After the first article in which we were talking about and describing the lesion process of the iliotibial band or the more commonly called knee of the runner, today we have to delve a little deeper into the injury, and talk about its therapeutic recovery possibilities that are different and varied
It is clear in advance that every technique has some kind of positive effect, as long as it is a technique well applied by health professionals. Some will be more effective than others, and some will not work the way we expect immediately … but it’s like playing “tiki-taka” style football and ending up losing a penalty in the 90 … today you lose but tomorrow you win! Of course, we must advise and treat us by health professionals, who have been trained and have experience in the field in question.
Returning to what concerns us, the possibilities of treating the pathology of the external region of the hip and knee, we could talk about “remedies” that can be applied by the athlete in a particular way, at home, based on totally useful recommendations and that do not require the intervention of a health professional; but in this article we will talk about the interventions that can be done by the health professional, the sports physiotherapist.
Obviously, the most important section of all. The main thing to be able to treat the affectation is to detect or arrive at the deduction of what is the cause of the problem. The runner’s knee is a multifactorial pathology , and therefore many factors must be analyzed. We include in the assessment an analysis of the static bipedal position, a gait analysis, a race analysis if you can(here we need you to give us a video in case we do not have space to run in a long corridor). With this we begin to see if there are deficits in terms of support, career technique, shortening step or support time, among other aspects. We will also evaluate at the level of joint ranges from the back to the feet, going through hip and knee; An alteration of the joint range can alter the mechanics of joint work, either by excess or by limitation of movement, thus changing the requirement of muscular work and leading to injury due to overload.
This point will relate to the assessment of muscle strength Other times we have talked about strength, which is essential ! Having a strong muscle group does not mean having the look of the gym “croissant” … the muscles have to be able to recruit their fibers effectively and in adequate time. A muscle weakness can lead to failure of the action and lead to injury to the muscle itself (and therefore the tendon) due to overload.
We must add to the assessment the analysis of other aspects such as the distribution of training loads in terms of training volume (train on your own or follow a plan?), As well as the surface on which you run, since no it’s the same to run on asphalt, much more aggressive, than to run on dirt or grass. Speaking of surfaces, analysis of the footprint and footwear. We begin to analyze it when evaluating the mobility of the foot, but if it is cavo, varus or flat, it will mean a mechanical alteration of the race that affects the whole leg, and that translates “forces upwards “reaching to affect the hip and back. We must make an assessment of the type of foot, footwear that is used and if necessary go to the podiatrist to make or review templates.
The first thing we must do is to differentiate the sports massage, oriented to prepare the athlete for the activity, which is characterized by faster and more superficial movements, of the muscular discharge massage . In the treatment of the iliotibial band the discharge massage is indicated, which is characterized by slower and deeper maneuvers, which also tend to be more annoying. The application of massage is important since it helps to reduce muscle tension, especially at the level of the Tensor Fascia Lata (TFL), such as the gluteus medius, gluteus maximus, peroneal musculature and lumbar muscles.
These muscle groups will increase the tone (it does not mean that they are strong muscles) in response to the affectation, and that increase in muscle tone implies a greater tension at the level of the tendon insertion, which in the long run can be another problem. Therefore the purpose of the therapy will be to reduce the tension, by means of kneading, frictions, digital pressures …
In this section we can include a multitude of techniques and methods of treatment that have the objective of direct action on tissues. In fact almost anything that physiotherapists do about the patient is a manual therapy … but let’s focus instead on the more specific part.
The objective of manual therapy is to mobilize body segments analytically or globally to assess the range of joint, the quality of movement, determine if there are alterations or unusual sensations in it. If it is necessary to recover joint range, the mobilizations will have a particular focus. It is important that the joints do not have any type of blockage to allow normal movement and not cause biomechanical alterations in the muscle recruitment pattern, nor in the race, for example. It should be assessed as we have previously mentioned from the lumbar level and the whole pelvis, up to the feet, with an adequate examination of each of the bones of the tarsus, going through the analysis of the fibula, for example. I stop at the fibula (the most lateral bone of the leg), since it is a bone that barely supports body weight, and that it can undergo slight anterior or posterior displacements, which at first sight we can not detect, and that will completely change the mechanical knee.
