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2012 19 4 24-31

Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

Comparison of Relative Thickness of the Iliotibial Band


Following Four Self-Stretching Exercises
Hyun-sook Kim1, PhD, PT, Tae-lim Yoon2, MA, PT

1Dept. of Physical therapy, Yeoju Institute of Technology,


2Dept. of Physical Therapy, The Graduate School, Yonsei University

Abstract1)

The aim of this study was to investigate the effectiveness of self-stretching exercises for iliotibial
band (ITB) (Side-lying; right hip and knee were flexed to support the pelvis while left hip was extended
and adducted, Standing A; side-bending of the trunk on standing with crossed leg, Standing B; same as
Standing A, except the hands were clasped overhead and shifted right side, and Standing C; same as
Standing B, except moving the arms diagonally downward) to help determine the most effective
self-stretching method to stretch ITB. Twenty-one healthy subjects who do not have ITB shortness from
Yonsei University (14 men and 7 women) between the ages of 18 to 28 years voluntarily participated.
Ultrasound was performed to measure the thickness of the ITB between the long axis of the ITB and
the level parallel to the lateral femoral epicondyle during four self-stretching exercises. All data were
found to approximate a normal distribution. We used a one-way repeated-measures analysis of variance
(ANOVA) to compare the thickness of the ITB among all self-stretching exercises. The level of
significance was set at =.05. The ANOVA was followed by Bonferronis correction. The overall mean of
ITB thickness was 1.14.4 ( standard deviation) in resting status. The change in the ITB thickness
in percentages between the tested position of each self-stretching exercises and resting status was
significant (p<.05) (Side-lying 26.6210.18% with 95% confidence interval [CI]=21.9931.25%; Standing A
29.4616.19% with 95% CI=22.0936.84%; Standing B 44.0614.82% with 95% CI=37.3150.81%; Standing
C 53.7612.1% with 95% CI=48.2559.29%). Results indicated significant differences among four
self-stretching exercises except Side-lying versus Standing A (p<.01). Based on these findings, the
Standing C self-stretching exercise was the most effective in stretching the ITB thickness among four
types of ITB self-stretching exercises. Additionally, the Side-lying self-stretching exercise using gravity
to stretch the ITB is recommended as a low-load (low-intensity), long-duration stretch.
[Hyun-sook Kim, Tae-lim Yoon. Comparison by Ultrasound of Relative Thickness of the Iliotibial Band in
Healthy Subjects Following Four Self-Stretching Exercises. Phys Ther Kor. 2012;19(4):24-31.]
Key Words:

Iliotibial band friction syndrome; Side-lying; Snapping hip; Ultrasound.


Introduction

The iliotibial band (ITB) is a longitudinal thickening of the lateral distal deep fascia latae and the superficial one-quarter of the fibers of the gluteus
maximus (Fairclough et al, 2006; Muhle et al, 1999).
the ITB is a dense fibrous connective tissue that

passes distally along the thigh (Fairclough et al,


2006). Proximal to the knee joint, the ITB has attachments to the intermuscular septum and the supracondylar tubercle of the femur; it continues distally to insert on the Gerdy tubercle at the anterolateral aspect of the proximal tibia (Fairclough et al,
2006; Muhle et al, 1999). As it approaches the knee,

Corresponding
Hyun-sook
kimhyun-sook@hanmail.net
This work wasauthor:
supported
by YeojuKimInstitute
of Technology Research Fund.
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2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

