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Reed Ferber, PhD, CAT(C), ATC1 • Brian Noehren, PT, PhD2 Joseph Hamill, PhD3 • Irene Davis, PT, PhD4 Competitive Female Runners With a History of Demonstrate Atypical and Kinematics

liotibial band syndrome (ITBS) is the second leading cause of knee gations that have examined knee flexion/ pain in runners and the most common cause of lateral knee pain.21,26 extension patterns in runners who had 16,22 Anecdotally, this syndrome has been associated with repetitive ITBS compared to healthy controls. It is possible that motions in other flexion and extension on a loaded knee, in combination with a planes, or at other joints, may contribute I 1,16,21-23 23 tight iliotibial band. Orchard et al suggested that frictional to ITBS. The primary functions of the ilio- forces between the iliotibial band and the lateral femoral condyle are tibial band are to serve as a lateral hip greatest at 20° to 30° of knee flexion, which occur during the first half and knee stabilizer and to resist hip ad- duction and knee internal rotation.8,17 The of the stance phase of . However, theory,1,21,23 no differences have been iliotibial band originates from the fibers despite this well-accepted sagittal-plane found in the few biomechanical investi- of the , , and tensor latae muscles, and at- taches proximal to the knee joint into the t Study Design: Cross-sectional experimental running gait were measured. laboratory study. lateral femoral condyle and distal to the Results: The ITBS group exhibited signifi- t knee joint into the infracondylar tubercle Objective: To examine differences in running cantly greater peak rearfoot invertor moment, t of the .1,17 As a result of the femoral mechanics between runners who had previously peak knee internal rotation angle, and peak hip sustained iliotibial band syndrome (ITBS) and run- and tibial attachments, it is possible that adduction angle compared to controls. No signifi- ners with no knee-related running injuries. cant differences in peak rearfoot eversion angle, atypical hip and mechanics, which t Background: ITBS is the second lead- peak knee flexion angle, peak knee external rotator both influence the knee, could play a role ing cause of knee pain in runners and the most moment, or peak hip abductor moments were in the development of ITBS. common cause of lateral knee pain. Despite its observed between groups. Distally, it has been suggested that prevalence, few biomechanical studies have been excessive rearfoot frontal-plane motion conducted to better understand its aetiology. Be- Conclusion: Females with a previous history t influences knee mechanics.3,9,14,28 During cause the iliotibial band has both femoral and tibial of ITBS demonstrate a kinematic profile that is attachments, it is possible that atypical hip and foot suggestive of increased stress on the iliotibial the first half of the stance phase, the cal- mechanics could result in the development of ITBS. band. These results were generally similar to caneus everts and the head of the talus internally rotates.11,13 Consequently, the t Methods: The running mechanics of 35 those reported for a prospective study conducted females who had previously sustained ITBS were within the same laboratory environment. J Orthop tibia internally rotates with the talus compared to 35 healthy age-matched and running Sports Phys Ther 2010;40(2):52-58. doi:10.2519/ due to the tight articulation of the ankle distance-matched healthy females. Comparisons jospt.2010.3028 joint mortise.11,13 Because the iliotibial of hip, knee, and ankle 3-dimensional kinematics band attaches to the lateral condyle of and internal moments during the stance phase of t Key Words: ankle, biomechanics, foot, running the tibia, it is postulated that excessive

1 Assistant Professor, Faculties of Kinesiology and Nursing, University of Calgary, Calgary, Alberta, Canada; Director, Running Injury Clinic, Calgary, Alberta, Canada. 2 Assistant Professor, Division of Physical Therapy, University of Kentucky, Lexington, KY. 3 Professor, Department of Exercise Science, University of Massachusetts, Amherst, MA. 4 Professor, Department of Physical Therapy, University of Delaware, Newark, DE; Drayer Physical Therapy Institute, Hummelstown, PA. The protocol for this study was approved by The University of Delaware Human Subjects Compliance Committee. Address correspondence to Dr Reed Ferber, Faculty of Kinesiology, 2500 University Drive NW, University of Calgary, Calgary, Alberta, Canada, T2N 1N4. E-mail: [email protected]

