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OUTPATIENT REHABILITATION FOR A PATIENT WITH SIGNS AND
SYMPTOMS CONSISTENT WITH ILIOTIBIAL BAND SYNDROME
A Doctoral Project
A Comprehensive Case Analysis
Presented to the faculty of the Department of Physical Therapy
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
DOCTOR OF PHYSICAL THERAPY
by
TomMa
SUMMER
2016
© 2015
TomMa
ALL RIGHTS RESERVED
11
OUTPATIENT REHABILITATION FOR A PATIENT WITH SIGNS AND
SYMPTOMS CONSISTENT WITH ILIOTIBIAL BAND SYNDROME
A Doctoral Project
by
TomMa
, First Reader
DPT, FAAOMPT
, Second Reader
Clare Lewis, PT, PsyD, MPH, MTC
Date
lll
Student: Tom Ma
I certify that this student has met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library
and credit is to be awarded for the project.
_____, Department Chair
EdD
Department of Physical Therapy
IV
/zzbo;c
1
I
Date
(
Abstract of
OUTPATIENT REHABILITATION FOR A PATIENT WITH SIGNS AND
SYMPTOMS CONSISTENT WITH ILIOTIBIAL BAND SYNDROME
by
TomMa
A patient with a diagnosis of left lateral thigh pain was seen for physical therapy
treatment for a total of7 sessions from 2/24115 to 4/21115 at an outpatient pro-bono
physical therapy clinic. Treatment was provided by a student physical therapist under
the supervision of a licensed physical therapist.
The patient was evaluated at the initial encounter with a subjective and
objective examination, and a plan of care was established. Main goal for the patient
was to identify the cause of her condition, decrease pain throughout daily activities,
and a return to running and playing sports without pain. Main interventions were
patient education, therapeutic exercises, motor control training, and manual therapy.
At discharge, the patient had a decrease in pain and sleep disturbance, improved
strength, motor control , flexibility, posture, gait mechanics, and functional mobility.
The patient was discharged to home with a progressive home exercise program and
1-22. -'
lb
Date
v
ACKNOWLEDGEMENTS
I acknowledge California State University, Sacramento, Department of Physical
Therapy, for allowing me to learn about and treat patients with orthopedic injuries, as
well as use a sub-acute rehabilitation. patient for my case study.
•
Vl
TABLE OF CONTENTS
Page
Acknowledgements ............................................................................................... vi
List of Tables ....................................................................................................... viii
Chapter
1. GENERAL BACKGROlJND .......................................................................... 1
2. CASE BACKGROlJND DATA ....................................................................... 4
3. EXAMINATION- TESTS AND MEASURES .............................................. 7
4. EVALUATION .............................................................................................. 15
5. PLAN OF CARE- GOALS AND INTERVENTIONS ................................ 18
6. OUTCOMES .................................................................................................. 28
7. DISCUSSION ................................................................................................. 33
References .............................................. .............................................................. 35
Vll
LIST OF TABLES
Tables
Page
1.
Medications ................................................................................... 6
2.
Examination Data ..................................................................... 13
3.
Evaluation and Plan of Care ......................................................... 18
4.
Outcomes ............................................................................... 28
Vlll
1
Chapter 1
General Background
Iliotibial band syndrome (ITBS) is considered to be one of the most common
overuse injuries in the lower extremity, as well as one of the most common causes of
lateral knee pain in runners. 14 The overall incidence of ITBS can range from between
1.6% and 52%, dependent on the population examined, 1•2.4 which may include cyclists,
soccer players, field hockey players, basketball players, rowers, and military
recruits. 1•2•4
While there is a consensus that ITBS is a non-traumatic overuse injury
associated with pain and inflammation of structures around the knee, especially the
lateral synovial recess, the periosteum of the lateral femoral epicondyle, and the
posterior fibers ofthe iliotibial band (ITB), the exact etiology is unclear. 1•2 •4 -8 Potential
etiological or risk factors associated with the development of ITBS have been the
subject of various studies; however, conflicting evidence limits its applicability. 1•8
Etiological or risk factors have been identified based on the potential those factors have
in increasing tension in the ITB. Abnormal kinematics and anatomical variations of the
lower extremity such as excessive hip adduction, knee internal rotation, ankle
pronation, and leg length discrepancy have been suggested as intrinsic risk factors. 7- 15
Other possible intrinsic risk factors include muscle weakness and decreased
flexibility. 7•12•16- 18 Extrinsic risk factors such as rapid increase in mileage, hill training,
lower speed or tar and dirt surfaces have also been suggested as contributing factors
leading to ITBS. 7•11 •14•15
2
The exact pathogenesis ofiTBS is also controversial. Traditionally, ITBS has
been regarded as a frictional syndrome from repetitive movement when the distal
portion of the ITB slides anterior to the lateral femoral epicondyle as the knee extends
and posterior to the lateral femoral epicondyle as the knee flexes. 11 •12•19-21 Orchard et
al. 14 proposed a biomechanical model based on runners, describing an "impingement
zone" occurring at, or slightly below, 30° of knee flexion during heel strike and the
early stance phase of running. As the ITB travels through this "impingement zone",
eccentric contraction of the tensor fascia lata and gluteus maximus muscle decelerates
the lower limb at various phases of running, and generates great tension through the
ITB. 14 This force in conjunction with repetitive flexion and extension through the
"impingement zone" leads to inflammation and pain. 11 •12•14•19-21 However, there are
studies that challenge the common belief that ITBS is a frictional syndrome caused by
the sliding movement between the ITB and lateral femoral epicondyle. Fairclough et
a1. 22 validated that the ITB is not a discrete structure, but simply a thickened part of the
fascia lata. The fascia lata is tethered throughout its length to the linea aspera and
firmly anchored to the lateral supracondylar region of the femur and to the epicondyle
by strong fibrous bands. 22 Thus, the potential for movement of the ITB is limited, and
friction is an unlikely cause ofiTBS due to the anatomical relationship ofthe
structures. 22 Instead, Fairclough et a1. 22 suggested that the ITB is progressively
tensioned from anterior to posterior during knee flexion, and exerts a compressive force
into the lateral epicondyle when the fascia tightens, leading to pain and inflammation.
