Clinical Utility of Qualitative Change of Direction Movement Assessment in ACL Injury Risk Evaluation

Anterior cruciate ligament (ACL) injuries are complex and influenced by numerous internal and external risk factors that should be considered to effectively mitigate injury and facilitate informed return to sport decision-making. Among these risk factors, movement quality exhibited during sport-specific tasks has been identified as a significant predictor of injury occurrence. Particularly, change of direction (COD) movements, when performed with sub-optimal movement quality, such as knee valgus and lateral trunk flexion, are prominent mechanisms of ACL injury in multidirectional sports. Unfortunately, the formal and objective assessment of COD movement quality is underutilized in clinical and sports practice, with existing methods often confined to expensive, sophisticated laboratory settings impractical for everyday clinicians. The purpose of this clinical commentary is to demonstrate the necessity of integrating COD movement assessments to screen for potential ACL injury risk, particularly among higher-risk populations. The authors will review cost-effective and clinic-friendly objective tests used to qualitatively screen COD movements, such as the Cutting Movement Assessment Score and The Expanded Cutting Alignment Tool. Additionally, this commentary will discuss key considerations when assessing COD movement.

Level of Evidence

5.

Cutting Technique Modification: A Way to Improve Movement Quality and Develop Agility in Youth?

Thieschäfer, L, Dos’Santos, T, and Büsch, D. Cutting technique modification: a way to improve movement quality and develop agility in youth? J Strength Cond Res 38(9): 1596–1606, 2024—High-quality cutting technique is essential for agility development and safer cuttings in adolescent athletes. Certain sidestep techniques and kinematics are characteristic of high movement quality and are associated with both, faster performance and lower knee joint loading (i.e., reduced anterior cruciate ligament injury risk). The aim of this study was to determine the effects of a 6-week, side step, technique modification training intervention targeting specific kinematics on agility performance and movement quality. Twenty-two adolescent American football players were recruited for a nonrandomized, controlled, intervention study. For 6 weeks, an intervention group (IG) of 11 players participated in 25-minute cutting technique training sessions integrated into team training twice a week, whereas a control group (CG) of 11 players continued their usual training routine. Agility performance was assessed based on percentage-based change of direction deficit (CODDp) obtained during reactive agility tests at 45° and 90° angles. The Cutting Movement Assessment Score (CMAS) qualitative screening tool was used to assess 2D high-speed videos of the cuts for movement quality. The significance level was set at α = 0.01. The intervention effectively altered players' sidestep technique irrespective of cutting angle with large time × group interaction effects observed for CMAS ( = 0.82). Statistical and practical significant improvements in CMAS pre-to-post intervention were evident in the IG (−2.30 ≤ g ≤ −1.75; 313.87 ≤ BF10 ≤ 2,342.00), whereas deteriorations were found in the CG for 90° (g = 1.38; BF10 = 64.21). However, in both groups, no statistically significant differences in CODDp were observed pre-to-post intervention (0.019 ≤ p ≤ 0.586; 0.34 ≤ BF10 ≤ 3.59). The cutting technique modification training meaningfully improved movement quality, without negatively affecting agility performance, and can be used by practitioners to foster a safe technical foundation for subsequent agility development in adolescent athletes.

Differences in Biomechanical Determinants of ACL Injury Risk in Change of Direction Tasks Between Males and Females: A Systematic Review and Meta-Analysis

BACKGROUND

Change of direction (COD) movements are associated with non-contact anterior cruciate ligament (ACL) injuries in multidirectional sports. Females appear at increased risk compared to males, which could be attributable to whole body kinematic strategies and greater multiplanar knee joint loads (KJLs) during COD which can increase ACL loading.

OBJECTIVE

The aim of this systematic review and meta-analysis was to examine and quantitatively synthesise the evidence for differences between males and females regarding KJLs and their biomechanical determinants (whole body kinematic strategies determining KJLs) during COD tasks.

