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The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners - A systematic review of the literature

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The aim of this literature review was to identify the biomechanical variables involved in the aetiology of iliotibial band syndrome (ITBS) in distance runners. An electronic search was conducted using the terms "iliotibial band" and "iliotibial tract". The results showed that runners with a history of ITBS appear to display decreased rear foot eversion, tibial internal rotation and hip adduction angles at heel strike while having greater maximum internal rotation angles at the knee and decreased total abduction and adduction range of motion at the hip during stance phase. They further appear to experience greater invertor moments at their feet, decreased abduction and flexion velocities at their hips and to reach maximum hip flexion angles earlier than healthy controls. Maximum normalised braking forces seem to be decreased in these athletes. The literature is inconclusive with regards to muscle strength deficits in runners with a history of ITBS. Prospective research suggested that greater internal rotation at the knee joint and increased adduction angles of the hip may play a role in the aetiology of ITBS and that the strain rate in the iliotibial bands of these runners may be increased compared to healthy controls. A clear biomechanical cause for ITBS could not be devised due to the lack of prospective research.
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Literature review
The biomechanical variables involved in the aetiology of iliotibial band
syndrome in distance runners eA systematic review of the literature
Maryke Louw
*
, Clare Deary
Department of Physiotherapy, School of Health Professions, University of Brighton, UK
article info
Article history:
Received 4 July 2012
Received in revised form
10 May 2013
Accepted 19 July 2013
Keywords:
Iliotibial band syndrome
Biomechanics
Aetiology
abstract
The aim of this literature review was to identify the biomechanical variables involved in the aetiology of
iliotibial band syndrome (ITBS) in distance runners. An electronic search was conducted using the terms
iliotibial bandand iliotibial tract.
The results showed that runners with a history of ITBS appear to display decreased rear foot
eversion, tibial internal rotation and hip adduction angles at heel strike while having greater
maximum internal rotation angles at the knee and decreased total abduction and adduction range of
motion at the hip during stance phase. They further appear to experience greater invertor
moments at their feet, decreased abduction and exion velocities at their hips and to reach
maximum hip exion angles earlier than healthy controls. Maximum normalised braking forces
seem to be decreased in these athletes. The literature is inconclusive with regards to muscle strength
decits in runners with a history of ITBS. Prospective research suggested that greater internal
rotation at the knee joint and increased adduction angles of the hip may play a role in the aetiology
of ITBS and that the strain rate in the iliotibial bands of these runners may be increased compared to
healthy controls.
A clear biomechanical cause for ITBS could not be devised due to the lack of prospective research.
Ó2013 Elsevier Ltd. All rights reserved.
1. Introduction
Iliotibial band syndrome (ITBS) is an overuse injury associated
with pain on the lateral aspect of the knee. Patients have no history
of trauma and describe an insidious onset of lateral knee pain during
a run. The pain typically appears a few kilometres into a run and
increases in intensity as they continue (Aronen, Chronister, Regan, &
Hensien, 1993; Fredericson, Guillet, & De Benedictis, 2000; Gunter &
Schwellnus, 2004; Renne, 1975). A recent review of the literature
found ITBS to be the third most frequent injury amongst distance
runners (Hespanhol, Carvalho, Costa, & Lopes, 2011).
1.1. Anatomy
The iliotibial band (ITB) originates from the fascia of the tensor
fascia latae and gluteus maximus muscles. This fascia is proximally
attached to the iliac crest (Fairclough et al., 2006; Falvey, Clark,
Franklyn-Miller, Bryant, Briggs, & McCrory, 2010), anterior supe-
rior iliac spine (Birnbaum, Siebert, Pandorf, Schopphoff, Prescher, &
Niethard, 2004) and to the capsule of the hip joint (Birnbaum et al.,
2004; Falvey et al., 2010; Tichy & Tillmann, 1989). Nearly three
quarters of the gluteus maximus tendon blends into the ITB, before
attaching at the gluteal tuberosity of the femur (Birnbaum et al.,
2004; Falvey et al., 2010; Fetto, Leali, & Moroz, 2002).
The ITB then continues down the lateral aspect of the femur
having a broad attachment to the linea aspera and is continuous
with the fascia that envelopes the thigh (Birnbaum et al., 2004;
Terry, Hughston, & Norwood, 1986). Fairclough et al. (2006) and
Falvey et al. (2010) found that the ITB was securely attached to the
lateral femoral condyle (LFC) with strong brous bands, some of
which attached directly onto the lateral femoral epicondyle (LFE).
In the area of the LFC the ITB has attachments to the patella
(Birnbaum et al., 2004; Merican & Amis, 2009; Renne, 1975). To-
wards the distal end of the LFC, it roughly splits into two bands and
crosses the lateral knee joint. The one band travels obliquely down
and attaches to the infracondylar tubercle of the tibia (Gerdys
tubercle) while the other attaches to the head of the bula
(Birnbaum et al., 2004; Terry et al., 1986).
*Corresponding author. Sportswise, The Welkin Building, The University of
Brighton, Carlisle Road, Eastbourne BN20 7SN, UK. Tel.: þ44 1323 745970.
E-mail address: maryke.louw@gmail.com (M. Louw).
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1.2. Function
The attachments of the ITB to the pelvis, femur and tibia mean
that it passively resists hip adduction and internal rotation as well
as anterior translation and internal rotation of the tibia (Ferber,
Kendall, & McElroy, 2010; Kwak et al., 2000; Yamamoto, Hsu, Fisk,
Van Scyoc, Miura, & Woo, 2006).
The gluteus medius muscle is often seen as the most important
stabiliser of the pelvis, preventing excessive hip adduction during
gait (Beers, Ryan, Kasubuchi, Fraser, & Taunton, 2008; Fredericson,
Cookingham, Chaudhari, Dowdell, Oestreicher, & Sahrmann, 2000).
Researchers have shown that these adduction forces can exceed
magnitudes of three times body weight during mid stance (Lu,
Taylor, OConnor, & Walker, 1997). Fetto et al. (2002) point out that
the amount of energy required to sustain this effort exceeds the
metabolic capacity of the gluteus medius. Theyargue that the robust
gluteus maximus muscle, through its attachment into the ITB, ten-
sions the ITB and increases the passive stability around the hip joint
(supported by Birnbaum et al., 2004). The tensor fascia latae and
vastus lateralis muscles also contribute to the tensioning effect of the
ITB (Becker, Baxter, & Woodley, 2010; Birnbaum et al., 2004).
1.3. Aetiology
1.3.1. Friction vs. compression
Early researchers believed that ITBS is caused by inammation
in tissue deep to the ITB due to excessive friction between the ITB
and the LFE when the former slides over the latter during repetitive
exion-extension movements e.g. running (Ekman, Pope, Martin, &
Curl, 1994; Muhle et al., 1999; Nemeth & Sanders, 1996; Noble,
1979; Orchard, Fricker, Abud, & Mason, 1996; Renne, 1975).
This view has recently been challenged by Fairclough et al.
(2006) and Falvey et al. (2010) who argued that the ITB is not a
loose structure and it is highly unlikely that the ITB can move from
anterior to posterior over the LFE. They found, through MRI, that
the ITB compresses against the LFE at about 30 degrees of knee
exion (Fairclough et al., 2006). The researchers concluded from
this that ITBS is more likely caused by excessive compression of the
richly vascularised and innervated layer of fat between the ITB and
LFC (Fairclough et al., 2006, 2007).