3
The clinical presentation of ITBS varies. Patients will typically complain of a
poorly localized pain in the lateral aspect of the knee, commonly at the lateral femoral
epicondyle, that may radiate proximally into the outer thigh or distally into the
calf. 2•12•20•21 •23 Tenderness, swelling, crepitation or snapping during movement and
thickening over the region of the lateral femoral epicondyle of the injured knee may
also be present. 2•12•20•21 •23 In mild cases, symptoms are aggravated by running, and the
longer the distance or time, the worse the pain becomes until the runner is forced to
stop. 3•12 In severe cases, pain can be present even with walking or ascending and
descending stairs. 3•12 The prognosis for ITBS varies, but majority of patients will
respond well to a multifaceted conservative approach addressing underlying
dysfunctions and compensatory patterns involving: control of inflammation, stretching
the ITB, strengthening weak musculature, activity modification, soft tissue
mobilization, and neuromuscular reeducation. 1-4· 11 •12•16•20•21 •24"27 For patients with
chronic ITBS, and who have had persistent symptoms despite conservative treatment,
corticosteroid injection or surgical interventions appear beneficial. 28 •29 Unfortunately, to
date, the optimal treatment for ITBS remains unclear. 1•4
4
Chapter 2
Case Background Data
Examination - History
The subject was a 22-year-old female student referred from the Student Health
Center at Sacramento State with the diagnosis of "left lateral thigh pain" that started 10
weeks prior to physical therapy evaluation. The patient's chief complaint was constant
variable stabbing and aching pain localized at the left lateral femoral epicondyle. The
patient also experienced variable pain along her left lateral thigh and variable numbness
and pain localized at her lumbar region; however, the patient described the complaint in
her lumbar region as more pain than numbness and that it was not her primary
complaint. It is important to note that the patient did not complain of problems with her
lumbar region until she was further questioned. Initial onset of current condition was
described as insidious. The patient recalled walking around downtown the night before
she woke up with pain, but denied any event that might have contributed to her current
condition and reported that her symptoms have progressively plateaued. The patient
denied any lumbar, hip, knee, or ankle problems prior to the current incident, but
reported cervical and upper back pain due to a motor vehicle accident two years ago
that has since resolved. Lastly, the patient denied fever, malaise, fatigue, weight
changes, incontinence, nausea, dizziness or cognitive changes. However, patient
admitted to a feeling of numbness that was later described as more painful than numb
localized in her lumbar region; otherwise, patient denied any other numbness in the
5
body. Currently, the patient reported that she is of good health and has no other comorbidities.
Prior to the current incident, patient lived independently without limitations and
was a full time student working two part time jobs that totaled 30-36 hours per week.
Patient reported that she has a baseline of constant variable pain of 3/10 throughout all
her daily activities but it has not prevented her from participating with school, work, or
her social life. Patient stated that she has continued to exercise five to six times per
week of at least one hour duration per session as she had before onset of her current
complaints, but admitted to significant exacerbation of her baseline symptoms that
would last 30-60 minutes post exercise prior to a return to baseline symptoms.
Additionally, patient has excluded running and playing sports (soccer, basketball) from
her exercise routine because it caused more pain than she could tolerate. Preceding
physical therapy intervention, patient did not use or own an assistive device for
ambulation. Lastly, patient used ibuprofen one to two times daily, as well as topical
medication (icy-hot) and an ice pack as needed to manage her symptoms.
The patient's goals were to identify the cause of her current condition, decrease
pain throughout all her daily activities, and return to running and playing sports without
symptoms.
Systems Review
The cardiopulmonary and integumentary systems were not affected based on
screening questions and integumentary observations. The musculoskeletal and
6
neuromuscular systems were affected based on objective examination, Lower
Extremity Functional Scale (LEFS), and patient report.
Examination - Medications
Table 1
Medications30
Ibuprofen
Ingestion, 1-2 times
daily
Analgesic
GI distress, dizziness,
nervousness, ringing in the
ears, unexplained weight
gain, fever, severe skin
reaction, difficulty breathing,
nausea, flu like symptoms,
difficult or painful urination,
vision problems, back pain,
stiff neck, headache,
Icy-Hot (Active
ingredients: Menthol,
Methyl Salicylate)
Topical, as needed
Analgesic
Allergic reaction such as
burning, hypersensitivity,
redness, and tingling
sensation of skin
7
Chapter 3
Examination- Tests and Measures
The patient's deficits were categorized using the International Classifications of
Functioning, Disability, and Health (ICF) Model. Body function or structure
impairments were identified utilizing the following: the numeric pain rating scale
(NPRS), Ober's Test, Noble Compression Test, and palpation were used to assess pain
as well as assist with physical therapy diagnosis; manual muscle tests (MMT) were
used to assess muscular strength; Ober's Test, Thomas' Test, and hamstring length
were used to assess muscle length/flexibility; observation of functional movements
inciuding squats, step up/down, and single leg stance were used to assess kinematic
abnormalities and motor control. Activity limitations were identified with the Lower
Extremity Functional Scale (LEFS), patient report, and observational analysis.
Participation restrictions were identified via patient report and Global Rating of Change
Scale (GROC).
NPRS is a segmented numeric scale in which a respondent selects from 0 to 10
to best reflect the intensity of their pain. The measure has high test retest reliability (r =
0.96), as well as high construct validity when compared to the visual analog scale
(correlation ranged from 0.86 to 0.95). 31 An estimate of minimal detectable change
(MDC) is approximately 3 NPRS scale points for patients with musculoskeletal
problems. 32 The MDC was used to measure improvements in pain for the patient; a
change of 3 points indicates that the patient has reached a change that surpassed the
threshold of error.
