Ijpr.2015.105EFFECT OF HIP ABDUCTOR STRENGTHENING AMONG NON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL...

Int J Physiother Res 20153(1)894-04 ISSN 2321-1822 894

Original ArticleEFFECT OF HIP ABDUCTOR STRENGTHENING AMONGNON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL BAND FRICTIONSYNDROMEJayanta NathPhD Scholar Department of Orthopaedics (PMRT GMCH) Padmashree Institute of PhysiotherapyBangalore Karnataka India

Background and Objectives The study was carried out to find out the effect of hip abductor strengthening amongnon-professional cyclists with iliotibial band friction syndromeSubjects 40 non-professional cyclists with ipsilateral ITBFS subject including male and female age between 18to 50 with positive oberrsquos and nobble test were included in this studyMethods 40 subject were selected according to the inclusion criteria and they were assessed pre and post forROM (hip adduction IR) hip abductor strength and pain using goniometersphygmomanometer and VAS Subjectwere assign experimental group(group A 20 subject) who received IT band stretchingUSand hip abductorstrengthening exercise and control group (group B 20 subject) who received same treatment except hip abductorstrengtheningData Analysis and Results Based on statistical analysis using Wilcoxon test to compare the pre and post testpain in both groupMann- whitney U- test to compare the post test pain scores of between groups Paired t - testto compare the pre and post ROM and strength in both groups Unpaired t ndash test to compare post test ROM inbetween groups showed that pre post difference within group A there was significant difference for adductionROM (p value lt0001)IR (p value lt0001)VAS(p value lt0001)and strength improve pre mean 4080 to postmean 6630 (p value lt0001)However in group B adduction ROM and VAS were found to be significantIn comparision in difference between groups it was found that adduction ROMIR ROMVAS and strength allwere significant Baseline data for outcome variable were not statistically significantConclusion Based on outcome variable there was significant difference of hip abductor strengthening amongnon-professional cyclist with iliotibial band friction syndromeKEYWORDS Iliotibial band Iliotibial band friction syndrome Repetitive stress injuryhip abduction strengthVASCycling injury

ABSTRACT

INTRODUCTION

Address for correspondence Jayanta Nath MPT PhD Scholar Department of Orthopaedics (PMRTGMCH) Padmashree Institute of Physiotherapy Bangalore Karnataka IndiaE-Mail jayanta0074uyahoocom

International Journal of Physiotherapy and ResearchInt J Physiother Res 2015 Vol 3(1)894-04 ISSN 2321-1822

DOI 1016965ijpr2015105

Iliotibial band friction syndrome (ITBFS) is acommon overuse injury of knee that occurs as aresult of repetitive soft-tissue trauma [12]Iliotibial band friction syndrome involves painin region of lateral femoral condyle or slightlyinferior to it that occurs after repetitive motionof knee

ITBFS is associated with overuse in long distancerunners cyclists and military personnel [3] Itis caused by friction of the iliotibial band (ITB)across the lateral femoral epicondyle duringsporting activities [45] Pain caused by ITBFSoccurs when the knee is flexed between 0 and30 degree but especially at 300 where theposterior fibers of the ITB experience the great-

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International Journal of Physiotherapy and ResearchISSN 2321- 1822

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DOI 1016965ijpr2015105

Received 19-01-2015Peer Review 19-01-2015Revised None

Accepted 29-01-2015Published (O) 11-02-2015Published (P) 11-02-2015


Jayanta NathEFFECT OF HIP ABDUCTOR STRENGTHENING AMONG NON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL BAND FRICTIONSYNDROME

-est friction [5] More common in age between15 to 50 years [6]A number of etiological factors have been relatedto ITBS include training errors biomechanicalfactors like genu varum foot hypersupinationfoot overpronation or cavus foot and leg lengthdiscrepancies footwear with poor shockabsorption and most recently hip abductorweakness [14]Incidence amp prevalence It is generally acceptedthat ITBFS is the most common running injury ofthe lateral knee with an incidence between 16and 12 [89] ITBFS comprises 22 of lowerextremity injuries [10] Although it is mostcommon in distance runners there is a growingnumber of cyclists with ITBFS ITBFS accountsfor approximately 15 of all overuse injuries atthe knee in cycling [5]Pathomechanics The pathogenesis of ITBFSinvolves inflammation and irritation of the lateralsynovial recess (Renne et al) as well ascontinued irritation of the posterior fibres of theITB (Ekman et al) and inflammation of theperiosteum of the lateral femoral epicondyle(McNicol et al) all of which describes thepathogenesis of ITBFSThe iliotibial band is a thick strip of fascia thatoriginates from tubercle of iliac crest continuesdown the lateral side of thigh and inserts intothe lateral tibial condyle (Gerdyrsquos tubercle) andinto the lateral proximal fibular head [47] Whenknee is flexed to an angle greater than 30o theITB lies posterior to the lateral femoralepicondyle when knee is extended however theITB moves anterior to this landmarkThereforefriction occurs at or slightly less than 300 of kneeflexion when the ITB crosses over the lateralfemoral epicondyle [4]The high number of revolutions of the bicyclecranks and tightness of the ITB resulting frommuscular effort can result in inflammation of theITB during cycling Additionally a snapping ofthe ITB may occur as it slides over the lateralfemoral epicondyle of the femur typically whenthe crank is approaching bottom center [5]Takaishi et al calculated peak pedal force forvarious cycling cadences in both competitiveand noncompetitive cyclists and determined thatnon-competitive cyclists preferred a lower

