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Iliotibial Band pain

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  #1  
Old 22nd March 2011, 02:27 PM
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Default Iliotibial Band pain

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I was wanting to pick peoples brains about pain over the iliotibial band region of the knee.

I have a patient coming in next week who has pain over the iliotibial band region. She has attended a Physio for exercises etc but haven't helped. The physio gave her a pair of OTC devices to wear as he thought "problem may be with her feet," as her pain is exasperated when standing whilst hairdressing. The orthotics haven't helped greatly.

I have been doing some reading in advance of her appointment regarding pain in this region in relation to foot mechanics and am not coming up with much. All information in relation to IT Band syndrome seems to be in relation to overuse injury in runners. Similarly, not finding much info. regarding relationship of foot and other differential diagnosis in this area.

I have not seen this patient yet and know nothing of her biomechanics but I do know she is 37 yrs, not a runner or sporty at all and no history of OA. I'm not asking anyone to diagnose here just asking for general advise on the use of orthotics for lateral knee pain around the iliotibial band region.

Not sure if her problem has been correctly diagnosised or not, but that aside can orthotics be used to relieve stresses in this area??
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Old 22nd March 2011, 03:50 PM
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Default Re: Iliotibial Band pain

Related threads:
Other threads tagged with Iliotibial band syndrome
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Old 23rd March 2011, 04:37 AM
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Smile Re: Iliotibial Band pain

Hi Issy1,

If during her assessment you still feel the symptoms indicate ITB irritation ask questions regarding flexion of her knee (presume its unilateral). Eg; has she recently moved into two storey living & climbing stairs, or renovating & climbing ladders, or hilly bushwalking or started a program doing lots squats, or quad strengthening or stepper apparatus at her gym etc.. in the absense of any obvious biomechanical issues that may require orthotic therapy then prescribed stretching excercises should go a long way resolving her ITB irritation ...good luck & cheers for now
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Old 23rd March 2011, 06:25 AM
Stephanie C Stephanie C is offline
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Default Re: Iliotibial Band pain

Hi Issy. In my opinion, ITB is 'all' about feet in 99% of cases. Here is why. Regards Stephanie (author of the article...... http://www.walkwithoutpain.com.au/il...-band-syndrome
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Old 23rd March 2011, 06:39 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by Stephanie C View Post
Hi Issy. In my opinion, ITB is 'all' about feet in 99% of cases. Here is why. Regards Stephanie (author of the article...... http://www.walkwithoutpain.com.au/il...-band-syndrome
Funny evidence seems to point it´s all about the hips and pelvic stability.

Also Fascia can be stretched everything in the world has an elastic nature so it not completely unstretchable . There is lots of quite definite statements in your Blog going any references ?

Quote:
Is iliotibial band syndrome really a friction syndrome?
Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M.


Abstract

Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present-but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.
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Old 23rd March 2011, 06:50 AM
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Default Re: Iliotibial Band pain

This may be of interest as well. http://radiology.rsna.org/content/21....full.pdf+html
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Old 23rd March 2011, 09:09 AM
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Default Re: Iliotibial Band pain

We have found the Cluffy Wedge (or hallux pad) to be highly effective for IT band pain.
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Old 23rd March 2011, 10:25 AM
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Default Re: Iliotibial Band pain

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Originally Posted by CamWhite View Post
We have found the Cluffy Wedge (or hallux pad) to be highly effective for IT band pain.
Cluffy Wedge brings windlass on quicker. Can you expand on your thinking behind this for IT band pain and also is this always in runners - ever work for none athletes?? Thanks
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Old 23rd March 2011, 01:49 PM
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Default Re: Iliotibial Band pain

Thanks everyone for info. has been very helpful. From Podiatry point of view I can see that I need to check for things which may cause abnormal stress to IT band eg leg length difference, genu varum, excessive internal rotation of tibia due to excessive pronation, weak hip abductors etc.

I understand CamWhite's above thinking for cluffy wedge bringing on windlass quicker and slowing internal rotation of tibia - but never been keen on trying these in female shoes due to toe room restrictions. A heel raise does the same thing so could this be used as part of orthotic prescription?

Anyway will see what the full story is next week - THANKS again for info. Will keep you posted.
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Old 23rd March 2011, 01:56 PM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by Stephanie C View Post
Hi Issy. In my opinion, ITB is 'all' about feet in 99% of cases. Here is why. Regards Stephanie (author of the article...... http://www.walkwithoutpain.com.au/il...-band-syndrome
Hi Stephanie,

Like Mike, I disagree with this. I would say in my clinical experience a far greater percentage of ITB issues are more likely to be associated with pelvic dysfunction/proximal stability issues than they are foot mechanics.

