ITB Syndrome: Knee Pain in Cyclists and Runners


 

shutterstock_277232012A mild ache down the leg and a sharp sting of the lateral knee is two descriptions which follow the presentation of iliotibial band syndrome. Often confused with other pathologies of the upper leg such as sciatica, ITB syndrome is common amongst runners and cyclists. In this article we look at the role of the ITB and how it is best managed when causing you grief.

The iliotibial band or ITB is a thickening of the fascia latae of the thigh. It originates at the greater trochanter (hip) as an intertwining of the glute max, glute med and the tensor fascia latae. It is a densely fibrous connective tissue which passes along the thigh distally and inserts proximally to the knee joint and more distally to the head of the tibia.
From a functional stance, the role of the ITB may change dependant on the position of the knee. If the knee is in full extension or less 20-30deg of flexion the ITB will function as an active knee extensor. Once the knee passes the 20-30deg flexion the position of the ITB insertion changes relative to the femoral epicondyle and acts as an active knee flexor.

ITB Syndrome is seen as being a result of repetitive flexion/extension moments causing fraction of the band over the lateral femoral condyle. Runners are said to experience this condition at ground contact due to the position of the knee at this time beginning approximately 30degrees, the same measurement associated with the ITB passing through an impingement zone and the same time the ITB changes its role from extensor to flexor activation.
Changes in force around the region can be seen to reduce the risk of ITB syndrome. In a comparison of runners and cyclists, looking at when the individuals are at 30degrees, it was found that cyclist spend 50% less time in the impingement zone than runners, with 17 – 19% reduction in force, potentially explaining the reduction in prevalence amongst cyclists. Furthermore, runners with decrease their stride length most often when there in a change in terrain such as hills and cambers leading to an increase in repetition and force production (Strauss, Kim, Calcei, & Park, 2011).

Activity Modification
Activity and equipment modification are the primary changes which need to made in the management of ITB syndrome, at least until the individual is pain free. This may mean ceasing activities such as running and cycling and replacing them with low impact activities of the lower body such as boxing, swimming and paddling. Additionally, adjusting the used equipment such as bike set up and footwear choices can also show to improve patient symptoms.

Medications
NSAIDs can be used to reduce pain levels, however, these should only be used for a limited time as they can have effects on other body systems but as always paracetamol should be the first point of call with pain reduction.

Soft Tissue Therapy
The use of soft tissue therapy is also highly recommended. Massage, both self-complete and practitioner based is beneficial for the reduction in muscle tightness and fatigue. Stretching the muscles and connective tissues will also cause a reduction in the soft tissue adhesions.

Biomechanics
Completing a full biomechanic assessment is best practice to understand what other unidentified forces may be playing a role on the individual’s complaint. Poor glute control and activation may be contributing through medial rotation of the thigh. Additionally, the motion of the foot, the amount of pronation and its impact further up the chain should be addressed, either through strength and conditioning or orthotics, better yet BOTH!

Strengthening
Strength and conditioning should be highly dependent on what has been identified as an issue through dynamic assessment. Functional deficits should be address in a way which not only provides the best outcome for a patient but also encourages the best likelihood of compliance.

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In Conclusion, like any injury or niggle for that matter, the best approach is to get onto it early. Addressing a situation which may be as simple as changing your runners or bike set up may mean less time in recovery and more time doing what you love!
Having yourself assessed and a management plan put in place will not cause more harm, it will pick up on weakness in you training load or daily life which need to be addressed or leave you confident that everything you are doing is correct – bar the missed rest day.

Until Next Time

Jackson McCosker
Director/ Chief Editor

 

References

Falvey, E., Franklyn-Miller, A., Bryant, A., & McCroy, P. (2009). Illiotibial Band Syndrome: An Examination of the Evidence Behind a Number of the Treatment Options. Journal of Medicine and Science in Sport, 1 – 8.