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knee, and ankle joint running biome- TABLE 1 Group Demographics* chanics between female runners who had previously sustained ITBS compared to Variables of Interest iliotibial Band Syndrome control healthy controls. Based on the current Age (y) 35.47  10.35 31.23  11.05 literature and the prospective study by 22 Mass (kg) 58.62  3.97 61.30  6.97 Noehren et al, it was hypothesized that Height (m) 1.65  0.06 1.67  0.07 female runners who had previously sus- Monthly running distance (km) 123.82  62.64 119.27  52.02 tained ITBS would exhibit greater peak rearfoot eversion, knee internal rotation, * Values are mean  SD. knee flexion, and hip adduction angles during stance. In addition, greater rear- rearfoot eversion, resulting in greater runners with a variety of musculoskeletal foot invertor, knee external rotator, and tibial internal rotation, could increase injuries, including ITBS. These authors hip abductor internal moments were the strain in the iliotibial band. Sev- also indicated that the injured runners expected. eral studies have cited increased rear- demonstrated significantly reduced hip foot eversion as a contributing factor to abductor muscle strength compared to Methods lower extremity injuries.15,24,28 Recently, the noninjured limb and compared to a Miller et al16 reported that at the end of group of noninjured runners. Thus, hip Subjects an exhaustive run, runners with ITBS abductor weakness, possibly leading to priori sample size power analy- demonstrated a greater rearfoot inver- increase hip adduction during the stance sis (ß =.20; α =.05) was conducted sion angle at heel strike compared to phase of running, may be related to the A using variability obtained from the controls, which they hypothesized con- development of ITBS. However, few kinematic variables of interest from pre- tributed to a greater peak knee (tibial) studies have investigated whether atypi- vious studies.5,22 Based on this analysis, a internal rotation velocity and thus tor- cal hip mechanics may play a role in the minimum of 14 subjects per group were sional strain to the iliotibial band. In aetiology of ITBS. needed to adequately power the study. contrast, Messier et al15 reported that A recent prospective study by Noeh- The subjects involved in this study (n = runners with a history of ITBS exhib- ren et al22 examined proximal (hip), 70) were part of a larger, ongoing pro- ited no difference in rearfoot mechan- distal (rearfoot), and local (knee) me- spective investigation of female runners ics while running, compared to healthy chanics in the development of ITBS. (n = 400; ages 18-45 years, minimum individuals. However, Messier et al15 did These authors concluded that runners running distance of 30 km/wk, and free not utilize an exhaustive run protocol, who developed ITBS exhibited increased of any obvious lower extremity mala- which may account for the different hip adduction and knee internal rota- lignments or injuries at the time of data findings between these 2 studies. Thus, tion angles compared to those runners collection). As part of the larger study, further investigation regarding the role who remained uninjured. No differences all previous lower extremity injuries for of atypical foot mechanics and the de- were found in rearfoot eversion or knee all participants were recorded. Thirty- velopment of ITBS is necessary. flexion. In addition, these authors re- five females, who had a past history of Proximally, abnormal hip mechanics ported that rearfoot, knee, and hip mo- ITBS documented by a medical profes- have also been suggested to play a role ments were all similar between groups. sional (ie, physical therapist, medical in development of ITBS.4,7 The gluteus Although prospective studies are more doctor, athletic trainer), were identified. medius muscle is the primary abduc- robust in design and can provide in- Thirty-five females, matched for age and tor of the hip joint,17 and weakness of formation concerning cause and effect, running distance, with no previous knee- this muscle may lead to an increase in we sought to confirm the results of our related musculoskeletal injuries, were hip adduction angle, thereby potential- previously published prospective study then chosen for the control group. No ly increasing the strain on the iliotibial with a retrospective analysis. Apart from significant differences in group demo- band.11,12, 25 Although running kinematics confirming the robustness of our previ- graphics were observed (TABLE 1). Prior to was not addressed, Fredrickson et al8 re- ous results, a follow-up retrospective participation, each subject signed a con- ported that runners with ITBS had sig- study of individuals with a history of sent form approved by the University of nificantly reduced hip abductor muscle ITBS would shed insight as to whether Delaware Human Subjects Compliance strength in the affected limb compared runners alter their mechanics once the Committee. to the unaffected limb, as well as com- injury has resolved. pared to healthy controls. In addition, The purpose of this retrospective Procedures Niemeth et al19 investigated a group of study was to examine differences in hip, Retroreflective markers for tracking 3-D

