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Stensdotter AK, Schelin L, Häger CK. Whole-body kinematics of squats two decades following anterior cruciate ligament injury. J Electromyogr Kinesiol 2024; 76:102870. [PMID: 38507930 DOI: 10.1016/j.jelekin.2024.102870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 02/22/2024] [Accepted: 03/02/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Kinematic studies suggest that injury of the anterior cruciate ligament (ACL) leads to long-lasting movement deficits or compensations to unload the injured knee. This study evaluated lower body kinematics during squats in individuals who suffered unilateral ACL-injury more than 20 years ago. METHOD Using motion capture, we compared maximum squat depth, time to complete the squat task, detailed kinematics, estimated kinetic-chain joint moments 0- 80° knee flexion, and weight distribution between legs across three groups with (ACLR, n = 27) and without ACL-reconstructive surgery (ACLPT, physiotherapy only, n = 28), and age-matched non-injured asymptomatic Controls (n = 31, average age across groups 47 years). RESULTS ACLPT demonstrated significantly reduced squat depth compared to Controls (p = 0.004), whereas ACLR performed similarly to Controls (p = 1.000). Other outcome variables were comparable between groups. All participants nevertheless demonstrated asymmetric weight distribution between legs but without systematic unloading of the injured side in the ACLgroups. CONCLUSION Expected compensatory strategies were not found in the ACL-groups, while poorer squat performance in the ACL-deficient group may depend on pure knee-joint mechanics, or lifestyle factors attributed to a less stable knee decades after ACL-injury.
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Affiliation(s)
- Ann-Katrin Stensdotter
- Faculty of Medicine and Health Sciences, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Community Medicine and Rehabilitation; Physiotherapy, Umeå University, Umeå, Sweden
| | - Lina Schelin
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Charlotte K Häger
- Department of Community Medicine and Rehabilitation; Physiotherapy, Umeå University, Umeå, Sweden.
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Kim H, Kipp K. Chronic ankle instability affects the association between knee joint angle and loading: musculoskeletal simulation study. Comput Methods Biomech Biomed Engin 2024:1-10. [PMID: 38469862 DOI: 10.1080/10255842.2024.2327632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Abstract
The purpose of this study was to calculate and compare (1) knee loads, (2) muscle-specific contributions to knee loads, and (3) effects of knee flexion angle on knee loads and muscle-specific load contributions during a forward jump-landing task in people with and without chronic ankle instability (CAI). Eight CAI patients and seven healthy controls performed a forward jump-landing task. We collected 3D kinematics, ground reaction force, and muscle activation and used musculoskeletal modeling. The results showed that only healthy controls exhibited an association between knee flexion angle and knee compressive impulse (r = 0.854, p = .014). The lack of association in CAI group may lead to knee instability and increase knee injury risk in people with CAI.
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Affiliation(s)
- Hoon Kim
- Department of Sports Medicine, Soonchunhyang University, Asan, South Korea
- Department of Software Convergence, Graduate School, Soonchunhyang University, Asan, South Korea
| | - Kristof Kipp
- Department of Physical Therapy - Program in Exercise Science, Marquette University, Milwaukee, USA
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Llurda-Almuzara L, Canet-Vintró M, López-de-Celis C, Perez-Bellmunt A, Labata-Lezaun N, Aiguadé-Aiguadé R, Rodriguez-Sanz J. Relationship Between Knee Frontal Plane Projection Angle and Lower Limb Muscle Activity in Female Athletes. J Sport Rehabil 2024; 33:166-173. [PMID: 38340711 DOI: 10.1123/jsr.2023-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/24/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
CONTEXT Anterior cruciate ligament injuries are directly related to the control of dynamic knee valgus in the landing of a jump, and this is mainly due to the correct activation and neuromuscular function of the lower-extremity muscles. The aim of the study is to assess the relationship between lower limb muscle activity during a single-legged drop jump and knee frontal plane projection angle (FPPA). DESIGN A correlation study. METHODS Thirty healthy collegiate female athletes were included in the study. Main outcomes measures were peak knee FPPA and muscle activity (% of maximal voluntary isometric contraction). Peak knee FPPA during a single-legged drop jump test was identified using a 2-dimensional motion analysis system. Muscle activity was assessed using a surface electromyograph for gluteus maximus, gluteus medius, biceps femoris, semitendinosus, vastus medialis quadriceps, vastus lateralis quadriceps, medial gastrocnemius, and lateral gastrocnemius. All variables were assessed for both dominant and nondominant limbs. A correlation analysis between peak knee FPPA and muscle activity was performed. Statistical significance was set at P <.05. RESULTS A mean peak knee FPPA of 14.52° and 13.38° was identified for dominant and nondominant limb single-legged drop jump test, respectively. Muscle activity (% of maximal voluntary isometric contraction) for muscles assessed ranged from 43.97% to 195.71% during the single-legged drop jump test. The correlation analysis found no significant correlation between any of the muscles assessed and peak knee FPPA during the single-legged drop jump test (Pearson coefficient between -.3 and .1). CONCLUSIONS There is no association between muscle activity from the lower limb muscles and the knee FPPA during a single-legged drop jump in female athletes. Thus, different muscle properties should be assessed in order to understand such an important movement as the knee FPPA during a jump.
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Affiliation(s)
- Luis Llurda-Almuzara
- Physiotherapy Department, Faculty of Health Sciences, Universidad Euneiz, Vitoria-Gasteiz, Álava, Spain
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
| | - Max Canet-Vintró
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
- Anatomy Unit, Basic Sciences Department, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
| | - Carlos López-de-Celis
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
- Physiotherapy Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
| | - Albert Perez-Bellmunt
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
- Anatomy Unit, Basic Sciences Department, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
| | - Noé Labata-Lezaun
- Physiotherapy Department, Faculty of Health Sciences, Universidad Euneiz, Vitoria-Gasteiz, Álava, Spain
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
| | - Ramón Aiguadé-Aiguadé
- Health Care Research Group (GRECS), Biomedical Research Institute of Lleida, St. Lleida, Spain
- Nursing and Physiotherapy Department, University of Lleida, St. Lleida, Spain
| | - Jacobo Rodriguez-Sanz
- ACTIUM Functional Anatomy Group, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
- Anatomy Unit, Basic Sciences Department, Universitat Internacional de Catalunya, Sant Cugat, Barcelona, Spain
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Morooka T, Yoshiya S, Tsukagoshi R, Kawaguchi K, Fujioka H, Onishi S, Nakayama H, Nagura T, Tachibana T, Iseki T. Evaluation of the Anterior Cruciate Ligament Injury Risk During a Jump-Landing Task Using 3-Dimensional Kinematic Analysis Versus the Landing Error Scoring System. Orthop J Sports Med 2023; 11:23259671231211244. [PMID: 38021305 PMCID: PMC10664432 DOI: 10.1177/23259671231211244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background The Landing Error Scoring System (LESS) has been utilized on the field or in the clinic to identify patients with an increased risk for anterior cruciate ligament (ACL) injuries; however, its validity and efficacy have not been fully confirmed. Purpose To assess the efficacy of the LESS in identifying the ACL injury risk by examining the correlation between the LESS score and motion patterns on 3-dimensional kinematic analysis. Study Design Controlled laboratory study. Methods The jump-landing motion was analyzed for 16 female basketball or badminton players who volunteered to participate in the study. All study participants were aged 19 or 20 years. The sequence of motion was evaluated with the LESS, while kinematic data were simultaneously acquired with a 3-dimensional motion analysis system utilizing the point cluster method. The correlation between the LESS score and knee kinematics was statistically analyzed. Results When a LESS score ≥6 was defined to be a risk factor for ACL injuries, 7 of the 16 participants (43.8%) were found to exhibit risky motion patterns. Significant correlations were noted between the LESS score and knee valgus (r = 0.87; P < .0001) and internal tibial rotation (r = 0.57; P = .02) at landing. By contrast, a substantial variability was present in knee flexion, showing no correlation with the LESS score. Conclusion Significant correlations were found between the LESS score and knee valgus and internal tibial rotation during a jump-landing task. Clinical Relevance The LESS can be regarded as an effective measure to identify risky motion patterns that may increase the likelihood of ACL injuries.
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Affiliation(s)
- Takatoshi Morooka
- Department of Orthopaedic Surgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Japan
| | - Rui Tsukagoshi
- Department of Physical Therapy, School of Rehabilitation, Hyogo Medical University, Kobe, Japan
| | - Kotaro Kawaguchi
- Department of Physical Therapy, School of Rehabilitation, Hyogo Medical University, Kobe, Japan
| | - Hiroyuki Fujioka
- Department of Orthopaedic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Shintaro Onishi
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Japan
| | - Hiroshi Nakayama
- Department of Orthopaedic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Takeo Nagura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo Medical University, Nishinomiya, Japan
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Matsumura U, Tsurusaki T, Ogusu R, Yamamoto S, Lee Y, Sunagawa S, Reid WD, Koseki H. The interrelationship between lower limb movement, muscle activity, and joint moment during half squat and gait. Heliyon 2023; 9:e21762. [PMID: 38028012 PMCID: PMC10651501 DOI: 10.1016/j.heliyon.2023.e21762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Joint moment is the resultant force of limb movements. However, estimation methods for joint moments using surface electromyography frequently use joint angles instead of limb angles. The limb angle in joint moment estimation using electromyography could clarify the effects of muscle activity on the limbs: acceleration, deceleration, or stabilization. No study has quantified the comprehensive relationship between limb movement, muscle activity, and joint moment. This study aimed to determine the influencing factors for ankle-joint moment and knee-joint moment in the sagittal plane among muscle activities and parameters related to limb movements during half squat and gait. This study included 29 healthy adults (16 female participants, 21.1 ± 2.09 years). Using inertial measurement units, thigh, shank, and foot inclination angles and angular accelerations were calculated as the parameters of limb movements. Muscle activations of the biceps femoris long head, rectus femoris, gastrocnemius, and tibialis anterior were measured. Ankle joint moment and knee-joint moment were measured using a three-dimensional motion capture system and two force plates. Regression models showed high accuracy in measuring ankle-joint moment during a half squat and gait (R2f = 0.92, 0.97, respectively) and knee-joint moment during a half squat (R2f = 0.98), but not knee-joint moment during gait (R2f = 0.63). However, only a maximum of five parameters were selected from muscle activities and limb angular information. Tibialis anterior and gastrocnemius activity were the largest contributors to ankle-joint moment during a half squat and gait, respectively, while muscle activities were not directly reflected in the knee-joint moment during either movement. Consideration of the interrelationships among limb movement, muscle activity, and joint moment is required when adjusting joint movements according to the target and aim of the therapeutic interventions.
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Affiliation(s)
- Umi Matsumura
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshiya Tsurusaki
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Rena Ogusu
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shimpei Yamamoto
- Department of Rehabilitation, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yeonghee Lee
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinya Sunagawa
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Rehabilitation, Wajinkai Hospital, Nagasaki, Japan
| | - W Darlene Reid
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Hironobu Koseki
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Forman DA, Alizadeh S, Button DC, Holmes MW. The Use of Elastic Resistance Bands to Reduce Dynamic Knee Valgus in Squat-Based Movements: A Narrative Review. Int J Sports Phys Ther 2023; 18:1206-1217. [PMID: 37795322 PMCID: PMC10547095 DOI: 10.26603/001c.87764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/17/2023] [Indexed: 10/06/2023] Open
Abstract
An elastic band wrapped around the distal thighs has recently been proposed as a method for reducing dynamic knee valgus (medial movement of the knee joint in the frontal/coronal plane) while performing squats. The rationale behind this technique is that, by using an external force to pull the knees into further knee valgus, the band both exaggerates the pre-existing movement and provides additional local proprioceptive input, cueing individuals to adjust their knee alignment. If these mechanisms are true, then elastic bands might indeed reduce dynamic knee valgus, which could be promising for use in injury prevention as excessive knee valgus may be associated with a greater risk of sustaining an ACL rupture and/or other knee injuries. Due to this possibility, certain athletic populations have already adopted the use of elastic bands for training and/or rehab, despite a limited number of studies showing beneficial findings. The purpose of this narrative review is to examine current literature that has assessed lower limb muscle activity and/or lower limb kinematics performance on squat-based movements with or without an elastic band(s). Importantly, this paper will also discuss the key limitations that exist in this area, propose suggestions for future research directions, and provide recommendations for training implementations. Level of Evidence 5.
