A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Science. Johannesburg, 2001 / Long distance running is characterised by a high injury rate (van Mechelen, 1995; Lysholm and Wiklander, 1987). It is an ever-growing sport, being tried by increasing numbers of people with varying degrees of athletic ability. Injuries are detrimental to training, increase the risk of sustaining another injury, and are expensive to treat placing demands on our already strained health care system. Runners are healthy people who would require less health care than most people if they could avoid injuries. Iliotibial band friction syndrome (ITBFS), is one of the most common running injuries experienced. Buttock and/or posterior thigh pain (BAOPTP) is another common condition, which is also resistant to treatment. It tends to become chronic and to result in ongoing morbidity. / IT2018

Thesis (MScPhysio)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Introduction: Iliotibial band syndrome (ITBS), an overuse injury, is the second most common running injury and the main cause of lateral knee pain in runners. Due to the increasing number of runners worldwide there has been an increase in its occurrence. Runners with ITBS typically experience symptoms just after heel strike at approximately 20°-30° of knee flexion (impingement zone) during the stance phase of running. A variety of intrinsic and extrinsic risk factors may be responsible for why some runners are more prone to developing symptoms during the impingement zone as opposed to others. Abnormalities in running biomechanics is an intrinsic risk factor which has been most extensively described in literature but little is known about its exact relationship to ITBS. Objectives: The purpose of this systematic review was to provide an up to date evidence synthesis of the biomechanical risk factors associated with ITBS. These risk factors may need to be considered in the prevention or management of ITBS in runners. A clinical algorithm is also presented. Methods: A systematic review with meta-analysis was conducted. An electronic search was performed in PubMed, PEDro, SPORTSDisc and Scopus of literature published up-until May 2014. Cross-sectional and cohort studies were eligible for inclusion if they evaluated the lower limb biomechanics of runners with ITBS or those who went onto developing it. All studies included in the review were methodologically appraised. Evidence was graded according to the level of evidence, consistency of evidence and the clinical impact. Data was described narratively using tables or narrative summaries where appropriate. A meta-analysis was conducted for biomechanical risk factors which were reported in at least two studies, provided that homogeneity in the outcomes and samples were present. Results: A total of 11 studies were included (1 prospective and 10 cross-sectional). Overall the methodological score of the studies was moderate. Increased peak hip adduction and knee internal rotation during the stance phase may predict the development of ITBS in female runners. These biomechanical risk factors may need to be screened for ITBS prevention, despite the evidence base being limited to a single study. Currently there is no conclusive evidence that any of the biomechanical parameters need to be considered when managing runners with ITBS. Stellenbosch University https://scholar.sun.ac.za iii Conclusion: Biomechanical differences may exist between runners with ITBS and those who may develop ITBS compared to healthy runners. Although a large variety of biomechanical risk factors were evaluated, the evidence base for screening or managing these risk factors for runners with ITBS is limited. This is due to a small evidence base, small clinical effect and heterogeneity between study outcomes and findings. Further prospective and cross-sectional research is required to ascertain if abnormalities in running biomechanics may be related to why runners develop ITBS or to ascertain which risk factors may be involved when managing these runners. / AFRIKAANSE OPSOMMING: Inleiding: Iliotibiale-band-sindroom (ITBS), ’n besering vanweë oormatige gebruik, is die tweede algemeenste hardloopbesering en die hoofoorsaak van laterale kniepyn by hardlopers. Namate die getal hardlopers wêreldwyd toeneem, neem die voorkoms van hierdie toestand ook toe. Hardlopers met ITBS ervaar tipies simptome ná