23   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

Research

Article

The Effect of Gluteus Medius Training 
on Hip Kinematics in a Runner with 

Iliotibial Band Syndrome

Corresponding Author:
Prof Quinette Louw 
Physiotherapy Division
Stellenbosch University 
Fransie van Zijl Avenue
Parow Valley 7500
E­mail: qalouw@sun.ac.za

AbSTrAcT:  Iliotibial band syndrome (ITBS) is a common clinical presentation 
in runners. There are several hypotheses to explain this condition including faulty  
control of the hip joint in the frontal plane during the stance phase of running. It is 
postulated that improving activity in the gluteus medius muscle may assist in produc-
ing more appropriate stabilization and therefore reduce the stress on the Iliotibial 
band (ITB). This single case study provides an interesting clinical scenario where 
a single-subject with ITBS was measured for hip kinematics during running, before 
and after a trial period of classic gluteus medius exercises. The biomechanical data show an initial (pre-intervention) 
increase in adduction position during the stance phase of running on the affected side (in contrast to the unaffected 
side). This was measured using a Moven motion analysis suit. After the trial intervention period, the relative position 
of the affected hip had reduced in adduction at both heel strike and at 30° knee flexion. This study provides support  
for the theory that hip control in the frontal plane may be a contributing factor in ITBS. Clinicians are encouraged 
to monitor hip control as well as ITBS symptoms when they utilise this gluteus medius protocol. Further research to 
establish whether change in pelvic control results in decrease in ITBS symptoms is warranted.
 
Key wordS:  IlIoTIBIAl BAnD SynDRoMe, RUnneRS, hIP kIneMATICS, BIoMeChAnICS, MoTIon 
AnAlySIS.

Schreiber R, MSc1
Louw Q, PhD1

 1 University of Stellenbosch

the repetitive knee flexion/ extension 
movements and consequently leads to an 
inflammatory process (Franco et al 1997, 
Fredericson and Wolf 2006, Khaund and 
Flynn 2005). In severe cases, the runner 
may not be able to continue running and 
needs to seek medical attention (Noehren 
et al 2007). ITBS in runners is thus a  
significant problem, as the intensity of 
the pain can lead to attrition from run­
ning (Miller et al 2007).

Pain develops after heel strike in 
the initial standing phase, while the 
knee joint angle is in less than 30 
degrees of flexion (Fredericson and 
Wolf 2005). This may be the maximal 
zone of impingement during running 
(Fredericson and Weir 2006). A relative 
smaller knee flexion angle at heel strike 
predisposes a runner to ITBS, since 
more time is then spent in the impinge­
ment arc of knee flexion (Fredericson 
and Wolf 2005). The relatively smaller 
knee flexion angle has been suggested 
to be due to hip muscle weakness of  
the gluteus medius (Fredericson et al 
2000). However it is not entirely clear 

BACKGROUND
Iliotibial band syndrome (ITBS) is the 
second leading cause of knee pain and 
the primary cause of lateral knee pain 
in runners (Noehren et al 2007). ITBS 
makes up 12% of all overuse injuries 
in running and 22% of all lower extre­
mity running injuries (Fredericson and 
Weir 2006, Grau et al 2008, Taunton et 
al 2002). Due to the increased aware­
ness of aerobic exercise to maintain a 
healthy lifestyle, jogging and running 
have become more popular. This is  
mirrored by an increase in acute and 
chronic running injuries (Dugan and 
Bhat 2005). ITBS is common among 
cyclists, football players, hockey players, 
downhill skiers, weight lifters and long 
distance runners (Gunter and Schwellnus 
2004). 

In long­distance running, repetitive 
flexion and extension of the knee joint 
leads to excessive rubbing of the distal 
iliotibial band across the lateral femo­
ral condyle (Grau et al 2008). The pain 
usually increases over the duration of 
the run due to cumulative effects of  

why distance runners may be prone to 
this weakness. Fredericson et al (2000) 
proposed that running is mainly a sagi­
ttal plane activity which requires less 
hip control in the frontal plane. 