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Affiliation(s)
| | - Shahab Alizadeh
- School of Human Kinetics and Recreation Memorial University of Newfoundland
| | - Duane C Button
- School of Human Kinetics and Recreation Memorial University of Newfoundland
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Nascimento MB, Vilarinho LG, Lobato DFM, Dionisio VC. Role of gluteus maximus and medius activation in the lower limb biomechanical control during functional single-leg Tasks: A systematic review. Knee 2023; 43:163-175. [PMID: 37422984 DOI: 10.1016/j.knee.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/30/2023] [Accepted: 05/12/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Single-leg (SL) tasks are included as assessment and intervention strategies in several dysfunctions due to the inherent motor control requirement. The recruitment of gluteus maximus (GMAX) and medius (GMED) muscles is essential for proper biomechanical control of the knee and hip joints. The study aims to identify the role of gluteal activation in the biomechanical control of the lower limb during SL tasks. METHODS This is a systematic review with searches performed in Pubmed, CINAHL, MEDLINE, Web of Science, and Sportdiscus databases. Cross-sectional studies carried out with asymptomatic individuals were selected, containing hip and knee kinematic and kinetic outcomes assessed through 3D or 2D movement analysis and EMG activity of GMED and GMAX muscles. Two independent reviewers performed the procedures to select the studies, determine the methodological quality and extract the data. RESULTS The initial search resulted in 391 studies, and after the assessment procedures, 11 studies were included. Lower GMAX activation was associated with greater hip internal rotation (HIR) excursion and greater HIR moment, and lower GMED activation was associated with greater hip adduction (HAD)/knee abduction (KAB) excursions and greater KAB moment during single-leg squat (SLS). CONCLUSIONS The SL tasks showed a relevant association between the gluteal EMG and other biomechanical outcomes, mainly the SLS task. Interpretation must be cautious, as most studies present high and moderate methodological quality, especially on kinetic data.
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Affiliation(s)
- Matheus Batista Nascimento
- Federal University of Uberlândia - UFU, Faculty of Physical Education and Physiotherapy- FAEFI, Uberlândia, Minas Gerais, Brazil.
| | - Lucas Gois Vilarinho
- Federal University of Uberlândia - UFU, Faculty of Physical Education and Physiotherapy- FAEFI, Uberlândia, Minas Gerais, Brazil
| | | | - Valdeci Carlos Dionisio
- Federal University of Uberlândia - UFU, Faculty of Physical Education and Physiotherapy- FAEFI, Uberlândia, Minas Gerais, Brazil
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Louder T, Thompson BJ, Woster A, Bressel E. Kinetics of Depth Jumps Performed by Female and Male National Collegiate Athletics Association Basketball Athletes and Young Adults. J Funct Morphol Kinesiol 2023; 8:108. [PMID: 37606403 PMCID: PMC10443298 DOI: 10.3390/jfmk8030108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/07/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023] Open
Abstract
The depth jump (DJ) is commonly used to evaluate athletic ability, and has further application in rehabilitation and injury prevention. There is limited research exploring sex-based differences in DJ ground reaction force (GRF) measures. This study aimed to evaluate for sex-based differences in DJ GRF measures and determine sample size thresholds for binary classification of sex. Forty-seven participants from mixed-sex samples of NCAA athletes and young adults performed DJs from various drop heights. Force platform dynamometry and 2-dimensional videography were used to estimate GRF measures. Three-way mixed analysis of variance was used to evaluate main effects and interactions. Receiver operating characteristic (ROC) curve analysis was used to evaluate the combined sensitivity and specificity of dependent measures to sex. Results revealed that reactive strength index scores and rebound jump heights were greater in males than females (p < 0.001). Additionally, young adult females showed greater peak force reduction than young adult males (p = 0.002). ROC curve analysis revealed mixed results that appeared to be influenced by population characteristics and drop height. In conclusion, sex-based differences in DJ performance were observed, and the results of this study provide direction for future DJ investigations.
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Affiliation(s)
- Talin Louder
- Department of Kinesiology and Health Science, Utah State University, Logan, UT 84322, USA; (B.J.T.); (E.B.)
- Dennis G. Dolny Movement Research Clinic, Sorenson Legacy Foundation Center for Clinical Excellence, Utah State University, Logan, UT 84322, USA
| | - Brennan J. Thompson
- Department of Kinesiology and Health Science, Utah State University, Logan, UT 84322, USA; (B.J.T.); (E.B.)
- Dennis G. Dolny Movement Research Clinic, Sorenson Legacy Foundation Center for Clinical Excellence, Utah State University, Logan, UT 84322, USA
| | - Alex Woster
- Department of Kinesiology and Health Science, Utah State University, Logan, UT 84322, USA; (B.J.T.); (E.B.)
| | - Eadric Bressel
- Department of Kinesiology and Health Science, Utah State University, Logan, UT 84322, USA; (B.J.T.); (E.B.)
- Dennis G. Dolny Movement Research Clinic, Sorenson Legacy Foundation Center for Clinical Excellence, Utah State University, Logan, UT 84322, USA
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Karimi K, Seidi F, Mousavi SH, Alghosi M, Morad NH. Comparison of postural sway in individuals with and without dynamic knee valgus. BMC Sports Sci Med Rehabil 2023; 15:75. [PMID: 37400853 DOI: 10.1186/s13102-023-00686-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Dynamic knee valgus (DKV) is a multi-planar faulty movement pattern that can cause faulty postural control. The primary objective of this study is to investigate the differences in postural sway (PS) between individuals aged 18-30 years old diagnosed with and without DKV. METHODS In this cross-sectional study, 62 students (39 males and 23 females) with and without DKV (age: 24.58 ± 2.63 years) were selected and assigned to two groups by conducting the single-leg squat test in the screening stage. The Biodex balance system was then employed to compare the two groups in PS. Mann-Whitney U test was conducted to compare the groups in PS (p ≤ 0.05). RESULTS The study's findings indicate that individuals with DKV did not exhibit any significant differences, compared to those without, about the anterior-posterior stability index (with p values for both static and dynamic situations at 0.309 and 0.198, respectively), medial-lateral stability index (with p values for both static and dynamic situations at 0.883 and 0.500, respectively), and overall stability index (with p values for both static and dynamic situations at 0.277 and 0.086, respectively). CONCLUSION Though several possible factors could contribute to the lack of significant differences in postural sway between individuals with and without DKV, such as measurement tool differences, variable sensitivity in postural stability tests, and differences in movement variability and test stance, we recommend analyzing postural sway in more functional tasks and with different methodological patterns in future studies. Such research could help develop targeted interventions for individuals with DKV and offer a better understanding of the relationship between postural control and DKV.
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Affiliation(s)
- Kimia Karimi
- Department of Health and Sports Medicine, Faculty of Sports Sciences and Health, University of Tehran, Tehran, Iran
| | - Foad Seidi
- Department of Health and Sports Medicine, Faculty of Sports Sciences and Health, University of Tehran, Tehran, Iran.
| | - Seyed Hamed Mousavi
- Department of Health and Sports Medicine, Faculty of Sports Sciences and Health, University of Tehran, Tehran, Iran
| | - Mohammad Alghosi
- Department of Health and Sports Medicine, Faculty of Sports Sciences and Health, University of Tehran, Tehran, Iran
| | - Nafiseh Homaie Morad
- Department of Health and Sports Medicine, Faculty of Sports Sciences and Health, University of Tehran, Tehran, Iran
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Behm DG, Alizadeh S, Daneshjoo A, Konrad A. Potential Effects of Dynamic Stretching on Injury Incidence of Athletes: A Narrative Review of Risk Factors. Sports Med 2023; 53:1359-1373. [PMID: 37162736 PMCID: PMC10289929 DOI: 10.1007/s40279-023-01847-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 05/11/2023]
Abstract
The use of dynamic stretching as a replacement for static stretching in the warm-up is widespread based on the reports of static stretching-induced performance impairments. While acute and chronic static stretching has been reported to reduce musculotendinous injuries, especially with explosive and change of direction actions, the influence of dynamic stretching on injury incidence lacks a similar volume of literature for acute and chronic responses. It was the objective of this narrative review to examine the acute and training effects of dynamic stretching on injury incidence and possible moderating variables such as dynamic stretching effects on range of motion, strength, balance, proprioception, muscle morphology, and psycho-physiological responses. One study demonstrated no significant difference regarding injury incidence when comparing a dynamic stretching-only group versus a combined dynamic stretching plus static stretching group. The only other study examined functional dynamic stretching training with injured dancers and reported improved ankle joint stability. However, several studies have shown that dynamic activity with some dynamic stretching exercises within a warm-up consistently demonstrates positive effects on injury incidence. Regarding moderating variables, while there is evidence that an acute bout of dynamic stretching can enhance range of motion, the acute and training effects of dynamic stretching on strength, balance, proprioception, and musculotendinous stiffness/compliance are less clear. The acute effects of dynamic stretching on thixotropic effects and psycho-physiological responses could be beneficial for injury reduction. However, the overall conflicting studies and a lack of substantial literature compared with SS effects points to a need for more extensive studies in this area.
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Affiliation(s)
- David G. Behm
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7 Canada
| | - Shahab Alizadeh
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7 Canada
| | - Abdolhamid Daneshjoo
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7 Canada
- Department of Sport Injuries and Corrective Exercises, Faculty of Sport Sciences, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Andreas Konrad
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7 Canada
- Institute of Human Movement Science, Sport and Health, Graz University, Graz, Austria
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Asymmetries in Two-Dimensional Trunk and Knee Kinematics During a Single-Leg Drop Landing Post Anterior Cruciate Ligament Reconstruction. INTERNATIONAL JOURNAL OF ATHLETIC THERAPY AND TRAINING 2023. [DOI: 10.1123/ijatt.2021-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The purpose of this study was to compare interlimb asymmetries in trunk and knee kinematics during a single-leg drop landing between athletes 9 months post anterior cruciate ligament reconstruction (post-ACLR) and healthy athletes using two-dimensional analysis. Thirty-three recreational athletes (12 post-ACLR and 21 healthy) participated in the study. Participants post-ACLR showed significantly higher limb symmetry indices in peak trunk flexion (144.0%, SE drop landing kinematics: 22.7%) when compared to healthy participants (100.6%, SE: 10.5%; z = 2.17, p = .03) and lower limb symmetry indices in peak knee flexion (85.3%, SE: 3.6%) when compared to healthy participants (98.0%, SE: 3.3%; z = −2.43, p = .01). Two-dimensional analyses of a single-leg drop landing is a clinically applicable tool that can identify interlimb asymmetries in peak trunk flexion and peak knee flexion kinematics in athletes greater than 9 months post-ACLR when compared to healthy athletes.
