iliotibial band syndrome

1. Hip osteoarthritis

2. Introduction
• Osteoarthritis (OA) is a common chronic disorder among elderly people
that affects joints such as the knee and hip in particular.
• an inflammatory and degenerative process that affects articular cartilage

3. • Osteoarthritis is a degenerative joint disease that causes progressive
damage to articular cartilage and surrounding structures. The hip is
the second most commonly affected joint (after the knee), and
around 11% (2.46 million) of people in England are affected.
Introduction

4. • Hip OA is a common disease presenting with joint stiffness, swelling,
and instability resulting in functional impairment (K U Rasi et al.,
2017).
• Hip OA is characterized by structural and functional failure of the
femoroacetabular joint (L Beumer et al., 2015).

5. ETIOLOGY
• The aetiology of hip OA can be
primary and secondary.
• The primary cause is
idiopathic. There may be
anatomical and
mechanical factors that
affect joint congruency
and predispose to
femoro-acetabular
impingement and erosion
of the articular surface.
• The secondary causes are
summarized in the table:

6. FACTOR
PREDISPOSING
TO HIP OA

7. CARDINAL FEATURES
• Progressive cartilage destruction
leads to narrowing of the joint
space
• Subarticular cyst formation
• Sclerosis of the surrounding bone
• Osteophytes formation
• Capsular fibrosis
• Bone remodelling

8. CLINICAL FEATURES
• Pain in groin may radiate to knee
• joint stiffness, Stiffness is noted chiefly after rest
• Age: usually over 50 year (Nearly, 10–15% of people between the ages of
50 and 65 years and 40% of those over age of 65 years suffer from OA )
• Positive trendelenburg sign
• Flexion deformity revealed by thomas test
• Deep pressure lead to tenderness
• GT (greater trochanter) is higher and posterior
• restricted range of motion
Seo P, Hakim A (2009) Oxford American handbook of
rheumatology.

9. RADIOLOGICAL CLASSIFICATION
Radiographs in AP view were used
to analyze the degree of OA using
the classification system
developed by Busse et al., 1972,
on a scale divided from 0 to 3, and
to evaluate the cervicodiaphyseal
angle.

11. DIAGNOSTIC CRITERIA
• Hip osteoarthritis can be diagnosed by a combination of the findings from a history and
physical examination.
• Sutlive et al., 2008 published a list of variables for detecting hip osteoarthritis in patients
with unilateral hip pain. If there are 3/5 variables present, the chance of having OA is
68%.
• With 4-5/5 the chance increases to 91%. The variables are positive when there’s pain or a
limited range of motion in the tests.The five variables are:
• Flexion
• Internal rotation
• Scour test: external and internal rotation in abduction and adduction of the hip.
• Patrick’s or FABER test: flexion,abduction and external rotation of the hip.
• Hip flexion test

12. CLINICAL PRESENTATION
• History
identify age, functional activity, pattern of arthritic involvement, overall
health and duration of symptoms
• Symptoms
function-limiting hip pain
effect on walking distances
• pain at night or rest
• hip stiffness
• mechanical
instability, locking, catching sensation

13. Physical examination
inspection
• body habitus
gait
leg length discrepancy
skin (e.g. scars)
• range of motion
lack of full extension (>5 degrees flexion contracture)
lack of full flexion (flexion < 90-100 degrees)
limited internal rotation
• Neurovascular exam
straight leg test negative

14. • EuroQoL (EQ-5D)
• The EQ-5D is a generic measure of HRQoL that is widely used for many
chronic disorders. This scale consists of 5 items each measuring a dimension
of health status including mobility, ability to self-care, pain or discomfort,
ability to perform usual activities, and anxiety or depression.
• The EQ-5D questionnaire also includes a Visual Analog Scale (VAS)
Self-report outcomes measures
Balestroni, G., & Bertolotti, G. (2012).

16. Self-report outcomes measures
HOOS
• The HOOS is an adaptation of the KOOS intended to evaluate symptoms and
functional limitations related to the hip.
• The HOOS consists of 40 items, selected from 51 original items assessing five
separate patient-relevant dimensions: Pain (10 items); Symptoms including
stiffness and range of motion (5 items);
Activity limitations-daily living (17 items);
Sport and Recreation Function (4 items); and Hip Related Quality of Life (4 items).
Anna K et al 2003

17. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is widely
used in the evaluation of Hip and Knee Osteoarthritis. It is a self-administered
questionnaire consisting of 24 items divided into 3 subscales:
•Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing
upright
•Stiffness (2 items): after first waking and later in the day
•Physical Function (17 items): using stairs, rising from sitting, standing, bending,
walking, getting in / out of a car, shopping, putting on / taking off socks, rising from
bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy domestic
duties, light domestic duties
WOMAC Index was developed in 1982 at Western Ontario and McMaster Universities
WOMAC is available in over 65 languages and has been linguistically validated

18. Performance-based functional measures
• included
• the timed up and go test
• the stair climbing test
• the 6-minute walk test

19. • At present, no cure is available. Thus only treatment of the person's
symptoms and treatment to prevent further development of the
disease as possible.
Treatment
R Altman, K Brandt, M Hochberg, et al.