the ITB separates into two functional components,


the iliopatellar band and the iliotibial tract, which attach to the Gerdys tubercle of the lateral tibia condyle and the lateral patella retinaculum, respectively
(Evans, 1979; Terry et al, 1986).
The tightness of ITB could be a reason for musculoskeletal disorders, such as iliotibial band friction
syndrome (ITBFS) and snapping hip. ITBFS was
rst specically described by Renne (1975) as a pain
felt on the lateral aspect of the knee in lower limb
activities, such as running and cycling (Renne, 1975).
ITBFS is the second most common injury from
overuse and the most commonly diagnosed in running, soccer, basketball, triathlons, and field hockey
(Barber and Sutker, 1992; Kirk et al, 2000; Noble,
1980; Strauss et al, 2011). Friction of the ITB
against the lateral femoral epicondyle during repetitive flexion and extension activities compresses the
fat and connective tissue deep into the ITB (Strauss
et al, 2011). Patients with ITBFS complain of severe
burning at the area around and under the lateral epicondyle, secondary to tightness, frictional irritation,
and inflammation of the posterior fibers of the ITB
and the periosteum of the epicondyle (Nishimura et
al, 1997; Orchard et al, 1996). Furthermore, external
snapping hip is present when the tightened iliotibial
tract and/or the anterior boarder of gluteus maximus
slide over the greater trochanter (Allen and Cope,
1995; Brignall and Stainsby, 1991; Choi et al, 2002;
Yoon et al, 2009). Symptomatic external snapping hip
is a painful condition affecting physical function in
people between 15 and 40 years (Provencher et al,
2004). Symptoms are often long-standing, and musculoskeletal pain and activity limitations often dominate the clinical picture (Allen and Cope, 1995;
Provencher et al, 2004).
Most rehabilitation plans for managing ITBFS and
snapping hip include stretching exercises to increase
ITB flexibility as a beneficial treatment (DeFranca,
1998; Jones and James, 1987; Lee et al, 2005;
Orchard et al, 1996; Suh et al, 2006). Begun after
acute inflammation subsides, stretching exercise is

commonly used to increase the length and extensibility of soft tissues (Fredericson et al, 2000;
Fredericson and Wolf, 2005). Self-stretching is a one
of stretching type, enables a patient to maintain or
improving flexibility independently, and is often an
essential component of a home exercise program
(Kisner and Colby, 2007). Applying an effective and
practical self-stretching exercise is essential to
stretch the ITB and re-establish functional tissue
length. A previous study compared the effectiveness
of three common variations of the ITB self-stretching, but only in a standing position (Fredericson et
al, 2002). Other ITB self-stretching exercise in
side-lying positions, similar position of Ober test, has
never been investigated by ultrasound (US) (Strauss
et al, 2011; Wang et al, 2006).
US is a real-time, high-resolution, noninvasive
imaging tool to assess ITB (Bonaldi et al, 1998; Goh
et al, 2003; Wang et al, 2008). Compared with
Magnetic resonance imaging, US is a more suitable
tool for defining morphologic changes in the ITB in
conjunction with the Ober or modified Ober test because of its dynamic examination capability (Wang
et al, 2006). A study calculated the length of the extensor carpi radialis muscle from the muscle thickness (Shi et al, 2009). Also, other study conclude
that US is a reliable means to directly assess the
real-time effects of stretching exercises (Wang et al,
2008).
Stretching exercises for the ITB has an important
role in maintaining the flexibility of soft tissue. In
particular, self-stretching exercises are highlighted in
education about home exercise. Therefore, this study
should be investigated further to ensure the most effective exercise for stretching the ITB and ameliorating its tightness. Our research objective was to
investigate the effectiveness of self-stretching exercises for ITB to help determine the most effective
method for ameliorating ITB tightness. This study
hypothesized that the changes of ITB thickness in
percentage caused by four self-stretching exercises
would show statistical differences.

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2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

Methods
Subjects

G-power software was used for power analysis.