I saw a textbook example just earlier this week - give me 10 mins and I'll post up some pictures.

Ian
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Old 23rd March 2011, 02:16 PM
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Default Re: Iliotibial Band pain

Here you go.

Here's a lass who isn't dissimilar in age or background to issy1's patient.

Take a punt at which side was symptomatic...
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Old 23rd March 2011, 02:29 PM
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Default Re: Iliotibial Band pain

my punt would be.... the right side?
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Old 23rd March 2011, 02:32 PM
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Default Re: Iliotibial Band pain

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Originally Posted by scott1 View Post
my punt would be.... the right side?
I had a dog... and his name was BINGO!

Caused by her foot mechanics Stephanie?
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Old 23rd March 2011, 02:52 PM
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Default Re: Iliotibial Band pain

i suppose i shouldnt be too proud of myself for getting that one right!
Just as a slight digression, I have been looking around pod arena for a post I read a while ago regarding ankle and cuboid manipulation and their influence on more proximal structures, particularly those that insert into the fibula e.g. ITB and biceps femoris. Did i dream this, or is there an easy way to search for it?

Cheers

ps i was in the vet recently and someone came out carryin two small fat dog called "Jamie" and "Kirsty"
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Old 24th March 2011, 03:31 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by Ian G View Post
Here you go.

Here's a lass who isn't dissimilar in age or background to issy1's patient.

Take a punt at which side was symptomatic...
Ian - For those of us with a less trained eye, can you explain what you see here that makes you think right side problematic?
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Old 24th March 2011, 03:53 AM
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Default Re: Iliotibial Band pain

Issy which side will put more tension in the Illiotibial Band right or left from Ian´s picture ?
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Old 24th March 2011, 04:18 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by m weber View Post
Issy which side will put more tension in the Illiotibial Band right or left from Ian´s picture ?
O.K. I'm thinking weak hip abductors on left due to dropped hip level which will increase strain on right side? Am I barking up right tree. Also tibial varum on both sides.
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Old 24th March 2011, 04:26 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by issy1 View Post
O.K. I'm thinking weak hip abductors on left due to dropped hip level which will increase strain on right side? Am I barking up right tree. Also tibial varum on both sides.
Could be a lot of things which Ian may tell us about, but yes as the left side the tension in the ITB should be much less than the right as the distance between origin and insertion of the ITB at the same stage of gait is clearly longer in the right side.

as to the cause of this Ian ?
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Old 24th March 2011, 04:41 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by issy1 View Post
O.K. I'm thinking weak hip abductors on left due to dropped hip level which will increase strain on right side? Am I barking up right tree. Also tibial varum on both sides.
Quote:
Originally Posted by m weber View Post
Could be a lot of things which Ian may tell us about, but yes as the left side the tension in the ITB should be much less than the right as the distance between origin and insertion of the ITB at the same stage of gait is clearly longer in the right side.

as to the cause of this Ian ?
Hi Issy,

As Mike says it's all about knowing our anatomy, and then identifying if we feel there are any movement patterns which we feel may be potentially 'pathological' (which in this case may increase the tensile loading force in the ITB).

You are right that there may be increased strain on the right side, but it is actually the right sided hip abductors/gluteii which are likely to be at fault here and not the left. As an easy to remember rule - the leg the person is standing on is the side that is being 'tested', and if they are dysfunctional then the contralateral side will drop. So when our lady is on her left leg you can see her pelvis is level in the frontal plane (i.e. flat like the horizon) --> therefore the left side seems to be functioning ok. However when she is on her right leg the pelvis becomes unstable and we see the left side drop --> therefore the right sided musculature may be dysfunctional. Does this make sense now?

When I have a bit more time later I will upload a doodle which I do for patients to explain this in very simple terms using a wall, a shelf and a bracket as an analogy.

As far as stating the muscles are 'weak' I would say they may be, but more often than not the problem is actually with their recruitment or timing characteristics. Making a muscle 'strong' is not usually enough in these cases (no good having a really powerful lightbulb if the switch and electrics are not working is it?). I'll post more on this later too - apologies for being so brief now - patients are limiting my time I can spend on here today.

IG
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Old 24th March 2011, 05:23 AM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by Ian G View Post
Hi Issy,


You are right that there may be increased strain on the right side, but it is actually the right sided hip abductors/gluteii which are likely to be at fault here and not the left. As an easy to remember rule - the leg the person is standing on is the side that is being 'tested', and if they are dysfunctional then the contralateral side will drop. So when our lady is on her left leg you can see her pelvis is level in the frontal plane (i.e. flat like the horizon) --> therefore the left side seems to be functioning ok. However when she is on her right leg the pelvis becomes unstable and we see the left side drop --> therefore the right sided musculature may be dysfunctional. Does this make sense now?
Yes, this makes sense. If you've time later maybe you could highlight your findings and treatment plan for this lady.