Biomechanical analysis can unlock 
explanations to presentations such as 
ITBS, but there is a dearth of biome­
chanical research into understanding 
the relationship between hip control 
and ITBS in runners (Fairclough et al 
2007). In healthy runners, the gluteus 
medius, especially the posterior part, is 
primarily a global stabilizer which initi­
ates external rotation of the hip. In addi­
tion, the gluteus medius muscle should  
contract eccentrically at heel strike and 
then concentrically during the stance 



24   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

phase to control frontal plane hip move­
ments (Fredericson et al 2000). Although 
the role of the gluteus medius during the 
running cycle in healthy individuals has 
been established, the role of this muscle 
in ITBS remains vague. 

A recent ITBS biomechanical theory 
is that the degree of frontal plane hip 
angles may influence an individual’s risk 
of developing ITBS (Miller et al 2008). 
During running, increased hip adduc­
tion and internal rotation angles during 
the stance phase may increase strain on 
the ITB (Fredericson and Wolf 2005, 
Noehren et al 2007). Miller et al (2008) 
further reported that runners who were 
prone to develop ITBS demonstrated 
coupled hip adduction/abduction and 
tibia internal/external rotation move­
ments. These coupled knee patterns may 
increase tension on the ITB, with ensuing 
micro­trauma of the tissue (Fredericson 
et al 2000).  These coupled movements 
may therefore be an effect or cause of 
ITBS (Noehren et al 2007). 

Gluteus medius muscle weakness 
may be related to impaired hip frontal 
plane control (Fredericson et al 2000). 
Weakness of this muscle may lead to 
relatively increased hip adduction and 
internal rotation and an increased valgus 
vector at the knee (Fredericson et al 
2000, Niemuth et al 2005). This finding 
is in agreement with researchers who 
postulate that impaired gluteus medius 
control is a predisposing factor for ITBS 
(Fairclough et al 2007). Grau et al (2008) 
reported no difference in hip abduction 
muscle strength between runners with 
and without ITBS, but a shortcoming 
was that functional biomechanical ana­
lyses of hip control during running was 
not conducted. The importance of the 
hip musculature in the prevention and 
treatment of ITBS thus remains contro­
versial. The aim of this study was thus to 
ascertain the effect of a gluteus medius 
strengthening program on hip control 
during the stance phase of running in a 
runner with ITBS. 

METHODOLOGy
This study was approved by the Human 
Research Ethics Committee of the 
Faculty of Health Sciences, Stellenbosch 
University (N08/09/245) and the subject 

provided signed consent. Permission to 
conduct the study was obtained from the 
Performance Institute of Stellenbosch 
University (SUSPI) where the study  
was conducted. 

Participant recruitment and eligibility 
criteria
The participant was recruited from the 
physiotherapy clinic of SUSPI. The 
inclusion criteria were: an amateur, 
male or female runner that ran on aver­
age between 80 and 100 km per week 
and competed in races without financial 
incentives. The participant was recruited 
being positive for the following criteria: 
Older than 18 years with complaints of 
lateral knee pain during or after run­
ning and which increased with downhill 
running; positive testing with the Ober, 
Noble and hop tests as well as on palpa­
tion of the ITB over the lateral condyle of 
the femur; wearing neutral running shoes 
without orthotics; good general health, 
no associated musculoskeletal injuries, 
and should not have been receiving any 
other form of medical or alternative 
treatment.  An objective inclusion cri­
terion was relative weakness of the glu­
teus medius muscle on the affected side 
compared with the unaffected side as 
measured by a hand­held dynamo meter. 
Relative weakness was defined as at 
least 20% less strength compared to the 
unaffected side (Maffiuletti 2010).  The 
exclusion criteria were previous lower 
limb injuries or any soft tissue treatment 
received for current ITBS. 

