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Immediate Effect of Tensor Fascia Latae
Stretching Exercise on Muscle Activity and
Hip Motion During Active Side−lying Hip
Abduction in Subjects With Tensor Fascia
Latae Shortness
Myungki Ji
The Graduate School Yonsei University
Department of Physical Therapy
Immediate Effect of Tensor Fascia Latae
Stretching Exercise on Muscle Activity and
Hip Motion During Active Side−lying Hip
Abduction in Subjects With Tensor Fascia
Latae Shortness
Myungki Ji
The Graduate School Yonsei University
Department of Physical Therapy
Immediate Effect of Tensor Fascia Latae
Stretching Exercise on Muscle Activity and
Hip Motion During Active Side−lying Hip
Abduction in Subjects With Tensor Fascia
Latae Shortness
A Masters Thesis Submitted to the Department of Physical Therapy
and the Graduate School of Yonsei University in partial fulfillment of the
requirements for the degree of Master of Science
Myungki Ji
June 2013
This certifies that the masters thesis of
Myungki Ji is approved.
Thesis Supervisor: Ohyun Kwon
Chunghwi Yi: Thesis Committee Member #1
Heonseock Cynn: Thesis Committee Member #2
The Graduate School
Yonsei University
June 2013
Acknowledgements
Many people contributed to my academic growth in preparing this thesis.
First of all, I would like to express my profound appreciation to professor Oh−yun
Kwon for his help and support. He guided me in the research topic, and writing of my
thesis. Furthermore, he gave me various advices and encouragement including
enlightened me by saying “Always think.”
Additionally, I want to express my deep gratitude to professor Chung−hwi Yi for his
great teaching who has various academic experiences and enormous knowledge. I
would like to express my gratitude to professor Heon−seock Cynn for his kindness
and careful concern, giving me encouragement and intelligent advice. I also sincerely
thank professors, Hye−seon Jeon, Sung−hyun You, and Sang−hyun Cho, who helped
expand my knowledge and perspective.
I wish to thank sincerely my colleagues and friends, Kyue−nam Park, Sung−dae
Choung, Il−woo Park, and Min−sue Cho, who have given me encouragement for
better or worse. Thank all of your support. Also, I would like to thank all of the
members in the Graduate School Department of Physical Therapy. They have
provided me enormous mental support and assistance for my graduate course.
I deeply appreciate all of the therapists and professors of the Seoul National
University Bundang Hospital Department of Rehabilitation Medicine. They always
gave me the time to study, opportunity, and valuable support.
More than anybody, I wish to express my deep love and gratitude to all family who
always pray for me. My parents have provided endless love and mental support, and
wife’s parents have given me encouragement and careful concern. Especially my wife,
Yoo−jin and sons, Sung−june, and Hye−june have given me too much love and
affection. Without their belief in me and encouragement, I could never have finished
my graduate study.
Finally, I thank and praise God. I was able to finish my thesis with grace and
guidance by God. Thank you.
- i -
Table of Contents
List of Figures ······································································································· iii
List of Tables ········································································································ iv
Abstract ················································································································· v
Introduction ··········································································································· 1
Method ·················································································································· 5
1. Subjects ··········································································································· 5
2. Experimental Equipment ················································································· 6
2.1 Surface Electromyography ·········································································· 6
2.2 Electromagnetic Motion Tracking System ·················································· 6
2.3 Inclinometer ································································································ 6
3. Clinical Measurement ····················································································· 7
3.1 Tensor Fascia Latae Length Test With Inclinometer ·································· 7
4. Outcome Measurements ·················································································· 8
4.1 Muscle Activity ··························································································· 8
4.2 Kinematic Data Using Electromagnetic Motion Tracking System ············· 9
5. Tensor Fascia Latae Stretching Exercise ························································ 10
5.1 Active−Tensor Fascia Latae Stretching Exercise ······································· 10
5.2 Passive−Tensor Fascia Latae Stretching Exercise ······································ 10
6. Experimental Procedure ·················································································· 12
- ii -
7. Statistical Analysis ·························································································· 14
Results ··················································································································· 15
1. General Characteristics of the Subjects ··························································· 15
2. Muscle Activity ······························································································· 17
3. Hip Flexion and Internal Rotation Angle ························································ 21
4. Tensor Fascia Latae Muscle Length ······························································· 25
Discussion ············································································································· 27
Conclusion ············································································································ 32
References ············································································································· 33
Abstract in Korean ································································································ 40
- iii -
List of Figures
Figure 1. Active−Tensor Fascia Latae Stretching Exercise ·································· 11
