Estudio Transversal Sind Banda Iliotibial

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Assessment of Strength, Flexibility, and Running Mechanics in Males with Iliotibial Band Syndrome Brian Noehren, P , Ph!" Anne Schmit#, Ph!" Ross $em%el, BS" &arolyn 'estla(e, MS" 'illiam Blac(, M!)
" )
!i*ision of Physical hera%y, +ni*ersity of ,entuc(y, -exington, ,., +SA !e%artment of S%orts Medicine, +ni*ersity of ,entuc(y, -exington, ,., +SA
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here are no funding sources to disclose/ he study %rotocol was a%%ro*ed by the Institutional Re*iew Board at the +ni*ersity of ,entuc(y/ Address corres%ondence to Brian Noehren, )01! 'ethington Building, 200 South -imestone Street, -exington, ,. 10345/ 67mail8 b/noehren9u(y/edu/
Study Design8 &ross7sectional laboratory study/ Objectives8 o assess differences in hi% strength, iliotibial band length, and hi% and (nee mechanics during running between male runners with iliotibial band syndrome and healthy controls/ Background8 Flexibility, strength, and running mechanics are commonly assessed in %atients with iliotibial band syndrome :I BS;/ $owe*er, these *ariables ha*e not been e*aluated concurrently in this %o%ulation/
Methods8
hirty7four males %artici%ated :"< healthy, "< I BS;/ $i% strength was
measured with a hand held dynamometer and iliotibial band flexibility was assessed using an inclinometer while %erforming the =ber>s test/ ,inetic and three7dimensional (inematic data were obtained during running/ ,inematic *ariables of interest included frontal and trans*erse %lane hi% and (nee ?oint angles during early stance/ Inde%endent sam%le t7tests as well as effect si#es were used to assess grou% differences/ Results8 &om%ared to the control grou%, %ersons with I BS had a significantly lower =ber>s measurement :"/)@;, wea(er hi% external rotators :"/) NmA(g;, greater hi% internal rotation :4/<@;, and greater (nee adduction :4/5@;/ $owe*er, only hi% internal rotation and (nee adduction exceeded the minimal detectable difference *alue/ Conclusions8 =ur results suggest that inter*ention strategies that target neuromuscular control of the hi% and (nee may be indicated for males with iliotibial band syndrome/ Key Terms: hip and knee mechanics, hip strength, Obers test, running
Iliotibial band syndrome :I BS; occurs in 37"1B of runners and is the leading cause of lateral (nee %ain and the second leading cause of o*erall (nee %ain in this
%o%ulation/4) !es%ite its high %re*alence, little is (nown about the etiology of this condition/ !e*elo%ment of I BS is thought to include extrinsic factors :e/g/ training *olume, shoe wear; as well as intrinsic factors :e/g/ flexibility, strength, running mechanics, etc/;/ Physical thera%y %rograms ty%ically focus on addressing the intrinsic factors that contribute to I BS/ 'hile there ha*e been limited re%orts on the role of these intrinsic factors indi*idually, there has been no com%rehensi*e analysis of these factors within
the same grou%/ Moreo*er, %re*ious studies ha*e consisted of males and females, or females only/ &onsidering males with I BS as a se%arate grou% may be im%ortant as %re*ious research has shown that men and women differ in terms of muscular strength and running mechanics// In addition, establishing an in?ury %rofile in men with I BS is im%ortant since males com%rise 30 to C"B of those suffering from I BS/ 4) $i% strength and iliotibial band :I B; flexibility are commonly assessed as %art of the e*aluation of an in?ured runner with I BS/ For exam%le, hi% abductor wea(ness has been demonstrated in trac( athletes with I BS/ ") $owe*er, this is in contrast to more recent research in which no differences in hi% abductor strength in %ersons with I BS were re%orted/"1 he conflicting results between %re*ious studies could be the result of
different testing %rocedures :isometric *ersus iso(inetic assessment of muscle strength; and grou% demogra%hics :high le*el athletes *ersus recreational runners;/ 'hile there ha*e been a limited number of re%orts on hi% abductor strength in runners with I BS, there ha*e been no studies e*aluating hi% external rotation strength in this %o%ulation/ $i% external rotation strength %lays an im%ortant role in %ro*iding rotary control of the hi% and wea(ness of the external rotators may contribute to greater
strain on the I B/" -astly, while the =ber>s test is commonly used as an indicator of I B flexibility, the authors are not aware of any %ublished re%orts e*aluating whether runners with sym%tomatic I BS exhibit diminished I B length/ Abnormal running (inematics, s%ecifically excessi*e motions of the hi% and (nee in the frontal and trans*erse %lanes, are often cited as im%ortant contributing factors with res%ect to the de*elo%ment of I BS/ he attachment sites of the I B ma(e this
structure %articularly *ulnerable to altered secondary %lane running mechanics/