Many Thanks. Issy
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Old 24th March 2011, 05:31 AM
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Default Re: Iliotibial Band pain

No problem. I suppose the point I was trying to make was after seeing this comment:

Quote:
Originally Posted by issy1 View Post
I have a patient coming in next week who has pain over the iliotibial band region. She has attended a Physio for exercises etc but haven't helped. The physio gave her a pair of OTC devices to wear as he thought "problem may be with her feet," as her pain is exasperated when standing whilst hairdressing. The orthotics haven't helped greatly.
Ask what exercises she has been doing. Just because they didnt help does not make this a "foot problem" (more a case of an "inappropriate exercise problem" perhaps?)

Also check her standing position (i.e. when she is at work cutting peoples hair). Bet she favours 'hanging' off of one hip - you never know - you may even be lucky and find its the side that hurts...
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Old 24th March 2011, 04:13 PM
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Default Re: Iliotibial Band pain

Right, here is the way I explain this to patients (and I make no apologies for its gross over-simplification)

The main culprits are usually Gluteus Medius, and to a degree Gluteus Maximus also. Their fibres tend to run in a inferior-lateral direction, from the ileum to the greater trochanter of the femur (and the ITB itself for maximus). I describe this like the bracket of a shelf, as in picture below on the right hand side. The shelf itself it the pelvis (i.e. the waistband of their shorts). The wall the shelf is attached to is the leg/femur they are standing on. Still with me?

If that bracket fails (is dysfunctional) then what happens to the shelf? If falls away from the wall - i.e. the end of the shelf opposite to the bracket falls down towards the earth. So if we take a right sided trendelenberg, as with the lady in the previous video analysis stills, she is on her right leg, the left side of the pelvis is falling towards the earth - therefore it suggests the hip abductors (brackets) on the right side are dysfunctional. Most patients understand this concept once explained to them.

So why does this happen? Well here is my take on it. As I said earlier in my opinion it is more of a recruitment or timing issue than isolated 'weakness'. This neuromuscular control seems to be lost in individuals who have sedentary jobs (... that'll be most people then). I saw a chap in London today who runs for up to 1 hour a day. Pretty impressive, but sadly still a very small percentage of time compared to the 16 hours a day he spends sitting in front of his 3 computer screens analysing the stock markets.

Sitting = hip flexion. Gluteal demand = zero. In my experience when these individuals then stand up to walk/run their gluteii just simply don't know what to do or when to do it. Almost like a de-conditioning effect, but more than that - a complete inability of the neuromuscular system to 'switch on' the muscles in this relatively extended hip joint position.
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Old 24th March 2011, 05:11 PM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by scott1 View Post
i suppose i shouldnt be too proud of myself for getting that one right!
Just as a slight digression, I have been looking around pod arena for a post I read a while ago regarding ankle and cuboid manipulation and their influence on more proximal structures, particularly those that insert into the fibula e.g. ITB and biceps femoris. Did i dream this, or is there an easy way to search for it?

Cheers

ps i was in the vet recently and someone came out carryin two small fat dog called "Jamie" and "Kirsty"
I believe it may have been Howard Danenberg who mentioned that particular one. I think he was referring to the link between all of the structures you mention. Ted Jadnik(spelling?)/TedJed mentioned it in this post

Quote:
Utilising one's clinical skills, one determines where the joint hypomobility lies (that is due to connective tissue restrictions) and then devises a treatment plan to treat that region AND the related joints/tissues. It's SO important to remember the interconnectivity between different joints and their relations. E.g. in treating a subluxed cuboid, one MUST check the fibula and the head of the femur/greater trochanter because of the peroneus longus>Lat. hamstring/ITB connections.
located on this thread.
http://www.podiatry-arena.com/podiat...ad.php?t=38213

If you want to search for anything in PA, put the search terms you are lloking for into google with podiatry arena as the last search term and it is more accurate than using PAs search. There is actually a thread about it.

Regards,

Robin
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Old 24th March 2011, 05:17 PM
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Default Re: Iliotibial Band pain

Quote:
Originally Posted by Ian G View Post
Right, here is the way I explain this to patients (and I make no apologies for its gross over-simplification)

The main culprits are usually Gluteus Medius, and to a degree Gluteus Maximus also. Their fibres tend to run in a inferior-lateral direction, from the ileum to the greater trochanter of the femur (and the ITB itself for maximus). I describe this like the bracket of a shelf, as in picture below on the right hand side. The shelf itself it the pelvis (i.e. the waistband of their shorts). The wall the shelf is attached to is the leg/femur they are standing on. Still with me?

