Análisis de medidas SEM

Step 6: Myofascial Release

To release the ITB, think of it as a tight tendon even though it is a ligamentous structure. You need to release the ITB to affect the underlying vastus lateralis. Proximally, this band comes off the fibers of the gluteus maximus and the tensor fasciae latae (TFL) and when it is tight or restricted it can cause lateral knee pain.

Start by working the gluteus maximus and medius with compressions. Bend the client’s knee to bring the hip into flexion. Then, over his or her clothing perform gentle cross- fiber gliding strokes, compressions, and trigger point work if needed to the TFL. To locate the TFL, palpate the ASIS and drop laterally off it. Have the client medially rotate the hip against your resistance and you will feel the TFL contract and broaden under your fingers. Use your fingers or thumbs to work the fibers from the hip toward the IT band. Be care- ful, as this area is likely to be tender.

Next, using the heel of your hands and thumb, hook the inferior angle of the ITB and rotate it from lateral to medial as you draw it distally toward the knee. Use the other hand on the other side of the leg to help create a rotational

FIGURE 2-68

moves the leg to adduction for about 2 seconds while you assist the stretch. At this new position, repeat this contract-relax, contract-antagonist with active assisted stretching two or three times, or until achieving the normal 30-degree range of motion. Then lean back and traction the client’s leg. Release very slowly.

2. TFL stretch #2: This stretch can be performed if the client is physically unable to cross one leg over the other as in stretch number 1. The client is supine with the leg straight and laterally rotated. That same hip is flexed about 30 degrees. Stabilize the hip on that side with one hand. Compress the TFL muscle with your finger pads, and do not allow the ilium to move. Bring this leg toward you (adduction), to the restriction, lengthening the TFL (Figure 2-71 ■). Ask the client to attempt abduction at 20 percent force for 5 to 10 sec- onds as you provide resistance with your hand under the knee to protect it. He or she relaxes, takes a breath, and on exhale actively moves the leg to adduction for about 2 seconds while you assist the stretch. Have the client keep the leg being stretched low and as close to the other leg as possible. At this new position, repeat this contract-relax, contract-antagonist with active assisted stretching two or three times, or until achiev- ing the normal 30-degree range of motion. Then lean back and traction the client’s leg. Release very slowly. 3. Gluteus Maximus stretch: The client is supine with

their knee bent 90 degrees. Stand on the opposite side of the table. Place one hand on the outside of the client’s thigh, on the distal quads. The other hand is placed over the lateral fibers of the glute max, pressing it down toward the table. Have the client actively bring their knee toward you; hip adduction, as you assist the stretch for about 2 seconds. Make sure you pin down the glute max during the stretch; the hip must stay on the table. Do not press down on the ilium.

Step 8: Multidirectional Friction

If the client experiences pain when performing the ITB stretch isolate the exact spot by having the client put a finger

Step 11: Stretching (During Therapy)

The ITB is relatively avascular and relatively noncontractile, therefore you actually stretch the TFL muscle and the lateral fibers of the gluteus maximus to keep the IT soft and released. 1. TFL stretch #1: The client is supine with the unin-

volved leg bent and crossed over the other leg, which is straight and laterally rotated, to also affect the TFL. Bring (adduct) the straight leg toward you, to the restriction, lengthening the TFL. Stabilize the pelvis on that side with your other hand, so it doesn’t move, or you are stretching only the QL (Figure 2-70 ■). Ask the client to perform abduction at 20 percent force for 5 to 10 seconds as you provide resistance with your hand under the knee to protect it. He or she relaxes, takes a deep breath, and on exhale, the client actively

FIGURE 2-71 Optional TFL Stretch.

FIGURE 2-70 TFL Stretch. FIGURE 2-69

QUADRICEPS

Step 11: Stretching (During Therapy)

directly on it. This will most likely be on the lateral side of the knee. This condition is known as iliotibial band friction syndrome, as indicated earlier in this chapter. According to recent clinical studies, there is rarely damage to the fibers that pass over the lateral condyle of the knee, needing the next part of this protocol to be done. Usually after you release and stretch the lateral fibers of gluteus maximus, and the TFL muscle, the pain on the lateral side of the knee goes away. You have treated the cause of ITB friction syndrome to eliminate the symptom in the area of the lateral condyle of the knee. However, in that rare situation where there is damage to those fibers due to prolonged frictioning over the lateral femoral condyle, place your finger on the spot and ask the client if he or she feels the pain directly under your finger. If so, it is probably damaged fibers, also described as a tear by other health care practitioners. Perform multidirectional friction to the area for 20 to 30 seconds. If the area is tender, use only feather-light pressure. Proceed with the next step.

Step 9: Pain-Free Movement

The client is in the same position as the TFL stretch. Have him or her move the leg on top of the table into adduction (toward the middle of the table) and back to neutral several times to redirect the scar tissue. If there is no pain, proceed with the eccentric contraction. If there is pain, return to the multi- directional friction working a little deeper, but still pain-free.

Step 10: Eccentric Scar Tissue Alignment

The client is supine with the leg straight and the hip flexed 45 degrees. Stabilize the hip with one hand. The client gently resists as you perform adduction (bringing the leg toward you). Tell him or her to “barely resist, but let me win.” Start with a resistance of only two fingers. If there is zero discom- fort the client can increase resistance. Repeat the eccentric contraction several times, then repeat the resisted test. If the client still experiences pain, return to the multidirectional friction again. After the eccentric contraction go back and finish the stretches. It is rare you will ever have to do this (Figure 2-72 ■).

FIGURE 2-72

Eccentric Contraction, ITB.

FIGURE 2-73 Quadriceps Stretch.

PRECAUTIONARY NOTE