Figure 2. Passive−Tensor Fascia Latae Stretching Exercise ································· 11
Figure 3. Active Side−Lying Hip Abduction ························································ 13
Figure 4. Gluteus Medius, Gluteus Maximus, and Tensor Fascia Latae Muscle
Activity ······························································································· 20
Figure 5. Hip Flexion and Internal Rotation Angle ·············································· 24
- iv -
List of Tables
Table 1. General Characteristics of Subjects ························································ 16
Table 2. Comparison of Gluteus Medius, Gluteus Maximus, and Tensor Fascia Latae
Muscle Activity Between Pre− and Post−Stretching Exercises ············ 18
Table 3. Comparison of Effects on Gluteus Medius, Gluteus Maximus, and Tensor
Fascia Latae Muscle Activity Between Passive− and Active−Tensor
Fascia Latea Stretching Groups ···························································· 19
Table 4. Comparison of Hip Flexion and Internal Rotation Angle Between Pre− and
Post−Stretching Exercises ····································································· 22
Table 5. Comparison of Effects on Hip Flexion and Internal Rotation Angle Between
Passive− and Active−Tensor Fascia Latae Stretching Exercise Groups
················································································································· 23
Table 6. Comparison of Tensor Fascia Latae Muscle Length Between Pre− and
Post−Stretching Exercises ····································································· 26
Table 7. Comparison of Effect on Tensor Fascia Latae Muscle Length Between
Passive− and Active−Tensor Fascia Latae Stretching Exercise Groups
················································································································· 26
- v -
ABSTRACT
Immediate Effect of Tensor Fascia Latae Stretching
Exercise on Muscle Activity and Hip Motion During
Active Side−lying Hip Abduction in Subjects With
Tensor Fascia Latae Shortness
Myungki Ji
Dept. of Physical Therapy
The Graduate School
Yonsei University
The purposes of this study were to investigate the effect of tensor fascia latae (TFL)
muscle stretching exercise on muscle activity and hip motion, and to compare the
effects of the passive− and active−TFL stretching exercise during active side−lying
hip abduction in subjects who have TFL shortness. Twenty subjects with TFL
shortness were recruited for this study and, using a random number table, were
randomly assigned to two groups: the passive−TFL stretching exercise group (PTS
- vi -
group) and the active−TFL stretching exercise group (ATS group). The subjects were
instructed how to perform PTS exercise or ATS exercise. Muscle activity of gluteus
medius (Gmed), gluteus maximus (Gmax), and TFL was measured with surface
electromyography (EMG), and electromagnetic motion tracking system was used to
measure the hip flexion and internal rotation angle during active side−lying hip
abduction. Measurement of TFL length is elicited by modified Ober test with
inclinometer. A paired t−test was utilized for determining the differences between
pre− and post−stretching exercise’s outcome (muscle activity of Gmed, Gmax, and
TFL, angle of hip flexion, and internal rotation, and TFL length). A comparison of the
effect of outcome measure of both groups was completed by an independent t−test.
The level of significance was set at α = 0.05. The results showed a significant
increase in Gmed muscle activity and significant decrease in hip flexion angle
between pre− and post−stretching exercise during active side−lying hip abduction.
Also, the results indicated that active−TFL stretching exercise significantly increased
the Gmax muscle activity than passive−TFL stretching exercise. It decreased the TFL
muscle activity, and decreased the hip flexion angle during active side−lying hip
abduction in subjects with TFL shortness. In conclusion, active−TFL stretching
exercise may be an effective method for modifying hip muscle activity and motion
during active side−lying hip abduction in people with TFL shortness.
Key Words: Active stretching, Passive stretching, Side−lying hip abduction, Tensor
fascia latae shortness.
- 1 -
Introduction
Hip abductor muscles play a major role in control of rotational alignment of the
limb (Fulkerson 2002; Lee 1999; Neumann 2002). The middle portion of the gluteus
medius (Gmed) muscle abducts the hip joint and the gluteus maximus (Gmax) muscle
is an extensor and an external rotator of the hip joint (Cutter, and KerVorkian 1999;
Neumann 2010). The superior portion of the Gmax also acts as a hip abductor during
gait (Lyons et al. 1983). The Gmed provides frontal plane stability for the pelvis
during walking and other functional activities (Earl 2004; Fredericson et al. 2000).
The Gmed has a more vertical pull and help initiate hip abduction, which is then
completed by the tensor fascia latae (TFL) (Gottschalk, Kourosh, and Leveau 1989).
The TFL muscle acts through the iliotibial band (ITB) by pulling it superiorly and
anteriorly (Gottschalk, Kourosh, and Leveau 1989). It assists in flexion, internal
rotation, and abduction of the hip (Fredericson et al. 2000; Travell, and Simons 1998).
Generally, one muscle dominates the movement pattern causing an imbalance to
occur, which may lead to injury (Jull, and Janda 1987; Page, Clare, and Robert 2010;
Sahrmann 2002). When muscle imbalance exists, some muscles are shortened and
other muscles are weakened (Jull, and Janda 1987; Page, Clare, and Robert 2010).
Muscle weakness is a common occurrence that arises in the synergistic muscles in the
hip. The TFL becomes short and the posterior fiber of the Gmed becomes weak
(Bewyer, and Bewyer 2003; Kendall et al. 2005). The imbalance of two synergistic
muscles contributes to compensatory joint motion and the development of movement
- 2 -
impairment (Sahrmann 2002). The weak Gmed is related to many injuries of the
lower extremities and abnormalities in the gait cycle (Kendall et al. 2005). The TFL
can become structurally short and mechanically incapable of lengthening to an
appropriate level and the weak Gmed can become structurally long and incapable of
shortening to an appropriate level (Comerford, and Mottram 2001; Kendall et al. 2005;
Sahrmann 2002). When muscles are incapable of firing correctly, compensation
occurs and this will alter joint motion and movement (Sahrmann 2002). Janda (1983)
have hypothesized a common muscle imbalance pattern in shortness of the TFL in
chronic musculoskeletal pain syndromes.