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GUBLER C, PRICE T, WALDHELM A. The effect of adding a tuck to the drop vertical jump test in collegiate soccer players. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.21.04706-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Vico-Moreno E, Sastre-Munar A, Fernández-Domínguez JC, Romero-Franco N. Motor Control and Regularity of Menstrual Cycle in Ankle and Knee Injuries of Female Basketball Players: A Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14357. [PMID: 36361236 PMCID: PMC9654706 DOI: 10.3390/ijerph192114357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
Inadequate motor control facilitates ankle and knee injuries in female basketball. Although biomechanical analysis could help to detect it, aspects such as irregular menstruation make these associations controversial. We aimed to evaluate associations between 2D biomechanics during landing and proprioception with ankle and knee injuries of female basketball players, considering their menstruation regularity. Seventy-one players participated in this study. In the preseason, participants performed a drop-jump to obtain biomechanics during landing and a weight-bearing proprioception test. During the competitive season, all the non-contact ankle and knee injuries were registered. Data showed that 16% of players sustained an ankle or knee injury, being more frequent in players with irregular menstruation compared to regulars (22% vs. 13%, χ2 = 6.009, p = 0.050, d = 0.6). Players who sustained a left-side injury displayed higher left-side dynamic valgus during landing than uninjured players (χ2 = 25.88, p = 0.006, d = 1.5). The rest of the variables did not show any significant difference (p > 0.05). Monitoring 2D dynamic valgus from a drop-jump could help to detect inadequate motor control that may facilitate ankle or knee injuries of female basketball players, mainly for those with irregular menstruation. Proprioception seems not to be related to injuries.
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Affiliation(s)
- Elena Vico-Moreno
- Nursing and Physiotherapy Department, University of the Balearic Islands, E-07122 Palma de Mallorca, Spain
| | - Andreu Sastre-Munar
- Nursing and Physiotherapy Department, University of the Balearic Islands, E-07122 Palma de Mallorca, Spain
- Sport High Performance Centre of Balearic Islands, E-07009 Palma de Mallorca, Spain
| | - Juan Carlos Fernández-Domínguez
- Nursing and Physiotherapy Department, University of the Balearic Islands, E-07122 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), E-07120 Palma de Mallorca, Spain
| | - Natalia Romero-Franco
- Nursing and Physiotherapy Department, University of the Balearic Islands, E-07122 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), E-07120 Palma de Mallorca, Spain
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14
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Strutzenberger G, David S, Borcard LM, Fröhlich S, Imhoff FB, Scherr J, Spörri J. Breaking new grounds in injury risk screening in soccer by deploying unsupervised learning with a special focus on sex and fatigue effects. Sports Biomech 2022:1-17. [PMID: 36004395 DOI: 10.1080/14763141.2022.2112748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
In injury prevention, a vertical drop jump (DJ) is often used for screening athletes at risk for injury; however, the large variation in individual movement patterns might mask potentially relevant strategies when analysed on a group-based level. Two movement strategies are commonly discussed as predisposing athletes to ACL injuries: a deficient leg axis and increased leg stiffness during landing. This study investigated the individual movement pattern of 39 female and male competitive soccer players performing DJs at rest and after being fatigued. The joint angles were used to train a Kohonen self-organising map. Out of 19,596 input vectors, the SOM identified 700 unique postures. Visualising the movement trajectories and adding the latent parameters contact time, medial knee displacement (MKD) and knee abduction moment allow identification of zones with presumably increased injury risk and whether the individual movement patterns pass these zones. This information can be used, e.g., for individual screening and for feedback purposes. Additionally, an athlete's reaction to fatigue can be explored by comparing the rested and fatigued movement trajectories. The results highlight the ability of unsupervised learning to visualise movement patterns and to give further insight into an individual athlete's status without the necessity of a priori assumptions.
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Affiliation(s)
- Gerda Strutzenberger
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedics, Balgrist University Hospital, University Centre for Prevention and Sports Medicine, University of Zurich, Zurich, Switzerland
- Motion Analysis Zurich, Department of Orthopaedics, Balgrist University Hospital, Children's Hospital, University of Zurich, Zurich, Switzerland
- UMIT Tirol, Psychology and Medical Sciences, Research Unit Sports Medicine, Innsbruck, Hall in Tirol, Austria
| | - Sina David
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, HV Amsterdam, The Netherlands
| | - Lana Mei Borcard
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Fröhlich
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedics, Balgrist University Hospital, University Centre for Prevention and Sports Medicine, University of Zurich, Zurich, Switzerland
| | - Florian B Imhoff
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Johannes Scherr
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedics, Balgrist University Hospital, University Centre for Prevention and Sports Medicine, University of Zurich, Zurich, Switzerland
- Motion Analysis Zurich, Department of Orthopaedics, Balgrist University Hospital, Children's Hospital, University of Zurich, Zurich, Switzerland
| | - Jörg Spörri
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedics, Balgrist University Hospital, University Centre for Prevention and Sports Medicine, University of Zurich, Zurich, Switzerland
- Motion Analysis Zurich, Department of Orthopaedics, Balgrist University Hospital, Children's Hospital, University of Zurich, Zurich, Switzerland
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15
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Collings TJ, Diamond LE, Barrett RS, Timmins RG, Hickey JT, DU Moulin WS, Williams MD, Beerworth KA, Bourne MN. Strength and Biomechanical Risk Factors for Noncontact ACL Injury in Elite Female Footballers: A Prospective Study. Med Sci Sports Exerc 2022; 54:1242-1251. [PMID: 35320148 DOI: 10.1249/mss.0000000000002908] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to determine if a preseason field-based test battery was prospectively associated with noncontact anterior cruciate ligament (ACL) injury in elite female footballers. METHODS In total, 322 elite senior and junior female Australian Rules Football and soccer players had their isometric hip adductor and abductor strength, eccentric knee flexor strength, countermovement jump (CMJ) kinetics, and single-leg hop kinematics assessed during the 2019 preseason. Demographic and injury history details were also collected. Footballers were subsequently followed for 18 months for ACL injury. RESULTS Fifteen noncontact ACL injuries occurred during the follow-up period. Prior ACL injury (odds ratio [OR], 9.68; 95% confidence interval (95% CI), 2.67-31.46), a lower isometric hip adductor to abductor strength ratio (OR, 1.98; 95% CI, 1.09-3.61), greater CMJ peak take-off force (OR, 1.74; 95% CI, 1.09-3.61), and greater single-leg triple vertical hop average dynamic knee valgus (OR, 1.97; 95% CI, 1.06-3.63) and ipsilateral trunk flexion (OR, 1.60; 95% CI, 1.01-2.55) were independently associated with an increased risk of subsequent ACL injury. A multivariable prediction model consisting of CMJ peak take-off force, dynamic knee valgus, and ACL injury history that was internally validated classified ACL injured from uninjured footballers with 78% total accuracy. Between-leg asymmetry in lower limb strength and CMJ kinetics were not associated with subsequent ACL injury risk. CONCLUSIONS Preseason field-based measures of lower limb muscle strength and biomechanics were associated with future noncontact ACL injury in elite female footballers. These risk factors can be used to guide ACL injury screening practices and inform the design of targeted injury prevention training in elite female footballers.
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Affiliation(s)
| | | | | | | | | | | | - Morgan D Williams
- School of Health, Sport and Professional Practice, Faculty of Life Sciences and Education, University of South Wales, Wales, UNITED KINGDOM
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16
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Nakahira Y, Taketomi S, Kawaguchi K, Mizutani Y, Hasegawa M, Ito C, Uchiyama E, Ikegami Y, Fujiwara S, Yamamoto K, Nakamura Y, Tanaka S, Ogata T. Kinematic Differences Between the Dominant and Nondominant Legs During a Single-Leg Drop Vertical Jump in Female Soccer Players. Am J Sports Med 2022; 50:2817-2823. [PMID: 35850117 DOI: 10.1177/03635465221107388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In soccer, the roles of the dominant (kicking) and nondominant (supporting) legs are different. The kinematic differences between the actions of the dominant and nondominant legs in female soccer players are not clear. PURPOSE To clarify the kinematic differences between dominant and nondominant legs during a single-leg drop vertical jump (DVJ) in female soccer players. STUDY DESIGN Controlled laboratory study. METHODS A total of 64 female high school and college soccer players were included in this study. Participants performed a single-leg DVJ test utilizing video motion capture with artificial intelligence during the preseason period. This study assessed the knee flexion angles, knee valgus angles, hip flexion angles, and lower leg anterior inclination angle at 3 time points (initial contact, maximum flexion of the knee, and toe-off) and compared them between the dominant and nondominant legs. These angles were calculated from motion capture data and analyzed in 3 dimensions. A paired t test was used to analyze the differences between legs, and the significance level was set at P < .05. RESULTS The knee valgus angle at initial contact was greater in the nondominant leg (mean ± SD, 0.8°± 5.2°) than the dominant leg (-0.9°± 4.9°) (P < .01). There were no differences between legs for any other angles at any of the time points. CONCLUSION The kinematics of the dominant and nondominant legs of female soccer players in a single-leg DVJ differ in knee valgus angle. CLINICAL RELEVANCE Leg dominance is associated with the risk of sports injuries. Kinematic differences between the dominant and nondominant legs may be a noteworthy factor in elucidating the mechanisms and risk of sports injury associated with leg dominance.
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Affiliation(s)
- Yu Nakahira
- Department of Rehabilitation Medicine, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Taketomi
- Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan; Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kohei Kawaguchi
- Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan; Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuri Mizutani
- Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan
| | - Masato Hasegawa
- Department of Rehabilitation Medicine, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chie Ito
- Department of Rehabilitation Medicine, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Emiko Uchiyama
- The Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yosuke Ikegami
- The Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Sayaka Fujiwara
- Department of Rehabilitation Medicine, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ko Yamamoto
- Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan; The Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yoshihiko Nakamura
- Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan; The Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Ogata
- Department of Rehabilitation Medicine, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; Tokyo Sports Science Initiative, The University of Tokyo, Tokyo, Japan.,Investigation performed at The University of Tokyo, Tokyo, Japan
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17
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Semjonova G, Davidovica A, Kozlovskis N, Okss A, Katashevs A. Smart Textile Sock System for Athletes’ Self-Correction during Functional Tasks: Formative Usability Evaluation. SENSORS 2022; 22:s22134779. [PMID: 35808274 PMCID: PMC9268753 DOI: 10.3390/s22134779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 11/24/2022]
Abstract
(1) Background: The development of a lightweight, easy-to-use system that measures the foot’s plantar pressure is becoming an increasingly important area of research in physiotherapy. For further development of the smart sock system, a formative usability study was conducted, where the smart textile sock sensor system was used for self-correction during functional tasks; (2) Methods: Five athletes from the football school participated in the formative usability study. Athletes performed pre-defined functional tasks for self-correction when interacting with the smart textile sock system. Formative usability evaluation methods: effectiveness (task success rate, error rate), efficiency (time-based), satisfaction evaluated by System Usability Scale (SUS); (3) Results: Formative usability indicators: task completeness effectiveness ranged from 40% to 100% in the first- and second-stage tasks. Completed task efficiency time: Stage 1, from 4.2 s (SD 1.3) to 88.8 s (SD 19.8); Stage 2, from 7.2 s (SD 1.9) to 9.6 s (SD 2.1). Satisfaction was assessed by the SUS system user group with 76 points (SD 7.42), which indicates “good” satisfaction; (4) Conclusions: formative usability indicators showed the need for technical improvements to the smart textile sock pressure sensor system. The SUS results indicate “good” satisfaction with the smart textile sock pressure sensor system and its application.
