OF THE GLUTEUS MEDIUS WAS FOUND ON THE SYMPTOMATIC SIDE

Figure 12: Exercises begin with weight-shift actions moving the pelvis to the affected side while keeping it level and avoiding any hip ‘dipping’.

IN A STUDY OF DISTANCE RUNNERS WITH ITBS, SIGNIFICANT WEAKNESS

Weight-bearing actions

Later stages of rehabilitation (phase II) sees the introduction of weight-bearing activities maintaining lumbo-pelvic alignment as the weight is taken onto the affected leg. Exercises begin with weight-shift actions (Figure 12) moving the pelvis to the affected side while keeping it level and avoiding any hip ‘dipping’. Once the weight can be shifted in a controlled fashion, the knee on the unaffected leg is bent to take the weight off this side and leave the affected leg taking full body weight. Again control is the focus here. As the weight is shifted

over the affected leg the pelvis should remain level, and as the unaffected leg is bent the pelvis must not dip towards this side or ‘hitch’ upwards. Lower limb alignment must also be emphasised as both excessive pronation and leg length discrepancy have been linked to ITBS in lateral hip pain (23,24). The knee should remain directly over the centre of the foot, avoiding a pronation (foot flattening) and hip adduction. The aim is to maintain precise alignment and to build muscle endurance. Progression is made of holding time, therefore, holding the correct alignment for 20–30 seconds and performing 5–10 repetitions.

The next stage is to perform the same alignment pattern 12a: Weight shift – normal standing 12b: Weight shift to left leg

12c: Weight shift to left leg, right leg bends

12d: Weight shift to left leg, left hip beginning to dip

12e: Close up of pelvis in normal alignment in standing

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12f: Close up of weight shift – normal pelvic alignment

but to allow controlled bending of the knee on the affected side using the mini-dip exercise (Figure 13). The subject stands with the foot of the affected leg on a small (5cm) block. Keeping the pelvis horizontal the weight is shifted towards the affected leg and then lowered into a single-leg squat controlling the action and maintaining lower limb alignment throughout the movement. This mini-dip is performed for 5–8 reps emphasising timing of the eccentric lowering aspect (5-10 seconds) rather than just the concentric lifting (2–3 seconds). Classic gym-based exercises such as squats, lunges and deadlifts are useful for phase III rehab, and may be modified if required. Squat exercises may be performed free standing (classic barbell squat) or using a frame (Smith frame) to guide the bar. Modifications include squatting with the patient’s back resting on a gym ball placed on a wall, squatting onto a chair, and using dumb-bells held in each hand to the side of the hip rather than a barbell held across the shoulders (dumb-bell squat). Performing a squat on a linear frame enables users to better maintain trunk alignment as the bar is unable to move forwards. In addition the action may be changed to a semi- recumbent starting position, where the knee stays over the foot and the users sits back rather than downwards (Hack squat). When performing this type of squat the knee moment has been shown to be greater than the hip moment with more muscle work on the knee extensors (quadriceps) than the hip extensors (gluteals and hamstrings). As the foot is moved forwards into a Hack squat position, the hip moment increases and the knee moment reduces, effectively reversing the muscle emphasis placing significantly

12g: Close up of weight shift – pelvis dips down on the right

sportEX dynamics 2012;34(October):15-23