Patellar Tendinopathy & Iliotibial Band Friction Syndrome PDF

COMMON INJURY CONDITIONS Patellar Tendinopathy Patellar tendinopathy, also known as jumper’s knee or patellar tendinitis or grouped with other conditions that cause anterior knee pain, is attributed to the overuse of the patellar tendon (Larsson and Nilsson-Helander 2012). There is no current evide...

COMMON INJURY CONDITIONS Patellar Tendinopathy Patellar tendinopathy, also known as jumper’s knee or patellar tendinitis or grouped with other conditions that cause anterior knee pain, is attributed to the overuse of the patellar tendon (Larsson and Nilsson-Helander 2012). There is no current evidence-based consensus on the optimal treatment of patellar tendinopathy; however, symptomatic treatment coupled with eccentric training has shown promise (Larsson and Nilsson-Helander 2012). Patellar tendinopathy is not an inflammatory condition, but a degenerative condition that results in derangement and weakening of the tendon’s fibers (Rodriguez-Merchan 2013). Danielson and colleagues (2008) found that the dorsal paratenon is sympathetically innervated and possesses a blood supply, which provides a rationale for treating this tissue with PRT. Common Signs and Symptoms • Patellar tendon pain • Increased pain with functional activity, particularly running, jumping, and cutting • Point tenderness of the patellar tendon and, at times, its attachment at the tibial tuberosity Common Differential Diagnoses • Osgood-Schlatter disease • Sinding-Larsen-Johansson disease • Tibial plateau stress fracture • Chondromalacia Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty jumping mechanics, faulty gait biomechanics, training errors, leg length discrepancy, weak hip musculature, surface or shoe alteration). • Consider requesting an MRI or bone scan to rule out stress fracture if tenderness is localized over the tibial tuberosity or plateau. • Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, you should base your treatment sequencing off the most dominant (tender) points first. • Follow PRT with thermal ultrasound or laser and PNF stretching of the patellar tendon. 118 Treatment Points and Sequencing 1. 2. 3. 4. 5. 6. 7. 8. 9. Patellar tendon Pes anserine Iliotibial band Tibialis posterior Popliteus Medial gastrocnemius Tensor fasciae latae Adductors of the thigh Psoas • Apply eccentric training with a focus on sport- or work-specific demands (or both) in conjunction with PRT and other therapeutic interventions. • For some patients, KT Tape or the use of a patellar strap or band reduces pain during the initial stage of therapy. • Apply instrumented soft-tissue mobilization (ISTM) if recalcitrant tissue adhesions are present. • Consider performing a biomechanical evaluation of jumping mechanics and gait if a training, movement, or biomechanical error is suspected. • Implement open- and closed-chain strengthening for the intrinsic foot, pretibial and hip, and core muscles to address weaknesses or compensations identified in the biomechanical analysis, with a particular focus on eccentric control of knee flexion and internal tibial rotation. • Temporary or custom orthotics to unload the patellar tendon may be warranted based on biomechanical evaluation outcomes. Patient Self-Treatment Interventions • Self-release the patellar tendon and tibialis posterior on a daily basis or when irritated. • PNF stretch the patellar tendon after eccentric exercise or on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Perform self-massage for five to eight minutes daily after stretching. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. COMMON INJURY CONDITIONS Iliotibial Band Friction Syndrome There is little consensus about what causes the lateral leg and knee pain associated with iliotibial band friction syndrome (Lavine 2010). Initially, pain at or below the lateral femoral condyle was thought to develop from a friction mechanism at the condyle as a result of band tightness. However, evidence points to a compression mechanism at this location and subsequent irritation of the underlying bursae and bone independent of iliotibial band tightness and friction (Lavine 2010). Moreover, intrinsic factors such as overpronation, weak hip abductors, and increased frontal plane movement of the limb, among others, have not been shown to increase the prevalence or risk of this syndrome (Bauer and Duke 2011; Lavine 2010). However, a general consensus is that treating tender and trigger points along the course of the band, or tract, as well as its communicating fascia helps in the treatment of this condition. Common Signs and Symptoms • Pain with ambulation, squatting, downhill running, and descending stairs • Point tenderness at the lateral knee; above, over, or below the lateral femoral condyle; and potentially at Gerdy’s tubercle and the fibular head • Positive Ober’s and Noble’s test • Weak hip rotators and abductors • Increased frontal plane movement of the limb • Pes planus or cavus Common Differential Diagnoses • Stress fracture • Disc pathology • Lateral meniscal tear • Popliteus tendinopathy • Patellofemoral pain syndrome Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty biomechanics, training errors, leg length discrepancy, weak hip musculature, surface or shoe alteration). • Consider requesting an MRI or bone scan to rule out stress fracture if tenderness is localized over the bone. Treatment Points and Sequencing 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Iliotibial band at the knee Pes anserine Popliteus Adductor group Adductor magnus Sartorius tendon Gluteus medius Sacroiliac joint Psoas Quadratus lumborum Flexor hallucis brevis • Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, you should base your treatment sequencing off the most dominant (tender) points first. • Follow PRT with diathermy, laser or thermal ultrasound, PNF stretching of the iliotibial band if tightness exists, and myofascial massage. • For some patients, KT Tape reduces pain during the initial stage of therapy. • Apply ISTM if recalcitrant tissue adhesions are present. • Consider performing a biomechanical gait evaluation if a training or biomechanical error is suspected. • Implement open- and closed-chain strengthening for the pretibial, hip, and core muscles to address weaknesses or compensations identified in the gait or movement analysis, with a particular focus on the control of abnormal frontal plane movement. • Have the patient use temporary or custom orthotics to unload the lateral knee tissues during the initial phase of rehabilitation. • Avoid having the patient run through the pain. The patient should perform only physical activity that is tolerable—ideally with no pain. • Slowly progress the patient to dynamic physical activity through aquatic therapy or gravity-assisted running devices. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 119 COMMON INJURY CONDITIONS Iliotibial Band Friction Syndrome > continued • Bursectomy may be warranted if traditional therapeutic interventions fail. Patient Self-Treatment Interventions • PNF stretch the iliotibial band and posterior hip musculature if it is tight after exercise or on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Perform self-massage or use a foam roll for five to eight minutes daily after stretching. 120 However, avoid these measures if they cause extreme pain because they may produce additional tissue lesions. • Apply ice or heat to the affected area to relieve tissue pain and spasm. Typically, patients with chronic symptoms respond best to heat (e.g., warm whirlpool or Jacuzzi). (Note: Consult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.) T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics.