Iliotibial Band (ITB) SyndromeIliotibial Band (ITB) Diagram

Pain and Tightness Along the Thigh

Having pain and tightness along the side of the thigh is quite common, especially for athletes. When the pain encompasses the lower half of the thigh towards the outside area of the knee, it often carries the diagnosis of Iliotibial Band (ITB) Syndrome. For many people it can be persistent or unresponsive to typical treatment. The IT band is a stiff layer of tissue that blends from a broad attachment of muscles from the side and back of the hip. The band becomes narrower as it descends toward the knee where its attachment broadly blends with tissues about the knee cap and into the tibia bone.

Stretch for Tensor Fascia Lata Muscle

Standing stretch for TFL and ITB.

The condition is frequently described as the ITB being ‘tight,’ and typical treatment often includes attempts at ‘stretching’ the ITB.  But when you look at the tissue of the band and how it attaches, it becomes difficult to understand how the band itself could get ‘tight’ in the first place. The tissue is relatively rigid and doesn’t have the quality to length or shorten. Then what could possibly have an effect to cause the band to functionally shorten or cause the pain?

Three Overlooked Components

In these cases, I see three major components that sometimes get overlooked. First, what does have the tendency to tighten up are the muscles that the band directly attaches to; a relatively small muscle coming off of the front and side of the hip called the tensor fascia lata (TFL), and the large gluteus maximus (the outer part of the major muscle of the buttock). These muscles can be stretched effectively with the following technique, among others. First, standing with the right leg crossed behind the left, then side-bending the trunk to the left (this stretches the TFL of the right leg and ITB). Also, lying on your back and pulling your right knee towards your chest would stretch the Gluteus Maximus. In my experience, however, these stretches are often not successful by themselves.

Stretch for Gluteal Muscles

Stretch for gluteus maximus.

A second influencing factor for ITB Syndrome are muscles that attach to the pelvis, spine, and thigh that have shortened. The iliopsoas, gluteus minimus, and deep hip rotators such as the piriformis, once shortened, cause the thigh bone to be rotated on the pelvis. Some signs that this condition may exist may be seen in the following: When standing erect, does one foot’s arch appear noticeably flat compared to the other? When lying flat on your back with legs relaxed, does one leg appear turned out noticeably more than the other? While these situations are not the only reason that may cause an arch to be flat or a leg to be turned out, it is a hallmark of a muscle imbalance that I see regularly in clients who have ITB pain. This condition is quite amenable to targeted stretching. It could include stretching the hip flexors (iliopsoas) as seen in a forward lunge stretch or similar modification, and a deep hip rotator stretch or the “pigeon pose” stretch. (See photos.)

Forward Lunge and Pigeon Pose

Forward Lunge and Pigeon Pose

Finally, there is a large and significant muscle that runs immediately underneath the IT band, the vastus lateralis. It is the outside muscle of the four quadricep muscles in the front of the thigh. This muscle can get irritated and develop trigger points. A trigger point (TP), is a small band of hypersensitive muscle fibers that, when pressed, can give rise to pain in characteristic patterns, in this case along the ITB, and can involve the outside of the knee. This component can be treated effectively with deep tissue mobilization.

Iliopsoas Muscle Group Diagram

Deep Tissue Rolling

Some people perform their own deep tissue mobilization by rolling the side of their thigh with a foam roller or ‘stick.’ (See photos.) For some, this can be quite effective, but I don’t believe it is ‘rolling out the ITB’ that is being effective; it is the muscle underneath. And sometimes deep tissue rolling and massage are not fully effective and the TP requires deactivation with dry needling.

Check out our VIDEO: Foam Rolling Techniques for Runners”

Trigger Point Dry Needling

Dry needling is a technique used by certified clinicians that uses a very thin, solid filament needle that is placed directly into the TP within the muscle. They are the same needles used in acupuncture, though this is only for the purpose of deactivating the TP. (See photo.) Again, the IT band itself does not have the ability to contract or lengthen to any substantial degree. When these deep tissue techniques or dry needling are effective, I believe it is predominantly due to the effect on the vastus lateralis muscle.

In the case where the pain is only in a small, local spot where the ITB attaches just to the side of the knee, ice can help reduce the pain temporarily. But the source of the problem is usually elsewhere, like the some of the faulty biomechanics described above, and it can include how and where a person might train. For example, the curved elements of a track will increase the strain on the left leg if you are running clockwise. Indoor tracks have tighter turns, and increase loading further if the turns are not banked. Even if you routinely jog on the road, always facing traffic results in an asymmetrical strain on the left and right legs due to the crown design for roads to shed water.