die hakslag met die knie ongeveer 20-30° gebuig (die wrywingsone of “impingement zone”) gedurende die staanfase van hardloop. Verskeie intrinsieke en ekstrinsieke risikofaktore kan ’n rol speel in waarom sommige hardlopers meer geneig is as ander om gedurende die wrywingsone simptome te ervaar. Abnormaliteite in hardloopbiomeganika is ’n intrinsieke risikofaktor wat reeds omvattend in die literatuur beskryf is. Tog is weinig bekend oor presies hoe dit met ITBS verband hou. Oogmerke: Die doel van hierdie stelselmatige ondersoek was om ’n sintese te bied van die jongste bewyse van die biomeganiese risikofaktore van ITBS. Hierdie risikofaktore kan dalk oorweeg word om ITBS by hardlopers te voorkom of te bestuur. ’n Kliniese algoritme word ook aangebied. Metodes: ’n Stelselmatige ondersoek is met behulp van meta-ontleding onderneem. PubMed, PEDro, SPORTSDisc en Scopus is elektronies deurgesoek vir literatuur wat tot en met Mei 2014 verskyn het. Deursnee en kohortstudies is ingesluit indien dit gehandel het oor die biomeganika in die onderste ledemate van hardlopers wat ITBS het of later ontwikkel het. Alle studies wat deel was van die ondersoek is metodologies geëvalueer. Bewyse is aan die hand van bewysvlak, bewyskonsekwentheid en kliniese impak beoordeel. Data is narratief beskryf met behulp van tabelle of narratiewe opsommings waar dit toepaslik was. ’n Meta-ontleding is onderneem waar biomeganiese risikofaktore in minstens twee studies aangemeld is, mits daar homogeniteit in die uitkomste sowel as die steekproewe was. Resultate: Altesaam 11 studies is ingesluit (een prospektief en tien deursnee). Die metodologiese telling van die studies was oorwegend gemiddeld. Verhoogde spitsheupadduksie en interne knierotasie gedurende die staanfase kan op die ontwikkeling van ITBS by vrouehardlopers dui. Hierdie biomeganiese risikofaktore kan dalk nagegaan word vir ITBS-voorkoming, al was die bewysbasis beperk tot ’n enkele studie. Daar is tans geen afdoende bewys dat enige van die biomeganiese parameters oorweeg behoort te word in die bestuur van langafstandatlete met ITBS nie. Gevolgtrekking: Daar bestaan dalk biomeganiese verskille tussen hardlopers wat ITBS het of kan ontwikkel en gesonde hardlopers. Hoewel ’n groot verskeidenheid biomeganiese risikofaktore beoordeel is, is die bewysbasis vir die toets of bestuur daarvan by atlete met ITBS beperk. Dít is vanweë die klein hoeveelheid bewyse, die klein kliniese impak, en heterogeniteit tussen studie-uitkomste en bevindinge. Verdere prospektiewe en deursneenavorsing word vereis om te bepaal of abnormaliteite in hardloopbiomeganika ’n rol kan speel in waarom langafstandhardlopers ITBS ontwikkel, of om vas te stel watter risikofaktore ter sprake kan wees in die bestuur van hierdie hardlopers.

The Gluteus Medius and the Tensor Fascia Lata are two of the main muscles involved in the action of hip abduction. This action is important for both dynamic movements in athletic pursuits and in every day ambulation. Weakness in these muscles has been connected to multiple injuries in the lower limb, but the question of the casual relationship between gait change, hip abductor weakness, and lower limb injury is still up for debate. As presented by the current research, younger populations tend to have overuse injuries with females having a greater susceptibility for injuries connected to hip abductor weakness, and older populations tend to have injures related to atrophy and degeneration of either the hip abductor muscles or the joint surrounding the hip. Research in this field has increasingly focused on sub-sets of the populations, such as just females or just males, trying to pinpoint the role that hip abductor weakness plays in these injuries. By trying to minimize or even eliminate the confounding variables that have previously made it difficult to determine the role hip abductor weakness plays in these gait changes and injuries, these studies have been able to make more clear conclusions at the expense of making a broader generalization. Similarities and differences between how the sub-groups present with hip abductor weakness are discussed, as well as discrepancies observed within the research done on similar cohorts. Future directions for research in this field are discussed, as well as implications for clinical implementation of targeted rehabilitation programs to ensure the best possible outcomes.