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Affiliation(s)
- Guna Semjonova
- Department of Rehabilitation, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia;
- Correspondence:
| | - Anna Davidovica
- Department of Rehabilitation, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia;
| | - Nikita Kozlovskis
- Institute of Applied Computer Systems, Riga Technical University, LV-1658 Riga, Latvia;
| | - Aleksandrs Okss
- Institute of Design Technologies, Riga Technical University, LV-1048 Riga, Latvia;
| | - Aleksejs Katashevs
- Institute of Biomedical Engineering and Nanotechnology, Riga Technical University, LV-1048 Riga, Latvia;
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18
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Effects of Patellofemoral Pain Syndrome on Changes in Dynamic Postural Stability during Landing in Adult Women. Appl Bionics Biomech 2022; 2022:7452229. [PMID: 35592870 PMCID: PMC9113904 DOI: 10.1155/2022/7452229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/07/2022] [Accepted: 04/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background This study investigated the effects of lower limb movements on dynamic postural stability (DPS) during drop landing in adult women with patellofemoral pain syndrome (PFPS). Methods Thirty-eight adult women were recruited and divided into two groups, the PFPS group and the control group. The study participants performed a single-leg drop landing from a 30 cm box, and their lower limb movements and DPS were measured. Differences between groups were examined using independent sample t-tests. In addition, stepwise multiple linear regression was used to examine the kinematic parameters that contribute to the DPS. Results The PFPS group had significantly lower hip flexion, internal rotation, knee flexion, ankle external rotation, pelvic oblique, tilt, rotation, and higher hip abduction, knee valgus, and ankle plantarflexion. In terms of DPS, the PFPS group had a significantly higher anteroposterior and a lower mediolateral than that of the control group. In the control group, regression analysis revealed a controlled anteroposterior using knee flexion, while the PFPS group controlled mediolateral through ankle plantarflexion. Conclusions Patients with PFPS experienced more shock on their knee joint during landing than patients in the control group with greater anteroposterior instability and lower mediolateral instability.
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19
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Editorial Commentary: Osseous Anatomy of the Knee in Female Patients is a Significant Risk Factor for Anterior Cruciate Ligament Injury and Anterior Cruciate Ligament Graft Failure. Arthroscopy 2022; 38:1605-1607. [PMID: 35501024 DOI: 10.1016/j.arthro.2021.11.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 02/02/2023]
Abstract
Risk for anterior cruciate ligament (ACL) injury is greater in female than in male patients for a myriad of reasons, with osseous anatomy about the knee proving to be one significant risk factor for ACL injury and/or ACL graft failure. While femoral intercondylar notch size/shape and posterior tibial slope have been well-examined in this regard for their contribution to potential ACL injury, morphology of the lateral femoral condyle is a newer entity that may be linked to risk for ACL injury. Smaller/stenotic femoral intercondylar notches, increased posterior tibial slope of the lateral tibial plateau, and increased posterior condylar depth of the lateral femoral condyle have all been shown to increase risk for ACL injury and/or ACL graft failure. Such associations provide knee surgeons with food for thought when considering procedures such as notchplasty, staged anterior closing wedge high tibial osteotomy, and anterolateral ligament reconstruction/augmentation at the time of primary or revision ACL reconstruction. Further investigation into the links between pre-operative imaging parameters and outcomes following such concomitant procedures is required in order for any significant conclusions to be drawn.
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20
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Jeon N, Choi NH, Hwangbo BH, Victoroff BN. An Increased Lateral Femoral Condyle Ratio in Addition to Increased Posterior Tibial Slope and Narrower Notch Index Is a Risk Factor for Female Anterior Cruciate Ligament Injury. Arthroscopy 2022; 38:1597-1604. [PMID: 34710572 DOI: 10.1016/j.arthro.2021.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/08/2021] [Accepted: 10/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the relationship between the lateral femoral condyle ratio (LFCR) among osseous morphologic characteristics of the knee and anterior cruciate ligament (ACL) injury in female patients. METHODS Inclusion criteria were female patients (ACL group, n = 59) undergoing primary ACL reconstruction from 2012 to 2018. Control female patients (control group, n = 58) were matched by age, height, and body mass index to ACL group. They had no meniscal or ligament tear, and no trochlear dysplasia on magnetic resonance imaging. The LFCR, notch width index (NWI), and posterior tibial slope (PTS) were measured and compared between the ACL and control groups. For each risk factor, the receiver operating characteristic curve and the area under the curve and its 95% confidence interval (CI) was calculated to determine the cutoff for detecting increased risk of ACL injury. RESULTS The LFCR was significantly larger in the knees in the ACL group than in the control group (P = .001). The NWI was significantly smaller and the PTS was significantly larger in the knees in the ACL group than in the control group (P = .000, P = .000, respectively). The NWI (odds ratio [OR] 1.41; P = .000) was the most significant factor, followed by the PTS (OR 1.29; P = .003) and the LFCR (OR 1.26; P = .001). The area under the curve (0.67, 95% CI 0.58-0.77) for the LFCR had a sensitivity of 66% and specificity of 66% to predict an ACL injury. The cutoff of 63.9 was associated with an increased risk for ACL injury (OR 3.71; 95% CI 1.73-7.95). CONCLUSIONS An increased LFCR was associated with female ACL injury. The LFCR, NWI, and PTS are predictive risk factors for an ACL injury. These findings need to be considered for clinician in identifying female patients at risk for an ACL injury. LEVEL OF EVIDENCE III, retrospective comparative prognostic trial.
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Affiliation(s)
- Neunghan Jeon
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Nam-Hong Choi
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea.
| | - Byung-Hun Hwangbo
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Brian N Victoroff
- Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, Ohio, U.S.A
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21
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Neuromuscular control and hop performance in youth and adult male and female football players. Phys Ther Sport 2022; 55:189-195. [DOI: 10.1016/j.ptsp.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
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22
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Screening Tests for Assessing Athletes at Risk of ACL Injury or Reinjury-A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052864. [PMID: 35270563 PMCID: PMC8910677 DOI: 10.3390/ijerph19052864] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 12/23/2022]
Abstract
Various tests are available to assess athletes for factors associated with their susceptibility and risk of anterior cruciate ligament (ACL) injury or reinjury; however, it is unclear which tests are clinically meaningful and what should be considered when using them. Therefore, the aim of this scoping review was to screen and summarize testing and to derive evidence-based recommendations for clinicians, practitioners and future research. Five databases were searched to identify studies addressing musculoskeletal morphology or functional-performance-related screening tests with a clear conceptual link or an evidence-based relationship to ACL (re)injury. A quality rating was carried out using the National Institutes of Health (NIH) Study-Quality Assessment Tool. Six different categories of common screening tests were identified: balance and postural control, gait- and running-related tests, joint laxity, joint morphology and anthropometrics, jump tests and strength tests. Predicting future injury in a complex, dynamic system based on a single screening test is methodologically challenging, which is also reflected in the highly controversial findings in the literature regarding potential associations between specific screening tests and the occurrence of ACL injuries and reinjuries. Nonetheless, various screening tests can provide clinically relevant information on ACL-(re)injury-related factors and help to provide tailored preventive measures. A selection of corresponding evidence-based recommendations is derived and presented in this scoping review.
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23
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Nishizawa K, Hashimoto T, Hakukawa S, Nagura T, Otani T, Harato K. Effects of foot progression angle on kinematics and kinetics of a cutting movement. J Exp Orthop 2022; 9:11. [PMID: 35041099 PMCID: PMC8766617 DOI: 10.1186/s40634-022-00447-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/07/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Foot progression angle is a key factor for biomechanical knee load, which is associated with noncontact anterior cruciate ligament (ACL) injury during sports-specific tasks. The purpose of the present study was to assess the biomechanics of trunk, pelvis, and lower extremities during a cutting maneuver under different foot progression angles. Methods Nineteen male collegiate athletes (ages 18–24) participated in the present study. Cutting motion was analyzed using eight infrared cameras (250 Hz), two force plates (1250 Hz), and 44 reflective markers. Subjects performed 45-degree side cutting maneuvers under three foot progression angles, including 20 degrees (toe-out: TO), 0 degrees (neutral: TN), and − 20 degrees (toe-in: TI). Peak values of each biomechanical parameters in trunk, pelvis, hip, and knee within a first 40% stance phase and each parameter at the timing of the peak vertical ground reaction force were assessed. A statistical analysis was performed to compare data among the three-foot progression angles using the Friedman test. Results Peak angles of knee abduction, tibial internal rotation, hip internal rotation, and hip adduction were significantly greater for TI position than for TO position (p < 0.01). Peak moments of knee abduction and tibial internal rotation under TI position were also significantly larger than TO position (p < 0.01). Moreover, greater peak pelvis-trunk rotation was found for TI position than for TN and TO positions (p < 0.01). Conclusion From the present study, TI position could lead to an increased risk of ACL injury during a pre-planned cut maneuver, compared to TO position.
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Affiliation(s)
- Kohei Nishizawa
- Graduate School of Health Management, Keio University, 4411 Endo, Fujisawa, Kanagawa, 252-0883, Japan.
| | - Takeshi Hashimoto
- Graduate School of Health Management, Keio University, 4411 Endo, Fujisawa, Kanagawa, 252-0883, Japan.,Sports Medicine Research Center, Keio University, Yokohama, Kanagawa, Japan
| | - Satoshi Hakukawa
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Takeo Nagura
- Department of Clinical Biomechanics, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Toshiro Otani
- International University of Health and Welfare Ichikawa Hospital, Ichikawa, Chiba, Japan
| | - Kengo Harato
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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24
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Peebles AT, Miller TK, Queen RM. Landing biomechanics deficits in anterior cruciate ligament reconstruction patients can be assessed in a non-laboratory setting. J Orthop Res 2022; 40:150-158. [PMID: 33738820 DOI: 10.1002/jor.25039] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 02/04/2023]
Abstract
Landing biomechanics provide important information pertaining to second anterior cruciate ligament (ACL) injury risk in patients following ACL reconstruction (ACLR). While traditional motion analysis technologies are often impractical for use in non-laboratory settings, methods to assess landing biomechanics which are inexpensive, portable, and user-friendly have recently been developed and validated. The purpose of this study was to compare landing kinematics and kinetics between ACLR patients and uninjured controls in a non-laboratory setting. Sixteen ACLR patients (7 male/9 female, 6-12 months post-ACLR) and 16 gender-matched controls completed seven bilateral drop vertical jumps and seven unilateral drop landings on each limb. Plantar force was measured bilaterally using force sensing insoles and frontal and sagittal-plane knee kinematics were measured using two tablets, six reflective markers, and automated point tracking software. Plantar force impulse normalized symmetry index (NSI) and knee frontal plane projection angle (FPPA) range of motion were computed during bilateral landing, and knee flexion range of motion NSI was computed during unilateral landing and compared between groups using independent samples t tests. ACLR patients had larger NSIs (reflecting less symmetry) for plantar force impulse during bilateral landing (p < 0.001) and knee flexion range of motion during unilateral landing (p = 0.004). No between-group differences were observed for knee FPPA range of motion (p = 0.111). This study is an important step towards assessing landing biomechanics in non-research settings with the goal of providing quantitative injury risk metrics in a clinical setting that can be used for return to sport decision making.