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Kinematic and Kinetic Data for TABLE 2 Iliotibial Band Syndrome (ITBS) Injured Limb Compared to the Control Group

Variables itBS* control* Difference† P Value Rearfoot peak eversion angle (deg) 8.94  3.16 10.04  3.22 1.10  0.06 (0.05, 2.17) .16 Rearfoot peak invertor moment (Nm/kg) 0.14  0.13 0.09  0.08 0.05  0.05 (0.02, 0.09) .05‡ Knee peak internal rotation angle (deg) 1.75  5.94 –1.14  4.96 2.89  0.98 (1.25, 4.86) .03‡ Knee peak external rotator moment (Nm/kg) 0.09  0.06 0.09  0.05 0.00  0.01 (–0.02, 0.02) .68 Knee peak flexion angle (deg) 45.30  4.50 45.21  5.00 0.10  0.50 (–1.56, 1.59) .95 Hip peak adduction angle (deg) 10.39  4.36 7.92  5.84 2.47  1.48 (0.54, 3.91) .05‡ Hip peak abductor moment(Nm/kg) 1.33  0.24 1.33  0.18 0.00  0.06 (–0.08, 0.06) .94 * Values are mean  SD. † Values are mean  SD (95% CI). ‡ ITBS group significantly greater than the control group.

system (Oxford Metrics, Ltd, Oxford, gle, (6) peak hip abductor moment, and UK). The cameras were calibrated to a (7) peak knee flexion angle. All moments volume of 2.0 m3, and calibration errors were expressed as internal moments and were all below 3 mm. Kinematic data normalized to body mass (Nm/kg). Data were sampled at 120 Hz and low-pass from the previously injured limb of the filtered at 8 Hz with a fourth-order zero- female runners in the ITBS group were lag Butterworth filter. Ground reaction used for analysis and were compared FIGURE 1. Retroreflective marker placement on the forces data were collected using a force with the right limb of the female runners tested lower extremity. plate (Bertec Corporation, Columbus, in the control group. Variables were sta- OH) at a sampling frequency of 960 Hz tistically compared between groups us- movement were attached to the , and low-pass filtered at 50 Hz, with a ing 1-way ANOVAs at a confidence level shank, , and rearfoot (FIGURE 1). Ad- fourth-order zero-lag Butterworth filter. of .05. ditional anatomical markers were placed Trials were normalized to 100% of stance over the bilateral greater trochanters, me- and the 5 trials were averaged for each RESULTS dial and lateral femoral condyle, medial subject. and lateral malleoli, and the heads of the Visual3D software (C-Motion Inc, comparison summary of the first and fifth metatarsals. These markers Rockville, MD) was used to calculate ki- kinematic and kinetic variables of were used to define the anatomical coor- nematic and kinetic variables. All lower A interest for the ITBS injured limb dinate systems and calculate the inertial extremity segments were modeled as a and the limb of the control group is pre- parameters for each body segment. After frustra of right cones model and anthro- sented in TABLE 2. At the foot, the runners data for a static standing calibration were pometric data provided by Dempster.2 in the ITBS group exhibited similar peak collected, the anatomical markers were The kinematic and kinetic variables of rearfoot eversion angle (P =.16) but sig- removed and dynamic trials were col- interest were extracted from individual nificantly greater peak rearfoot invertor lected. Subjects ran along a 25-m runway trials, selected from the first 60% of the moments (P =.05) compared to controls at a speed of 3.65 m/s (5%), striking a stance phase of gait, and included ankle, (FIGURE 2). At the knee, the runners in force plate at its center. Running speed knee, and hip joint 3-D kinematic and the ITBS group exhibited a significantly was monitored using photoelectric cells kinetic variables. The first 60% of stance greater peak knee internal rotation angle placed 2.86 m apart along the runway. was analyzed because, in general, peak (P =.03) but similar peak knee external Data for the stance phase of 5 running joint moments, maximum ground reac- rotator moment (P = .68) compared to trials were collected. All subjects wore tion forces, and peak joint angles occur controls (FIGURE 3). Peak knee flexion an- the same laboratory neutral (cushioning) within this time frame. The specific kine- gle was similar between groups (P = .95). running shoes. matic variables of interest were (1) peak At the hip, the runners in the ITBS group rearfoot eversion angle, (2) peak rearfoot exhibited a significantly greater hip ad- Data Collection and Analysis invertor moment, (3) peak knee internal duction angle (P = .05) but no differences Kinematic data were collected with a rotation angle, (4) peak knee external ro- in peak hip abductor moment (P = .94) 6-camera, 3-D VICON motion analysis tator moment, (5) peak hip adduction an- compared to controls (FIGURE 4).