Proximally, the I B is attached to the %el*is through both the tensor fascia latae and gluteal muscles/ !istally, its insertion includes the lateral femoral e%icondyle and Derdy>s tubercle/ herefore, greater hi% and (nee adduction, as well as greater hi% and (nee rotation may increase the tensile strain in the I B/ $amill et al/ ha*e confirmed that runners with sym%toms do ex%erience greater I B strain rates during the early stance %hase of running/ "3 $owe*er, %re*ious in*estigations e*aluating the (inematic *ariables that may contribute to the de*elo%ment of I BS ha*e been mixed/ For instance, one study of women with I BS found greater %ea( hi% adduction and (nee internal rotation whereas another study using a mixed sam%le of males and female runners with I BS found no differences in hi% or (nee (inematics/ he lac( of consensus among studies suggests that males with I BS may ha*e a different (inematic %rofile when com%ared to females/ he %ur%ose of the current study was to assess differences in hi% abduction and external rotation strength, I B length :=ber>s test;, as well as frontal and trans*erse %lane (inematics at the hi% and (nee in males with and without I BS/ Based on what is (nown about the intrinsic factors that may contribute to I BS, it was hy%othesi#ed that
male runners with I BS would ha*e significantly wea(er hi% abductor and external rotators, diminished length of the I B, increased hi% and (nee adduction, and increased hi% internal and (nee external rotation angles com%ared to a %ain7free control grou%/
METHODS A total of 41 male runners between the ages of "C713 %artici%ated in this study :"< with I BS and "< %ain7free controls;/ he control and I BS grou%s were similar in
terms of age, distance run %er wee(, mass, and height : able ";/
he number of
sub?ects was chosen to detect a moderate effect si#e :&ohen>s d of 0/3; with reasonable statistical %ower :EF0/C;/ he study was a%%ro*ed by the Institutional Re*iew Board of the +ni*ersity of ,entuc(y/ Sub?ects were recruited from local races, %osted flyers, and %hysician offices/ Prior to %artici%ation, all sub?ects %ro*ided written informed consent/ o be considered for the study, sub?ects in both the I BS and control grou%s had to re%ort running at least "5 (ilometers %er wee(/ In addition, %ersons with I BS had to re%ort being free from any other lower extremity in?ury other than I BS for the %ast 5 months/ Similarly, the control grou% had to be in?ury free for the %ast 5 months/ Indi*iduals with I BS were e*aluated by a %hysical thera%ist to determine if they Gualified for the study/ Runners in the I BS grou% had to re%ort an insidious onset lateral (nee %ain while running during the %ast ) months/ Partici%ants were included in the I BS grou% if they had re%orted %ain of at least 4 out of "0 on the numeric rating scale during running/ he re%eatability and *alidity of this scale %re*iously has been
re%orted :I&& 0/2470/23;/ ","< !uring the e*aluation, %otential sub?ects had to re%ort %ain with direct %al%ation of the distal attachments of the I B at either Derdy>s tubercle or the
lateral femoral e%icondyle, or re%ort %ain during the Noble com%ression test which has been re%orted to ha*e acce%table inter7rater reliability/ 5 As %art of the e*aluation, %ossible ligamentous :*arus stress test; and meniscus in?uries :McMurray test; were ruled out/"C 6ach sub?ect>s hi% strength was measured with a hand held dynamometer :-afayette Instruments, -afayette, IN; using %re*iously re%orted %rocedures that ha*e been shown to be reliable/ o measure hi% abduction strength of the in*ol*ed leg, the
sub?ect was %ositioned in sidelying :non7in*ol*ed side; and %ushed into the dynamometer using the in*ol*ed leg/ he dynamometer was secured 3 cm %roximal to the tibiofemoral ?oint line with a stabili#ation stra% around the dynamometer and the testing table/ $i% external rotation strength was measured in a seated %osition, with the dynamometer %laced on the inside of the in*ol*ed leg 3 cm su%erior to the an(le ?oint and held in %lace with a stabili#ation stra%/ "5 For both strength tests, the %artici%ants were instructed to gradually increase how much they %ushed o*er 4 seconds and then to hold their maximum effort for the next ) seconds/ All indi*iduals %erformed ) %ractice trials followed by 4 testing trials/ he