The main difference between Fairclough et al. (2006)s study
and the previous investigations (Muhle et al., 1999; Orchard et al.,
1996) is that both of the earlier studies were conducted on ca-
davers. In response to an opinion piece written by Fairclough et al.
(2007), Orchard (2007) admitted that the specimens we examined
in this study [Orchard et al., 1996]had already had the ITB dissected
away from the remaining (previously attached) fascia latae, so they
may not have been representative of the anatomy in vivo.
Whether one agrees with the slipping bandtheory of the
original research or the compressiontheory of recent studies
does not really matter. Both theories rely on an abnormal increase
in compression forces between the ITB and the LFC to cause irri-
tation and inammation in the tissue, since these movements
(slipping/compression) appear to be characteristic of an asymp-
tomatic population as well (Fairclough et al., 2006; Muhle et al.,
1999; Orchard et al., 1996).
1.4. Contributing factors
The most common factor reported in the literature as contrib-
uting to the development of ITBS is a sudden increase in exercise
intensity (mileage/hill training/speed work) (Almeida, Williams,
Shaffer, & Brodine, 1999; Firer, 1989; Messier et al., 1995; Noble,
1979; Sutker, Barber, Jackson, & Pagliano, 1985; Tenforde, Sayres,
McCurdy, Collado, Sainani, & Fredericson, 2011).
Several other possible causes, due to their ability to potentially
increase tension in the ITB by altering hip and knee angles, have
been identied: downhill running, wearing old shoes, always
running on the same side of a cambered road, leg length discrep-
ancies, excessive pronation of the foot, a tight ITB and weakness of
the gluteus medius muscles (Barber & Sutker, 1992; Firer, 1989;
Fredericson, Cookingham, et al., 2000; Krivickas, 1997; Orchard
et al., 1996; Sutker et al., 1985).
Messier et al. (1995) proposed that, in athletes who possess a
certain combination of intrinsic factors, the musculoskeletal system
becomes overwhelmed if the mileage is increased beyond a
threshold level and manifests itself as injury. Several researchers
have tried to build on this hypothesis by investigating the biome-
chanics of runners with ITBS during running (Ferber, Noehren,
Hamill, & Davis, 2010; Grau, Krauss, Maiwald, Axmann, Horstmann,
& Best, 2011; Grau, Krauss, Maiwald, Best, & Horstmann, 2008;
Grau, Maiwald, Krauss, Axmann, & Horstmann, 2008; Hamill,
Miller, Noehren, & Davis, 2008; Messier et al., 1995; Messier &
Pittala, 1988; Miller, Lowry, Meardon, & Gillette, 2007; Miller,
Meardon, Derrick, & Gillette, 2008; Noehren, Davis, & Hamill,
2007; Orchard et al., 1996). These researchers, though, have re-
ported varying and sometimes contradicting results and their work
is the main focus of this literature review.
The aim of this literature review is to establish whether distance
runners who suffer from or develop ITBS demonstrate lower limb
biomechanics that are different from those of runners who do not
suffer from or develop ITBS. Identication of such predisposing
biomechanics could lead to early intervention to better treat and
prevent injuries.
2. Methods
2.1. Literature search
An electronic search was conducted, using the terms iliotibial
bandand iliotibial tract, of the following databases and websites
from inception to July 2011: PEDro, Cochrane Library, National
Institute for Health and Clinical Excellence, NIHR Health Technol-
ogy Assessment programme, Allied and Complementary Medicine,
British Nursing Index, CINAHL Plus with full text, E-Journals,
Highwire Medical Journals, PsycARTICLES, PsycINFO, SPORTDiscuss,
Biomed central, EMBASE, Expanded Academic ASAP, ProQuest
Medical Library, Pubmed Central, PubMed, SAGE Premier 2011,
Science Citation Index Expanded, Science direct, Web of Science,
Wiley-Blackwell Journals, Ingenta Connect, Google Scholar, www.
clinicaltrials.gov, World Health Organisation: International Clin-
ical Trials Registry Platform Search Portal, Health Management
Information Consortium, Library of Archives of Canada, University
of Helsinki, ProQuest Dissertation and Thesis website, Australian
Digital Theses, Cybertesis.net, National Library of Australia (TROVE),
Ethos UK, DUT Library.
Relevant articlesreference lists were hand searched for addi-
tional relevant titles.
2.2. Study selection
The following inclusion and exclusion criteria were used during
study selection:
Inclusion criteria:
Literature: Published and unpublished research.
Study design: Prospective or retrospective randomised
controlled trials, non-randomised controlled trials and case
control studies were included.
M. Louw, C. Deary / Physical Therapy in Sport 15 (2014) 64e75 65
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Intervention of interest: Studies researching the dynamic
biomechanical aspects involved in the development of ITBS
in runners.
Participants: Male and/or female distance runners with ITBS
or who developed ITBS during the study.
Outcome measurements of interest: Including at least one of
the following but not restricted to: muscle strength, joint
angles and joint moments.
Exclusion criteria:
Studies without a control group.
Studies investigating only static biomechanical measure-
ments (e.g. Q angle and leg length).
Studies failing to supply enough information in order to
conduct an evaluation of the study methodology.
Studies published in languages other than English.
2.3. Quality assessment
The methodological quality of each article was reviewed by the
same researcher on two different occasions. The ratings were then
compared and any discrepancies investigated and dealt with. The
Quality Assessment Tool For Quantitative Studies developed by the
Effective Public Health Practice Project was used to assess each
paper (Thomas, Ciliska, Dobbins, & Micucci, 2004). This tool was
developed to assess both the methodological quality of rando-
mised controlled trials and quasi-experimental study designs by
awarding it a STRONG, MODERATE or WEAK quality rating (QR)
(Table 1). Its reliability (Kappa 0.74 and Kappa 0.61) and validity
has been established (Thomas et al., 2004) and it was recently
shown to have better inter-rater reliability than the Cochrane
Collaboration Risk of Bias Tool (Armijo-Olivo, Stiles, Hagen,
Biondo, & Cummings, 2010). Deeks et al. (2003) conducted a re-
view of the literature and identied this tool (from 194) as one of
six best tools available to evaluate the methodological quality of
non-randomised trials.
Matching for gender was treated as the main confounding factor
for the studies, as the literature seem to suggest that there are
biomechanical differences between men and women at rest and
specically during running (Ferber, McClay Davis, & Williams III,
2003; Horton & Hall, 1989; Livingston, 1998). Recently Grau,
Maiwald, et al. (2008) demonstrated that matching for height and
weight may also inuence the results of kinematic and kinetic
studies during running. It was decided not to treat these as con-
founding factors as, to the researchers knowledge, only one study
to date supports these results.
2.4. Analysis
Quantitative analysis was not possible due to the heterogeneity
of the included studies. A qualitative analysis was achieved by
adapting the method described by Reid and Rivett (2005). Different
levels were used to rate the scientic evidence which support or
refute each nding.
LEVEL 1
STRONG EVIDENCE eprovided by generally consistent ndings in
multiple STRONG QR studies.
