An Anatomic Investigation of the Ober Test

Gilbert M. Willett,*y PhD, Sarah A. Keim,y PhD,Valerie K. Shostrom,z MS, and Carol S. Lomneth,y PhDInvestigation performed at University of Nebraska Medical Center, Omaha, Nebraska, USA

Background: Recent studies have questioned the importance of the iliotibial band (ITB) in lateral knee pain. The Ober test ormodified Ober test is the most commonly recommended physical examination tool for assessment of ITB tightness. No studiessupport the validity of either Ober test for measuring ITB tightness.

Purpose/Hypothesis: The purpose of this study was to assess the effects of progressive transection of the ITB, gluteus mediusand minimus (med/min) muscles, and hip joint capsule of lightly embalmed cadavers on Ober test results and to compare themwith assessment of all structures intact. In addition, thigh position change between gluteus med/min transection and hip capsuletransection was also assessed for both versions of the Ober test. It was hypothesized that transection of the ITB would signifi-cantly increase thigh adduction range of motion as measured by an inclinometer when performing either Ober test and that sub-sequent structure transections (gluteus med/min muscles followed by the hip joint capsule) would cause additional increases inthigh adduction.

Study Design: Controlled laboratory study.

Methods: The lower limbs of lightly embalmed cadavers were assessed for midthigh ITB transection versus intact by use of theOber (n = 28) and modified Ober (n = 34) tests; 18 lower limbs were assessed for all conditions (intact band, followed by sequentialtransections of the ITB midthigh, gluteus med/min muscles, hip joint capsule) by use of both Ober tests. Paired t tests were usedto compare changes in Ober test results between conditions.

Results: No significant changes in thigh position (adduction) occurred in either version of the Ober test after ITB transection. Sig-nificant differences were noted for intact band versus gluteus med/min transection and intact band versus hip joint capsule tran-section (P \ .0001) for all findings for both tests. Mean inclinometer measurements for the modified Ober were 4.28� (n = 34 forintact vs ITB transection comparisons), 3.33� (n = 18 for subsequent intact vs gluteus muscle and hip capsule transection com-parisons), 5.00� (n = 34 for midthigh ITB transection), 11.20� (gluteus med/min transection), and 13.20� (hip capsule transection).For the Ober test, measures were –2.90� (n = 28 for intact vs ITB transection comparisons), –2.20� (n = 18 for subsequent intact vsgluteus muscle and hip capsule transection comparisons), –2.20� (n = 34 for midthigh ITB transection), 6.50� (gluteus med/mintransection), and 9.53� (hip capsule transection). Statistically significant differences were also noted between test findings com-paring gluteus med/min transection to hip capsule transection (Ober, P \ .0001; modified Ober, P = .0036).

Conclusion: The study findings refute the hypothesis that the ITB plays a role in limiting hip adduction during either version of theOber test and question the validity of these tests for determining ITB tightness. The findings underscore the influence of the glu-teus medius and minimus muscles as well as the hip joint capsule on Ober test findings.

Clinical Relevance: The results of this study suggest that the Ober test assesses tightness of structures proximal to the hip joint,such as the gluteus medius and minimus muscles and the hip joint capsule, rather than the ITB.

Keywords: Ober test; modified Ober test; iliotibial band; knee pain; lightly embalmed cadaver

The iliotibial band (ITB), also known as iliotibial tract, isa fibrous band that reinforces the fascia lata laterallyand can be observed on the lateral aspect of the thigh asit continues inferiorly to the lateral tibial condyle.22 Painon the lateral side of the knee near the lateral epicondylein runners, cyclists, and other athletes who experiencerepetitive movement of the knee under loaded conditionshas been attributed to irritation of the ITB.2,11,23 Tightnessof the ITB is considered to be a possible contributing factorto irritation.4 In addition to palpation for localized tender-ness of the area inferior to the lateral epicondyle of theknee (superior to the joint line), other key clinical examina-tion tools frequently recommended are the Ober test (OT)

*Address correspondence to Gilbert M. Willett, PhD, University ofNebraska Medical Center, 986395 Nebraska Medical Center, Departmentof GCBA, Omaha, NE 68198-6395, USA (email: gwillett@unmc.edu).

yDepartment of Genetics, Cell Biology and Anatomy, University ofNebraska Medical Center, Omaha, Nebraska, USA.

zCollege of Public Health Biostatistics, University of Nebraska Medi-cal Center, Omaha, Nebraska, USA.