Assessments of movement are considered an important part of the physical
examination because movement may contribute to excessive stress and compression
on joints, and muscle, resulting in musculoskeletal pain and various injuries
(Sahrmann 2002). Janda (1983) suggested that in hip abduction movement pattern test,
the sign of an altered movement pattern is the tensor mechanism of hip abduction
facilitated by a short TFL. Instead of pure hip abduction in the plane of the trunk, the
movement is combined with hip flexion due to the TFL’s dual action as a hip flexor
and abductor (Page, Clare, and Robert 2010). Sahrmann (2002) suggested that lack of
posterolateral stabilization of the proximal femur is caused by impaired positioning
and overstretch of the muscles of the hip. This impaired movement is associated with
recruitment of TFL for hip abduction and flexion (Sahrmann 2002). Sahrmann (2002)
proposed that in lower quarter examination, the TFL is dominant when hip flexes and
- 3 -
the Gmed is weak when the hip is unable to tolerate during applying maximum
resistance in side−lying hip abduction with lateral rotation and extension.
It has been suggested that there are relative to a shortened TFL and a weak Gmed
with various lower extremity injuries and low back pain. Trendelenberg (1998) was
the first to describe a hip drop upon weight−bearing which indicated a Gmed
weakness in the gait, and concluded that lateral leg stability was solely maintained by
the tensile strength of the TFL. With a Trendelenburg gait, the pelvic drop occurs
when the Gmed doesn’t produce a sufficient internal hip abduction moment to
balance the external hip adduction moment that occurs during single leg stance (Earl
2004). Therefore, those with a Trendelenberg gait will have reduced gait efficiency
and be at greater risk of developing low back pain as a result of the pelvis not being
stabilized during the gait and other activities or when performing unilateral weight
training exercises (Bewyer, and Bewyer 2003; Earl 2004). Fredericson et al. (2000)
suggested that ITB syndrome may occur as a result of weakness of the Gmed, which
lead to decreased control of thigh abduction and external rotation. Fredericson et al.
(2000) hypothesized that this sequence of events places the ITB under increased
tension, making it more prone to impingement on the lateral epicondyle of the femur.
Earl (2004) described patellofemoral pain syndrome as an overuse injury. Inhibition
or dysfunction of the Gmed may contribute to decreased hip control, allowing greater
femoral internal rotation (Hertel, Sloss, and Earl 2005). This produces a larger valgus
vector at the knee, increasing the laterally directed forces acting on the patella (Earl
2004; Hertel, Sloss, and Earl 2005). Ober (1936) reviewed TFL shortness as a factor
- 4 -
in low back pain. Duchenne (1949) attributed that lower extremity changes from the
tough ITB contractures as femoral internal rotation, hip flexion contractures.
In previous studies, intervention methods to lengthen TFL and increase gluteal
muscle activity have been used. Fredericson et al. (2000) suggested that runners with
ITB syndrome have weaker hip abduction strength in the affected leg compared with
their unaffected leg. Through TFL−ITB self−stretching exercise, symptom
improvement with a successful return to the pre−injury training program parallels
improvement in hip abductor strength (Fredericson, and Wolf 2005). Tyler et al. (2006)
suggested that patients with patellofemoral pain syndrome have associated hip
weakness. Also, improvements in TFL−ITB flexibility were associated with excellent
results in patients with patellofemoral pain syndrome (Tyler et al. 2006).
Among previous studies related TFL stretching, hip muscle activity and hip motion
were not demonstrated in side−lying position. In addition, the comparison of passive−
and active−TFL stretching exercise on hip muscle activity and motion was not
established during active side−lying hip abduction in subjects with TFL shortness.
The purposes of this study were to investigate effect of TFL stretching exercise on
hip muscle activity and hip motion, and to compare effects of passive− and
active−TFL stretching exercise on muscle activity and hip motion during active
side−lying hip abduction in subjects with TFL shortness. The hypothesis of this study
was that the stretching exercise on TFL increases the muscle activity of Gmed, and
reduces angle of hip flexion and hip internal rotation during active side−lying hip
abduction in subjects with TFL shortness.
- 5 -
Method
1. Subjects
Twenty volunteers at the Yonsei University were recruited. The inclusion criteria for
subject selection in this study included that the shortness of TFL were a positive sign
by modified Ober test. Twenty subjects were randomly allocated into one of two
exercise groups: passive−TFL stretching exercise group, or active−TFL stretching
exercise group. Subjects with restricted passive range of motion of hip joint, history
of direct trauma or surgery to the lower extremity, diagnosis with disease in hip joint,
and significant weakness of Gmed, Gmax and TFL that interfere with hip abduction
were excluded (Arab et al. 2010). Prior to the study, the principal investigator
explained all procedures to the subjects, and all subjects signed an informed consent
form. This study was approved by Yonsei University Wonju institutional review board.
- 6 -
2. Experimental Equipment
2.1 Surface Electromyography
Muscle activity was measured using a Noraxon Telemyo 2400T (Noraxon, INC.,
Scottsdale, AZ, USA) with a pair of Ag−AgCl surface electrodes 2cm in diameter.
Raw electromyography (EMG) signals were band−pass sampled at 1000Hz, filtered
between 20 and 450Hz, and converted to root mean square using the MyoResearch
Master Edition 1.06 XP software (Noraxon, INC., Scottsdale, AZ, USA).
2.2 Electromagnetic Motion Tracking System
An electromagnetic motion tracking system (Liberty® Polhemus, Colchester, VT,
USA) was used to measure angle of hip flexion and internal rotation. This system
consists of a transmitter, receivers, digitizers and a system electronics unit.
