Elsevier

Clinical Biomechanics

Volume 22, Issue 9, November 2007, Pages 951-956
Clinical Biomechanics

ASB Clinical Biomechanics Award Winner 2006: Prospective study of the biomechanical factors associated with iliotibial band syndrome

https://doi.org/10.1016/j.clinbiomech.2007.07.001Get rights and content

Abstract

Background

Iliotibial band syndrome is the leading cause of lateral knee pain in runners. Despite its high prevalence, little is known about the biomechanics that lead to this syndrome. The purpose of this study was to prospectively compare lower extremity kinematics and kinetics between a group of female runners who develop iliotibial band syndrome compared to healthy controls. It was hypothesized that runners who develop iliotibial band syndrome will exhibit greater peak hip adduction, knee internal rotation, rearfoot eversion and no difference in knee flexion at heel strike. Additionally, the iliotibial band syndrome group were expected to have greater hip abduction, knee external rotation, and rearfoot inversion moments.

Methods

A group of healthy female recreational runners underwent an instrumented gait analysis and were then followed for two years. Eighteen runners developed iliotibial band syndrome. Their initial running mechanics were compared to a group of age and mileage matched controls with no history of knee or hip pain. Comparisons of peak hip, knee, rearfoot angles and moments were made during the stance phase of running. Variables of interest were averaged over the five running trials, and then averaged across groups.

Findings

The iliotibial band syndrome group exhibited significantly greater hip adduction and knee internal rotation. However, rearfoot eversion and knee flexion were similar between groups. There were no differences in moments between groups.

Interpretation

The development of iliotibial band syndrome appears to be related to increased peak hip adduction and knee internal rotation. These combined motions may increase iliotibial band strain causing it to compress against the lateral femoral condyle. These data suggest that treatment interventions should focus on controlling these secondary plane movements through strengthening, stretching and neuromuscular re-education.

Introduction

Iliotibial band syndrome (ITBS) is the leading cause of lateral knee pain in runners (Taunton et al., 2002). This syndrome is believed to result from friction of the iliotibial band (ITB) as it slides over the lateral femoral condyle (Orchard et al., 1996). Biomechanical factors which result in increasing the strain of the ITB may contribute to the development of this injury (Fredickson et al., 2000). While, the relationship between running mechanics and ITBS is not well understood, proximal, local, and distal factors have all been investigated.

Proximally, the ITB acts as a lateral hip stabilizer resisting hip adduction (Fredickson et al., 2000). It originates in the facial components of the gluteus maximus, gluteus medius, and tensor fasciae latae muscles (Muhle et al., 1999, Birnbaum et al., 2004; Terry et al., 1986). The ITB is attached distally to the supracondyle tubercle of the femur and the lateral intramuscular septum. In addition it has fibers that attach to the patella (Muhle et al., 1999, Birnbaum et al., 2004; Terry et al., 1986). Due to these attachments, increased hip adduction is likely to lead to increased tension on the ITB. Increased hip adduction may necessitate a greater eccentric demand from gluteal musculature, resulting in a higher hip abduction moment. In fact, Fredickson et al. (2000) reported that runners who currently have ITBS exhibited weak hip abductors. Since their subjects were already injured at the time of the measurement, it is unclear whether the weakness was the cause or result of the ITBS. However, it is interesting to note that the ITBS symptoms were resolved in 90% of the subjects following a six week program of hip abductor strengthening (Fredickson et al., 2000).