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40-02 Ferber_folio.indd 54 1/20/10 3:57:51 PM its insertion on the tibia, increased knee 12 rotation increases torsional loads to the 10 tissues of the knee joint such as the ilio- tibial band.6,10,14,18,20,28 In addition, Terry 8 et al27 suggested that the iliotibial band

6 provides a significant amount of rotation-

al restraint at the knee joint, increasing (deg) 4 the potential for injury with increases in Angle

2 knee joint transverse plane motion. Our results are consistent with those provided 0 16 Rearfoot by Miller et al, who reported that run- 020406080 100 –2 ners with a history of ITBS exhibited a greater peak knee internal rotation veloc- –4 ity at the beginning and end of an exhaus- tive run compared to controls. Similar to –6 the results of the current study, Miller –8 et al16 and Noehren et al22 also reported that the runners with a history of ITBS 0.04 remained more internally rotated at the knee throughout stance compared to 0.02 noninjured runners (FIGURE 3). However, an exhaustive run protocol was not used 0.0 in the current study, so comparisons with

020406080 100 the data of Miller et al16 must be made –0.02 with caution. (Nm/kg) Numerous authors have suggested –0.04 that greater rearfoot eversion can lead Moment to knee-related injuries, including –0.06 14,18,20,28

Rearfoot ITBS. However, greater rearfoot eversion in the group with a history of –0.08 ITBS was not found in the current study. In fact, the runners in the ITBS group –0.10 exhibited slightly lower peak eversion

values compared to the control group, –0.12 which is similar to the results from the prospective study by Noehren et al.22 Percent of Stance (%) Similarly, Messier et al15 reported that runners with a history of ITBS exhibited FIGURE 2. Rearfoot inversion/eversion angles (top graph) and moments (bottom graph) for the iliotibial band syndrome (dashed orange line) and control (solid blue line) groups during the stance phase of running. Positive reduced rearfoot eversion during heel- values indicate rearfoot eversion and invertor moment. strike compared to healthy runners. Interestingly, in our study, the rearfoot DISCUSSION At the knee, the peak flexion angle was invertor moment was significantly high- not different between groups. This find- er in the ITBS group. It is possible that he purpose of this retrospective ing provides further evidence that knee the increased rearfoot invertor moment study was to examine differences in flexion, by itself, does not play a signifi- reflects a compensatory mechanism to Trunning mechanics between run- cant role in the aetiology of ITBS as has try to control eversion and the associ- ners with a history of ITBS and runners been historically believed.1,21,23 However, ated tibial and knee internal rotation. with no history of running-related knee the increased peak knee internal rotation Moreover, strain on the iliotibial band injuries. Compared to previous studies in angle in the ITBS group measured in the is related to motion of the tibia and not this area, we chose to conduct a compre- current study is likely an important factor necessarily motion of the rearfoot. The hensive assessment including hip, knee, in the development of ITBS. A number fact that the foot eversion-tibial rotation and rearfoot mechanics. of authors have suggested that, due to ratio is not a 1:1 relationship and varies