cadence (70 RPM) than competitive cyclists (80ndash90 RPM) for a moderate rate of work intensity(150 W) [11]In cycling the ITB is pulled anteriorly on thepedaling down stroke and posteriorly on theupstroke The ITB is predisposed to frictionirritation and microtrauma during this repetitivemovement because its posterior fibers adhereclosely to the lateral femoral epicondyleCyclists with an external tibia rotation greaterthan 200 stress is created on the ITB if theathletersquos cycling shoe is placed in a straight-ahead position or the toe is in a cleat positionCyclists with varus knee alignment or activepronation place a greater stretch on the distalITB when they ride with internally rotated cleatsPoorly fitted bicycle saddle a high-riding saddlecauses the cyclist to extend the knee more than1500 This exaggerated knee extension causesthe distal ITB to abrade across the lateralfemoral condyle Bicycle saddles that arepositioned too far back cause the cyclist to reachfor the pedal with a resultant stretch to the ITB[12]The power exerted on the pedal is the mostreliable parameter to determine the training loadin cycling biomechanically and hence a crucialfactor to optimize performance [13] Commercialpower meters are meanwhile part of thestandard equipment of professional cyclists butalso used by an increasing number of nonprofessional cyclists [13]Proximally the ITB acts as a lateral hip stabilizerresisting hip adduction (Fredickson et al 2000)It originates in the facial components of thegluteus maximus gluteus medius and tensorfasciae latae muscles (Muhle et al 1999Birnbaum et al 2004 Terry et al 1986) TheITB is attached distally to the supracondyletubercle of the femur and the lateralintramuscular septum In addition it has fibersthat attach to the patella (Muhle et al 1999Birnbaum et al 2004 Terry et al 1986) Due tothese attachments increased hip adduction islikely to lead to increased tension on the ITBIncreased hip adduction may necessitate agreater eccentric demand from glutealmusculature resulting in a higher hip abductionmoment



Schafer recommends treating ITBFS as an acutesprain with initial cryotherapy and adequate restwith ingestion of a nonsteroidal anti-inflammatory to help relieve the inflammatoryprocess Trigger points should be treated usingcross fibre friction massage for several minutesas recommended by Simons Treatments may beconcluded by interferential current therapy toachieve analgesia followed by functionalmuscle stimulation for muscle reeducationBilateral passive and active stretching exercisesfor the tensor fascia latae hamstrings andquadriceps should be prescribed Trainingshould be modified to include non-percussiveexercise such as cycling and swimming with icemassage of the affected areas following theactivity Surgical release of the ITB or removalof the lateral femoral epicondyle has been usedwhen conservative treatment fails Howeverreturn to full and normal lower limb mechanicsmay not be achievedStudies have shown that ITBFS responds well toconservative treatment (Anderson 1991 Kirk etal 2000 Levin 2003) with success ratesreported as high as 94 (McNicol et al 1981)A number of different treatment options arereported in the literature however it should bequestioned whether these treatments aredelivered based on sound evidenceReid and Fredericson outline the followingtreatments the reduction of inflammation (usingice and anti-inflammatory) reduction oftautness and myofascial trigger points in theband (employing stretch techniques and triggerpoint therapies) Corrective actions and thecorrection of biomechanical abnormalities withorthotics Surgery is sometimes opted for inespecially stubborn chronic casesMajority of the studies on ITBS thus far hasfocused mainly on the effectiveness of varioustreatment techniques to the ITB itself and itsassociated tensor fascia latae (TFL) muscle withvarying results reported which includeconservative therapies like rest ice andstretching of the tight band myofascial triggerpoint therapies like dry needling Nonoperativemeasures specific to cyclists consist of bicycleadjustments and training modifications [15]Other studies have been aimed at identifying

