk, 33 year old female Iliotibial Band Syndrome was first diagnosed following the 2012 Soweto Marathon. After physiotherapy and resting for approximately 11 months running was commenced. Pain on the outside of the leg was always present and increased when distance was increased to more than 21km. ITBS increased due to carrying of my toddler on one hip only as well as increased distance while training for the 2017 Two Oceans Ultra Marathon. Training had to be stopped following a 32 km run and crippling knee pain. A physiotherapist was visited 2 days later and rest was recommended together with dry needling and stretching exercises. Following a 3 week physiotherapy program Pilates was recommended to further strengthen muscles. It was recommended that I do not run again or drastically reduce mileage due to permanent damage and scared tissue. I have tried to run again and ran a 21km race in August. Following a setback in my recovery due to the race I have decided to stop running indefinitely and follow the below training program. The below recommended plan would have been my approach following my initial injury and and is an essential part of my ongoing recovery. This will assist in strengthening my muscles especially my leg, glute and hip muscles. Strengthen abdominals and upper back muscles to assist in keeping my body symmetrical and improve my overall posture and distributing my weight throughout my body. 9

RECOMMENDED BASI PILATES PROGRAM BASI BLOCK WEEK 1 10 WEEK 11-16 Warm Up Roll Down Roll Down Fundamental Warm Up Building up strength and the Pilates fundamentals including breathing, correct activation of the correct muscles, form, body awareness and precision is essential. Feet can be supported on a ball at a 90-degree angle if the smaller angle hurts the knees while doing chest lifts and chest lifts with rotation while the inflammation is healing. Foot Work Week 1 5 Reformer: Foot Work Series The support of the reformer assists in making it easier to focus on keeping the knee and heel aligned to prevent further injury while activating and strengthening the hamstrings. The objective is also hip extensor strength and knee extensor strength that is key for recovery of ITBS. Week 6 10 Wanda Chair: Foot Work Series The Wanda chair foot work series offers more of a challenge to the client without adding additional strain on the knees and legs especially the Intermediate Warm Up As the client shows improvement in their recovery and increase in strength the warm up can be increased to the intermediate warm up as long as they can show control and maintain form. Alignment and core connection should at all times be monitored and maintained. Cadillac: Foot Work Series Introducing the Cadillac foot work series will be a new and aditional challenge. The client s hamstrings might have been too tight to maintain form while performing these exercises. It is important to ensure the knees stay aligned with the ankle at all times. It is more important to keep neutral and maintain the alignment than straight extended legs. 10

hamstrings that might also be tight. Abdominal Work Week 1 5 Reformer: Hundred Prep building up to Hundreds (depending on strength of client) Good alignment and core activations while the carriage offers support. The knee is at a 90-degree angle that should not cause any discomfort. The objective of Hundreds is also Pelvic Lumbar stabilizations that can assist in strengthening the pelvis to assist in keeping the pelvis, hips and knees aligned. Cadillac: Breathing with Push Through Bar This exercise will assist in improving coordination, balance and breathing that can ensure the brain is more aware of the body and the body alignment, to try and create awareness around their running style and being aware of their body while training. The Spinal articulation also assists in lengthening the spine and improving overall posture and alignment. Week 6 10 Wanda Chair: Cat Stretch Kneeling Maintain hip alignment over the knees while performing the exercise and keep the Femurs up right as long as possible. The back extensor control will assist in achieving a better posture that will assist with the overall alignment and symmetry of the body. Hip Work Week 1 5 Reformer: Supine Leg Series This is an essential series in the plan with the objectives including hip adductor strength, stretch and control, knee extensor control as well as pelvic lumber stabilization. Cadillac: Basic Leg Springs This series offer less support and requires more control from the client. It also adds additional hip extensor strength and control that will assist in the recovery process. 11

Week 6 10 Step Barrel: Supine Leg Series Objectives include hip flexor control, stretch and strength, hip abductor stretch and control, hip extensor control and stretch as well as hip joint mobility and control and pelvic stability. All of these are objectives that needs to be met during the recovery process. Spinal Articulation Week 1 5 Reformer: Bottom Lift and Bottom lift with extension The muscle focus is on the hamstrings and abdominals, however the glutes must also be activated. The objective is hip extensor control while maintaining the heel and knee alignment. Reformer: Short Spine This ads to abdominal strength and spinal articulation while providing a hamstring stretch. Week 6 10 Step Barrel: Roll Over This offers hamstring stretch and lower back stretch while offering the necessary support while building up strength. Stretch Week 1 5 Ladder Barrel: Selecting 1 of the following stretches that focuses on each of the muscles included in the exercise name: Gluteals Hamstrings Adductors Reformer: Side Split Assisting with hip adductor stretch and strength. If the client does feel their knees then they can go into a slight external rotation of the feet. 12

