1407
ORIGINAL ARTICLE
Assessment of Stretching of the Iliotibial Tract With Ober
and Modified Ober Tests: An Ultrasonographic Study
Tyng-Guey Wang, MD, Mei-Hwa Jan, MS, PT, Kwan-Hwa Lin, PhD, PT, Hsing-Kuo Wang, PhD, PT
ABSTRACT. Wang T-G, Jan M-H, Lin K-H, Wang H-K.
Assessment of stretching of the iliotibial tract with Ober and
modified Ober tests: an ultrasonographic study. Arch Phys Med
Rehabil 2006;87:1407-11.
Objective: To assess stretching of the iliotibial tract with
Ober and modified Ober tests, by assessing morphologic
changes of the tract using ultrasonography during stretching.
Design: Cross-sectional study.
Setting: Orthopedic laboratory.
Participants: Thirty-six healthy subjects (age, 24.3⫾4.0y)
were recruited. They had no history of previous low back,
gluteus, hip, or knee pain and satisfied the inclusion criteria for
this study.
Intervention: Each subject was randomly assigned to first
undergo either the Ober test or the modified Ober test, and 30
minutes after the first to undergo the other test. Measurements
were obtained with the subjects lying on the right side. The left
knee was flexed 90° for the Ober test and positioned at 0° for
the modified test.
Main Outcome Measures: The iliotibial tract widths in
subjects were measured in 3 gradually increased hip adduction
positions (neutral, adducted, adducted with weight) when per-
forming Ober and modified Ober tests. Ten of these 36 subjects
were randomly chosen to undergo a repeat of the same protocol
to test the reliability of ultrasonographic measurements in the
iliotibial tract.
Results: Ultrasonography was reliable in measuring the
width of iliotibial tract (intraclass correlation coefficient range,
.81–.82). The width of the iliotibial tract was significantly
reduced from the neutral to adducted position of the hip with
both Ober (P⫽.001) and modified Ober (P⬍.001) tests. How-
ever, with further stretching using a greater hip adduction
angle, the width of the iliotibial tract was only reduced with the
modified Ober test.
Conclusions: Both the Ober and modified Ober tests are
effective in the initial stage of stretching of the iliotibial tract.
However, the modified Ober test might be more effective in
stretching the iliotibial tract if a further stretching effect is
desired.
From the Department of Physical Medicine & Rehabilitation, National Taiwan
University Hospital, College of Medicine, National Taiwan University, Taipei, Tai-
wan, ROC (T-G Wang); and School and Graduate Institute of Physical Therapy,
College of Medicine, National Taiwan University, Taipei, Taiwan, ROC (Jan, Lin,
H-K Wang).
Supported by the National Science Council, ROC (grant no. NSC93-2314-B-002-
097).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Hsing-Kuo Wang, PhD, PT, Sports Physiotherapy Laboratory,
School and Graduate Institute of Physical Therapy, College of Medicine, National
Taiwan University, Fl 3, No. 17, Xuzhou Rd, Zhongzheng District, Taipei City 100,
Taiwan, ROC, e-mail: hkwang@ntu.edu.tw.
0003-9993/06/8710-10688$32.00/0
doi:10.1016/j.apmr.2006.06.007
Key Words: Rehabilitation; Ultrasonography.
© 2006 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
TRETCHING IS A COMMONLY used technique that
S 1
increases the length and extensibility of soft tissues. The
effectiveness of therapeutic stretching on soft tissues has been
indirectly estimated by palpation, kinematic, and goniometric
analyses.2-5 Recently, morphologic changes in soft tissues un-
der stretch have been demonstrated in noninvasive laboratory
studies with magnetic resonance imaging (MRI) and ultra-
sonography.6-8 Previous studies have shown that the gastroc-
nemius tendon increases in its length when the ankle moves
from neutral position to dorsiflexion6; so do the patellar ten-
don7 and posterior cruciate ligament when the knee moves
from full extension to flexion.8 In addition to elongation, the
stretched soft tissues simultaneously decrease in cross-sec-
tional area, width, and thickness, which has been confirmed by
cadaveric studies.9,10 However, few studies have analyzed the
morphologic changes of soft tissues with therapeutic stretch in
clinical practice.
