PREÁMBULO

The iliotibial band (ITB) runs vertically down the lateral thigh over the vastus lateralis and attaches to the tibial tubercle, which is on the lateral side of the tibia. Fibers of the gluteus maximus and tensor fasciae latae (TFL) attach to the proxi- mal end of the ITB and together help stabilize the hip and knee. Excessive stress, or a restricted or contracted condi- tion of the ITB, iliotibial band friction syndrome, can cause pain on the lateral side of the knee. The client will report

FIGURE 3-30 ITB Friction Test.

 Stretch the lateral fibers of gluteus maximus by hav- ing the client flex the hip to 90 degrees. Stand on the opposite side of the table. Place one hand on the lat- eral thigh, supporting the lateral joint line of the knee. The other hand in on the lateral fibers of the gluteus maximus, pressing it down toward the table to stabi- lize the hip. Assist the stretch as the client actively adducts the leg across the body (Figure 3-33 ■). The hip must stay on the table.

 Then stretch the TFL to help release the ITB tension for better mobilization of the band, as you next free it up from the vastus lateralis. The client is supine with the leg straight. The hip is flexed 30 degrees and later- ally rotated. Stand on the opposite side of the table. Place one hand on the ilium with gentle pressure and three fingers on the TFL muscle to stabilize the hip. With your other hand under the thigh also stabilize the lateral joint line of the knee. The client abducts the hip 30 degrees and then actively adducts across the midline as you assist the stretch. Do a pin and stretch

Step 4: Assess Resisted Range of Motion (RROM)

Clinical studies indicate that it is best to not friction the dis- tal end of the ITB. The pain on the lateral knee is rarely ever due to scar tissue in the distal end of the band. The tension in the lateral knee is best relieved by creating length in the lateral fibers of gluteus maximus, and the TFL muscle. After lengthening the contractile portion of the band, you can do a myofascial technique to free the band from the underly- ing vastus lateralis. Then if you correct abnormal external tibia–fibular rotation of the knee, the pain will usually go away. The pain in the lateral knee can be multifaceted and involve the lateral meniscus, lateral collateral ligament, fix- ated proximal fibular head, and ITB tension. You must iden- tify and treat the correct structures and not look at this as a generic situation like runner’s knee.

Step 5: Area Preparation

Goal: to prepare the client before performing myofascial release.

Do not use ice unless there is inflammation (heat, redness, or swelling). Ice may cause the fascia to become less mobile and may restrict movement. This is counterproductive to the mobilizing and healing process, which the therapy work is promoting.

You must follow the protocol for pelvic stabilization through the anterior quadriceps release before you begin the ITB work.

Step 6: Myofascial Release

Goal: to warm up, soften, and mobilize the ITB, and to move the fascial layers back to normal resting or length- ened position.

Always perform myofascial release before proceeding to deeper, more specific work.

After the anterior and medial quadriceps work, work the ITB. Think of it as a tight tendon even though it is a ligamentous structure.

 The client is supine. Bend his or her knee to bring the hip into flexion.

 Start by working into the gluteus maximus and medius with compressions (Figure 3-31 ■).

 Then, over the clothing, perform cross-fiber gliding strokes, and compressions to the TFL (Figure 3-32 ■).

 To locate the TFL, palpate the ASIS and drop laterally off it. Have the client medially rotate the hip and you will feel the TFL move under your fingers. Use your fingers or thumbs and be careful, as this area is likely to be tender.

FIGURE 3-31

Gluteus Maximus Compression.

FIGURE 3-32 TFL Myofascial Release.

during the compressions you may not have fully released the ITB. Go back and repeat the rotational movement. Length- ening the vastus lateralis and strengthening the oblique fibers of the vastus medialis can oftentimes eliminate the cause of chondromalacia and patellar tendinosis. Because the cartilage of the patella has minimal or no pain receptors, once you stop the tracking, the underlying damaged cartilage will not cause pain. The pain from lateral patellar tracking is usually due to the nipping of the bursa and fatty sacs of the knee, not the cartilage degeneration under the knee cap.

Step 7: Cross-Fiber Gliding Strokes/Trigger Point Therapy

CROSS-FIBER GLIDING STROKES

Goal: to tease apart tight muscle fibers in muscle groups causing the ITB to be tight.

Remember, the band itself is a relatively nonvascular and noncontractile structure.

of the TFL. Do not let the hip come up off the table (Figure 3-34 ■).

 Next, using the heel of your hand, hook the inferior angle of the ITB and rotate it from medial to lateral as you draw the skin and band toward the knee. Use your other hand on the other side of the leg to help create a rotational movement (Figure 3-35A ■). Do not slide over the skin. Work from the hip toward the knee to lengthen the band, and thus reduce symptoms over the lateral femoral condyle (work proximal to distal).

 Then perform compressions into the vastus lateralis, working from origin to insertion to create length. If there is lateral tracking of the patella make sure to intentionally lengthen the vastus lateralis. This will help eliminate the lateral patella tracking problem (Figure 3-35B ■).

Pin your elbow into your side and with the palm of your hand and work along the ITB several times (proximal to distal). This will help release adhesions along the ITB. Alternate with compressions. If the vastus lateralis is tender

FIGURE 3-34 TFL Stretch.

FIGURE 3-35A ITB Mobilization.

FIGURE 3-35B

Compression Broadening from Gluteus Maximus Distally through Vastus Lateralis (Work from Hip to Knee). FIGURE 3-33

 Pain? Repeat step 8, working slower and deeper, but still pain-free. Repeat step 9 and then proceed to step 10 when there is no pain.

Step 10: Eccentric Scar Tissue Alignment

Goal: to apply pain-free eccentric contraction by length- ening an injured ITB against mild resistance to realign or redirect the scar tissue (step not required).

Use cross-fiber gliding strokes, working from origin to insertion (proximal to distal) to tease through and gently spread muscle fibers in the gluteus maximus and tensor fas- ciae latae (TFL).

TRIGGER POINT THERAPY

Goal: to release trigger points in the muscle belly, if found.

If there is a specific area of pain that radiates or refers, apply trigger point therapy.

 Use direct, moderate pressure for 10 to 12 seconds.

 As the trigger point softens, compress the tissue sev- eral times.

 Gently stretch the tissue.

Go to the end of the table and lean back and traction the leg. Release very slowly.

Step 11: Stretching (During Therapy)

Refer back to medial gluteus maximus and TFL stretch prior to mobilizing the ITB.

Goal: to create normal range of motion of 30-degree hip adduction.

Contracting the muscle against resistance to fatigue the mus- cle prior to the stretch becomes a muscle resistance test and the client may report pain in a specific area, which is a mus- cle strain. If so, proceed to multidirectional friction (step 8), pain-free movement (step 9), and eccentric scar tissue align- ment (step 10) until the client is pain-free.

Since the ITB is relatively noncontractile you need to stretch the gluteus maximus and the tensor fasciae latae releasing the forces on the band.

Step 8: Multidirectional Friction

Goal: to soften the collagen matrix by working in multi- ple directions to prepare for a more functional mobiliza- tion of scar tissue fibers.

As mentioned earlier, based on new clinical studies, it is not recommended to friction the distal end of the ITB.

Step 9: Pain-Free Movement

Goal: to determine if the client can actively perform knee flexion and extension without pain. Since the distal band is rarely injured we will skip this step, nor is it required for ITB distal fibers.

 Pain-free? Proceed to step 10.

PRECAUTIONARY NOTE