Deep Tissue Rolling

Deep Tissue Rolling

Customized Orthotics and Kinesiology Taping

Orthotics, or inserts for shoes that customize the arch for the individual, as well as specialty elastic tape (Kinesiotape or Rock Tape®) can be helpful components for selective individuals. I recommend you consult a professional trained in orthotics or taping application.

Note that while I have described the IT band condition as it presents on only one leg, it is possible that some folks have the pain on both legs, though the same principles apply.

Finally, the challenging part of ‘persistent’ IT Band Syndrome is in knowing how many of these components are contributing to the individual’s condition, and which ones are the predominating factors. The good news is that clinicians well trained in these conditions can help you if needed.

I hope you have found the information helpful.

Billy Cioffredi, PT/founder

Cioffredi & Associates

Trigger Point Dry Needling

Trigger Point Dry Needling

RELATED CONTENT

Overview of the Knee

Runner’s Knee (Patellofemoral Pain Syndrome)

Common Running Injuries

Trigger Point Dry Needling: Applications & Evidence

Piriformis Syndrome: That Pain in the Butt

 

 



standing quad stretch

Pull one ankle back toward your buttock, bending your knee to stretch the front of your thigh.

First of all, effective stretching is not a total secret, though in my experience it is not a commonly understood concept. When we think about stretching, it’s often done with the idea that it’s like taking a piece of leather and, using force, mechanically lengthening it out. One of the problems with this idea is that ligaments and tendons are not designed to lengthen. Muscle tissue is designed to actively shorten and lengthen, however it will not lengthen effectively if it is held in an activated or tense state. Activation or tension causes muscle tissue to be more rigid—more leather-like—and it can be irritated if forced. That may be one reason some people don’t ‘enjoy’ the process of stretching. The other problem is that rigid tissue, like Turkish taffy, gets thinner and weaker as we forcibly stretch it out. That doesn’t sound good, especially to athletes who simultaneously want to optimize their strength.

Now, instead of thinking of leather that you are stretching and thinning out, think of a spring that has shortened, and your goal in stretching is to relax the tension of the spring.

Muscles will shorten when we activate them, just like tightening a spring. When we release the tension on a spring it lengthens and becomes longer. This is not an ‘all or none’ concept. If, for example, you tense your muscles to make a tight fist, you can ‘let go’ of the fist a little, a lot, or somewhere in between. Our effectiveness is the

standing forward fold

Flex forward from the hips (touching toes) without rounding your back, to stretch the backs of the thighs.

degree to which we can intentionally ‘relax’, ‘release,’ or ‘let go’ of our muscle tension. For some, it’s helpful to picture the tissue doing this. It seems tensing our muscles is easier than selectively releasing muscle tension. But it is a skill and, like any skill, we can improve with practice.

The final piece to understand is that we activate groups of muscles. And we often tend to activate groups of muscles in patterns. Developing skill to release groups and patterns of muscle tension can result in tremendous success. Whether for athletic performance or just basic daily living, this can result in increased freedom of movement, comfort and ability.

Start with stretches that focus on only a few or selected muscles. For example, stand and pull one ankle back toward your buttock, bending your knee to stretch the front of your thigh. Another simple stretch, from the standing position, is to flex forward from the hips without rounding your back, to stretch the hamstrings on the back of your thigh. Then, gradually move into more complex stretches.

Warrior II Pose

The “Warrior II” pose lengthens on diagonals.

Lengthening on diagonals, and when different parts of our bodies are positioned to go in different directions simultaneously, can be especially effective. It requires us to release holding ‘patterns’ of muscle groups that can be a fundamental limiting factor on greater dynamic movement. For those reasons, some yoga poses can be of particular value. Warrior Pose is one example.

So the next time you do some stretching, think of “releasing” your body into that position. See how far it takes you. It’s safer, and quite possibly more enjoyable.

I hope you found this helpful.

Billy Cioffredi, PT/founder
Cioffredi & Associates

P.S. Our eldest daughter, Anna, was kind enough to model these stretches for me. She is now a school teacher (English as a Second Language) in the Greater Boston area, and was home for a summer visit.

