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Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete

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Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE VOLUME 4, ISSUE 1 WINTER 2015/2016 Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete Femoroacetabular Impingement in the Adolescent Population: A Review Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Spine Range of Motion after Cervical or Thoracic Thrust Manipulation in Patients with Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial IAOM-US CONNECTION DIRECTORY is published by John Hoops PT, COMT The International Managing Editor Academy of Orthopedic Medicine-US (IAOM-US) Valerie Phelps PT, ScD, OCS, FAAOMPT PO Box 65179 Chief Editor / Education Director Tucson, AZ 85728 (p) 866.426.6101 Tanya Smith PT, ScD, FAAOMPT (f) 866.698.4832 Senior Editor (e) [email protected] (w) www.iaom-us.com John Woolf MS, PT, ATC, COMT Business Director CONTACT (p) 866.426.6101 Sharon Fitzgerald (f) 866.698.4832 Executive Assistant (e) [email protected] (w) www.iaom-us.com Andrea Cameron All trademarks are the property Administrative Assistant/ of their respective owners. Marketing Liaison The IAOM-US CONNECTION VOLUME 4 CONNECTION Differential Diagnosis and Dear Colleagues: Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid We hope you’ve had a happy and healthy 2015 2 in a 24-Year-Old Female Tri-Athlete and are ready to set your sights on 2016. Our 2016 course schedule is set, though we’re always adding new course locations and topics. If you haven’t had a chance to see what’s coming to your neck of the woods, here’s a link to the schedule. Femoroacetabular Impingement We’re getting really excited to see our faculty at the in the Adolescent Population: Westward Look Resort here in Tucson next month for 7 A Review our annual Faculty Meeting. It’s always invigorating and energizing to catch up with colleagues, update everyone on what’s new and what we’ve accomplished in the previous year, and just enjoy the time together as a team here in beautiful Tucson. Immediate Changes in Widespread Pressure This year, we’re also pleased to introduce a new member of our team, Joel Gaines. Joel comes to us Pain Sensitivity, Neck Pain, with much experience as a systems analyst and project 12 and Cervical Spine Range of manager, and is well on his way to making our Motion after Cervical or Thoracic processes run smoother and our lives a little easier. Thrust Manipulation in Patients with Bilateral Chronic Mechanical Neck We hope you enjoy this latest issue of the IAOM-US Pain: A Randomized Clinical Trial Connection. As always, we welcome any clinical discussions or feedback in a “Letter to the Editor” segment, so let us know what’s on your mind. Thanks for being part of the IAOM-US family, and enjoy the holiday season! Valerie, John, Sharon, Andrea and Joel INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete Brandon K, Patla C. J Man Manip Ther. 2013;21(3):142-147. Abstracted by Sarah Wyant, DPT, OCS, COMT, IAOM-US Fellowship Candidate, Seattle, Washington; Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Lubbock Texas, IAOM-US Fellowship Director Background: Cuboid syndrome is a minor disruption or subluxation Imaging may not be useful in diagnosing cuboid syn- of the structural congruity of the calcaneocuboid por- drome as transient symptoms or minor mobility changes tion of the mid-tarsal joint, which can irritate the joint may lack signs of disruption such as effusion or edema. capsule, ligaments, and peroneus longus tendon. Cuboid Diagnosis should be based on a thorough subjective syndrome may develop due to increasing body weight, history and physical examination. Dysfunctional joint training on uneven terrain, and inversion ankle sprains. motion is best appreciated through passive motion tests of osteokinematic and arthrokinematic motion. Addi- Cuboid syndrome has been linked to plantar flexion and tionally, observation of provocative motions or activities inversion ankle sprains; however no current literature should be assessed. In this case presentation, symptoms has looked at cuboid hypomobility in association with were exacerbated during specific phases of gait. Cuboid distal iliotibial band (ITB) syndrome. Hypomobility motion during the gait cycle should progress from pro- or hypermobility of the calcaneocuboid joint may lead nation, or plantar movement, at heel strike and initial to altered mechanics more proximally in the kinematic loading, to supination, or dorsal movement, during heel chain. (Figure 1) Figure 1: lateral view of cuboid and calcaneus https://commons.wikimedia.org/wiki/File:Gray291.png#/media/File:Gray291.png 2 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION rise to toe off. If the cuboid lacks supination mobility (LEFS) score of 93%. Pain was rated on the numeric pain throughout the gait cycle, this would likely cause exces- rating scale (NPRS) as 