LEVEL 2
MODERATE EVIDENCE eprovided by generally consistent ndings
in one STRONG QR study and one or more MODERATE QR studies.
LEVEL 3
LIMITED EVIDENCE eprovided by generally consistent ndings in
one or more MODERATE QR studies.
LEVEL 4
NO EVIDENCE eif there were only WEAK QR studies or if the re-
sults were conicting.
Generally consistent ndingswas dened as 75% or more
of the studies having statistically signicant results in the same
direction (Reid & Rivett, 2005).
A sensitivity analysis was conducted at the end to test the
robustness of the synthesis process.
3. Results and discussion
3.1. Study selection
The search identied 1732 titles for possible inclusion. Only
twelve articles survived the nal scrutiny to be included in the
literature review. A description of the included studies can be found
in Table 2 while Table 3 shows the methodological quality rating of
each study.
3.2. Results reported by category (Tables 4e9)
In order to better explore the relationship of the results be-
tween the studies, they were divided into the following cate-
gories: kinetic and kinematic variables of the foot; kinetic and
kinematic variables of the ankle; kinetic and kinematic variables of
the knee; kinetic and kinematic variables of the hip; ground re-
action forces; joint coupling; muscle strength; ITB strain and
impingement.
Please note that for Grau, Maiwald, et al. (2008) only the results
of control group 3 are reported, since they were the best matched
group.
3.3. Analysis of results
Please note, for analysis purposes, the results from Miller et al.
(2007) and Miller et al. (2008) were treated as follows: The re-
sults for variables at the start of the exhaustive run were compared
to the other studies, but the results for variables at the end of the
exhaustive run were considered on their own. This was done since
ones biomechanics might change when fatigued and subjects did
not reach exhaustion (self reported) during any of the other studies
(Gerlach, White, Burton, Dorn, Leddy, & Horvath, 2005). Results for
the retrospective and prospective studies were analysed separately
since the possibility exists that ones biomechanics may change as a
result of injury (Ferber, Noehren, et al., 2010).
This literature review produced only level 3 (limited) and 4 (no)
evidence due to the low methodological QRs achieved by the
included research. This may not be an accurate representation of
the quality of the research, but rather of the quality of report
writing as most of the categories were rated low due to incomplete
reporting.
Table 1
The quality assessment tool for quantitative studies: guide to the global quality
rating of a paper.
STRONG Four STRONG ratings with no WEAK ratings in rst
six categories
MODERATE Fewer than four STRONG ratings and no more than
one WEAK rating in the rst six categories
WEAK Two or more WEAK ratings in the rst six categories
regardless of other ratings
M. Louw, C. Deary / Physical Therapy in Sport 15 (2014) 64e7566
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Table 2
Summary of included studies.
AUTHOR POPULATION MAIN OUTCOME MEASURES AND TESTING ACTION
Ferber,
Noehren, et al.
(2010)
Design: RCCT
QR: Moderate
Female runners
18 45 years old
Mileage: min of 30km/wk
Diagnosis: physical examination only
Injury free at time of data collection
6 camera 3-D VICON motion analysis system and
force plate (Bertec Corporation, Columbus, OH)
Subjects ran in same neutral running shoes along a
25m runway at a speed of 3.65 m/s ( 5%), striking a
force plate at its centre.
EXP GROUP
-History of
ITBS
-n = 35
CONTROL
-No history
of ITBS
-n = 35
MATCHED
-Age
-Mileage
-Gender
Fredericson,
Cookingham, et
al. (2000)
Design: RCCT
QR: Moderate
Male and female runners
18 - 41 years old
Mileage: unknown
Diagnoses: physical examination only
No history of knee surgery or unsuccessfully
rehabilitated lower limb injuries
Strength was measured using a hand-held
dynamometer (Nicholas Manual Muscle Tester).
Intraclass correlation coefficient = 0.96
Subject was in side-lying and asked to abduct the leg
towards the ceiling.
Isometric contraction at 30 degrees abduction and
force required to break isometric contraction was
measured (max resistance).
Normalised for body weight and height.
EXP GROUP
-Current ITBS
-n = 24
CONTROL
-Uninjured
-n = 30
MATCHED
-Gender
Grau, Krauss, et
al. (2008)
Design: RCCT
QR: Moderate
Male and female runners
18 50 years old
Mileage: min of 20km/wk
Diagnosis: physical examination and MRI
No previous knee surgery or related injuries
Isokinetic dynamometer (Isomed 2000, Ferstl,
Germany)
Subjects lay on their sides and were fixed at the
waist. The thigh and lower leg of the tested side were
the isokinetic device.
EXP GROUP
-Current ITBS
-n = 10
CONTROL
-Uninjured
-n = 10
MATCHED
-Gender
-Weight
-Height
Grau, Maiwald,
et al. (2008)
Design: RCCT
QR: Moderate
Male and female runners
18 50 years old
Mileage: min of 20km/wk
Diagnosis: physical examination and MRI
No previous knee surgery or related injuries
6 camera 3-D infrared system (ViconPeak, Oxford,
UK) and pressure platform (Emed-X, Munich,
Germany)
Ran barefoot in lab on 13m foam runway at a
consistent velocity of 3.3m/s (±5%).
EXP GROUP
-Current ITBS
-n = 18
CONTROL 1
-Uninjured
-n = 18
CONTROL 2
-Uninjured
-n = 18
CONTROL 3
-Uninjured
-n = 18
MATCHED
CONTROL 1
-Weight
CONTROL 2
-Gender
-Weight
CONTROL 3
-Gender
-Weight
-Height
Grau et al.
(2011)
Design: RCCT
QR: Moderate
Male and female runners
18 50 years old
Mileage: min of 20km/wk
Diagnosis: physical examination and MRI
No previous knee surgery or related injuries
6 camera 3-D infrared motion capture system
(ViconPeak, Oxford, UK) and force plate (Emed-X,
Munich, Germany)
Ran barefoot in lab on 13m foam runway at a
consistent velocity of 3.3m/s.
EXP GROUP
-Current ITBS
-n = 18
CONTROL
-Uninjured
-n = 18
MATCHED
-Gender
-Weight
-Height
Hamill et al.
(2008)
Design: PCCT
QR: Moderate
Female runners
18 - 45 years old
Mileage: min 20miles/wk
Diagnosis: physical examination only
No previous knee surgery
6 camera motion capture system and force plate
Subjects ran along a 25 m runway in neutral running
shoes at a speed of 3.7 m/s (±5%).
ITB strain, impingement and symmetry indexes were
calculated on a subject specific basis using a model
of the lower extremity derived from Software for
Interactive Musculoskeletal Modelling (SIMM 4.0,
MusculoGraphics, Santa Rosa, CA, USA).
Used kinematic data from Noehren et al. (2007)
EXP GROUP
-Developed
ITBS
-n = 17
CONTROL
-Uninjured
-n = 17
MATCHED
-Gender
-Age
-Mileage
(continued on next page)
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AUTHOR POPULATION MAIN OUTCOME MEASURES AND TESTING ACTION
Messier and
Pittala (1988)
Design: RCCT
QR: Moderate
Male and female runners
Age unknown
Mileage: min of 10miles/wk
Diagnosis: physical examination only
Locam Model 51, 16mm high speed video camera
positioned 9.1 m from and perpendicular to the
Person was filmed during 5th minute of treadmill run at
training pace in their own running shoes.