METHODS

Databases including SPORTDiscus, Web of Science, and PubMed were systematically searched (July 2021-June 2023) for studies that compared differences in knee joint loads and biomechanical determinants of KJLs during COD between males and females. Inclusion criteria were: (1) females and males with no prior history of ACL injury (18-40 years); (2) examined biomechanical determinants of KJLs and/ or KJLs during COD tasks > 20°; (3) compared ≥ 1 outcome measure between males and females. Studies published between 2000 and 2023 examining a cutting task > 20° with a preceding approach run that compared KJLs or the whole body multiplanar kinematics associated with them, between sexes, using three-dimensional motion analysis.

RESULTS

This meta-analysis included 17 studies with a pooled sample size of 451 participants (227 males, 224 females). Meta-analysis revealed females displayed significantly less peak knee flexion during stance (SMD: 0.374, 95% CI 0.098-0.649, p = 0.008, I2: 0%); greater knee abduction at initial contact (IC) (SMD: 0.687, 95% CI 0.299-1.076, p = 0.001, I2: 55%); less hip internal rotation (SMD: 0.437, 95% CI 0.134-0.741, p = 0.005, I2: 34%) and hip abduction at IC (SMD: -0.454, 95% CI 0.151-0.758, p = 0.003, I2: 33%). No significant differences were observed between males and females for any internal or externally applied KJLs. All retrieved studies failed to control for strength, resistance training or skill history status.

CONCLUSION

No differences were observed in KJLs between males and females despite females displaying greater knee abduction at IC and less peak knee flexion during the stance phase of CODs, which are visual characteristics of non-contact ACL injury. Further research is required to examine if this translates to a similar injury risk, considering morphological differences in strain characteristics of the ACL between males and females. This observation may in part explain the disproportionate ACL injury incidence in female multidirectional athletes. Further higher quality controlled research is required whereby participants are matched by skill training history, resistance training history and strength status to ensure an appropriate comparison between males and females.

Effects of six-week stroboscopic training program on visuomotor reaction speed in goal-directed movements in young volleyball players: a study focusing on agility performance

BACKGROUND

In team sports, deficits in visuomotor reaction speed are considered a significant and modifiable risk factor that can lead to decreased performance and an increased risk of injuries. Thus, identifying effective methods to enhance visuomotor abilities is crucial. The main objective of this research was to investigate the impact of a six-week stroboscopic intervention on visuomotor reaction speed in goal-directed specific movements based on agility among young volleyball players. Additionally, the study aimed to explore the impact of saccade dynamics on visuomotor reaction speed performance throughout the experiment.

METHODS

There were 50 athletes (26 males and 24 females) with an average age of 16.5 years (± 0.6) who participated in this study. Over a six-week training period, athletes performed volleyball-specific training either wearing stroboscopic glasses (intervention) or under normal visual conditions (control). Prior to and after the training period, the agility tests based on change-of-direction speed (CODS) and reactive agility (RA) were used to identify visuomotor reaction speed performance. To measure agility performance a five-repetition shuttle run to gates was conducted. The REAC-INDEX, which represents visuomotor reaction speed, was analyzed as the resulting difference between the CODS test and the RA test. To elicit saccadic dynamics, a laboratory visual search task was performed.

RESULTS

A significant GROUP×TIME interaction was observed for the REAC-INDEX (p = 0.012, ηp2 = 0.13). ANCOVA analyses revealed significant GROUP differences, indicating improved post-training REAC-INDEX results (p = 0.004, d = 0.87), regardless of gender. Training-induced modulations in saccade acceleration did not reach significance, but a significant relationship was observed between changes in saccade acceleration and changes in the REAC-INDEX (r = -0.281, p = 0.048), indicating that higher performance gains following training were associated with a stronger increase in saccade acceleration.

CONCLUSIONS

This study demonstrates that stroboscopic training effectively enhances visuomotor reaction speed in goal-directed movements based on agility. Furthermore, visuomotor reaction speed gains could potentially be mediated by saccade dynamics. These findings provide valuable insights into the effectiveness of stroboscopic eyewear for training sport-specific visuomotor skills among young volleyball players.

Are change of direction speed and agility different abilities from time and coordinative perspectives?

