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ITB REHABILITATION

both knee positions are tried and that which yields a greater stretching sensa- tion be chosen as an exercise.

The Ober stretch targets the whole of the ITB. However, where trigger points are present within the TFL-ITB, these tissues may be placed on stretch and a self mas- sage technique employed. Now, the start- ing position is for the subject to lie on their back and to flex the hip and knee of both legs. The unaffected leg is crossed over the affected one and the hip pulled into adduction. This places some stretch on the upper portion of the ITB and allows the subject to press into the painful area 15-25 cms below the greater trochanter. Where a painful trigger point is found, firm pressure should be applied and held for 30-40 seconds until the pain begins to subside. This form of self treat- ment, called ‘ischaemic compression’ is an accepted method of management for an active trigger point (15).

In parallel with stretching the TFL-ITB, the gluteus medius muscle must be enhanced. Several authors have described lack of inner range holding to be the major dys- function of this muscle (5,9). In this situ- ation, 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 diffi- cult 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 move- ment can be performed for 5-10 repetions, the subject can progress to phase (II) of the rehabilitation programme.

Phase (II) Rehabilitation in 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 moving the weight to the affected side while keeping the pelvis level (Fig.6b) and avoiding any hip ‘dipping’ (Fig.6c).

Figure 7: Mini dip with single leg on a block www.sportex.net

Once the weight can be shifted in a con- trolled 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 (Fig.7). 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 ITB syndrome (16,17). The knee should remain directly over the centre of the foot, avoiding pronation (foot flattening) and hip adduction. The aim is to maintain precise alignment and to build muscle endurance. Progression is made of holding time there- fore, holding the correct alignment for 20- 30 seconds and performing 5-10 repetitions.

The next stage is to perform the same alignment pattern but to allow controlled bending of the knee on the affected side using the mini-squat exercise (Fig.7). The subject stands with the foot of the affect- ed leg on a small (5 cms) block (a thick book or telephone directory is ideal). Keeping the pelvis horizontal they weight shift towards the affected leg and then lower into a single leg squat controlling the action and maintaining lower limb alignment throughout the movement. This mini squat is performed for 5-8 reps emphasising timing of the eccentric lower- ing aspect (5-10 seconds) rather than the concentric lifting (2-3 seconds).

The final exercise in phase (II) is the eccentric step up. If the right leg is affect- ed, the subject steps up onto a low (10cms) platform leading with their left leg. They bring their right leg up onto the step and take the bodyweight through it as they lower the left leg to the floor. Repeating this action provides concentric work for the unaffected (left) leg and eccentric work for the affected (right) leg. Leg and pelvic alignment are emphasised

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