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

El Síndrome de la banda iliotibial es la principal causa de dolor lateral de rodilla en corredores. Se asocia a debilidad en la musculatura abductora de cadera, entre otras causas que siguen siendo investigadas. El presente estudio consistió en determinar el tiempo de activación muscular del glúteo medio y tensor de la fascia lata en atletas sanos y con síndrome de la banda iliotibial, durante la carrera. La población estudio se compuso de atletas fondistas y triatletas pertenecientes a distintos clubes de corredores de la Región Metropolitana, de edades promedio de 26,31 ±7,47años. La muestra se conformó de 16 sujetos de género masculino; 9 sanos y 7 lesionados. El protocolo de estudio se llevó a cabo en el laboratorio de análisis de movimiento de la Escuela de Kinesiología de la Universidad de Chile. Cada sujeto realizó una prueba de carrera en cinta rodante, a una velocidad de 10 km/h, con 2 grados de inclinación. Se realizó un registro electromiográfico de superficie del músculo tensor de la fascia lata y del glúteo medio en ambas extremidades. Se aplicó una prueba t de student (95% intervalo de confianza) para muestras relacionadas (p<0.05). Los resultados obtenidos mostraron gran variabilidad en los tiempos de activación entre sujetos, sin embargo, se mantienen relativamente constantes para un mismo sujeto. En sujetos sanos, el tiempo de activación del glúteo medio fue -0,087±0,059 segundos y el tiempo de activación del tensor de la fascia lata fue 0,02±0,025 segundos, en donde la activación del glúteo medio precedió a la del tensor de la fascia lata, y a su vez al contacto inicial del pie, a diferencia del tensor de la fascia lata, que se activa después del contacto inicial del pie. En los individuos con síndrome de la banda iliotibial, el tiempo de activación del glúteo medio correspondió a -0,074± 0,046 segundos, y el correspondiente al tensor de la fascia lata fue de -0,005±0,038 segundos. Se concluyó que las diferencias entre los tiempos de activación de ambos grupos no fueron significativas. Tampoco lo fueron para los valores de tiempo de activación en relación al porcentaje de la fase de apoyo. / The iliotibial band syndrome is the leading cause of lateral knee pain in runners. It is associated with weakness in the hip abductor muscles, among other causes are being investigated. The present study was to determine the activation time of gluteus medius and tensor fascia lata in healthy and iliotibial band syndrome athletes during the race. The study population consisted of distance runners and triathletes from different running clubs in the metropolitan region, average age 26.31 ± 7.47 years. The sample consisted of 16 male subjects, 9 healthy and 7 injured. The study protocol was carried out in the motion analysis laboratory of the School of Kinesiology, University of Chile. Each subject performed a test of treadmill running at a speed of 10 km / h, with 2 degrees of inclination. A record was made of surface electromyography from tensor fascia lata and gluteus medius on both ends. We applied a Student's t test (95% confidence interval) for related samples (p <0.05). The results showed great variability in activation times between subjects, however, remain relatively constant for a given subject. In healthy subjects, the activation time of the gluteus medius was -0.087 ± 0.059 seconds and the activation time of the tensor fascia lata was 0.02 ± 0.025 seconds, where activation of the gluteus medius preceded the tensor fascia lata, and in turn the initial foot contact, unlike the tensor fascia lata, which is activated after initial contact of the foot. In individuals with iliotibial band syndrome, the time of activation of the gluteus medius corresponded to ± 0.046 -0.074 seconds, and for the tensor fascia lata was -0.005 ± 0.038 seconds. It was concluded that the differences between the activation times of both groups were not significant. Neither were the values for activation time relative to the percentage of the stance phase.

The iliotibial band (ITB) is a complex structure that is unique to humans among apes and is derived from the fascia lata (FL) of the thigh. Although the ITB evolved in the hominin lineage, it is unclear whether it evolved to improve locomotor economy, increase stability, or serve a different function. This dissertation tests the hypothesis that the ITB stores and recovers elastic energy during walking and running. / Human Evolutionary Biology

