Gait & Posture 77 (2020) 64–68

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Gait & Posture

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Full length article

Relationship between iliotibial band syndrome and hip neuromechanics in T

women runners
Eric Focha,*, Kevin Aubolb, Clare E. Milnerb
a
Department of Health Sciences, Central Washington University, 400 East University Way, 208-12 Black Hall, 98926, Ellensburg, WA, USA
b
ReHAB Group, Department of Physical Therapy & Rehabilitation Sciences, Drexel University, 1601 Cherry Street, Philadelphia, PA, USA

ARTICLE INFO ABSTRACT

Keywords: Background: Atypical frontal plane hip kinematics are associated with iliotibial band syndrome in women
Running runners. Gluteus medius is the primary muscle controlling the hip adduction angle during the loading response
Hip adduction of stance. It is unclear if differences exist in gluteus medius activity magnitude and activity duration between
Electromyography runners with previous iliotibial band syndrome and controls. Furthermore, hip neuromechanics may change
Gluteus medius
after a prolonged run.
Research Question: Do differences exist in the hip adduction angle and gluteus medius activity between women
with previous iliotibial band syndrome and controls at the beginning and end of a 30-minute moderate paced
treadmill run?
Methods: Thirty women participated (n = 15 controls). Lower extremity kinematics and gluteus medius activity
were recorded at the start and end of a 30-minute treadmill run at participants’ self-selected pace. Hip kinematics
and gluteus medius activity were analyzed via separate two-way (group x time) mixed-model analysis of var-
iance with time as the repeated measure.
Results: Hip neuromechanics were similar at the start and end of a 30-minute treadmill run in women with
previous iliotibial band syndrome and controls. However, hip adduction excursion was less in women with
previous iliotibial band syndrome compared to controls. Average gluteus medius activity magnitude and activity
duration were not significantly different between groups.
Significance: These findings support the growing body of literature that smaller hip adduction motion is related
to previous iliotibial band syndrome in women. Regardless of injury history, gluteus medius activity was similar
between groups during the loading phase of stance.

1. Introduction
Running is a common physical activity that many individuals select
to improve their physical and mental health. Despite running’s popu-
larity, the injury rate among runners is high. A recent prospective in-
vestigation of runners found that 66 % of participants sustained at least
one overuse injury during a two-year observation period [1]. Runners
that do develop an overuse running injury have a 50 % likelihood of
injury recurrence [2]. Furthermore, both prospective and retrospective
evidence indicates that the knee is the most common anatomical lo-
cation for overuse injury [1–4]. The overuse knee injury iliotibial band
syndrome (ITBS) is the second most common overuse injury and is
twice as likely to be sustained by women compared to men [4].
A large peak hip adduction angle is implicated in the etiology of
ITBS [5,6]. Excessive hip adduction during stance may compress a fat
pad located over the lateral knee that contains free nerve endings and
pressure receptors [7]. Thus, the lateral knee pain experienced by
runners with ITBS may at least partially be due to a large peak hip
adduction angle. However, both larger and smaller peak hip adduction
angles have been exhibited by women with previous ITBS compared to
controls [5,8]. Despite kinematic differences, the peak hip abductor
moment generated to control hip adduction during stance was similar
among asymptomatic ITBS groups and controls [5,6,8]. However,
muscle activity contributing to the net moment may differ among
groups.
Gluteus medius is the primary hip abductor, and its function during
the loading response of stance is to control hip adduction [9]. Muscle
activity is preplanned to counter lower extremity loading [10]. It has
been suggested that gluteus medius activity duration is more important
than activity magnitude to control hip adduction [5,11]. If gluteus

⁎
Corresponding author.
E-mail address: eric.foch@cwu.edu (E. Foch).

