Pilates: Iliotibial Band Syndrome Prevention Program for Long Distance Runners Name: Carla A Villarroel Date: June 12, 2014 Location: Brooklyn NY, Physiologic.
Abstract. I encountered my first running injury two years ago, it was a combination of rookie mistakes, poor training techniques but the most important of all muscle imbalance. After a 2 months out of running, 8 weeks of physical therapy you start wondering, could I prevent this? Will this happen again? How can I increase my mileage and performance without getting hurt? It is no secret that the key of running performance can not be restricted as just running, however is a common mistake to see runners not incorporating strength routines to their training, which can improve your running performance but also prevent injuries causes for muscle imbalance. 40% of injuries in runners are knee related, some of them easily preventable. As running gets popular the increase of this type of injury unfortunately will be seen more and more often. 2
Table of Contents Abstract...2 Ilotibial Band Syndrome...3 Diagram...5 Case study...6 Conditioning program with BASI approach...7 Conclusion...14 Bibliography...15 3
Iliotibial band syndrome (ITBS) ITBS is one of the most common injuries seen in runners, accounting for 8-10% of all injures. It's characterized by pain along the lateral aspect of the knee. This pain is often described as sharp or burning, and usually occurs during or after a long run. The iliotibial (IT) band is a long band of fascial tissue that runs along the lateral aspect of thigh. It connects a portion of the gluteus medius and the tensor fasciae latae to the proximal lateral tibia, functioning to stabilize the runner's knee during footstrike. The lateral knee pain of ITBS if a result of an overly tense IT band producing friction at the lateral femoral condyle during repetitive flexion/extension of the knee. A host of factors have been implicated in causing ITBS in runners; these can be divided into factors intrinsic and extrinsic to a runner's anatomy. Intrinsic factors thought to play a role in causing ITBS include: 1) weak core muscles, 2) hip abductor muscle weakness or imbalance, 3) dominance of hip flexor muscles over hip extenders, 4) flat feet or high arches, 5) deformities of the knee (bow legs or knock knees), and 6) leg length inequality. Extrinsic factors blamed for causing ITBS include: 1) sudden changes in training routines (increased mileage, hill-work, or intensity of training), 2) over-striding, 3) worn out running shoes, 4) failing to warm up or cool down, or 5) running on crowned running surfaces. Recent research has focused on hip abductor and external rotator weakness as causing ITBS. Results show, for example, that 91% of runners who experience ITBS have been found to have weak hip abductors. So why does the IT band get tense? A healthy and strong gluteus medius works to abduct and externally rotate the hip, limiting strain on the IT band. The tensor fasciae latae (TFL) is a secondary muscle which assists in hip abduction; it also functions to stabilize the knee. As mentioned, both the gluteus medius and the TFL 4
attach to the IT band before it crosses the lateral condyle of the femur. Under normal circumstances, nerve sensors embedded in the lateral condyle are stimulated by increased tension of the IT band. These signals tell the gluteus medius to fire, thus restoring external rotation of the hip and relaxing the IT band. When the gluteus medius is weak or fatigued, however, the resultant internal rotation of the hip causes increased friction of the IT band as it passes over the lateral condyle during knee flexion/extension. To make matters worse, under extreme IT band tension, the nerve sensors at the lateral condyle get crushed (they don't fire) causing a loss of the feedback loop, exacerbating IT band tension. Now the smaller TFL is now called upon to abduct and externally rotate the hip, causing even more tension of the IT band. 5
Case Study. Most patients will go home with a list of stretch and strength exercises that at long term will be boring and not challenging, maintenance will turn to be a key factor. As a rehabilitated patient of ITBS my major concern was getting back there and not get injured again, after a little while I realized regular fitness program wouldn't offer what my body needed it. Name: Carla (self) Age: 38 Injuries: Rehabilitated patient of ITBS (left knee). Two ankle sprains in the last 3 years (both legs). Hamstring strain a year ago (left leg). No surgeries or major health issues Fitness level: Active. She runs around 33 miles per week (three time per week, a combination of different distances with one longer run), takes two boxing classes, one body conditioning (with weights) and two to three classes of Pilates a week. She races regularly and complete her first marathon last November. Pilates level: Intermediate. Posture: A recent x-ray showed not major deviations in the coronal plane, however it did show a decrease in the normal degree of the curvature in the lumbar spine or flat back (from the saggital plane). In addition to that, her shoulders tend to round forward (round shoulder syndrome). Limitations: Problem at the time to execute back extension. Her back is not flexible. Other considerations: After long runs, she tends to get tied mostly in the hamstrings and calves. Special attention should be considered if the session is after or before a long run session. 6