maximum efforts attained during the 4 testing trials were then a*eraged for each sub?ect/ he raw force *alues were multi%lied by femur length to %ro*ide a torGue *alue, normali#ed by mass to account for body si#e, and then multi%lied by "00/ Femur length was measured as the distance from the greater trochanter to the medial tibiofemoral ?oint line/ A %ost7hoc analysis demonstrated that the normali#ed torGue *alues were not correlated with mass or height, thus confirming the effecti*eness of the normali#ation strategy to minimi#e the influence of sub?ect si#e/)
he length of the I B was assessed using the =ber>s test using %re*iously established %rocedures/ standing %osteriorly/ he indi*idual was %laced in sidelying with the examiner
he in*estigator>s (nee was %laced on the sub?ect>s bac( for
stabili#ation and to %re*ent the s%ine from rolling bac(wards during the e*aluation/ 'hile maintaining the (nee in a slightly flexed %osition :"07"3@;, the sub?ect>s u%%er thigh was then brought into hi% extension and adduction until the %el*is started to tilt or when there was no additional hi% adduction mo*ement/
his techniGue has been
%re*iously shown to be reliable :I&& 0/20;/)< In addition, an inclinometer :&raftsman, Model 4)0/1C)23, accuracy of 0/"@; was %laced 3 cm from the distal lateral femoral e%icondyle, gi*ing a measure of degrees from the hori#ontal/ Following strength and flexibility testing, indi*iduals com%leted an instrumented running analysis/ Retroreflecti*e mar(ers were %laced on the s(in at the -173 ?unction, bilateral iliac crests, anterior su%erior iliac s%ines, greater trochanters, medial and lateral femoral e%icondyles, tibial %lateaus, malleoli, as well as the first and fifth metatarsal heads/ Rigid shells with clusters of four mar(ers were %laced bilaterally on the thigh and shan(/ Additional trac(ing mar(ers were %laced on the %osterior as%ect of the shoes/ o control for the influence of footwear, all sub?ects wore New Balance 'R55) running shoes :New Balance, Brighton, MA, +SA;/ A standing calibration was then collected, followed by a hi% motion trial to establish the hi% ?oint center/)C After a warm7u% consisting of wal(ing for 3 minutes, sub?ects ran at 4/4 mAs on an instrumented treadmill :Bertec &or%, &olumbus, =hio;/ his s%eed was chosen to be consistent with %re*ious studies and to %ro*ide acce%table re%eatability/ )5 Mar(er
tra?ectories were recorded at )00$# with a "3 camera motion analysis system :Motion Analysis &or%, Santa Rosa, +SA;/ Force data was collected at ")00 $#/ Hisual 4! software :&7motion, Dermantown, M!, +SA; was used to filter the data, identify the functional hi% ?oint center, and calculate ?oint angles for 3 running cycles/ Mar(er tra?ectory data was filtered at C $# and force data was filtered at 43 $# using a 1th order Butterworth low %ass filter with #ero lag/ he cutoff freGuencies were selected using the results of a residual analysis of the data/ 45 $eel stri(e and toe off for
a running cycle occurred when the *ertical ground reaction force was 40 N/ Ioint coordinate systems were defined in the Hisual 4! software using %re*iously %ublished %rocedures/)1 he %el*is coordinate system was %laced at the mid%oint of the line connecting the iliac crests, the J7axis was oriented along the line connecting the mid%oint of the iliac crests and the mid%oint of the greater trochanters, and the KJ7%lane was established through a %lane best fit to the iliac crests and greater trochanters *ia least7sGuares/ A segment fixed coordinate system for the femur was %laced at the functional hi% ?oint center)C with the J7axis defined along a line connecting the hi% ?oint center and the mid%oint of the femoral e%icondyles and the KJ7%lane established by the e%icondyles and greater trochanter/ he shan( coordinate system was %ositioned at the mid%oint of the tibial %lateaus, the J7axis was oriented along a line connecting the origin and mid%oint of the malleoli, and the KJ7%lane was established by minimi#ing the sum of sGuares distance between e%icondyles, malleoli, and a %lane/ For all segments, the .7axis was oriented forward and %er%endicular to the frontal :KJ; %lane and the K7axis as the cross7%roduct of the J and .7axes/