0/10 at rest, 3/10 after running sive hindfoot pronation transmitted through the calca- two miles, which quickly increased to 6/10 over the neocuboid joint.1 Abnormal pronation of the subtalar lateral femoral condyle and Gerdy’s tubercle. Pain was joint may cause increased internal rotation of the tibia, most exacerbated at 7-8/10 if running on the beach or ultimately increasing tension on the ITB at its insertion. performing lunges or squats. As the knee flexes and internally rotates, the ITB com- presses against the femoral condyle potentially leading to Clinical Presentation: increased risk of irritation to the fat pad found between All knee examination findings were negative includ- the ITB and lateral epicondyle. (Figure 2) ing special tests for the capsuloligamentous structures, meniscus and the patellofemoral joint. In weight bear- ing, the patient was observed to have reduced midfoot active pronation and supination, and reduced cuboid internal and external rotation compared to uninvolved side. Passive midfoot pronation and supination were pain free and limited: pronation more limited than supina- tion. Passive accessory motion of the cuboid revealed decreased dorsal translation, as well as decreased plantar translation to a lesser degree. Bilateral and unilateral heel raises showed decreased midfoot supination on the involved side. The tissue specific impairment and physical therapy diagnosis was hypothesized to be a hypomobile cuboid with plantar stiffness greater than dorsal stiffness. Figure 2: Distal insertion of iliotibial band to Gerdy’s tubercle http://www.physio-pedia.com/File:Fig_1_for_nobles_test.png Intervention: The cuboid whip technique was performed to improve Patient Characteristics: mobility at the calcaneocuboid joint. Performance as The 24 year-old female runner was referred to physi- follows: The patient is positioned in prone with the mid- cal therapy by her primary care physician with primary tarsal joints at the end of the table. The manipulation complaint of acute onset pain over the lateral femoral is performed by first placing the thumb on the plantar condyle and Gerdy’s tubercle. Subjective history included surface of the cuboid and index fingers on the dorsal/ several probable causative factors including an increase in lateral side of the foot. The thumb and index finger are biking/running mileage and an abnormal landing from a along a diagonal line relative to the plantar surface of the step stool the evening before her pain onset. Symptoms foot in a dorsal and lateral direction. (Figure 3) The knee started the next day during the first minutes of her run is flexed to approximately 70° and the ankle is dorsiflexed and she was unable to complete her work out. to approximately 0°. The thrust is performed by passively extending the knee and simultaneously plantar flexing The patient exhausted conservative treatment for ilio- the talocrural joint, with a rotational force applied via the tibial band syndrome (ITBS) over the course of three thumb placement on the plantar aspect of the cuboid and years, including treatment by multiple physical therapists, a rotation of therapist’s trunk. (Figure 4) a corticosteroid injection to the distal ITB insertion, and Figure 3: Hand two trials of prolotherapy. A fourth attempt of physical placement for the therapy by the author of the study included extensive cuboid whip into subjective questioning, which revealed a history of mul- a dorsal direction tiple ankle sprains and cuboid subluxations. This infor- with the thumb and mation, with the patient’s history of unsuccessful treat- index fingers on opposite sides of the ment to the ITB, shifted the focus to the kinetic chain’s cuboid and oriented influence from the ground up. diagonally from plantar-medial to At the onset of this final round of physical therapy, the dorsolateral. patient presented with a lower extremity functional scale IAOM-US | CONNECTION 3 A B Figure 4: (A) Initial stance for the cuboid whip. (B) Final stance for the cuboid whip into supination with clinician’s body rotating in the direction of the mobilization. Re-evaluation of passive accessory mobility of the mid- tarsal joint after cuboid manipulation was found to be symmetrical to the opposite side. The manual therapy treatment was followed with active range of motion of midfoot pronation and supination for 3 sets of 12 repeti- tions. Further follow up treatment included 3 sets of 12 repetitions of manual neuromuscular re-education for pronation and supination in supine. Concentric manual resistance for midfoot pronation was provided with pres- sure on the medial plantar aspect of the mid-tarsal joints and counter pressure on the dorsal lateral aspect of the calcaneous. This was followed by an eccentric resistance into mid-tarsal supination with manual resistance on the dorsal mid-tarsal surface and a counter force on the plantar medial aspect of the forefoot.
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