[ RESEARCH REPORT ] REED FERBER, PhD, CAT(C), ATC1 • Brian noehren, PT, PhD2 Joseph hamill, PhD3 • irene Davis, PT, PhD4 Competitive Female Runners With a History of Iliotibial Band Syndrome Demonstrate Atypical Hip and Knee 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 running. 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 gluteus maximus, gluteus medius, and tensor fascia 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 tibia.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 foot 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] 52 | february 2010 | volume 40 | number 2 | journal of orthopaedic & sports physical therapy 40-02 Ferber_folio.indd 52 1/20/10 3:57:47 PM 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