EXP GROUP
-Current ITBS
-n = 13
CONTROL
-No injury
-n = 19
MATCHED
-None
Messier et al.
(1995)
Design: RCCT
QR: Moderate
Male and female runners
Mean age: EXP 33.9 (±1.2); Control 35(±1.2)
Mileage: min of 10miles/wk
Diagnosis: physical examination only
CybexII isokinetic dynamometer:
-
-
Motion analysis high speed video camera
-ITBS group wore running shoes in which symptoms
first appeared and control group wore usual running
shoes during a 15 min treadmill run.
Force plate
-Ran at training pace on a 22.75 m runway equipped
with a force plate to assess the ground reaction
forces.
EXP GROUP
-Current ITBS
-n = 56
CONTROL
-Uninjured
-n = 70
MATCHED
-None
Miller et al.
(2007)
Design: RCCT
QR: Weak
Gender not stated - runners
Mean age: EXP 27.5 (±9.0); Control 26.4
(±7.7)
Mileage: unknown
Diagnosis: physical examination only
8 camera motion capture system (Vicon Peak,
Centennial, CO)
Participants ran in their own shoes at a self selected
pace (to reach exhaustion in 20 min).
ITB strain and impingement were calculated on a
subject specific basis using a model of the lower
extremity derived from Software for Interactive
Musculoskeletal Modelling (SIMM 4.0,
MusculoGraphics, Santa Rosa, CA, USA).
EXP GROUP
-History of
ITBS
-n = 8
CONTROL
-Uninjured
-n = 8
MATCHED
-Age
Miller et al.
(2008)
Design: RCCT
QR: Weak
Gender not stated - runners
Mean age: EXP 27.5 (9.0); Control 26.4 (7.7)
Mileage: unknown
Diagnosis: physical examination only
No history of other major injuries
8 camera motion capture system (Vicon Peak,
Centennial, CO)
Participants ran in their own shoes at a self selected
pace (to reach exhaustion in 20 min).
EXP GROUP
-History of
ITBS
-n = 8
CONTROL
-Uninjured
-n = 8
MATCHED
-Age
Noehren et al.
(2007)
Design: PCCT
QR: Moderate
Female runners
18 45 years old
Mileage: minimum of 20miles/week
Diagnosis: physical examination only
Injury free at time of data collection
6 camera Vicon 512 motion analysis system (Oxford
Metrics Ltd, Oxford, UK) and force plate
Subjects ran along a 25 m run way at a speed of 3.7
m/s (±5%) in standard neutral running shoes.
EXP GROUP
-Developed
ITBS
-n = 18
CONTROL
-Uninjured
-n = 18
MATCHED
-Gender
-Age
-Mileage
Orchard et al.
(1996)
Design: RCCT
QR: Moderate
Male and female runners
Mean age: 27 (±9.5) years
Mileage: unknown
Diagnosis: physical examination only
History of unilateral ITBS in last 6 months
No previous surgery to either lower limb or
concomitant injuries
VICON VX 3D Motion Analysis System (Oxford
Metrics, Oxford, United Kingdom) and 9KN XTRAN
S1W load cell
Each subject performed two 2 minute runs on a
treadmill in their normal running shoes and at their
normal training pace.
The second run was performed with a 0.5cm heel
raise inserted to increase knee flexion angles in the
affected leg.
EXP GROUP
-History of
ITBS
-n = 9
CONTROL
-Uninvolved
limb of EXP
group
-n = 9
MATCHED
-N/A
Note: ITBS = iliotibial band syndrome; PCCT = prospective case control trial; RCCT = retrospective case control trial; EXP =
experimental; min = minimum; QR = quality rating.
Table 2 (Continued)
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3.4. Kinetics and kinematics
3.4.1. Retrospective
Limited evidence was found to suggest that runners with a
history of ITBS display signicantly less rear foot eversion (Grau,
Maiwald, et al., 2008; Messier et al., 1995), decreased tibial inter-
nal rotation (Grau, Maiwald, et al., 2008) and decreased hip
adduction angles at heel strike (Grau, Maiwald, et al., 2008)
compared to healthy controls. The literature is inconclusive with
regards to maximum adduction angles at the hip. During stance
phase, these runners seem to have greater maximum internal
rotation angles at the knee (Ferber, Noehren, et al., 2010) and
decreased total abduction and adduction range of motion at the hip
(Grau et al., 2011). The kinematic variables of the ankle joint appear
to be similar between groups.
Runners with a history of ITBS further appear to experience
greater invertor moments (Ferber, Noehren, et al., 2010) at their
feet, decreased abduction and exion velocities at their hips (Grau
et al., 2011) and to reach maximum hip exion angles earlier (Grau
et al., 2011) in the rollover process than healthy controls. Maximum
normalised braking forces appear to be decreased in runners with a
history of ITBS (Messier et al., 1995).
A lack of variability of joint coupling during cyclical (repetitive)
movements has been suggested to lead to repetitive local tissue
strain and to possibly contribute to overuse injuries (Miller et al.,
2008). There is currently only limited evidence that runners with
Table 3
Methodological quality assessment of the twelve included studies (in alphabetical order).
Author QR of rst 6 categories of the quality assessment tool for quantitative studies Global QR
Selection bias Study design Confounders Blinding Data collection
methods
Withdrawal and
dropouts
Ferber, Noehren, et al. (2010) moderate moderate strong moderate moderate weak moderate
Fredericson, Cookingham, et al. (2000) moderate moderate strong moderate strong strong moderate
Grau, Krauss, et al. (2008) moderate moderate strong weak moderate moderate moderate
Grau, Maiwald, et al. (2008) moderate moderate strong moderate strong weak moderate
Grau et al. (2011) moderate moderate strong moderate strong moderate moderate
Hamill et al. (2008) moderate moderate strong moderate moderate weak moderate
Messier and Pittala (1988) moderate moderate weak moderate moderate moderate moderate
Messier et al. (1995) moderate moderate weak moderate moderate moderate moderate
Miller et al. (2007) weak moderate strong moderate moderate weak weak
Miller et al. (2008) weak moderate strong moderate moderate weak weak
Noehren et al. (2007) moderate moderate strong moderate moderate strong moderate
Orchard et al. (1996) weak moderate strong moderate moderate strong moderate
Note: QR ¼quality rating.
Table 4
Results for the kinematic and kinetic variables of the foot and ankle.