2.3 Inclinometer
An inclinometer (Johnson Magnetic Angle Locator, Johnson, Mequon, WI, USA) is
a circular shape with a weighted needle that indicates the number of degrees on a
scale of a protractor. An inclinometer with markings at 1° increments was used for
the measurement of TFL length.
- 7 -
3. Clinical Measurement
3.1 Tensor Fascia Latae Length Test With Inclinometer
Measure of TFL length is elicited by modified Ober test with inclinometer. The
subjects were asked to lie laterally recumbent with the affected side uppermost. The
affected lower limb was then brought into full extension by the examiner, with some
abduction at the hip and the knee is extended. The examiner then slowly releases
support of the limb, allowing the limb to fall into adduction past the neutral position.
A short TFL restricts adduction and prevents the knee from falling past the neutral
position. An inclinometer was used during the modified Ober test to measure hip
adduction as an indication of TFL flexibility. Bandy et al. (2003) purposed that the
use of an inclinometer to measure hip adduction using the modified Ober test appears
to be a reliable method for the measurement of TFL length. During each measurement
session, subjects were positioned lying down with their tested side facing up. The
inclinometer was positioned at the popliteal fossa of the knee on the involved side
using the double sided tape to hold it securely in place, and hip adduction was
measured using the modified Ober test. If the limb was horizontal, it was considered
to be at 0 degrees, below horizontal (adducted) was recorded as a positive number,
and above horizontal (abducted) was recorded as a negative number (Bandy et al.
2003).
- 8 -
4. Outcome Measurements
4.1 Muscle Activity
Prior to electrode placement, the electrode sites were shaved and cleaned with
rubbing alcohol to prepare the skin. The electrode placement for the Gmax was
middle area in the line between greater trochanter and second sacrum spinous process
(S2). The electrode placement for Gmed was proximally 2cm area in the line between
iliac crest and greater trochanter of femur. The electrode on TFL was attached on the
2cm area below anterior superior iliac spine (ASIS).
Raw data was processed into the root−mean−square (RMS) with a moving window
of 50 milliseconds. For normalization, the mean RMS of three trials of 5−seconds
maximal voluntary isometric contraction (MVIC) was calculated for Gmed, Gmax
and TFL. The MVIC for the Gmax was tested such that hip extension was resisted
with the subject lying fully prone, with the knee flexed to 90°. The MVIC for the
Gmed was obtained during resisted hip abduction while subjects were lying in supine
position on the treatment table. Subjects exerted maximal abduction force against
resistance on the distal lateral leg, in a position of 30° of hip abduction, with the hip
and knee at 0° of flexion. The MVIC for the TFL was acquired in the same supine
position used for the Gmed, except that the hip was positioned in 45° between the
sagittal and coronal planes (Kendall et al. 2005).
- 9 -
4.2 Kinematic Data Using Electromagnetic Motion Tracking System
The receivers were mounted to thermoplastic frames and secured firmly to lower
third of the lateral thigh and over the first sacrum spinous process (S1) with double
sided tape. An anatomically relevant reference system for identifying the hip joint
centre was defined with a predicative method based on each subject’s pelvic and
lower limb anthropometrics (Bush, and Gutowski 2003). Using anatomically relevant
local coordinate axes derived from digitized bony landmarks data were reduced using
standard matrix transformations to determine the rotational matrix of the femur with
respect to the pelvis. Coronal plane motion was calculated as a composite angle
between hip and pelvis rotating about the sagittal axis of the pelvis. Transverse plane
motion was calculated as relative angle about the vertical axis (Bussey, Milosavljevic,
and Bell 2009). Thus, hip motion is described in three angles of movement in the
side−lying position; abduction (in the sagittal plane), flexion (in the transverse plane)
and rotation (in the coronal plane).
- 10 -
5. Tensor Fascia Latae Stretching Exercise
5.1 Active−Tensor Fasica Latae Stretching Exercise
Active−stretching exercise begins with the subject lying in prone position on the
treatment table. The subjects were asked to hip being positioned in rotation 0° and
adduction 0°, and flexed the knee 90°. The opposite hip was in the neutral rotation
and full knee extension. The subject slowly rotated the hip externally before
separating the ASIS of the pelvis in a direction to the upper side from the floor of the
table with pelvis hold to hand. This motion continues until the subject feels a stretch
on the side of the hip around the greater trochanter. The subjects were instructed to
maintain this position for 30 seconds and then rest for 30 seconds. The subjects were
asked to perform this exercise for 10 sets (Figure 1).
5.2 Passive−Tensor Fascia Latae Stretching Exercise
Passive−stretching exercise started in the same position as active stretching exercise.
The examiner conducted subjects to stretching exercise. The examiner executed the
exercise with his hand, holding pelvis with one hand and holding ankle with the other
hand. The examiner applied subjects to rotate the hip externally until the examiner
feels the end−feel. The examiner maintained this position for 30 seconds and the rest
for 30 seconds. This exercise completed 10 sets (Figure 2).
- 11 -
Figure 1. Active−Tensor Fascia Latae Stretching Exercise.
Figure 2. Passive−Tensor Fascia Latae Stretching Exercise.