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Affiliation(s)
- Alexander T Peebles
- Granata Biomechanics Lab, Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, Virginia, USA
| | - Thomas K Miller
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Robin M Queen
- Granata Biomechanics Lab, Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, Virginia, USA.,Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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Kuntze G, Nettel-Aguirre A, Lorenzen KN, Küpper J, Ronsky JL, Whittaker JL, Emery CA. Vertical Drop Jump Biomechanics of Patients With a 3- to 10-Year History of Youth Sport-Related Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211058105. [PMID: 34917690 PMCID: PMC8669131 DOI: 10.1177/23259671211058105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background A better understanding of movement biomechanics after anterior cruciate ligament reconstruction (ACLR) could inform injury prevention, knee injury rehabilitation, and osteoarthritis prevention strategies. Purpose To investigate differences in vertical drop jump (VDJ) biomechanics between patients with a 3- to 10-year history of youth sport-related ACLR and uninjured peers of a similar age, sex, and sport. Study Design Cross-sectional study. Level of evidence III. Methods Lower limb kinematics and bilateral ground-reaction forces (GRFs) were recorded for participants performing 10 VDJs. Joint angles and GRF data were analyzed, and statistical analysis was performed using 2 multivariate models. Dependent variables included sagittal (ankle, knee, and hip) and coronal (knee and hip) angles at initial contact and maximum knee flexion, the rate of change of coronal knee angles (35%-90% of the support phase; ie, slopes of linear regression lines), and vertical and mediolateral GRFs (normalized to body weight [BW]). Fixed effects included group, sex, and time since injury. Participant clusters, defined by sex and sport, were considered as random effects. Results Participants included 48 patients with a history of ACLR and 48 uninjured age-, sex-, and sport-matched controls (median age, 22 years [range, 18-26 years]; 67% female). Patients with ACLR demonstrated steeper negative coronal knee angle slopes (β = -0.04 deg/% [95% CI, -0.07 to -0.00 deg/%]; P = .025). A longer time since injury was associated with reduced knee flexion (β = -0.2° [95% CI, -0.3° to -0.0°]; P = .014) and hip flexion (β = -0.1° [95% CI, -0.2° to -0.0°]; P = .018). Regardless of ACLR history, women displayed greater knee valgus at initial contact (β = 2.1° [95% CI, 0.4° to 3.8°]; P = .017), greater coronal knee angle slopes (β = 0.05 deg/% [95% CI, 0.02 to 0.09 deg/%]; P = .004), and larger vertical GRFs (landing: β = -0.34 BW [95% CI, -0.61 to -0.07 BW]; P = .014) (pushoff: β = -0.20 BW [95% CI, -0.32 to -0.08 BW]; P = .001). Conclusion Women and patients with a 3- to 10-year history of ACLR demonstrated VDJ biomechanics that may be associated with knee motion control challenges. Clinical Relevance It is important to consider knee motion control during activities such as VDJs when developing injury prevention and rehabilitation interventions aimed at improving joint health after youth sport-related ACLR.
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Affiliation(s)
- Gregor Kuntze
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Alberto Nettel-Aguirre
- Centre for Health and Social Analytics, National Institute for Applied Statistics Research Australia, School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kristin N Lorenzen
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Küpper
- Department of Mechanical and Manufacturing Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Janet L Ronsky
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada.,Department of Mechanical and Manufacturing Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
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Wang ZH, Wang JC, Zheng S, Xue P, Han FJ. Three-dimensional gait characteristics of patients after unilateral total knee arthroplasty. Medicine (Baltimore) 2021; 100:e26968. [PMID: 34449463 PMCID: PMC8389957 DOI: 10.1097/md.0000000000026968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 08/01/2021] [Indexed: 01/04/2023] Open
Abstract
The purpose of this study is to evaluate the gait characteristics of bilateral limbs after unilateral total knee arthroplasty (TKA) using three-dimensional (3D) dynamic capture technology.Forty-two patients who underwent TKA were selected from the Orthopedic Medical Center of The Second Hospital of Jilin University from November 2018 to May 2019. We used a 3D dynamic capture system to measure the gait characteristics of patients at 3 months after TKA. The data, including relative position and direction of different body parts, the force between feet and ground, spatial and temporal relationship of the lower limb muscles, were measured. Besides, the surface electromyogram signal and the force plate analog signal were also collected. The walking ability, knee 3D kinematic, and kinetic characteristics were analyzed by the Cortex software.Spatial and temporal parameters, including stride frequency, double support phase, single support phase, step length, step time, step width, stride length, gait cycle, velocity, were no significant difference in bilateral lower extremities (P > .05). The reaction force of hip, knee, and ankle joint in the operation side were less than that of the healthy side, but the difference was not statistically significant (P > .05). However, when compared with the healthy side, the hip joint in operation side had a larger maximum extension angle (P < .001), the knee joint in operation side had a larger maximum valgus angle and valgus activity (P < .05), and had a smaller tibial maximum internal rotation angle (P < .05). Besides, the surface electromyogram signals of tibialis anterior muscles were reduced (P < .05).3D gait analysis, as an objective and quantitative evaluation method, is a safe, effective, and reliable method for evaluating postoperative knee function. The data of gait analysis prove that TKA is a vital treatment to improve the function of patients with knee arthritis. Besides, gait analysis also showed that there were various kinematic and biomechanical abnormalities in the knee after TKA, which may be the reason why the surgical knee could not immediately return to normal level.
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Affiliation(s)
- Zong-Han Wang
- Department of the Oncology, Cancer Center, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jin-Cheng Wang
- Department of the Orthopaedic, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Shuang Zheng
- Department of the Orthopaedic, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Pan Xue
- Department of the Orthopaedic, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Fu-Jun Han
- Department of the Oncology, Cancer Center, The First Hospital of Jilin University, Changchun, Jilin Province, China
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Molinaro L, Taborri J, Santospagnuolo A, Vetrano M, Vulpiani MC, Rossi S. Sensor-Based Indices for the Prediction and Monitoring of Anterior Cruciate Ligament Injury: Reliability Analysis and a Case Study in Basketball. SENSORS 2021; 21:s21165341. [PMID: 34450783 PMCID: PMC8398404 DOI: 10.3390/s21165341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/30/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
The possibility of measuring predictive factors to discriminate athletes at higher risk of anterior cruciate ligament (ACL) injury still represents an open research question. We performed an observational study with thirteen female basketball players who performed monopodalic jumps and single-leg squat tests. One of them suffered from an ACL injury after the first test session. Data gathered from twelve participants, who did not suffer from ACL injury, were used for a reliability analysis. Parameters related to leg stability, load absorption capability and leg mobility showed good-to-excellent reliability. Path length, root mean square of the acceleration and leg angle with respect to the vertical axis revealed themselves as possible predictive factors to identify athletes at higher risk. Results confirm that six months after reconstruction represents the correct time for these athletes to return to playing. Furthermore, the training of leg mobility and load absorption capability could allow athletes to reduce the probability of new injuries.
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Affiliation(s)
- Luca Molinaro
- Department of Economics, Engineering, Society and Business Organization (DEIM), University of Tuscia, 01100 Viterbo, Italy; (L.M.); (J.T.)
| | - Juri Taborri
- Department of Economics, Engineering, Society and Business Organization (DEIM), University of Tuscia, 01100 Viterbo, Italy; (L.M.); (J.T.)
| | - Adriano Santospagnuolo
- Physical Medicine and Rehabilitation Unit, Sant ‘Andrea Hospital, “Sapienza” University of Rome, 00189 Rome, Italy; (A.S.); (M.V.)
| | - Mario Vetrano
- Physical Medicine and Rehabilitation Unit, Sant ‘Andrea Hospital, “Sapienza” University of Rome, 00189 Rome, Italy; (A.S.); (M.V.)
| | - Maria Chiara Vulpiani
- Physical Medicine and Rehabilitation Unit, Sant ‘Andrea Hospital, “Sapienza” University of Rome, 00189 Rome, Italy; (A.S.); (M.V.)
- Sports Medicine Institute CONI Rome, 00197 Rome, Italy;
| | - Stefano Rossi
- Department of Economics, Engineering, Society and Business Organization (DEIM), University of Tuscia, 01100 Viterbo, Italy; (L.M.); (J.T.)
- Correspondence: ; Tel.: +39-07-6135-7049
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Asymmetries in Dynamic Valgus Index After Anterior Cruciate Ligament Reconstruction: A Proof-of-Concept Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137047. [PMID: 34280984 PMCID: PMC8297279 DOI: 10.3390/ijerph18137047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/01/2023]
Abstract
Individuals with anterior cruciate ligament reconstruction (ACLR) are at a higher risk for subsequent anterior cruciate ligament (ACL) tears. Risk factors for ACL injuries likely involve a combination of anatomical, biomechanical, and neuromuscular factors. Dynamic knee valgus has been indicated as a possible biomechanical factor for future ACL injuries. Given that knee valgus is often accompanied by contralateral pelvic drop during single-leg activities, a dynamic valgus index (DVI) that quantifies combined kinematics of the knee and hip in the frontal plane has recently been developed. As the premise of asymmetrical DVI between limbs in the ACLR population has not been examined, this cross-sectional study was conducted with the aim to compare DVI between individuals with ACLR and healthy controls. Videos were taken for 12 participants with ACLR and 20 healthy controls when they performed single-leg hopping. One-way ANOVA revealed a higher DVI in the injured limb of the ACLR group when compared to their non-injured limb and to the healthy limb of the control group. As our data showed increased DVI in the injured limb of the ACLR group, the DVI approach accounting for hip and knee kinematics may be used to identify frontal plane movement deficits during single-leg hopping in individuals with ACLR.
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Drop Jump? Single-Leg Squat? Not if You Aim to Predict Anterior Cruciate Ligament Injury From Real-Time Clinical Assessment: A Prospective Cohort Study Involving 880 Elite Female Athletes. J Orthop Sports Phys Ther 2021; 51:372-378. [PMID: 34192883 DOI: 10.2519/jospt.2021.10170] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether visually assessed performances of the single-leg squat (SLS) and vertical drop jump (VDJ) were associated with future noncontact anterior cruciate ligament (ACL) injury. DESIGN Prognostic accuracy cohort study. METHODS Elite female handball and football (soccer) athletes (n = 880) were tested from 2007 to 2014 and tracked through 2015. Trained physical therapists visually rated each leg during a SLS and overall control during a VDJ. Receiver operating characteristic curve, Pearson chi-square, and logistic regression analyses were used to determine the prognostic accuracy of the 2 screening tests. RESULTS Sixty-five noncontact ACL injuries occurred during the follow-up period. Fourteen percent of athletes who sustained an ACL injury had poor SLS performance, compared to 17% of the noninjured athletes (P = .52 and .67 for hip and knee ratings, respectively). Side-to-side asymmetry in the SLS was not different between injured and noninjured athletes (P = .10 and .99 for hip and knee asymmetry, respectively). Twenty-one percent of athletes who sustained an ACL injury had a poor VDJ rating, compared to 27% of the noninjured athletes (P = .09). Furthermore, area under the curve values ranged from 0.43 to 0.54 for the SLS and VDJ, demonstrating no to poor prognostic accuracy. CONCLUSION Neither SLS nor VDJ test performance distinguished between athletes who sustained a subsequent noncontact ACL injury and those who did not. J Orthop Sports Phys Ther 2021;51(7):372-378. doi:10.2519/jospt.2021.10170.
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Clark NC. Noncontact Knee Ligament Injury Prevention Screening in Netball: A Clinical Commentary with Clinical Practice Suggestions for Community-Level Players. Int J Sports Phys Ther 2021; 16:911-929. [PMID: 34123542 PMCID: PMC8169033 DOI: 10.26603/001c.23553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 04/22/2021] [Indexed: 12/20/2022] Open
Abstract
Netball is a predominantly female team court-sport which is played worldwide. Netball is becoming more popular in the United States following its countrywide introduction to schools and community centers. A unique characteristic of netball is the footwork rule which restricts players to a one-step landing after catching the ball. Most netball landings are single-leg landings resulting in high vertical ground reaction forces and high skeletal tissue forces. Thus, high-risk landing events that have the biomechanical potential for injury occur frequently. Noncontact knee ligament injuries are common following a knee abduction collapse when landing. Because the consequences of noncontact knee ligament injury are profound, strategies are needed to mitigate the burden of such injury for players, teams, and society. The purpose of this clinical commentary is to demonstrate how theoretical principles, different types of research, and different levels of evidence underpin a rational clinical reasoning process for developing noncontact knee ligament injury prevention screening procedures in netball. The theoretical principles that are discussed in this commentary include injury control, the sequence of prevention, principles of screening in injury prevention, the multifactorial model of injury etiology, complex systems theory, and systems science. The different types of research that are reviewed include descriptive and analytic-observational studies. The different levels of evidence that are discussed include prospective studies, cross-sectional studies, and clinicians' own kinesiological modelling. Subsequently, an integrated approach to the evidence-informed development of noncontact knee ligament injury prevention screening procedures is presented. Clinical practice suggestions include a selection of evidence-informed screening tests that are quickly and easily implemented with netball players in local communities. The need for repeated screening at strategic timepoints across a season/year is explained. Sports physical therapists will find this commentary useful as an example for how to undertake clinical reasoning processes that justify the content of screening procedures contributing to noncontact knee ligament injury prevention in community-level netball. LEVEL OF EVIDENCE 5.