Results Signicant difference Insignicant difference
Foot ADD/ABD
Max ADD angle Greater in ITBS group at beginning of run: Miller et al. (2007) Similar at end of exhaustive run B/G: Miller et al. (2007)
Rear foot INVER/EVER
Max INVER angle Greater in ITBS group at end of exhaustive run: Miller et al. (2007) Similar at beginning of run B/G: Miller et al. (2007)
Max invertor moment Greater in ITBS group: Ferber, Noehren, et al. (2010) B/G: Noehren et al. (2007)
Max INVER velocity Greater in ITBS group: Messier et al. (1995)* B/G: Grau et al. (2011)
Max EVER angle B/G: Ferber, Kendall, et al. (2010), Ferber, Noehren,
et al. (2010)
B/G: Grau et al. (2011)
B/G: Grau, Maiwald, et al. (2008)
B/G: Messier and Pittala (1988)
B/G: Messier et al. (1995)
B/G: Noehren et al. (2007)
EVER angle at heel strike Less in ITBS group: Grau, Maiwald, et al. (2008)
Less in ITBS group: Messier et al. (1995)
EVER angle at 10% stance B/G: Messier et al. (1995)
Total EVER ROM B/G: Messier et al. (1995)
Max EVER velocity B/G: Grau et al. (2011)
B/G: Messier and Pittala (1988)
B/G: Messier et al. (1995)
Rear foot EVER/INVER ROM B/G: Grau et al. (2011)
B/G: Messier and Pittala (1988)
Ankle PF/DF
Max PF angle B/L: Orchard et al. (1996)
PF at heel strike B/L: Orchard et al. (1996)
PF at toe-off B/L: Orchard et al. (1996)
Max PF velocity B/G: Grau et al. (2011)
Max DF angle B/G: Grau et al. (2011)
Max DF velocity Greater in ITBS group at beginning of run: Miller et al. (2007)
Decreased in ITBS group: Grau et al. (2011)
Similar at end of exhaustive run B/G: Miller et al. (2007)
DF/PF ROM B/G: Grau et al. (2011)
Note: *Signicant at a level p0.1 not p0.05; ITBS ¼iliotibial band syndrome; B/G ¼between groups; B/L ¼between involved and uninvolved legs of ITBS group;
ABD ¼abduction; ADD ¼adduction; INVER ¼inversion; EVER ¼eversion; PF ¼plantar exion; DF ¼dorsiexion; max ¼maximum; ROM ¼range of motion.
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a history of ITBS may display differences in the timing of maximum
hip exion and further research is needed (Grau et al., 2011).
The results above should be interpreted with caution since the
subjects in Grau, Maiwald, et al. (2008)sandGrau et al. (2011)s
studies ran barefoot. Jenkins and Cauthon (2011) found in their re-
view of the literature that runners consistently have a decreased
stride length, increased stride rate as well as decreased ROM at the
ankle, knee and hip during barefoot running. They also land with a
more plantar exed ankle. Grau, Maiwald, et al. (2008) and Grau
et al. (2011) also forced their barefoot runners to heel-strike which
may have altered their biomechanics even further since the litera-
ture suggests that most people alter their running pattern to mid-
foot and fore-foot strike when asked to run barefoot (Jenkins &
Cauthon, 2011; Williams, Green, & Wurzinger, 2012) Their results
may thus not be a true representation of the kinematics/kinetics
of the normal gait of the test subjects and may explain the
Table 5
Results for the kinetic and kinematic variables of the knee and hip.
Results Signicant difference Insignicant difference
Knee F/E
Max F angle Greater in ITBS group at end of exhaustive run: Miller et al. (2007) B/G: Ferber, Noehren, et al. (2010)
At beginning of run B/G: Miller et al. (2007)
B/G: Grau et al. (2011)
B/L: Orchard et al. (1996)
F angle at heel strike ITBS group more exed than control at end of exhaustive run:
Miller et al. (2007)
At start of run B/G: Miller et al. (2007)
B/G: Noehren et al. (2007)
B/L: Orchard et al. (1996)
F angle at toe off B/L: Orchard et al. (1996)
Min F angle Smaller in control group at beginning of run: Miller et al. (2007) At end of run B/G: Miller et al. (2007)
Knee IR/ER
Knee max IR angle Greater in ITBS group: Ferber, Noehren, et al. (2010)
Greater in ITBS group: Noehren et al. (2007)
Knee max external rotator moment B/G: Ferber, Noehren, et al. (2010)
B/G: Noehren et al. (2007)
Tibia IR at heel strike in relation to foot Less in ITBS group: Grau, Maiwald, et al. (2008)
Max tibial IR in relation to foot B/G: Grau, Maiwald, et al. (2008)
Tibial internal rotation (global) B/G: Noehren et al. (2007)
Femoral ER (global) Greater in ITBS group: Noehren et al. (2007)
Knee Max IR velocity Greater in ITBS group at end of exhaustive run: Miller et al. (2007) At beginning of run B/G: Miller et al. (2007)
Hip ABD/ADD
Max ADD angle Greater in ITBS group: Ferber, Noehren, et al. (2010)
Less in ITBS group: Grau et al. (2011)
Less in ITBS group: Grau, Maiwald, et al. (2008)
Greater in ITBS group: Noehren et al. (2007)
ADD angle at heel strike Less in ITBS group: Grau, Maiwald, et al. (2008)
ADD/ABD ROM Less in ITBS group: Grau et al. (2011)
Max abductor moment B/G: Ferber, Noehren, et al. (2010)
B/G: Noehren et al. (2007)
Max ABD velocity Decreased in ITBS group: Grau et al. (2011)
Max ADD velocity B/G: Grau et al. (2011)
Hip F/E
Max F angle B/G: Grau et al. (2011)
B/L: Orchard et al. (1996)
F angle at heel strike B/L: Orchard et al. (1996)
F angle at toe off B/L: Orchard et al. (1996)
F/E ROM B/G: Grau et al. (2011)
Max F velocity Decreased in ITBS group: Grau et al. (2011)
Min F velocity Greater at end of exhaustive run in ITBS group: Miller et al. (2007) At beginning of run B/G: Miller et al. (2007)
Max hip E velocity B/G: Grau et al. (2011)
Note: ITBS ¼iliotibial band syndrome; B/G ¼between groups; B/L ¼between involved and uninvolved legs of ITBS group; ABD ¼abduction; ADD ¼adduction; F ¼exion;
E¼extension; IR ¼internal rotation; ER ¼external rotation; max ¼maximum; min ¼minimum; ROM ¼range of motion.
Table 6
Results for ground reaction forces.
Results Signicant difference Insignicant difference
Rear foot
Lateral: Force-time integral B/G: Grau, Maiwald, et al. (2008)
Lateral: Max force normalised to body weight B/G: Grau, Maiwald, et al. (2008)
Medial: Force-time integral B/G: Grau, Maiwald, et al. (2008)
Medial: Max force normalised to body weight B/G: Grau, Maiwald, et al. (2008)
Max normalised braking force Less in ITBS group: Messier et al. (1995)*
Max normalised propulsive force B/G: Messier et al. (1995)
Forefoot
Lateral: Force-time integral B/G: Grau, Maiwald, et al. (2008)
Lateral: Max force normalised to bodyweight B/G: Grau, Maiwald, et al. (2008)
Medial: Force-time integral B/G: Grau, Maiwald, et al. (2008)
Medial: Max force normalised to body weight. B/G: Grau, Maiwald, et al. (2008)
Note: *Signicant at p0.1 and p0.05; ITBS ¼iliotibial band syndrome; B/G ¼between groups; max ¼maximum; min ¼minimum.
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contradicting results reported for hip adduction angles (Ferber,
Noehren, et al., 2010; Grau, Maiwald, et al., 2008; Grau et al., 2011).
Grau, Maiwald, et al. (2008) found that matching subjects for
gender, weight and height accentuated kinematic differences and
attenuated kinetic differences between runners with ITBS and
healthy controls i.e. some kinematic differences became signicant
while some kinetic differences became insignicant. The results of
studies that did not match their subjects in this way may thus show
insignicant differences in kinematic and signicant differences in
kinetic variables when in fact the opposite is true. This does how-
ever not explain the contradictory results reported by Grau,
Maiwald, et al. (2008), Grau et al. (2011) and Ferber, Noehren,
et al. (2010) for maximum hip adduction angle during stance phase.
