REHABILITATION

True hip abduction Pelvis remains fixed and only femur moves

False hip abduction Femur remains fixed rela- tive to pelvis. Pelvis has tipped laterally, forcing lumbar spine to sidebend.

Figure 5: False hip abduction in side lying

upper leg allowed to fall into adduction and medial rotation. Again palpation pressure is maintained over the ITB as the hip is moved.

REHABILITATION Rehabilitation aims to redress the muscle imbalance process which may be consid- ered as a major factor in the development of this condition. ■ In phase (I) the aim is to stretch the tight lateral structures and build the endurance of the gluteus medius muscle.

■ In phase (II) general hip and lumbo- pelvic alignment is enhanced with an emphasis on controlling the weight shift during single leg standing especially.

■ Phase (III) is more sport-specific and seeks to build control of the hip in functional sports actions.

Phase (I) Stretching the ITB is a subject of consider- able debate. As the band attaches directly to the femur via the intermuscular septa, lengthening it would seem impossible (12). However clinically, patients with ITBS do respond to stretching exercises showing increased range of motion, reduced pain and an alteration in tissue tension to palpation. It is suggested therefore that the superficial portion has some indepen- dence from the deeper portions.

An effective ITB stretch must combine movement in three regions, the pelvis, hip and knee. In order to stretch the ITB, hip adduction and extension on a fixed pelvis must be combined with knee extension. Justification for this joint positioning is that ITBS occurs when the gluteus medius shows poor endurance, and single leg standing is supported by action of the tensor fascia lata (TFL) alone. This muscle is overworked and develops painful trigger points. To limit the pelvis tipping lateral- ly, the muscle tone increases and the mus- cle ‘shortens’, or more accurately becomes overactive in its outer range. As the TFL is placed anteriorly, a position of hip exten- sion will stretch it. The ITB passes over the knee to attach into the head of the fibula and the lateral fascia covering the knee. This tissue is placed on stretch when the knee is extended and tension is taken from it as the knee is flexed. Combining hip adduction-extension with knee extension will therefore optimally

stretch the ITB. Stretch will however be taken off the fascia if false hip adduction is performed. This can occur in the side lying position (Fig. 5) if the pelvis tilts laterally allowing the anterior superior iliac spine (ASIS) to move caudally.

To perform an effective ITB stretch the pelvis must remain fixed. The Ober test position (13) is chosen in the first instance, with the affected leg uppermost. Initially the leg is abducted (45° to the horizontal) and extended (10-15° behind the bodyline). The underside of the trunk is then pressed into the floor and kept in this position throughout the exercise. The upper leg is then lowered back towards the horizontal while maintaining the extended leg position. A useful visual cue is for the subject to look down towards their foot. If they can see their patella, the hip exten- sion has been lost, if they cannot, the leg is extended and the view of the patella is blocked by the front of the pelvis. A tactile cue which may be used is to place a folded towel between the floor and the side of the body, just above the pelvis. The aim is to press down hard on the towel throughout the exercise.

It should be noted that performing the Ober test with either knee flexion or with knee extension has been shown to pro- duce significantly different values of hip adduction (14).

For this reason it is recommended that

Figure 6a: Lumbo-pelvic alignment in normal stand- ing

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Figure 6b: Good lumbo-pelvic alignment with weight shift

Figure 6c: Poor lumbo-pelvic alignment (pelvic dip) with weight shift

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