and correcting primary etiological factors suchas biomechanical abnormalities (eg genu varuscavus foot type leg length inequalitiessacroiliac joint fixations and fibular headfixations) also with varying resultsSome of the latest studies have identified anassociation between weak hip abductors(especially the gluteus medius) and ITBS Thesestudies suggest that gluteus medius weaknessand myofascitis of the gluteus medius is anothercontributing factor to ITBS in long distancerunners Gluteus medius strengthening in thetreatment of ITBS has been a recent focus ofinvestigation in the literature The literaturereveals that the comparative effectiveness ofthis new approach to ITBS treatment based ongluteus medius strengthening to any other formof conservative treatment requires furtherinvestigation Stretch therapy has traditionallybeen the basis of the conservative treatment forITBS ie to stretch the tight band and therebyreduce the friction syndrome a proven effectivecomponent of conservative treatment for ITBSFredericson explain that the gluteus medius andtensor fascia latae are both hip abductors butthe gluteus medius (mainly its posterior fibres)also externally rotates the hip whereas thetensor fascia latae also internally rotates thehip They have consequently postulated thatfatigued runners or those who have a weakgluteus medius are therefore prone to increasedthigh adduction and internal rotation atmidstance leading to an increased valgus vectorat the knee and that this increases tension onthe ITB making it more prone to impingementon the lateral epicondyle of the femur especiallyduring the early stance phase of gait (footcontact)ITBFS sufferers had hip abductor weakness orincreased hip adduction during the stance phaseof gait a finding which could be interpreted asbeing due to hip abductor weakness [11617]Several studies have investigated forces duringcycling while others have studied causes of ITBFSin cyclists In fact Fredickson et al (2000)reported that runners who currently have ITBSexhibited weak hip abductors Since theirsubjects were already injured at the time of themeasurement it is unclear whether theweakness was the cause or result of the ITBS


Jayanta Nath EFFECT OF HIP ABDUCTOR STRENGTHENING AMONG NON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL BAND FRICTIONSYNDROME

There is conflicting evidence in the literature asto whether ITBS is a true friction syndrome ormore the result of tissue compression From aclinical perspective training error combined withhip muscle weakness tends to be the mostconsistent finding with variable contributionsfrom other factors In triathletes it is notuncommon for errors in bike setup to causemuscle imbalances that cause ITBS to manifestin the run (even if cycling is pain free)It is hypothesized that ITBFS is a commonsymptom among cyclist and athletes Variousstudies so far have done proved the efficacy ofvarious treatments like stretching deep frictionmassage and modified ober test As hip abductorweakness is common finding in ITBFS and oftenneglected during physiotherapy managementThe study is aimed to find out the effect of hipabductor strengthening in non professionalcyclists with iliotibial band friction syndromeOBJECTIVES To examine the effect of Hipabductor strengthening among non-professionalcyclists with ITBFS and to compare the effect ofHip abductor strengthening over conventionalphysiotherapy among non-professional cyclistswith ITBFS

MATERIALS AND METHODS

Source of data 1 Padmashree PhysiotherapyampRehabilitation Centre Nagarbhavi Bangalore2 ESI hospital Rajaji Nagar Bangalore 3 KCGhospital Malleshwaram Bangalore 4Padmashree diagnosticsBangaloreCollection of data Population Non-professionalcyclists with ITBFS Sample design Convenientsampling Sample size 40 Type of Study preand post test experimental design Duration ofstudy 6 weeksInclusion criteria Non-professional cyclists withunilateral iliotibial band friction syndromediagnosed by orthopaedic surgeon Agebetween 18 to 50 years Both genders withPositive oberrsquos and nobble testExclusion criteria Presence of anatomical limblength discrepancies of more than 1cm Subjectswith other associated pathologies of the lowerlimbs like ankle sprains anterior cruciateligament injuries meniscal injuriesdegenerative joint disease lateral injury of

knee popliteal or biceps femoris tendinitiscommon peroneal nerve injury reffered pain fromlumbar spine Sign symptoms of other kneepathology (meniscal-tear degenerative jointdisease patellofemoral pain syndrome) historyof any previous knee surgeries and any ongoingspine hip or lower extremity injuryMaterials used Universal GoniometerExamination table Ultrasound machineTheraband SphygmomanometerProcedure Subjects who fulfill the inclusion andexclusion criteria were included in the study Awritten consent form was taken from each ofthe subjects General screening procedure wasdone by the examining physicaltherapistDemographic data were collected fromthe subject Subjects were divided into twogroups Each group consist of 20 subjectsGROUP A (experimental group)-physiotherapyincluding ITB stretchingUltrasound therapy withhip abductor strengthening exercise were givenGROUP B (control group)- physiotherapyincluding ITB stretching ultrasound therapywithout hip abductor strengthening exerciseDuration of the study was six weeks Pre testevaluation was done before starting treatmentwhich includes pain assessment using VAS hipabductor strength using modifiedsphygmomanometer and ROM usingGoniometer Patient received one session oftreatment per day up to six weeksAt the end ofsix weeks post test evaluation was conductedfor groups The differences between pre and posttest values were compared within groupsIntervention to be conducted on participantsRehabilitation programme used in this studyfocused on improving hip abductor strengthTheside-lying hip abduction exercise was gluteusmedius isometric contraction held atapproximately 30 degree of hip abduction withslight hip external rotation and neutral hipextension This exercise was done with the backagainst a wall In the fourth week a 1-metre-long green theraband was added around theankleHip abduction exercise Side-lying hip abductionexercises and pelvic drops to strengthen thegluteus medius was started at 1 set of 10