Study design
A single­subject, ABA –design study 
(where A represents the baseline phases 
and B the treatment phase) was con­
ducted over eight weeks. The study 
timeline consisted of the following  
three phases:

Baseline phase (A1): Baseline assess­
ments were conducted one week after  
the inclusive criteria were met and the 
participant had been diagnosed with 
ITBS. The assessments included biome­
chanical analyses of the hip joint angles 
in the frontal plane (hip adduction/
adduction) on three alternate days in the 
same week (Monday, Wednesday and 
Friday). Hip angles were analysed using 

the MOVEN motion analysis system. 
Pain was monitored using the Visual 
Analogue Scale (VAS) on all three days 
when the biomechanical analyses were 
done.  

Intervention phase (B): During this 
phase, the six­week gluteus medius 
strengthening program was implemented.

The follow-up phase (A2): Biome­
chanical analyses were of the frontal 
hip joint angles were repeated on three 
alternate days during the eighth week  
of the study. Pain was monitored using 
the VAS. 

intervention
The intervention was a six­week, daily 
gluteus medius strengthening program 
which was aimed at increasing muscle 
control and local muscle endurance on 
the affected leg. The mode of delivery 
was a combination of supervised and 
home­based sessions.  Three supervised 
sessions which lasted about 40 minutes 
were conducted at SUSPI throughout 
the eight weeks intervention phase. 
The principle researcher supervised all 
sessions. In addition, the participant 
received a printed copy of the program 
at the beginning of the inter vention 
program to continue the exercises at 
home, bar the days when attending  
sessions at SUSPI. The home­based  
exercises were followed up telepho­
nically.

description of exercises:
The program consisted of the exercises 
described in figures 1, 2 and 3. The  
rationale of including transverse abdomi­
nal muscle exercises is that function of 
this stabilizer is a prerequisite to any  
form of strength training as it ensures 
load balance within the kinetic chain 
(Akuthota et al 2008). Core stability 
is imperative for initiation of func­
tional limb movements (Akuthota et 
al 2008). In this case, the activation of 
transverse abdominals was important 
to keep the spine in the neutral position 
during execution of the hip exercises. 
Electromyographic studies have illu­
strated that the exercises in figures 2 
and 3 are optimal for improving strength 
control of the gluteus medius (Distefano 
et al 2009). 



25   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

Verbal feedback during exercise  
execution
The exercises were monitored and cor­
rected as necessary by the principle 
researcher. If pain was experienced in 
the knee, the exercise technique was 
corrected by verbal feedback. Pain  
may be an indication that strain is 
imposed on the ITB that may lead to 
increased hip internal rotation and  
consequent irritation over the distal part 
of ITB.

exercise progression 
Exercises were progressed by increas­
ing the number of repetitions, when  
the participant demonstrated good tech­
nique (neutral spine and appropriate hip 
ROM) without fatigue. This was ensured 
during the supervised training sessions 
at SUSPI.

Figure 3 AB
Figure 3 A and B: A) Single Leg Hitch of Step - Spine in neutral with transverse 
abdominus activated. The gluteus medius of the affected side slowly pulls the  
unaffected pelvis upwards to neutral spine. Repeat 8 times, three sets. (Fredericson 
and Weir 2006, Fredericson et al 2000). B) Sideways step up (Progression of Single 
Leg Hitch). Side step up with transverse abdominal activated. Repeat 8 times, four 
sets (Fredericson and Wolf 2005, Khaund and Flynn, 2005).

Study Procedures 

clinical evaluation

ITBS diagnostic tests•	
At the first appointment (day one), a 
subjective and physical examination 
was conducted using clinical diagnostic 
tests including the Noble test, the Hop 
Test, the Ober test and palpation over  
the distal ITB area (Barber and Sutker 
1992, Franco et al 1997, Fredericson and 
Weir 2006, Khaund and Flynn 2005). 
The participant was diagnosed with 
ITBS because both the Noble and Hop 
tests and the palpation were positive, 
and subjectively reported lateral knee 
pain while or after running (Fredericson 
and Weir 2006).