This study aimed to test whether agility and change of direction speed (COD) are independent capacities using the same movement pattern (1) in terms of the completion time and (2) the entropy. Seventeen semi-professional female football players participated in the study. The agility task consisted of a Y-shaped (45° COD) task with three possible exit options (center, right and left) performed pre-planned or in reaction to the movement of two testers (i.e., blocking exit gates). Players' acceleration was measured using an inertial measurement unit. Entropy was calculated from the acceleration signal and completion time was extracted using a magnet-based timing system. Significantly greater times and lower entropy (p<0.001) were found during agility runs to pre-planned COD runs. Furthermore, weak to moderate correlations were found between COD and agility for both completion time (r = 0.29, p<0.001) and entropy (r = 0.53, p<0.001, r2 = 28.1%). These results highlight that COD speed and agility are independent capacities and skills, and as such, should be tested and trained as distinct, separate qualities. Modifying task constraints including a reactive stimulus (i.e., cognitive factors), is essential for increasing task complexity by altering the biomechanical and coordinative aspects of the action.

Development of a Cutting Technique Modification Training Program and Evaluation of its Effects on Movement Quality and Cutting Performance in Male Adolescent American Football Players

This study developed a cutting technique modification training program and investigated its effects on cutting performance and movement quality in adolescent American football players. For six weeks, an intervention group (IG) of 11 players participated in 25 min cutting technique modification training sessions integrated into team training twice a week, while a control group (CG) of 11 players continued their usual team training. Movement quality was assessed by evaluating 2D high-speed videos, obtained during preplanned 45° and 90° cutting tests, using the Cutting Movement Assessment Score (CMAS) qualitative screening tool. Cutting performance was assessed based on change of direction deficit (CODD). Significant interaction effects of time × group were found for CMAS in 45° and 90° cuttings (p < 0.001, ηp2 = 0.76, p < 0.001, ηp2 = 0.64, respectively), with large improvements in the IG (p < 0.001, g = -2.16, p < 0.001, g = -1.78, respectively) and deteriorations in the CG for 45° cuttings (p = 0.002, g = 1.15). However, no statistically significant differences in CODD were observed pre-to-post intervention. The cutting technique modification training was effective at improving movement quality without impairing cutting performance, and it can be used by practitioners working with adolescent athletes.

Change of direction speed and deficit over single and multiple changes of direction: Influence of biological age in youth basketball players

The study analysed the difference in change of direction (COD) deficit among young male basketball players of different age groups and biological ages and analysed the relationships in COD performance (time and deficit) across single and multiple CODs depending on their biological age. Fifty-four highly-trained male players (U-13 and U-17) were tested on sprinting (25-m) and COD ability over single and multiple CODs through total times and the percentage-based COD deficit (CODD). Results showed that older age groups performed significantly (ES = 0.43-2.32, p < 0.05) better in linear and COD times, especially those players with post-peak height velocity (PHV) (ES = 0.89-1.90). Controlling for age at PHV, no significant differences were found in any group or inter-limb asymmetries. Moderate relationships were found between CODD in the pool data (r = 0.36 to 0.50). All CODD and time relationships in any test (i.e., 180º COD and V-cut) were considerably lower (r= -0.27 to 0.32) across individual biological groups. The study highlights the impact of maturation on COD performance, whereas CODD seems to be not affected. Interestingly, the CODD is independent, highlighting this measurement's specific nature. Practitioners should use common distances, angles, and the number of CODs linked to biological status to create a COD profile.

How do soccer players sprint from a tactical context? Observations of an English Premier League soccer team

The aim of this study was to quantify and tactically contextualise (i.e., phase of play and tactical outcome [TO]) sprints (≥7.0 m/s) of an English Premier League (EPL) soccer team during match-play. Videos of 901 sprints (10 matches) were evaluated using the Football Sprint Tactical-Context Classification System. Sprints occurred within a variety of phases of play (attacking/defensive organisation and transitions) and TOs, both out- and in-possession, with position-specific differences. Most sprints were completed out-possession (58%), with "closing down" the most observed TO (28%). In-possession, "run the channel" (25%) was the most observed TO. Centre backs predominantly performed "ball down the side" sprints (31%), whereas central midfielders mostly performed "covering" sprints (31%). Central forwards and wide midfielders mostly performed "closing down" (23% and 21%) and "run the channel" (23% and 16%) sprints when out- and in-possession, respectively. Full backs most frequently performed "recovery" and "overlap" runs (14% each). This study provides insights into the specific physical-tactical characteristics of sprints performed from an EPL soccer team. This information can be used to assist in the development of position-specific physical preparation programmes, and more ecologically valid and contextualised gamespeed and agility sprint drill construction to better reflect the demands of soccer.