- 12 -
6. Experimental Procedure
All subjects were evaluated for study inclusion/exclusion at the visit. The length of
each subject’s TFL was assessed by modified Ober test with inclinometer. The angle
of the hip motion and EMG data were collected during active hip abduction in
side−lying position. The subjects were asked to lie on the table in side−lying position
and the leg on the table was flexed to 45° at the hip and 90° at the knee. The subjects
were instructed to perform three times of active hip abduction extending knee (Figure
3). A target bar was placed to control the angle of the abducted hip. The target bar
was placed at 20° hip abduction position. The subject was asked to abduct their hip
until their ankle touched target bar and hold the position for 5−seconds. When the
subjects performed this motion, the examiner was not involved in any of the verbal
cue and touch. A large board was used to minimize the movement of pelvic, back,
and neck related to hip motion. The angle for hip was collected three times for the
tested side. The angle of the hip motion was measured using an electromagnetic
motion tracking system. EMG data were collected in three times by surface EMG and
were normalized by percent of MVIC. Subjects were allowed to rest for 1 minute
between trials. Following the pre−stretching exercise measurement, the subjects
received instruction in each TFL stretching exercise by a licensed physical therapist
with 7 years of clinical experience. All measurements were performed three times at
- 13 -
the time of entry into the study and at the direct time after each TFL stretching
exercise (pre− and post−stretching exercise).
Figure 3. Active Side−Lying Hip Abduction.
- 14 -
7. Statistical Analysis
The data are expressed as the means ± standard deviations. Statistical significance
between pre− and post−stretching exercise measurement was assessed through paired
t−test. This method was used to assess statistical significance of muscle activity of
Gmed, Gmax, and TFL, angle of hip flexion and internal rotation, and TFL length.
The independent t−tests were used to evaluate statistical significance of effects on
muscle activity for Gmed, Gmax, and TFL, angle of hip flexion and internal rotation,
and TFL length between passive− and active−stretching groups. The level of
statistical significance was set at p < 0.05. All statistical analysis was performed using
the statistical package for the Social Sciences for windows version 18.0 (SPSS, Inc.,
Chicago, IL, USA).
- 15 -
Results
1. General Characteristics of the Subjects
The general characteristics of the subjects including age, height, weight, body mass
index (BMI) are shown in Table 1. There were no significant differences in
parameters between passive−TFL stretching exercise group and active−TFL
stretching exercise group (p > 0.05).
- 16 -
Table 1. General characteristics of the subjects. (N=20)
Parameters
Passive−TFLa stretching
group (n1=10)
Active−TFL stretching
group (n2=10)
t p
Age (yrs) 23.4 ± 2.5b 23.3 ± 2.5 0.11 0.92
Height (cm) 174.2 ± 3.7 173.8 ± 5.4 0.19 0.85
Weight (kg) 67.8 ± 5.9 69.1 ± 7.1 -0.45 0.66
BMIc (kg/m2) 22.4 ± 2.2 22.9 ± 2.8 -0.51 0.61
aTFL: Tensor fascia latae. bMean ± standard deviation. cBMI: Body mass index. p value is comparison of groups using an independent t−test.
- 17 -
2. Muscle Activity
The muscle activity of the post−exercise Gmed was significantly greater than the
pre−exercise Gmed muscle activity (p<0.05). The post−exercise Gmax muscle
activity showed significantly greater activity when it was compared with the
pre−exercise Gmax in active−TFL stretching exercise group (p<0.05). The
post−exercise TFL muscle activity was significantly lower than the pre−exercise in
active−TFL stretching exercise group (p<0.05). However, there was no significant
difference in Gmax muscle activity between the pre− and post−stretching exercise in
passive−TFL stretching group (p>0.05). Also, there was no significant difference in
TFL muscle activity between the pre− and post−stretching exercise in passive−TFL
stretching group (p>0.05) (Table 2) (Figure 4).
There was significant difference in effects on Gmax or TFL muscle activity between
passive− and active−TFL stretching groups (p<0.05). However, there was no
significant difference in effect on Gmed muscle activity between passive− and
active− TFL stretching groups (p>0.05) (Table 3) (Figure 4).
- 18 -
Table 2. Comparison of gluteus medius, gluteus maximus, and tensor fascia latae
muscle activity between pre− and post−stretching exercises.
Muscle Group Stretching exercise
t p Pre Post
Gmeda PTSd 42.24 ± 12.52f 49.42 ± 15.17 -6.21 <0.01*
ATSe 48.38 ± 14.80 56.85 ± 14.79 -2.89 0.01*
Gmaxb PTS 50.50 ± 24.67 43.98 ± 14.63 1.53 0.15
ATS 32.61 ± 18.23 43.01 ± 16.66 -2.83 0.02*
TFLc PTS 25.77 ± 13.57 26.84 ± 13.29 -0.95 0.36
ATS 41.51 ± 18.70 30.40 ± 13.61 2.90 0.01*
aGmed: Gluteus medius. bGmax: Gluteus maximus. cTFL: Tensor fascia latae. dPTS: Passive tensor fascia latae stretching exercise. eATS: Active tensor fascia latae stretching exercise. fMean ± standard deviation. *p < 0.05, p value is comparison of pre− and post−stretching exercise using paired t−test.
- 19 -
Table 3. Comparison of effects on gluteus medius, gluteus maximus, and tensor fascia
latae muscle activity between passive− and active−tensor fascia latae stretching
groups.
