Failure to Adduct the hip in symptomatic runners with iliotibial band syndrome.

This is an interesting finding. They took symptomatic iliotibial band runners and looked at the hip adduction as they fatigued. When they found was not what one might initially expect, meaning more hip adduction because of the fatigue. Instead, they found was that when exerted, the female subjects independently modify their running gait to decrease hip adduction, potentially as a result of pain....... they compensated to protect. Not earth shattering, but support for the neuroprotective biomechanical mechanisms. This is how we all find a way to keep going, we find away around the problem. The problem here is that by the time they come to see us for care, we may be hearing of the next level of compensatory break down, and not the primary issue.

https://www.ncbi.nlm.nih.gov/pubmed/27718393

How relaxed, or shall we say “sloppy” is your gait ?Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion. Now, visualize a line up from that right foot through the spine. You will see that i…

How relaxed, or shall we say “sloppy” is your gait ?

Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion. 

Now, visualize a line up from that right foot through the spine. You will see that it is clearly under the center/middle of the pelvis. But of course, it is easier to stand on one leg (as gait is merely transferring from one single leg stance to the other repeatedly) when your body mass is directly over the foot.  To do this the pelvis has to drift laterally over the stance leg side.  Sadly though, you should be able to have enough gluteal and abdominal cylinder strength to stack the foot and knee over the hip. This would mean that the pelvis plumb line should always fall between the feet, which is clearly not the case here.  This is sloppy weak lazy gait. It is likely an engrained habit in most people, but that does not make it right. It is pathology, in time something will likely have to give. 

This is the cross over gait we have beaten to a pulp here at The Gait Guys over and over … . . and over.   This gait this gait, this single photo, means this client is engaging movement into the frontal plane too much, they have drifted to the right. We call it frontal plane drift. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain, this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, a compensation in arms swing or thoracic spine rotation or head tilt  … … something has to give, something has to compensate. 

So, how sloppy is your gait ? 

Do you kick or scuff the inside of your opposite shoe ? Can you hear your pants rub together ? Just clues. You must test the patterns, make no assumptions, please.

Shawn Allen, one of the gait guys

Change the foot, change the knee (and vice versa). A video case of External Tibial Torsion.

Here is a perfect example of external tibial torsion. Are you treating and training people and messing with their orthotics, squat knee-foot posturing or making gait/running/jumping changes or recommendations? If you are doing all of this and you do not know about tibial torsions, then shame on you, go apologize to these people right now. You could be causing them mechanical grief. Go buy them ice cream (even if they are “paleo”), that fixes most unintentional human mistakes. 

This is a classic presentation of external tibial torsion. This is an anatomic problem, you cannot fix this intrinsically, but you can help extrinsically. You teach these people about this issue and why the foot and the knee cannot cooperate. You teach them why their feet are spun out (increased foot progression angle) while their knee tracks straight forward sagittally. You teach them why they might heel strike far laterally and why their pronation phase might be abrupt. As in this video, you teach them why they might fashionably choose to narrow the foot progression angle (foot turned in) while at the same time having to bear weight on the lateral foot (in supination to externally spin the tibia) to keep the knee tracking sagittally. You teach them why this will be impossible to do in pumps (inversion sprain ouch) and why over time this will anger many joints and tendons. You teach them that without this accommodation they will track the knee inside the sagittal plane (as seen in the video).  You teach them why they might be at greater risk of having foot prontation issue pathologies, why they might have limited internal hip rotation, why orthotics likely do not do much for them (yes, there are exceptions), why certain shoes are a challenge for them while others are magical and why over time their once beautiful arch has begun to “fall” and be less prominent as they attenuate the plantar tissues.  

As you get good with this gait and biomechanics stuff, you should readily see and understand all of the issues discussed here today in a mere flash of instant brilliance so you know what to offer your client, in understanding and remedy options. As you have seen in this video, when left to their own devices, they naturally allow the knee to find the sagittal plane in a nice forward hinge. In this posture the foot is excessively progressed outward. Again, this is because of the tibial long bone torsion. This is their anatomy, this is not functional in this case. You cannot fix this, you help them manage this, first with their awareness, then with your brilliance.  You may implement exercises and gait strategies to help them become aware of mechanical issues and how to protect the foot-ankle, the knee and the hip. You teach them why they might have a tendency towards anterior pelvis posturing or sway back type postures. You teach them why, in some cases, they choose knee hyperextension as a comfortable yet lazy stance postural habit. You teach them why some shoes are “happy” shoes for them, and why others are pure evil.