Effects of the menstrual cycle phase on anterior cruciate ligament neuromuscular and biomechanical injury risk surrogates in eumenorrheic and naturally menstruating women: A systematic review

BACKGROUND

Eumenorrheic women experience cyclic variations in sex hormones attributed to the menstrual cycle (MC) which can impact anterior cruciate ligament (ACL) properties, knee laxity, and neuromuscular function. This systematic review aimed to examine the effects of the MC on ACL neuromuscular and biomechanical injury risk surrogates during dynamic tasks, to establish whether a particular MC phase predisposes women to greater ACL injury risk.

METHODS

PubMed, Medline, SPORTDiscus, and Web of Science were searched (May-July 2021) for studies that investigated the effects of the MC on ACL neuromuscular and biomechanical injury risk surrogates. Inclusion criteria were: 1) injury-free women (18-40 years); 2) verified MC phases via biochemical analysis and/or ovulation kits; 3) examined neuromuscular and/or biomechanical injury risk surrogates during dynamic tasks; 4) compared ≥1 outcome measure across ≥2 defined MC phases.

RESULTS

Seven of 418 articles were included. Four studies reported no significant differences in ACL injury risk surrogates between MC phases. Two studies showed evidence the mid-luteal phase may predispose women to greater risk of non-contact ACL injury. Three studies reported knee laxity fluctuated across the MC; two of which demonstrated MC attributed changes in knee laxity were associated with changes in knee joint loading (KJL). Study quality (Modified Downs and Black Checklist score: 7-9) and quality of evidence were low to very low (Grading of Recommendations Assessment Development and Evaluation: very low).

CONCLUSION

It is inconclusive whether a particular MC phase predisposes women to greater non-contact ACL injury risk based on neuromuscular and biomechanical surrogates. Practitioners should be cautious manipulating their physical preparation, injury mitigation, and screening practises based on current evidence. Although variable (i.e., magnitude and direction), MC attributed changes in knee laxity were associated with changes in potentially hazardous KJLs. Monitoring knee laxity could therefore be a viable strategy to infer possible ACL injury risk.

Development and trainability of agility in youth: A systematic scoping review

Background

Agility is acknowledged as a crucial factor of performance in various open skill sports in both adult and youth athletes. However, despite its significance for sports performance the development and the trainability of agility are under-researched within the pediatric literature. A systematic scoping review was considered most appropriate to provide researchers and practitioners with an overview of the current body of literature approaching agility in youth.

Objectives

The objectives of this scoping review were to map the extent, range, and nature of existing evidence regarding trainability and "natural" development of agility and to summarize corresponding study results.

Methods

The scoping review protocol was pre-registered at Open Science Framework. Systematic searches were conducted using the databases PubMed, Scopus, ProQuest, Web of Science, SURF, and SPONET to identify sources covering agility in youth. Among other inclusion criteria, only references applying unplanned agility concepts were included.

Results

Ultimately, 41 reports were included comprising 23 observational studies, 14 experimental studies, and 4 references of secondary research. A total of 3,087 subjects were assessed in the included studies. Subject groups were predominantly male, above 10 years of age, and soccer athletes. Outcomes of observational studies indicate an effect of age and maturation on agility performance resulting in a non-linear "natural" development of agility. Furthermore, relationships between contributing perceptual-cognitive factors and agility performance tend to increase with progressing age, whereas relationships between physical factors and agility performance diminish. Evidence of training studies suggests that agility is trainable in youth, albeit with various underlying mechanisms.

Conclusions

This systematic scoping review is the first mapping of the body of literature about agility in youth. It outlines the current evidence base, reveals research gaps, and points out future directions to support researchers and practitioners in this field. Although, increasing research activity in this field is discernible, agility research in youth is still in its infancy. Considering the significance of agility for sports performance, future research is postulated to design evidence-based strategies for long-term agility development in young athletes.