From the data of a pilot study of 5 subjects, the
necessary sample size was 6 subjects to achieve a
power of .80 and the effect size of 2.58 (calculated
by partial 2 of .869) with an alpha level of .05.
Twenty-one healthy subjects from Yonsei University
(14 men and 7 women) between the ages of 18 to 28
years participated voluntarily. The characteristics of
the subjects are presented in Table 1. These healthy
volunteers were screened by using historical and
physical assessments by an examiner with nine
years of clinical experience. The inclusion criteria
were as follows: 1) no leg-length discrepancy
(distance from the anterior superior iliac spine
[ASIS] to the superior surface of the most prominent
aspect of the medial malleolus) of more than 1.5 ;
2) no genu varum (tibiofemoral angle < 15); and 3)
no functional over-pronation of the foot arch (the
angle formed between the distal medial malleolus, the
navicular tuberosity, and the first metatarsal head <
90) (Wang et al, 2006). Subjects were excluded
from this study for the following reasons: 1) showed
a positive response in the Ober test, which is consistent with a restricted ITB; 2) had a focally thickened or poorly defined border of ITB, with a fluid
collection between the ITB and the lateral femoral
epicondyle when the US measurements were conducted; 3) previous history of knee surgery, history
of pain in the ITB area; 4) history of anterior or
lateral knee pain; 5) history of low back pain in the
Table1. General characteristics of the subjects

last six months (Bonaldi et al, 1998; Nishimura et al,


1997; Wang et al, 2006). Prior to their participation,
all subjects were informed of the purpose of the
study, and informed consent was obtained. This
study was approved by the Yonsei University Wonju
Campus Human Studies Committee.
Instrumentation2)

US1) was performed on 7.5 mode with L5-12EC


linear-array transducer (40 field of view) to
measure the thickness of the ITB during four
self-stretching exercises. US was a reliable method
for measuring the thickness of ITB. It also has a
potentially important role in the diagnosis and follow-up of ITBFS (Goh et al, 2003; Wang et al, 2006).
Procedures

Four ITB self-stretching exercises (Side-lying,


Standing A, Standing B, and Standing C) evaluated
in this study were selected to compare their widespread usage and prescription, simplicity of performance, and effectiveness (Fredericson et al, 2002;
Strauss et al, 2011) (Figure 1). The effectiveness of
each self-stretching exercise was evaluated based on
change in the thickness of ITB. Change in the
thickness of ITB was measured with US and calculated as a percentage (the ITB thickness of resting
status - the ITB thickness of self-stretching []) /
the ITB thickness of resting status [] 100) between a relaxed supine position and the end point of
each self-stretching exercise. It was assumed that
the most efficient self-stretching exercise would
mostly reduce the thickness of ITB (Goh et al, 2003;

Variables
Male (n1=14)
Female (n2=7)
Age (years)
21.52.8
21.01.8
Height ()
175.05.5
162.44.4
Weight ()
68.98.1
51.14.4
a
BMI (/)
22.52.7
19.41.2
abody mass index, values are presented as meanstandard deviation.

1) SonoAce X8, Medison Co., Ltd, Seoul, Korea.


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Total (N=21)
21.32.5
170.87.9
63.011.1
21.52.7

2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

Side-lying

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

Standing A

Standing B

Standing C

Self-stretching exercises of ITB.


Lai et al, 2011). We investigated the left leg only. the level parallel to the lateral femoral epicondyle
Before the measuring of ITB, familiarization with (Figure 2). After measuring resting status of ITB,
four self-stretching exercises was performed for an the subjects were then allocated in random order to
hour. At first, the subject was positioned as supine perform the Side-lying, Standing A, Standing B, and
on an examination table with knee extended at 0. Standing C self-stretching exercises (Goh et al, 2003;
The ITB was easily visualized and then palpated on Wang et al, 2006). The US measuring performed in
its long axis. A line crossing the long axis of the real-time, usually no more than 10 seconds, at the
ITB at the level parallel to the lateral femoral epi- final angle of hip adduction, and then moved back
condyle, which was identified by palpation 2 starting position. All stretches were performed withabove the corresponding lateral joint line, was out aid and observed by investigator to prevent
marked with a pen on the subjects skin to indicate compensation movement. When compensation movethe placement position of the ultrasonic transducer ment was presented, the trial was not measured. All
(Goh et al, 2003; Gyaran et al, 2011; Wang et al, data collection was repeated three times, with a
2006). A water-based hypoallergenic ultrasound gel five-minute rest between each trial (Wang et al,
was applied to the marked area on the lateral femo- 2006). The results for each test were averaged for
ral epicondyle. The transducer was positioned parallel statistical analysis.
to the previously marked line and was held vertical
to the skin surface to prevent compressing the skin
1) Side-lying self-stretching of ITB
and underlying tissues. The thickness of ITB was
The subjects lay on their right side, aligning their
measured as a reference of resting status of ITB at shoulders and pelvis with the edge of the examination table. The hip and knee of the right leg were
flexed to support and stabilize the pelvis. To stretch
the ITB, the left hip was in a straight line to torso
of subject with the knee extended at 0 and dropped
down by gravity into the available range of hip adduction for self-stretching the ITB until hip movement stopped. During asking the subject to not rotate their trunk, plevic and hip and to use only hip
adduction movement. The thickness of ITB was
measured by US at the final angle of hip adduction
Figure 2. US image showing the thickness
of ITB.
(Wang et al, 2006).
Figure 1.