Gluteus medius muscle strength test• 
In side­lying, the participant produced 
an isometric action of hip abduction for 
three to five seconds in approximately 
30˚ of hip abduction and 5˚ of hip exten­
sion with the hip in neutral rotation 
(Fredericson et al, 2000). Maximum 
resistance was applied by the researcher 
using a hand­held dynamometer proxi­
mal to the lateral malleolus (Fredericson 
et al, 2000). During the testing, conti­
nuous monitoring of movement was 
done to ensure appropriate stabilisation 
and that no hip flexion was allowed and 
rest periods were given between testing. 
During the test procedures of the gluteus 
medius strength, no pain was produced 
at any stage.  Three measurements were 
taken and the average score was used  
for the final score. 

The muscle strength test using the 
hand­held dynamometer has demon­
strated good test­retest reliability and 
the validity assessments have been 
compared to isokinetic testing of shoul­
der and hamstrings (Hyde et al, 1983, 
Bohannon et al, 1986). We need to 
acknowledge that with the strength test 
of gluteus medius the tensor fasia latae 
and gluteus minimus could have been 
recruited due to both being hip abductors 
(Hollingshead et al 1982). 

Figure 1: Transverse Abdominal activation. Hold the position and do 8 breaths 10 
times (Hodges and Richardson 1996)

Figure 2 A    B
Figure 2 A and B: A) Clam – Beginner phase, transverse abdominals activated, hold 
the position and lift the knee. Repeat 8 times, three sets. B) Straight leg raise in side 
lying (progression of Clam). Side lying with transverse abdominal activated. Repeat 8 
times four sets (Fredericson et al 2000).



26   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

Pain assessment• 
The principal researcher administered a 
uni­dimensional Visual Analogue scale 
(VAS) for resting pain as well as pain 
with walking and running (Collins et al, 
1997). 

 
Motion analysis of hip angles during 
running
The biomechanical measurement of hip 
motion in the frontal plane was done 
using the MOVEN motion analysis  
system (developed by Xsens Techno­
logy B.V, Netherlands, inertial motion 
system). The MOVEN motion analysis 
system consists of Lycra strips with  
sixteen attached inertial sensors which 
are placed over the joints. Each sensor 
is comprised of a 3D gyroscope, 3D 
accelerometers and 3D magnetometers. 
These motion trackers give the total ori­
entation estimate of the hip. This was 
used to calculate the 3D linear accele­
ration, giving the translation estimate of 
the joint. All the sensors were positioned 
to ensure accurate orientation of the suit, 
although only hip angles were analysed.  
Validity and reliability of the MOVEN, 
compared to the Vicon motion analysis 
system have been previously established 
by Scheffer and Cloete (2008).

The biomechanical analysis was con­
ducted in the Stellenbosch University 
Gymnasium Sports Hall. The participant 
started with a two­minute, warm­up cycle 
before running. No pain was present 
before any biomechanical testing was 
conducted or during the running trails. 
The participant was then instructed to 
run at a speed of 9­10km/hour, which is 

reportedly the participant’s average run­
ning speed when training. The speed was 
monitored with the MOVEN’s detach­
able speedometer. 

One running trial of ten minutes was 
captured on each of the three alternate 
test days during the baseline and follow­
up phases. The last two minutes of the 
ten­minute run were captured, however 
the participant was blinded as to the 
length of the run and to when the data 
were recorded, hence he altered his 
style. The biomechanical data of the 
last three steps of the tenth minute dur­
ing the run was analysed for each of the 
three trials (one trial on three alternate 
days) Therefore, the hip biomechanics 
of a total of nine steps were analysed for 
the baseline and the follow­up phases. 
Reliability and repeatability for the bio­
mechanical assessment was conducted 
on the same day before the trails were 
performed.