Muscle
Group
t p
PTSd ATSe
Gmeda 7.17 ± 3.64f 8.46 ± 9.25 -0.40 0.68
Gmaxb -6.51 ± 13.39 10.40 ± 11.63 -3.01 0.01*
TFLc 1.07 ± 3.54 -11.11 ± 12.10 3.05 0.01*
aGmed: Gluteus medius. bGmax: Gluteus maximus. cTFL: Tensor fascia latae. dPTS: Passive tensor fascia latae stretching exercise. eATS: Active tensor fascia latae stretching exercise. fMean ± standard deviation. *p < 0.05, p value is comparison of passive− and active−stretching exercise using independent t-test.
- 20 -
Figure 4. Gluteus medius, gluteus maximus, and tensor fascia latae muscle activity.
prePTS: Pre−passive tensor fascia latae stretching exercise.
postPTS: Post−passive tensor fascia latae stretching exercise.
preATS: Pre−active tensor fascia latae stretching exercise.
postATS: Post−active tensor fascia latae stretching exercise.
Gmed: Gluteus medius.
Gmax: Gluteus maximus.
TFL: Tensor fascia latae.
*p<0.05: significant difference between pre−post test.
**p<0.05: significant mean difference between passive tensor fascia latae
stretching and active tensor fascia latae stretching exercise groups.
- 21 -
3. Hip Flexion and Internal Rotation Angle
The angle of post−exercise hip flexion was significantly lower than pre−exercise hip
flexion (p<0.05). The post−exercise internal rotation was significantly lower than
pre−exercise internal rotation in active−stretching group (p<0.05). However, there
was no significant difference in internal rotation angle between pre− and
post−stretching exercise in passive−stretching group (p>0.05) (Table 4) (Figure 5).
There was significant difference in effect on flexion angle between passive− and
active−stretching groups (p<0.05). However, there was no significant difference in
effect on internal rotation angle between passive− and active−stretching groups
(p>0.05) (Table 5) (Figure 5).
- 22 -
Table 4. Comparison of hip flexion and internal rotation angle between pre− and
post−stretching exercises.
Hip motion Group
Stretching exercise t p
Pre Post
Flexion PTSb 10.69 ± 4.70d 8.31 ± 4.51 3.25 0.01*
ATSc 14.16 ± 9.52 7.78 ± 9.59 6.12 <0.01*
IRa PTS 13.91 ± 5.01 12.70 ± 3.38 1.59 0.14
ATS 19.43 ± 9.23 12.63 ± 14.52 2.34 0.04*
aIR: Internal rotation. bPTS: Passive tensor fascia latae stretching exercise. cATS: Active tensor fascia latae stretching exercise. dMean ± standard deviation *p < 0.05, p value is comparison of pre− and post−stretching exercise using paired t−test.
- 23 -
Table 5. Comparison of effects on hip flexion and internal rotation angle between
passive− and active−tensor fascia latae stretching exercise groups.
Hip motion
Group
t p
PTSb ATSc
Flexion -2.38 ± 2.31d -6.68 ± 3.45 3.27 <0.01*
IRa -1.20 ± 2.38 -6.80 ± 9.16 1.87 0.08
aIR: Internal rotation. bPTS: Passive tensor fascia latae stretching exercise. cATS: Active tensor fascia latae stretching exercise. dMean ± standard deviation. *p < 0.05, p value is comparison of passive− and active−TFL stretching exercise using independent t−test.
- 24 -
Figure 5. Hip flexion and internal rotation angle.
prePTS: Pre−passive tensor fascia latae stretching exercise.
postPTS: Post−passive tensor fascia latae stretching exercise.
preATS: Pre−active tensor fascia latae stretching exercise.
postATS: Post−active tensor fascia latae stretching exercise.
IR: internal rotation.
*p<0.05: significant difference between pre−post test.
**p<0.05: significant mean difference between passive tensor fascia latae
stretching and active tensor fascia latae stretching exercise groups.
- 25 -
4. Tensor Fascia Latae Muscle Length
The TFL length of post−exercise was significantly greater than pre−exercise (p<0.05)
(Table 6). However, there was no significant difference in effect on TFL length
between passive− and active−TFL stretching groups (p>0.05) (Table 7).
- 26 -
Table 6. Comparison of tensor fascia latae muscle length between pre− and
post−stretching exercises.
Group Stretching exercise
t p Pre Post
TFLa length
(°)
PTSb -7.20 ± 2.39d -2.50 ± 2.27 -5.40 <0.01*
ATSc -7.00 ± 3.09 0.10 ± 4.28 -8.11 <0.01*
aTFL: Tensor fascia latae. bPTS: Passive tensor fascia latae stretching exercise. cATS: Active tensor fascia latae stretching exercise. dMean ± standard deviation. *p < 0.05, p value is comparison of pre− and post−stretching exercise using paired t−test.
Table 7. Comparison of effect on tensor fascia latae muscle length between passive−
and active−tensor fascia latae stretching exercise groups.
Group
t p
PTSb ATSc
TFLa length (°) 4.70 ± 2.75d 7.10 ± 2.76 -1.94 0.07
aTFL: Tensor fascia latae. bPTS: Passive tensor fascia latae stretching exercise. cATS: Active tensor fascia latae stretching exercise. dMean ± standard deviation. *p < 0.05, p value is comparison of passive− and active−TFL stretching exercise using independent t−test.
- 27 -
Discussion
The purposes of the present study were to investigate the effect of TFL stretching
exercise on hip muscle activity and hip motion in subject with TFL shortness, and
compare effects on muscle activity and hip motion between passive− and active−TFL
stretching exercises during active side−lying hip abduction.