One or more of the authors has declared the following potential con-flict of interest or source of funding: This study was sponsored by the Uni-versity of Nebraska Medical Center Department of Genetics, Cell Biology,and Anatomy.

The American Journal of Sports Medicine, Vol. 44, No. 3DOI: 10.1177/0363546515621762� 2016 The Author(s)

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and modified Ober test (MOT). Both the OT and MOT arebelieved to assess extensibility of the ITB.20

The OT was originally described in 1935 as a test for flex-ibility of the ITB.24 The test consists of placing an individualin the side-lying position with the limb to be tested facing up.The examiner flexes the knee of the limb being tested to 90�followed by abduction and extension of the hip to place thethigh in line with the trunk. Next, the examiner allows grav-ity to lower the thigh into adduction as far as possible whilenot allowing a change of thigh position in the sagittal ortransverse planes. A modification of the OT was describedby Kendall et al19 in 1952. The MOT is identical to the OTexcept with the MOT, the knee is maintained in full exten-sion and the pelvis is stabilized manually. The rationalefor this modification is to reduce the potential influence ofa tight rectus femoris muscle on the test findings.

Irritation of the ITB, often called ITB friction syndrome,has been thought to be caused by a tight ITB rubbing on thelateral epicondyle of the femur during repetitive flexion andextension of the knee.11,13,17 Previous investigations haverefuted this hypothesis.8,9,18 Fairclough et al9 concludedthat the ITB is not a distinct anatomic structure but merelya thickened zone within the lateral aspect of the fascia lata,which is firmly connected to the linea aspera by an inter-muscular septum. This description is consistent with anearlier study that also reported fascia lata attachment tothe lateral epicondyle of the femur.18 Kaplan concludedhis article as follows: ‘‘The importance of the tensor fasciaelatae and of the ITB has been, possibly, overestimated asa deforming factor in patients.’’18 These anatomic consider-ations make it difficult to conclude that anterior-posteriorglide of the ITB is even possible, and thus raise the questionas to whether ITB friction can occur.

No studies have supported the validity of the OT orMOT for measuring a tight ITB. Melchione and Sullivan21

stated: ‘‘No studies have examined the reliability of judg-ments made by clinicians concerning ITB tightnessthrough use of the test.’’ Melchione and Sullivan21

designed a new method to measure the length of the ITBusing their own modified version of the OT (5� of hip exten-sion and 5� of knee flexion and a standardized procedurefor maintaining pelvic position); the investigators testedtheir method for intra- and intertester reliability onpatients with anterior knee pain and found the methodto be reliable. Unfortunately, their research addressedmethod and reliability, but not validity, of ITB assessment.

Knowledge of the anatomic features of the ITB andexperience with clinical examination and rehabilitation ofathletes diagnosed with ITB syndrome lead to the questionof whether the OT and MOT are valid assessments of ITBflexibility or whether more proximal tissues such as thehip abductor muscles or hip joint capsule may havea greater influence on OT or MOT findings. Access tolightly embalmed cadavers whose tissue mobility andextensibility is similar to those of live individuals enabledinvestigation of this question.3,28 The purpose of this con-trolled laboratory study was to determine whether progres-sive transection of the ITB, gluteus medius and minimus(med/min) muscles, and hip joint capsule of lightlyembalmed cadavers would result in changes in OT or

MOT results compared with assessment with all structuresintact. The hypothesis was that transection of the ITBwould result in a significant increase of thigh adductionduring the OT and MOT and that subsequent tissue trans-ections would result in further changes in thigh adduction.

METHODS

State anatomic review board approval was obtained for thisstudy, in which 18 lightly embalmed cadavers were used (14female, 4 male; average age, 78 years; range, 45-97 years).Thirty-four lower limbs were assessed for mid-ITB transec-tion versus intact by use of the MOT (the initial 6 were pilotstudy data for MOT mid-ITB transection change only) and28 by use of the OT (the initial 10 were pilot study datafor a MOT vs OT midtransection change comparison); 18lower limbs were assessed for all 3 transection conditionsby use of both the MOT and OT. Data from the 2 pilot stud-ies were included with the 18 complete assessments to max-imize the amount of data available for analysis. Limbs thathad total hip arthroplasty or evidence indicating major sur-gery or trauma of the hip-thigh region (visible scars ordeformities) were not included in the study. Two of the 36available lower limbs were not used for this study basedon these exclusion criteria.

