Tight Band Sidelines Fitness Walker
by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
History and Presenting Symptoms
A 34-year-old female reports persistent pain at her right knee with walking. She localizes this pain to the lateral aspect, and says that it becomes worse as she continues her regular fitness walking program. She has been trying to walk three miles daily for the past six months, in order to control her weight. On a 100mm Visual Analog Scale, the woman rates her right knee pain at about 65mm. She describes the pain as a sharp soreness in her knee upon each step, with tightness in the adjacent muscles. The tightness builds up after she has gone about a mile, and it then continues for several hours afterward. Acetaminophen has not helped, and ibuprofen provides only partial relief. She doesn’t recall any specific injury.
Vitals. This moderately overweight woman stands 5’5″ and weighs 158 lbs, which results in a BMI of 27. She has never smoked tobacco, and her blood pressure and pulse rate are in the normal range.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. Otherwise, she demonstrates generally good alignment throughout her spine. She has a mild bilateral knee valgus and moderate calcaneal eversion, with definite hyperpronation on the right side. There are no significant findings on gait screening, although she demonstrates a tendency to toe out with the right foot. Measurement of her navicular drop from seated to standing identifies a medial arch drop of 4mm on the left and 8mm on the right, with an asymmetry of 4mm.
Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the right SI joint, the lumbosacral junction, T11/12, and the cervicothoracic junction. There is no localized tenderness in these regions, and all spinal, hip, and knee ranges of motion are full and pain-free.
Lower extremities. Strength asymmetry in the hip abductor muscles is noted upon manual testing of the right tensor fascia lata. Palpation finds the entire right iliotibial band to be tight and tender, with an area of sharper tenderness upon pressure over the distal femoral condyle. Ober’s test for abductor contracture is only marginally positive.
Imaging No imaging of the knees or spine was performed.
Iliotibial band tightness causing irritation at the lateral knee with fitness walking. This is associated with an underlying functional leg length discrepancy due to asymmetrical pronation.
Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions were provided as needed. Manipulation of the right navicular, cuboid, and calcaneal bones were also performed.
Support. Flexible, stabilizing orthotics were custom-made, with a pronation correction added to the right side. The patient reported that they were very comfortable in her walking shoes, and she had no difficulty in adapting to the orthotics.
Rehabilitation. She was shown a series of active stretching procedures for the iliotibial band and instructed to perform these both before and after each walk. Initially, her walks were limited to one mile only. After two weeks in her orthotics, she began to increase by a half mile each week, until she was back to her regular three-mile route.
Response to Care
The spinal, pelvic, and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in her postural alignment. The combination of the stabilizing orthotic support and her active stretches resulted in rapid relief of her knee symptoms. She was then able to gradually increase the length of her walks. After eight weeks she was back to walking three miles every day, with no return of her right knee pain. At that point, she was released to a self-directed maintenance program.
Moderate lower extremity asymmetries often go unnoticed, until a person becomes physically active. In this case, the combination of overweight and poor function in the right foot resulted in the development of chronic iliotibial band tightness with regular fitness walking. Once the foot asymmetry was identified and supported, she was able to return to her walking program for health and weight control.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is a clinical professor at Tufts University Medical School and for 25 years was the chairperson of the United States Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. He can be reached by e-mail at [email protected].