All too often, we therapists are overly concerned with "reaching the site of the lesion." Our schools taught us this philosophy, which is based on the work of James Cyriax. While Dr. Cyriax was brilliant, and we should absolutely consider the site of the lesion, we must realize Dr. Cyriax was a physician first. Physicians are largely concerned with the pathology; their primary consideration is the irritated tissue itself. They devote less time to considering why that tissue is irritated.
We, as therapists, must also consider the irritation of tissues involved, as well as why they are breaking down. Generally, it is due to a challenging environment, meaning muscle imbalances elsewhere in the body, such as a leg-length discrepancy, or poor biomechanics during gait/running.
My favorite analogy is comparing an angry tissue to a raging fire in your patient's body. If you want to get rid of the anger in the tissue, you must:
1. Find the fire
2. Put the fire out
3. Take the matches away from the patient.
IT band syndrome is a perfect example. I had a patient who was a sponsored marathon runner. She had a diagnosis of IT band syndrome. She had seen three doctors, three physical therapists and two massage therapists, but nothing had solved her problem. She was sent to me for another try. Needless to say, she wasn't excited to be in my clinic.
My subjective included the usual: What was the MOI? Where in the gait cycle did she feel pain? What had been tried? With each question, her frustration grew. I had to stop and gain her confidence.
I asked the following questions: How long have you had scoliosis? Has anybody addressed your leg length issue? How long does your back hurt after a long run? All of these pieces of information I had gathered was watching her in the waiting room and watching her walk back to the treatment room. No one had ever asked her these questions before. Yes, she had raging IT band syndrome (the fire!) But nobody had looked at contributing factors. I then took her outside and asked her to run. Why not a treadmill? I find running mechanics are different on a treadmill.
She ran around the parking lot, and I stopped her. Her running mechanics were a mess (patient striking the matches!) She had dysfunctions in her running encompassing all three planes of motion not to mention her postural dysfunctions.
Treatment consisted of lift in her shoe on the side of the shorter leg, slight posterior pelvic tilt in running, and correction of her cross-over gait (no there was no glut med weakness, just an abnormal pattern). Manually, we worked to improve her thoracic mobility, providing improved transverse plane mobility, which eliminated her excess hip rotation in running. She was gone in six visits. She subsequently ran a half marathon and posted her best time ever.
- Leg length discrepancy.
I know, you've probably checked for this. But measurements taken the day of the eval could be wrong, especially if you were rushed for time. Consider using going deeper. Use your standard measurement techniques, such as bridging and comparing malleolus to ASIS length bilaterally. Follow up with long seated test. Does all of the testing fit the postural analysis? E.g. one foot supinated and one pronated? One hip back and one forward? Spend ample time checking the hips to discover the true source of a leg length discrepancy. Are tight QLs elevating the pelvis?
- Poor functional movement
Watch the patient move functionally. It's all fine and good to watch your patient run on a treadmill, if that is where they are experiencing pain. But don't forget to watch a patient run on the actual aggravating terrain. Sidewalks are sloped and excessive time on uneven terrain can be a bad combination with leg length issues.
- Foot problems
Pes cavus, pes planus, and positional faults as well as movement faults in the feet can cause proximal issues. If you don't feel comfortable fully examining the foot as a part of your IT Band examination, find someone who does and learn from them. As a new grad, feet can be intimidating and frustrating, especially when they're the culprits behind pain elsewhere in the body. Don't be afraid to ask your peers for help.
- Spinal issues
Scoliosis, lordotic tissues (too much or too little lordosis), Spinal rigidity (hypo versus hyper). Sometimes, a lack of thoracic rotation can lead to excessive hip rotation during gait, which transfers stresses into the ITB. Spend a little time taking a look a the spine to see if it could be contributing to the issue.
- Gait or running mechanics.
Marathon running and sprinting have different mechanics. Don't forget to carefully watch your patient to look for cross over gait, pelvic positioning, heel strike runners and so on. New grad physical therapists may need extra time with gait mechanics. We all miss things on the first pass. If your patient is comfortable with the idea, consider filming them and observing the gait later, at your own pace.