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Sep 12, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses treatment progressions for lateral knee pain/"IT band" pain. Mark encouraged beginning with open chain exercises as a starting point for individuals with high irritability. These exercises can help decrease force on tissues while still providing a stimulus for the body to adapt. Additionally, open chain exercises stimulate the release of endorphins, which can have a positive effect on pain and mood.

Mark mentions several open chain exercises that are beneficial for individuals with high irritability, including hip abduction, hip extension, and hip rotation. These exercises can be performed in different positions, such as bent over hip extension against a table or in a quadruped position with significant bracing of the anterior trunk.

It is important to note that the intensity and volume of open chain exercises should be adjusted based on the individual's irritability level. For individuals with high irritability, the podcast recommends starting with a high volume of open chain exercises, such as two to three sets of 20 repetitions with a low load intensity. The goal is to challenge the individual and provide a stimulus to the nervous system.

Overall, open chain exercises can be a beneficial starting point for individuals with high irritability as they help decrease force on tissues while still providing a stimulus for adaptation. It is important to adjust the intensity and volume of these exercises based on the individual's irritability level.

As symptoms decrease and heavy, slow resistance training is introduced, closed chain exercises such as the hip thruster and Bulgarian split squat are recommended. These exercises effectively strengthen the hip and quad muscles while improving stability and control in the lower extremities. The hip thruster involves thrusting the hips upward while keeping the feet planted on the ground, targeting the glutes and hamstrings. On the other hand, the Bulgarian split squat is a single-leg exercise that requires the back foot to be elevated on a bench or step, improving balance, stability, and leg strength.

In addition to closed chain exercises, proprioceptive training or reactive neuromuscular training can be incorporated. This involves using loop bands around the knees to provide feedback and improve body awareness. Proprioceptive training enhances control and stability during movements, reducing the risk of injury.

Once individuals can handle both heavy slow resistance training and reactive neuromuscular training, they can progress to plyometric training. Plyometric exercises involve explosive movements like jumping and hopping to develop power and improve muscular endurance. The recommended goal is three sets of 20 repetitions or three sets lasting a minute for endurance, and 10 sets of three to six repetitions for power. Plyometric training enhances both endurance and power, important for athletic performance and overall functional fitness.

Mark finishes this episode by offering a number of different options to reintroduce running, if it's part of that patient's goals.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 INTRO

All right, what's up PT on Ice daily crew. Dr. Mark Gallant here, lead faculty with the extremity management division alongside Lindsey Hughey and Eric Chaconas. Coming at you here Tuesday morning, Clinical Tuesday. Before we dive in, a few upcoming courses that we want to announce. I'm going to be in Cincinnati, Ohio this weekend with Onward Cincinnati. So if you've all been looking to check the extremity management course and haven't had that opportunity yet, definitely sign up today. Get on the list for Onward Cincinnati. There's still seats left. If that's not available, Cody will be in Rochester, Minnesota first weekend of October. So that'll be your next opportunity to check the extremity management crew out.

1:01 LATERAL KNEE PAIN

So I was on here a few weeks ago and we talked about the myths of iliotibial band pain, where we came from, from the research in the 70s, and now how we've adapted with newer research and things we now know. Mainly being that this is no longer believed to be a friction mechanism of the lateral knee because we know the IT band is firmly attached to the lateral femoral condyle, the patella, the tibia, and that this is more of a magnitude or a volume of load with a potential lack of frontal plane control or simply too much volume to the lateral knee. So what are we gonna do if that person comes in? Tim's been running on the treadmill for most of the year, he decides that he wants to get out and do some trail runs, start working some downhill in. Brittany has been relatively unfit for most of her life and decides, you know what, this fall, it's the time that I'm gonna run that half marathon. And then they start to develop some lateral knee pain. Well, how are we gonna treat those folks out? And what we're really gonna look at, that's gonna depend on where their irritability is. So we have four or five steps that we're gonna go through and that individual can jump onto that highway wherever they're at on this progression. So if that person comes in and they're highly irritable, they tell you that they've got eight out of 10 lateral knee pain, it hurts when they're going downstairs, when it's the trail leg that's walking, they begin to have some discomfort, they're certainly having trouble getting out and doing any of their runs, and it's really a quite uncomfortable pain for them. Well, when that person comes in, like we talked about last time, we'll do the dry needling, the myofascial decompression, the soft tissue to help modulate their pain. How do we work the exercises in and how do we specifically dose those exercises? So if the person has that 8 out of 10 or above or even 7 out of 10 irritability, oftentimes a good place to start with our exercises is open chain exercises. they're really going to decrease the amount or magnitude of force going into those tissues while giving them a nice stimulus so that the body knows it has to adapt, we get some good endorphins going. We specifically like open chain abduction of the hip, open chain extension of the hip, and if you want to get some open chain rotation of the hip, that works as well. So we like either a bent over hip extension so that person is leaning against the table so they can really contract their abs so that we know they're not getting any back arching there. Or if they go into a quadruped position, really brace the anterior trunk significantly, and then do their hip extensions. For the open chain abduction, we'd like to get them against a wall, starting them so where their hip is in neutral, so their hip is either, their leg's propped up on a ball or a bench, heels against the wall, slightly internally rotated so we know we're really hitting those glutes and working our hip abduction that way.

