Episode 1554 - IT Band pain: the plan

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses treatment progressions for lateral knee pain/"IT band" pain. Mark encouraged beginning with open chain exercises as a starting point for individuals with high irritability. These exercises can help decrease force on tissues while still providing a stimulus for the body to adapt. Additionally, open chain exercises stimulate the release of endorphins, which can have a positive effect on pain and mood.

Mark mentions several open chain exercises that are beneficial for individuals with high irritability, including hip abduction, hip extension, and hip rotation. These exercises can be performed in different positions, such as bent over hip extension against a table or in a quadruped position with significant bracing of the anterior trunk.

It is important to note that the intensity and volume of open chain exercises should be adjusted based on the individual's irritability level. For individuals with high irritability, the podcast recommends starting with a high volume of open chain exercises, such as two to three sets of 20 repetitions with a low load intensity. The goal is to challenge the individual and provide a stimulus to the nervous system.

Overall, open chain exercises can be a beneficial starting point for individuals with high irritability as they help decrease force on tissues while still providing a stimulus for adaptation. It is important to adjust the intensity and volume of these exercises based on the individual's irritability level.

As symptoms decrease and heavy, slow resistance training is introduced, closed chain exercises such as the hip thruster and Bulgarian split squat are recommended. These exercises effectively strengthen the hip and quad muscles while improving stability and control in the lower extremities. The hip thruster involves thrusting the hips upward while keeping the feet planted on the ground, targeting the glutes and hamstrings. On the other hand, the Bulgarian split squat is a single-leg exercise that requires the back foot to be elevated on a bench or step, improving balance, stability, and leg strength.

In addition to closed chain exercises, proprioceptive training or reactive neuromuscular training can be incorporated. This involves using loop bands around the knees to provide feedback and improve body awareness. Proprioceptive training enhances control and stability during movements, reducing the risk of injury.

Once individuals can handle both heavy slow resistance training and reactive neuromuscular training, they can progress to plyometric training. Plyometric exercises involve explosive movements like jumping and hopping to develop power and improve muscular endurance. The recommended goal is three sets of 20 repetitions or three sets lasting a minute for endurance, and 10 sets of three to six repetitions for power. Plyometric training enhances both endurance and power, important for athletic performance and overall functional fitness. Mark finishes this episode by offering a number of different options to reintroduce running, if it's part of that patient's goals.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 INTRO All right, what's up PT on Ice daily crew. Dr. Mark Gallant here, lead faculty with the extremity management division alongside Lindsey Hughey and Eric Chaconas. Coming at you here Tuesday morning, Clinical Tuesday. Before we dive in, a few upcoming courses that we want to announce. I'm going to be in Cincinnati, Ohio this weekend with Onward Cincinnati. So if you've all been looking to check the extremity management course and haven't had that opportunity yet, definitely sign up today. Get on the list for Onward Cincinnati. There's still seats left. If that's not available, Cody will be in Rochester, Minnesota first weekend of October. So that'll be your next opportunity to check the extremity management crew out. 1:01 LATERAL KNEE PAIN So I was on here a few weeks ago and we talked about the myths of iliotibial band pain, where we came from, from the research in the 70s, and now how we've adapted with newer research and things we now know. Mainly being that this is no longer believed to be a friction mechanism of the lateral knee because we know the IT band is firmly attached to the lateral femoral condyle, the patella, the tibia, and that this is more of a magnitude or a volume of load with a potential lack of frontal plane control or simply too much volume to the lateral knee. So what are we gonna do if that person comes in? Tim's been running on the treadmill for most of the year, he decides that he wants to get out and do some trail runs, start working some downhill in. Brittany has been relatively unfit for most of her life and decides, you know what, this fall, it's the time that I'm gonna run that half marathon. And then they start to develop some lateral knee pain. Well, how are we gonna treat those folks out? And what we're really gonna look at, that's gonna depend on where their irritability is. So we have four or five steps that we're gonna go through and that individual can jump onto that highway wherever they're at on this progression. So if that person comes in and they're highly irritable, they tell you that they've got eight out of 10 lateral knee pain, it hurts when they're going downstairs, when it's the trail leg that's walking, they begin to have some discomfort, they're certainly having trouble getting out and doing any of their runs, and it's really a quite uncomfortable pain for them. Well, when that person comes in, like we talked about last time, we'll do the dry needling, the myofascial decompression, the soft tissue to help modulate their pain. How do we work the exercises in and how do we specifically dose those exercises? So if the person has that 8 out of 10 or above or even 7 out of 10 irritability, oftentimes a good place to start with our exercises is open chain exercises. they're really going to decrease the amount or magnitude of force going into those tissues while giving them a nice stimulus so that the body knows it has to adapt, we get some good endorphins going. We specifically like open chain abduction of the hip, open chain extension of the hip, and if you want to get some open chain rotation of the hip, that works as well. So we like either a bent over hip extension so that person is leaning against the table so they can really contract their abs so that we know they're not getting any back arching there. Or if they go into a quadruped position, really brace the anterior trunk significantly, and then do their hip extensions. For the open chain abduction, we'd like to get them against a wall, starting them so where their hip is in neutral, so their hip is either, their leg's propped up on a ball or a bench, heels against the wall, slightly internally rotated so we know we're really hitting those glutes and working our hip abduction that way. 04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS For our hip rotation in open chain, the traditional clamshell has come under fire quite a bit in the last handful of years. What we like to do is a pseudo open chain clamshell where their feet, their bare feet are gonna be against the wall. So they have to keep that flat foot against the wall and then go into their clamshell. How are we going to dose this? Well, if you've been to the course, you know, we talk about the rehab dose, eight to 20 repetitions, 30 to 80% of their one rep max basing that that volume and intensity on their irritability. Well, these folks are higher on the irritability, so we're going to go higher volume. We're going to hit two to three sets of 20 repetitions with a really low load intensity. It's hard to get a high intensity load an open chain without volume anyway. So that's really going to lend itself to this to begin with. So our hip extension, our abduction, our pseudo clamshell, we're going to hit those two to three sets of 20 reps where they feel challenged when they approach that 20. It's getting a lot of stimulus to that nervous system. It's letting the tissues know that we want you to be active, but it's not giving them a magnitude of load that's going to be threatening to the tissue. Once the person says, you know what, I went downstairs last night and my pain was only a 3 out of 10 or my symptoms were only a 3 out of 10 or less, or that person comes in and says, you know what, now when I'm walking, when that leg's the trail leg, really doesn't seem to bother me that much. Maybe a 2 out of 10 at best. That's when we really want to make sure we're progressing to a more closed chain activity. What we love for our closed chain exercises, again, working into that hip extension, getting the quad stronger. We like a hip thrust, so a barbell hip thrust that we can really load up a lot of weight. If we see a big side-to-side discrepancy in strength, we can go single leg