https://doi.org/10.1016/j.gaitpost.2019.12.021
Received 8 March 2019; Received in revised form 2 December 2019; Accepted 14 December 2019
0966-6362/ © 2020 Elsevier B.V. All rights reserved.
E. Foch, et al.
medius activity duration is short, then its ability to control active
frontal plane stiffness [12] during the loading response of stance may
be limited. Short gluteus medius activity duration may increase hip
adduction excursion, and consequently, result in a larger peak hip ad-
duction angle during the stance phase of running.
Moderate paced running constitutes the majority of recreational
runners’ weekly mileage. It is unclear if women with previous ITBS
respond differently compared to controls during a moderate paced
training run. There has been a report of no differences in frontal plane
hip motion and gluteus medius activity magnitude during a 30-minute
exhaustive run in runners with current ITBS and controls [11]. How-
ever, it was not determined if gluteus medius activity magnitude
changed throughout the run. Therefore, how gluteus medius activity
magnitude was affected during running is unknown. Investigating hip
neuromechanics during a moderate paced run would fill a gap in the
literature highlighting how women with previous ITBS respond to a
typical moderate paced run compared to controls.
Therefore, the purpose of this cross-sectional study was to de-
termine if differences existed in hip neuromechanics between women
with previous ITBS and controls at the beginning and end of a 30-
minute moderate run. Given the inconsistent findings reported in the
literature, we tested the null hypothesis of no differences in peak hip
adduction angle and hip adduction excursion between groups.
Additionally, we tested the null hypothesis of no difference in gluteus
medius activity magnitude and activity duration between women with
previous ITBS group and controls.
2. Methods
2.1. Participant details
Central Washington University’s Human Subjects Research Council
approved all procedures prior to the commencement of this investiga-
tion. Thirty women were recruited from a rural community via word of
mouth and flyers. Upon arrival to the laboratory, participants received
a verbal overview of the study’s procedures and provided informed
written consent agreeing to participate. All women were between the
ages of 18 and 45, currently uninjured, and running a minimum of 10
km∙wk−1. Participants were assigned to either the previous ITBS group
(n = 15) or control group (Table 1) based on their responses to a
custom running history questionnaire. Any participant was excluded
from further participation if she reported previous major lower ex-
tremity injury or had undergone lower extremity surgery. Additionally,
if participants were not healthy enough to exercise by answering ‘yes’ to
any question on a Physical Activity Readiness-Questionnaire (PAR-Q),
then their participation ended [13]. Women with previous ITBS re-
ported prior diagnosis for their injury by a healthcare professional
(physical therapist, physician, or athletic trainer). Furthermore, women
with previous ITBS were running without pain over the lateral knee
region for at least one month prior to the study. All participants were
comfortable running on a treadmill as indicated by reporting at least an
Table 1
Mean (standard deviation) of participant demographics in the previous iliotibial
band syndrome (ITBS) and control groups. Isometric hip abductor strength
(HABD) was normalized to participants’ body mass (BM) and height (h).
ITBS Controls
Age (years) 26.7 (9.3) 1.68 (0.07)
Height (m) 25.1 (7.0) 1.66 (0.06)
Mass (kg) 61.4 (7.1) 58.5 (6.5)
Distance Run (km∙wk−1) 34.2 (23.1) 36.5 (16.4)
HABD Strength (%BM∙h) 9.2 (3.1) 12.1 (4.1)
Treadmill velocity (m∙s−1) 2.7 (0.5) 2.9 (0.4)
Cadence (steps∙min−1) 167 (10) 175 (11)
Step length (m) 0.98 (0.15) 1.01 (0.11)
65
Gait & Posture 77 (2020) 64–68
“8″ on a 10-point visual analog scale [14]. Sample size was determined
a priori (α = 0.05, β = 0.20, desired effect size = 0.80) for a two-way
(group x time) mixed-model analysis of variance (ANOVA) with time as