The result showed that the muscle activity of the post−exercise Gmed was
significantly greater than the pre−exercise. Also, the muscle activity of the
post−exercise TFL was significantly lower than the pre−exercise in active−stretching
group. There are several possible explanations for lower muscle activity of TFL
during active side−lying hip abduction. First of all, mechanical factors involving the
viscoelastic properties of the muscle may affect the muscle’s length-tension
relationship. Previous studies (Kokkonen, Nelson, and Cornwell 1998; Nelson, and
Kokkonen 2001) have suggested that the primary mechanism underlying the
stretching induced decreases in force may alter the muscle length−tension relationship.
Secondly, it has also been hypothesized that neural factors contribute to the
stretching−induced decrease in force. A number of peripheral mechanisms have been
proposed to explain the reduced muscle activation after stretching (Avela et al. 1999;
Behm, Button, and Butt 2001; Fowles, Sale, and MacDougall 2000). The peripheral
mechanism includes the autogenic inhibition of the Golgi tendon reflex,
mechanoreceptor and nociceptor afferent inhibition, joint pressure feedback inhibition
- 28 -
due to excessive ranges of motion during stretching, and stretching reflex inhibition
originating from the muscle spindle. Additionally, Avela et al. (1999) suggested that a
central nervous system mechanism may be responsible for the decreases in muscle
activation.
The increase in Gmed activation and decrease in TFL following the stretching
exercise was contrary with the original hypothesis that their activation would
respectively reduce and increase in subject with TFL shortness (Fredericson, and Weir
2006). Some investigators have also hypothesized a common muscle imbalance
pattern of weakness in hip abductor and shortness of TFL (Sahrmann 2002;
Comerford, and Mottram 2001). It is assumed that when the primary muscle
responsible for hip abduction; gluteus medius, is weakened, the synergistic muscle;
TFL, is substituted and becomes overactive to be the primary muscle (Sahrmann 2002;
Comerford, and Mottram 2001). Hence, in theory, it is thought that hip abductor
increase is accompanied with TFL decrease in these subjects. Finally, this study
suggests that the TFL stretching exercise affect increase of Gmed activation and
decrease of TFL muscle activity during active side−lying hip abduction in subjects
with TFL shortness.
The results of this study indicate that hip flexion is significantly decreased during
active side−lying hip abduction following stretching exercises. Also, the angle of the
post−exercise internal rotation was significantly lower than the pre−exercise in
active−stretching exercise group. There are numerous possible reasons for these
results. Firstly, although the Gmed and TFL are both hip abductors, the Gmed,
- 29 -
especially the posterior fiber of Gmed is an external rotator of the hip and TFL is an
internal rotator and a flexor of hip. Thus, the function of hip abductor muscle
following the stretching exercise could not be completely substituted by TFL, but the
function of hip abductor muscle could be acted by Gmed. In the second place, it is
assumed that when primary muscle responsible for a specific joint movement is
weakened, the synergistic muscle is substituted and becomes overactive to be the
primary muscle responsible for the movement (Sahrmann 2002). Based on this
hypothesis, it is speculated that TFL shortness is a compensatory mechanism.
Accordingly, TFL stretching exercise allows the subjects with TFL shortness to be
responsible for the activation of the primary muscle: Gmed, during the hip abduction.
Therefore, this study recommended that TFL stretching exercise affects decrease of
hip flexion and internal rotation angle during active side−lying hip abduction in
subjects with TFL shortness.
Hip flexion angle between pre− and post−stretching exercise differences were -2.38
± 2.31 in passive−TFL stretching exercise group and -6.68 ± 3.45 in active−TFL
stretching exercise group. Our results indicate that the active−TFL stretching exercise
decreased the hip flexion angle significantly more than the passive−TFL stretching
exercise during active side−lying hip abduction. Also, the differences of Gmax and
TFL muscle activity between pre− and post−stretching exercise were -6.51 ± 13.39
and 1.07 ± 3.54 in passive−TFL stretching exercise group, and 10.40 ± 11.63 and -
11.11 ± 12.10 in active−TFL stretching exercise group, respectively. The results
indicate that the active−TFL stretching exercise increased the muscle activity of
- 30 -
Gmax and decreased TFL muscle activity significantly more than the passive−TFL
stretching exercise during active side−lying hip abduction. Nonetheless, there was no
significant difference in effects of TFL stretching exercise on hip internal rotation
angle, the muscle activity of Gmed, and TFL length between passive− and
active−stretching exercise groups. Previous studies (Medeiros et al. 1977; Tanigawa
1972; Taylor et al. 1990) proposed that improvements made by patients using passive
stretching may be the result of both autogenic inhibition and tensile stress applied to
the muscle according to muscles’ viscoelastic characteristics; when stress is applied
over a constant period of time, the muscle will gradually relax and increase in length.
With autogenic inhibition, the muscle being stretched is inhibited and is thought to
simultaneously relax. Active stretching also places a tensile stress on the muscle
being stretched, but additional increases in length are thought to be achieved through
relaxation via reciprocal inhibition (Kandel, Schwartz, and Jessell 2000). Although
the neurologic mechanisms of muscle relaxation in active and passive stretching are
thought to be different, tensile stress is common to both types of stretching and is
probably the primary factor for increasing muscle flexibility. This could explain
various results about this topic. White, and Sahrmann (1994) suggested that active
stretching increase the flexibility of the tight muscles while concomitantly improving
function of the antagonistic muscles. This study assessed the effect of stretching type
on the function of the antagonist muscles. There are significant differences in effects
on Gmax muscle activity between passive− and active−stretching exercises.