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Zhang M, Li Y, Feng R, Wang Z, Wang W, Zheng N, Wang S, Yan F, Lu Y, Tsai TY, Wei H. Change in Susceptibility Values in Knee Cartilage After Marathon Running Measured Using Quantitative Susceptibility Mapping. J Magn Reson Imaging 2021; 54:1585-1593. [PMID: 34031930 DOI: 10.1002/jmri.27745] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Quantitative susceptibility mapping (QSM) has been used to study the magnetic susceptibility properties of collagen fibers in articular cartilage; however, it is unclear whether QSM is sensitive to changes due to degradation caused by long-distance running. It is clinically important to understand the link between long-distance running and microstructural changes in knee cartilage. PURPOSE To investigate the ability of QSM to assess microstructural changes within cartilage after repetitive loading. STUDY TYPE Prospective. POPULATION Thirteen recreational, male long-distance runners. FIELD STRENGTH/SEQUENCE Three-dimensional gradient recalled echo acquired at 3 T. ASSESSMENT Magnetic resonance imaging (MRI) and 3D kinematics (translations and rotations during treadmill walking and running) of the knee joint were collected before and after marathon running. The compartments for analysis included the patella, trochlea, and subregions of femoral and tibial cartilage. Changes in regional susceptibility and cartilage thickness were calculated after marathon running. A susceptibility profile was obtained by fitting susceptibility as a function of the normalized depth of cartilage from the superficial to deep layers. STATISTICAL TESTS Paired t-test or Wilcoxon signed-rank test, 95% confidence interval (CI) of the depth-wise susceptibility profile, Pearson correlation or Spearman correlation. RESULTS There was a statistically significant increase in susceptibility value in the weight-bearing region of central medial femoral cartilage (cMF-c) after marathon running (pre-marathon: -0.0219 ± 0.0151 ppm, post-marathon: -0.0070 ± 0.0213 ppm, P < 0.05), while the cartilage thickness did not show significant changes in any regions (P-value range: 0.068-0.963). Significant susceptibility elevations occurred in the middle and deep layers of cMF-c (95% CIs did not overlap). A trend toward a positive correlation was found between the changes in susceptibility value in cMF-c and proximal-distal translation of the knee joint during walking (r = 0.55, P = 0.101) and running (r = 0.57, P = 0.089). DATA CONCLUSION Localized magnetic susceptibility alterations were observed within knee cartilage in the weight-bearing area after repetitive loading without any morphologic changes. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Ming Zhang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yufei Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ruimin Feng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongzheng Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjin Wang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Nan Zheng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Shaobai Wang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Fuhua Yan
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Lu
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Hongjiang Wei
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
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Tseng HJ, Lo HL, Lin YC, Liu WC, Lin SY, Chou PH, Lu CC. Analyze the Differential Rates of Anterior Cruciate Ligament Injuries Between Men and Women by Biomechanical Study of Single-Leg Landing in Badminton. Indian J Orthop 2021; 55:409-417. [PMID: 34306555 PMCID: PMC8275743 DOI: 10.1007/s43465-021-00421-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND In female badminton players, certain landings are associated with injury to the anterior cruciate ligament (ACL). However, the kinematic and kinetic changes of the landing leg and the effects of risky posture on ACL injuries among female vs male badminton players are still unknown. We hypothesized that female players land with a significantly higher knee valgus angle and moment compared to male players during single-leg landings in badminton. METHODS Ten male and ten female badminton players were enrolled in this study. In the laboratory, these subjects performed back-stepping to the backhand side with a concurrent overhead stroke, a single-leg landing on the force plate, and a return to the starting position. The kinematic data in the stance phase were normalized ranging from 0% as initial contact to 100% as toe-off; and 0% as initial contact to 100% as maximum knee flexion in the impact phase. RESULTS The knee valgus angle in female players was significantly higher in initial contact (5.06° ± 6.83° vs - 5.10° ± 4.30, p = .001) and maximal knee valgus angle (7.58° ± 9.54° vs - 3.93° ± 4.22°, p = .004) compared to male players. The knee valgus moment was significantly higher in male players than female players ( - 0.09 ± 0.12 vs 0.03 ± 0.10 N∙m/kg, p = .032) in initial contact during the impact phase. During landings, female badminton players had lower hip flexion angles, greater knee valgus angles, and greater ankle dorsiflexion angles. CONCLUSION Female badminton players presented higher knee valgus angles but smaller knee valgus moments compared with male players during backward single-leg landings. The concomitant kinematic and kinetic changes of the hip, knee, and ankle joints also can play an important role in the higher incidence of ACL injury in female athletes. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00421-6.
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Affiliation(s)
- Hsiang-Jui Tseng
- Department of Orthopaedic Surgery, Kaohsiung Municipal Siaogang Hospital, Siaogang Dist, No. 482, Shanming Rd, Kaohsiung, Taiwan ,grid.412027.20000 0004 0620 9374Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hon-Lok Lo
- grid.412027.20000 0004 0620 9374Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yu-Chuan Lin
- grid.412027.20000 0004 0620 9374Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Chih Liu
- Department of Orthopaedic Surgery, Kaohsiung Municipal Siaogang Hospital, Siaogang Dist, No. 482, Shanming Rd, Kaohsiung, Taiwan
| | - Sung-Yen Lin
- grid.412027.20000 0004 0620 9374Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan ,grid.412019.f0000 0000 9476 5696Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Hsi Chou
- grid.412027.20000 0004 0620 9374Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan ,grid.412019.f0000 0000 9476 5696Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Chang Lu
- Department of Orthopaedic Surgery, Kaohsiung Municipal Siaogang Hospital, Siaogang Dist, No. 482, Shanming Rd, Kaohsiung, Taiwan ,grid.412019.f0000 0000 9476 5696Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Yokoyama S, Fukuda W, Ikeno Y, Kataoka Y, Horan SA. Lower limb kinematics of single-leg squat performance in patients with anterior cruciate ligament deficiency. J Phys Ther Sci 2021; 33:429-433. [PMID: 34083883 PMCID: PMC8165361 DOI: 10.1589/jpts.33.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study investigated the parameters that characterize the knee, hip, and pelvic kinematics during a single-leg squat in preoperative anterior cruciate ligament rupture injury. [Participants and Methods] Overall, 15 patients with unilateral anterior cruciate ligament deficiency were enrolled in this study. For each single-leg squat, data from two-dimensional video cameras and three-dimensional motion analysis were collected. Measurement indices included the articular angles of the knee, hip, and trunk. The anterior cruciate ligament-injured leg was compared with the uninjured leg. [Results] The maximum knee valgus and flexion angles during a single-leg squat were smaller in the injured leg than in the uninjured leg. During the single-leg squat, the effect of "compensatory mechanisms" appeared as knee valgus and flexion movements. In particular, the knee valgus angle decreased in the anterior cruciate ligament-injured leg compared to that in the uninjured leg. [Conclusion] This phenomenon suggests that it is possible to utilize recurrence prevention training for anterior cruciate ligament injury.
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Affiliation(s)
- Shigeki Yokoyama
- Kyoto Tachibana University: 34 Yamada-cho, Oyake, Yamashina-ku, Kyoto 607-8175, Japan
| | - Wataru Fukuda
- Department of Physical Therapy, Center of Joint Surgery, Kaisei General Hospital, Japan
| | - Yutaro Ikeno
- Department of Physical Therapy, Center of Joint Surgery, Kaisei General Hospital, Japan
| | - Yusuke Kataoka
- Department of Physical Therapy, Center of Joint Surgery, Kaisei General Hospital, Japan
| | - Sean A Horan
- School of Allied Health Sciences, Griffith University, Australia
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Nilstad A, Petushek E, Mok KM, Bahr R, Krosshaug T. Kiss goodbye to the 'kissing knees': no association between frontal plane inward knee motion and risk of future non-contact ACL injury in elite female athletes. Sports Biomech 2021; 22:65-79. [PMID: 33906580 DOI: 10.1080/14763141.2021.1903541] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The aim of this study was to investigate if frontal plane knee and hip control in single-leg squats or vertical drop jumps with an overhead target were associated with future non-contact anterior cruciate ligament (ACL) injury in elite female athletes. Of the 429 handball and 451 football athletes (age 21.5 ± 4.0 years, height 169.6 ± 6.4 cm, body weight 67.1 ± 8.0 kg), 722 non-injured and 56 non-contact ACL injured participants were eligible for analysis. We calculated lateral pelvic tilt, frontal plane knee projection angle, medial knee position, and side-to-side asymmetry in these from 2D videos recorded at baseline, and recorded any new ACL injuries prospectively. None of the aforementioned variables in either screening task were different or could discriminate between injured and non-injured athletes (all p values >.05 and Cohen's d values < .27). Two-dimensional video assessment of frontal plane knee and hip control during both a single-leg squat and vertical drop jump was unable to identify individuals at increased risk of non-contact ACL injury, thus should not be used for screening.
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Affiliation(s)
- Agnethe Nilstad
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Erich Petushek
- Health Research Institute, Department of Cognitive and Learning Sciences, Michigan Technological University, Houghton, MI, USA
| | - Kam-Ming Mok
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Office of Student Affairs, Lingnan University, Hong Kong, China
| | - Roald Bahr
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Tron Krosshaug
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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35
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Stiff Landings, Core Stability, and Dynamic Knee Valgus: A Systematic Review on Documented Anterior Cruciate Ligament Ruptures in Male and Female Athletes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073826. [PMID: 33917488 PMCID: PMC8038785 DOI: 10.3390/ijerph18073826] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 01/13/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are the most common ligament injury of the knee, accounting for between 100,000 and 200,000 injuries among athletes per year. ACL injuries occur via contact and non-contact mechanisms, with the former being more common in males and the later being more common in females. These injuries typically require surgical repair and have relatively high re-rupture rates, resulting in a significant psychological burden for these individuals and long rehabilitation times. Numerous studies have attempted to determine risk factors for ACL rupture, including hormonal, biomechanical, and sport- and gender-specific factors. However, the incidence of ACL injuries continues to rise. Therefore, we performed a systematic review analyzing both ACL injury video analysis studies and studies on athletes who were pre-screened with eventual ACL injury. We investigated biomechanical mechanisms contributing to ACL injury and considered male and female differences. Factors such as hip angle and strength, knee movement, trunk stability, and ankle motion were considered to give a comprehensive, joint by joint analysis of injury risk and possible roles of prevention. Our review demonstrated that poor core stability, landing with heel strike, weak hip abduction strength, and increased knee valgus may contribute to increased ACL injury risk in young athletes.