Week 6 10 Selecting 1 of the below exercises Reformer: Hamstring Stretch Group Standing Lunge Stretching hamstrings and hip flexors Kneeling Lunge Addressing hamstring strength and assisting in hip flexor strength Full Lunge The objective is hip flexor stretch and hamstring strength Full Body Integration 1 (fundamental + intermediate) (The flow during week 6 10 is not ideal but the exercises are selected for best results. Week 1 5 Cadillac: Sitting forward Hamstring stretch while focusing on the abdominals Week 6 10 Reformer: Stomach Massage Series The key objectives in all 3 of the exercises are knee extensor strength as well as ankle plantar flexor strength that can also assist their running style. Arms Week 1 5 Cadillac: Arms standing series Overall workout for the shoulders and pectoralis major Reformer: Up stretch 1 Offering a deep hamstring stretch while working on trunk and shoulder stabilization. Reverse Knee Stretch Key objective is hip flexor strength while offering a strong abdominal workout. Reformer: Arms Supine Series Full body workout without kneeling on the knees directly. 13

while focusing on trunk stabilization without any unnecessary flexion or extensions of the knees. This series also offers an intense abdominal workout to improve abdominal strength and control. Full Body Integration 2 (Advanced) Week 6 10 Cadillac: Shoulder adduction Single as well as Double Arm. Focusing on the Latissimus Dorsi to ensure a full body workout without applying unnecessary pressure on the knees. Not recommended in the first 10 weeks Leg Work Week 1 10 Rotate between the following 3 series Without additional ankle weights in first 5 weeks Gluteals Side Lying Series It is essential in the recovery and prevention series to increase Gluteus Medius strength (Depending on client) Reformer: Long Back Stretch While focusing on the triceps strength it is also an excellent exercise to improve Hip Extensor Control. Wanda Chair: Frog Front The muscle focus being on hip external rotators that are required to strengthen and prevent future ITBS. It also assists knee extensor control and hip external rotator control that Is important. Gluteals Kneeling Series While focusing on strengthening the Gluteus Medius it is also focuses on Hip extensor and adductor strength Magic Circle Prone series This series assists in strengthening knee flexors, hip 14

extensor and hip adductors. A winning series for ITBS recovery Lateral Flexion Week 1 5 Mat: Saw An intense stretch of the hamstrings as well as improving back extensor control and abdominal oblique control working towards a better posture and body alignment Wanda Chair: Side Stretch Improve abdominal strength with oblique emphasis to assist with body alignment and symmetry. Week 6 10 Mat: Corkscrew Strengthening the abdominals while assisting in achieving hip flexor control Back Extension Week 1 5 Mat: Back Extension Finish of the session with a basic back extension exercise to ensure the fundamentals behind a back extension is understood without putting strain on the lower back. Wanda Chair: Swan Basic Finishing off with back extension while also focusing on abdominal control. Week 6 10 Mat: Single leg kick The muscle focus is on hamstrings while finishing off the session with working towards strength in the upper back extensors. 15

OUTCOME By strengthening my Gluteal Medius muscles and stretching all leg muscles my knees are almost pain free and my legs are stronger than before. My Iliotibial Band is less tight and my knee is not swollen or bruised. As a result of my Pilates training my hamstrings are less tight and allows me to be more flexible and stronger. My overall body posture has improved and I have grown an additional 2cm s due to a better posture in the past 12 months. I have decided to not run again to prevent any further long term damage to my knees and having an impact on my Pilates career but have incorporated Spinning into my exercise plan to ensure my fitness levels stay up while improving my strength and flexibility by doing Pilates. I agree with the wise words of Joseph Pilates: In 10 sessions you ll feel the difference, in 20 you ll see the difference, and in 30 you ll have a new body. Joseph Pilates, 1920s 16

BIBLIOGRAPHY https://www.medicinenet.com/iliotibial_band_syndrome/article.htm#what_is_iliotibial_ba nd_it_band_syndrome - Medical Author: Benjamin Wedrop https://www.medicinenet.com/image-collection/iliotibial_band_itb_picture/picture.htm https://www.runnersworld.com/injury-prevention/essential-exercises-for-it-band - Brook Benten June 21 2017 https://www.runnersworld.com/it-band-syndrome http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/iliotibial-band-syndrome http://www.mapleclinic.ie/bloghome/running-injuries-common-in-your-30s/ - September 30 2016 http://www.azquotes.com/quote/866736 - Quotes by Joseph Pilates Author and date information supplied where available 17