The iliotibial band (ITB) is a continuation of the tensor
fascia latae and the gluteus maximus at the lateral aspect of the
thigh. As it approaches the knee, the ITB separates into 2
functional components, the iliopatellar band and the iliotibial
tract (ITT), which attach to the Gerdy tubercle of the lateral tibial
condyle and the lateral patella retinaculum, respectively.11 Clini-
cians and physiotherapists often use the Ober or modified Ober
test to stretch a tight ITB or ITT.12 The Ober test with knee
flexed 90° was originally designed to stretch the ITB and the
tensor fascia latae muscle in patients with low back pain or
sciatica (fig 1A).13 To perform this maneuver, the patient is
positioned sidelying with the bottom knee flexed to flatten the
lower back.13 After the examiner stabilizes the hip on the top
and passively flexes the hip and knee to 90°, the hip is stretched
passively through abduction and extension by the examiner,
who then allows the knee to slowly drop by gravity until
reaching its final angle. Kendall et al2 modified the Ober test by
extending the knee to 0° before the stretch (fig 1B). In these
tests (Ober, modified Ober), a normal ITT or distal ITB is
stretched and becomes taut when the hip adducts beyond 0° and
10°, respectively. If a greater stretch on the ITT is desired,
further hip adduction is created by applying pressure on the
lateral side of the knee.2 However, there is a lack of in vivo
noninvasive studies in literature that have evaluated the effect
of stretching exercises on the morphologic changes of the ITB,
or assessed the effectiveness of these 2 different stretching
maneuvers.
Ultrasonography is a real-time, high-resolution, noninvasive
imaging tool.14,15 In comparison with MRI, ultrasonography is
a more suitable tool in defining the morphologic change of the
ITB with the Ober or modified Ober test, because of its capa-
bility of dynamic examination. Pilot work of this study has
proven validity of our ultrasonographic measurements on the
ITT width by comparing MRI. This study measured morphol-
Arch Phys Med Rehabil Vol 87, October 2006
1408 ASSESSMENT OF STRETCH EFFECTIVENESS, Wang
ogies of the ITT and attempted to assess the stretching effec-
tiveness of Ober and modified Ober tests by ultrasonographic
examinations. The reliability of ultrasonographic measure-
ments was also assessed. It was our assumption that morpho-
logic changes of the ITT are mostly due to the strain placed on
the structure during stretching.
METHODS
Participants
Our institutional review board approved this study, and all
subjects provided informed consent. From February 2004 to
July 2004, we recruited 38 asymptomatic, healthy volunteers
through the university student center. These healthy volunteers
were screened including using historical and physical assess-
ments by examiners of this study (2 board-certified physiother-
apists, 1 musculoskeletal ultrasonographer). They were without
a history of previous low back, gluteal, hip, or knee pain that
caused them to seek prior medical care. The physical assess-
ments were conducted with the subjects in a standing position
using a series of bilateral anthropometrica and goniometric
measurements. The inclusion criteria for this study based on
these measurements were: (1) no leg-length discrepancy (dis-
tance from the anterior superior iliac spine [ASIS] to the
superior surface of the most prominent aspect of the medial
malleolus) of more than 1.5cm, (2) no genu varum (tibiofemo-
ral angle ⬍4°), and (3) no functional overpronation of the foot
arch (the angle formed between the distal medial malleolus, the
navicular tuberosity, and the first metatarsal head ⱕ90°). When
the ultrasonographic measurements were conducted, subjects
were excluded from this study if they (1) showed positive
response consistent with a restricted ITB with the Ober or
modified Ober test in the adducted position (ie, a hip adduction
angle of ⬍0°, a hip adduction angle of ⬍10°, respectively); (2)
had a focally thickened or poorly defined border of the ITT,
with a fluid collection between the ITT and the lateral femoral
epicondyle when the ultrasonographic measurements were con-
ducted. These anatomic abnormalities and morphologic changes,
such as pronated foot or fluid collection, have been postulated as
factors that predispose people to develop irritation of the ITT at
the level of the lateral femoral epicondyle.14,16,17 Two of the 38
subjects were excluded by the first exclusion criteria. Data of the
remaining 36 subjects (17 men, 19 women; mean, 24.3⫾4.0y;
height, 166.9⫾8.6cm; weight, 58.8⫾10.6kg) were analyzed.
Ultrasonographic Measurements
We performed ultrasonographic measurements using an HDI
5000 imaging unitb with a 5- to 10-MHz linear-array transducer
(model CL10-5b; axial resolution, 0.7mm). Before the mea-
Arch Phys Med Rehabil Vol 87, October 2006
Fig 1. (A) Ober test and (B)
modified Ober test.
surements were made, the subject was placed in a relaxed,
seated position on an examination table with the knees ex-
tended. A line crossing the longitudinal axis of the ITT was
drawn on the subject’s skin to indicate the placement posi-
tion of the ultrasonic transducer at the level corresponding to
the superior border of the patella. The subjects were as-
signed in a random sequence to undergo the Ober test or the
modified Ober test; then each underwent the other test 30
minutes after the first.