20. MANAGEMENT (GOALS)
• Patient education
• Muscle strengthening
• Modification of risk factors:
Weight control
Switching from high-impact to low-impact activities
Minimization of pain aggravating activities

21. PATIENT EDUCATION
• Pathology and disease process
• Role of physiotherapy and expected outcomes of physiotherapy
interventions
• Importance of weight reduction
• Self-management of pain

22. EXERCISE THERAPY
• Exercise therapy is an effective treatment modality for hip OA.
Specific exercises can increase range of motion and flexibility, as well
as strengthen the muscles of the hip and leg.
• Hydrotherapy is effective in the management of hip osteoarthritis.
The combination of buoyancy and the reduction of gravity greatly
assists patients that are struggling to weight-bear as a result of the
pain from the hip osteoarthritis.
• A study on a 6 week education and exercise programme has shown
significant and sustained improvements in pain and disability on
patients wait-listed for joint replacement surgery. Further positive
results included improvements in function, knowledge and psycho-
social aspects (Saw MM et al., 2015).

24. MANUAL THERAPY
• A range of manual therapies is used in
the treatment of hip osteoarthritis:
• Soft tissue techniques and stretches
• Mobilization of accessory and
physiological movements
• Manipulation

25. • Research is inconclusive results on the effect of manual therapy in the
treatment of hip osteoarthritis.
• The immediate effect of a manual therapy, specifically joint mobilization
decrease pain and improve hip range of motion, especially in the elderly
population. Joint mobilization might reduce pain, might ‘provide a
stretching effect on the joint capsules and muscles, thus restoring normal
arthrokinematics or may induce pain inhibition and improved motor
control’ and might reduce kinesiophobia.

26. SURGICAL MANAGEMENT
• Indications
End-stage, symptomatic or severe osteoarthritis arthritis
Preferred treatment for older patients (>50) and those with advanced
structural changes .
• Arthroscopic debridement
• Periacetabular osteotomy +/- femoral osteotomy
• Femoral head resection
• Hip resurfacing
• Hip arthroplasty (THR/ PHR)

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28. Iliotibial band
syndrome
BY : Lujain Aldahash

29. Iliotibial band
• Connects to 2 muscles at the hip (Gluteua Maximus and Tensor
Fasciae Latea) and then down below the outside of the knee to the
tibia
• The Primary function is to provide stability to the lateral knee while
standing
• It helps to maintain hip extension in standing and hip/knee flexion in
running and walking
• The IT-Band moves forward at the knee as the knee extends and
slides backward at the knee as the knee flexes, but is tense in both
positions

30. 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 at approximately 20-30° of
knee flexion, friction which ‘inflames’ the tract or a bursa.
It’s the second most common running injury
Taunton JE et al, 2002

31. Risk factor
•Anatomical factors :
leg length differences
increased prominence of the lateral epicondyles
•Modifiable factors :
reduced flexibility
muscle weakness particularly the hip abductor muscles
Fredericson M, 2000

32. •training factors
excessive running in the same direction on a track
downhill running, a lack of running experience
abrupt increase in running distance or frequency, and
running long distances
Running on uneven surfaces
Risk factor

33. PATIENT EVALUATION
• History
Athletes with ITBS complain of a sharp or burning pain roughly 2cm
superior to the lateral joint line.
The pain may radiate proximally or distally. In less severe cases, the pain
begins after a reproducible time or distance and subsides quickly upon
cessation of activities. With increasing severity, normal walking or sitting
with the knee in flexion may become painful

34. Physical Examination
• There usually is tenderness on palpation of the ITB 2 to 3 cm superior to the lateral
joint line
• local edema
• Leg-length discrepancies also contribute to ITBS and should be assessed as part of a
routine examination
• Noble’s test
• Ober’s test

35. Special test
• Noble’s test
To perform the test, the
physician applies pressure over
the lateral femoral epicondyle
while extending the knee from
90 degrees of flexion. If the
patient experiences pain when
the knee is flexed around 30
degrees, the test result is
positive

36. • Ober’s test
is recommended to assess tightness
of the ITB. If the leg can be passively
stretched to a position horizontal but
not completely adducted to a table,
this constitutes minimal tightness. If
the leg can be passively adducted to
horizontal at best, this constitutes
moderate tightness. If the leg cannot
be passively adducted to horizontal,
this constitutes maximal tightness.
Special test

37. Outcome Measure
the Lower Extremity
Functional Scale (LEFS) is to
measure "patients' initial
function, ongoing progress,
and outcome" for a wide
range of lower-extremity
conditions

38. Imaging
• Results of an MRI in athletes with
ITBS may be normal or show poorly
defined signal intensity changes
under the ITB. In chronic cases, one
may see a thickened ITB at the level
of the lateral femoral epicondyle

39. Phases of ITBS
1
Acute Phase
2
Subacute Phase
3
Return-to-Running
Phase

40. TREATMENT AND REHABILITATION

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