One should further keep in mind that, even though the partic-
ipants were pain free at the time of testing, the differences
observed between runners with a history of ITBS and healthy
controls could have been learnt pain avoidance strategies which
they adopted as a result of their injury (Heiderscheit, 2000).
Table 7
Results for coordination of the lower limbs.
Results Signicant difference Insignicant difference
Timing of maximum joint excursions
Time to max rear foot EVER B/G: Grau et al. (2011)
B/G: Messier and Pittala (1988)
B/G: Messier et al. (1995)
Time to max rear foot EVER velocity B/G: Messier et al. (1995)
Time to max ankle PF B/L: Orchard et al. (1996)
Time to max ankle DF angle B/G: Grau et al. (2011)
Time to max knee F B/G: Grau et al. (2011)
B/L: Orchard et al. (1996)
Time to max ADD B/G: Grau et al. (2011)
Time to max hip F Earlier for ITBS group: Grau et al. (2011) B/L: Orchard et al. (1996)
Over complete stride cycle
Knee F/E eFoot ABD/ADD ITBS group more variable at start of run: Miller et al. (2008) At end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eFoot INV/EVER ITBS group less variable at end of run: Miller et al. (2008) At start of run B/G: Miller et al. (2008)
Tibia IR/ER eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eTibia IR/ER At start and end of run B/G: Miller et al. (2008)
During swing phase
Knee F/E eFoot ABD/ADD ITBS group more variable at start of run: Miller et al. (2008) At end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Tibia IR/ER eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eTibia IR/ER At start and end of run B/G: Miller et al. (2008)
During stance phase
Knee F/E eFoot ABD/ADD ITBS group more variable at start and end of run: Miller et al. (2008)
Thigh ADD/ABD eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Tibia IR/ER eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eTibia IR/ER At start and end of run B/G: Miller et al. (2008)
At heel strike
Knee F/E eFoot ABD/ADD At start and end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eFoot INV/EVER At start and end of run B/G: Miller et al. (2008)
Tibia IR/ER eFoot INV/EVER ITBS group less variable at start of run: Miller et al. (2008) At end of run B/G: Miller et al. (2008)
Thigh ADD/ABD eTibia IR/ER At start and end of run B/G: Miller et al. (2008)
Note: ITBS ¼iliotibial band syndrome; B/G ¼between groups; F ¼exion; Eextension; ABD ¼abduction; ADD ¼adduction; IR ¼internal rotation; ER ¼external rotation;
INVER ¼inversion; EVER ¼eversion.
Table 8
Results for muscle strength and endurance.
Results Signicant difference Insignicant difference
Hip ABD/ADD strength
ABD: Isometric Decreased B/G þB/L: Fredericson, Cookingham, et al. (2000) B/G þB/L: Grau, Krauss, et al. (2008)
ABD: Concentric B/G þB/L: Grau, Krauss, et al. (2008)
ABD: Eccentric B/G þB/L: Grau, Krauss, et al. (2008)
ABD: Concentric endurance B/G þB/L: Grau, Krauss, et al. (2008)
ADD: Isometric B/G þB/L: Grau, Krauss, et al. (2008)
ADD: Concentric B/G þB/L: Grau, Krauss, et al. (2008)
ADD: Eccentric B/G þB/L: Grau, Krauss, et al. (2008)
ADD: Concentric endurance B/G þB/L: Grau, Krauss, et al. (2008)
ABD/ADD ratio for isometric, concentric and eccentric B/G þB/L: Grau, Krauss, et al. (2008)
Knee F/E strength
Strength at 60
/s
F max torque/body weight (concentric) B/G: Messier et al. (1995)
E max torque/body weight (concentric) B/G: Messier et al. (1995)
F/E ratio (concentric) Higher in ITBS group: Messier et al. (1995)*
Flexion/extension decit B/G: Messier et al. (1995)
Endurance at 240
/s
Endurance ratio F (concentric) B/G: Messier et al. (1995)
Endurance ratio E (concentric) B/G: Messier et al. (1995)
Note: *Signicant at p0.1 and p0.05; ITBS ¼iliotibial band syndrome; B/G ¼between groups; B/L ¼between legs; F ¼exion; E ¼extension; ABD ¼abduction;
ADD ¼adduction; reps ¼repetitions; max ¼maximum.
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3.4.2. Prospective
Prospective results suggest that runners who eventually
develop ITBS also display greater maximum internal rotation angles
at the knee during stance phase than healthy controls (Noehren
et al., 2007). They appear however to differ from runners with a
history of ITBS in that they display greater hip adduction angles
during stance phase and that they experience similar invertor
moments at their feet compared to healthy controls (Noehren et al.,
2007).
There is some evidence that the strain rate in the ITBs of runners
who eventually develop ITBS is greater than in healthy runners
(Hamill et al., 2008). A weak positive correlation may exist between
maximum strain and hip adduction, maximum strain and knee
internal rotation, strain rate and hip adduction as well as strain rate
and internal rotation of the knee (Hamill et al., 2008). These results
should again be interpreted with caution, as the model these re-
searchers used to calculate strain discounted the role the muscles
play in creating tension in the ITB. They modelled the ITB as a
completely passive structure, relying only on joint angles to in-
crease strain (Miller et al., 2007). The validity of this model has to be
questioned, as several researchers agree that the tension in the ITB
can be inuenced by contracting the gluteus maximus, tensor fascia
latae and vastus lateralis muscles (Becker et al., 2010; Birnbaum
et al., 2004; Fetto et al., 2002). The weak correlation found be-
tween strain/strain rate and the angles of the knee and hip may
even be an indication that muscular control (timing) plays a more
important role than joint kinematics (Noehren et al., 2007).
Since only prospective research can provide information
regarding cause and effect (Ferber, Noehren, et al., 2010), one can
argue that only internal rotation of the knee and adduction angles
of the hip have been shown to possibly play a role in the devel-
opment of ITBS. These results may however only apply to shod
female runners as these studies did not include any males.
3.4.3. Theories
It has been proposed that ITBS is caused by excessive friction as
the ITB slips over the LFE during exion and extension of the knee
(Orchard et al., 1996; Renne, 1975). Orchard et al. (1996) proposed
that certain peoples anatomy combined with decreased knee
exion angles during running, may predispose them to ITBS.
Researchers, however, have been unable to nd any differences
in knee exion angles between runners with a history of ITBS and
healthy controls (Ferber, Noehren, et al., 2010; Grau et al., 2011;
Miller et al., 2007; Orchard et al., 1996). It is therefore unlikely
that knee exion angles play a role in the aetiology of ITBS.
Hamill et al. (2008) used computer software to model
impingement between the ITB and the LFE of the femur. They found
no difference in impingement between runners who developed
ITBS and healthy controls. The validity of this method is debatable,
as it relies heavily on Orchard et al. (1996)s theory of the aetiology
of ITBS (see introduction). Their results could even be interpreted as
disproving the slipping band theory. It may indicate that
compression of other structures (than the LFE) deep to the ITB plays
a greater role, or that the combination of certain joint angles and
muscle actions are required to increase pressure on these struc-
tures (Fairclough et al., 2006).