The cadavers used in the study were embalmed witha glutaraldehyde-based embalming fluid (ChampionMillennium Alpha Factor Arterial 24; The Champion Com-pany of Springfield). Twenty-four ounces of the concen-trated chemical per 2½ gallons of water were used for anaverage-sized cadaver.3,28

Initial pilot data (first 6 lower limbs, 34 total) wereobtained by use of the MOT and ITB transection only, fol-lowed by inclusion of the OT (28 lower limbs; 10 were pilotdata comparing the MOT and OT after ITB transection).Gluteus med/min transection and hip capsule transectionin addition to ITB transection were performed on 18 lowerlimbs. The order of conditions and measurements (2 meas-urements were performed for each condition) are shown inFigure 1.

Intact cadaver: MOT (knee extended) assessment followed by OT (knee flexed 90°)

Midthigh ITB transec�on: MOT (n = 34) followed by OT (n = 28)

Gluteus medius and minimus muscle transec�ons (a�er ITB transec�on): MOT (n = 18) followed by OT (n = 18)

Hip joint capsule transec�on (a�er gluteus med/min and ITB transec�ons): MOT (n = 18) followed by OT (n = 18)

Figure 1. Order of conditions and measurements. ITB, ilioti-bial band; MOT, modified Ober test; OT, Ober test.

AJSM Vol. 44, No. 3, 2016 The Ober Test 697

The tests were performed on the lightly embalmedcadavers as described by Ober24 and Kendall et al.19 Thesame assistant helped manually stabilize the pelvis duringall tests on all cadavers. An inclinometer placed at the lat-eral epicondyle of the femur was used to measure limbposition (Figure 2). Horizontal was considered 0�; anadducted position or below horizontal was recorded asa positive number and an abducted position or above hori-zontal was recorded as a negative number.25 This approachto measurement of ITB flexibility has been found to be reli-able and simple to perform.25

The MOT and OT were assessed twice for each conditionby a board-certified orthopaedic physical therapist whowas blinded to the measurements. The blinded measure-ments were read and recorded by the same individual forall conditions on all cadavers. All transections were per-formed by the same individual (anatomist with 20 yearsof experience). Transections were performed as follows:

1. ITB: Midthigh (based on tape measure from greater tro-chanter to lateral epicondyle of femur), 5.08 cm inlength, beginning at the lateral intermuscular septumof the thigh and proceeding anteriorly, perpendicularto the longitudinal fibers of the ITB (Figure 3)

2. Gluteus med/min: Lateral approach through the tendi-nous attachment of the muscles to the greater trochan-ter16 (Figure 4)

3. Hip joint capsule: In an arc through the superior-distalattachment on the greater trochanter, deep to the glu-teus med/min attachments

Statistical Analysis

Descriptive statistics including the mean, standard devia-tion, minimum, and maximum were provided for each vari-able as well as the difference in variables that werecompared.

SAS for PC (version 9.4; SAS Institute Inc) was used fordata analyses. The statistical level of significance for anal-yses was .05. The 2 goniometer measurements were aver-aged before analysis, and the averages were then used inthe statistical calculations. The data were tested for nor-mality with the Shapiro-Wilk test. Since each variablepassed the test of normality, paired t tests were used tomake the following comparisons:

MOT:1. Intact versus ITB transection2. Intact versus gluteus med/min transection3. Intact versus hip capsule transection4. Gluteus med/min transection versus hip capsule

transection

OT:5. Intact versus ITB transection6. Intact versus gluteus med/min transection7. Intact versus hip capsule transection8. Gluteus med/min transection versus hip capsule

transection

RESULTS

Table 1 provides descriptive statistics for the inclinometermeasurements of the conditions and the t test statistics forcomparisons between conditions.

The mean goniometric measurements of thigh positionfor the intact ITB versus ITB transection during theMOT were 4.28� (intact) and 5.00� (ITB transection),with the thigh below the horizontal plane. For the OT,

Figure 2. Modified Ober test performed on cadaver.

Figure 3. Iliotibial band transection.

Figure 4. Gluteus medius and minimus transection.