Ioint angles were determined using a &ardan rotation seGuence of flexion, adduction, and internal rotation, referencing the distal segment to the %roximal segment/ A custom -ab*iew code :National instruments, Austin, exas; was used to extract frontal and trans*erse %lane hi% and (nee ?oint angles at the time of the initial im%act %ea( for each trial/ Halues were then a*eraged across the 3 trials for each sub?ect/ Ioint angles were obtained during early stance since I BS sym%toms ha*e been re%orted to occur during this %eriod of time/
Means and standard de*iations of the following *ariables of interest were calculated for each grou%8 hi% strength, I B length, and frontal and trans*erse %lane hi% and (nee ?oint angles at the time of the im%act force %ea(/ o assess grou% differences between these *ariables, inde%endent t7tests were %erformed using SPSS *ersion "C/0 :IBM SPSS, &hicago, Illinois;/ he in?ured limb in the I BS sub?ect was com%ared to the same limb in the matched control %artici%ant/ !ifferences were considered significant if %L0/03/ If a *ariable was shown to be statistically significant, clinical rele*ance was established using the effect si#e and M!&/ 6ffect si#es were calculated in DMPower/ < he minimal detectable change :M!&; was Guantified according to 'il(en 44 where the intra7class correlation coefficients were assumed to be 0/2 for the =ber>s test
)<
, 0/2 for
the isometric strength tests,"< and 0/2C for ?oint angles/2 'e considered statistically significant findings to be clinically meaningful if the effect si#e was greater than 0/3 3 and the difference between grou%s was greater than the M!&/
RESU TS
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&om%ared to the control grou%, males with I BS exhibited significantly greater hi% internal rotation and (nee adduction angles during the early stance %hase of running, wea(er hi% external rotators, and decreased I B length : able );/ No grou% differences were noted in hi% abduction strength or the hi% adduction angle/
D!SCUSS!O" I BS is a leading source of (nee %ain in male runners/ 4) Pre*ious studies relating
intrinsic factors to the de*elo%ment of I BS only ha*e examined a single factor in isolation as o%%osed to assessing multi%le factors concurrently/ In the current study, we com%ared hi% strength, hi% and (nee (inematics, and I B length between males with I BS and matched controls with the intent of de*elo%ing a more com%rehensi*e in?ury %rofile for this %o%ulation/ =n a*erage, male runners with I BS had diminished I B length, altered hi% and (nee (inematics, and diminished hi% strength/ S%ecifically, males with I BS exhibited significantly greater (nee adduction, hi% internal rotation, and wea(er hi% external rotators com%ared to the control grou%/ Although the strength difference for the hi% external rotators did not exceed the M!&, there was a relati*ely large effect si#e/ As such, the obser*ed increase in hi% internal rotation could ha*e been the result from a shorter I B, wea(ness of the hi% external rotators, or altered neuromuscular control/ &ontrary to our hy%othesis, males with I BS had neither greater hi% adduction angles nor wea(er hi% abductor muscles when com%ared to the control grou%/ As those in the in?ured grou% currently had I BS, we cannot rule out the %ossibility that these indi*iduals may ha*e attem%ted to control hi% adduction as a %otential com%ensatory
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strategy to reduce %ain while running/ 6*en though %re*ious research in females with I BS suggests runners do not alter their mechanics in the %resence of chronic %ain, it is %ossible that males and females res%ond to %ain differently/ =ur strength findings are in contrast to a study that found both males and females with I BS had wea(er hi% abductor muscles/ ") It is %ossible the difference in testing %rotocols such as using a stabili#ing stra% and sub?ect demogra%hics may ha*e contributed to the differences between studies/
he stabili#ing stra% as used in the
current study limited the influence of the e*aluator>s strength in determining force out%ut/ $owe*er, our results are in agreement with Drau et al/ who re%orted no