Excessive eversion of the rear foot has also been suggested to
play a role in the development of ITBS as this could lead to excessive
internal rotation of the tibia and thus excessive strain in the ITB,
due to its attachment to Gerdys tubercle (Ferber, Noehren, et al.,
2010). This hypothesis is however not supported by the results of
this literature review. Retrospective and prospective studies agree
that there is no difference between groups for maximum eversion
angles observed at the rear foot (Ferber, Noehren, et al., 2010; Grau,
Maiwald, et al., 2008; Grau et al., 2011; Messier et al., 1995; Messier
& Pittala., 1988; Noehren et al., 2007). The only difference in ever-
sion angle has been found at heel strike, where retrospective evi-
dence suggests that runners with a history of ITBS display
decreased eversion angles (Grau, Maiwald, et al., 2008; Messier
et al., 1995) compared to healthy runners and this appears to be
accompanied by decreased internal rotation of the tibia at heel
strike (Grau, Maiwald, et al., 2008). No prospective evidence could
be found for the position of the rear foot at heel strike.
Research from prospective and retrospective studies both have
found greater maximum internal rotation angles at the knee during
stance phase in the ITBS groups (Ferber, Noehren, et al., 2010;
Noehren et al., 2007). Noehren et al. (2007) (prospective) ana-
lysed this further and found that the observed internal rotation was
due to a more externally rotated femur and not excessive internal
rotation of the tibia. This may point to a more proximal cause for
ITBS. No study could be found which investigated the sagittal plane
motion of the hip. Noehren et al. (2007) proposed that this exter-
nally rotated femur could be due to insufcient activity in the
medial rotators of the hip (gluteus minimus; anterior bres of
gluteus medius; tensor fascia latae). Conversely one can argue that
over activity or increased tone in the external rotators of the hip
Table 9
Results for strain and impingement.
Results Signicant difference Insignicant difference
Strain and impingement
Max strain during stance Higher in ITBS group at start and end of run: Miller et al. (2007)
Strain at heel strike B/G þB/L: Hamill et al. (2008)
Start and end of run: Miller et al. (2008)
Strain at max knee F B/G þB/L: Hamill et al. (2008)
Strain rate Higher for ITBS group vs. control group: Hamill et al. (2008) B/L: Hamill et al. (2008)
Number of ITBs impinging against femur B/G: Miller et al. (2007)
Duration of impingement during stance phase B/G þB/L: Hamill et al. (2008)
Symmetry index for strain at touch down B/G: Hamill et al. (2008)
Symmetry index for strain at max knee F B/G: Hamill et al. (2008)
Symmetry index for strain rate B/G: Hamill et al. (2008)
Symmetry index for impingement B/G: Hamill et al. (2008)
Correlations:
Max strain and hip ADD weak: Hamill et al. (2008)
Max strain and knee IR weak: Hamill et al. (2008)
Strain rate with hip ADD weak: Hamill et al. (2008)
Strain rate with IR of knee weak: Hamill et al. (2008)
Note: ITBS ¼iliotibial band syndrome; max ¼maximum; F ¼exion; ADD ¼adduction; IR ¼internal rotation; max ¼maximum; B/G ¼between groups; B/L ¼between
involved and uninvolved legs of ITBS group.
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(piriformis; gemellus superior; obturator internus; gemellus infe-
rior; obturator externus; quadratus femoris) would have the same
effect.
Due to the ITBs attachment to the pelvis and femur, increased
hip adduction angles have been proposed as an etiological factor for
ITBS as it could potentially lead to increased strain in the ITB
(Ferber, Kendall, et al., 2010; Ferber, Noehren, et al., 2010; Noehren
et al., 2007). Prospective results (Noehren et al., 2007) of shod fe-
male runners would appear to support this hypothesis. Results
from retrospective studies (Ferber, Noehren, et al., 2010; Grau,
Maiwald, et al., 2008; Grau et al., 2011) are however inconclusive
and further research is required in this eld. Although two litera-
ture reviews (Murphy, Connolly, & Beynnon, 2003; Van Gent, Siem,
Van Middelkoop, Van Os, Bierma-Zeinstra, & Koes, 2007) agree that
static biomechanical variables do not appear to increase the risk of
developing ITBS, it may be worth investigating static hip and pelvic
alignment as the studies included in these reviews mostly inves-
tigated Q-angles as well as foot and knee alignment.
Interestingly, in neither prospective nor retrospective studies
did increased hip adductor angles lead to increased hip abductor
moments, which may mean that the demands on the hip abductor
muscles were similar between the groups (Ferber, Noehren, et al.,
2010; Noehren et al., 2007). This led the researchers to question
whether timing rather than magnitude of muscle activation played
a role in the development of ITBS (Ferber, Noehren, et al., 2010;
Noehren et al., 2007). None of the studies reported the move-
ments of the pelvis or trunk which may also inuence the kinetics
and kinematics of the hip.
3.5. Muscle strength and endurance
It has been suggested that weakness of the gluteus medius
muscle could lead to increased adduction angles at the hip joint,
thus increasing strain in the ITB (Ferber, Noehren, et al., 2010;
Fredericson, Cookingham, et al., 2000; Noehren et al., 2007). To
date, no prospective evidence for this mechanism exists and the
retrospective evidence is contradictory. Fredericson, Cookingham,
et al. (2000) used a handheld dynamometer and reported signi-
cant (isometric) weakness in the abductors of legs aficted with
ITBS, while Grau, Krauss, et al. (2008) could nd no difference in
(concentric, eccentric, isometric) strength or endurance, using an
isokinetic dynamometer. The reliability of handheld dynamome-
ters are regularly questioned in the literature (Beers et al., 2008;
Grau, Maiwald, et al., 2008), but Fredericson, Cookingham, et al.
(2000) did report an ICC of 0.96.
Studies evaluating muscle strength in other populations of
athletes (track athletes; skiing, gym) suffering from ITBS have also
failed to nd weakness in the hip abductors (Beers et al., 2008;
Williams, 2005). Hip abductor weakness thus does not appear to
contribute to the aetiology of ITBS. This nding may support Fetto
et al. (2002)s suggestion that the gluteus maximus may play an
important role in tensioning the ITB and preventing excessive hip
adduction during gait and future research should include strength
tests for the gluteus maximus.
Messier et al. (1995) found a bigger knee exion/extension
strength ratio in runners with ITBS. This may indicate muscle im-
balances between the knee exors and extensors in the aetiology of
ITBS, but this is unlikely since strength and endurance for these
muscles did not vary between the groups (Messier et al., 1995).
Grau, Krauss, et al. (2008) makes the point that none of the tests
used during these trials can give an accurate impression of a
muscles functional strength. Noehren et al. (2007),Ferber, Kendall,
et al. (2010) and Ferber, Noehren, et al. (2010) both suggested that
future research should include EMG evaluations of muscle function,
as they are of the opinion that the timing of muscle action rather
than the magnitude thereof may be important. Miller et al. (2007)
further hypothesised that abnormal biomechanics would become
more pronounced as fatigue sets in. However, their research
received a WEAK QR and so the evidence in support of this is still
lacking.