A foundational principle we teach here at The Gait Guys is that the knee is a simple hinge between two multiaxial joints on either side of the knee, the hip and the foot-ankle complex. The knee really can only flex and extend, and when the mechanics above and below are challenged the knee has little depth to its abilities to tolerate much of anything except simple sagittal hinging. You can see that the foot posturing and tibial torsion rule the roost here in this video. You should learn in time that managing this case above and below the knee is where the pot of gold is found. You will learn in time that taping the knee is often futile, yet a worthy experiment both for you and the client in the discovery process, but that a life time of taping is not logical. External tibial torsion, although affording the knee that sagittal hinge plane, can narrow its range of safe sagittal mechanics and it is up to you to  help them learn and discover that razor’s edge safely and effectively when the torsion is large.  You should also discuss with them that as they plastically tissue adapt over the years (ie. pronate more and lose more arch integrity), this razor’s edge may widen or narrow for the knee mechanics as well as the hip and foot-ankle complex.  

For your reading pleasure, a classic example of how to interrogate a safe sagittal knee progression was discussed in this blog video piece we wrote recently, linked here.

Look and you shall find, but only if you know what you are looking for.

* Please now know that you should never off the cuff tell someone to turn inwards their outwardly spun foot. But if you do, have ice cream on hand, just in case.

Need more to spin your head ? Think about whether their IT band complex is going to be functioning normally.  Oy, where is that ice cream !

Shawn Allen, one of the gait guys

So you think you are an iliotibial band syndrome guru ?  This study has some interesting provoking thoughts about the mechanics we have all previously assumed. It is good to challenge established teachings, for it is only through interrogating old w…
So you think you are an iliotibial band syndrome guru ?  This study has some interesting provoking thoughts about the mechanics we have all previously assumed. It is good to challenge established teachings, for it is only through interrogating old ways that we may see the true light of things.
The iliotibial band (ITB) syndrome is a common overuse injury that is commonly misunderstood. It has been regarded as a friction syndrome where the ITB rubs against he lateral femoral epicondyle because of its previously assumed variable function, below 30 degrees knee extension it has been though to act as an extensor of the knee, and above 30 degrees (ie more knee flexion) it has been thought to act as flexor.  It is thought to be a culprit (with the biceps femoris) of the shift phenomenon in the “pivot shift test” for posterolateral rotatory instability of the knee (PLRI).  Here is an interesting perspective from a 2006 journal article.
“In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30° of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.”

We found this article interesting because it challenges many thoughts about its actual movement, (“it creates an illusion of movement”) because of changing of tension in the anterior and posterior fibres. As this article suggests, it is unlikely that there is any forward and backward motion of the band over the epicondyle during flexion and extension, rather the illusion of movement is from a gradual shifting of load to and from the anterior and posterior fiber bundles during flexion/extension. It is also an interesting article to us because it suggests and challenges that the clinical phenomenon is associated with fat compression rather than friction over the epicondyle.  The authors go into discussion of how the fat beneath the distal ITBand at the knee level is well vascularized and that Pacinian corpuscles can be present in adipose tissue supporting the view that fat compression may have a proprioceptive role and a roll in pain production when the corpuscles undergo hypertrophy in such a clinical setting.
Just remember what we have been saying all along when treating what you think are lateral chain problems, the ITBand receives most of the tendon of the gluteus maximus so do not forget to examine the hip and pelvis function, but so not forget the critical contribution that impaired foot and ankle function can have proximally at the knee.
This study has some interesting provoking thoughts about the mechanics we have all previously assumed. It is good to challenge established teachings, for it is only through interrogating old ways that we may see the true light of things.
If you are looking for more of our thoughts on this topic, we discussed a clinical case in our last podcast (link here). 
Shawn and Ivo, 
the gait guys

Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 2006;208(3):309-316. doi:10.1111/j.1469-7580.2006.00531.x
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Approaching joint assessment from the perspective of “cylinders”.

Our approach to every joint assessment has long been to visualize and assess the joint(s) as a cylinder since the body parts are cylindrical in form. This has been our approach, and they way we teach, for many years. At each number on the clock (cylinder) there is a theoretical muscle that provides stability to the joint in that vector during loading. The most accurate assessment would be one that investigates the ability of each muscle around the clock (cylinder) to see if it has sufficient S.E.S. (Skill, Endurance, Strength) as well as how well that muscle(s) participates with the synergists, antagonists and agonists (ie. motor patterns for stability and mobility).  We do this at each joint along the kinetic chain when assessing someone with a clinical or functional problem.  