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Zipser MC, Plummer HA, Kindstrand N, Sum JC, Li B, Michener LA. Hip Abduction Strength: Relationship to Trunk and Lower Extremity Motion During A Single-Leg Step-Down Task in Professional Baseball Players. Int J Sports Phys Ther 2021; 16:342-349. [PMID: 33842030 PMCID: PMC8016437 DOI: 10.26603/001c.21415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/08/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The single-leg step down task (SLSD) is a clinical tool to assess movement and control of the lower extremity and trunk. Hip abduction weakness may impact movement quality during the SLSD, however the relationships between movement and strength are unclear. PURPOSE To determine the relationship between hip abduction isometric strength and movement during the SLSD of trunk lean, pelvic drop, knee valgus, and hip flexion. STUDY DESIGN Cross sectional, cohort study. METHODS One hundred-eighteen Minor League baseball players (age=21.6 ± 2.0 years; n=68 pitchers, n=50 position players) participated. Bilateral hip abduction isometric strength was measured using a handheld dynamometer (HHD), and then multiplied by distance from the greater trochanter to the HHD and expressed as hip abduction torque. Video cameras captured the SLSD, with participants standing on one leg while lowering their contralateral heel to touchdown on the floor from a 0.203m (8in.) step. Trunk lean, trunk flexion, pelvic drop, knee valgus, and hip flexion were measured using Dartfish at heel touchdown. A value of 180° indicated no knee valgus. Pearson correlations examined the relationships between hip abduction torque and SLSD motions. RESULTS There were no significant correlations for position players. For pitchers, on the lead leg increased hip abduction torque weakly correlated with a decrease in knee valgus (r= 0.24, p=0.049). Also for pitchers on the trail leg, increased hip abduction torque weakly correlated with decreased pelvic drop (r= -0.28, p=0.021). CONCLUSION Hip abduction strength contributes to dynamic control of the trunk and legs. Specifically in pitchers, hip abduction weakness was related to increased movement of the lower extremity and lumbopelvic regions during the dynamic SLSD task. These deficits could translate to altered pitching performance and injury. LEVELS OF EVIDENCE 2.
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Cardoso VA, Resende RA, Aquino CF, Andrade AGP, Silva PLP, Amaral GM, Fonseca ST, Ocarino JM. A novel single-leg squat test with speed and accuracy requirements: Reliability and validity in anterior cruciate ligament reconstructed individuals. Knee 2021; 29:150-159. [PMID: 33636564 DOI: 10.1016/j.knee.2021.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 12/18/2020] [Accepted: 01/28/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Some traditional single-leg squat tests focused on number of repetitions may not demand precise control of lower limb dynamic alignment, especially in the frontal and transverse planes. The primary objective of this study was to evaluate test-retest reliability and construct validity of a novel single-leg squat test - the 'precision-squat test' (PST) - designed to assess performance under varying task demands that can impact the execution of lower limb movements. A secondary objective was to investigate whether musculoskeletal factors predict performance in the PST in healthy individuals. METHODS Thirty healthy participants were assessed to verify test-retest reliability. To verify the test's construct validity, we compared the performance of 21 anterior cruciate ligament reconstructed (ACLR) individuals and 21 matched controls. Finally, 36 healthy individuals were assessed to verify the musculoskeletal factors related to PST performance. All participants performed the PST: they executed single-leg squats while moving a laser pointer (attached to the thigh) between two targets. We varied target size and distance between targets to manipulate the task difficulty. RESULTS Reliability of the PST was excellent at all demand levels (intraclass correlation coefficient (ICC)(3,2) > 0.93). Squat time increased under test conditions involving higher task difficulty (P < 0.001) and in ACLR individuals compared with age-matched controls (P < 0.05). Regression analyses revealed that reduced knee extensors and hip external rotators torques are related to increased squat time (P < 0.05). CONCLUSIONS PST is a valid and reliable tool to assess performance of healthy and ACLR individuals. In addition, hip and knee strength are associated with performance during the test.
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Affiliation(s)
- Vanessa A Cardoso
- Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil
| | - Renan A Resende
- Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil
| | - Cecília F Aquino
- Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil; Department of Physical Therapy, Universidade José do Rosário Vellano, Campus Divinópolis, Brazil; Department of Physical Therapy, Universidade do Estado de Minas Gerais, Unidade Divinópolis, Brazil
| | - André G P Andrade
- Department of Sports, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil
| | - Paula L P Silva
- Center for Cognition, Action, & Perception, Department of Psychology, University of Cincinnati, Cincinnati, OH, USA
| | - Giovanna M Amaral
- Biological and Health Sciences Institute, Centro Universitário de Belo Horizonte, Brazil
| | - Sérgio T Fonseca
- Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil
| | - Juliana M Ocarino
- Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais, Brazil.
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Reduced 2-D Frontal Plane Motion During Single-Limb Landing Is Associated With Risk of Future Anterior Cruciate Ligament Graft Rupture After Anterior Cruciate Ligament Reconstruction and Return to Sport: A Pilot Study. J Orthop Sports Phys Ther 2021; 51:82-87. [PMID: 33356796 DOI: 10.2519/jospt.2021.9302] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the association between 2-D frontal plane movement and second anterior cruciate ligament (ACL) injury risk in young athletes at return to sport (RTS) after ACL reconstruction. DESIGN Prospective cohort. METHODS Forty-nine participants who had ACL reconstruction (mean ± SD age, 16.5 ± 3.0 years) performed a single-leg drop landing from a 31-cm box at the time of their RTS. Frontal plane trunk, pelvis, and knee angles were measured using 2-D video analysis at the point of maximum depth during landing. Summated frontal plane angles were calculated by adding trunk, pelvis, and knee angles. Participants were grouped based on whether or not they sustained an ACL graft rupture over the 24 months after RTS. RESULTS Seven participants (14%) sustained an ipsilateral graft rupture within 24 months after RTS. Participants who suffered a second ACL injury had a significant reduction in the summated frontal plane angle of the trunk, pelvis, and knee (P = .018) and of the trunk and knee (P = .02) compared to those who did not suffer a second injury. For every 5° increase in the summated trunk, pelvis, and knee angle (odds ratio [OR] = 0.54; 95% confidence interval [CI]: 0.31, 0.94) and the summated trunk and knee angle (OR = 0.48; 95% CI: 0.25, 0.94), the athletes were 46% to 52% less likely to sustain a graft rupture. CONCLUSION Athletes who suffered an ACL graft rupture within 24 months of RTS had a more rigid posture when landing compared to their uninjured peers. The results of this pilot study should be replicated in a larger sample to determine whether this method has merit as a screening tool to identify athletes at high risk for second ACL injury. J Orthop Sports Phys Ther 2021;51(2):82-87. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9302.
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A new method for assessing landing kinematics in non-laboratory settings. Phys Ther Sport 2021; 49:21-30. [PMID: 33550202 DOI: 10.1016/j.ptsp.2021.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES 1) Determine the concurrent validity of using automated 2D video analysis relative to 3D motion capture for assessing frontal and sagittal-plane knee kinematics during landing, 2) compare the accuracy of visually estimating joint center locations (2D Manual) with computing joint center locations using anatomical markers (2D Automatic), and 3) compare landing kinematics between a controlled laboratory setting and a non-laboratory setting. DESIGN Validity/repeatability study. SETTINGS Biomechanics research laboratory and non-laboratory athletic facility. PARTICIPANTS Thirty uninjured recreational athletes. MAIN OUTCOME MEASURES Peak knee flexion, knee flexion range of motion, peak knee frontal plane projection angle, and knee frontal plane projection angle range of motion during bilateral and unilateral landing were measured simultaneously in 3D using motion capture and in 2D using two low-cost video cameras during the first study session (biomechanics research laboratory), and in 2D only during the second study session (non-laboratory athletic facility). RESULTS There was good to excellent agreement between 3D motion capture and both 2D Manual (ICC = 0.86-0.99) and 2D Automatic (ICC = 0.89-0.99) video analysis methods. There was good to excellent agreement between data collected in a laboratory and non-laboratory setting (ICC = 0.75-0.95). CONCLUSION The methods introduced in this study are inexpensive, reliable, and feasible for use in non-laboratory settings.
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Collings TJ, Bourne MN, Barrett RS, du Moulin W, Hickey JT, Diamond LE. Risk Factors for Lower Limb Injury in Female Team Field and Court Sports: A Systematic Review, Meta-analysis, and Best Evidence Synthesis. Sports Med 2021; 51:759-776. [DOI: 10.1007/s40279-020-01410-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 02/01/2023]
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Intra- and interrater reliability of subjective assessment of the drop vertical jump and tuck jump in youth athletes. Phys Ther Sport 2021; 47:156-164. [DOI: 10.1016/j.ptsp.2020.11.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 01/16/2023]
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Osteopathic Manipulative Treatment Versus Exercise Program in Runners With Patellofemoral Pain Syndrome: A Randomized Controlled Trial. J Sport Rehabil 2020; 30:609-618. [PMID: 33333491 DOI: 10.1123/jsr.2020-0108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/22/2020] [Accepted: 09/05/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT The effects of an exercise program (EP) for the treatment of patellofemoral pain syndrome (PFPS) are well known. However, the effects of osteopathic manipulative treatment (OMT) are unclear. OBJECTIVE To evaluate the effects of OMT versus EP on knee pain, functionality, plantar pressure in middle foot (PPMF), posterior thigh flexibility (PTF), and range of motion of hip extension in runners with PFPS. DESIGN This is a randomized controlled trial. SETTING Human performance laboratory. PARTICIPANTS A total of 82 runners with PFPS participated in this study. INTERVENTIONS The participants were randomized into 3 groups: OMT, EP, and control group. The OMT group received joint manipulation and myofascial release in the lumbar spine, hip, sacroiliac joint, knee, and ankle regions. The EP group performed specific exercises for lower limbs. The control group received no intervention. MAIN OUTCOME MEASURES The main evaluations were pain through the visual analog scale, functionality through the Lysholm Knee Scoring Scale, dynamic knee valgus through the step-down test, PPMF through static baropodometry, PTF through the sit and reach test, and range of motion through fleximetry. The evaluations were performed before the interventions, after the 6 interventions, and at 30-day follow-up. RESULTS There was a significant pain decrease in the OMT and EP groups when compared with the control group. OMT group showed increased functionality, decreased PPMF, and increased PTF. The range of motion for hip extension increased only in the EP group. CONCLUSION Both OMT and EP are effective in treating runners with PFPS.
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Romero-Franco N, Ortego-Mate MDC, Molina-Mula J. Knee Kinematics During Landing: Is It Really a Predictor of Acute Noncontact Knee Injuries in Athletes? A Systematic Review and Meta-analysis. Orthop J Sports Med 2020; 8:2325967120966952. [PMID: 33344669 PMCID: PMC7731707 DOI: 10.1177/2325967120966952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Although knee kinematics during landing tasks has traditionally been considered to predict noncontact knee injuries, the predictive association between noncontact knee injuries and kinematic and kinetic variables remains unclear. PURPOSE To systematically review the association between kinematic and kinetic variables from biomechanical evaluation during landing tasks and subsequent acute noncontact knee injuries in athletes. STUDY DESIGN Systematic review; Level of evidence, 2. METHODS Databases used for searches were MEDLINE, LILACS, IBECS, CINAHL, SPORTDiscus, SCIELO, IME, ScienceDirect, and Cochrane from database inception to May 2020. Manual reference checks, articles published online ahead of print, and citation tracking were also considered. Eligibility criteria included prospective studies evaluating frontal and sagittal plane kinematics and kinetics of landing tasks and their association with subsequent acute noncontact knee injuries in athletes. RESULTS A total of 13 studies met the eligibility criteria, capturing 333 acute noncontact knee injuries in 8689 participants. A meta-analysis revealed no significant effects for any kinematic and kinetic variable with regard to subsequent noncontact knee injuries. CONCLUSION No kinetic or kinematic variables from landing tasks had a significant association with acute noncontact knee injuries. Therefore, the role and application of the landing assessment for predicting acute noncontact knee injuries are limited and unclear, particularly given the heterogeneity and risk of bias of studies to date.
