IT Band Syndrome: The Solution to a Difficult Problem

Meet today’s Guest Blogger:

 Suzie Freeman, MPT, OCS physical therapist

Suzie Freeman, MPT, OCS
Suzie works as a Senior Physical Therapist at California Rehabilitation and Sports Physical Therapy in Huntington Beach, California. She earned her Bachelor’s Degree in Kinesiology from the University of California, Los Angeles, and then moved on to the University of Southern California for her Masters in Physical Therapy.  Suzie is the Center Coordinator for Clinical Education, as well as a Clinical Instructor, taking physical therapy students from local universities on a year-round basis. 

 

So, it’s the New Year, and you have taken up running, or recently increased your mileage.  Things are going great.  Your pants are looser, and you feel on top of the world.  Then, the side of your thigh or the outside of your knee starts hurting.  You have developed IT Band pain. You check the internet, and it is filled with stories of how stubborn IT Band pain is to treat, and how long it takes to recover; that is, if people recover at all.  Things seem pretty dismal.  You pop a few ibuprofens, try some ice, buy some new running shoes… but the IT Band pain just won’t go away.  You see your doctor, try some physical therapy; perhaps orthotics.  Still not better.  You wonder, “Is this the best the medical community can do for me?”

There is a lot of new research being done on this and other chronic problems with soft tissue and tendons.  Your doctor may have called your problem “tendonitis”, which is inflammation of a tendon (the structures that attach muscles to bones).  There are a lot of treatments for inflammation (i.e. ice, anti-inflammatory medication, cortisone shots, or rest).  These treatments may help, but only temporarily.  New research has shown that with many chronic tendonitis and chronic soft tissue cases, the problem does not even involve inflammation at all, and that’s why ant-inflammatory treatments don’t provide long-term relief.  As the machines that visualize the structures of the human body have gotten better, scientists can now see that the painful tendon is actually degenerating.  In a degenerative tendon, healthy tendon cells are replaced by fibrotic (scar) tissue.  Even the blood supply in a degenerative tendon looks different – there are actually areas where the tiny blood vessels are not even attached to the main blood lines.  That means that the blood products necessary for healing are not being delivered to the degenerated areas.  By the time a tendon is degenerative –due to injury or overuse – the body has tried to heal, but has done so in a very inferior way.

The question then becomes:  How do we get the body back on the right track to proper healing?

There is a new treatment available called “Astym”, which is often interpreted as “a stimulation of healing”.  It was developed by physicians, physical therapists, and university researchers who demonstrated that Astym is an effective treatment for resolving chronic tendonitis.  Certified Astym clinicians have been performing this technique around the United States for over 9 years and have been getting outstanding and consistent results.  It has been found that Astym treatment has a success rate of 92% with ITB Syndrome. (Source: Astym Analyst Outcome Report, courtesy of Performance Dynamics).

You can check the Astym website to see if there is a certified clinician in your area.  In the meantime, you can try this stretch to see if you can relieve your symptoms on your own.  Like most stretches, the position should be pain free and held for 30 seconds, and repeated several times throughout the day.

IT Band Stretch

 Effective IT Band Stretch

So, don’t let these chronic problems keep you from your sport or running.  Astym could be just what you need to get you back to doing what you love and into those tight pants again.

Tendonitis/Tendinosis: How Do You Get Better?

You need to first determine the underlying cause of your tendon pain.  Is your tendonitis (also called tendinitis) caused by inflammation?  If so, then it is the kind of tendinopathy that the healthcare system is best at resolving in short order.  The traditional treatments for inflammatory tendonitis are rest (which can include bracing), ice, and anti-inflammatory medicines, such as ibuprofen.  Once these treatments are applied, inflammatory tendonitis should resolve within 6 weeks.

If tendonitis recurs after these treatments stop, or if the condition does not resolve with these tendonitis treatments, then you may have a degenerative tendon disorder, more correctly referred to as tendinosis.  In order to resolve a degenerative tendinopathy (also called tendinosis or tendonosis), you must stimulate the affected tendon to heal or regenerate.  Since medical science only recently discovered that chronic tendonitis and tendinosis are mainly degenerative in nature, there are only a few treatments that work on stimulating regeneration.  Astym treatment was scientifically developed to stimulate regeneration of soft tissues, and has emerged as the treatment of choice in physical and occupational clinics nationwide to consistently resolve chronic tendonitis and other tendinopathies.

On a different front, physicians recently began injecting platelet rich plasma (PRP) into patients with tendinopathy in an effort to regenerate tendons.  Although many had hoped that this approach would prove to be effective in controlled studies, a recent well designed study was published in the Journal of the American Medical Association, and it showed that PRP injections were no more effective than placebo injections.  To view a copy of this journal article, click here: http://jama.ama-assn.org/cgi/content/long/303/2/144

Plantar Fasciitis, Achilles Tendonitis: A Patient Talks About a Treatment That Works.