Jelsing, E., Finnoff, J., Cheville, A., Levy, B., & Smith, J. (2013). Sonographic Evaluation of the Illiotibial Band at the Lateral Femoral Epicondyle. Journal of Ultrasound Medicine, 1199 – 1206.

Kraub, I., Maiwald, C., Horstmann, T., & Best, R. (2009). Kinematic Classification of Illiotibial Band Syndrome in Runners. Scandinavian Journal of Medicine and Science in Sport, 184 – 189.

Michel, F., Colombet, P., & de Lavigne, C. (2008). An Arthroscopic Technique to Treat the Illiotibial Band Syndrome. Knee Surgery Sports Traumatology and Arthroscopy.

Strauss, E., Kim, S., Calcei, J., & Park, D. (2011). Illiotibial Band Syndrome: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons, 728 – 736.

Troilo, L., & Davis, I. (2016). Successful Treatment of the Underlying Causes of ITB Syndrome. American College of Sports Medicine, 2321.

 

Tibialis Posterior Tendinopathy: Medial Foot and Ankle Pain


Ashutterstock_215893306rch and ankle pain can present in many forms. It sometimes coincides with heel pain, it sometimes results from an increase in activity and it sometimes is influenced by recent or steady weight gain. The impact on an individual’s quality of life associated with arch pain can be huge, leaving some unable to work. Due to the insertion, the Tibialis Posterior is commonly misdiagnosed as plantar fascial injury as arch pain is so commonly contributed. Below we take a closer look at the tibialis posterior and the injury which can leave an individual struggling to walk.

The Tibialis Posterior lies deep within the sub-compartment of the posterior lower leg and attaches to the medial aspect of the navicular bone and is known as an inverter of the foot. More so, the tibialis posterior is a used to reduce the speed and amount of pronation during dynamic uses. It is important to understand the multiple functions of a muscle and its insertions to ensure adequate rehabilitation. Tibialis Posterior Tendinopathy has been found to be a degenerative condition rather than an inflammatory condition and will require strengthening as part of its management plan.

Rigid tape has been found to be a more effective intervention in the reduction of pain than elastic tape when offloading the tibialis posterior (Lee, Lee, Hong, Yu, & Kim, 2015). Additionally, home based and clinic based have been found to be equally effective, however, the study did not take into account the benefits of compliance of exshutterstock_322333514ercise rehabilitation and only subjective pain reports.

When it comes to managing tibialis posterior tendinopathy, it all comes to down LOAD! In fact, controlling load is probably a more accurate way to address an injury such as this. You want to offload the region to reduce stress, you want the region strengthened to improve tolerance to stress, you want to manage the stress of the compensating regions and you want to modify any activity that may increase the stress in those areas.

–  Offload:           Tape, Orthotics, Footwear
– Rehab:               Extrinsic and Intrinsic Muscles
– Activities:         Modify all unnecessary activities to non-weight bearing
– Therapy:           Soft tissue therapy including massage, needling and mobilisation

  • Additional management options are also available in chronic or even unresponsive individuals such as ECSWT, PRP injections and Cortisone injections but these are more invasive measures.

The management of tendinopathies has begun to consolidate the benefits of exercises based training as the cornerstone for treatment over the last eight years or so. A damaged tendon loves controlled load and the continual adjustments to a patient’s rehabilitation is a necessity in developing the best outcomes. Furthermore, the use of custom orthotics to offload the insertion of the tibialis posterior tendon is recommend for the managing and attenuating load through the region. Soft tissue therapy to improve ankle joint range of motion and reduce stressors on compensatory muscles is also best when looking at the patient overall health. Using not only a diverse management structure within your own clinic but a multidisciplinary team in close communication with each other will optimize the patient’s wellbeing.

 Until Next Time

Jackson McCosker
Director/ Chief Editor

 

References

Bar, R., Brandon, M., Raffert, D., Sturrock, R., Steultjens, M., Turner, D., & Woodburn, J. (2014). Kinematic, Kinetic and Electromyographic Response to Customized Foot Orthothses in Patients with Tibialis Posterior Tenosynovitis, Pes Plano Valgus and Rheumatoid Arthritis. Rheumatology, 123 – 130.