repetitions and over a course of several weeksincreased to the goal of 3 sets of 30 repetitionsThe patients were instructed to increase by fiverepetitions per day provided there will nosignificant post work-out soreness the followingday For the side-lying hip abduction specificinstructions were given to keep the lower legflexed for balance the abdominals braced andthe upper leg in slight hip extension and externalrotation Instructions ensured that the leg shouldbe slowly brought into an arc of abduction of20ndash30deg with each repetition held for 1 secondat extremes of motion and then slowly returnedto adductionThe pelvic drop exercise involved standing on astep with the involved leg while holding onto awall or stick if necessary for support with bothknees locked the opposite non involved pelviswill be lowered towards the floor shifting onersquosbody weight to the inside part of the foot andinvolved leg creating a swivel action at the hipThen by contracting the gluteus medius on theinvolved side the pelvis will be brought back toa level positionAll subjects instructed to discontinue runningcycling and any other activities that continuedto cause pain Subjects needed to be pain freewith all daily activities and have progressed to3 sets of 30 repetitions of the 2 strengthexercises before being allowed to start a returnto running program at the end of the 6-weekrehabilitation program

Progression of Hip Abduction exercise

Iliotibial band stretching Standing IT bandstretch Stretches were maintained for 60seconds each and conducted twice daily for theentirety of the programme Standing lateralfascia stretch with trunk lateral flexionrotationcontralateral to involved legThe involved leg iscrossed behind the uninvolvedOutcome Measure Pain (Visual analoguescale) Strength (Modified sphygmomanometer)Range of motion (adduction amp internal rotationof hip)Data analysis Wilcoxon test used to comparethe pre and post test pain in both groupMann- whitney U- test used to compare the posttest pain scores of between groups Paired t -test used to compare the pre and post ROMand strength in both groups Unpaired t ndash testused to compare post test ROM in betweengroups The statistical analysis was done usingSPSS softwareEthical clearance As this study involve humansubjects the ethical clearance has beenobtained from the ethical committee ofPadmashree institute of physiotherapyNagarbhavi Bangalore as per ethical guidelinesresearch from biomedical research on humansubjects 2000 ICMR New Delhi

RESULTS

Treatment parameters for UltrasoundtherapyDuration 6 MinutesMode continuousIntensity 1 wattcm2

Frequency 6 treatment session every alternateday

Study design A pre and post test experimen-tal design study was done consisting of 40subjectsIn which there were 30 male 10 femalesin age group of 18-50 years All subject wereable to complete their intervention there wasno drop outTable 1 show that for baseline variables meanage of Group A was 3360 with SD (997) andGroup B was 3545 with SD (923) which wasnot statistically significant (pgt0546)



Number of male and female in Group A was 15and 5 respectively and Group B was 15 and 5respectively which was not statistically signifi-cant (p=1)

Table 1 Baseline data for demographic variables

Sl No Variables Group A Group B THORN-value

1 Age 3360plusmn997 3545plusmn923 gt546

2Gender (MF) 1515 1515 1

Data are meanplusmnSDTable 2 Baseline data for outcome variables


1 Adduction ROM 1615plusmn418 1475plusmn444 gt311

2 Internal Rotation ROM 3635plusmn325 3700plusmn296 gt512

3 VAS 670plusmn130 695plusmn111 gt529

4 Strength 4080plusmn1202 4075plusmn1417 gt952

Data are meanplusmnSD

Table 2 show that Adduction ROM mean ofGroup A was 1615 with SD (418) and Group Bwas1475 with SD (444) which was notstatistically significant (pgt0311)Internal Rotation ROM mean of Group A was3635 with SD(325) and Group B was 3700 withSD (296) which was not statistically significant(pgt0512 )VAS mean of Group A was 670 with SD (130)and Group B was695 with SD (111) which wasnot statistically significant (pgt0529)Strength mean of Group A was 4080 with SD(1202) and Group B was 4075 with SD (1417)which was not statistically significant (pgt0952)

Table 3 Pre-post difference within the group A

Sl No Variables Pre Post THORN-value

1 Adduction ROM 1615plusmn418 2390plusmn363 lt0001

2 Internal Rotation ROM 3635plusmn325 3970plusmn290 lt0001

3 VAS 670plusmn130 095plusmn089 lt0001

4 Strength 4080plusmn1202 6630plusmn1466 lt0001

Table 3 shows that in group A for AdductionROM pre test score mean was1615 and SD(418) post test score mean was 2390 and SD(363) with p value lt00001 which wasstatistically significantFor Internal Rotation pre test score mean was3635 and SD (325) post test score mean was3970 and SD (290) with p value lt00001 whichwas statistically significantFor VAS pre test score mean was 670 and SD