Few things are more frustrating than having chronic plantar fasciitis and Achilles tendonitis (also spelled Achilles tendinitis).  Here is the story of one patient who suffered from Achilles tendon pain and plantar fasciitis, and tried multiple treatments before she finally got better with Astym at KORT physical therapy.

Lori Childs talks about Astym therapy at KORT

As an Achilles tendonitis treatment, Astym improves 94.7% of Achilles tendinitis (tendonitis), or Achilles tendinopathy cases.  Astym also resolves plantar fasciitis well, with 91.9% of plantar fasciitis or plantar fasciopathy cases improving after Astym treatment.   Chronic tendonitis can affect many areas of the body.  To view the resolution rates (outcomes) of Astym on particular types of chronic tendonitis/tendinosis, click here:  http://astym.com/upload/pdf/Astym%20Outcome%20Reports.pdf

Plantar Fasciitis: The Three Best, Most Effective Stretches for Athletes. Inside Tips From a Sports Medicine MD.

Plantar fasciitis causes a great deal of heel pain and disability among athletes.  As a sports medicine doctor, I have seen thousands of athletes sidelined by plantar fasciitis.  Most patients who receive Astym therapy respond favorably, and their plantar fasciitis resolves.  To find out if Astym therapy is right for you, please locate a provider near you, and schedule an appointment to be evaluated.

However, there are some athletes who struggle with relapse or their condition becomes chronic, or long term.  Some sports physicians and medical researchers suspect that a portion of these recalcitrant patients are not stretching properly, and that may be a factor in their failure to recover from plantar fasciitis.

Here are some stretches that may help you recover from plantar fasciitis:

Best plantar fasciitis stretch

Stretch #1:  Gastroc  Stretch: foot flat on the floor, knee straight, lean forward with your other foot extended in front of you, but keep most of your weight on your back foot until you comfortably feel the stretch in the back of your calf (gastroc muscle and Achilles tendon).

Stretch #2:  Soleus Stretch:  foot flat on the floor, KNEE BENT, lean forward on the other foot that is extended in front of you, but keep most of your weight on your back foot until you comfortably feel the stretch in the back of your calf (by bending your knee, you relax the gastroc muscle, which allows you to focus the stretch on the soleus muscle and the Achilles tendon).

Best plantar fasciitis stretch

Best Plantar Fasciitis StretchStretch #3:  Flexor Hallicus Longus (FHL) Stretch:  Often, plantar fasciitis sufferers will do some version of stretches #1 and #2 above, but fail to do this last stretch.  This stretch can often be the key in helping patients recover from plantar fasciitis.  Use a stair step or a wall to aid you in this stretch.  Stretch your toes up vertically using the wall or stair step and, keeping your heel on the floor, bend you knee slightly and push foward gently, until you comfortably feel the stretch in the bottom of your foot, the inside part of your ankle, and up the back of your calf.

As with any rehabilitation method, you should talk with your doctor prior to doing any stretching activity or other type of treatment.  In the cases of chronic plantar fasciitis,  experienced sports doctors often recommend that these stretches be done 2 times a day, with each stretch performed 3 times per session, and held for 40-60 seconds if a patient’s condition comfortably allows for this.

Botox® for Tennis Elbow?

Sounds strange to some people, but these injections are being tried to relieve tennis elbow pain, and with some success.  As a sports physician, I have seen many patients with tennis elbow.  I also do medical research, and as a result, I was invited to perform a review of a proposed article for a professional journal on botulinum toxin (Botox® is a trade name for botulinum toxin A) in the treatment of tennis elbow (lateral epicondylitis). This type of review is part of the peer review process that helps to ensure that quality articles get published in medical and scientific journals.  The editors of a peer-reviewed journal contact other researchers or knowledgeable professionals in the field to review  submitted articles and render an opinion on whether an article should be published, and what modifications, if any, should be made to the article before publishing.

The editors of a medical journal asked me to be a peer reviewer on an article about a study where botulinum toxin was used in the treatment of tennis elbow.  Overall, it was a good prospective, pilot study comparing botulinum toxin injections with corticosteroid injections in the treatment of acute and subacute tennis elbow.  After the review process, the study was published.  Here is a link to the abstract for that article (summary of the article):   http://www.ncbi.nlm.nih.gov/pubmed/20134306   Although I am not going to comment on this particular article, I do think commenting on this treatment approach in tennis elbow is worthwhile.   Significant study of this approach has not been done, however there does appear that at times, there may be some benefit to this type of injection.  There may also be a downside.