8
MMT evaluates the ability of the muscle tested to meet or adapt to the
resistance provided by the examiner or the force of gravity. The examiner evaluates the
muscle(s) tested on numerical scores ranging from 0, which represents "no activity," to
5, which represents "normal" or best possible response. 33 Based on a systematic review
conducted by Cuthbert et al. in 2007, test-retest reliability was found to be moderate to
excellent (ranging from 0.63 to 0.98). Validity requires further testing, but several
authors argue that MMT has content validity because the test construction is based on
known physiological, anatomic and kinesiologic principles. 34 Although MCD or MCID
has not been established for MMT, the authors suggested that scores must change more
than one full grade in order to be confident that a true change in strength has occurred. 34
The MMT was used to measure improvements in strength for the patient; a change in
one full grade would indicate that a true change had occurred.
Currently, there are no specific prognostic factors or clinical prediction rule for
ITBS predictive ofpatient condition or outcome. 1.4 As stated in Chapter 1, the evidence
for potential risk factors associated with ITBS are conflicting, therefore, this limits its
applicability towards prognosis or development of a clinical prediction rule. There are
also no single diagnostic protocol for ITBS, and ITBS tend to be diagnosed on the basis
of patient history and presentation, complemented by clinical findings and absence of
other pathologies. 1•3•7•10•12•16•17•21 •22•25 •28 •29 Positive Noble compression test is often used
to confirm the diagnosis ofiTBS 1•7•10•12•17•18•28 •29 and positive supplementary tests such
as the Ober's test are associated with ITBS. 1•10•18•26 However, the two tests have not
9
been validated for patients with ITBS, but seem to have good face validity. 1 MRI may
be used if there is doubt about the diagnosis and to exclude other pathologies. 1•5
The Noble compression test may be used to provoke symptoms to confirm the
diagnosis of ITBS and has been reported to have moderate inter-rater reliability. 18•35
Otherwise, no other psychometric properties have been reported for the Noble
Compression test. 1 The Noble compression test is performed by positioning the patient
in supine or sidelying with the affected knee up and flexed to 90°; the clinician then
applies pressure to the iliotibial band over the lateral femoral epicondyle and gradually
extends the knee. A positive test will be indicated by complaint of pain over the lateral
femoral epicondyle or the patient's comparable sign as the knee approaches 30° of
flexion. 12
The Ober test measures the flexibility or the length of the iliotibial band and has
been reported to have good inter-rater as well as intra-rater reliability (ICC= 0.90). 35 •36
The patient is positioned lying on their side with the tested extremity up. The clinician
flexes the knee to be tested to 90°, the thigh is then passively abducted and extended to
catch the iliotibial band over the greater trochanter. Next the limb is passively allowed
to adduct via gravity as far as possible. If the leg can be passively adducted to
horizontal at best, this constitutes moderate tightness, and if it cannot be passively
adducted to horizontal, this is maximal tightness. The degree of adduction of the hip
reflects the flexibility of the iliotibial band. 37 Noehren et al. performed a cross sectional
study between 17 patients with ITBS and 17 healthy patients, and determined the MDC
10
for the Ober test in that specific study to be 3.8°. 18 No other psychometric properties
for the Ober test have been reported. 1
Observation of functional movements (squats, single leg stance, step
ups/downs), posture, and gait was used to clinically assess impairments found in
alignment and kinematics, as well as motor control of the patient. Whatman et al. 38
compared the quality of movement patterns of a range of lower extremity movements
from visual rating by physical therapists against camera motion analysis systems. They
found that mean intra-rater agreement was substantial (percent agreement [PA]
88%; agreement coefficient 1 [ACl]
=
79-
= 0.60-0.78), inter-rater agreement ranged from
fair to substantial (PA = 67-80%; ACl
= 0.37-0.61), sensitivity (0.80) and specificity
(0.50) were all acceptable for all tests except for the drop jump. High sensitivity
ensures those who actually have poor alignment will be detected by the physical
therapists. Using experienced clinicians (diagnostic odds ratio [DOR]
= 1.6-2.8) and
observation of slower movements (DOR = 4.9) improved rating accuracy. 38 In
agreement with the study conducted by Whatman et al. 38 , a systematic review
conducted by Maclachlan et al. 39 found clinically acceptable results, in terms of the
accuracy of observer ratings. These findings were achieved when slow, speedcontrolled movements such as single leg or two legged squats were rated. Conversely,
lower levels of agreement were evident when faster, more explosive movements such
as drop jump and cutting maneuvers were assessed. While multi-camera, three
dimensional motion analysis are recognized as the gold standard in kinematic and
movement assessment, the above evidence conveys that visual rating by physical
11
therapists can be a valid tool for identification of impairments. 38·39 The information
gained from visual observation of the current patient aided in the clinical decision
making process and determination of appropriate interventions.
The LEFS is an ICF activity level outcome measure that evaluates the
functional level of a wide range of patients with lower-extremity orthopedic conditions
who have various disability levels, comorbidities, treatments, and age. 40 The LEFS has
20 questions with a total possible score of 80; a lower score will indicate a higher level
of disability to complete everyday tasks. For patients with various lower extremity
injuries, the standard error of measurement (SEM9s) is 3.9 points, the minimal
detectable change (MDC9s) is 9 points, and the minimal clinically important difference
(MCID) is also 9 points. 40 The LEFS can be used to assess initial activity and/or
functional level, set functional goals, measure ongoing progress, as well as measure
outcome of an intervention(s) for patients with ITBS. The MDC and MCID was used to
measure improvements in the patient. Improvement of 9 points for the MDC and
MCID will indicate that the patient has reached a change that has surpassed the
threshold for error inherent in the measure and considered to be clinically important,
respectively.
The Global Rating of Change Scale (GROC) is an ICF participation level
outcome measure to determine if the patient's health condition has improved or
deteriorated through a course of care to determine the efficacy of the care. GROC asks
the patient to assess his or her current health status, and compare it from the time that
they began treatment on an 11 or 15 point numerical or visual analog scale, dependent
12
on which GROC version was given. The "global" aspect of the GROC distinguishes it
from other outcome measures that are typically directed towards one specific dimension
of the patient's health status; instead, the GROC allows a patient to decide what they
consider as important in their health status. 41 The MDC calculated from the SEM from
a single study was 0.45 points on an 11 point scale; the MCID calculated from five
studies was 2 points on an 11 point scale; and a cut of score of ±5 on a 15 point scale
was described in a single study as clinical important. 41 Since the patient in this case
report utilized the 15-point version of the GROC, an improvement of 5 points would
indicate that a change in the patient status was due to the course of care.