the repeated measure using the power analysis software G*Power 3.1
[15]. The power analysis indicated that a minimum of 16 participants
were needed in total to achieve the desired power. The chosen large
effect size reflects differences in peak hip adduction angle reported in
prospective and retrospective ITBS studies [6,8].
2.2. Experimental protocol
Participants wore compression shorts and an athletic top and ran in
a neutral laboratory shoe (model 890v5, New Balance, Boston, MA).
Gluteus medius activity was recorded on controls’ right side and the
previously injured side for the ITBS group. Prior to electrode placement,
participants’ skin over gluteus medius was cleaned with an isopropyl
alcohol wipe. Then, a bipolar silver-silver chloride electrode
(Tringo™Wireless Sensor, Delsys Inc., Boston, MA) was attached to the
skin over gluteus medius following established methods [16]. Briefly,
the iliac crest and greater trochanter were palpated on the side of in-
terest. Then, the surface electrode was placed on the skin over the
proximal third of the distance between the two bony landmarks [16].
Electrode placement was assessed while participants where side-lying
and abducting the lower extremity to fixed resistance of an isokinetic
dynamometer (System 4 Biodex, Biodex Medical Systems, Shirley, NY).
Gluteus medius activity was recorded using a 16-channel electro-
myography (EMG) system sampling at 1200 Hz (Tringo™ Wireless EMG
System, Delsys Inc., Boston MA). The EMG system was synchronized
with an eight camera motion capture system sampling at 120 Hz
(Motion Analysis, Santa Barbara, CA).
After electrode placement, a two-second side-lying trial was re-
corded to measure gluteus medius activity at rest. Then, maximal vo-
luntary isometric contraction (MVIC) during side-lying hip abduction
was measured via an isokinetic dynamometer following established
procedures [17]. Briefly, two 5-second MVIC practice trials were per-
formed before completing a single test trial; thirty seconds of rest were
given between trials. Participants’ peak MVIC hip abductor strength
was averaged for the three-trials (Table 1).
After MVIC testing, molded thermoplastic shells with four non-col-
linear markers [18] were secured via neoprene wraps and Velcro® on
the posterolateral proximal thigh and distal shank [19] of participants’
test side. Participants then performed a five-minute warm-up on the
laboratory’s treadmill (MedTrack® CR60, Quinton, Bothell, WA) by
increasing the treadmill’s velocity to their pace for a moderate paced
30-minute run. To determine if running velocity was different between
groups, an independent t-test was performed. Treadmill running velo-
city was not significantly different between the previous ITBS group
and controls (Table 1; P = 0.194).
After the warm-up, anatomical markers were placed on the skin to
define lower extremity joint centers and segment endpoints for parti-
cipants’ test side. The anatomical landmarks were: superior iliac crests,
greater trochanters, femoral epicondyles, medial and lateral malleoli,
and first and fifth metatarsal bases (via windows in the shoe) [20].
Additional tracking markers were placed on the skin over the posterior
superior iliac spines and mid-sacrum. Three non-collinear markers
placed on the posterior heel tracked rearfoot motion. Finally, a single
marker was placed on the shoe over the distal second metatarsal to aid
in determining toe-off. To provide additional temporal distance in-
formation, runners’ cadence and step length were measured by in-
cluding a marker on the non-test limb’s posterior heel and over the
distal second metatarsal (Table 1). A static calibration trial was re-
corded, and then, anatomical only markers were removed before be-
ginning the run. Three-dimensional marker trajectories and gluteus
medius activity were recorded a minute after the test velocity was
reached (minute 1) and the last minute of the run (minute 29). Data
from five consecutive stride cycles at each point were used for analysis.
E. Foch, et al. Gait & Posture 77 (2020) 64–68