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ated the clinical anatomy of the iliotibial 3 band and suggested that the combination of tensile loading from hip adduction and torsional loading from knee internal ro- 0 tation may result in greater tissue strain 020406080 100 than either of these types of loads in iso-

lation. Using a musculoskeletal model of –3 the lower extremity based on the kine- (deg)

matics from the exhaustive run, Miller et Angle al16 reported that strain in the iliotibial –6 Knee band was higher for the ITBS runners

throughout all of stance and from the beginning to the end of the exhaustive –9 run compared to controls. These authors attributed this increased strain primarily to the torsional stress experienced at the –12 knee joint.

The increased hip adduction position 0.02 was expected to be associated with great- er demands on the hip abductor muscles, 0.0 resulting in a greater hip abductor mo- 020406080 100 ment. However, this hypothesis was not

supported. These results are, however, –0.02 consistent with the results of the prospec- 22

tive ITBS study by Noehren et al, who (Nm/kg) –0.04 also reported no differences and nearly

Moment identical patterns in the hip abductor

moment between runners who developed Knee –0.06 ITBS and controls. It is possible that the timing of muscle activation is more im- –0.08 portant in controlling hip adduction than the magnitude of activation. Future studies, possibly using electromyographic –0.10 monitoring, are necessary to answer these Percent of Stance (%) questions. Increased hip adduction and knee internal rotation, likely resulting in FIGURE 3. Knee internal/external rotation angles (top graph) and moments (bottom graph) for the iliotibial band syndrome (dashed orange line) and control (solid blue line) during the stance phase of running. Positive values increased strain to the iliotibial band, indicate knee internal rotation and internal rotator moment. may result from hip muscle weakness. Fredricson et al8 reported that runners from person to person7,11,13 may explain rotation, the runners with a previous his- with ITBS exhibited significantly re- why eversion was not different between tory of ITBS remained in greater hip ad- duced hip abductor muscle strength in groups. Finally, the greater rearfoot in- duction throughout stance (FIGURE 4). Due the affected limb compared to healthy vertor moment could be associated with to the insertion of the iliotibial band at controls. These authors also reported the greater inversion angle observed at the distal femur, increased hip adduction that following a 6-week hip abductor heel strike (FIGURE 2), which appears to can result in greater tensile strain to this muscle-strengthening program, 22 of be approximately 2° to 3° greater for the tissue. Coupled with the torsional strain 24 patients with ITBS demonstrated ITBS group compared to controls. due to increased knee internal rotation a 34.9% to 51.4% increase in muscle Consistent with our hypothesis, the angle, increased hip adduction may place strength, and were free of ITBS pain ITBS group exhibited a significantly the iliotibial band at further risk for irrita- while running. Thus, weakness of the greater peak hip adduction angle com- tion as it slides across the lateral femoral hip abductor muscles may result in pared to controls. As with knee internal condyle. In fact, Fairclough et al4 evalu- greater hip adduction and knee internal

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40-02 Ferber_folio.indd 56 1/20/10 3:57:55 PM 12 is more related to atypical hip and knee mechanics as compared to foot mechan- ics. Therefore, the current retrospective study provides further evidence linking 9 atypical lower extremity kinematics and ITBS.

6 Additional limitations and delimita-

tions in this study are recognized. First, (deg) the runners in the ITBS group were inju- Angle ry-free at the time of testing but did have

Hip 3 a history of ITBS that was confirmed by a medical professional. However, the sub- jects involved in the current study were 0 16 020406080 100 similar to those of Miller et al, who were also pain-free at the time of testing. Sec- ond, the participants in the present in- –3 vestigation all ran within a running speed

0.2 range of 3.65 m/s (5%). However, the running speed range chosen was a com-

0.0 fortable pace for all the subjects and was 02040 60 80 100 similar to their own regular training pace.