13
Table 2
Examination Data
1.
pain
B)NPRS
reported by
patient during
Ober's Test
2.
Flexibility
2.
C)NPRS
reported by
patient during
Noble
Compression
Test
Muscle Length
Tests
3.
Strength
3.
MMT
4.
Motor Control
4.
Observation of
Functional
Movements
A) Left lateral thigh (femoral epicondyle,
region along ITB) of constant variable
nature: overall (3-9/1 0), at rest (3/1 0),
aggravation with activity (9/10)
Lumbar region: intermittent variable (01/10)
B) 7/10, comparable pain
C) 7/10, comparable pain
2.
3.
4.
Hamstring length (popliteal angle test): R
= 142°, L = 132°; no provocation of
symptoms
Hip flexors via Thomas' Test: R knee
flexed = 10° from table, L knee flexed = 27°
from table; R knee straight= parallel with
table, L knee straight= 10° from table; no
provocation of symptom/chief complaint
ITB via Ober's Test: R = -3° past horizontal
plane of table; L = 7° away from horizontal
plane of table; provocation of symptoms/chief
complaint
Hip abductors: L = 4/5, R = 5/5
External rotators: L = 4/5, R = 515
Squat: body (center of mass) deviates over L
LE > R LE during descend associated with L
hip adduction; no provocation of symptoms
Step up: no abnormalities observed with R
LE; (+)Trendelenburg observed with L LE
with provocation of symptoms/chief
complaint
Step down: (+)Trendelenburg observed
bilaterally; no provocation of symptom/chief
14
2.
Posture
2.
Observational
analysis
2.
3.
Gait Kinematics
3.
Observational
analysis
3.
4.
Sleeping Pattern
4.
Patient report
4.
-
Decreased weight bearing on L side during
standing and sitting as observed with lateral
lean and weight shift to R
(+)Trendelenburg observed with L LE,
decreased stance time with L LE leading to
decreased step length with R LE; increasing
step length with L LE provoked
symptoms/chief complaint
Unable to sleep through the night secondary
to pain; difficulty finding a comfortable
position during initiation of sleep; waking at
least twice a night during positional changes
such as rolling towards R or laying on L LE
with knee flexed
Unable to maintain workout routine
secondary to pain; unable to run or play
soccer; only able to tolerate elliptical for <30
minutes; symptoms will be aggravated to
9110 post exercise that lasts approximately
30-60 minutes
NPRS = Numeric Pain Rating Scale; R = Right; L = Left; MMT = Manual Muscle
Test;(+)= Positive; LE =Lower Extremity; LEFS =Lower Extremity Functional Scale
15
Chapter4
Evaluation
Evaluation Summary
Patient was a 22-year-old female who was a full time student and part time
employee at two different jobs that totaled 30-36 hours per week. The patient was
referred from the Student Health Center at Sacramento State to Pro-Bono Clinic with a
10-week history of constant and variable pain in her left lateral thigh. This was the
patient's first attempt at treatment since initial onset of symptoms. The impairment to
body structure and function included: pain, range of motion deficits, decreased strength,
and poor motor control. The patient's activity limitations included: impaired functional
mobility (work or school activities, sporting activities, squatting, performing heavy
activities around home, walking a mile, going up or down a flight of stairs, standing or
sitting for 1 hour, running on even or uneven ground, making sharp turns while running
fast, hopping, and rolling over in bed), impaired posture, impaired gait kinematics, and
sleep disturbance. The patient's participation limitations included alteration in hobbies
such as the inability to maintain her workout routine or play sports.
Diagnostic Impression
The patient had signs and symptoms consistent with ITBS, this was classified
on the basis of the patient's history and presentation, complemented by clinical findings
and absence of other pathologies. The patient's chief complaint stemmed from a nontraumatic injury, and it was inferred from the subjective examination that she was very
physically active, which indicated pathologies associated with overuse. Other overuse
16
pathology such as osteoarthritis was ruled out because of the patient's age, no
complaints of morning stiffness, and hip flexion and internal rotation was not limited
by pain. The patient had constant variable pain at the lateral femoral epicondyle and
along her lateral thigh, which was provoked with activities such as running and
climbing stairs, as well as with palpation. The patient did not have signs of swelling or
inflammation. Upon objective examination, the patient was found to have hip abductor
weakness, abnormal kinematics of the lower extremity ~n standing and during
movement, as well as decreased muscle length of the ITB, hip flexors, and hamstrings.
Additionally, the patient tested positive for Noble Compression Test and Ober's test,
both of which replicated the patient's symptoms as a comparable pain. Based upon the
above examination, it was concluded that the patient had signs and symptoms
consistent with ITBS.
G-Codes
Current with modifier: 08978 CJ
Goal with modifier: 08979 CI
Prognostic Considerations
While there are currently no prognostic factors or clinical prediction rules
associated with ITBS, the current evidence, albeit coming from studies with small and
heterogeneous samples, suggests that conservative treatment and activity modifications
appear beneficial in the management ofiTBS. 1•4 Additionally, it has been suggested
that an implementation of care involving staged application of various types of
rehabilitation services for musculoskeletal injuries appears to result in more rapid and
17
sustained recovery. 42 Thus, the patient has good rehabilitation potential if she adheres
to a conservative treatment plan that addresses her underlying dysfunction and
compensatory patterns.
Expected Discharge Destination/Status
The patient was discharged after 7 sessions with an independent and progressive
home exercise program.