Often spoken, more and more on everyone’s lips, the work of lumbopelvic stability is vital from the point of view that it will offer greater body control at the level of the abdomino-lumbar region, and this will improve the transfer and absorption of the loads that they must then go through the hips towards the floor, and vice versa. There are many scientific articles that relate the lesion incidence of the legs with a lack of control of the CORE, and that in turn show that an adequate work of it greatly reduces these injuries. The work of CORE We should not see it as the realization of great exercises or very complicated either. We must learn (and we, the professionals, teach) to control the muscles involved to know how to activate, and gradually relate this to natural movements.
The dreaded hooks! it is nothing more than an instrumented work that allows to reach with more precision than with the fingers (for a matter of thickness, since the end of the hook is much finer than a finger) to the area that you want to treat.
The hooks as such are used to treat the fascias, which are the tissue that covers all the muscles, tendons, ligaments, bones, organs, it is like the plastic film with which we wrapped the sandwiches , to understand each other, but much finer. The fascias are totally related to the muscles and tendons, and therefore if these are affected by an increase in tone or inflammation, the fascias are also affected, and should be treated. Through the hooks what we get is to perform rhythmic mobilizations of the muscle groups in order to mobilize the fascias analytically.
This technique is one of those that we can include in the techniques offered by the health professional, but it is the most widely performed by the runners themselves. The stretches help us to reduce the tension of the muscle groups, to keep the muscular gliding planes free, to recover muscle length or flexibility, and thus to increase the range of movement, or a relaxing effect, among others. It should be noted that it is very important that stretches have the appropriate duration and intensity for each objective. A stretch to increase or recover muscle length, which will be smooth but long lasting, is not the same as a stretch prior to activity, which will be short and intense, or even ballistic. Stretching modalities are different, and you have to choose properly which and when to use it.
After the initial assessment, we must determine where there is some kind of deficit in terms of activation, recruitment or muscle weakness, at the lower train level. As mentioned above, if the TFL or the buttocks for example, are rigid or hard, does not mean that they are strong … it is possible that it is a protective reaction of the body itself to defend against the affectation.
After treating it properly to reduce this tension, we must apply active muscular work to strengthen the muscle groups and reeducate them in their function, so that they can support the loads that are applied to them. This type of exercise is not necessary with high gym loads, at least in the initial phase. It is based on exercises, analytical or functional, with slight resistance that can be repeated without problems the times that are scheduled, and that serve both as a treatment and as a warm-up before the race, for example. The exercises that at one time apply as a treatment guide, can later be considered as a prevention guideline.
Not in terms of exercises typical of the career technique, which are part of the technical training of your specialty. As we have said before, we will analyze the way of walking and the way of running (live, with video recording …). We will look for correction strategies for different support times between left and right side, different length of passage, major alterations in the distribution of body weight between both sides, foot collection deficit, deficits in hip and knee flexion … etc. Any of these technical alterations entails a bad biomechanics and therefore directs us towards an injury.
What sometimes happens is that when these alterations are structured, that is, they are taken as normal for oneself, it is difficult to realize the deficits, and it takes an external eye to determine them. Likewise, it is also interesting to evaluate the squat dynamically, to assess the activation of the gluteus medius, for example; Basically, if the knee goes inwards when the knees are flexed, it will indicate that there is a deficit of activation of the external rotators of the hip (pyramidal, gluteus medius, obturators …) and this can lead to an affectation of TFL (and to other more serious ones). as the anterior cruciate ligament).
If we determine that the runner suffers from digging, varus or flat, we will teach him / her adequate exercises to work the intrinsic muscles (tiny muscles between the bones of the foot), to give greater stability and solidity to the foot, at the same time that proprioception must work to “teach” the body to respond to alterations such as loss of stability when stepping on a stone, for example. But even with all this, we will recommend to the runner that he go to see the podiatrist, to review with the appropriate material if he requires a template or not, and what kind of template he should carry.
So far we have made a collection of the main techniques that are usually applied in the treatment of the belt by physiotherapists. Even so, there are other techniques (EPI, shock waves …) that can be applied, we have not made a compilation of all the possible options, but if the most extended and demonstrated.