Conditioning Program from BASI perspective. The goals of this program will be focus on: 1. Maintenance of an overall healthy knee reinforcing strength hip abductors, hip adductors, hip flexors, hip extensors, hip rotators (specially gluteus medius), knee extensor and knee flexors, 2. Core strength to help stabilize hip complex and lower back. 3. Stretch. Allowing muscle to work in full ROM preventing imbalances and unwanted compensations in the kinetic chain. 4. Stretch of shoulder extensors and strengthening back extensors for posture of upper back. Reformer: 1. Foot work: Option 1: Parallel heels, parallel toes, V position toes, open V heels, open V toes, calf raises, prances, prehensile. Option 2: V position toes, open V heels, open V toes, single leg heel, single leg toes. 2. Abdominal work: Option 1: Hundred prep, hundred and coordination. Option 2: Climb a tree, abdominal leg in strap series; double leg and double leg with rotation. Option 3: Short box series: round back, flat back, tilt and twist. 3. Hip Work: Opening, circle up and down, extended frog, extended frog reverse. 4. Spinal articulation: Option 1: Long spine, short spine. Option 2: Bottom lift and bottom lift with extension. 5.Stretches: Side split and Hamstring stretch group. 7
Option 1: Standing lunge Option 2: Kneeling lunge. Option 3: Full lunge. 6.Arm work: Option 1: Sitting series: Chest expansion, biceps, rhomboids, hug a tree, salute. Option 2: Rowing back 1 and rowing back 2. 7. Full Body integration: Option 1: Up stretch 1, elephant. Option 2: Stomach massage flat back and stomach massage reaching. Leg work: Option 1: Hamstring curl. Option 2: Single leg skating. Lateral Flexion/Rotation: Mermaid. Back extension: Option 1: Breaststroke prep. Option 2: Pulling straps1. Option 4: Pulling straps 2.(light) Cadillac Warm up series: Roll up with roll up bar, mini roll up and mini roll up with obliques. Foot work: Option 1: Parallel heels, parallel toes, V position toes, open V heels, open V toes, calf raises and prances. Option 2: V position toes, open V heels, open V toes, calf raises, prances, single leg heel and single leg toes. 8
Abdominal: Bottom lift with roll up bar. Hip work: Option1: Frog, circles up and down, bicycle and walking. Option 2: Single leg supine: frog, circle up and down, hip extension and bicycle. Spinal Articulation: Monkey original and tower prep. Stretch: Shoulder stretch. Full body integration: Option 1: Sitting forward (push through group) and side reach. Option 2: Kneeling cat stretch. Arm work: Option1: Arm standing series: chest expansion, hug a tree, circles up and down, punches, biceps and butterfly. For triceps please go to Wunda chair. Option 2: Shoulder adduction double arm. Leg work: Wunda Chair. Lateral flexion/rotation: Wunda chair or Step barrel. Back extension: Prone 1. Wunda Chair Foot work: Parallel heels, parallel toes, V position toes, open V heels, open v toes, calf raises, single leg heel, single leg toes. Abdominal work: Option 1: Standing pike, torso press sit. Option 2: Standing pike reverse, torso press sit. Spinal articulation: Pelvic curl. Lateral flexion/rotation: Side stretch. 9
Leg work: Hip opener and backward step down. Back extension: Swan basic. Avalon Arm work: arm sitting series; chest expansion, biceps, rhomboids, hug a tree, circle up, circles down and salute. Ladder barrel Stretches: Shoulder stretch lying side. Back Extension: Swan prep. Leg work Option 1: Gluteal side lying series: Side lift, forward and lift, forward with drops. Option 2: Gluteal kneeling box series: Hip extension bent knee, hip abduction bent knee and hip extension straight leg. This was an election of exercises considering the goals, I wrote it as a mini block system for this particular client, so I can easily adjust the program according with the day and what kind of load this runner put on herself the day before a session. In addition to the two sessions of Pilates a week, she will be doing certain mat exercises by herself, that will give an extra boost to her core and flexibility. For a healthy knee program, foot work is essential, I am aware of the inclusion of three pieces of equipment, because of the different benefits they provide, the foot work in the reformer is excellent source of muscle strength and endurance, for this client, maintain her neutral pelvis through the exercise has benefit her spine. In the cadillac, allows to focus in alignment, pelvis stability and hamstring stretch, good muscle activation after a long run and in the Wunda chair the knee extensor control and engaging abdominal work. Hip work in the cadillac (single leg supine) for pelvis stabilization and hip extensor (hamstrings) and hip adductor or basic leg springs is a great option for 10
hip stabilization and hamstring work. Standing lunge and kneeling lunge for hamstring and hip flexor stretch, it also allowed the client to focus in the alignment of the knee and the position of the pelvis. For gluteus medius, I introduce single leg skating, backward set down for hip extensor and abductor control, gluteal side lying series (side lift, forward and lift, forward with drops) and from gluteal kneeling series hip abduction bent knee. In the abdominal work place a 3 option set with different rage of motion: hundred prep, hundred and coordination for flexion and lattisimus dorsi control, short boxes series for its co contraction of the back extensor and abdominal. Torso press sit in the Wunda chair for the same reason plus extra extension of the chest. Several exercises included in this program has some multiple function: Up stretch 1 and elephant provide a hamstring and shoulder stretch