When dealing with a frontal plane drift, as in the 3rd photo above where you see the person’s (black shorts) pelvis drift laterally outside the perpendicular foot line, one could naturally assume that the gluteus medius is weak (9 o'clock) but the wise clinician would also look at the other side of that cylinder to see if the adductors were involved (3 o'clock) since that is 180 degrees through the joint axis.  (Note: Runners are sagittal athletes so frontal plane weaknesses are often seen. This is not desirable however, this is a perfect example why runners should cross train more into lateral and angular sports to ensure that the sagittal plane does not dominate.) Obviously the foot and the knee also need a similar cylindrical assessment approach. We have spoken loudly many times  here and on our podcasts over the years that quite often there are multiple flaws in a presentation, typically a focal cause and one if not several compensations as a functional adaptation strategy around that central flaw. In this runner’s case there could be medial knee weakness or foot weaknesses that are affording too much medial drift and spin of the limb resulting in the lateral pelvic drift compensation.  But, just because the gluteus medius shows up weak does not mean that it is the focal point of clinical intervention. If one facilitates the gluteus medius and does not address the causative lower cylinder issues then they are quite possibly empowering the compensation and enabling the aberrant activity to continue. Knowingly or unknowingly layering armor or inappropriate strength to a pathologic compensation pattern at a focal joint level that is not the focal cause should be a clinical crime, but it is done every day by people who do not know better even though their efforts are well intended.

Ok, we got on a bit of a soap box rant there, sorry. Back to the case at hand.  

Your assessment should not stop at the frontal plane in this case. If there is an imbalance in the sagittal plane in this sagittal athlete this can be a causative problem as well, which is why the cylinder approach should not stop at the frontal plane or when you find that first major weakness. In frontal pelvic drift cases, there is quite often an anterior pelvic tilt where the lower abdominals can be weak, the low back is slightly extended and the paraspinals are more active. This is the classic “impaired hip extension pattern” and sets up a Janda/Lewitt style “Layered Syndrome”. Most of the time, resolving this sagittal flaw will show immediate improvement of the frontal plane deficits.  But, do not think it is as simple as re-facilitating these 2 patterns. Remember, neuromotor reprogramming and patterning takes 8-12 weeks by some sources. And remember, the initial strength gains in the first few weeks are from neuroadaptation (ie, skill gains in coordination), these gains are not the true physiological endurance and strength gains that we desire for an athlete.  Those gains take time but they are the ones that we need for sport performance and joint power.

And then there is the rotational or axial component, which we did not even begin to discuss here. We have briefly talked about the frontal and sagittal cylinder aspects, and yes, we have just skimmed the surface as there are multiple patterns and issues which we have had to leave out here so that this doesn’t turn into a full fledged chapter for our next book. This stuff gets complicated and can leave you running in mental circles at times.  But these concepts will help you better understand why you often see neuro-protective tightness 180 degrees on the other side of the cylinder from tightness, and when you address the weakness the other side of the cylinder some of that neuro-protective tone is eased.  But again, it is not nearly this simple because you must remember that if your assessment is static or on a table then your findings will be functionally imprecise.  And, not stopping there, there are multiple joints below the joint you are focusing on, and multiple joint complexes above as well. Plus, there are 3 other limbs that can play into the function and dysfunction of a given limb and its joints. There are breathing patterns, postural patterns and many other issues. This is not an easy game to play, let alone play it well or wisely for your athlete.

In today’s photos we wanted to show you 3 runners. One a distance runner with good joint stacking and one sprinter with amazing joint stacking.  And then the runner in the black shorts, who cannot stack the foot, knee or hips even remotely well.  This runner in the back shorts will have the cross over gait and likely have the medial ankle scuff marks to prove it. But remember, there is one component that we often talk about, one we did not discuss here … . . are there also torsional issues in this runner ? Do they have femoral or tibial torsion(s) ? What is their foot type ? Are they in the right shoe for their foot type ? Are some of these components playing into their visibly flawed mechanics ? 

Below is an article we have put up here on the blog previously.  It is a study where the investigators examined hip abductor strength (watch this video here ) in distance runners with iliotibial band syndrome comparing injured limb strength to the unaffected limb to determine whether correction of the strength deficits in the HAM’s (hip abductor muscles) correlates with successful outcomes.  The study showed the obvious, that runners with ITBS have weaker HAM strength compared to the asymptomatic leg.  