RELATED ARTICLES

Getting Out of Our Own Way
Off Season Training Gains
Piriformis Syndrome
Plantar Fasciitis: The Pain That Won’t Go Away
Can Stretching Really Be Bad?
Play it Safe: Prevent Injury

 


Bill Cioffredi, PT - Founder

In the bodywork and exercises that we use in our work, I often feel we are simply undoing what people have done to themselves. Most of our clients didn’t have an accident. Rather, they developed a painful condition gradually, often times without a known reason. Postural pain, as well as joint and muscle pain, are often the result of unknowingly tensing or activating muscles that don’t need to be working or are working too much for the demand. Herniated discs, sciatica, arthritis pain, and rotator cuff problems are all just examples that are influenced by this issue. To a large degree, our work in helping people to restore pain-free movement involves freeing up stiff tissues in joints. But then we need to teach people how to “relax” their muscles. “Release” may be a better term, as we want our clients to release the excessive tension and muscle activation—not have muscles go totally soft.

“Good posture” is not a held position; it is free of excessive tension. You can see this kind of freedom in action in a master glassblower. They move smoothly and effortlessly, free of excessive tension as they work with the glass. We are often involved in teaching people to “release” their excessive muscle tension and “get out of their own way.” It can be learned. To that end, we have added a Qigong movement class on the weekends taught by Peter Payne, who is a master at teaching people how to “get out of their own way.” Check out the videos at Cioffredi.com/Qigong.

Best Wishes,
Billy Cioffredi, PT
Founder

Related Articles

Pain and Resilience: What I’ve Learned
Treating the Cause of Tension Headaches
Why Qigong?

 


Pediatric Physical Therapy Benefits Child with Cerebral Palsy

Sofia Tomek has received pediatric physical therapy care at Cioffredi & Associates since the age of four, after being diagnosed with spastic diplegia cerebral palsy at age two. As a result of her condition, Sofia has stiffness in both legs and issues with balance. Her mother, Sheri Hancock of Hanover, shared these words recently about Sofia’s experience here with the Cioffredi team.Ten-year-old Sofia Tomek works with PT Becca Swope

“Rebecca and the other wonderful staff at Cioffredi’s have worked with [Sofia], often twice a week, for a number of years and have seen her progress from using a walker to canes to now independent walking and even running. Currently they are working to prepare her muscles for an upcoming surgery and will be a vital part of her rehabilitation. They make exercising fun but challenging, knowing her personality so well as to offer the perfect distractions and encouragement. Thank you Cioffredi for always being there for her!!”

UPDATE: Sofia is now rehabilitating from surgery, under Becca’s care, and she continues to inspire us with her strength and resilience.

 

Read an earlier newsletter article about Sofia from January 2015.

Learn more about Pediatric Physical Therapy.

Read more about pediatric PT success and featuring Graham Portnoy and Marsha Wykes, PT, OCS, Cert. MDT


Back on the Job: Hanover Firefighter Jack Emerson

Jack Emerson, Hanover Firefighter and Cioffredi Client

“When I hurt my back at work I was unsure if I would ever be able to return to work at the firehouse. The staff here was so encouraging and motivating. I had to put the hard work in, but Zac kept me focused and on track. The entire staff knows your name, it feels like they are all in your corner. I had heard I might be out for 4-6 months, at best, but 2 ½ months later I’m back on shift working full duty.” –Lieutenant Jack Emerson, Hanover FD

 

 

Did You Know?

Low Back Pain is Responsible for 33% of Workers’ Comp Claim Costs

Low back pain is one of the most frequent and disabling conditions affecting workers in their productive years. Quality of life and job selection are limited, and recurrence is a major reason for early retirement and disability claims. Low back pain is responsible for 16% of workers’ compensation claims, and a disproportionate 33% of total claim costs.
-Garg et al. BMC Musculoskeletal Disorders 2013, 14:84
http://www.biomedcentral.com/1471-2474/14/84

How Can We Help?

Learn more about the benefits of physical therapy for low back pain.

 


Get a Grip on Your Texting Thumb

Texting Thumb is Painful

While many people will admit to spending a little too much time with their mobile device, few people may be considering the risk of repetitive strain injuries that result from all that use. Fewer still have ever heard of texting thumb, a painful condition that can affect the tendons of the thumb and wrist.
U.S. mobile service subscribers send and receive an average of 764 text messages per month, according to the most recent nationwide data (Neilson, 2013), and it’s a safe bet that teen texting totals are much higher. Even the average of 25 texts per day can put a person at risk for the pain of texting thumb, a real and growing pain problem in our smartphone-saturated society.