Bek, N., Simsek, I., Erel, S., Yakut, Y., & Uygur, F. (2012). Home-Based General Versus Center-Based Selective Rehabilitation in Patients with Posterior Tibial TendonDysfunction. Acta Orthop Traumatol Turc, 286 – 292.

Lee, S., Lee, D., Hong, J., Yu, J., & Kim, J. (2015). The Effect of Elastic and Non-Elastic Tape on Flat Foot. Indian Journal of Science and Technology, 1 – 5.

Yao, K., Yang, T., & Yew, W. (2015). Posterior Tibialis Tendon Dysfunction: Overview of Evaluation and Management. 385 – 391.

Cuboid Syndrome: Sub-Laxation of the Lateral Mid-Foot


Foshutterstock_299010728ot pain can be an inconvenience and confusing at times as it will develop seemingly out of no-where. One day you are fine the next you take a step out of bad and seem to hit the roof as quickly as you hit the floor. For those who have pain on the outside (lateral) of their foot it can be even more frustrating as it very rarely lines up with what they expect for someone with a “flat feet”.

The cuboid bone is a lateral tarsal bone which is supported in part by the peroneal tendons. Cuboid Syndrome is a painful injury effecting the proximal aspect of the lateral mid-foot. It can be both acute or chronic in nature and common in those with hypermobile joints and recurrent lateral ankle sprains. A number of mechanisms of injury are possible including; direct trauma, poor rehabilitation, movement patterns and ankle sprains.
Cuboid Syndrome can be missed at times to the vague presentations and confusing pain patterns. Pain can present at the plantar, dorsal and lateral aspects of the midfoot at times and only at one of those aspect at others. This can lead to misinterpretation of symptoms by the clinician and the patient all the same and continue lead to referral of medical imaging – which will commonly come up with little to no conclusion, dependant on severity.

The incidence is believed to be rare or under reported. It is most common in ballet dancers as the result of an inversion sprain where the foot is in a plantarflexed at ground contact leading to a reflex contraction of the peroneal tendon as the foot looks to pronate for shock attenuation on landing (Adams & Madden, 2009).

shutterstock_72272335Management of the condition requires mobilisation and adjustment of the joint if deemed necessary by the practitioner, however, in many cases this is not required and simple off-loading techniques and a rehabilitative strengthening program is required.
The rehabilitative program should include activation, control and strengthening of the extrinsic muscle which cross into the foot from the lower leg as well as intrinsic muscle strengthening. Additionally, proprioceptive exercises should be complete by the patient to increase ankle joint stability.
The exercises should be continued until the patient reaches pre-injury ability and in many cases should be taken beyond that point for best outcomes.


In conclusion, it doesn’t matter if you have a flat or high arched foot when it comes to cuboid syndrome. The most common cause is associated with previous injury or chronic ankle instability leading to an overload of tissues and a sub-laxation of the cuboid from its original position. 

Until Next Time

Jackson McCosker
Director/ Chief Editor

References

Adams, E., & Madden, C. (2009). Cuboid Sublaxation: A Case Study and Review of the Literature. Current Sports Reports, 300 – 307.

Borrelli, J., De, S., & VanPelt, M. (2012). Fracture of the Cuboid. Journal of the American Academy of Orthopedic Surgery, 472 – 477.

Gallagher, S., Rodriguez, N., Anderson, C., Granberry, W., & Panchbhavi, V. (2013). Anatomic Predisposition to Ligamentous Lisfranc Injury: A MAtched Case- Control Study. The Journal of Bone and Joint Surgery, 2043 – 2047.

