What Is Noble Compression Test/Noble Test?
The purpose of the noble compression test or noble test is to assess pain coming from iliotibial band syndrome. Iliotibial band syndrome is also known as iliotibial band friction syndrome. The noble test is commonly used as an indication for iliotibial band syndrome.
Iliotibial band friction syndrome is an overuse injury that is caused by excessive friction between the iliotibial band and lateral femoral condyle. However, there is no evidence-based research that has been conducted to control the validity of the noble test.
However, you people are encountering two words the iliotibial band and the lateral femoral condyle. Now let’s understand the connection between the iliotibial band and lateral femoral condyle.
Clinically Relevant Anatomy
While studying the anatomy of the human body. First comes the skin then comes the superficial fascia and then comes the deep fascia.
The deep fascia of the thigh is also known as “Fascia lata”. As in Latin, the word “Latus” means broad. Now you can get the idea of its work by its name as the fascia lata encloses a wide area of the thigh. Although, the deep fascia of the thigh (fascia lata) is very strong and it envelops the thigh like a sleeve.
Modification of Deep Fascia of the Thigh
The deep fascia of the thigh has two modifications, the iliotibial tract and the saphenous opening. Here we will discuss only the iliotibial tract.
The fascia lata of the thigh is thickened on the lateral side of the thigh to form about 2 inches (5 cm) wide band called the iliotibial tract. The Iliotibial tract is also called as iliotibial band. Superiorly the iliotibial tract is divided into two layers to enclose two muscles (gluteus Maximus and tensor fascia lata). And it also forms a single thickened sheet, the gluteal aponeurosis between them, which covers/envelopes the gluteus medius. Let’s talk about the origin and insertion of the iliotibial tract
Origin – The superficial lamina is attached to the tubercle of the iliac crest. In other words, the iliotibial tract originates from the tubercle of the iliac crest.
Insertion – Inferiorly, the iliotibial tract is attached (inserts) to the smooth area on the anterior surface of the lateral condyle of the tibia.
Note – The upper part of the iliotibial tract provides insertion to two muscles, the tensor fascia late and the gluteus Maximus (except deep fibers of its lower half)
- The iliotibial band/ tract stabilized the knee both in partial flexion and extension. It is therefore used constantly during running and walking.
- On leaning forward with a slightly flexed knee, the iliotibial tract/band is the main support of the knee against gravity. And it restricts the individual from falling forward.
Now inflammation or irritation of the iliotibial band can occur as the knee flex and extends repeatedly. That’s why iliotibial band syndrome is considered as an overuse injury.
Who Suffers From Iliotibial Band Syndrome?
Generally, cyclists, runners, hikers, weight lifters, and soccer players, or anyone who does a lot of (repeated) flexion and extension at the knee suffers from iliotibial band syndrome.
Cycling, running, weight lifting, and playing soccer involve repeated flexion and extension movement of the knee. Now one thing is clear those who perform repeated flexion and extension movement of the knee can suffer from iliotibial band syndrome.
What happens in repeated flexion and extension movement?
In flexion and extension movement of the knee, the iliotibial band slides over the lateral femoral condyle. Therefore, when flexion and extension movement of the knee is performed repeatedly (overuse), it can lead to
- Friction between the iliotibial band and the lateral femoral condyle
- Compressive forces over the lateral femoral condyle
Well, it is normal that, if you perform any movement in the body, again and again, the chances of getting an injury in that particular area increases. So that’s why you’ll have to take precautions to lessen the chance of injury. Hence, you’ll have seen many cricketers, footballers, and athletes. They took a lot of precautions during their workout and sports session so that the injury should not occur.
Now you understand the reason behind that, how repeated flexion and extension movement can lead to iliotibial band syndrome. Well, there are also many other causes that can lead to iliotibial band syndrome, like tightness in the iliotibial band.
As explained above, the iliotibial tract is connected to two muscles in its upper portion, the tensor fascia lata muscle and the gluteus maximus muscle. And in its lateral side, it is connected with the vastus lateralis.
Now, if a problem comes in any of these muscular structures. It can lead to tension (tightness) in the iliotibial band. As much as your iliotibial band gets tenser (tighter), the more likely you could get a rubbing effect (friction) over the lateral side of the knee. In other words, as much as the iliotibial band gets tighter, there will be more rubbing (friction) between the IT band and the lateral epicondyle.
So that means any factor that contributes to tightening of the iliotibial band. It will lead to an increased risk for developing iliotibial band syndrome.
Some of the Most Important Contributing Factors Are
As in bow legs, both the legs appear as bow-shaped structures. Therefore, this abnormal shape of the leg increases tension/tightness in the iliotibial band.
Leg length difference
In this one leg is longer than the other leg and especially the longest leg is a contributing factor to iliotibial band syndrome. Because of the obliquity of the pelvis, there will be increased tension (tightness) in the iliotibial band in the longer leg.
Therefore due to increased tension (tightness) in the IT band in the longer leg, the longer leg is usually predisposed to developing IT band syndrome. Hence, the more tight the iliotibial band is, the more rubbing (friction) effect will occur on the lateral side of the knee (between the iliotibial band and the lateral epicondyle).
How To Conduct Noble Compression Test?
- Ask your patient to lie down in a supine position. The examiner passively flexes the patient’s knee into 90 degrees of flexion and hip into approximately 50 degrees of flexion.
- Now, with the left hand’s thumb, the examiner applies the pressure on the lateral femoral epicondyle or 1 to 2 cm proximal to it. While the pressure is maintained, the patient knee is passively extended.
- In more simple language, the examiner applies and maintains pressure on the lateral femoral condyle or 1 to 2 cm proximal to it while extending the knee.
Noble Test Results
A positive noble test is indicated if the patient complains of pain over the lateral femoral condyle at approximately 30 degrees of flexion. And a positive noble test indicates an iliotibial band syndrome.
Why does the Patient Complain of Pain at 30 degrees of flexion?
The pain will be more felt over the lateral femoral epicondyle at 30 degrees of flexion. The reason behind it is that
- At 30 degrees of flexion, the iliotibial band moves over the lateral femoral epicondyle.
- Extending the hip from 30 degrees of flexion places maximum pressure on the iliotibial band/tract.
In conclusion, if the patient complains/experiences pain over the later femoral epicondyle at 30 degrees of flexion, it will indicate a positive noble test. And a positive noble test indicates an iliotibial band syndrome.
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