698 Willett et al The American Journal of Sports Medicine

the findings were –2.90� (intact) and –2.20� (ITB transec-tion), with the thigh above the horizontal plane. Thesecomparisons were not statistically significantly differentfor either the MOT or OT (MOT, P = .2629; OT, P =.3353) (Table 1). These results indicate that the thigh didnot move further into adduction after ITB transectionwhen assessed with either version of the Ober test.

The mean inclinometer measurements of thigh positionfor the intact ITB versus gluteus med/min transection dur-ing the MOT were 3.33� (intact) and 11.20� (gluteus med/min transection), thigh below horizontal plane. For theOT, the findings were –2.20� (intact), thigh above horizon-tal plane, and 6.50� (gluteus med/min transection), thighbelow horizontal plane. These comparisons were statisti-cally significant different for the MOT and OT (MOT,P \ .0001; OT, P \ .0001) (Table 1). These results indicatethat the thigh did move further into adduction after

transection of the gluteus med/min muscles relative tothe intact ITB condition when assessed with both versionsof the Ober test.

The mean goniometric measurements of thigh positionfor the intact ITB versus hip joint capsule transection dur-ing the MOT were 3.33� (intact) and 13.2� (hip cap transec-tion). For the OT, the findings were –2.2� (intact) and 9.53�(hip cap transection). These comparisons were statisticallysignificant for the MOT and OT (MOT, P \ .0001; OT, P \.0001) (Table 1). These results indicate that the thigh didmove further into adduction after transection of the hipjoint capsule relative to the intact ITB condition whenassessed with both versions of the Ober test.

Last, the mean goniometric measurements of thighposition after transection of the gluteus med/min versusafter hip capsule transection during the MOT were 11.2�(gluteus med/min transection) and 13.2� (hip cap

TABLE 1Descriptive Statistics for Modified Ober and Ober Test Results and Statistical Comparison Between Conditionsa

Difference Between Conditions

ConditionNo.

(per Group)Inclinometer Measurement,

deg, Mean 6 SD (Range)SD

(95% CI), deg t Value Pr . |t|

Modified Ober testITB intact vs ITB transected 34 Intact: 4.28 6 5.53

(–8.00 to 15.50)Transected: 5.00 6 4.48(–4.00 to 15.50)

3.69(–2.00 to 0.57)

–1.14 .2629

ITB intact vsgluteus med/min transected

18 Intact: 3.33 6 5.40(–8.00 to 10.00)Transected:11.20 6 3.92(5.00 to 19.50)

4.55(–10.12 to –5.60)

–7.33 \.0001b

ITB intact vs hip cap transected 18 Intact: 3.33 6 5.40(–8.00 to 10.00)Transected: 13.20 6 4.98(4.50 to 22.0)

5.17(–12.40 to –7.26)

–8.07 \.0001b

Gluteus med/min transectedvs hip cap transected

18 Gluteus med/min: 11.20 6 3.92(5.00 to 19.50)Hip cap: 13.20 6 4.98(4.50 to 22.00)

2.48(–3.21 to –0.74)

–3.37 .0036b

Ober testITB intact vs ITB transected 28 Intact: –2.90 6 7.88

(–23.00 to 9.00)Transected: –2.20 6 8.29(–22.00 to 11.50)

3.37(–1.93 to 0.68)

–0.98 .3353

ITB intact vsgluteus med/min transected

18 Intact: –2.20 6 6.31(–15.00 to 9.00)Transected: 6.50 6 6.86(–7.00 to 16.50)

3.95(–10.63 to –6.70)

–9.31 \.0001b

ITB intact vs hip cap transected 18 Intact: –2.20 6 6.31(–15.00 to 9.00)Transected: 9.53 6 6.51(–1.00 to 21.00)

4.93(–14.14 to –9.24)

–10.07 \.0001b

Gluteus med/min transectedvs hip cap transected

18 Gluteus med/min: 6.50 6 6.86(–7.00 to 16.50)Hip cap: 9.53 6 6.51(–1.00 to 21.00)

2.42(–4.23 to –1.82)

–5.30 \.0001b

acap, capsule; med/min, medius and minimus; ITB, iliotibial band.bStatistically significant (P \ .05).