04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS

For our hip rotation in open chain, the traditional clamshell has come under fire quite a bit in the last handful of years. What we like to do is a pseudo open chain clamshell where their feet, their bare feet are gonna be against the wall. So they have to keep that flat foot against the wall and then go into their clamshell. How are we going to dose this? Well, if you've been to the course, you know, we talk about the rehab dose, eight to 20 repetitions, 30 to 80% of their one rep max basing that that volume and intensity on their irritability. Well, these folks are higher on the irritability, so we're going to go higher volume. We're going to hit two to three sets of 20 repetitions with a really low load intensity. It's hard to get a high intensity load an open chain without volume anyway. So that's really going to lend itself to this to begin with. So our hip extension, our abduction, our pseudo clamshell, we're going to hit those two to three sets of 20 reps where they feel challenged when they approach that 20. It's getting a lot of stimulus to that nervous system. It's letting the tissues know that we want you to be active, but it's not giving them a magnitude of load that's going to be threatening to the tissue. Once the person says, you know what, I went downstairs last night and my pain was only a 3 out of 10 or my symptoms were only a 3 out of 10 or less, or that person comes in and says, you know what, now when I'm walking, when that leg's the trail leg, really doesn't seem to bother me that much. Maybe a 2 out of 10 at best. That's when we really want to make sure we're progressing to a more closed chain activity. What we love for our closed chain exercises, again, working into that hip extension, getting the quad stronger. We like a hip thrust, so a barbell hip thrust that we can really load up a lot of weight. If we see a big side-to-side discrepancy in strength, we can go single leg landmine hip thruster to make sure we can load that up. We also like a Bulgarian split squat. For our IT band folks, we're gonna modify this split squat a bit Instead of having all the weight on the front leg, you're gonna have a majority of your weight on the leg that's slightly elevated so that we can get a big eccentric load into that posterior leg. How do we like to dose this one? Three sets of eight to 12 repetitions at a weight where they feel like they've only got two or three left in the tank by the time they get to that eight out of 12. You'll notice that three sets of 10 fits beautifully into that eight to 12 repetitions. A lot of clinicians out there like to bash the three sets of 10 calling other clinicians lazy. Three sets of 10 is a wonderful stimulus as long as you're dosing it out appropriately, as long as they're approaching failure. We're not saying they have to get to failure, but can they get in the ballpark of that failure? So again, three sets, of eight to 12 reps. We really love three sets of 10. It's easy for us, it's easy for the patient, and making sure they've only got two to three reps left in the tank, specifically with the barbell hip thruster, the Bulgarian split squat with the weight shifted posteriorly. You can also add, if you want to continue to work on those hip abductors, we really like a kettlebell-weighted hip hike to get a closed-chain version of that hip abduction. At the same time you're doing your heavy, slow resistance training with your Bulgarian split squats, your hip thrusters, with your hip hikes, we also want to get that person to start being able to feel where they can control that lower extremity in space. So we really like reactive neuromuscular training, often used the acronym RNT for short, where they're going to have a band around their knees, so a small loop band that's going to pull their knees into valgus. with a flat foot, they're going to drive their knees outward. We're going to do this at a high volume. So either two to three sets of 20 or setting a timer and saying, I'm going to have you rock this three sets for a minute each. Again, we're really trying to get that nervous system to feel where that limb is and is in space to gain more control. So we want that volume to be a bit higher. You can also do this single leg where you have a meter loop band attached to a rig or a door frame. It's going to pull them into that, that valgus force with a flat foot. They have to drive that out again, high volume, three sets, 20 reps, three sets for a minute. You can progress this into having them do step downs, lunges or squats with that band on. So they have to feel their lower extremity limb where it's at in space while going through a movement. So, Just to rehash where we're at right now, high irritability, we're going open chain exercises at a high volume, lower intensity. Once they can tolerate that with mild pain, we're going to go into our closed chain exercises, increasing the intensity, making it really challenging for that three sets of eight to 12. At the same time, doing our closed chain proprioceptive work or our reactive neuromuscular training.