We performed measurements on the left leg. The subjects
were lying on their right side with their shoulders and pelvis
perpendicular to the examining table. In addition, the hip and
knee of the right leg were flexed to flatten the low back,
therefore stabilizing the pelvis. The left knee was kept in
flexion at 90° for the Ober test and positioned at 0° for the
modified Ober test. With each test, the width of the ITT was
sequentially measured with the hip in 3 positions to gradually
increase hip adduction: neutral, adducted, and adducted with
weight.
There were separate examiners for the subject stabilization,
hip angle measurement, and ultrasonographic measurement.
For subject stabilization while in the neutral position, an ex-
aminer (physiotherapist) pushed below the left anterior aspect
of the superior ilium (ASIS) to stabilize the pelvis in an anterior
tilt position. This examiner also held just below the ipsilateral
knee, to abduct and hyperextend the hip without internal rotation
and flexion during measurements. A second examiner (physio-
therapist) placed an inclinometer,c which had markings of 1°
increments, over the lateral epicondyle to confirm that the hip
adduction angle was neutral (ie, 0°).5 The third examiner (ul-
trasonographer) positioned the transducer on and parallel to
the previously marked line and held it perpendicular to the
skin surface to avoid compressing the skin and underlying
tissues.
For the adducted hip position, we applied the transducer on
the marked line and the support that had been applied to the
subject’s left knee in neutral position was removed by grasping the
left ankle lightly but with enough tension to keep the subject’s hip
from flexing and internally rotating. To stretch the tract, the test
leg was allowed to drop (adduct) by gravity into the available
range of adduction. The examiner stabilized the subject’s pelvis
and controlled the speed with which the knee joint was lowered to
allow the ultrasonographer to trace the image of the ITT and
measure its width without moving the transducer from the marked
line (to ensure the same measurement point). The final angle of
hip adduction was then measured by placing the inclinometer
on the lateral epicondyle after the ultrasonographic measure-
ment was recorded. Each subject was instructed to relax and
 ASSESSMENT OF STRETCH EFFECTIVENESS, Wang 1409

Table 1: Mean Values and Reliability of Ultrasonographic Table 3: Degrees of Hip Adduction Achieved in the Ober and
Measurements of the Width of ITT in Ober and Modified Modified Ober Tests
Ober Tests
Hip Adduction Ober Test Modified Ober Test
Measurements Ober Test Modified Ober Test
Adducted position (deg) 17.8⫾4.6 21.1⫾5.5*
Hip neutral position 5.1⫾0.8 5.1⫾0.8 Hip adduction with weight (deg) 27.1⫾6.8 28.7⫾5.8
Hip adducted position 4.6⫾0.8 4.5⫾0.9
Hip adducted with weight position 4.4⫾0.8 4.0⫾0.8 *Significant difference of hip angles between Ober and the modified
P (repeated 1-way ANOVA) .001 ⬍.001 Ober tests (P⫽.01; power, 0.8).
ICC* .82 .81

NOTE. Values are mean width ⫾ standard error (mm).

*Only 10 subjects were included for the reliability test.
return the hip to its neutral position with stabilization by the
examiner at the end of the test.
To generate a greater hip adduction angle than that of the
adducted position and to further stretch the ITT, a 3-kg sand
bag was hung on the distal aspect of the subject’s left knee in
the adducted with weight position during ultrasonographic
measurements. The examiner stabilized the subject’s pelvis and
controlled the dropping speed of the knee joint using the same
technique as in the adducted hip position. The left knee was
allowed to stretch and drop by gravity with the added weight in
the available range of adduction until hip movement stopped.
The ITT width and the end angle of hip adduction were
measured using sonograms (fig 2) and the inclinometer. Each
position was repeated 3 times at 5-minute intervals, and width
and hip angle were taken as the average of 3 recordings. To
rule out confounding effects during the ultrasonographic mea-
surements, we confirmed that there was no significant increase
in myoelectric activity (⬍2 times the standard deviation of
mean electromyographic signal for 40 seconds of relaxed mus-
cles) of gluteus medius and tensor fascia latae muscles using
surface electromyography.d
Reliability of Ultrasonographic Examination
To assess intratester test-retest reliability, 10 of the 36 sub-
jects were randomly chosen to undergo a repeat of the same
protocol on a second day with the same investigators.
Statistical Analysis
We used repeated 1-way analysis of variance (ANOVA)
with Bonferroni posthoc testing to analyze differences in the
width of the ITT in the 3 hip positions for each test. The
intrarater intraclass correlation coefficient (ICC) was used to
Table 2: Post Hoc (Bonferroni) Comparison of the ITT Width in
Ober and Modified Ober Tests
Ober Modified
Comparison Measurement Position Test Ober Test
P value of post hoc Hip neutral to adducted .020 .011
comparisons of position
width Hip neutral to adducted .001 .001
with weight position
Hip adducted to adducted .583 .04
with weight position
estimate the reliability of the ultrasonographic measure-
ments. In addition, a paired t test was used to analyze mean
differences in the hip angles during the Ober and the mod-
ified Ober tests. All analyses were performed in the null
form, and ␣ was set at .05.