(130) post test score mean was 095 and SD(089) with p value lt00001 which wasstatistically significant For Strength pre test score mean was 4080and SD (1202) post test score mean was 6630and SD (1466) with p value lt00001 which wasstatistically significant

Table 4 Pre-post difference within the group BSl No Variables Pre Post THORN-value





Table 4 shows that in group B for AdductionROM pre test score mean was1475 and SD(444) post test score mean was 1980 and SD(440) with p value lt00001 which wasstatistically significantFor Internal Rotation pre test score mean was3700 and SD (296) post test score mean was3765 and SD (268) with p value gt091 whichwas statistically not significantFor VAS pre test score mean was 695 and SD(110) post test score mean was 390 and SD(129) with p value lt00001 which wasstatistically significantFor Strength pre test score mean was 4075and SD (1417) post test score mean was 4150and SD (1368) with p value gt083 which wasstatistically not significant

Table 5 Difference between group






Table5 shows that Adduction ROM mean ofGroup A was 2390 with SD (363) and Group Bwas1980 with SD (440) which was statisticallysignificant (p value lt003)Internal Rotation ROM mean of Group A was3970 with SD(290) and Group B was 3765 withSD (268) which was statistically significant (pvalue lt026)VAS mean of Group A was 095 with SD (089)and Group B was 390 with SD (129) which wasstatistically significant (p value lt0001)Strength mean of Group A was 6630 with SD



(1466) and Group B was 4150 with SD (1368) which was statistically significant (p value lt0001)Graph 1 No of subject in age

distributionGraph 2 No of subject in gender

distribution in group AGraph 3 No of subject in gender

distribution in group B

Graph 4 Adduction Internalrotation variable in group A amp B

Graph 5 VAS outcome variable ingroup A amp B

Graph 6 Strength outcome variablein Group A amp B

Graph 7 Pre post difference withingroup A amp B showing Adduction

ROM

Graph 8 Pre post difference withingroup A amp B showing Internal

rotation ROM

Graph 9 Pre post difference withingroup A amp B showing VAS

Graph 10 Pre post differencewithin group A amp B showing Hip

abductor strength

Graph 11 difference between groupVAS score

Graph 12 difference between groupstrength score

Graph 13 Difference between group Adduc-tion and Internal rotation ROM score



DISCUSSIONObjective of the study was to examine the effectof hip abductor strengthening among non-professional cyclists with ITBFS and to comparethe effect of hip abductor strengthening overconventional physiotherapy among non-professional cyclists with ITBFS The parametersselected were ROM VAS score and strengthIn this study the baseline data of thedemographic and outcome variables did notshow any statistically significant differencebetween the patient population in Group A andGroup BBaseline data for outcome variable strength (hipabductor) was not statistically significant thiswas similar to the study done by Amir M ArabMohammad R Nourbakhsh (The relationshipbetween hip abductor muscle strength andiliotibial band tightness in individuals with lowback pain) concluded that the relationshipbetween ITB tightness and hip abductorweakness in patients with LBP was notsupported as assumed in theory which was ITBtightness in individuals with LBP was acompensatory mechanism following hipabductor muscle weaknessThey hypothesizedthat more clinical studies needed to assess thetheory of muscle imbalance of hip abductorweakness and ITB tightness in LBP All patientsin group A and group B were able to completethe studyThe result in group A showed that for AdductionROM pre test score mean was1615 and SD(418) post test score mean was 2390 and SD(363) with p value lt00001 which wasstatistically significant for Internal Rotation pretest score mean was 3635 and SD (325) posttest score mean was 3970 and SD (290) with pvalue lt00001 which was statisticallysignificantfor VAS pre test score mean was 670and SD (130) post test score mean was 095and SD (089) with p value lt00001 which wasstatistically significantfor Strength pre testscore mean was 4080 and SD (1202) post testscore mean was 6630 and SD (1466) with pvalue lt00001 which was statistically significantthis was in accordance with study done by BrianNoehren Irene Davis and Joseph Hamill(Prospective Study of the Biomechanical Factors