The seeming purpose of the injection is to lessen the pain of tennis elbow.  Botulinum toxin has been regularly used to paralyze muscles with great success, so it would follow that botulinum toxin could also paralyze or deaden sensory nerves and thereby relieve the pain of tennis elbow.  However, there has been no suggestion that botulinum toxin promotes any real healing of the degenerative tendinopathy, which is the actual underlying problem of chronic tennis elbow.   The real question is whether a decrease in the symptoms of tennis elbow would be due to the deadening of the sensory nerve, or could it be due to the weakening of the muscles that attach to the abnormal tendon which would decrease the stress on the tendon.

Short term tennis elbow (lateral epicondylitis) may be due to inflammation.  In short term cases of tennis elbow (less than four weeks), most healthcare professionals prescribe rest, ice and anti-inflammatory medication.  If these treatments do not resolve the tennis elbow and the condition persists, then the more chronic condition is often thought to be caused by degeneration and referred to as lateral epicondylosis, and other treatments or tennis elbow therapy are employed.

Longer term cases tennis elbow, also known as chronic lateral epicondylitis, lateral epicondylosis and elbow tendinosis/tendinopathy, can be treated by various means, including:

• Astym treatment
• Autologous Blood Injections
• Corticosteroid Injections
• Eccentric Exercise
• Electrical Stimulation and Iontophoresis
• Extracorporeal Shockwave Therapy (ESWT)
• Fenestration (percutaneous tenotomy)
• Friction Massage
• Glyceryl Trinitrate (Nitroglycerin) Patches
• Laser/Light Therapy
• NSAIDs/Anti-inflammatory Drugs
• Platelet Rich Plasma (PRP) Injections
• Prolotherapy (Sclerotherapy):
• Relative Rest/Splinting/Immobilization
• Stretching/Ice
• Surgery
• Ultrasound and Phonophoresis

Botulinum toxin injection has not made the list of the most common tendonitis treatments.  Since the purpose of the injection seems to be limited to pain relief with no healing benefit, it may not become a regular treatment for tennis elbow.  The downside of these injections can include muscle weakness and possible decrease in function while the botulinum toxin is active.  And although botulinum toxin may reduce pain, there is not any significant supporting evidence showing that it can improve function for patients with tennis elbow.

Research on Astym: Summary of Astym Treatment’s Evidence Base

At its core, Astym treatment was developed from solid basic science research to stimulate regeneration at a cellular level.  Following that, there were a number of case studies published and then a randomized controlled clinical trial on patellar tendinopathy.  A large randomized controlled clinical trial on lateral epicondylosis was awarded a platform presentation at the American Society for Surgery of the Hand’s national meeting, and is now being submitted for publication(for more information on this study, click here: http://blog.astym.com/blog/astym/0/0/effective-treatment-for-tennis-elbow-presented-at-hand-surgeons-meeting).

Several other studies have also been completed and are being prepared for publication or submitted for publication. To see a full listing of research on Astym treatment, please visit the research page by clicking here: http://astym.com/professionals/research.asp

One of the main reasons for the effectiveness of Astym treatment is its sound evidence base.  Astym treatment was scientifically developed to target the true underlying cause of many soft tissue problems:  degeneration and inappropriate scarring/fibrosis that interferes movement and causes pain.  One of the factors that guided the scientific research and development of Astym treatment was medical science’s recent discovery that tendinopathy is degenerative (worn or broken down) in nature and only rarely has a component of inflammation (the body’s immune system actively responding to an injury or threat).  Generally, most treatments of tendinopathy focus on reducing inflammation, and those treatments have not been very successful.  In light of the recent evidence indicating that degeneration is the underlying cause of tendinopathy, Astym treatment was developed with a focus on stimulating the regeneration of healthy tissue, rather than on reducing inflammation, and that is one reason why Astym is so effective at resolving tendinopathies.

In addition to ongoing clinical and scientific research, the Astym program also emphasizes the collection of practical, clinically useful information.  Astym treatment has put major effort into developing a reliable national outcomes collection system and database, where clinicians from all across the country independently enter data to create a national bank of dependable outcomes data.  These outcomes (treatment results) show the percentage of people with each condition that resolve (get better).  Not only does this provide a good real-world evidence base for Astym treatment, it also allows patients and health care providers to know how many treatments it should take to resolve a certain condition, and what percentage of those cases should resolve.  For instance, for a patient with plantar fasciitis, you can predict that in 10 therapy visits, 91.8% of patients will be improved or much improved.  To see a full listing of diagnoses and outcomes, click here:  http://www.astym.com/upload/pdf/Astym%20Outcome%20Reports.pdf

Achilles Tendinosis in Elite Runners

Meet today’s guest blogger:

Stephanie Penny, PT, DPT

Stephanie practices at Lakeshore Sports Physical Therapy in Chicago, Illinois. She earned her Doctor of Physical Therapy degree from Central Michigan University in 2008. She has a special interest in sports medicine and vestibular rehabilitation, has completed coursework in manual therapy, and is a certified Astym® provider. Stephanie is an active member of the American Physical Therapy Association.