18
Chapter 5
Plan of Care-Goals and Interventions
Table 3
Evaluation and Plan of Care
PROBLEM
Short Term Goals
(4 weeks)
•
•
Pain at baseline as
measured by the
NPRS
• L lateral thigh
(3-9/1 0)
• Lumbar region
(0-1/10)
• Ober's Test
(7/10)
Noble
•
Compression
Test (7/10)
Reduce pain as
measured by the
NPRS
L lateral thigh
(1-6/10)
• Lumbar region
(0/10)
• Ober's Test
(4/10)
Noble
•
Compression
Test (4110)
•
Reduce pain as
measured by the
NPRS
• L lateral thigh
(0-3/10)
• Lumbar region
(0/10)
• Ober's Test
(1/1 0)
Noble
•
Compression
Test (1110)
•
•
Interventions are Direct
or Procedural unless they
are marked: (E) =
Educational intervention
Interventions were
performed once a week
for seven sessions over
of
weeks
the
(E) Monitor use of
medication for pain
reduction during each
patient visit; provide
education and references
about the difference
between NSAID (antiinflammatory and
analgesic) and
acetaminophen
(analgesic only)
(E) Educate patient of the
proposed etiology and
pathology ofiTBS and
why activity
modifications and rest
are important for
recovery. Activity
modifications included:
sleeping with a pillow to
prevent adduction ofLEs
or rolling during sleep,
avoidance of activities
that exacerbate her
symptoms (eg. running,
soccer) or stopping prior
to threshold of
19
•
•
•
Decreased flexibility
at baseline as
measured by muscle
length tests
• Hamstring:
R= 142°, L=
132°
Hip
flexors:
•
R = parallel with
table, L = 10°
from table
• ITB: R= -3°
past horizontal
plane of table, L
= 7° from
horizontal plane
of table
Improve
flexibility as
measured by
muscle length tests
• Hamstring:
R=152°,L=
142°
• Hip flexors:
R =past
parallel with
table, L =5°
from table
• ITB: R=
remains past
horizontal
plane of table,
L= 3° from
horizontal
plane of table
Improve
flexibility as
measured by
muscle length tests
• Hamstring:
R=152°,L=
152°
• Hip flexors:
R=remains
past parallel
with table, L =
parallel with
table
• ITB: R=
remains past
horizontal
plane oftable,
L =past
horizontal
plane oftable
•
•
•
(eg. elliptical), and
choosing alternative
activities that does not
exacerbate her symptoms
(eg. weight lifting, arm
bike, swimming with
UEs only)
Lumbar traction in
supine, Grade II,
2x30seconds;
discontinued after
cessation pain in lumbar
region
Soft tissue massage and
myofascial release along
symptomatic area, 25minutes per session
Ice massage over
symptomatic area, 25minutes, but did not
perform every session
Hip mobilization:
~ Lateral glide,
Grade III,
2x30sec
~
Caudal glide,
Grade III,
2x30sec
~
PA glide, Grade
III, 2x30sec
PA glide in
~
FABER, Grade
III, 2x30sec
Manual stretching of
surrounding musculature
ofthe hip (hamstring, hip
flexors, tensor fascia lata)
~
Static stretching
to be part of
home exercise
program (see
below)
~
Tack and pull
forTFL, 23sets, 30-60
seconds per set
(E) Home exercise
program with stretching
20
Decreased strength
at baseline as
measured by MMT
• Hip abductors:
L = 4/5, R = 515
External
•
rotators:
L = 4/5, R = 515
Improve strength
as measured by
MMT
• Hip abductors:
L= 5/5, R=
Improve strength
as measured by
MMT
• Hip abductors:
L=5/5, R=
515
•
External
rotators:
L= 5/5, R=
515
•
515
•
External
rotators:
L= 5/5, R=
515
•
•
•
•
exercises for LE
(hamstring, hip flexors,
tensor fascia lata,
piriformis, gluteus
medius, rectus femoris)
);> 3 sets x 30-60
seconds
Several of the exercises
below was part of the
patient's (E) home
exercise program; "7"
indicates progression;
exercises was progressed
once patient was able to
perform 3xl2-15 or
3x30sec and subjectively
reported that the exercise
was no longer a
challenge; exercises can
be progressed with
increasing the number of
repetitions, adding elastic
bands, or increasing
isometric durations;
patient encouraged to
complete each exercises
for 3xl2-15, 3x30sec, or
to fatigue, whichever one
comes first
Side lying hip abduction
7 sidelying hip
abduction with elastic
band
Single leg stance 7
single leg stance with toe
tab in
lateral/oblique/anterior
direction 7 single leg
RDL with contralateral
reach
Tri-planar lunges 7
plyometric tri-planar
lunges
Squats 7 squats with
elastic band around thigh
7 squats with elastic
band around thigh with
slow eccentric descend
21
•
•
•
Impaired motor
control at baseline as
measured by
observation of
functional
movements
• Squat: uneven
distribution of
weight during
movement with
deviation
towards L LE
during descend
• Step up:
(+)Trendelenbur
g with L LE
only,
provocation of
symptoms
• Step down:
(+)Trendelenbur
g observed
bilaterally, L > R
Improve motor
Improve motor
control as
·control as
measured by
measured by
observation of
observation of
functional
functional
movements
movements
Squat: even
• Squat: even
distribution of
distribution of
weight during
weight during
movement
movement
Step
up:
•
• Step up:
(()Trendelenbur
)Trendelenbur
g withL LE,
g withL LE,
minimal
no
provocation of
provocation of
symptoms
symptoms
• Step down:
• Step down:
(()Trendelenbur
)Trendelenbur
g observed
g observed
bilaterally
bilaterally
•
•
•
•
•
with pause "in the hole"
prior to explosive
concentric phase
Monster walks 7
monster walks with
elastic band 7 monster
walks with elastic band
and catching/throwing
ball in sagittal and
transverse plane
Double leg bridging 7
double leg bridging with
elastic band and/or single
leg bridging
Trunk strength:
quadruped, static plank,
dynamic plank
Main focus was
neuromuscular
reeducation to improve
abductors activation and
control to decreased
Trendelenburg sign; time
performed ranged from 5
to 15 minutes; sets and
reps varied, but
attempted to have patient
reach fatigue before
stopping
Squatting with visual
(mirror), verbal, and
tactile (PNF provided by
SPT) cues 7 squatting
without cues
Step up with visual
(mirror), verbal, and
tactile (elastic band
around thigh pulling in
opposing direction to