Associated with Iliotibial Band Syndrome) foundfrom their results that individuals who go ontoto develop ITBS exhibit greater hip adduction andknee internal rotation These results suggest thatinterventions should be directed at controllingthese motionsFerber et al (2003) found that runners who wenton to develop ITBS had greater peak eversiongreater peak eversion velocity and excursion Ahip mechanism for developing ITBS has beenproposed as well Weakness of the hip abductorshas been associated with ITBS (Fredrikson 2000)Weakness of the hip abductors has been shownto be related to increased hip adduction inrunners with patellofemoral pain syndrome(Dierks 2005) However there were no studiesof the role of increased hip adduction in ITBS Itis possible that increased hip adductioncombined with knee internal rotation increasesITB tension This could increase contact of theITB with the lateral femoral condyle and lead toirritation with repeated exposure Another studydone by Michael Fredericson et al (QuantitativeAnalysis of the Relative Effectiveness of 3Iliotibial Band Stretches) shows that adding anoverhead arm extension to the most commonlateral ITB stretch increases average ITB lengthchange and average external adductionmoments in male elite-level distance runnersand that these differences are statisticallysignificantImprovement in hip abductor strength and VASpre post difference within group A may bebecause of effect of hip abductor strengtheningand ultrasound treatment this was similar to thestudy done by Reed Ferber Karen D et al A 3-week hip-abductor muscle-strengtheningprotocol was effective in increasing musclestrength and decreasing pain and stride-to-strideknee-joint variability in individuals with PFPSAnother study done by Michael FredericsonCurtis et al where injured runners were enrolledin a 6-week standardized rehabilitation protocolwith special attention directed to strengtheningthe gluteus medius After rehabilitation thefemales demonstrated an average increase inhip abductor torque of 349 in the injured limband the males an average increase of 514After 6 weeks of rehabilitation 22 of 24 athletes



were pain free with all exercises and able toreturn to running and at 6- monthrsquos follow-upthere were no reports of reoccurance Theyconcluded that long distance runners with ITBShave weaker hip abduction strength in theaffected leg compared with their unaffected legand unaffected long-distance runnersAdditionally symptom improvement with asuccessful return to preinjury training programparallels improvement in hip abductor strengthAnother mechanism that accounts for pain relief(improvement of VAS) for both groups may bebecause of mild heating effect of ultrasound inreducing pain and promoting the healingprocess Accelerated protein synthesisstimulates the rate of damaged tissuesHowever in group B mean VAS score improvedfrom pre score of 695 to post score of 390 andadduction ROM from 1475 to 1980 which wasstatistically significant this may be due to effectof IT band stretching and ultrasound treatmentHowever IR and strength pre post differencewithin group B was not significant this was inaccordance to study done by Grau et al foundno significant difference for isometricconcentric or eccentric peak torque of the hipabductors in controls versus those with ITBSFor IR study done by Willson and Davis suggestthat subjects with PFPS exhibited greater hipadduction but also greater hip external rotationthan controls The researchers did not assesship strength thus precluding the ability to notean association between hip weakness andaltered kinematics In a follow-up study Willsonand Davis examined trunk hip and kneestrength as well as hip and knee kinematics andkinetics during repeated single leg jumpsAlthough subjects with PFPS demonstratedgreater hip-adduction excursion they did notdemonstrate differences in hip-internal-rotationexcursion When only analyzing subjects withPFPS they found a fair correlation (r = ndash40)between hip-abductor strength and hipadduction excursion There was a poorcorrelation (r = ndash07) however between hipexternal- rotator strength and hip-internal-rotation excursion Dierks et al examined hipstrength and hip and knee kinematics in runnerswith and without PFPS before and after prolonged

CONCLUSION

running Like in the study by Willson and Davisthere was a fair correlation (r = -34) betweenhip-abductor strength and peak hip adductionat the beginning of the run After prolongedrunning subjects with PFPS demonstrated ahigher correlation (r = ndash74) between hip-abductor strength and peak hip adduction Noassociation was found between hip external-rotator weakness and peak hip internal rotationIn summary these findings suggest that subjectswith PFPS might not exhibit altered hipkinematics until their muscle strength fallsbelow a certain threshold More important itremains elusive whether hip weakness was thecause or the result of PFPS Additional researchis needed to better understand the associationbetween hip weakness hip kinematics and PFPSetiologyPre post difference between groups there wassignificant difference in adduction IR ROMVASand hip abductor strength this was in accordanceto study done by Amanda Beers et al showedthat increases in hip abductor strength wereobserved over the course of the 6 weeks duringwhich the participants were taking part in thestandardized rehabilitation programme andthese strength changes seemed to paralleldecreases in the symptoms of ITBFSLIMITATION OF THE STUDY1 Sample size was small2 Duration of study was less3 No follow up was done4 Functional activity was not monitoredFURTHER RECOMMENDATION1 Isolated hip abductor strengthening inexperimental group and control group withoutany treatment can be conducted2 Outcome using lower extremity functionalscale for quality of life3 Isokinetic dynamometer can be used as a toolfor measurement of strength as well as handheld dynamometer4 Long term follow up needed

The primary objective of the study was to findout the effect of hip abductor strengtheningamong non-professional cyclist with ITBFS