Moraleda, L., Salcedo, M., Bastrom, T., Wenger, D., Albinana, J., & Mubarak, S. (2012). Comparison of the Calcaneo-Cuboid-Cuneiform Osteotomies and Calcaneal Lengthening Osteotomy in the Surgical Treatment of Symptomatic Flexible Flatfoot. Journal of pediatric and Orthopaedics, 821 – 829.

Sanudi, J., & Vazquez, T. (2014). The Peroneocubiod Joint: Morphogenesis and Anatomical Study. Journal of Anatomy.

Senaran, H., Mason, D., & De Pellegri, M. (2006). Cuboid Fractures in Preschool Children. Journal of Pediatrics and Orthopedics , 741 – 744.

 

Plantar Heel Spurs: Radiographically Significant or an Expected Abnormality in Patients with Heel Pain


shutterstock_344043560Heel pain can be one of many different diagnosis involving both hard and soft tissues of the rearfoot and lower leg. It has been found to affect 1 in 10 people of the population and can have an impact on the quality of life of individuals who experience it. One such objective finding in those with heel pain can be heel spurs, but are they the real reason for pain?

The region of the foot identified as the heel or rearfoot is composed of a number of structures, both soft and hard tissue. However, in most cases people will be referring to the plantar surface of the calcaneus bone and superior fat and dermal layers. A Plantar Heel Spur will commonly form at the calcaneal tuberosity also associated with the origin of the plantar fascia.
Heel spurs are slowly fading out as a lay term for what is more commonly plantar fasciitis or heel pain not directly associated with the spur at all. A number of reasons for the development of heel spurs have been suggested nominating both longitudinal stress and vertical stressors as potential causes. That is, the heel spur may be caused by factors associated with increased tension in the plantar fascia due to a pronatory moment over a long period of time or a bone reaction to long term vertical ground forces. Both which will be explored in the up-coming article.

In a study by Menz et al 2008, it was found that those assessed radiographically for heel spurs between the ages of 62 and 94 were more likely to be considered obese and have previously or currently have experienced heel pain and the presence of osteoarthritis. There was no relationship found between heel spurs and gender or foot posture.
As a result of the findings, vertical compression theory was supported over that of longitudinal stress.
Although the study was well thought out and executed, it does not supply information related to a patient’s foot structured during dynamic movement and the forces placed upon the calcaneal tuberosity during pronation and resupination.sesamoids

The dynamic function of the foot during walking and running will change multiple times over a life time. As a standard for foot function during walking gait the premise of landing on the lateral heel, before pronating toward mid-stance and resupination as the individual moves into toe off.
This is important to be aware of as it is with the act of pronation that the plantar fascia with begin to stretch, tighten and store energy for releasing that energy in the propulsion of an individual. The plantar fascia’s origin is at the calcaneal tuberosity where a typical heel spur will form and thus longitudinal stress can occur at this origin leading to a number of physiological and anatomical changes at the site.
With people taking as many as 10,000 steps a day and an increased rate of obesity in the population stressors at this structure are increased and place more longitudinal force at the plantar heel.


Heel spurs have now been dismissed as the direct cause of pain at the heel unless associated with a stress fracture or atrophied fat pad and muscle bulk which increases the direct forces at the site of the plantar heel. Plantar heel spurs have been seen in patients without pain as much as those with pain. Additionally, those who have had pain in the past and been identified radiographically as having heel spurs have been shown to be treated for their pain and continued to have the heel spur increase in size. At this point in time radiographic evidence of a heel spur should have little to no impact on clinical decisions.

Until Next Time

Jackson McCosker
Director/ Chief Editor

References

Brukner, P., & Khan, K. (2013). Clinical Sports Medicine 4th Addition. Sydney: McGraw-Hill.

Hylton, M., Zammit, G., Landorf, K., & Munteanu, S. (2008). Plantar Calcaneal Spurs in Older People: Longitudinal Traction or Vertical Compression. Journal of Foot and Ankle Research, 1-7.

Leitze, Z., Sella, E., & Aversa, J. (2003). Endoscopic Decompression of the Retrocalcaneal Space. The Journal of Bone and Joint Surgery.