while working abdominals and back extensors. Stomach massage flat back for back extensors and abdominal with plantar flexor strength necessary for runners, plus extra stretch of the chest. Monkey original also allows to work in mobility with a hamstring and calf stretch. In this case the back extension program will have to be close accompanied by shoulder stretch and scapula stabilization,swan prep in the Wunda chair is a great combination for back extensor strength and scapula stabilization. Swan prep in the ladder barrel emphasizes the upper back and shoulder stretch lying side to finish. Pulling back 1 and 2 for strength. The stretch of the chest will allow a better posture and a more efficient breathing cycle through the open up of the thoracic cavity. No running program will be complete and if I would not address the upper body, the sitting series in the reformer and arm sitting series in the Avalon will be working on rhomboids (scapula stabilizators) and latissimus dorsi for better running posture specially in the later stage of a long run, hug a tree, salute and biceps for a complete arm work. 11
Session 1. Warm up: Pelvic curl, chest lift, chest lift with rotation, leg changes Reformer: Parallel heels, parallel toes, V position toes, open V heels, open V toes, calf raises, prances, prehensile. Abdominal work: Hundred prep, hundred, coordination. Hip work Opening, circle up and down, extended frog, extended frog reverse. Spinal articulation Long spine, short spine. Stretches: standing lunge, side spilt. Arm work: arm sitting series; Chest expansion, biceps, rhomboids, hug a tree and salute Full Body integration: Up stretch and elephant. Leg Work: Single leg skating. Lateral flexion rotation: Mermaid. Back extension: Pulling strap 1 and 2. Cool down: Roll down. Session 2: After long run Warm up: Pelvic curl, legs changes, roll up with bar, roll up bar with oblique. Cadillac Foot work: Parallel heels, parallel toes, V position toes, open V heels, open V toes, calf raise and prances. Abdominal: bottom lift with roll up bar. Hip work: frog, circle up and down, bicycle and walking. Spinal articulation: Monkey original Stretch: shoulder stretched. Full body integration: Sitting forward and side reach. Leg work/wunda chair: Hip opener and backward step down. Lateral Flexion/rotation Wunda chair: Side stretch Back extension/ Wunda chair: Swan basic. Cool down: gluteal and roll down Session 3 Warm up: Pelvic curl, chest lift, chest lift with rotation. Foot work Reformer: V position toes, open V heels, open V toes, single leg heel, single leg toes. Abdominal: Short box series: round back, flat back, tilt and twist. Hip work: frog, openings, circle up and down. Spinal articulation: bottom lift and bottom lift with extensions. Stretches: Side split and kneeling lunge.arm work: Rowing back 1 and rowing back 2. Full body integration: Stomach massage and stomach massage reach. Leg work: single leg skating and hamstring curl Lateral flexion/rotation: side over box. Back extension: Breaststroke prep. 12
Session 4. Warm up: Pelvic curl, Chest lift, Chest Lift with rotation, spine twist supine Foot work Wunda Chair: Parallel heels, parallel toes, V position toes, open V heels, open V toes, single leg heel, single leg toes. Abdominal work: Standing pike, torso press sit. Hip work Cadillac: Single leg supine; frog, circle up and down, hip extension and walking. Spinal articulation: Monkey original. Arm work: Arm standing series: chest expansion, hug a tree, circle up and down, punches, biceps. Lateral flexion rotation: Butterfly. Full Body integration: Sitting forward and side reach. Leg work: Backward step down and hip opener. Back extension Ladder barrel: Swan prep. Cool down: Shoulder stretch lying side and roll down. The client will be incorporating gluteal side lying series and gluteal kneeling box series in her work out routine once a week. 13
Conclusion. I have incorporated Pilates has part of my training for more than a year, at the very beginning it was focus in ITBS prevention and healthy knees overall, but luckily it turned in to something else, something better. In time, I realized how my core become stronger, my flexibility improve and gave me awareness of what I should be working next in order to enhance performance. Tightness and muscle imbalance are one of the two big enemies of the long distance runners, two elements that can be easily address with the introduction of Pilates in their training schedule. Not only I have been injury free since I started this program, my personal best has drop consistently and mileage has been increasing gradually pain free. 14
Bibliography. Running Anatomy, Joe Puleo and Dr Patrick Milroy Human Kinetics, 2010 Pilates Anatomy, Rael Isacowitz and Karen Clippinger Human Kinetics, 2011 The concise book of muscle, Chris Jarmey second edition, Lotus publishing 2008 Iliotibial band syndrome: cause, cure and your core by Stephen M Pribut, DPM, May 25, 2014. Iliotibial band friction syndrome by Ronald Lavine Biomechanics and analysis of running gait by Sheila A Dugan MD and Krisna P Bhat MD Department of Physical medicine and rehabilitation, Rush university medical center. A runner's guide to ITBS by Ann Schofield, PT MCSP. BASI Study Guide, comprehensive course by Rael Isacowitz http://breakingmuscle.com/mobility-recovery/your-it-band-is-not-the-enemy-but-maybe-your-foamroller-is by Robert Camacho http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/iliotibial-band-syndrome http://www.runnersworld.com/health/big-7-body-breakdowns?page=single 15