The results of the study shows that there issignificant difference of hip abductorstrengthening among nonprofessional cyclistswith ITBFSSUMMARYITBFS is a common problem of lateral knee andcomes under the repetitive stress injury causedue to repetitive flexion and extensionassociated with other biomechanicalabnormalitiesMost common in runners andcyclistsA high incidence has been found amongcyclistMajority of the studies on ITBS has focusedmainly on the effectiveness of various treatmenttechniques to the ITB itself andor its associatedtensor fascia lata (TFL) muscle with varyingresults reported which include conservativetherapies like rest ice and stretching of the tightband myofascial trigger point therapies like dryneedling Nonoperative measures specific tocyclists consist of bicycle adjustments andtraining modifications [15]It has been proved that there is hip abductorweakness in patients with ITBFS andpatellofemoral pain syndromeSo the purpose ofthe study was to find out the effect of hipabductor strengthening among non-professionalcyclist with ITBFS40 Subject consisting of 30male and 10 female assigned into control groupB (20 subject) which was given ultrasoundtreatmentstretching of IT band and experimentalgroup A(20 subject) received hip abductorstrengthening in addition to Ultrasound and ITband stretchingThe duration of study was 6 weeks and it waspre post experimental study where subject wereassessed pre and post for ROM (hip IRadduction) using Goniometer pain using VAS andstrength using modified sphygmomanometerThe results of the study indicated that there wassignificant difference of hip abductorstrengthening exercise among non-professionalcyclists with ITBFS

Conflicts of interest None

REFERENCES

[2] Barber FA Sutker AN Iliotibial band syndromeSport med 1992 14144ndash148

[3] Kirk LK Kuklo T Klemme W Iliotibial band frictionsyndrome Orthopaedics 200023(11)1209 ndash1214

[4] Orchard JW Fricker PA Abud AT Mason BRBiomechanics of iliotibial band friction syndromein runners Am j sport med 199624(3)375ndash379

[5] Holmes JC Pruitt AL Whalen NJ Iliotibial bandsyndrome in cyclists Am Orthop Soc sports med199321419 ndash424

[6] Ningthoujam Sandhyarani I liotibial bandsyndrome Available from URL httpwww buzz lec omart ic lesi l io t i bial -b and-syndromehtml

[7] Krivickas LS Anatomical factors associated withoveruse sports injuries Sport Med 199724132ndash146

[8] Orava S Iliotibial tract friction syndrome inathletes-an uncommon exertion syndrome on thelateral side of the knee Br j sports med 19781269ndash73

[9] Taunton J Ryan M Clement D McKenzie D Lloyd-Smith D Zumbo B A retrospective casendashcontrolanalysis of 2002 running injuries Br j sports med200236(2)95-101

[10]Linenger JMCC Is i liotibial band syndromeoverlooked Phys sports med 19922098 108

[11] Takaishi T Yamamoto T Ono T Ito T Moritani TNeuromuscular metabolic and kinetic adaptationsfor skilled pedalling performance in cyclists Medsci Sports exercise 199830(3)442 ndash449

[12] Jerold MS Pietro MT Timothy DM Iliotibial BandSyndromeAvailable from URL httpemedicinemedscapecomarticle91129-overviewUpdated Jan 4 2008

[13] Reinhardt T Norbert W Thomas J Ronald V Powermeasurement in cycling using inductile couplingof energy and data The engineering of sport 20081397-403

[1] Michael F Curtis LC Ajit MC Brian CD Nina O BSShirley AS Hip abductor weakness in distancerunners with iliotibial band syndrome Clinicaljournal of sport medicine 2000 March10169-175


AcknowledgementAuthor Convevying the gratudes to MrSNagaraj(asst prof Padmashree institute of physio-therapy) Mr Pravin aaron(principal Padmashree

institute of physiotherapy) DrKabul ChandraSaikia (Principal Cum Chief SuperintendentGMCH)

Abbreviations

ITBS- Iliotibial band friction syndromeIR-Intrnal RotationUS- UltrasoundITB- Iliotibial BandTFL-Tensor Fascia LataePFPS- Petello Femoral Pain Syndorome


[14]Steven J KCynthia K Il iotibial band frictionsyndrome 2009 Available fromURL httpwwwemedicinemedscapecomarticle1250716-overview

[15]James CH Andrew LP Nina J W Iliotibial bandsyndrome in cyclist Am j sport med 1993June21(3)419-424

[16]Mac Mahon JM Chaudhari AM Andriacchi TPBiomechanical injury predictors for marathonrunners striding towards iliotibial band syndromeinjury prevention Conference of the internationalsociety of biomechanics in Sports Hong Kong June2000