Bakgrund: Knäskador är en av de vanligaste skadorna inom en rad idrotter. Hos nybörjarlöpare som följdes under ett år var 32% av de rapporterade skadorna knäskador/besvär. Iliotibialbandsyndrom, också känt som löparknä, är vanligt hos framför allt löpare, cyklister och militärer. Det saknas konsensus kring patologi och etiologi och flertalet förklaringsmodeller finns. Konservativ behandling har oftast god effekt men med varierad tid för återgång till normal aktivitetsnivå. Behandling kan bestå av både patientstyrd samt terapeutberoende behandling. Det saknas emellertid evidens för vilken typ av behandling som har bäst effekt. Syfte: Syftet var att undersöka terapeutberoende och patientstyrda behandlingars effekt på smärta och funktion hos patienter med iliotibialbandsyndrom. Metod: Datainsamling till denna litteraturöversikt genomfördes via sökning i databaserna Pubmed, PEDro, Cinahl samt ONE search via Linnéuniversitetets bibliotek utifrån givna sökkriterier under perioden 220730 – 220808. Resultat: Totalt inkluderades sex studier vars kvalité bedömdes utifrån PEDro scale. Tre av studierna hade patientstyrda behandlingar och tre hade terapeutberoende behandlingar. Terapeutberoende behandlingar minskade smärta signifikant i samtliga tre studier. Patientstyrda behandlingar minskade smärta signifikant efter studietiden. Gällande funktion hade både terapeutberoende och patientstyrda behandlingar effekt. De patientstyrda behandlingarna uppvisade en viss fördel gällande funktionsförbättringar jämfört med terapeutberoende behandling. Konklusion: Resultatet tyder på att båda typerna av behandling har en god effekt på smärta. Gällande funktion verkar ett rehabiliteringsprotokoll med successiv ökad belastning ge en större förbättring. / Background: Knee injuries are one of the most common injuries in a range of sports. In novice runners followed for one year, 32% of reported injuries were knee injuries. Iliotibial band syndrome, also known as runner's knee, is common in runners, cyclists and the military. There is a lack of consensus regarding pathology and etiology when it comes to iliotibial band syndrome and several explanatory models exist. Conservative treatment has been noted to achieve good effects, but with a varied time for return to normal activity level. Treatment can consist of both patient-controlled and therapist-dependent treatment. There is, however, a lack of evidence to determine which treatment type is the most effective to relieve symtoms and improve functional ability. Aim: The aim was to examine the effect of therapist-dependent and patient-controlled treatments on pain and function in patients with iliotibial band syndrome. Method: Data collection was carried out by searching the databases Pubmed, PEDro, Cinahl and ONE search via Linnaeus University's library during the period 220730 - 220808. Results: A total of six studies were included, the quality of which was assessed based on the PEDro scale. Therapist-dependent treatments significantly reduced pain. Patient-controlled treatments significantly reduced pain after the study period. Regarding function, both therapist-dependent and patient-controlled treatments had an effect. The patient-directed treatments showed a certain advantage regarding functional improvements compared to therapist-dependent treatment. Conclusion: The results indicate that both types of treatment have a good effect on pain. Regarding function, a rehabilitation protocol with successively increased load appears to provide a greater functional improvement.