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2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

2) Standing A, Standing B, and Standing C


self-stretching of ITB

Standing A self-stretching began with the subject


standing upright. The left leg was in a straight line
to the torso of subject and adducted across the right
leg till shoulder width. And then, the foot position
was marked with marking tape to maintain same
foot position in every trial. The subject exhaled
while slowly flexing the trunk in a direction lateral
to the right side. This movement continued until a
stretch was felt on the side of the left hip around
the greater trochanter. Standing B was the same as
Standing A, except the hands were clasped overhead
and shifted to a right side direction until a stretch
was felt on the side of the left hip. The subject was
asked to not rotate their trunk, pelvic and hip and to
use only hip adduction movement during Standing A
and Standing B self-stretching. Standing C was the
same as Standing B, except the subject no longer
extended the arms overhead but diagonally downward as possible (Fredericson et al, 2002).
Statical Analysis

Descriptive statistics were calculated for all


variables. All the continuous variables were found to
approximate a normal distribution (Kolmogorov-Smirnov
Z test, p>.05). We used a one-way repeated-measures analysis of variance (ANOVA) with four within-subject factors (Side-lying, Standing A, Standing
B, and Standing C) to compare the thickness of the
ITB between all self-stretching exercises. The level
of significance was set at =.05. If a significant difference was found, a Bonferronis correction was
performed. All statistical analyses were performed
with SPSS, ver. 14.0 software.
Result

At the level of the lateral femoral condyle, the


thickness of the ITB ranged from .8 to 1.8 on the
left side, with an overall mean of 1.14.4

Change in ITB thickness (*p<.05).


(standard deviation). During, all self stretching exercises, the ITB thickness is reduced and shown in
Figure 3 in percentage change (Side-lying
26.6210.18% with 95% confidence interval [CI]=21.9
931.25%; Standing A 29.4616.19% with 95%
CI=22.0936.84%; Standing B 44.0614.82% with
95% CI=37.3150.81%; Standing C 53.7612.1% with
95% CI=48.2559.29%). Results indicated significant
differences among four self-stretching exercises
(Side-lying, Standing A, Standing B, and Standing
C) (p<.05). Figure 3 also shows that there were significant differences between all self-stretching exercises except between Side-lying versus Standing A
(p<.01).
Figure 3.

Discussion

This research purpose was to assess the thickness


of ITB by US to help determine the effectiveness of
ITB self-stretching exercises. At the parallel level of
the lateral femoral condyle, the thickness of the ITB
ranged from .8 to 1.8 on the left leg, with an
overall mean of 1.14.4 (standard deviation). The
result was similar with a previous study that the

