EVIDENCE INFORMED PRACTICE
reach across your client’s leg and apply deep transverse frictions (DTF) and specific soft tissue mobilisation (SSTM). For DTF draw your hands towards you (upwards and across the body) to contour the leg. For SSTM hook your fingers beneath the ITB and draw it towards you bending the fascia. Hold the stretched position for 30–60 seconds. If you find this position uncomfortable for SSTM, use the side lying position of Upper ITB release. To access the lower ITB use the little finger side (pisiform grip) of your hand. Remember that the ITB is a thick, tough structure so work into it gradually. It may take 3–4 minutes before your notice any change in tissue tension.
Abductor muscle acupressure To reduce pain and tension in ITB consider applying acupressure, a technique which applies sustained pressure over the acupuncture points travelling in a painful area [see also Norris, 2003 (21)]. For the lateral hip, the upper leg should rest on a cushion / pillow in a horizontal position. For greater stretch it may be lowered to couch level (Figure 9). Use your thumbs or knuckle as your massage contact. The acupressure points on the lateral aspect of the thigh lie on the gallbladder (GB) meridian. The most important points for ITB tightness are GB-29 lying at the midpoint of a line joining the anterior superior iliac spine (ASIS) and the greater trochanter, GB-31 seven finger breaths up (proximal) from the outer knee joint line, and GB-34 in front and slightly below the head of the fibula (Figure 10). Press each of the points in turn using a steadily increasing pressure. Maintain the pressure for 30–40 seconds and then release. If you have very flexible thumbs, use your knuckle to apply the technique to avoid stress on your thumb tissues, or select an appropriate massage tool.
Working the lateral stabilising muscles In parallel with releasing and then stretching the TFL-ITB, the lateral stabilising muscles must be enhanced. Several authors have described lack of inner range holding to be the major dysfunction of this area (15,22). Here, the muscle is unable to hold the femur in a fully abducted (inner range) position over a prolonged period of time, normally up to 10 repetitions holding each for 10 seconds. To enhance this ability the subject begins lying on the side with the affected leg uppermost, hip and knee flexed. Keeping the feet together, the aim is to lift the knee without allowing any trunk rotation. Many subjects with ITBS find this end position of the exercise difficult to achieve. In this case, a training partner is used to lift the leg into position and the subject tries to slowly lower the leg back to the starting position (eccentric control). Once this can be performed in a controlled fashion for 5 repetitions, the subject should begin the movement by holding the leg in the upper position (full inner range) again for 5 seconds (isometric control). Finally, the subject lifts the leg (concentric control), holds it in its upper position (isometric control) and lowers it slowly (eccentric control). Once this movement can be performed for 5–10 repetitions, the subject can progress to phase (II) of the rehabilitation programme. This clam shell position has both advantages and disadvantages. By flexing the knee and hip the lever arm
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Figure 10: Gallbladder
acupuncture points on the lateral leg. (Reproduced with permission from Complete Guide to Clinical Massage, A & C Black, 2013)
of the leg is reduced making the action easier to achieve for the client. However the non-weight-bearing starting position with the hip–knee flexion does not mimic the functional straight leg weight-bearing position. It is important therefore to progress from the clam shell muscle isolation action to weight-bearing whole body movement as soon as the client is able (Figure 11).
Figure 11: Clam shell using tactile cueing.
THE CLIENT’S BODY WEIGHT ACTING ON ONE SIDE AND MUSCLE FORCE ON THE OTHER
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THE HIP CAN BE THOUGHT OF AS A PIVOT – LIKE A SEESAW – WITH
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