2.3. Data processing Table 2

Mean (standard deviation) of hip neuromechanics in the previous iliotibial
Marker trajectories were filtered via a 4th order Butterworth filter band syndrome (ITBS) and control groups. Descriptive statistics are included for
with a cut-off frequency of 8 Hz (Visual3D, C-Motion Inc., Rockville, sagittal plane and transverse plane hip angles; no additional statistical testing
was performed on these variables.
MD). Joint angles were computed using the right-hand rule and a
Cardan X-Z-Y (mediolateral-anteroposterior-vertical) rotation sequence Time ITBS Controls
[21]. Established kinematic methods were used to determine foot-strike
Peak hip adduction angle (°) Minute 1 13.1 (2.9) 14.0 (3.6)
[22] and toe-off [23]. Cadence and step length were computed via
Minute 29 13.9 (3.3) 14.5 (3.6)
commercial software (Visual3D, C-Motion Inc., Rockville, MD). Custom Hip adduction excursion* (°) Minute 1 2.2 (1.7) 4.5 (2.6)
code extracted angles at foot-strike and peak angles from the first 60 % Minute 29 3.0 (2.4) 4.8 (2.1)
of stance (MATLAB, TheMathWorks, Natick, MA) [5]. Kinematic vari- Peak hip flexion (°) Minute 1 −33.2 −30.6 (4.4)
Minute 29 (4.8) -31.7 (5.6)
ables of interest were peak hip adduction angle and hip adduction ex-
-31.9 (3.9)
cursion. Excursion was the difference between the peak hip adduction Peak hip internal rotation (°) Minute 1 14.2 (5.9) 13.4 (5.1)
angle and angle at foot-strike. Additionally, to provide a complete de- Minute 29 15.2 (6.7) 13.9 (5.4)
scription of hip angles exhibited during the stance phase running, sa- Gluteus medius activity magnitude (% Minute 1 93.5 (28.8) 88.0 (33.5)
gittal plane and frontal plane hip angles were reported. MVIC) Minute 29 91.1 (35.0) 88.7(40.7)
Gluteus medius activity duration (ms) Minute 1 183 (61) 165 (50)
DC bias was removed from the gluteus medius activity signal via a
Minute 29 180 (69) 171 (61)
high-pass Butterworth filter with a cutoff frequency of 30 Hz. Then, to
compute gluteus medius activity magnitude, a moving root-mean- *
Indicates a significant main effect for group determined via two-way
square (RMS) created EMG envelopes using custom code. For the MVIC ANOVA with time as the repeated measure.
trial, a moving RMS with a 500 ms window filtered gluteus medius
activity. Gluteus medius activity during running was examined from significant group-by-time interaction (P = 0.709) with respect to peak
foot-strike to peak knee flexion (loading period). The loading period hip adduction angle during the 30-minute treadmill run (Table 2).
and not the entire stance phase was analyzed due to low gluteus medius There was no main effect for group (P = 0.529) or time (P = 0.078) for
activity magnitude during the propulsive period, consistent with pre- peak hip adduction angle. Additionally, there was no significant group-
vious work [24]. Due to the loading period’s short duration (< 200 ms) by-time interaction (P = 0.401) for hip adduction excursion. However,
compared to the 5-second MVIC trial, a moving RMS with a 50 ms there was a main effect for group (P = 0.009) but not time (P = 0.100)
window filtered the muscle activity for each running trial. Gluteus for hip adduction excursion. Runners with previous ITBS exhibited less
medius activity magnitude during each running trial was normalized to hip adduction excursion than controls at minute 1 and minute 29 of the
the MVIC trial (%MVIC) and then averaged over the loading period for run (Fig. 1.). Peak hip flexion and hip internal rotation angles (Table 1),
each trial. as well as group sagittal and transverse planes ensemble time-averages
To compute gluteus medius activity duration, the signal was pro- (Fig. 1.) are included for additional hip angle information.
cessed and conditioned with a Teager-Kaiser energy operator (TKEO) Women with previous ITBS and controls demonstrated no sig-
[25]. Further signal processing was performed using custom code. nificant group-by-time interaction (P = 0.769) with respect to gluteus
Signal conditioning with a TKEO amplifies energy of the action po- medius activity magnitude (Table 2). And, there was no main effect for
tentials and improves the detection of a contracting muscle compared group (P = 0.742) or time (P = 0.877) for gluteus medius activity
to a relaxed muscle. The processed gluteus medius signal was averaged magnitude. Additionally, women with previous ITBS and controls ex-
during the quiet trial to determine a resting average [24]. A threshold hibited no significant group-by-time interaction (P = 0.514) with re-
of five standard deviations above the resting average was used to in- spect to gluteus medius activity duration during the 30-minute tread-
dicate gluteus medius activity onset during running [24]. Based on mill run. There was no main effect for group (P = 0.552) or time
visual inspection of runners’ gluteus medius activity data during pilot (P = 0.716) for gluteus medius activity duration.
testing, the window over which the muscle was considered to be “on”
was 150 ms prior to foot-strike through toe-off. Gluteus medius activity
duration was the sum of the time its activity remained above the resting 4. Discussion
average threshold. Due to technical issues in post-processing, gluteus
medius activity duration data could not be determined for one runner The purpose of this study was to determine if differences existed in
each in the control group and previous ITBS group. frontal plane hip kinematics and gluteus medius activity between
women with previous ITBS and controls. In partial support of our hy-
2.4. Statistical analysis pothesis, hip adduction excursion was less in runners with previous
ITBS compared to controls at minute 1 and minute 29 of the treadmill
Boxplots were used to identify extreme outliers (greater than three run. However, the peak hip adduction angle was similar between
times the inter-quartile range away from the median) [26] in hip ki- groups. Contrary to our hypothesis, both groups exhibited similar glu-
nematics and gluteus medius activity data. In the ITBS group, one teus medius activity magnitude and activity duration.
participant’s gluteus medius activity magnitude data were identified as Peak hip adduction angle was not different between groups at
an extreme outlier at minute 1 and minute 29 of the run and were minute 1 and minute 29 of the treadmill run. Past ITBS investigations
removed from further analysis. have reported that women with previous ITBS exhibited larger [5] and
Participants’ five trial mean was computed for each hip kinematic smaller peak hip adduction angles [8] compared to controls. Thus, it
and gluteus medius activity dependent variable. Dependent variables remains unclear whether peak hip adduction angle is an important
were compared between groups via separate two-way (group x time) biomechanical feature in runners with previous ITBS. However, the
mixed-model analysis of variance (ANOVA) with time during the run smaller hip adduction excursion demonstrated by women with previous
being the repeated measure (IBM SPSS Statistics, Chicago, IL). Alpha ITBS compared to controls is consistent with past ITBS investigations.
was set at 0.05 for all statistical tests. Approximately, 1.4–2.5 degrees less hip adduction excursion was de-
monstrated by women with previous ITBS compared to controls [5,8].
3. Results Less hip adduction excursion may be a biomechanical feature of pre-
vious ITBS.
Women with previous ITBS and controls demonstrated no Gluteus medius activity magnitude was similar between runners