AJSM Vol. 44, No. 3, 2016 The Ober Test 699

transection). For the OT, the findings were 6.5� (gluteusmed/min transection) and 9.53� (hip cap transection).These comparisons were statistically significant for theMOT and OT (MOT, P = .0036; OT, P \ .0001) (Table 1).These results indicate that the thigh did move furtherinto adduction after transection of the hip joint capsule rel-ative to after gluteus med/min muscle transection whenassessed using both versions of the Ober test.

DISCUSSION

Lateral knee pain is a common occurrence in athletes andactive individuals that is frequently attributed to tightnessof the ITB.7,14,20,26 The most commonly recommendedphysical examination procedure for assessment of ITBtightness is the OT or MOT.1,7,10,12,15,27 Recent studieshave challenged whether the ITB is the problematic tissuein cases diagnosed as ITB syndrome.8,10 In addition torecent evidence questioning the cause of lateral kneepain commonly attributed to ITB tightness, our studyresults also question the validity of the OT and MOT fordetermination of ITB extensibility and tightness.

Authors of several studies of ITB stretches propose thathip and thigh muscle extensibility changes may be respon-sible for increased adduction of the hip rather thanchanges in the ITB.9,13 Fredericson et al13 noted that it ispossible that changes in the gluteal muscles, tensor fascialata, and vastus lateralis could have contributed toincreased hip adduction range of motion during stretchesmeant to stretch the ITB versus actual changes in ITBband length. Falvey et al10 expanded on these findingsand concluded that the fascial component of the ITB playsa limited role in lengthening of the ITB–tensor fascia latamuscle complex and that the muscular components in thehip area are the key factors to consider.

Our study results concur with the above-mentioned find-ings. No notable changes in MOT or OT hip adduction rangeof motion were recorded after transection of the ITB (meanchange \1� for both tests) (see Table 1). Statistically andclinically significant increases in hip adduction range ofmotion with MOT and OT assessment were found after glu-teus med/min transection (MOT mean change .7�, OTmean change .8�) and after hip joint capsule transection(MOT mean change .9�, OT mean change .11�). Fora change in goniometric measurement to be considered clin-ically significant, a minimum difference of 3� to 4� is neces-sary when the same examiner performs a measure.5 Onestudy supported interchangeable use of goniometric andinclinometer measurements of the hip based on the findingsof high interrater reliability (intraclass correlation coeffi-cient, 0.91-0.92) between use of these instruments.6

Comparisons between changes in hip adduction range ofmotion measures with the MOT and OT after hip joint cap-sule transection after gluteus med/min transectionrevealed statistically significant increases in hip adduction(MOT mean change, 2�; OT mean change, .3�). The OTmeasurement of increased hip adduction change for hipjoint capsule transection versus gluteus med/min transec-tion is considered to be within the clinically significant

range. This finding regarding the influence of the hip jointcapsule on MOT and OT measures has never beenaddressed in the literature. Based on our study, hip jointcapsular tightness should also be considered as a potentialfactor contributing to the findings of the MOT and OT.

Drawbacks of this study include use of lightly embalmedcadavers and the age of the cadavers tested. Tissue extensi-bility is likely to have been influenced somewhat by thechemicals used during embalming. However, Anderson3

reported the tissue of lightly embalmed cadavers to be ‘‘closeto that found in the living body, both in color and texture.’’Information concerning the premorbid physical activity lev-els of the cadavers was not available. Since the cadaverswere much older than typical athletes, the muscle bulk ofthe cadavers was likely not equivalent to that of healthyathletes. However, the primary focus of this investigationwas to determine the contribution of different anatomicstructures to MOT and OT findings. The robust resultslead one to consider the possibility that these findingsmay indeed be applicable to live individuals.

CONCLUSION

The findings of this study refute the hypothesis that theITB plays a role in limiting hip adduction during eitherversion of the Ober test. The gluteus medius and minimusmuscles as well as the hip joint capsule appear to influenceMOT and OT findings. These findings question the validityof the Ober tests for determining ITB tightness but under-score the influence of the gluteus medius and minimusmuscles as well as the hip joint capsule on MOT and OTfindings. The results of this study suggest that the Obertest is an assessment of tightness of the gluteus mediusand minimus muscles and the hip joint capsule ratherthan the ITB.

ACKNOWLEDGMENT

The authors thank individuals who donate their bodies andtissues for the advancement of education and research.

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