Elite runners alternate between intensive physical training and recovery to improve performance.  However, many runners fail to maintain a balance between intensity of training and appropriate recovery, resulting in a breakdown of tissue reparative mechanisms which eventually leads to overuse injuries.  Historically, these injuries have been referred to as “tendinitis” or “tendonitis”, words that point to inflammation as the cause of the problem.  Continue reading Achilles Tendinosis in Elite Runners

Rib pain: The buck can stop here.

Meet today’s guest blogger:

Gus Gutierrez, PT, OCS, FAAOMPT
Gus is an owner of and serves as clinical director of BRPT-Lake, a multi-clinic private practice that specializes in the treatment of orthopedic patients and sports-related injuries. He received his Orthopedic Certified Specialization distinction in 1994 and then again in 2004. He is certified as a Level 2 Manual Therapist and is Fellow of the American Academy of Orthopedic Manual Physical Therapists. He has over 23 years of clinical experience and working with athletes on all levels. Gus has been certified in Astym since 2001.  He is also certified in Kinesiology Taping and as an Active Release Technique practitioner for the upper extremity, lower extremity and spine.

Often times patients who develop rib pain with no known etiology (cause) are processed through the medical system undergoing countless medical diagnostic tests and consultations.  Physical therapy needs to be part of the assessment team to determine whether treatment for soft tissue and joint restrictions can be helpful.  Often time these patients respond very quickly to manual therapy techniques including joint manipulation, mobilizations and Astym for the intercostal soft tissues.

A patient with a 3 month history of mid costal (rib) pain was referred to me by an Orthopedist that believed Astym could be helpful and asked us to assess her.  Clinically she presented with all the signs and symptoms of costochondritis as he indicated.  After 6 treatments including Astym, rib mobilizations and thoracic manipulation she was 100% better.  She is instructed in postural exercises for home and given foam roller exercises.  This is an example of how physical therapy can be an important part of the consultation algorithm and Astym can be an effective adjunct to your manual joint mobilization techniques.

 

What is De Quervain’s Tenosynovitis?

Meet today’s guest blogger:

Kristy Uddin, OTR/L, Astym Provider
Integrated Rehabilitation Group, Inc.
Locations throughout the greater Puget Sound, Washington area
Pacific Avenue Hand Therapy – (425)374-2846
Snohomish Physical Therapy – (360)568-7774

Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers.

 

How does this condition develop?  De Quervain’s tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should. Activities such as opening jars, wringing out washclothes or sponges, cutting with scissors, any activity that involves ulnar deviation and weight on the wrists (lifting a frying pain or heavy objects out of the oven that put resistance on your wrists.

What are the symptoms?
• Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist.
• Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region.
• A “catching” or “snapping” sensation may be felt when moving the thumb.
• Pain and swelling may make it difficult to move the thumb and wrist.
• Numbness may be experienced on the back of the thumb and index finger. This is caused as the nerve lying on top of the tendon sheath is irritated.

What tests are done to determine what it is?
The Finkelstein test is conducted by making a fist with the fingers closed over the thumb and the wrist is bent toward the little finger. The Finkelstein test can be quite painful for the person with De Quervain’s tendinitis.
Tenderness directly over the tendons on the thumb side of the wrist is a common finding with this test.

How can you make the pain go away?  (Conservative care & surgery)
• Conservatively – Splints. Splints may be used to rest the thumb and wrist
• Astym treatment
• Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
• Avoiding activities that cause pain and swelling. This may allow the symptoms to go away on their own.
• Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.

If you elect surgery what is the goal?
Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons.

Tendonitis: Why Won’t It Go Away?

Because it’s probably tendinosis.  Often, chronic tendonitis (also spelled tendinitis), which lasts more than 6 weeks is really tendinosis (also spelled tendonosis).  The difference is that acute, short-term tendinitis is thought to be caused by inflammation, which is an active immune response of the body to a perceived threat.  The acute, inflammatory tendonitis can be treated and usually resolved within several weeks by icing the area 3 to 4 times daily for 20-30 minutes, resting, and taking over-the-counter or prescription strength anti-inflammatory medication, such as ibuprofen.

Chronic tendonitis is usually defined by the tendon pain lasting more than 6 weeks, and the condition is more accurately referred to as tendinosis.  Tendinosis is mainly caused by degeneration of the tendon.  In order to effectively treat and resolve tendinosis, you must stimulate regeneration of the affected tendon.  There are very few approaches that do this.  Astym treatment has been used successfully for years and is the most established treatment to stimulate regeneration of a tendon and other soft tissues.  To view the resolution rates (outcomes) of Astym on particular types of tendonitis/tendinosis, click here:  http://www.astym.com/Content/documents/ASTYM%20Outcome%20Report.pdf

Restore – Revitalize – Recover