Journal of The Korean Society of Integrative Medicine (대한통합의학회지)

Korean Society of Integrative Medicine (대한통합의학회)
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Immediate Effect of TFL Stretching in Weight Bearing Versus Non-Weight Bearing

  • Park, Sieun (Professor, Dept. of Physical Therapy, Woosong University) ;
  • Kim, Kijong (Professor, Dept. of Occupational Therapy, Woosong University) ;
  • Kim, Sunghee (Professor, Dept. of Physical Therapy, Woosong University) ;
  • Lee, Gyeonglin (Student, Dept. of Physical Therapy, Woosong University)
  • Received : 2020.02.27
  • Accepted : 2020.04.10
  • Published : 2020.06.30
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Abstract

Purpose : The purpose of this paper is to compare the immediate effects of tensor fascia latae (TFL) stretching with weight bearing (standing position) or non-weight bearing (side-lying position). Methods : The study was conducted on 30 adults (12 men, 18 women) in their 20s. Modified Thomas's test was conducted to find out if the TFL muscle has a tightness for current study. This study randomly divided the subjects into two groups and set the standing stretching group (n=15) or the side-lying stretching group (n=15). Both groups applied self-stretching under the therapist's supervision. TFL stretching in each positions was performed 30 seconds per set, 3 times, and 30 seconds per set could rest. The Ober test were conducted to investigate the effect of TFL stretching in each positions. Results : For the Ober test measurements within each group, both groups significantly increased after intervention compared to before (p<.05). There was no significant difference between the groups (p>.05). Conclusion : TFL stretching in standing position and side-lying position increased the range of motion of the TFL muscle. Therefore, if it is difficult to apply TFL stretching in standing position (weight bearing) due to pain or other reasons, it will be able to TFL stretching in side-lying position (non-weight bearing).

Keywords

Ⅰ. Introduction

Tensor fascia latae (TFL) muscle starts with anterior supe rior iliac spine and is connected to the iliotibial band (ITB) to attach to the lateral condyle of the tibia (Reese & Bandy, 2003). TFL muscle and ITB are located on the lateral porti on of the femur and are particularly well-used during sports with muscle shortening (Gose & Schweizer, 1989). TFL mu scles are prone to fatigue and shortening because they perfo rm various functions in the hip joints, and when shortened, they often develop clinical symptoms such as the iliotibial band syndrome (ITBS) or the patellofemoral syndrome (Par é et al., 1981; Reese & Bandy, 2003). It is also connected to the ITB to engage in the function of the hip and knee joints and is restricted to the movement of the knee and in the rotation of the legs when the TFL muscle has shortened (Kasunich, 2003). On the biomechanics aspect, even when walking, the TFL and the ITB work together to influence th e movement of hip and knee joints. During the swing phas e, the TFL and the ITB are located at the front of the great er trochanter, acting as the axis of the hip flexion and exten sion, and in the stance phase (push-off phase), the ITB pri marily acts as the back of the greater trochanter, thus worki ng extension of the hip joint. Furthermore, the knee joint ac ts to maintain the knee flexion well when walking (Gose & Schweizer, 1989). Therefore, shortening the TFL and ITB c an pose problems in the behavior of walking and running.

TFL stretching is mainly used in clinicians to alleviate cli nical symptoms due to TFL shortening (Fredericson et al., 2000). The TFL stretching method is mostly applied with se lf-stretching techniques, in which the subject performs the s tretching independently under the therapist's supervised instr uction, which allows the application of TFL muscle in vario us postures, such as standing, side-lying and prone position (Arumugam & Govindharaj, 2018). The self-stretching tech nique in standing position is mainly applied to ordinary peo ple who have shortened the length of the TFL muscle (Aru mugam & Govindharaj, 2018; Fredericson et al., 2002). Ho wever, the TFL muscle stretching in standing position is dif ficult to apply to subjects who have unstable knee joint or have lower extremity’s pain with the weight bearing.