 

Exploring Opportunities Outside of Podiatry Qualifications – with Nicole Ellis


Nicole front_on
Hi there!

My name is Nicole Ellis and I like to introduce myself as a Dancer/Podiatrist. I kept my dancing up all through my Uni years for my own personal enjoyment and fitness. I am specifically trained as a Ballet dancer but have since branched into Cheerleading for the NRL, NBL and other more commercial styles of dance required for overseas contract work such a being a Showgirl in Las Vegas! I have recently returned to Melbourne after completing a 15-month dance contract in Tokyo Disneyland.

1. What drew you to Podiatry as a profession?

I had taken a gap year after completing high school to study Ballet full time. After giving my all and realising it wasn’t for me University was my next choice. I come from a very academic family so have always had an appreciation for how important it is to study and work towards attaining a degree. As a dancer I knew I wanted to study something that related to the Human Body, and after researching I found that Dance Podiatry would be a perfect fit for me as it would keep me in the dance world and it is also a relatively niche market so job opportunities wouldn’t be a problem!

2. Has arts and sports always been a big part of your life?

Massively so! I have always been extremely physically active with dancing outside of school and taking all forms of sports within school. I have been dancing since I was 6 years old, which means every Saturday for the past 26 years has been dedicated to dance with multiple days during the week also spent going straight from school/uni/work to dance classes. I love to keep busy! There is nothing more satisfying than being physically fit, and I fond that even though it consumed a lot of my time it also helped to keep my mind sharp whilst studying and working.

3. For someone so young you have accomplished a lot in your short time, can you let us in on some of the highlights and how hard you had to work to grab those moments?

The obvious highlights to being an international dancer are the travel. I have been lucky enough to live in Las Vegas, Japan, and all over Australia whilst getting paid for it. I have complete control over my life in terms of what I want to do next and where I want to go, however there is also the downside between contracts where I have been lucky enough to have jobs waiting for me when I return to Melbourne each time, but for others it can be a little difficult to find steady work due to the nature of contracts needing you to be able to pack up your life when they need you. It is definitely hard work; you have to hustle and audition and put yourself out there, and in between contracts you work hard so that on top of life’s normal expenses you can afford dance classes to keep your body in the physical condition it needs to be for a dance contract. It definitely keeps me busy but I consider myself very fortunate to now have friends all over the world, to get paid to donicole side what I love, and to have Podiatric Qualifications under my belt for when I’m ready to begin that part of my career. Who knows maybe I will begin practicing Podiatry part time to keep my knowledge up to date and still dance on the side – it’s completely up to me! 

4. You have just returned from Japan playing a number of Disney characters on stage, who was your favourite and when you did return to Australia what was the thing you realised you missed the most?

My favourite Disney Princess to portray was Aurora, better known as Sleeping Beauty, as the scene she dances in is extremely romantic and opened the whole scene for a Princess Ball. It also involved me ‘sleeping’ on stage, which is a pretty rare experience!

What I missed most about Australia was being able to communicate clearly with people. Not having a language barrier is a truly wondrous thing! And the good old Aussie mateship and friendly approach is extremely refreshing. The variety of culture and nightlife that we have here is phenomenal, and I definitely do not intend to take it for granted now that I’m back! Also being able to start my day before 10am is definitely a welcome opportunity, as all shops, Gyms and cafes in Japan don’t open until 10am – far too late for me!

5. What do you have planned next in the adventuring life that is Nicole Ellis?

I’m hoping my next adventure will be to dance on a Cruise Ship! Getting paid to perform is the ultimate joy, but doing it whilst travelling to beautiful exotic islands really wouldn’t be half bad! I’m also looking into practicing Podiatry part-time to keep up my knowledge, and hopefully I can achieve a healthy blend of the two disciplines: Dance and Podiatry!

Thanks for spending the time with us Nicole, all the best for the future!

Jackson McCosker
Director/ Chief Editor