differences in hi% abductor strength between %ersons with I BS and %ain7free controls/"1 he =ber>s test is a common clinical measure used to assess the length of the I B/ In the current study, the I BS grou% exhibited decreased I B length com%ared to the control grou%/ 'hile statistically significant howe*er, the obser*ed difference between grou%s was only "/) degrees/ &onsidering that the differences between grou%s neither exceeded the M!& score nor were associated with at least a moderate effect si#e, caution should be used in inter%reting the clinical significance of this result/ =ur finding is in agreement with the wor( of Miller et al/ who re%orted no differences in =ber>s test results when e*aluating a non7sym%tomatic retros%ecti*e grou% of %atients with a history of I BS/)" !ue to the multi%le attachments of the distal I B to both the femur and tibia, excessi*e frontal and trans*erse %lane (nee motion may increase I B strain/ Persons in the I BS grou% were significantly more adducted at the (nee, which is in agreement with %re*ious studies that ha*e shown %ersons with I BS to ha*e greater static *arus
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alignment/ 'hile not statistically different, runners with I BS did exhibit greater (nee external rotation :1/<@; during early stance com%ared to the control grou%/ 'hile this difference was relati*ely large, there was considerable *ariability among sub?ects/ 'ith the femur as the shared segment between the hi% and (nee, it is li(ely that changes in (nee (inematics may in %art, be a reflection of altered hi% (inematics/ Since the hi% was more internally rotated in the I BS grou%, it is reasonable that this motion could ha*e contributed to obser*ed (nee rotation/
=ur study is not without limitations/ he study design was cross7section in nature, thus limiting our ability to ex%licitly establish cause7and7effect relationshi%s/ Also, measurement of isometric strength in a non7weight bearing %osition does not necessarily reflect muscle function during a dynamic tas(/ $owe*er, isometric strength testing is commonly used in the literature and in the clinic/ -astly, it is well documented that there are limitations in motion ca%ture due to s(in mo*ement artifact, %articularly in the frontal and trans*erse %lanes of motion/ "2 $owe*er, mar(er clusters were used to minimi#e this effect, and any artifact due to s(in mo*ement would ha*e been consistent between the grou%s/"2
CO"C US!O" &ollecti*ely, we found that male runners with I BS exhibited significantly greater hi% internal rotation and (nee adduction angles during running, less hi% external rotation strength, and diminished length of the I B/ 'hile statistically significant, differences in I B length and hi% external rotation strength did not exceed the M!& score, suggesting other factors such as neuromuscular control may %lay a larger role in contributing to altered hi% and (nee (inematics in this %o%ulation/
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#E$ %O!"TS
&!"D!"'S( Males with I BS exhibited greater hi% internal rotation and (nee adduction angles during the early stance %hase of running/ 'hile statistically significant, grou% differences in hi% external rotator strength and I B length were not considered clinically rele*ant/
!M% !C)T!O"S( =ur data suggest that inter*ention strategies that target neuromuscular control of the hi% may be indicated for males with iliotibial band syndrome/
C)UT!O"( he study design was cross7sectional/ herefore, these results cannot be used to establish ex%licit cause7and7effect relationshi%s/
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)C#"O* ED'EME"TS Research re%orted in this %ublication was su%%orted by the National Institute of Arthritis and Musculos(eletal and S(in !iseases of the National Institutes of $ealth under award number ,)4AR05)052/ he content is solely the res%onsibility of the authors and does not necessarily re%resent the official *iews of the National Institutes of $ealth/ here are no conflicts of interest to disclose/
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41/
'illson I!, !a*is IS/ -ower extremity mechanics of females with and without %atellofemoral %ain across acti*ities with %rogressi*ely greater tas( demands/ Clin #iomech/ )00CN)48)047)""/
43/
'illy R', Manal , , 'it*rouw 66, !a*is IS/ Are Mechanics !ifferent between Male and Female Runners with Patellofemoral PainQ Med Sci Sports '(erc/ )0")N118)"537)"<"/
45/
'inter !A/ #iomechanics and motor control o human mo!ement/ 1th/ 'aterloo, =ntario8 'ileyN )002/
21
22
Subject 'rou+ Control !liotibial Band Syndro,e