3.6. Sensitivity analysis
If Noehren et al. (2007)s (prospective) results had been pooled
with those of the retrospective studies the following results would
have changed:
Knee exion at heel strike: The level of evidence would have
changed from 4 to 3 and would have shown that there is no
difference for knee exion at heel strike between runners with
and without ITBS.
Invertor moment at the foot: For this variable, the level of ev-
idence would have changed from having limited evidence for
the respective groups to having no evidence supporting any
ndings regarding invertor moments at the foot.
3.7. Critical appraisal of this literature review
The results of this literature review may have been inuenced
by error and bias, since only one researcher screened all the articles
for inclusion, extracted the data and conducted the methodological
quality analysis of the articles (Centre for Reviews and
Dissemination, 2009). In an attempt to limit error, the researcher
analysed the articles on two separate occasions and adhered to
strict inclusion and exclusion criteria during the selection process.
Language bias may also have inuenced the results, as only English
articles were included. An attempt to limit publication bias was
made by searching the available databases which list unpublished
dissertations and theses.
The method used to analyse the level of evidence provided by
the results has been adapted from the levels of evidence approach
as recommended by the Cochrane Collaboration Back Review
Group (Ellis, Hing, & Reid, 2007; Reid & Rivett, 2005). The use of
different analysis guidelines may have led to different levels of
evidence for the present study (Reid & Rivett, 2005).
4. Conclusion and recommendations
4.1. Conclusion
Traditional theories of the aetiology of ITBS are challenged by
the results of this literature review. It appears unlikely that
abnormal biomechanics at the foot or tibia is responsible for
increasing tension in the ITB. It does however point to a more
proximal cause e.g. sagittal and frontal plane motion of the hip
joint. There is currently no evidence to suggest that reduced muscle
strength plays a role in the aetiology of ITBS.
The results of this literature review should be interpreted with
caution as it mostly relies on retrospective evidence.
4.2. Recommendations
Prospective studies with large sample sizes evaluating static
biomechanics, kinetics, kinematics, muscle activity (through EMG)
and muscle strength (Ferber, Kendall, et al., 2010, Ferber, Noehren,
et al., 2010; Noehren et al., 2007) of the lower limbs, pelvis and
trunk are needed. Subjects should be matched for weight, height
and gender (Grau, Maiwald, et al., 2008). Kinematic evaluations
should include the frontal plane motions of the hip. Runners should
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be classied according to their regular running style (forefoot, mid
foot, rear foot strikers) and different fatigue protocols (specic
muscle groups vs. fatigue measure by VO
2
max) should be included
(Grau et al., 2011; Miller et al., 2007). The biomechanics of downhill
running should also be investigated, since this is regularly reported
as the most painful activity for runners suffering from ITBS
(Orchard et al., 1996). Ideally one should also log the participants
training so that confounding factors e.g. increased intensity can be
controlled for.
Conict of interest
The authors declares there are no conicts of interest regarding
the work.
Funding
This review was not supported by any sources of funding.
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... This might imply that a single difference at one level, unilaterally, might be insignificant, however, it may become significant if the sum of all deviations in all joints, in more than one plane of motion, leads to a significant total change in the lower limb alignment, reflected by the GPS. This may explain the conflicting findings of several researchers who found no correlation between single kinematic deviations and injuries [32,38]. Ceyssens et al. in their systematic review, found no conclusive biomechanical mechanism to explain the development of running related injuries [38] and concluded that current prospective evidence relating biomechanical variables to running-related injury risk is scarce and inconsistent, with findings largely dependent on the population and injuries being studied. ...
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Hip abductor strengthening probably has more value than stretching in iliotibial band syndrome (ITB), but cortisone injections and surgery may still be useful management options. Local anaesthetic blocks may be more accurate at diagnosing ITB syndrome than MRI scan.
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The objectives of our study were: 1) to examine differences between a noninjured cohort of runners (N = 70) and runners afflicted with iliotibial band friction syndrome (ITBFS) (N = 56) according to selected anthropometric, biomechanical, muscular strength, and training measures; 2) to explore multivariate relationships among these measures in both the well and injured groups; and 3) to develop specific hypotheses concerning risk factors for injury that will later be tested in a prospective observational study. High speed videography (200 fps), a force platform (500 Hz), and a Cybex II+ isokinetic dynamometer were used to assess rearfoot motion, ground reaction forces, and knee muscular strength and endurance, respectively. A linear discriminant function analysis of the training data revealed weekly mileage, training pace, number of months using current training protocol, % time spent swimming, and % time spent running on a track to be significant (P < 0.10). Height was a significant anthropometric discriminator, while seven isokinetic strength and endurance measures were found to discriminate significantly between the groups. Calcaneal to vertical touchdown angle, and maximum supination velocity were significant rearfoot movement discriminators. Maximum braking force was the only significant kinetic discriminator. A combined discriminant analysis using those variables found to be significant in the previous analyses revealed weekly mileage, and maximum normalized braking force to be the best discriminators (model P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Both forefoot strike shod (FFS) and barefoot (BF) running styles result in different mechanics when compared to rearfoot strike (RFS) shod running. Additionally, running mechanics of FFS and BF running are similar to one another. Comparing the mechanical changes occurring in each of these patterns is necessary to understand potential benefits and risks of these running styles. The authors hypothesized that FFS and BF conditions would result in increased sagittal plane joint angles at initial contact and that FFS and BF conditions would demonstrate a shift in sagittal plane joint power from the knee to the ankle when compared to the RFS condition. Finally, total lower extremity power absorption will be least in BF and greatest in the RFS shod condition. The study included 10 male and 10 female RFS runners who completed 3-dimensional running analysis in 3 conditions: shod with RFS, shod with FFS, and BF. Variables were the angles of plantarflexion, knee flexion, and hip flexion at initial contact and peak sagittal plane joint power at the hip, knee, and ankle during stance phase. Running with a FFS pattern and BF resulted in significantly greater plantarflexion and significantly less negative knee power (absorption) when compared to shod RFS condition. FFS condition runners landed in the most plantarflexion and demonstrated the most peak ankle power absorption and lowest knee power absorption between the 3 conditions. BF and FFS conditions demonstrated decreased total lower extremity power absorption compared to the shod RFS condition but did not differ from one another. BF and FFS running result in reduced total lower extremity power, hip power and knee power and a shift of power absorption from the knee to the ankle. Alterations associated with BF running patterns are present in a FFS pattern when wearing shoes. Additionally, both patterns result in increased demand at the foot and ankle as compared to the knee.
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Barefoot running is slowly gaining a dedicated following. Proponents of barefoot running claim many benefits, such as improved performance and reduced injuries, whereas detractors warn of the imminent risks involved. Multiple publications were reviewed using key words. A review of the literature uncovered many studies that have looked at the barefoot condition and found notable differences in gait and other parameters. These findings, along with much anecdotal information, can lead one to extrapolate that barefoot runners should have fewer injuries, better performance, or both. Several athletic shoe companies have designed running shoes that attempt to mimic the barefoot condition and, thus, garner the purported benefits of barefoot running. Although there is no evidence that either confirms or refutes improved performance and reduced injuries in barefoot runners, many of the claimed disadvantages to barefoot running are not supported by the literature. Nonetheless, it seems that barefoot running may be an acceptable training method for athletes and coaches who understand and can minimize the risks.