09:28 PLYOMETRIC TRAINING

From there, when they say they're starting to tolerate that really well, then we wanna start working into our plyometric training. We talked about last week, we know that iliotibial band has a lot of similar properties to tendons. We wanna make sure that it has the ability to transfer force and absorb force quite well. We need to do this from both an endurance perspective and a power perspective. So can that tendon or that iliotibial band Absorb a lot of force and generate a lot of force and can it absorb and generate a high volume of force? So we like to do Lateral skater hops for a high volume to really get that endurance. So they're gonna be jumping side to side To get that that that volume for the endurance piece of three sets of 20 or three sets of a minute We also like pogo hops, where they're having to hop on one leg. Again, three sets of 20 or three sets of a minute. And then we really want to work on the power component. How high can they jump? How long can they jump? And can they go laterally against resistance? A couple of exercises that we really like for this, box jumps are great. Our long jump, just the traditional long jump. And then again, strapping either a band around the hips or a strap that's attached to an anchor cable column, and then we have them go three sets of three to six repetitions. So we're gonna have them go relatively low. If you've got the time in clinic, what we really prefer is 10 sets of three to six repetitions, because it's really gonna train that power very specific to how like our Olympic lifters would train. So again, if time is short in clinic, get the job done, get it in. What we really like is that 10 sets of three to six repetitions for our power. Another thing you can do for power is your rebound jumping. So they come off of a small step and they immediately have to jump to a higher box. That's going to train that lower extremity to both absorb force and immediately generate force overall.

12:01 RUNNING PROGRESSIONS FOR IT BAND PAIN

As they're tolerating those plyometrics better, both from an endurance perspective and from a power output perspective, then we're going to really look at how we're able to get them running more effectively. So what this is going to look like is early on for running to get them out of symptoms, we're often going to have them run on a treadmill with a fairly steep incline. This typically will reduce symptoms for a lot of our iliotibial band folks. Then we're going to lower the treadmill. have them make sure that they can run with relatively low symptoms at a normal treadmill where it's a very controlled environment. Once they can run on a regular treadmill at that very controlled environment, then we're going to have them outdoor run. Once they can outdoor run on something like a track, a blacktop, or a sidewalk where it's relatively controlled, then we'll progress them to their trail running when they can handle a relatively flat trail then we'll progress them back to their downhills and then get them back out there on the circuit, hitting their runs. So again, these folks can enter this anywhere along that progression, depending on their irritability. If they're highly irritable, start them out open chain, high volume exercise. As their symptoms decrease, get them into that heavy, slow resistance with closed chain exercises. We like the hip thruster and the Bulgarian split squat. As you're doing the heavy slow resistance, also getting them into some proprioceptive training or reactive neuromuscular training with loop bands around the knees so that they can feel where those knees are in space. Once they can handle both the heavy slow resistance and the reactive neuromuscular training, we're gonna get them into their plyometric training. We want them to have both endurance and a lot of power. So three sets of 20 or three sets of a minute for the endurance piece. 10 sets of three to six reps for their power piece. And then, of course, whatever their functional activity is that was initially their aggravator, the thing that they love to do that they wanna get back to, making sure we're incorporating that. Starting out incline treadmill, go to a neutral treadmill, get them on the outdoor, on a blacktop, pavement, or a track, then progress them to a trail, and then progress them to the downhill running. Hope this helped as far as the plan for IT band pain goes. Hope to see you all out on the road next week in Cincinnati. If not, catch Cody in Rochester. Hope you all have a great Tuesday in clinic. Thanks for your time. Have a great day.

14:14 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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