Ruth Cioffredi, OTR/L Occupational Therapist“Repetitive tasks should never be done for more than 20 minutes continuously without a break. Switching the muscle group allows for tissues to be more flexible and avoids strain in chronically overused areas.”

Symptoms

Are you experiencing sharp or shooting pain, a constantly aching thumb joint, or a thumb that seems to pop out of place when it’s extended during typing? You might be suffering from Texting Thumb. The strain of constantly holding a cellphone and curling the wrist and thumb to type text messages restricts and thickens the tendons responsible for flexing the thumb and wrist, causing inflammation, searing joint pain, and eventual weakness.

Two Different Sources of Texting Thumb Pain

TRIGGER THUMB

Trigger Thumb Diagram Cioffredi

Pain centered at the base of the thumb on the palm side, which can radiate up the thumb and is often accompanied by snapping or locking of the thumb, is likely caused by an aggravated and inflamed tendon—a condition called trigger thumb that is the most commonly associated with texting.

DEQUERVAIN SYNDROME

Pain that originates on the thumb side of the wrist. A person with DeQuervain Syndrome may feel localized tenderness, pain, and, swelling at the wrist near where the thumb is attached to the forearm. They also may have difficulty pinching or grasping with the thumb or hand, and feel pain when moving the wrist from side to side or when twisting it. DeQuervain Syndrome causes difficulty when flexing the thumb, and may result in limited motion and feeling of weakness in the thumb.

DeQuervain Syndrome Diagram

Treatment

If you are experiencing the symptoms of either trigger thumb or DeQuervain Syndrome, for best results you should seek treatment early. A physical or occupational therapist will work with you to assess your condition and review how you use your thumb, and start working with you to relieve pain and inflammation. Your therapist can give suggestions on how to make adjustments to alleviate stress to that area, and can also help you with exercises for your hand, wrist, and arm that strengthen your muscles and reduce painful tendon irritation. In some cases, an immobilizing splint may be prescribed to support recovery.

Ruth Cioffredi OT Hand Specialist

WE CAN HELP Call us today to schedule an evaluation with one of our physical therapy clinicians: 603-643-7788 

 

Is it Necessary to Have a Referral?

While a written referral is not required to seek care, it may be a requirement of your insurance company.

A benefit of getting a written referral from your doctor or dentist is that it will ensure that they get a copy of your evaluation, re-evaluation, and discharge notes, so that they can keep up with your treatment progress. We are happy to provide referral forms upon request.

RELATED ARTICLES

Is it really carpal tunnel syndrome?
Surgery Avoided with a Little Teamwork
Preventing “Computer Neck”

Further Reading

The American Society of Hand Therapists  (https://www.asht.org/patients/education-resources)

Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. J Am Osteopath Assoc 2010;110(5):294-296. (Accessed from: http://jaoa.org/article.aspx?articleid=2094077&resultClick=1)

American Physical Therapy Association (Accessed from: http://www.moveforwardpt.com/SymptomsConditions.aspx)

 

 

 


Angie Hinton: Back to Running for Better Health

Angie Hinton, PT ClientPhysical therapy has meant a great deal to me. I have been a member of the (Lebanon, NH, Recreation & Parks) Couch to 5k running group for three years now, and I had been feeling pretty confident about trying my first 10k this summer. That was put on hold in February when I fell on the ice while working. I ignored the pain for a little while, but it did not go away so I began PT. Come to find out, it was not my leg that was the issue but my back. The impact from my fall hurt my lower back causing several problems with my leg and foot. I wanted PT to help clear up the monster amounts of pain I was having and I wanted to get strong enough to run again. Working with Kate has been challenging and very rewarding, I did not think I could get to the point of sitting comfortably, let alone run, but she helped me believe that I could do it. Injuries can sideline you but you can come back. I am practicing with the run club and will run in the 5k race on the 4th of July!

Angie Hinton Runs the Couch to 5KI started to run because I wanted better health and better control of my diabetes. A month ago, after being on medications since 1994, I was taken off insulin and am beginning the process of getting off medication all together! The team at Cioffredi has given me so much more than they will ever know (so much more than PT). I thank them from the bottom of my heart and running shoes!!