prevent hip adduction)
cues 7 progressed with
height of steps and
removal of cues
Step down with visual
(mirror), verbal, and
tactile (elastic band
around thigh pulling in
opposing direction to
22
prevent hip adduction)
cues ~ progressed with
height of steps, removal
of cues, and eccentric
control
Impaired functional
mobility at baseline
as measured by
LEFS
• LEFS = 53/80
Improve
functional
mobility as
measured by LEFS
•
LEFS = 62/80
Improve
functional
mobility as
measured by LEFS
• LEFS = 71/80
•
The aforementioned
treatment above that
addresses pain,
flexibility, strength and
motor control will
indirectly improve ability
to perform activities
Impaired posture at
baseline as measured
by observational
analysis
•
Decreased
weight bearing
on L side during
standing and
sitting
Improve posture
as measured by
observational
analysis
• Equalize
weight
towards
midline during
standing and
sitting
Improve posture
as measured by
observational
analysis
• Maintain
weight at
midline during
standing and
sitting
•
(E) Postural reeducation
with visual, verbal, and
tactile cues; explain the
proposed model on how
poor posture in standing
(eg. hip adduction) can
increase strain on ITB
and provocation of
symptoms
The treatment of
decreasing pain,
improving flexibility,
strength and motor
control will indirectly
improve posture
Improve gait
mechanics as
measured by
observational
analysis
• ()Trendelenbur
gLLE,
increase
stance time
with L LEas
tolerated to
achieve stride
length
symmetry
between L and
RLE, able to
take
Improve gait
mechanics as
measured by
observational
analysis
• ()Trendelenbur
g L LE, stride
length
symmetry
between L and
RLE, able to
take large
strides with no
provocation of
symptoms
Impaired gait
mechanics at
baseline as measured
by observational
analysis
• (+)Trendelenbur
gLLE,
decreased stance
time with L LE
leading to
decreased stride
length with R
LE, increased
stride length
provoked
symptoms
•
•
•
Gait training exercises:
correct deviations and
asymmetry as tolerated
with visual, verbal, and
tactile cues; time varied
per session
};;> Increase weight
bearing on L LE
to achieve a
larger stride
with L LE,
timing of gait
mechanics, hip
abductors
activation/contr
ol
The aforementioned
treatment above that
23
strides with
minimal
provocation of
symptoms
Sleep disturbance at
baseline as measured
by patient report
•
Difficulty
finding a
comfortable
position during
initiation of
sleep, waking up
throughout the
night (>2) during
position changes
Decrease sleep
disturbance as
measured by
patient report
• Able to find a
comfortable
position
during
initiation of
sleep and be
able to sleep
through the
night with
minimal (<2)
disturbances
Decrease sleep
disturbance as
measured by
patient report
• Able to sleep
through the
night with no
disturbance
Decreased/altered
participation with
hobbies at baseline
as measured by
patient report
• Unable to
maintain gym
routine (eg.
elliptical for <30
minutes), run or
play sports
(soccer,
basketball)
Improve
participation with
hobbies as
measured by
patient report
• Able to
perform
elliptical for
30 minutes
with minimal
irritability and
no increase of
symptoms
afterwards
• Able to jog
without
aggravation of
pain as
tolerated (time
is arbitrary)
Able
to
•
perform
athletic
movements at
50% of
Improve
participation with
hobbies as
measured by
patient report
• Able to
perform
elliptical for
30 minutes
with no
irritability and
no aggravation
of symptoms
afterwards
• Able to run
without
aggravation of
pain as
tolerated (time
is arbitrary)
• Able to
perform
athletic
movements at
maximal
•
•
•
•
addresses pain,
flexibility, strength and
motor control will
indirectly improve gait
mechanics
(E) Activity
modification: sleeping
with pillow in between
legs to prevent adduction
of L LE during rolling
towards R, taking note of
specific position that
causes minimal pain
during initiation of sleep
and utilize that position
every night
The aforementioned
treatment above that
addresses pain and
flexibility might
indirectly decrease sleep
disturbance
(E) Patient education
about importance of pain
management and not
exercising past the
threshold that increases
her symptoms
The aforementioned
treatment above that
addresses pain,
improving flexibility,
strength and motor
control will indirectly
improve ability to
perform activities
24
maximal
intensity as
intensity as
perceived by
perceived by
the patient (eg.
the patient (eg.
cuts, change
cuts, change
of speed)
of speed)
L = Left; R = Right; NPRS = Numenc Pam Ratmg Scale; (E) = Educational Intervention; NSAID =
Non Steroid Anti-Inflammatory Drug; ITB = Iliotibial Band; ITBS = Iliotibial Band Syndrome; LEs =
Lower Extremities; UEs =Upper Extremities; eg. =Example Given; PA =Posterior Anterior;
FABER = Flexion Abduction External Rotation; TFL =Tensor Fascia Lata; MMT =Manual Muscle
Test; RDL = Romanian Deadlift; (+) =Positive; (-) =Negative; SPT = Student Physical Therapist;
PNF = Proprioceptive Neuromusuclar Facilitation; LEFS = Lower Extremity Functional Scale
25
Overall Approach
During this episode of care, the patient was seen once a week for seven sessions
over the span of eight weeks. The overall treatment strategy utilized was a multifaceted
approach with an emphasis on therapeutic exercises and neuromuscular control to
address all deficits. The plan of care was constructed to address the body structure and
function impairments and activity limitations identified from the subjective and
objective examinations. By addressing the impairments found in the body structure and
function and activity categories, the multifaceted approach indirectly improved the
participation restrictions caused by ITBS.
PICO question:
For a 22 year oldfemale with sub-acute ITBS, what is the best combination of
conservative treatment (i.e. not surgical) for the management of ITBS?