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2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

mean values of sonographically measured ITB thickness were 1.1.2 at the lateral femoral epicondyle.
On the other hand, two other study reported that
mean ITB values of 1.9.3 and 1.9.2 at the
lateral femoral epicondyle, respectively (Goh et al,
2003; Wang et al, 2006). The results of this investigation suggested that Standing C self-stretching
exercise was the most successful method for generating change in ITB thickness among four types of
ITB self-stretching exercises. In addition, the
Side-lying self-stretching exercise using gravity to
stretch the ITB was considered a low-load (low-intensity), long-duration stretch.
The Standing C self-stretching exercise was the
most effective technique among four types of ITB
self-stretching exercises because the biggest change
of ITB thickness in percentage was presented in the
Standing C self-stretching exercise. The reason
would be facilitation of hip rotation by adding flexion
and rotaion of trunk movement while other stretch
exercises only had hip adduction movement. This result is not in line with a previous study that used
three-dimensional image measurement, which indicated that Standing B was most effective method
between Standing A, B, and C self-stretching exercises (Fredericson et al, 2002). Fredericsons study
had main limitation, such as not directly measuring
the ITB. Instead, the study estimated changes in
length according to angular changes in markers of
the iliac crest, greater trochanter, and lateral midline
of the knee (Fredericson et al, 2002). Therefore, this
study directly measuring the change in thickness of
ITB by US would be more objective and apparent
indicator of stretching effects. However, extreme
flexion with rotation of the trunk was observed in
Standing C self-stretching and would aggravate
symptoms for patient with disc disorders (Cohen et
al, 2009). Consequently, the Standing C self-stretching should be recommended for someone who does
not have disc disorders.
Interestingly, Standing A was the second least effective method to stretch ITB among the four

self-stretching exercises although it is one of the


most common and well-known ITB self-stretching
exercises. In addition, Standing A was the only
technique showing no change in ITB thickness (2
out of 21 subjects) from the ITB thickness in resting
status. These results indicated that the Standing A
self-stretching exercise was a complicated method
for stretching the ITB and was not so effective.
Furthermore, the effectiveness of the Side-lying
self-stretching exercise using gravity to stretch ITB
was not significantly different from Standing A although it was reported as the least effective method
in stretching the ITB. The Side-lying self-stretching
exercise had an advantage of performing stretch effortlessly for a long duration. Two previous studies
claimed that a low-load (low-intensity), long-duration stretch is considered the safest form of stretch
and yields the most significant, elastic deformation
and long-term, plastic changes in chronic contractures (Kottke et al, 1966; Light et al, 1984).
Therefore, the Side-lying self-stretching exercise is
recommended over the Standing A self-stretching
exercise, especially for chronic contractures of ITB.
A limitation of this study is the sample size.
However, despite the small sample size, the response
of ITB thickness to self-stretching was sufficient to
identify a statistically signicant difference between
self-stretching exercises (p<.05). In addition, because
only healthy young adults were investigated, the results should not be generalized. Moreover, this study
did not directly assess ITB length but ITB thickness
to estimate ITB length. The change in ITB thickness
does not give perfect assurance of the change in
ITB length. Furthermore, the errors present in using
US were dominated by the position of the transducer
because it was not exactly the same for each trial
However, the potential error was minimized in this
study because all data were collected by one
well-experienced investigator. A longitudinal study is
needed to confirm the immediate effect of the
stretching exercises used in this study in a patient
population or different age groups.

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2012 19 4 24-31
Phys Ther Kor 2012;19(4):24-31

ISSN (Print) 1225-8962, ISSN (Online) 2287-982X


http://dx.doi.org/10.12674/ptk.2012.19.4.024

Conclusion

This research investigated the effectiveness of


self-stretching exercises for ITB to help determine
the most effective method for ameliorating ITB
tightness. The results of this investigation showed
that the Standing C self-stretching exercise was the
most successful among four types of ITB
self-stretching exercises and recommendable method
for someone who does not have low back pain.
Furthermore, the use of the Side-lying self-stretching exercise using gravity to stretch the ITB is recommended as a low-load (low-intensity), long-duration stretch.
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This article was received September 13, 2012, was


reviewed September 13, 2012, and was accepted
October 5, 2012.

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