Local factors, those related to mechanics of the knee joint, have also been examined. ITBS has been associated with lateral knee pain that occurs just after heel strike when the knee is in approximately 20° of flexion (Orchard et al., 1996). This pain has been reported to be exacerbated with downhill running (Orchard et al., 1996; Noble, 1980). During downhill running, an individual lands in near extension and moves through greater knee flexion excursion than in level running. It has been suggested that an impingement zone exists between 20–30° of knee flexion. In this range, the distal fibers of the ITB are believed to compress and slide over the lateral femoral condyle (Orchard et al., 1996). This proposed mechanism led Orchard et al. (1996) to examine sagittal plane knee mechanics of runners with ITBS. Interestingly, they found no differences in knee flexion at foot strike, peak knee flexion, or in the percent of time spent in knee flexion in runners with ITBS compared to their non-injured leg (Orchard et al., 1996). This suggests that knee motions, other than those in the sagittal plane, may contribute to the development of ITBS. With attachments at the lateral femoral condyle and at Gerdy’s tubercle, the ITB is likely strained with internal rotation of the knee. However, only one previous retrospective investigation has addressed knee internal rotation. These authors found that knee internal rotation was significantly greater in runners with a history of ITBS as compared to the healthy controls (Noehren et al., 2006). The combination of increased knee internal rotation angle, and an associated high external rotation moment could place greater demands on passive structures that control internal rotation.

Distal factors may also play a role in ITBS. Increased rearfoot eversion, with associated talar adduction, results in increased tibial internal rotation (Lundberg et al., 1989). With its attachment to Gerdy’s tubercle, the ITB is elongated as the tibia internally rotates. While this distal mechanism of ITBS seems logical, evidence to support it is contradictory. Messier et al. (1995) reported that runners with ITBS exhibited twice the peak rearfoot movement as compared to controls. While not measured in their study, this increased eversion may be associated with greater eccentric demands of the inverter muscles due to high inverter moment. Noehren et al. (2006) found that runners with a history of ITBS exhibited decreased peak rearfoot eversion. Therefore, the distal mechanism involving increased rearfoot eversion needs further examination.

In summary, the etiology of ITBS is still unclear. Evidence to date does not support a sagittal plane knee mechanism. Retrospective studies suggest that proximal and distal mechanisms may be involved in the development of ITBS. However, there are no prospective studies of lower extremity kinematics and kinetics in runners who develop ITBS. Therefore, the purpose of this prospective investigation was to compare the pre-existing frontal and transverse plane lower extremity kinematics and kinetics between a group of female runners who develop ITBS compared to healthy controls. It was hypothesized that runners who go on to develop ITBS will initially exhibit greater hip adduction, knee internal rotation and rearfoot eversion angles. Additionally, no difference in knee flexion at heel strike was expected between groups. Lastly, it was hypothesized that the ITBS subjects would have greater hip abduction, knee external rotation, and ankle inversion moments.

Section snippets

Methods

The subjects in this study are part of a larger, ongoing, prospective investigation of lower extremity injuries in female runners. To be included, all subjects ran a minimum of 20 miles a week, were between the ages of 18–45, and were free from any injuries at the time of data collection. Prior to participation, each subject signed a consent form approved by the University’s Human Subjects Compliance Committee.

The bilateral 3D lower extremity kinematics and kinetics during running were then

Results

The age, monthly mileage, and body mass index (BMI) of the ITBS and control groups are presented in Table 1. An outlier analysis was performed to remove any subjects whose data were greater than three standard deviations from the mean (Newton and Rudestam, 1999, Winer et al., 1991). In the control group, this resulted in the removal of two outliers for knee internal rotation, one for rearfoot eversion, two for rearfoot inversion moment and two for knee external rotation moment. In the ITBS

Discussion

The aim of this prospective study was to compare the lower extremity kinematics and kinetics of female runners who develop ITBS to those of healthy controls. In support of our hypotheses, we found the ITBS group exhibited greater hip adduction and knee internal rotation. However, the ITBS group unexpectedly exhibited less rearfoot eversion than the controls. Also, we found no significant differences in any of the moments.

The increased hip abduction in the ITBS group was consistent with our

Conflict of Interest

The authors have no personal or financial conflict interest that influenced this work.

Acknowledgement

This study was funded by a Department of Defense grant DAMD17-00-1-0.

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