–Angie Hinton, Lebanon


Dawn Famiglietti: A Story of ResilienceDawn Famiglietti: A Picture of Resilience

When Dawn Famiglietti of Sunapee reached out suddenly to break someone’s fall one day in late 2011, she was acting on instinct. She had no idea that this quick action would change her life forever, sending her on a journey of pain and healing that would test her to the core. Today, with rods and cages fusing together seven vertebrae in her lower back, Dawn shares inspiration and encouragement with everyone she meets.  Her message: “Don’t stop moving!”

UNBEARABLE PAIN

The scope of Dawn’s back injury did not become fully apparent for several months after the incident. During that time her life became a waking nightmare of unbearable pain. “We tried everything at first: steroid injections, chiropractic adjustments, massage, the pool,” but relief just wouldn’t come without increasing doses of narcotic pain medication—and then with greater frequency.  She suffered headaches, couldn’t sleep, and the pain that shot down her leg like an electric current was unrelenting. She found herself constantly lying on the floor, and away from her loved ones. “Standing was difficult, driving was almost impossible, and I couldn’t sit long enough to even have dinner with my family.”

EMOTIONAL TOLL

To hear her explain it, Dawn fought hard against the idea of being disabled, but the pain and the growing distance between living and merely existing took their toll. “I tried to stay positive in front of my family, but when they were gone I had panic attacks and anxiety. I was depressed.” Like so many people, Dawn found it hard to share her pain or ask for help, but it became too much. “I reached a point where I stopped caring, and I felt very desperate.” When the Christmas decorations didn’t even come out of storage in 2012, she knew she had hit bottom.

SURGERY AND REHABSeven-Vertebrae Lumbar Fusion X-Ray

A surgeon in Boston was finally able to repair Dawn’s severely damaged spine with a multilevel lumbar fusion, a procedure that took two days to complete. Then more than a year since her injury, he challenged her to take charge of her own care. “You can do anything you want,” he told her, “the question is only whether you want to do it.” Right away she knew that her top priority was to get back to normal living, and to move as pain free as possible with minimal use of medications.

Dawn arrived at Cioffredi  & Associates with a limp and still hurting from her initial recovery rehab, but determined to get back her life and her sense of herself.

“When you have back pain, people can’t see it. It’s not like there’s something obviously wrong with you. I had a hard time when I went back to work, because I think I felt like people wouldn’t believe that I was really injured—that they would think I was soaking the system.”

HELP FROM CIOFFREDI & ASSOCIATESDawn Famiglietti PT Client

Physical Therapists Marsha Wykes and Anna Hinman worked with Dawn during her rehabilitation. “They were wonderful,” Dawn reported. “They made me feel important, and that I wasn’t there for no reason. They gave me good information to follow; they educated me, and when I didn’t do my exercises the way I was supposed to,” she explained sheepishly, “I was gently prodded. I almost didn’t want to leave.”

JUST KEEP MOVING

Dawn’s PT experience helped her to be constantly thinking about her posture and the way she does things, and even today she misses no opportunity to stretch or move. Most of her coworkers have no idea of the ordeal she has gone through since 2011, but they might just notice how energetic and positive she is. She always takes the stairs, often two at a time, and sometimes takes an extra set just to push herself. In her office, which is equipped with both a standing desk and a yoga mat, she’ll take a break and do a few stretches. If her door is open and someone sees her bending over in a forward fold, “l just tell them I’m looking for my contact lens. I don’t want anyone to say ‘Poor Dawn,’ I just know that I’ve got to keep moving, just keep those muscles moving.”

POSITIVE OUTLOOKDawn Famiglietti Back on Her Horse

While Dawn’s outcomes are remarkable, she will likely always have good days and “not-so-good days,” when back pain intrudes. She’s determined to keep her positive outlook, but on the tough days she allows herself a break—and occasionally even some Tylenol—and acknowledges that there are things she will always need to approach differently. There won’t be any sit-ups or back bends in her daily fitness routine, for example, but her doctors have cleared her for “everything but skydiving.” Mostly she just wants to keep on gardening, caring for her horses, taking her dog for longs walks, and filling the wood box.

“I set goals for myself that aren’t huge. I look at my behavior and I try not to get down on myself; to go easier for the big things and just always keep moving.”

Her next big goal has to do with her daughter’s wedding in September 2017, she explains bashfully, pointing to her feet. “I want to be able to wear shoes with a little heel.”

LEARN MORE about the kind of excellent physical therapy care that Dawn received at Cioffredi & Associates.

This article appeared in the Cioffredi & Associates July 2017 newsletter. View the entire issue online.