I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan HealthCare in Moses Lake, Washington. In this case, we're talking about iliotibial band syndrome, which, as we know, the iliotibial band runs the length of the outer thigh, attaches just below the knee joint at a prominence on the tibia called Gertie's tubercle. The more proximal attachment is in conjunction with the tensor fasciae latae muscle, which sits more on the front side of the pelvis. And its action is to help with walking, position transfer, running, jumping, all of those things. So we see a lot of IT band syndrome in runners, in basketball players, and anyone that's having to do a lot of impact exercises. One of the tests that help us to determine if the IT band is truly the problem and not just the tensor fasciae latae is to do Ober's test. Ober's test requires that one leg, the bottom leg, if they're laying in a lateral recumbent position, the bottom leg is brought forward. The knee and hip are flexed up towards the upper torso. And the leg that we're testing is elevated. The hip brought into extension. The knee is maintained at flexion, about 90 degrees. And then we ask the patient to just relax. And that knee should drop down. And if it goes all the way to the table and there's no pain or no sense of tightness as we stretch on that IT band, the test is negative. But in this case, they have IT band syndrome. And so this type of testing will induce pain, recreate the symptoms that they're having all along the lateral thigh, and a lot of times along the lateral knee joint. Treatment always consists first, especially when we're dealing with the areas of the pelvis or other sensitive areas, with consent and information. Educating the patient on where you're going to be working, why you're going to be working there, and that they understand and give you permission to do so. Also, in this situation, if you're working with someone of the opposite gender or sex, that you make sure to ask them if they would prefer a chaperone present while treatment is being performed. All of those are for the patient's safety as well as your own. Now when we're treating, there's different approaches and thoughts. Do we use muscle energy, which is just going back into that Ober's test, stretching, and then having the patient lift their knee up towards the ceiling against your own resistance, doing that for two to three seconds and then relax, and then stretching further after the point of relaxation, and doing that several times? We could do a deep tissue, where we get in and use our thumb or a finger to really scrape along, starting at the tensor fasciae latae, going into the iliotibial band, and scraping along the fascial plane all the way down to GERDI's tubercle. Again, this can be an area that you need to maintain appropriate consent and awareness by the patient that what you're trying to do is treatment. That scraping can also be quite painful. So you also need to alert the patient that it is going to be painful. And if you're deep enough to get to that fascial layer, not just above the IT band, but also underneath it, the amount of force can induce some capillary reaction or bruising. So the last thing we want is for the patient to go home, and they're getting ready in the morning or getting ready at night, and then they see this large bruise down the outside of their leg, and you didn't tell them anything about that. So that's part of the informed consent of what we're doing as well. However, the mode of treatment that I prefer is a technique called facilitated positional release. And that's where we come in, and we'll grasp on the iliotibial band. You can either start proximal and work your way distal, or vice versa. And with both hands, you're compressing down on the structure that's being treated. In this case, if we're starting proximal, you're going to grasp and compress on the TFL, as well as the more proximal portion of the IT band. Compress, add in some torsion, as well as compression together, until you find a point where it feels that the tissue, the tendinous tissue, the fascial tissue, as well as the muscles, are starting to relax. Once you're at that point, then you add in a quick stretch. So moving your hands away from each other. So this is what it looks like, as I come in and I'll compress, gathering on the tensor fasciolata. More proximal, on my cephalad hand. On my caudad hand, the one closest to the feet, I come down and compress on these tissues. Compress down, compress together, then add in some torsion to find that spot that gets relaxation. And once I'm there, I hold for a second, and then I add a quick motion of my hands away from each other to get a quick stretch. And then I'll do that at separate points all along the tensor fascia and the IT band, all the way down to the knee. Again, this is something you need to make the patient aware of what the purpose is, and that's to treat the tissues. It's also a technique that can be repeated several times, like some of the other treatments with counter strain or muscle energy. I would typically do this three to four times, starting proximal, going distal, and then going distal to proximal, and then repeat that again so I get four good treatments. Then have them stand up and do whatever actions that had been inducing the pain, such as jumping, running, or stretching, and see how much pain was left after the treatment. Typically, it's a treatment that will have to be done periodically over a course of six weeks, periodically meaning once a week or once every other week. And then, of course, the biggest part is educating the patient that they need to be doing the stretching exercises on their own at home to help complete the recovery.

3rd Edition, CASE 28

3rd Edition

Knee

iliotibial band syndrome

Ober's test

muscle energy techniques

deep tissue massage

athlete recovery