RESULTS
The results of Ober and modified Ober tests showed that the
ITT width was reduced significantly from the neutral position to
the adducted position (P⫽.001, P⬍.001, respectively) (table 1). In
the adducted with weight position, a further reduction in the ITT
width from an adducted position was only significant with the
modified Ober test (P⫽.04) (table 2). The ICCs of ultrasono-
graphic measurements of width with Ober and modified Ober tests
were .81 and .82, respectively (see table 1). The hip angle of
adduction position with the modified Ober test was signifi-
cantly greater than that with the Ober test (P⫽.01) (table 3).
There were no statistically significant differences in the angles
of adducted with weight position between 2 tests (27.1°⫾6.8°
vs 28.7°⫾5.8°, P⬎.05).
DISCUSSION
This study demonstrated: (1) the width of the ITT was
reduced when the knee moved from the neutral to the adducted
position for both the Ober and modified Ober tests, and (2) a
further reduction of tract width was observed when the hip
moved from the adducted position to the adducted with weight
position in the modified Ober test, but not in the Ober test.
Therefore, both tests are effective in this initial stage of stretch-
ing, but the modified Ober test may be more effective than the
Ober test when a greater hip adduction angle is applied (ad-
ducted with weight position).
Some researchers believe that the Ober test may stretch the
tensor fascia latae muscle more than the ITT; therefore, the
potential interference of stretching on the ITT in the Ober test
is greater than for the modified test.2,4,18 Furthermore, the
modified Ober test is believed to be conducted with greater
specificity and less interference in stretching the ITT.4,18 This high
specificity of the modified Ober test, in which the knee is kept
extended, may be achieved by placing more stress on the lateral
thigh and less stress on the medial aspect of the knee. In
addition, potential interference by a tight rectus femoris muscle
is minimized when stretching is conducted on an extended
knee.4 From previous and present results, we suggest that the
modified Ober test is a better choice for stretching the ITT
(distal part of ITB).
The advantage of using ultrasonography in this study is to
observe the real-time morphologic changes of soft tissues as
objective direct indicators of stretching effectiveness in dif-
ferent tests. Previously, ITB or ITT stretching maneuvers
had been compared in only 1 kinematic study,3 which was
based on indirect estimates of the changes of tissue length.
Our newly developed approach may prove to be beneficial
for sports medicine personnel for assessing stretching out-

Arch Phys Med Rehabil Vol 87, October 2006

1410 ASSESSMENT OF STRETCH EFFECTIVENESS, Wang
Fig 2. Sonographic measurements of the iliotibial tract width for the modified Ober test taken from the cross-caliper data: (A) neutral
position, (B) adducted position, and (C) adducted with weight position. Figures were processed with auto-contrast by Adobe Photoshop CS
(version 8.0).
come. In this study, we assumed that the change in the width
of the ITT reflected the strain on the structure, as in the
cadaver studies.9,10 However, without inserting a strain
gauge parallel to the ITT and without directly measuring the
length of the ITB, we could not exclude the possibility that
the changes in width resulted partly from changing the
position of the subject’s knee. Further investigation is sug-
gested.
In this work, we recommend a new method for assessing the
effectiveness of stretching with ultrasonography. However,
some limitations should be addressed. First, the ITT may not be
measured exactly at the same point in the 2 maneuvers, al-
though all ultrasonographic measurements were performed at
the similar suprapatellar level. Movement of the ITT between
knee angles of flexion and extension make direct comparison
questionable. Second, the participants were healthy and lacked
any history of hip or knee pain, so the correlations regarding
stretch effectiveness in the modified Ober test might not apply
to patients with injuries. Subsequent studies will recruit pa-
tients with hip or knee injuries. In summary, the results of this
study provided the morphologic evidence of the stretching
effect by the ultrasonographic measurement in healthy sub-
jects. Therefore, the ultrasonographic measurement with high
frequency transducer (⬇10 –15MHz) to detect the superficial
muscle or fascia changes may become a reliable, objective, and
dynamic approach for verifying the effectiveness of clinical
maneuvers such as stretch.
CONCLUSIONS
Ultrasonography was a reliable noninvasive tool to measure
the morphology of the ITT. Both the Ober and modified Ober
tests can effectively stretch the ITT but the modified Ober test
seems more effective when stretching is done with a greater hip
adduction angle.
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d. TSD150; Biopac Systems Inc, 42 Aero Camino, Goleta, CA 93117.
Arch Phys Med Rehabil Vol 87, October 2006