66
E. Foch, et al.
Fig. 1. Sagittal plane, frontal plane, and transverse plane hip angle ensemble averages during the stance phase of treadmill running in women with previous iliotibial
band syndrome (red dashed line (red shaded area)) and controls (black solid line (grey shaded area)). The shaded areas represent one standard deviation from each
group’s ensemble average. Data were collected during minute 1 (Start) and during minute 29 (End) of the moderate paced treadmill run (For interpretation of the
references to colour in this figure legend, the reader is referred to the web version of this article).
with previous ITBS and controls at minute 1 and minute 29 of the
treadmill run. To date, gluteus medius activity magnitude has not been
reported in women with previous ITBS. However, gluteus medius ac-
tivity magnitude was reported in a group consisting of both women and
men with current ITBS during a 30-minute exhaustive run [11]. Con-
sistent with the current study, there were no differences in gluteus
medius activity magnitude (%MVIC) between runners with current
ITBS and controls at the beginning and end of the run [11]. While the
gluteus medius activity magnitudes found in the current study are
higher than the 20–25 % MVIC values previously reported the overall
pattern of time not affecting activity is the same [11]. Regardless of
injury history, gluteus medius activity was similar between groups
during the loading phase of stance.
Despite women with previous ITBS exhibiting less hip adduction
excursion throughout the 30-minute run, no differences in gluteus
medius activity duration were found between groups. This suggests that
other factors may contribute more than the duration of gluteus medius
activity to controlling hip adduction excursion during running. For
example, to limit the painful symptoms associated with ITBS, runners
with previous ITBS may have reduced their hip adduction excursion
when injured to limit frontal plane motion during loading. This reduced
frontal plane excursion may persist even after ITBS has been resolved as
demonstrated by the previous ITBS group in this study.
Limitations to this study are noted. To enable a prolonged run,
participants ran on a treadmill during this study. However, since hip
adduction is similar during treadmill and overground running, these
findings can be extrapolated to overground running [27]. Additionally,
the current study was cross-sectional and so cannot indicate whether
similar hip adduction angles were present before the initial injury. Al-
though the moderate paced running velocity was not standardized
among participants, running velocity was not different between groups,
so groups were compared during running at a similar velocity. Finally,
some runners in both groups exhibited gluteus medius activity magni-
tude during the run that was greater than MVIC. Thus, not all runners
performed a true MVIC. However, all runners completed the same
67
Gait & Posture 77 (2020) 64–68
protocol and instances of %MVIC greater than 100 were found in both
groups.
5. Conclusion
Women with previous ITBS demonstrated less hip adduction ex-
cursion and similar gluteus medius magnitude and duration compared
to controls throughout a 30-minute moderate paced treadmill run.
Furthermore, group differences in hip kinematics do not appear to be
affected by run duration. Reducing hip adduction excursion may have
been a movement pattern adopted when runners with previous ITBS
were currently injured to reduce pain. Even after ITBS symptoms were
resolved, smaller hip adduction excursion persisted while maintaining
gluteus medius activity. These findings support the growing body of
literature that smaller hip adduction motion is related to previous ITBS.
Declaration of Competing Interest
The authors declare no conflict of interest.
Acknowledgments
The authors thank Betsy Arlt and Mary Emmert for their assistance
in participant recruitment and data collections. This research did not
receive any specific grant from funding agencies in the public, com-
mercial, or not-for-profit sectors.
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