Vander Wrop et al. 1 conducted an extensive, quality-controlled, systematic
review; one of their conclusions was that there is limited evidence to support a specific
treatment ofiTBS. Five studies on the conservative treatment ofiTBS met the
inclusion criteria and were included in the systematic review, with evidence level
between 1b to 2b according to the Centre of Evidence Based Medicine. Overall, the
results on the conservative treatment of ITBS provided some evidence of the
effectiveness and benefits of pain medication or injection, stretching of the ITB, hip
abduction exercises, and advice about training. 1 Unfortunately, no randomized clinical
trials have investigated the benefit ofthese different treatments in isolation. 1
26
While there is no consensus for which conservative treatment is superior,
numerous studies, clinical reviews and systematic reviews have suggested that
conservative treatment plans with a multifaceted approach appears to be effective in the
management of ITBS. 1-4· 11 •12•16•17•20 •24"27 Several clinical reviews, cohort studies, and
case reports have outlined conservative treatment progressions, beginning with
treatment of the acute inflammatory response, progressing through a corrective
treatment phase, and an eventual return to regular activities. A summary of the
treatment progression is outlined in the next paragraph. 3•12•16•17.24 -27
Care in the acute phase focuses on measures to relieve pain and inflammation
such as ice, oral NSAIDs, corticosteroids, and soft tissue massage have been suggested.
Patient education is critical to a successful outcome, as activity limitation or
modifications are needed to reduce the repetitive stress at the lateral femoral
epicondyle. Once acute inflammation subsides, stretching exercises addressing all
flexibility deficits can begin, with particular attention given to increasing the length of
the TFL and ITB complex. Strengthening approaches for ITBS have supported
strengthening of the hip abductors, some have recommended multidimensional
movement patterns involving weight shift, and other aspects of hip abductor function as
treatment strategies. Improvement with neuromuscular control during gait has also been
suggested as a useful approach for ITBS. Gradual return to activity is dependent upon
being able to perform exercises or movements with proper form and no pain.
27
Since there is no evidence that suggests a specific combination of treatment that
is superior to another, I decided to utilize a multifaceted treatment progression outlined
by clinical reviews, cohort studies, and case reports that had successful outcomes.
28
Chapter 6
Outcomes
Table 4
Outcomes
OUTCOMES
:?;
:~~~¥.: '
;"Rf'lnV,J!'ISJ~'
f_,,'
,_,_,. ~:"''.!'' ""
Outcome
Initial
Follow-up
NPRS via
patient report,
Ober's Test,
Noble
Compression
Test
1.
l.
Change
Goal
Met
(YIN)
2.
3.
4.
Muscle
length tests
1.
2.
3.
Left lateral thigh
of constant
variable nature:
overall (3-9/10),
at rest (3/10),
aggravation with
activity (9/10)
Lumbar region:
intermittent
variable (0-1110)
Ober's Test:
(7/10)
Noble
Compression
Test: (7/10)
Hamstring length
(popliteal angle
test): R = 142°, L
= 132°
Hip flexors via
Thomas' Test: R
knee flexed = 1oo
from table, L
knee flexed= 27°
from table; R
knee straight =
parallel with
table, L knee
straight = 10°
from table
ITB via Ober's
Test: R = -3° past
2.
3.
4.
Left lateral thigh
of intermittent
variable nature:
overall (0-4/10),
at rest (0-111 0),
aggravation with
activity (3-411 0)
Lumbar region:
(0/10)
Ober's Test:
(1/10)
Noble
Compression
Test: (1110)
•
1.
2.
3.
4.
NPRSMDC=3
points
Left lateral thigh
pain decreased by
3-5 points
Lumbar pain
decreased by 1
point
Ober's Test pain
decreased by 6
points
Noble
Compression Test
pain decreased by
l.Y
2. y
3. y
4. y
6po~
1.
2.
3.
Hamstring length
(popliteal angle
test): R = 147°, L
= 145°
Hip flexors via
Thomas' Test:
L/R knee flexed =
parallel with
table, L/R knee
straight = parallel
with table
ITB via Ober' s
Test: R = -5° past
horizontal plane
of table; L = 0°
from horizontal
plane oftable
•
I.
2.
3.
Mean value of
popliteal angle
for women43 =
152° (SD = 10.6°)
Hamstring length:
R=+5°,L=
+12°
Thomas' Test
improved to
negative
Ober's Test
improved to
negative
l.N
2. y
3. y
29
MMT
1.
2.
Observation
of
functional
movements
1.
2.
3.
; ;"~:?:!,;""''I"
"~
horizontal plane
of table; L = 7°
away from
horizontal plane
of table
Hip abductors: L
= 4/5, R = 515
External rotators:
L = 4/5, R = 515
Squat: center of
mass deviates
over L LE > R LE
during descend,
no provocation of
symptoms
Step up: no
abnormalities
observed with R
LE;
(+)Trendelenburg
observed with L
LE with
provocation of
symptoms/chief
complaint
Step down:
(+)Trendelenburg
observed
bilaterally with no
provocation of
symptoms/chief
complaint
Outcome
"-"'
-~ ::',
Initial
LEFS
l.
~!"J~-
1.
Hip abductors: L
l.
= 5/5, R = 5/5
2.
1.
2.
3.
External rotators:
L = 5/5, R = 515
Squat: no
deviations
observed
Step up: no
abnormalities
observed with R
LE;
(+)Trendelenburg
observed with L
LE, but noted
improvements in
consecutive
weeks, no
provocation of
symptoms/chief
complaint
Step down: no
abnormalities
observed with R
LE
(+)Trendelenburg
observed with L
LE, but noted
improvements in
consecutive
weeks\
2.
l.
2.
3.
L hip abductors
improved by 1
point
L external
rotators improved
jlyl_p()int
Squats: improved
to even
distribution of
weight during
movement
Step ups:
improvements
made with L LE,
but continues to
have
(+)Trendelenburg
sign; improved to
no provocation of
symptoms/chief
complaint
Step downs:
improvements
made with L LE,
but continues to
have
(+)Trendelenburg
sign;
Jln"·T
Follow-up
Change
l.Y
2. y
l.Y
2.N
3.N
~
Goal
Met
(YIN)
LEFS 57/80
1.
LEFS 75/80
•
l.