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Affiliation(s)
- Natalia Romero-Franco
- Nursing and Physiotherapy Department, University of the Balearic Islands, Palma de Mallorca, Spain
- Natalia Romero-Franco, Nursing and Physiotherapy Department, University of the Balearic Islands, Road to Valldemossa km 7.5, E-07122, Palma de Mallorca, Spain () (Twitter: @NRomeroFranco)
| | | | - Jesús Molina-Mula
- Nursing and Physiotherapy Department, University of the Balearic Islands, Palma de Mallorca, Spain
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Hearn DW, Frank BS, Padua DA. Use of double leg injury screening to assess single leg biomechanical risk variables. Phys Ther Sport 2020; 47:40-45. [PMID: 33152587 DOI: 10.1016/j.ptsp.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this article was to determine if differences in kinematic and kinetic variables observed in a double-leg screen carried over to a single-leg task. DESIGN We used a case-control design with grouping based on performance during a double-leg jump landing. SETTING All participants were selected from a large university setting and testing was performed in a biomechanics laboratory. PARTICIPANTS Participants were females between 18 and 25 years of age with at least high school varsity experience in one or more of the following sports: soccer, lacrosse, field hockey, rugby, basketball, or team handball. MAIN OUTCOME MEASURES Primary outcome measures were knee angles in the frontal and sagittal planes as well as vertical ground reaction force (vGRF). RESULTS There were significant between group differences in peak knee flexion and knee flexion displacement during both the double and single-leg tasks, however between group differences for peak knee valgus and knee valgus displacement noted in the double-leg task were not observed in the single-leg task. vGRF was significantly different in the single-leg task but not the double-leg task. CONCLUSION A double leg screening may not provide complete identification of risk of injury during sports requiring single leg tasks.
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Affiliation(s)
- Darren W Hearn
- Department of Exercise and Sport Science, MOTION Science Institute, University of North Carolina, Chapel Hill, NC.
| | - Barnett S Frank
- Department of Exercise and Sport Science, MOTION Science Institute, University of North Carolina, Chapel Hill, NC
| | - Darin A Padua
- Department of Exercise and Sport Science, MOTION Science Institute, University of North Carolina, Chapel Hill, NC.
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Risk factors for noncontact anterior cruciate ligament injury in female high school basketball and handball players: A prospective 3-year cohort study. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2020; 22:34-38. [PMID: 32821647 PMCID: PMC7417616 DOI: 10.1016/j.asmart.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/23/2020] [Accepted: 06/19/2020] [Indexed: 11/24/2022]
Abstract
Introduction The risk factors of noncontact anterior cruciate ligament (ACL) injury remain an enigma. The purpose of this study was to prospectively evaluate the risk factors for noncontact ACL injury in female high school basketball and handball players. Materials and Methods We conducted a 3-year prospective cohort study between 2009 and 2014, and it included 317 female high school athletes aged 15 years. At baseline, they underwent detailed examinations for various parameters that were documented during their first year of high school. The parameters assessed were height (cm), weight (kg), general joint laxity (points), navicular drop (mm), anterior laxity of the knee using the KT-1000 Knee Ligament Arthrometer (mm), angle of femoral anteversion (º), knee extensor/flexor muscle strength (Nm/kg), and hip abductor strength (Nm/kg). All ACL injuries that occurred during these 3 years were recorded. Results Of 317 players, 27 were excluded because they either had a history of ACL injury or could not complete the study. Thirty ACL tears occurred. Three of the ACL injuries were contact injuries, whereas the remaining 27 were noncontact injuries. Greater body weight (95% confidence interval [CI], 1.030–1.174; P = 0.004), a high hip abductor strength (95% CI, 1.462–4.827; P = 0.001), and small femoral anteversion (95% CI, 0.746–0.982; P = 0.027) were found to be risk factors in logistic regression analysis. Conclusion Greater body weight, a high hip abductor strength, and small femoral anteversion were risk factors for noncontact ACL injury in female high school basketball and handball players.
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Cronström A, Creaby MW, Ageberg E. Do knee abduction kinematics and kinetics predict future anterior cruciate ligament injury risk? A systematic review and meta-analysis of prospective studies. BMC Musculoskelet Disord 2020; 21:563. [PMID: 32819327 PMCID: PMC7441716 DOI: 10.1186/s12891-020-03552-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/31/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To systematically review the association between knee abduction kinematics and kinetics during weight-bearing activities at baseline and the risk of future anterior cruciate ligament (ACL) injury. METHODS Systematic review and meta-analysis according to PRISMA guidelines. A search in the databases MEDLINE (PubMed), CINAHL, EMBASE and Scopus was performed. Inclusion criteria were prospective studies including people of any age, assessing baseline knee abduction kinematics and/or kinetics during any weight-bearing activity for the lower extremity in individuals sustaining a future ACL injury and in those who did not. RESULTS Nine articles were included in this review. Neither 3D knee abduction angle at initial contact (Mean diff: -1.68, 95%CI: - 4.49 to 1.14, ACL injury n = 66, controls n = 1369), peak 3D knee abduction angle (Mean diff: -2.17, 95%CI: - 7.22 to 2.89, ACL injury n = 25, controls n = 563), 2D peak knee abduction angle (Mean diff: -3.25, 95%CI: - 9.86 to 3.36, ACL injury n = 8, controls n = 302), 2D medial knee displacement (cm; Mean diff:: -0.19, 95%CI: - 0,96 to 0.38, ACL injury n = 72, controls n = 967) or peak knee abduction moment (Mean diff:-10.61, 95%CI: - 26.73 to 5.50, ACL injury n = 54, controls n = 1330) predicted future ACL injury. CONCLUSION Contrary to clinical opinion, our findings indicate that knee abduction kinematics and kinetics during weight-bearing activities may not be risk factors for future ACL injury. Knee abduction of greater magnitude than that observed in the included studies as well as factors other than knee abduction angle or moment, as possible screening measures for knee injury risk should be evaluated in future studies.
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Affiliation(s)
- Anna Cronström
- Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden. .,Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden.
| | - Mark W Creaby
- School of Exercise Science, Australian Catholic University, Brisbane, Australia
| | - Eva Ageberg
- Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden
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Validity of Using Automated Two-Dimensional Video Analysis to Measure Continuous Sagittal Plane Running Kinematics. Ann Biomed Eng 2020; 49:455-468. [PMID: 32705424 DOI: 10.1007/s10439-020-02569-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/11/2020] [Indexed: 02/08/2023]
Abstract
Two-dimensional video analysis is commonly used to assess kinematics when three-dimensional motion capture is unavailable. However, videos are often assessed using manual digitization, which limits the ability to extract outcomes that require continuous data. Here, we introduced a method to collect continuous kinematic data in 2D using an inexpensive camera and an open-source automated marker tracking program. We tested the validity of this method by comparing 2D video analysis to 3D motion capture for measuring sagittal-plane running kinematics. Twenty uninjured participants ran on a treadmill for 1-min while lower extremity kinematics were collected simultaneously in 3D using a motion capture system and in 2D using a single digital camera, both at 120 Hz. Knee, ankle, and foot angle at contact, peak knee flexion, knee flexion excursion, and knee-ankle flexion vector coding variability were computed using both the 3D and 2D kinematic data, and were compared using intraclass correlation coefficients and Bland-Altman plots. The agreement between collection methods was excellent for foot angle at contact and knee flexion excursion, good for ankle and knee angle at contact and knee-ankle vector coding variability, and moderate for peak knee flexion. However, Bland-Altman plots revealed significant differences between the 2D and 3D collection methods, which varied across study participants. These low-cost methods could be useful for collecting continuous sagittal plane running kinematics in non-laboratory settings.
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Association Between Functional Movement Screen Scores and Injuries in Male College Basketball Players. J Sport Rehabil 2020; 29:621-625. [DOI: 10.1123/jsr.2017-0351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/19/2019] [Accepted: 03/24/2019] [Indexed: 11/18/2022]
Abstract
Context: The functional movement screen (FMS) is an assessment tool for movement dysfunction, which is used to reduce the risk of injury. Although the relationship between the FMS composite score and injuries has been extensively studied, the association between FMS scores and injuries in only college basketball players remains unknown. Objective: To examine the relationship between the FMS score and injuries in basketball players. Design: Cross-sectional study. Setting: University research laboratory. Participants: Eighty-one male college basketball players (average age 20.1 [1.3] y) participated. Main Outcome Measures: The FMS composite score was calculated from 7 movement tests. The incidence of injuries over a 1-year period prior to the test day was determined based on a questionnaire. Individuals were categorized into 2 groups: injury (with a serious basketball-related injury resulting in the loss of practice and game time for at least 4 wk) and noninjury groups. Mann–Whitney U and chi-square tests were used to evaluate group differences in the composite FMS and 7 movement scores, respectively. Furthermore, the scores significant on univariate analyses were submitted to a multivariate logistic analysis, adjusting for participant characteristics. Results: The composite FMS scores of the 2 groups were not significantly different (P = .38). Among the 7 tasks, only the deep squat and hurdle step showed significant group differences (P = .03 and P = .001, respectively). The multivariate logistic analysis revealed that deep squat (odds ratio, 6.48; 95% confidence interval, 1.23–34.01; P = .03) and hurdle step scores (odds ratio, 25.80; 95% confidence interval, 1.81–368.73; P = .02) were significantly associated with injuries, even after adjustment for participant characteristics. Conclusions: Deep squat and hurdle step scores may be associated with injuries in basketball players. Further research should be conducted to confirm that these 2 scores can predict the incidence of injuries in basketball players.
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Barber-Westin S, Noyes FR. One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years. Sports Health 2020; 12:587-597. [PMID: 32374646 DOI: 10.1177/1941738120912846] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
CONTEXT Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures. OBJECTIVE To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates. DATA SOURCES A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases. STUDY SELECTION Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. RESULTS A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS. CONCLUSION A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.
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Affiliation(s)
- Sue Barber-Westin
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, and the Noyes Knee Institute, Cincinnati, Ohio
| | - Frank R Noyes
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, and the Noyes Knee Institute, Cincinnati, Ohio
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Hip Kinematics During Single-Leg Tasks in People With and Without Hip-Related Groin Pain and the Association Among Kinematics, Hip Muscle Strength, and Bony Morphology. J Orthop Sports Phys Ther 2020; 50:243-251. [PMID: 31905098 PMCID: PMC7196020 DOI: 10.2519/jospt.2020.9150] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare 3-D hip kinematics during the single-leg squat and step-down in patients with hip-related groin pain to those in asymptomatic participants, and to assess relationships among hip kinematics, muscle strength, and bony morphology. DESIGN Controlled laboratory cross-sectional study. METHODS Forty patients with hip-related groin pain and 40 matched, asymptomatic participants between 18 and 40 years of age participated. A handheld dynamometer was used to assess hip abductor and external rotator strength. An 8-camera motion-analysis system was used to quantify 3-D kinematics during the single-leg squat and step-down. Magnetic resonance imaging was used to quantify bony morphology. The independent t test and Mann-Whitney U test were used to assess between-group differences. Pearson coefficient correlations were used to assess relationships. RESULTS Patients with hip-related groin pain had smaller peak hip flexion angles, smaller knee flexion angles, and lesser squat depth compared to asymptomatic participants during the single-leg squat. Among patients with hip-related groin pain, smaller hip flexion angles during the single-leg squat were associated with hip abductor weakness (r = 0.47, P≤.01). Among asymptomatic participants, smaller peak hip flexion angles during the single-leg squat were associated with less acetabular coverage (r = 0.33, P = .04) and shallow squat depth (r = 0.48, P≤.01); a smaller hip internal rotation angle during the step-down was associated with larger femoral neck shaft angle (r = -0.43, P<.01). CONCLUSION Compared to asymptomatic participants, patients with hip-related groin pain had smaller hip and knee flexion angles and shallower squat depth during the single-leg squat. Smaller hip flexion angles were associated with hip abductor weakness among those with hip-related groin pain. J Orthop Sports Phys Ther 2020;50(5):243-251. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9150.
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