–0.2 Third, the anthropometric model used to calculate the kinetic variables of interest

–0.4 was not specific to female subjects. Using a model that accounts for the true mass

(Nm/kg) –0.6 segment properties of females may influ- ence the results of the study. However, Moment –0.8 because the data were normalized to sub- Hip ject mass and height, this limitation was –1.0 reduced. It is acknowledged that future studies using an anthropometric model –1.2 specific to female subjects may provide slightly different results. –1.4

Percent of Stance (%) CONCLUSION

emale recreational runners FIGURE 4. Hip abduction/adduction angles (top graph) and moments (bottom graph) for the iliotibial band syndrome (dashed orange line) and control (solid blue line) groups during the stance phase of running. Positive who had previously sustained ITBS values indicate hip adduction and adductor moment. Fexhibited significantly greater stance phase peak hip adduction and peak knee rotation during the stance phase of run- similar conditions but with different sub- internal rotation angles, and greater ning and increased strain to the iliotibial jects. The current retrospective study also rearfoot invertor moments compared to band. While the current study did not noted a significant increase in the rear- a control group during running. These measure hip abductor muscle strength, foot invertor moment in the ITBS group, results were generally similar to those re- future studies should include hip abduc- which may indicate a compensatory ported for a prospective study conducted tor strength measures to better elucidate mechanism following injury. However, within the same laboratory environment the possible aetiology of ITBS. aside from this variable, these results be- with a separate group of subjects. The It is encouraging to note that these gin to suggest that lower extremity gait common results between the prospective overall findings were consistent with the mechanics do not change as a result of study and the current retrospective study results of a recently published prospec- ITBS. Moreover, the similar results of provide strong evidence related to atypi- tive study of ITBS by Noehren et al,22 the current study and those of Noehren cal running mechanics and the aetiology conducted in the same laboratory under et al22 suggest that the aetiology of ITBS of ITBS. t

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Key Points J Anat. 2006;208:309-316. http://dx.doi. org/10.1016/j.gaitpost.2006.10.007 org/10.1111/j.1469-7580.2006.00531.x 17. Moore KL, Dalley AF. Clinically Oriented Anato- Findings: During running, stance phase 5. Ferber R, Davis I, Hamil J, Pollard CD. my. 5th ed. Philadelphia, PA: Lippincott Williams peak hip adduction angles, peak knee Prospecitve biomechanical investigation of & Wilkins; 2005. internal rotation angles, and greater iliotibial band syndrome in competitive female 18. Nawoczenski DA, Saltzman CL, Cook TM. The rearfoot invertor moments were signifi- runners [abstract]. Med Sci Sports Exerc. effect of foot structure on the three-dimensional cantly greater in female recreational 2003;35:S91. kinematic coupling behavior of the leg and rear 6. Ferber R, Davis IM, Williams DS, 3rd. Effect foot. Phys Ther. 1998;78:404-416. runners who had previously sustained of foot orthotics on rearfoot and tibia joint 19. Niemuth PE, Johnson RJ, Myers MJ, Thieman ITBS compared to a control group. coupling patterns and variability. J Biomech. TJ. Hip muscle weakness and overuse injuries Implication: Our results suggest that 2005;38:477-483. http://dx.doi.org/10.1016/j. in recreational runners. Clin J Sport Med. correction of atypical lower extremity jbiomech.2004.04.019 2005;15:14-21. 7. Ferber R, Davis IM, Williams DS, 3rd. Gender 2 0 . Nigg BM, Cole GK, Nachbauer W. Effects of arch kinematics may decrease iliotibial band differences in lower extremity mechanics dur- height of the foot on angular motion of the lower stress/strain and should be considered ing running. Clin Biomech (Bristol, Avon). extremities in running. J Biomech. 1993;26:909- in the treatment of persons with ITBS. 2003;18:350-357. 916. 8. Fredericson M, Cookingham CL, Chaudhari AM, 21. Noble CA. Iliotibial band friction syndrome in Caution: Our study was retrospective Dowdell BC, Oestreicher N, Sahrmann SA. Hip runners. 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