ITB REHABILITATION

sustain an upright stance. As the knee flex- es to 30° the ITB passes posteriorly to the knee joint axis, and in so doing it glides over the lateral femoral condyle. In running, during the swing phase the ITB lies anterior to the greater trochanter and hip flexion/extension axis, reducing the work- load required for hip flexion.

The contraction of the gluteus medius and the TFL is transmitted by the ITB to con- trol and decelerate adduction of the thigh (7). Where the gluteus medius shows poor endurance and control, gait alteration may occur leading to ITB pain. In a study of distance runners (14 male, 10 female) with ITBS, significant weakness of the gluteus medius was found on the sympto- matic side. Strengthening the muscle over a 6-week period resulted in 92% of the runners being pain free (8).

addition it throws branches to the sacro- tuberous ligament, the ischial tuberosity, and the pubis, effectively surrounding the upper thigh. On the lateral aspect of the thigh, the fascia is thickened into two dis- tinct layers forming a non-elastic collagen cord, the ITB.

The gluteus maximus and gluteus medius muscles both insert into the ITB posteri- orly. The TFL inserts anteriorly, with con- tractile fibres travelling one third of the way down the band.

As the ITB travels down the lateral side of the thigh its deep fibres form inwardly directed sheets attaching to the linea aspera of the femur. These are the medial and lateral intermuscular septa. The superficial fibres of the ITB continue downwards to attach to the lateral femoral condyle, lateral patellar retinacu- lum and anterolateral aspect of the tibial condyle (Gerdy’s tubercle). A large amount of the lateral retinaculum of the patella actually arises from the ITB to form the iliopatellar band (6) having a direct effect on patellar tracking.

BIOMECHANICS In standing, the ITB lies posterior to the hip axis and anterior to the knee axis and there- fore helps to maintain hip and knee exten- sion, reducing the muscle work required to

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Muscle balance tests for the lower limb (4) often show a reduction in abduction endurance by the gluteus medius (side lying hip abduction test Fig.2) and com- pensation by over activity of the tighten- ing of the TFL-ITB (Ober test Fig.3). Although both the gluteus medius and the TFL are able to abduct the femur, the TFL will also medially rotate the hip while the postural posterior portion of the gluteus medius is a lateral rotator (9). As a con- sequence, dependence on the TFL alone for abduction power during gait causes excessive medial rotation and adduction

of the hip increasing the valgus stress on the limb and therefore increasing passive tension in the ITB. For more information on muscle balance of the lower limb see Norris (4).

PALPATION As with many overuse conditions, a sub- ject may not have pain when they initial- ly present for treatment. Pain may be elicited by palpation with the subject in the side lying test position but with the knee flexed to 30° (Fig.4a). Pain is com- monly located approximately 2cms above the knee joint line within the distal por- tion of the ITB. The sensation which the patient feels on activity may often be reproduced by asking then to flex and extend the knee while palpation pressure is maintained (Fig.4a+b). This will cause the ITB to flick over the epicondyle.

The same test may be performed in stand- ing (Fig.4b). In standing, the patient takes weight through the affected leg alone, knee flexed to 30°. The palpating finger is placed over the epicondyle once more and the subject performs a series of mini squats to reproduce his/her symp- toms (Renne’s test) (10). In lying, the hip and knee are flexed to 90° and the epi- condyle palpation is maintained as the knee is extended (Noble’s test) (11).

Palpation of the greater trochanter is sim- ilarly achieved in side lying with the

Figure 2: Gluteus medius/hip abduction test in side lying

Figure 4a: Pain provocation in lying

Figure 3: Ober test

Figure 4b: Pain provocation in standing 7