"u,ber oSubjects "< "< 7
AB-6"/Sub?ect !emogra%hics )ge .yrs/ Distance Run Mass .kg/ +er *eek .k,/ )C/" R 3/< 44/3 R5/5 0/5)C 40/C R "</2 4"/1 R )"/< 0/45) 52/2 R C/< <5/< R 3/< 0/5)5
Height .,/ %ain "/C0 R 0/0< 0/0 "/<2 R 0/05 1/2 R "/5 0/54C 7
+0value
23
AB-6 )/Drou% !ifferences in Strength, Flexibility, and ,inematics

Test Controls !TBS )verage Di--erence bet1een 'rou+s "/) 0/" 0/< "/) -./0 Mini,al Detectable Change Statistical Signi-icance E--ect Si2e
Hi+ Ober3s Test .4/ Hi+ )bduction Strength .",5kg/ Hi+ )dduction .4/ Hi+ E6ternal Rotation Strength .",5kg/ Hi+ !nternal Rotation .4/
"C/C R 1/0 "</C R 4/5 C/5 R 1/" </C R "/) 2/5 R 3/)
"</5 R 1/< "</< R 1/" </2 R )/5 5/5 R )/) "4/4 R 5/5
4/C 4/1 "/4 "/5 )/4
%F0/04 %F0/"1 %F0/32 %F0/04 %F0/04
0/)<3 0/0)5 0/)01 0/5<< 0/5)4
#nee #nee )dduction .4/ #nee E6ternal Rotation .4/ 4/< R 4/5 </3 R </1 </4 R )/C ")/) R </C -./1 -2/0 "/4 4/0 %F0/00" %F0/"" "/""< 0/5"C

Estudio Transversal Sind Banda Iliotibial

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1

structure %articularly *ulnerable to altered secondary %lane running mechanics/

he in*estigator>s (nee was %laced on the sub?ect>s bac( for

his techniGue has been

he stabili#ing stra% as used in the

Subject 'rou+ Control !liotibial Band Syndro,e

"u,ber oSubjects "< "< 7

AB-6 )/Drou% !ifferences in Strength, Flexibility, and ,inematics

4/C 4/1 "/4 "/5 )/4

%F0/04 %F0/"1 %F0/32 %F0/04 %F0/04

0/)<3 0/0)5 0/)01 0/5<< 0/5)4

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