The etiology of iliotibial band syndrome (ITBS) is not fully understood, however, dysfunction at the hip and decreased resistance to fatigue have been suggested to contribute to development of the syndrome. The objective of this study was to investigate differences in hip abductor strength and fatigue resistance, hip muscle activation timing and hip joint kinematic, kinetic and joint coupling patterns in female runners with and without ITBS. In addition, this study examined the effects of a run to exertion on these variables. Twelve female runners with ITBS and 20 healthy female runners participated in this study. Gluteus medius strength and electromyographic (EMG) data were collected during isometric testing. In addition, EMG data from the gluteus medius and tensor fascia latae muscles as well as 3-dimensional kinematic, kinetic and joint coupling data were collected during overground running. All data were collected prior-to and following a run to exertion. Prior to the run to exertion, with runners in a "fresh" state, there were no differences in hip abductor strength, kinematic joint coupling and terminal swing phase muscle activation timing between runners with ITBS and healthy runners. In a "fresh" state, ITBS runners demonstrated less resistance to fatigue at their gluteus medius muscle than did the healthy runners. As a result of exertion, runners with ITBS demonstrated decreased peak hip adduction angles during the stance phase of running gait. There were no group-by-exertion interactions for peak hip internal rotation angles, hip abductor and external rotator moments, kinematic joint coupling or hip abductor strength. There was a main effect of exertion for hip abductor moments, hip external rotator moments and hip abductor strength whereby both healthy and injured runners demonstrated 3.8, 4.2 and 7.3% decreases respectively following the run to exertion. In addition, there was a main effect of exertion on hip frontal/knee transverse plane kinematic joint coupling during the first half of loading where runners demonstrated a 7.3% increase in joint coupling values following the run to exertion. Our data did not detect group-by-exertion interactions or main effects of group or exertion with respect to terminal swing muscle activation timing. There was a significant group-by-exertion interaction when examining fatigue resistance. In a fresh-state, runners with ITBS demonstrated less resistance to fatigue than their healthy counterparts. Following the run to exertion, these differences did not exist. The results of this study suggest that currently symptomatic runners with ITBS demonstrate a potentially compensatory pattern of decreased stance phase hip adduction as compared with healthy runners. Hip internal rotation, abductor moments, external rotator moments or kinematic joint coupling do not appear to discriminate between the two groups. The results of this study also suggest that hip abductor strength may not be as large of a factor in the development of ITBS as previously thought. Instead, this muscle's endurance, or its ability to resist fatigue may play a larger role. / Physical Therapy

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Iliotibial band friction syndrome is a common dysfunction seen in athletes. Athletes develop biomechanical changes yet still continue with their sport. However, this syndrome limits their ability to participate at peak performance. This study determined which participants benefitted in terms of biomechanical and clinical outcomes in one of four groups: ankle joint, superior tibio-fibular joint, sacroiliac joint or a combination manipulation group (which contained any two of the three joint restrictions). Methods: This Durban University of Technology Institutional Research and Ethics Committee approved prospective clinical trial, utilised stratified sampling, with 48 participants across four groups: ankle (14); superior tibio-fibular (11), sacroiliac (12) and combination (11). The participants underwent six treatments in three weeks. Data collection occurred before consultations one, three, five and seven. The data included primary measures of the knee score questionnaire (KSQ), the algometer, the visual analogue scale (VAS) and the secondary measures of the Feiss line, the heel leg alignment, bilateral leg length, Q angle and tibio-femoral angle. All data was computed utilising the ANOVA testing, with a p-value <0.05 being significant and a 95% confidence interval. Pearson’s correlations were completed for intragroup associations between primary and secondary outcome measures. Results: The intragroup analysis revealed that all groups had significant changes in the KSQ and VAS, with the exception of the sacroiliac joint manipulation group (KSQ outcome not significant). Intergroup analysis revealed no differences between the groups with the exception of the combination group, which showed a significant increase in the tibio-femoral angle. Most commonly, the Pearson’s correlation revealed that changes in leg length were related to differences in primary outcome measures, irrespective of the group being tested. Conclusion: The outcomes of this study indicated that manipulation of the distal kinematic chain improved alignment and clinical outcomes to a greater degree than manipulating proximal restrictions. It is suggested with caution (due to limited sample size) that patients should first have their distal kinematic chain manipulated before more proximal joints are manipulated to achieve better outcomes. / M