Noble’s Test

Noble’s Test (also called Noble’s Compression Test) is a clinical provocation test used to assess iliotibial band syndrome (ITBS). Developed by Clive Noble, the test is widely used in sports medicine, especially among runners and cyclists who frequently suffer from ITBS.

ITBS is an overuse injury caused by friction and compression of the iliotibial band over the lateral femoral epicondyle during repetitive activity. Symptoms are typically localized pain on the outside of the knee, often occurring at around 30° of knee flexion when the IT band passes over the lateral femoral epicondyle.

Although commonly applied in clinical practice, there is no strong evidence supporting the diagnostic validity of Noble’s Test. Nevertheless, it remains clinically useful, especially when combined with tests such as the Modified Ober’s Test and Renne’s Creak Test.

Purpose

The aim of Noble’s Test is to:

• Assess irritation, compression, and pain related to the iliotibial band at the lateral femoral epicondyle.

• Differentiate ITBS from other causes of lateral knee pain (e.g., meniscal injury, patellofemoral pain syndrome).

Relevant Anatomy

The iliotibial band (ITB) is a thickening of the fascia lata, originating from the iliac crest. At the level of the greater trochanter, it blends with fibers from tensor fascia lata (TFL) and gluteus maximus before running distally along the femur. The ITB passes over the lateral femoral epicondyle and inserts on Gerdy’s tubercle on the lateral tibia.

During running and cycling, the ITB undergoes repetitive friction across the epicondyle. Risk factors include poor footwear, biomechanical imbalances, and muscular weakness.

Test Procedure

Patient position:

• Supine or side-lying with the affected side up.

Execution:

1. Examiner supports the ankle with one hand.

2. With the other hand, the examiner palpates the lateral femoral epicondyle with the thumb.

3. The knee is slowly flexed from 0° to 90° while firm pressure is applied to the epicondyle.

4. The examiner may move the knee repeatedly between 0°–90° while maintaining compression, observing for pain or crepitus.

Observation:

• Positive test: Localized pain or discomfort over the lateral epicondyle, typically at ~30° knee flexion. Patients may describe a “squeaky hinge” or “clicking” sensation.

• Negative test: No pain or crepitus during the maneuver.

Interpretation

Positive Noble’s Test:

• Localized pain at ~30° flexion

• Palpable friction or crepitus over lateral femoral epicondyle

• Pain worsens with increased compression

Negative Noble’s Test:

• No pain or abnormal sensations elicited

Clinical Relevance

• Useful in the evaluation of runners, cyclists, and athletes with repetitive lateral knee pain.

• Helps rule out differential diagnoses such as lateral meniscus tear or patellofemoral pain.

• Most effective when combined with Modified Ober’s Test and Renne’s Creak Test to increase diagnostic accuracy.

Evidence and Limitations

• No established sensitivity or specificity values

• No high-quality validation studies published

• Can produce false positives in lateral knee conditions (e.g., meniscal injury)

• Clinical experience suggests utility as part of a comprehensive assessment rather than a stand-alone test

Summary

Noble’s Test is a simple orthopedic test for evaluating iliotibial band syndrome (ITBS). It involves applying pressure over the lateral femoral epicondyle while flexing the knee, with pain at ~30° flexion indicating a positive result. Despite lacking strong evidence for validity, it is widely used in sports medicine as part of the clinical assessment of lateral knee pain.

Sources:

1. Kasunich NJ. Changes in low back pain in a long distance runner after stretching the iliotibial band. Journal of Chiropractic Medicine 2003; number 1, volume 2; 37-40.

2. Noble CA. The Treatment of Iliotibial Band Friction Syndrome. Brit. J. Sports Med 1979;13;51-54

3. Rosenthal MD. Clinical Testing for Extra-Articular Lateral Knee Pain. A Modification and Combination of Traditional Tests. North American Journal of Sports Physical Therapy 2008; volume 3, number 2:107-109

4. Dubin J. Evidence Based Treatment for Iliotibial Band Friction Syndrome: Review of Literature.Biomechanics August 2005

5. SieunNarine-McKay J. Evaluation of outcomes in assessment of iliotibial band syndrome rehabilitation programs (Doctoral dissertation, University of British Columbia.)

6. Knee Orthopaedic Test - A Strategic Approach to Assessing the Knee; University of Western States, College of Chiropractic, Clinic Protocol; Renne; Page No.34; Adopted 12/12.