If that bracket fails (is dysfunctional) then what happens to the shelf? If falls away from the wall - i.e. the end of the shelf opposite to the bracket falls down towards the earth. So if we take a right sided trendelenberg, as with the lady in the previous video analysis stills, she is on her right leg, the left side of the pelvis is falling towards the earth - therefore it suggests the hip abductors (brackets) on the right side are dysfunctional. Most patients understand this concept once explained to them.

So why does this happen? Well here is my take on it. As I said earlier in my opinion it is more of a recruitment or timing issue than isolated 'weakness'. This neuromuscular control seems to be lost in individuals who have sedentary jobs (... that'll be most people then). I saw a chap in London today who runs for up to 1 hour a day. Pretty impressive, but sadly still a very small percentage of time compared to the 16 hours a day he spends sitting in front of his 3 computer screens analysing the stock markets.

Sitting = hip flexion. Gluteal demand = zero. In my experience when these individuals then stand up to walk/run their gluteii just simply don't know what to do or when to do it. Almost like a de-conditioning effect, but more than that - a complete inability of the neuromuscular system to 'switch on' the muscles in this relatively extended hip joint position.
Nice way of explaining it Ian. I'll have to take people to my house and explain to them that their gluteals are functioning in much the same way as the bracket for the "floating shelf" that I bought from B&Q. That is ....not at all.

I have the only "floating shelf" that is bracketed on to the wall.

Regards,

Heath Robinson
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Old 25th March 2011, 11:17 PM
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Default Re: Iliotibial Band pain

Another way of explaining. Right leg stance phase. Body weight (gravity) acts on center of mass of trunk downward. Femur applies an upward force to keep the trunk in the air. These two forces are not directly in line so they will create a force couple that will cause the trunk to rotate to the left. Something has to prevent that rotation. The right hip abductor muscles will rotate the trunk to the right, which is the same as saying they will create a moment in the opposite direction as gravity. In the picture, the muscles are not holding the pelvis level and the pelvis rotates to the left. When the pelvis rotates far enough to the left the right iliotibial band will become tight and create downward force on the pelvis at a point that is lateral to the upward force from the femur. In other words the IT band creates a moment that wants to rotate the pelvis to the right.

Eric
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Old 26th March 2011, 08:01 AM
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Default Re: Iliotibial Band pain

Ian:

It would be more accurate to model the gluteus medius as being rubber bands or a cord that are attached, by a nail, for example, to the top surface of the shelf and then extending to the top surface of the table, that is "superior" to the "joint axis" and creating a tension force to hold the shelf up. Your current model, unfortunately, uses compression force on the "inferior" side of the joint axis, a type of force which muscles, ligaments and tendons do not use to accomplish such tasks.

Thought that this point should be made before others start using this same model without understanding it's limitations.
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Old 26th March 2011, 12:45 PM
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Default Re: Iliotibial Band pain

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Ian:

It would be more accurate to model the gluteus medius as being rubber bands or a cord that are attached, by a nail, for example, to the top surface of the shelf and then extending to the top surface of the table, that is "superior" to the "joint axis" and creating a tension force to hold the shelf up. Your current model, unfortunately, uses compression force on the "inferior" side of the joint axis, a type of force which muscles, ligaments and tendons do not use to accomplish such tasks.

Thought that this point should be made before others start using this same model without understanding it's limitations.
Thanks for this Kevin. I only devised this model/description as an illustration for my patients (i.e. lay people). In my experience what confuses most people regarding a trendelenberg is the fact that the side which drops is actually the contralateral side to the dysfunctional side. To this end, my analogy has been very easily understood by all I have explained it to, and therefore I regard it as useful (despite it's limitations that you have highlighted). The reason I posted it here was that I felt it may help some people in the same way.
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Old 26th March 2011, 07:09 PM
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Default Re: Iliotibial Band pain

Ian:

I like your idea of the folding shelf on a desk for explaining the Trendelenburg sign. I thought the cord on top of the table and shelf made more sense from a modelling sense.
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California School of Podiatric Medicine at Samuel Merritt College

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**************************************************
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Old 28th March 2011, 12:48 AM
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Default Re: Iliotibial Band pain

Well put ...I agree with you on that one....kevin
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Old 28th March 2011, 01:06 AM
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Default Re: Iliotibial Band pain

Ian: I really like your wall grids.
There is another muscle imbalance/recruitment-timing that I find is often involved. It is the Psoas Minor. It balances the anterior tilt of the pelvis above the contact leg while the other is lifting. Often there is a locked rotation and uneven enervation at T11/12 as the source.
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