In a non-weight bearing position, the TFL stretching is a pplied to pain or instability in the lower extremity. In previ ous studies, both weight bearing and non-weight bearing gr oups increased the ankle dorsiflexion passive range of moti on (ROM) when applying stretching with weight bearing an d non-weight bearing to the gastrocnemius muscle (Dinh et al., 2011). The results create a question of whether weight bearing stretching makes different result compared with non -weight bearing stretching or not. However, so far, studies are very limited to distinguish between weight bearing stret ching and non-weight bearing stretching for TFL muscles. F or example, in previous studies, the effects of TFL stretchin g in standing position and side-lying position were conducte d respectively (Arumugam & Govindharaj, 2018; Fredericso n et al., 2002; Kasunich, 2003), but studies of the effects of the comparison of the TFL muscle stretching in standing po sition and side-lying position were infrequent. Therefore, thi s study compared the immediate effects of TFL stretching in standing position (weight bearing) and side-lying position (non-weight bearing).

Ⅱ. Methods

1. Subjects

The present study was conducted on 30 adults (12 men, 18 women) in their 20s. The study participants were chosen to have no experience of serious leg injury and had a tightness of the TFL muscle. Modified Thomas's test was conducted to find out if the TFL muscle has a tightness. The therapist instructed the subjects to do prone position and hold one-side of their knee that was not involved this study, and another side of their leg lay on the treatment table until the ischial tuberosity was met. The therapist then applied the hip extension by lightly pressing the far side of the thighs to be measured. When passive hip adduction was applied in this position after thigh were lowered to the horizontal, persons who did not reach 15~20 ° were selected as the subjects (Tunnell, 1998)(Fig 1-A). Prior to this study, all the subjects were informed of the purpose and method of the study and were given a voluntary signature on the consent form.

DHTHB4_2020_v8n2_21_f0001.png 이미지

Fig. 1. Measurement and intervention of TFL muscle, A: TFL muscle tightness test, B: TFL stretching in standing position, C: TFL stretching in side-lying position, D: Measurement of TFL lengthening (Ober test)

2. Procedures

To find out the effect of weight bearing stretching and non-weight bearing stretching on TFL muscle, we randomly divided the subjects into two groups; TFL standing stretching group (n=15), and TFL side-lying stretching group (n=15). Table 1 shows the general characteristics of subjects in current study. In the TFL standing stretching group, the hip joint of the wall-side direction was performed with extension, external rotation and adduction and the hands on the wall pressed against the wall for a stable posture. Keep all the soles of your feet in contact with the floor (Fig 1-B). The TFL side-lying stretching group lay sideways so that the legs applying the stretching face the floor, and did it extension and external rotation of the legs, then flexing the hip and knee joints of the other leg (the non-stretching leg), and then placing them in front of the other knee(the stretching leg). The lower leg was applied by touching the floor with both hands facing forward for stretching (Fig 1-C). Both groups applied self-stretching under the physical therapist's supervision. TFL stretching in each positions was performed 30 seconds per set, 3 times, and 30 seconds per set could rest.

3. Instrumentation

This study conducted an Ober test to find out the effects of TFL stretching according to weight bearing of the subjects (Reese & Bandy, 2003; Willett et al., 2016). For the Ober test, the subjects performed side-lying position, and the therapist stood behind the patients. After bending the knee joint, the therapist held subject's pelvis with one hand, and made it extension and external rotation of the hip joint, and then performed the hip adduction. In neutral position (0 °), the hip adduction angle is related to the length of the TFL muscle (Kendall et al., 2005). Hip adduction was performed to the point where stiffness was felt by the therapist or the downward tilt of the pelvis was displayed (Fig 1-D). At this point, the angle was measured at the point where the greater trochanter and the lateral epicondyle of the femur are met. The Ober test was conducted twice, and the average value was used as data. To measure the hip ROM, a plastic roller and a phone application Clinometer (Clinometer, PlaincodeTM, Germany) were used.

4. Statistical analysis

Statistical analysis of this study used SPSS version 25.0 (SPSS Inc., Chicago IL, USA), and the values of each data represent the Mean±SD. In order to compare the differences between the standing stretching group and the side-lying stretching group, an independent t-test was performed, and paired t-test was conducted to identify the effects of intervention before and after each group. The statistical significance level α was set at .05.

Ⅲ. Results

In this study, we identified the immediate effects of TFL stretching in standing position and side-lying position in the persons with TFL tights. For the Ober test measurements within each group, both groups (standing and side-lying stretching groups) significantly increased after intervention compared to before (p<.05)(Fig 2). While both groups significantly increased after the intervention compared to before the intervention, the TFL side-lying stretching group were shown to be higher in the significant p-value. The ROM value in TFL side-lying stretching group increased more than in TFL standing stretching group, but there was no significant difference between the groups (p>.05)(Table 2).

