Effects of Excessive Pronation on the Knee

For an example of the interactions between the structures of the knee’s kinetic chain, let us take a look at a person whose foot is excessively pronated (rolled inwards). This pronation causes the person’s foot to flatten out during normal walking. This flattening then causes the tibia to rotate inwards (medially) and the femur to rotate outward (laterally).

These actions place a considerable amount of stress on the knee, eventually leading to friction, inflammation, altered motion patterns, and injury of the soft- tissues of the knee. Thus, a problem that started at the foot ends up causing abnormal hip and femur rotation, which in turn leads to knee problems.

From a therapy perspective, it is possible to achieve moderate success by treating just the immediate structures of the knee. However, in order to truly resolve the problem, we should also treat those structures that were the original cause of the excessive pronation – that is, the structures in the knee’s kinetic chain. For example, restriction in any of the following structures may be the actual cause of the excessive pronation:

• Peroneus longus and peroneus brevis muscles help you to point your feet and aid in eversion (rolling inward) of the foot when walking or running.
• Tibialis anterior lets you bend your foot upwards (dorsiflexion) and also helps to invert the foot (roll outwards) when you walk. Proper inversion of the foot is an important part of a normal gait pattern.
• Abductor hallucis, this muscle is responsible for flexing the big toe and allows your big toe to move laterally (sideways). This is important since a normal walking/running stride requires us to push-off with our big toe.
• Flexor hallucis brevis, this muscle is responsible for flexing the big toe and for supporting the medial arch of the foot.
• Flexor hallucis longus, this muscle is responsible for flexing the big toe, supinating the ankle (turning inwards), and in pointing your foot (plantar flexion).

Restrictions in any of these structures can cause excessive pronation, which in turn leads to hip restrictions, and subsequent knee problems.

Obviously, in such situations, treating just the structures in the knee will not resolve the knee problem. Instead, the practitioner must treat the knee, and then, based on the biomechanical analysis, treat all other affected structures in the knee’s kinetic chain. The knee problem will only be resolved when restrictions in all these affected structures are removed.

Exercise

For every restriction that occurs, an altered muscle-firing pattern is also created. These dysfunctional movement patterns will still remain after the restriction (adhesion/ scar-tissue) has been removed. Only a corrective program of exercises will re-establish a normal motion pattern by retraining these structures to properly work together. This is why it is essential to combine the removal of the adhesions with appropriate and specifically designed exercise protocols.

Bottom line, as good as any therapy is without rehabilitative exercises the problem will most likely return.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Iliotibial Band Syndrome (ITBS) - Part 4

Treatment of Iliotibial Band Syndrome

The first thing practitioners must do in treating Iliotibial Band Syndrome (ITBS) is to perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns. This will give them an initial hypothesis as to which structures are involved. Refer to Parts 2 and 3 of this Blog to see what muscles are involved in what actions.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area to be treated has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions (Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation).

Fascia and ITB Syndrome

When we evaluate a case of ITBS, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle, knee, and hip motion.

In the case of ITBS, some of the fascial connections we should consider are in the Lateral Line (see Anatomy Trains by Thomas Meyers).

The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.

Lateral Line

· Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae).

· The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.

· The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, and scalenes).

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating ITBS with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic ITBS problem if you do not consider, and treat, the fascial interconnections.

The key is to any therapy is to address all the structures involved in the kinetic chain.

Treatments need to be specific and based upon the individual requirements of each person. Treatment should not be a cookbook approach. Practitioners need to find the specific tissues that are restricted and physically work them back to their normal consistency.

Exercise is Essential

Often getting professional help in the way of manual therapy is essential to get a complete resolution of ITBS, but just as important is exercise. Without the right exercise program the probability of this condition returning is very high.

There are three important areas which must be addressed when prescribing exercise routines for ITBS, strength, flexibility, and balance.

Why strengthening exercises are essential:

Every time you injure yourself, your body lays down new tissue to repair itself. The new tissue is initially very fragile, thin, and easily torn or re-injured. Strength or weight training places stress upon these new tissues, causing them to go through a process of remodeling. In this process, the new tissue literally converts from one type of collagen to a different type which is up to 10 times thicker and 10 times stronger. However, this collagen conversion only occurs when you apply continued stress upon the tissue as you do in weight- and strength–training exercises.

Exercise example: Because the iliotibial band is formed from the deltoid complex, having strong balanced hips is essential for a full resolution of ITBS. One of my favorite exercises to increase hip strength is the Bulgarian Split Squat.

Why Flexibility exercises are essential:

During the regenerative or repair phase of an injury, your body creates and lays down collagen to repair the injured area. When the injured person performs the correct stretching exercises, the majority of new tissue will be laid down in the same direction as the tissue that is being repaired - thereby allowing this tissue to properly perform its function.

Exercise example: We suggest that patients combine stretching with self myofascial release (foam rollers). The following is an example of an ITB stretch, and a foam roller video you will find very useful.