The data were transferred wirelessly 
to a laptop to process the hip kinematics. 
The motion capture’s software converts 
acceleration and orientation measure­
ments (obtain form motion capture 
sensors) to translation (three Cartesian 
components) and rotation (quaternion 
vector) measurements. The orientation 
of each segment is calculated by means 
of quaternion multiplication (Baker 
2009). This enables the calculation of 
each joint’s flexion angle by subtracting 
the orientation measures of the joint’s 
inner and outer segment. Each joint’s 
translation in 3­D space and its rotation 
angles are therefore available for export, 
in this case, an excel spreadsheet. The 

point of heel strike and 30˚ was visually 
estimated by the engineer. The data were 
then accurately documented and orga­
nised in columns which included the day, 
step number, time frame and abduction 
in an Excel spreadsheet for each leg. 

Data Analysis
Descriptive statistical techniques were 
used to analyse the hip adduction data. 
The measurement closest to heel strike 
and to 30° of knee flexion of each of the 
three steps in the trial was documented 
and plotted in an MSExcel spread sheet. 
The definition of direction of movement 
was stipulated by the engineer and the 
MOVEN analysis system. The abduc­
tion movement in the affected (right) leg 
was negative and adduction was posi­
tive. In the unaffected leg (left) it was 
the reverse i.e. adduction was negative 
and abduction was positive. 

RESULTS

Subject description
The participant was a 21 year­old male, 
who had no history of any injury to his 
affected leg which was his right (and 
dominant) leg. His running program 
consisted of 15 to 20 km per day on the 
road during the week and 30 km’s on a 
Saturday. Sundays were rest days. He 
consistently ran on the same surfaces, 
and did not change any of his training 
intensity or running shoes. His shoes 
were deemed to be in good condition 
and appropriate for the study.  Mean glu­
teus medius strength of the affected leg  
was 12.5kg (SD: 1.95) and the un affected 

Table 1: Means (sd) of pre- and post-test scores for the position of the affected and unaffected hips at two points in the 

running cycle, measured in degrees.

Affected leg at 
heel strike 

unaffected leg at 
heel strike 

Affected leg at 30° 
knee flexion 

unaffected leg at 30° 
knee flexion 

Pre- intervention  

Mean(sd) +3.27 (2.76) add +0.58 (6.43) abd +12.4 (2.68) add -5.64(4.00) add

Post- intervention 

Mean(sd) -0.20 (4.14) abd -3.7 (4.29) add +9.8 (3.37) add -12.1 (2.4) add

Change score 

Mean (sd) -3.47 (5.74) -0.78 (7.22) -2.63 (3.86) -6.46 (6.15)

NB – affected leg abduction values = -ve, adduction values = +ve; non-affected abduction values = +ve, adduction values = -ve.



27   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

leg was 20kg (SD: 2.59). Thus the 
affected side was 37.5% weaker than the 
unaffected side. 

The pre­intervention biomechanical 
data showed an increase in hip adduc­
tion of the affected leg (M: 3.27º, SD: 
2.76) compared to the unaffected side 
at heel strike (M: 0.58º SD 6.43) and at  
30° knee flexion (affected M: 12.4° 
adduction, SD: 2.68 versus unaffected 
M: 5.64°, SD: 4.00) (see Table 1). 

After the intervention phase, the 
affected leg had a mean decrease in 
hip adduction at the affected leg at heel 
strike (M: 0.20° abduction, SD: 4.14) 
and at 30° knee flexion (M: 9.80° adduc­
tion, SD: 3.37) (see table 1). After the 
intervention phase there was an increase 
in adduction of the unaffected leg at heel 
strike and at 30° of knee flexion. 

Pain VAS assessment
The participant reported a 5/10 VAS pain 
score with walking and jogging and no 
pain at rest at the first day of assessment. 
A week later, the participant reported 
a VAS of ‘0’ with walking or any acti­
vities, indicated that no pain was expe­
rienced before the study was conducted. 
All subsequent pain measures were  
0/10 VAS during the running trails of 
this study. 

DiSCUSSiON
The main objective of this study was to 
investigate the biomechanical effect of 
gluteus medius training (which focused 
on the control and endurance in the  
frontal plane of hip kinematics) during 
the stance phase of running in a patient 
with ITBS. 