DHTHB4_2020_v8n2_21_f0002.png 이미지

Fig. 2. Hip adduction ROM in TFL standing stretching group and TFL side-lying stretching group

Table 2. Measurement value of Ober test (ROM of hip adduction)

DHTHB4_2020_v8n2_21_t0002.png 이미지

Ⅳ. Discussion

This study conducted an Ober test to find out the immedi ate effect of the TFL stretching, whether weight bearing (st anding stretching position) or not (side-lying stretching posit ion), and TFL stretching of both positions increased TFL R OM after the intervention. Authors think that this study is considered to have clinical meaning. This is because, first, this intervention was easy to apply immediately in clinical practice and in everyday life. For example, the Ober test is not only relatively comfortable to apply but also highly reli able or TFL muscle testing. As a result, the most commonl y Ober test have used a method for measuring the TFL and ITB lengthening (Gajdosik et al., 1992; Reese & Bandy, 20 03). Second, this technique can reduce ITBS. This is becaus e in this study, ROMs were increased after both standing an d side-lying stretching positions. An article demonstrated th at TFL stretching may reduce low back and sacroiliac pain that seemed to originate from a dysfunctional ITB (Kasunic h, 2003), and the stretching with conservative management could make subjects with return to sport at 8 weeks and a 91.7 % cure rate with return to sports at 6 months after inju ry (Beals & Flanigan, 2013). Authors think the results for this study are significant because researchers said that adult s who have exercised often experience ITBS, and that the ratio is up to 15 % for women and 7 percent for men (Falv ey et al., 2010; Segal et al., 2007).

In the present study, there was no significant difference i n the TFL stretching effect according to posture. This is an interesting result that is very different from the effect than we expected (Bae et al., 2017; Kim, 2019). We explain the reasons for the result with the following sentences. First, it can be inferred that the TFL muscles were applied as tight targets but were not necessarily in a condition that causes pain. For example, a prior study found that the pain of hip joint was not related to the TFL, sartorius, and the rectus femoris muscle size (Emery et al., 2019). Considering these points, as mentioned in this study’s introduction, it was not possible to apply the TFL stretch effectively when subjects feel pain in the knee and ankle in the standing position. Th erefore, the authors think that the subjects from this study had a shortening of TFL muscles but felt little or no pain. Second, we think there was no difference because the study participants were in their 20s. Bae et al. (2017) article show ed that TFL muscle shortening may have caused pain in the waist or pelvic region, since the average age in the study w as in their 40s. On the other hand, the subjects of this study were in their 20s, so there was a shortening of the TFL, but other tissues around them would have supplemented it. In o ther words, muscle volume, ligaments and smooth blood cir culation would have complemented the tightness of the TF L, which in turn would have produced similar results betwe en the two groups as they did not reach for experiencing IT BS. This also be a limitation of this study. Thus, further stu dies should show more direct results based on posture not only in the shortening of the TFL but also in the presence of pain when selecting the subjects. However, this study is considered to have clinical meaning. First, this article shows that the subjects who have unstable knee joint and have lo wer extremity’ pain have another option to apply TFL musc le stretching. From the results of this study, TFL stretching showed effects in the both positions (standing and side-lying) to muscle length. Therefore, if it is difficult to TFL stret ching due to lower extremity’s instability in standing positio n, it will be able to TFL stretching in side-lying position. Second, there is a few TFL stretching papers comparing, sta nding and side-lying positions. Third, using only one plastic ruler and a mobile phone application used to measure the a ngle of hip joint adduction for conducting the study. We thi nk more people will have suggested a way to apply this int ervention for a TFL stretching method.

Ⅴ. Conclusion

TFL stretching in standing position and side-lying position increased the ROM of the TFL muscle. Therefore, if it is difficult to apply TFL stretching in standing position (weight bearing) due to pain or other reasons, it will be able to TFL stretching in side-lying position (non-weight bearing). We suggest the training of Ober test by the physical therapist to the public so that they can easily see the effect of TFL stretching at home.

Acknowledgements

We would like to thank all people who helped this study.

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