MCDandMCID
= 9 points
Increased by 18
points, or 2 MCD
andMCID
l.Y
30
Observational
analysis of
posture
1.
Observational
analysis of
gait
1.
Patient report
of sleep
disturbance
1.
Decreased weight
bearing on L side
during standing
and sftting
(+)Trendelenburg
observed with L
LE; decreased
stance time with
L LE leading to
decreased stride
length with R LE;
increasing stride
length with L LE
provokes patient's
symptoms/chief
complaint
Unable to sleep
through the night
secondary to pain;
difficulty finding
a comfortable
position during
initiation of sleep;
waking through
night during
position changes,
especially with
rolling towards R
'i:~"t:<.~~ t~;;,:::~o11:r ,,,.c,:,
1.
1.
1.
No deviations in
weight bearing in
standing and
sitting
(-)Trendelenburg
observed with L
LE; normalized
gait symmetry in
stance time and
stride; increasing
stride length with
L LE still
provokes
symptoms/chief
complaint
1.
Improved
postural
deviations
l.Y
1.
Improved to (-)
Trendelenburg
sign and
normalized gait
symmetry; but
continues to be
provoked by
longer strides
with L LE
l.N
Able to sleep
through the night
with pillow in
between legs; no
difficulty finding
a comfortable
position during
initiation of sleep
1.
Improved to be
able to sleep
through the night
and no longer
have difficulty
finding a
comfortable
position during
initiation of sleep
l.Y
-
Outcome
Initial
Follow-up
Change
Patient report
of
participation
in hobbies
1.
1.
1.
Unable to
maintain workout
routine secondary
to pain- unable
to run or play
soccer, only able
to tolerate
elliptical for <30
minutes;
symptoms will be
aggravated to
9/10 post exercise
that lasts -30
minutes after
cessation
Able to perform
·elliptical for 30
minutes prior to
ons"et/aggravation
of symptoms to 34/1 0 that lasts for
-1 0 minutes after
cessation; able to
play soccer and
run, but
experiences
aggravation of
symptoms to 34/10 that lasts -10
minutes after
but
Goal
Met
(YIN)
Improvements
made, but
symptoms
continues to be
aggravated by
hobbies
l.N
31
GROC
1.
Not applicable
(n/a)
stated that it did
not hinder her
performance as
much as before
1. +7
1. +5 indicates a
clinically important
change; patient
reported a + 7
1. n/a
L = Left; R = Right; ITB = Iliotibial band; NPRS = Numeric Pain Rating Scale; MDC = Minimal
detectable change; SD =Standard deviation; Y =yes; N =No; LEs =Lower Extremities;(+)=
Positive;(-)= Negative; LEFS =Lower Extremity Functional Scale; MCID =Minimal clinical
important difference; GROC = Global Rating of Change Scale
32
Discharge Statement
The patient attended Pro Bono Clinic for treatment with the diagnosis of
"lateral thigh pain" for seven visits over a span of eight weeks. The patient received
manual therapy, soft tissue massage, manual stretching, therapeutic exercises, and
patient education to address signs and symptoms consistent with ITBS. Not all of the
patient's goals were met during this episode of care; however, significant progress was
achieved. Objectively, the patient achieved improvements associated with decrease in
pain, increase in strength and flexibility, as well as improvement with motor control
and gait kinematics. While the patient continued to be limited with participation of her
hobbies, she reported that she felt a significant improvement in her condition due to
this episode of care. Additionally, the GROC of+7 indicated that this episode of care
made a significant improvement in her health status. Upon discharge, the patient was
independent with a home exercise program, and was provided instructions on how to
progress the home exercise program. No follow up visits were made.
DC G-Code with modifier:
G8979 CI
33
Chapter 7
Discussion
Overall, the plan of care provided for the patient was successful. While the
patient did not meet all of the proposed long-term goals, significant progress and
meaningful changes were made during this episode of care. The patient objectively
met more than half the proposed goals, and subjectively reported an overall
improvement with her condition, as well as her ability to perform activities and
participate with hobbies. Improvements can be attributed to the patient's participation
with Pro-Bono Clinic, as shown by the GROC score and patient report, and
interventions that improved her underlying dysfunctions and compensatory patterns.
Several factors might have contributed to the patient not reaching all proposed long
term goals, such as: limited number of visits allotted per week, inability of the student
physical therapist to immediately diagnose ITBS during initial evaluation, inadequate
adherence to the home exercise program and recommendation to limit aggravating
activities as reported by the patient.
The patient responded to the treatment provided as expected. This expectation
came from utilizing a multifaceted conservative treatment approach outlined by
previous studies and cases that had successful outcomes. The multifaceted
conservative treatment approach that was utilized for this patient was a strength of this
episode of care, as a variety of progressive interventions were provided to address the
patient's underlying dysfunction and compensatory patterns. There were several
limitations throughout this episode of care. Limited amount of visits hindered the
34
evaluation process as well as decreased the treatment frequency allotted to the patient;
this might have affected the patient's outcome. Another limitation was the poor
objective data obtained for motor control of squats, step up, and step down, as well as
for impaired posture and gait mechanics. While observational analysis can provide
information on gross impairments or dysfunction, it is difficult to objectively measure
visual observation; this becomes problematic to objectively assess whether a patient
has regressed or made improvements. Future studies should obtain measurable and
objective data for the aforementioned movements via force plates to assess weight
distribution, plumb line hanging from a ceiling to assess posture, and motion cameras
to assess abnormal kinematics. Lastly, ankle kinematics was not assessed during this
episode of care, and there is evidence suggesting that the ankle has a role in the
development ofiTBs.?- 10•13 •14
Although conservative treatment appears to be beneficial in the management of
ITBS, the evidence in support of such management appears to be limited and of
insufficient quality at this time. Further research of the clinical effect of conservative
therapies, or of a specific conservative therapy in the treatment of ITBS, will be of
great benefit to the evidence based management of this condition. Until then, the
evidence utilized to assist with management of patients with ITBS is based on
anecdotal evidence from studies and case reports with small and heterogeneous
samples.
35
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