Gluteus medius strengthening has 
been part of a wide range of treatment 
plans for athletes with ITBS. Other  
interventions previously reported for 
ITBS include stretching, soft tissue 
mobilization, dry needling and biome­
chanical correction of the footwear 
(Fredericson and Weir 2005).  

The biomechanical test results of this 
study during the pre­intervention phase 
reported increased hip adduction in the 
affected leg, with the gluteus medius 
weakness compared to the unaffected 
leg. This confirmed that the participant 
in this study presented with a similar 

clinical presentation to those described 
in the biomechanical study of Noehren 
et al (2007). This adds further support 
that a relationship exists between the hip 
muscle weakness and an injury pattern 
in runners suffering from ITBS.

With the use of the MOVEN system, 
measurements after the intervention 
stage reported a reduction of adduction 
at heel strike and 30˚ knee flexion of 
the affected side during running (mean 
change 3.47° and 2.63° respectively). 
According to Scheffer and Cloete (2008) 
any change result of two degrees or less 
indicates an inaccurate measurement or 
no change. Therefore we have evidence 
to suggest that there was a true change 
in hip abduction control during the study 
period. These changes in kinematics 
observed might have been clinically 
relevant even bearing in mind the large 
standard deviations indicate quite large 
variance. Given the study design we 
cannot say with certainty that the change 
was as a result of the intervention.

The uninvolved leg was also measured 
and monitored by the MOVEN system 
before and after the intervention. Before 
the intervention, the unaffected leg with 
a 37.5% stronger gluteus medius strength 
reported an increased in hip abduc­
tion compared to the affected hip. The  
intervention phase was only conducted 
on the gluteus medius of the affected 
side. Although at the end of the post­
intervention phase the unaffected leg 
reported a decrease in abduction of the 
hip. This could be due to compensatory 
strategies of the pelvis for stability after 
only training a specific muscle group. 
Currently, no published evidence could 
be found to support this.

There were many limitations to this 
study. Although the MOVEN system 
showed reliability according to Scheffer 
and Cloete (2008), the sensitivity of the 
system at heel strike point was question­
able due to the subjective time­point 
estimate of the engineer. Furthermore, 
limited conclusions can be made from 
a single­case design. A larger sample  
size will be of more value to con­
firm this study’s preliminary findings. 
Measuring post­intervention strength 
of gluteus medius would have indicated 
that a six­week program of the above­ 

mentioned exercises was either adequate 
or inadequate for an athlete to increase in 
strength and endurance. The participant 
did continue with cycling for 30 min­
utes, on alternative days, to keep fit. He 
was cycling at the same intensity before 
the study, so this probably did not affect  
the end result of the study. The partici­
pant complied with all required exer­
cises and stayed within the parameters 
of the study.

A longer trial period may be needed 
to measure gluteus medius strength/
control because it is a global stabilizer 
that may need more than a six­week 
strength training program (Hodges and 
Richardson 1996). The exercises could 
have also been progressed with adding 
resistance to increase the level of mus­
cle activation and potentially improve 
the strengthening effects. It must be 
remembered, though, that it is not neces­
sarily strength that improves functional  
ability, but rather motor coordination 
parameters such as timing, sequencing 
or grading of force production.

CONCLUSiON
The high incidence numbers of ITBS 
among long­distance runners demon­
strates the importance of more bio­
mechanical research in athletes with 
ITBS (Noehren et al 2007). The use of 
the gluteus medius strengthening pro­
gram which focuses on endurance and 
control demonstrated changes in the 
abduction/adduction hip angles during 
the stance phase of running. Clinicians 
should continue to trial this intervention 
with clear outcome measures to monitor 
individual responses in ITBS symptoms. 
In future studies, larger numbers should 
be included to further our understanding 
of the faulty kinematics in ITBS during 
running.



28   SA JournAl of PhySiotherAPy 2011 Vol 67 no 2 

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