Why balance exercises are essential:

Proprioceptive or balance training is a fundamental requirement that should not be ignored in Rehabilitation Therapy. Your ability to balance depends on feedback from your auditory, visual, proprioceptive (sense of body position), and vestibular systems (relating to the sense of equilibrium). All of these systems must be trained to achieve optimal results. As with all injuries your nervous system is often affected. Training these systems, ensures a greater chance of a complete recovery.

Exercise example: The follow exercise is an example of the type of exercises that we prescribe to our patients. This is the Squat - Single leg balance exercise from Core Performance.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Iliotibial Band Syndrome (ITBS) - Part 3

Hip Muscles Directly Affect Knee Function

Actions of the hip directly affect knee function; in fact, if these relationships are not considered, the practitioner will have little hope of resolving a great percentage of chronic knee problems such as Iliotibial band syndrome.

Muscles involved in hip flexion:

· Adductor Longus and brevis

· Gluteus minimus and medius (front section)

· Psoas and Iliacus Tightness in the psoas muscle often occurs from hyperextension of the low back (lumbar spine).

· Rectus femoris (Quadricep)

o This is the only quadriceps muscle that crosses both the hip and knee joint.

· Tensor fasciae latae

Muscles involved in hip extension:

· Adductor Magnus

· Hamstrings (Biceps femoris (long head), Semimembranosis, Semitendinosis

· Gluteus Maximus, Gluteus medius (posterior section)

Muscles involved in hip abduction:

· Gemellii

· Gluteus minimus and medius

· Obturators

· Pelvic Deltoid muscle –

· The tensor fasciae latae and gluteus maximus (superficial layers) insert into the Iliotibital band. These muscles work in concert to abduct the hip. If you have a problem with any of these muscles it will affect ITB function.

· Piriformis

· Sartorius

Muscles involved in hip adduction:

· Adductors (brevis, longus, magnus)

· Bicep femoris (long head of this hamstring muscle)

· Gluteus Maximus

· Gracilis

· Iliacus

· Pectineus

· Psoas

Muscles involved in internal hip rotation:

· Gluteus Medius/Minimus

· Tensor Fascia Latae

Muscles involved in external hip rotation:

· Gemelli and Obturator muscles

· Besides their rotational function these muscles help to decompress the hip joint. Some authors refer to this as a hammock effect.

· Gluteus Maximus

· Piriformis

· Quadratus Femoris

In part four of Resolving ITBS, we will cover treatment and exercise.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Iliotibial Band Syndrome (ITBS) - Part 2

Understanding Motion Patterns

The successful resolution of Iliotibial Tibial Band Syndrome (ITBS) involves a complex understanding of kinetic chain relationships, and a functional understanding of how motion of the knees is related to specific anatomical structures. When you observe a deviation from normal motion patterns it is a direct indication of what structures may be involved in creating and perpetuating ITBS.

The structural problem will be a combination of four functional muscle groups:

• Agonists (Prime mover) – Muscles that contract to produce a specific movement. Example: The quadricep is a prime knee extensor.
• Antagonists – Muscles on the opposite side of the joint of the agonist. Example: Hamstrings are antagonists to the quadriceps.
• Synergist – Muscles which limit motion as the prime movers contract and also assist motion. Example: The Iliopsoas, and tensor fascia lata are synergists to the quadriceps.
• Stabilizers – Muscles which fix or stabilize the bones of the origin of the prime movers.

This, combined with a whole body examination of kinetic chain relationships, provides the practitioner with insight into what it will take to resolve your ITBS.

In the next section I review some specific knee actions and some of the structures involved in those actions. Optimal knee function is about maintaining a balance of these structures in order to achieve stability in the knee with all motions performed. It is important to note that many of these structures are far from the site of pain yet they can have a direct effect on knee function.

Specific Structure that Affect Knee Stability

Muscles involved in knee flexion:

· Semimembranosis, Semitendinosis, Biceps Femoris (hamstrings)

· Tension in biceps femoris can easily cause lateral knee pain.

· Gastrocnemius (Calf muscle)

· Popliteus (small muscle behind knee)

Muscles involved in knee extension:

· Gluteus Maximus

· Quadriceps femoris (all four quadriceps)

· TFL (Tensor fasciae latae)

Muscles involved in internal rotation of the knee:

· Gracilis - This muscle is frequently injured with sudden inward (adduction) movements of the knee.

· Sartorius – The longest muscle in the body. This muscle crosses both the hip and knee joint, and can be a direct connection between hip and knee function.

· Semitendinosis (hamstring)

· The Gracilis, Semitendinosis, and Sartorius all insert into an area called the pes anserinus. This area is at the bottom of the leg (femur) on the inside of the knee. The pes anserinus is a common area in which to develop knee pain.

· Semimembranosis (hamstring)

· Popliteus

Muscles involved in external rotation of the knee:

· Biceps Femoris (Long and short head - hamstring)

· Gluteus Maximus

· TFL (Tensor fasciae latae)

In part three of Resolving ITBS, we will cover hip muscles that effect knee function.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)