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How to cite this articleJayanta Nath EFFECT OF HIP ABDUCTOR STRENGTHENING AMONG NON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL BAND FRICTION SYNDROMEInt J Physiother Res 20153(1)894-904 DOI 1016965ijpr2015105




-est friction [5] More common in age between15 to 50 years [6]A number of etiological factors have been relatedto ITBS include training errors biomechanicalfactors like genu varum foot hypersupinationfoot overpronation or cavus foot and leg lengthdiscrepancies footwear with poor shockabsorption and most recently hip abductorweakness [14]Incidence amp prevalence It is generally acceptedthat ITBFS is the most common running injury ofthe lateral knee with an incidence between 16and 12 [89] ITBFS comprises 22 of lowerextremity injuries [10] Although it is mostcommon in distance runners there is a growingnumber of cyclists with ITBFS ITBFS accountsfor approximately 15 of all overuse injuries atthe knee in cycling [5]Pathomechanics The pathogenesis of ITBFSinvolves inflammation and irritation of the lateralsynovial recess (Renne et al) as well ascontinued irritation of the posterior fibres of theITB (Ekman et al) and inflammation of theperiosteum of the lateral femoral epicondyle(McNicol et al) all of which describes thepathogenesis of ITBFSThe iliotibial band is a thick strip of fascia thatoriginates from tubercle of iliac crest continuesdown the lateral side of thigh and inserts intothe lateral tibial condyle (Gerdyrsquos tubercle) andinto the lateral proximal fibular head [47] Whenknee is flexed to an angle greater than 30o theITB lies posterior to the lateral femoralepicondyle when knee is extended however theITB moves anterior to this landmarkThereforefriction occurs at or slightly less than 300 of kneeflexion when the ITB crosses over the lateralfemoral epicondyle [4]The high number of revolutions of the bicyclecranks and tightness of the ITB resulting frommuscular effort can result in inflammation of theITB during cycling Additionally a snapping ofthe ITB may occur as it slides over the lateralfemoral epicondyle of the femur typically whenthe crank is approaching bottom center [5]Takaishi et al calculated peak pedal force forvarious cycling cadences in both competitiveand noncompetitive cyclists and determined thatnon-competitive cyclists preferred a lower

cadence (70 RPM) than competitive cyclists (80ndash90 RPM) for a moderate rate of work intensity(150 W) [11]In cycling the ITB is pulled anteriorly on thepedaling down stroke and posteriorly on theupstroke The ITB is predisposed to frictionirritation and microtrauma during this repetitivemovement because its posterior fibers adhereclosely to the lateral femoral epicondyleCyclists with an external tibia rotation greaterthan 200 stress is created on the ITB if theathletersquos cycling shoe is placed in a straight-ahead position or the toe is in a cleat positionCyclists with varus knee alignment or activepronation place a greater stretch on the distalITB when they ride with internally rotated cleatsPoorly fitted bicycle saddle a high-riding saddlecauses the cyclist to extend the knee more than1500 This exaggerated knee extension causesthe distal ITB to abrade across the lateralfemoral condyle Bicycle saddles that arepositioned too far back cause the cyclist to reachfor the pedal with a resultant stretch to the ITB[12]The power exerted on the pedal is the mostreliable parameter to determine the training loadin cycling biomechanically and hence a crucialfactor to optimize performance [13] Commercialpower meters are meanwhile part of thestandard equipment of professional cyclists butalso used by an increasing number of nonprofessional cyclists [13]Proximally the ITB acts as a lateral hip stabilizerresisting hip adduction (Fredickson et al 2000)It originates in the facial components of thegluteus maximus gluteus medius and tensorfasciae latae muscles (Muhle et al 1999Birnbaum et al 2004 Terry et al 1986) TheITB is attached distally to the supracondyletubercle of the femur and the lateralintramuscular septum In addition it has fibersthat attach to the patella (Muhle et al 1999Birnbaum et al 2004 Terry et al 1986) Due tothese attachments increased hip adduction islikely to lead to increased tension on the ITBIncreased hip adduction may necessitate agreater eccentric demand from glutealmusculature resulting in a higher hip abductionmoment















RESULTS










2Gender (MF) 1515 1515 1








































ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations























RESULTS










2Gender (MF) 1515 1515 1








































ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations



















RESULTS










2Gender (MF) 1515 1515 1








































ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations













RESULTS










2Gender (MF) 1515 1515 1








































ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations














2Gender (MF) 1515 1515 1








































ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations


















ROM


rotation ROM



abductor strength











CONCLUSION







REFERENCES

















Abbreviations















CONCLUSION







REFERENCES

















Abbreviations











CONCLUSION







REFERENCES

















Abbreviations












REFERENCES

















Abbreviations
















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Ijpr.2015.105EFFECT OF HIP ABDUCTOR STRENGTHENING AMONG NON-PROFESSIONAL CYCLISTS WITH ILIOTIBIAL...

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