But here is our question, did they just strengthen the compensation for an apparently successful outcome, or did they address the problem ? Only time will tell if you actually fixed something or merely enabled the dysfunctional motor pattern by layering it with more armor for the next battle. If it is fixed the problem and all of its associated problems should go away. But if the runner comes back weeks later with knee complaints, foot pain, back pain or the like … . . then the message should be loud and clear.

Shawn and Ivo, The Gait Guys……today with soap on the bottom of our feet.

References:

Clin J Sport Med. 2000 Jul;10(3):169-75. Hip abductor weakness in distance runners with iliotibial band syndrome. Fredericson MCookingham CLChaudhari AMDowdell BCOestreicher N,Sahrmann SADepartment of Functional Restoration, Stanford University, California 94305-5105, USA.

Step width alters iliotibial band strain during running.

More substantiation that “the cross over gait” is a pathologic process.

Did you get to hear podcast #23 yet ?  Here is the link (iTunes).  In podcast #23 we talked at length about the effects of step width in runners.  Reducing ones step width will result in a progression into what we have been referring to for years as “the cross over gait”.  We have been reducing this phenomenon in our runners, and many walkers, for over a decade now to reduce many of the lower limb pathologic processes that ensue when the cross over is left unchecked and worse yet, strength and endurance is loaded upon the faulty pattern.  Everyone’s gait in this realm will differ because of pelvis width, femoral and tibial torsion, genu posturing (knee valgum, varum)  and foot structure and type. All of these factors must be taken into account when deciding upon the degree of step width correction.  Ultimately the goal in a perfect world would be to have the foot and knee stack pristinely under the centrated hip joint proper, but we all know that ideal biomechanics are the unicorn when it comes to humans. Anatomic variation is the known norm and this must not be forgotten, this was pounded into all of our heads in medical school.
As this article from the Nov 2012 J. of Sports Biomechanics clearly states, iliotibial band strain and strain rate is significantly greater in narrow based gait scenarios and that increasing step width during running, particularly in those who tend towards the lazier narrower step width, may be beneficial in not only the treatment but the prevention of future lateral hip and knee biomechanical syndromes such as IT band syndrome.  So, if you are a slave to your foam roller and need your IT band foam roller fix daily, you might want to look a little deeper at your biomechanics and make some changes.  Our videos here will be helpful to you and our writings on the Cross Over gait  and link here will be helpful as well.
In  summary, there is just so much more to good running form than just following the mantra “let my feet fall under my body mass and everything will be just fine”.  We wish it was this easy, but it is not. Unfortunately, too many of the sources on the internet are maintaining that good running form is mostly just that simple. Sadly, we find it our mission to bring the bitter tasting truth to the web when it comes to these things.  One just cannot ignore the factors of pelvis
width, femoral and tibial version and torsion, genu posturing (knee valgum, varum) and foot structure and foot type (and we mean so much more than are you a pronator or supinator).  These factors will alter lower limb biomechanics and may drive even the runner with heightened awareness of foot strike and running form into less than optimal foot strike positioning and loading response. Furthermore, one needs to be acutely aware that merely taking the cooked down under-toned postulation of this journal article, that being increasing step width will resolve their IT band problems, may not resolve their problem. In fact, without taking the issues of pelvis width, torsion, version, foot type and the like into account, making these changes could bring about more problems.  Seeking the advise of a knowledgeable physician in this complicated field of human locomotion is paramount to solve your chronic issues.
There is more to clean running than just a
midfoot-forefoot strike under the body mass, a good forward lean and high cadence. And we are here to bring those other issues to light, for the sake of every injured and frustrated runner.  Remember, uninjured does not always mean efficient. And efficient does not always mean uninjured.

Shawn and Ivo, The Gait Guys

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Sports Biomech.
2012 Nov;11(4):464-72.Meardon SA, Campbell S, Derrick TR.

Step width alters iliotibial band strain during running.

Abstract
excerpted:

“Greater ITB strain and strain rate were found in the narrower step width condition (p < 0.001, p = 0.040). ITB strain was significantly (p < 0.001) greater in the narrow condition than the preferred and wide conditions and it was greater in the preferred condition than the wide condition. ITB strain rate was significantly greater in the narrow condition than the wide condition (p = 0.020). Polynomial contrasts revealed a linear increase in both ITB strain and strain rate with decreasing step width. We conclude that relatively small decreases in step width can substantially increase ITB strain as well as strain rates. Increasing step width during running, especially in persons whose running style is characterized by a narrow step width, may be beneficial in the treatment and prevention of running-related ITB syndrome.”