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

La performance sportive et la prévention des blessures en cyclisme sont étroitement liées à l'amélioration des capacités physiques, de la technique gestuelle ainsi qu'à l'optimisation du matériel utilisé.Dans ce contexte, nous avons étudié l'influence du recul de selle sur l'efficacité du mouvement de pédalage ainsi que sur les efforts internes au niveau du genou. Une approche de modélisation musculo-squelettique a été développée afin de quantifier indirectement les forces musculaires et articulaires exercées à partir de mesures externes cinématiques et dynamiques. Un intérêt tout particulier a été porté sur l'adéquation entre les mesures des efforts extérieurs, le modèle anthropométrique et les mesures cinématiques afin de diminuer les incohérences dynamiques associées à un système surdéterminé.A partir de ces mesures, les effets du recul de la selle sur la performance ont été évalués à travers l'indice d'efficacité de la force produite à la pédale et un nouvel indice, basé sur le travail mécanique externe. Les résultats ont montré qu'un positionnement de la selle plus reculé augmente l'efficacité du mouvement de pédalage.Concernant la prévention des blessures, notre analyse s'est portée sur l'effet du recul de selle sur deux troubles musculo-squelettiques (TMS) fréquents en cyclisme : le syndrome fémoro-patellaire et le syndrome de la bandelette ilio-tibiale. Nos résultats ont montré que le recul de selle ne modifie pas les forces fémoro-patellaires communément incriminées dans la survenue de ce syndrome. Par ailleurs, une position plus reculée augmente les forces fémoro-tibiales de compression par le biais notamment de la contraction excentrique des muscles ischio-jambiers. Bien que le syndrome de la bandelette ilia-tibiale soit classiquement décrit comme un syndrome de friction (syndrome de l'essuie-glace), le calcul de la force d'interaction entre la bandelette iliotibiale et l'épicondyle fémoral a montré que la compression est le facteur discriminant dans le pathoméchanisme. L'approche méthodologique de simulation développée dans ce cadre possède par ailleurs un fort potentiel afin de corriger les défauts techniques, d'optimiser les réglages matériels et améliorer la prise en charge thérapeutique des TMS.Plus généralement, les développements méthodologiques et implications cliniques issus de ces travaux trouvent des applications directes dans le milieu du cyclisme mais aussi dans l'étude de nombreuses activités sportives (notamment sur ergomètre) du point de vue de la performance, de la prévention des blessures et de la rééducation. / Performance and prevention of injuries in cycling are closely linked to the optimisation of individual's physical capacity and technique as weil as sport equipment.In this context, we have studied the influence of saddle setback on the effectiveness of pedalling and on knee joint loads. A musculoskeletal modelling was developed to estimate muscle and joint forces from experimental kinematic and dynamic measurements. We first focused on the adequacy between sensors data, anthropometrie model and kinematic measurements to obtain dynamically consistent input data.Then, the effect of sadd le setback on perforn1ance was evaluated through the index of pedal force effectiveness and a new index based on extemal mechanical work. Results have showed that a more backward sadd le position increases the effectiveness of pedalling.As regards to in jury prevention, our analysis focused on the effect of the saddle setback on two knee injuries commonly observed in cycling: the patellofemoral syndrome and iliotibial band syndrome. Our results showed that saddle setback do not influence patellofemoral joint forces that are usually linked to this syndrome. Moreover, a more backward saddle position increases tibiofemoral compression forces due to increasing eccentric contraction of the hamstrings.Commonly described as a friction syndrome, the computation of interaction force between iliotibial band and lateral femoral epicondyle have showed that the compression was the discriminating factor in the occurrence of the syndrome. The simulation approach developed here could be used as an additional tool to help correct potentially hartnful sport techniques, optimise equipment setup/design and improve the treatment of injuries.More generally, this thesis brings new methodological improvements and clinical implications that have broader applications on sport perfortnance, injury prevention and rehabilitation.

Purpose: To determine the relationship between iliotibial band (ITB) length and the presence of patellofemoral pain syndrome (PFPS), compare the difference in ITB length between the painful knee and the non-painful knee in subjects with unilateral PFPS, determine the test-retest reliability, standard error of measurement, and minimal detectable change (MDC) of the Ober test and modified Thomas test, and explore the relationship between the Ober test and the modified Thomas test in measuring ITB length. Subjects: Forty-eight subjects were recruited (PFPS group n=24, control group n=24) from three different outpatient physical therapy clinics. Methods: The Ober test and modified Thomas test was conducted on both legs of each subject to determine ITB length with the use of a digital inclinometer. Examiners were blinded to group assignment and an independent observer recorded all the results. Results: The mean values for hip adduction during the Ober test was 7.2 degrees in the control group and 2.3 degrees in the PFPS group. One way ANOVA revealed a significant difference between groups (p= .011). There were no differences in ITB length comparing the painful knee to the non-painful knee for both the Ober test and modified Thomas test. The ICC values calculated for the test-retest reliability were .95 for the Ober test and .86 for the modified Thomas test. Pearson correlational analysis revealed a weak negative correlation (r=-.40, p=.005) between the Ober test and modified Thomas test on the left side and no correlation on the right side. Discussion and Conclusion: The Ober test is better at distinguishing between a PFPS group and a control group than the modified Thomas test supporting the clinical utility of the Ober test. The use of a digital inclinometer for both the Ober test and modified Thomas test appears to be a reliable method for the measurement of ITB length. However, given the lack of relationship found between the two tests, the two examination procedures should not be used interchangeably for the measurement of ITB length.

Im Mittelpunkt dieser kumulativ angefertigten Arbeit stehen fünf verschiedenartige biomechanische Untersuchungen faseriger Bindegewebe, welche in einer Gesamtschau zusammengeführt werden. Die einzelnen Beiträge setzen sich zusammen aus Untersuchungen zum Einfluss zellulärer Bestandteile auf die mechanischen Eigenschaften faseriger Bindegewebe und die Beeinflussung dieser Ergebnisse durch Messfehler, speziell am Beispiel des Materialschlupfs. Über diese beiden Beiträge wird eine Verbindung hergestellt zur rechnergestützten Simulation der Wirkung eines Beckenkompressionsgurts auf die Bänder des Beckenrings und dem Transmissionsverhalten faseriger Bindegewebe bei Zugbelastung. Im fünften Beitrag wird am Beispiel des Zusammenwirkens von Achillessehne, Fersenfettpolster und Plantarfaszie in vitro die Komplexität der Betrachtung faseriger Bindegewebe aufgezeigt. Die Zusammenführung der einzelnen Untersuchungen wird begleitet von der Frage, ob die bestehenden biomechanischen Untersuchungsansätze ausreichend sind, um ein umfassendes Verständnis zur funktionellen Bedeutung faseriger Bindegewebe aufbauen zu können.