Consequently, present study suggests that active−stretching exercise was more
- 31 -
effective than passive−stretching exercise on Gmax and TFL muscle activity, and hip
flexion angle during active side−lying hip abduction in people with TFL shortness.
Both post−exercise showed a significantly greater increase in the length of TFL than
pre−exercise. The present study showed that TFL stretching exercise lengthened the
TFL muscle. Our results are consistent with those of a previous study showing that
stretching TFL is an effective method for increasing TFL length (Fredericson et al.
2002). Therefore, this study suggests that TFL stretching exercise in this study was
effective method for elongating the TFL.
The present study has several limitations. First of all, we did not directly measure
the length of TFL muscle. Besides, we studied the effect of the TFL stretching
exercise, and it is not clear whether our results can be generalized to other functional
activities in subjects with TFL shortness. In addition, generalization of the study is
limited because a small number of subjects participated and our subjects were young.
Finally, the stretching exercise was a short−term intervention. Further studies are
needed to determine the long−term effect of TFL stretching on hip motion and muscle
activity during active side−lying hip abduction in more subjects than present subjects
with TFL shortness.
- 32 -
Conclusion
The present study investigated the effect of the TFL stretching exercise on hip
muscle activity and motion, and compared the effect of the passive− and
active−stretching exercise during active side−lying hip abduction in subjects with
TFL shortness. The findings of this study showed significant increase in Gmed
muscle activity and significant decrease in hip flexion angle between pre− and
post−stretching exercise during active side−lying hip abduction. The results indicate
that active−stretching exercise is compared with passive−stretching exercise
significantly increased the Gmax muscle activity, decreased the TFL muscle activity,
and decreased the hip flexion angle during active side−lying hip abduction in subjects
with TFL shortness. In conclusion, active−TFL stretching exercise may be an
effective method for modifying hip muscle activity and motion during active
side−lying hip abduction in people with TFL shortness. In its final analysis, the
findings of the present study provide evidence for the effectiveness of TFL stretching
in subjects with TFL shortness.
- 33 -
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국문 요약
넙다리근막긴장근 단축 대상자에게 신장운동이
근활성도와 엉덩관절 움직임에 미치는 즉각적인 영향
연세대학교 대학원
물리치료학과
지 명 기
본 연구의 목적은 넙다리근막긴장근이 단축된 대상자에게 수동적 넙다리
근막긴장근 신장운동과 능동적 넙다리근막긴장근 신장운동을 시킨 후 옆으
로 누운 자세에서 엉덩관절 벌림 시 근활성도와 엉덩관절 움직임에 미치는
영향을 알아보고 수동적 신장운동과 능동적 신장운동의 효과를 비교하는
것이다. 본 연구를 위해 넙다리근막긴장근이 단축된 20명의 대상자가 참
여하였고, 수동적 넙다리근막긴장근 신장운동 집단과 능동적 넙다리근막긴
장근 신장운동 집단에 난수표를 이용하여 무작위로 할당하였다. 각각의 대
상자들은 수동적 신장운동이나 능동적 신장운동 수행 방법을 교육받았다.
- 41 -
중간볼기근, 큰볼기근, 그리고 넙다리근막긴장근의 근활성도는 표면 근전
도 장비를 사용하여 측정하였고 전자기 움직임 추적 시스템은 옆으로 누워
엉덩관절 벌림 시 엉덩관절의 굽힘과 안쪽 돌림 각도를 측정하는데 사용하
였다. 중간볼기근, 큰볼기근과 넙다리근막긴장근의 근활성도, 엉덩관절 굽
힘과 안쪽 돌림의 각도, 그리고 넙다리근막긴장근의 길이에 대한 신장운동
전과 후 간 차이를 알아보기 위해 짝비교 t−검정을 하였다. 수동적 신장운
동 집단과 능동적 신장운동 집단 간의 차이가 있는지를 알아보기 위해 독
립 t−검정을 하였다. 통계학적 유의수준 α = 0.05로 하였다. 연구 결과
옆으로 누워 엉덩관절 벌림 시 신장운동 전과 후 중간볼기근의 근활성도는
유의하게 증가하였으며, 엉덩관절 굽힘 각도는 유의하게 줄어들었다. 또한,
수동적 넙다리근막긴장근 신장운동과 비교하여 능동적 넙다리근막긴장근
신장운동이 넙다리근막긴장근이 단축된 대상자가 옆으로 누워 엉덩관절을
벌림 시 유의하게 큰볼기근의 근활성도는 증가하였고 넙다리근막긴장근의
근활성도는 감소하였으며, 엉덩관절 굽힘 각도는 유의하게 감소하였다. 결
론적으로, 능동적 넙다리근막긴장근 신장운동이 넙다리근막긴장근이 단축
된 사람들이 옆으로 누워 엉덩관절을 벌림 시 엉덩관절 근활성도와 움직임
을 교정하는데 효과적인 중재방법으로 사료된다.
핵심 되는 말: 넙다리근막긴장근 단축, 능동적 신장, 수동적 신장, 옆으로
누워 엉덩관절 벌림.