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Abstract

Objective: The objective of this systematic review was to evaluate the association between ankle dorsiflexion (DF) range of motion (ROM) and dynamic knee valgus (DKV). Methods: Electronic searches were conducted in MEDLINE, EMBASE, CINAHL and SPORTDiscus. A modified Downs and Black checklist was used for quality assessment and meta-analysis was performed to compare standardised mean differences (SMD) of DF ROM outcomes. Results: Seventeen studies met the inclusion criteria. Meta-analysis showed that reduced DF ROM is associated with participants presenting with DKV compared to controls (SMD -0.65, 95% CI -0.88 to –0.41). Subgroup analysis showed consistent results regarding different forms of DF ROM measurement; restriction in DF ROM measured in weight-bearing position (SMD -1.25, 95% CI -2.24 to -0.25), non-weight-bearing with knee flexed (SMD -0.56, 95% CI - 0.97 to -0.16) or non-weight-bearing with knee extended (SMD -0.54, 95% CI -0.80 to - 0.28) was significantly associated with DKV. Conclusion: The meta-analysis results provide evidence that reduced DF ROM is correlated with DKV. The assessment of DF ROM in the clinical setting is important, as it may be related to harmful movement patterns of the lower limbs.

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... Restriction of ankle dorsiflexion range of motion (ankle DF ROM) can also affect knee valgus, as shown in the meta-analysis by Lima et al. [24]. The researchers revealed a significant relationship between weight-bearing and non-weight-bearing positions. ...
... The researchers revealed a significant relationship between weight-bearing and non-weight-bearing positions. Restriction of the DF ROM may engage forces toward compensation for excessive foot pronation, internal tibia rotation, adduction, hip internal rotation, and pelvic drop, leading to a full DKV pattern [24][25][26]. ...
... This may be due to the fact that limited mobility of the hip influences the occurrence of compensation at the knee joint, which manifests itself in greater dynamic knee valgus [10]. The effect of reduced ankle DF ROM on knee valgus has been demonstrated in previous studies [24][25][26]55]. In the study, Wyndow et al. showed that a lower ankle DF ROM was associated with a greater peak FPPA (greater valgus) on the SLS test in 30 healthy people [25]. ...
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This study aimed to examine the relationship between knee valgus in the frontal plane projection angle (FPPA) during single-leg squat (SLS), single-leg landing (SLL), and other selected clinical tests in young athletes. Forty-three young healthy elite football players (age: 13.2 (1.7) years) that were regularly training in a local sports club participated in the study. The FPPA was assessed using 2D video analysis. The screening tests included the passive single-leg raise (PSLR), hip external and internal rotation (hip ER and IR), sit and reach test, weight-bearing lunge test (WBLT), modified star excursion balance test (mSEBT), countermovement jump (CMJ), single-leg hop for distance (SLHD), and age peak height velocity (APHV). There was a significant positive relationship between the knee valgus angles in the SLS test and the sit and reach test (r = 0.34) and a negative relationship with the hip ER ROM (r = −0.34) (p < 0.05). The knee valgus angles in the SLL were negatively associated with the hip IR (r = −0.32) and ER ROM (r = −0.34) and positive associated with the WBLT (r = 0.35) and sit and reach test (r = 0.33) (p < 0.05). Linear regression analysis showed that the results of the hip ER ROM and sit and reach tests were independent predictors of the FPPA in the SLS test (r2 = 0.11, p = 0.03 and r2 = 0.12, p = 0.02, respectively). The conducted study showed that individuals with more hip range of motion, more spine flexion extensibility, and less ankle dorsiflexion ROM may be more likely to experience high degrees of knee valgus in FPPA.
... Thirty-two articles mentioned the application of a guideline and 15 articles did not. Thirty-two studies adhered to the PRISMA guidelines and two studies applied the 2015 PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols) guidelines [28,29]. One of the studies [28] mentioned the Measurement Tool to Assess Meta-analysis of Observational Studies in Epidemiology (MOOSE) [30]. ...
... Thirty-two studies adhered to the PRISMA guidelines and two studies applied the 2015 PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols) guidelines [28,29]. One of the studies [28] mentioned the Measurement Tool to Assess Meta-analysis of Observational Studies in Epidemiology (MOOSE) [30]. ...
... Describe methods used for assessing risk of bias of individual studies (including specification of whether this was performed at the study or outcome level), and how this information is to be used in any data synthesis. 28 ...
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This review of reviews aimed to evaluate the reporting quality of published systematic reviews and meta-analyses in the field of sports physical therapy using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This review of reviews included a literature search; in total, 2047 studies published between January 2015 and December 2020 in the top three journals related to sports physical therapy were screened. Among the 125 identified articles, 47 studies on sports physical therapy were included in the analysis (2 systematic reviews and 45 meta-analyses). There were several problems areas, including a lack of reporting for key components of the structured summary (10/47, 21.3%), protocol and registration (18/47, 38.3%), risk of bias in individual studies (28/47, 59.6%), risk of bias across studies (24/47, 51.1%), effect size and variance calculations (5/47, 10.6%), additional analyses (25/47, 53.2%), and funding (10/47, 21.3%). The quality of the reporting of systematic reviews and meta-analyses of studies on sports physical therapy was low to moderate. For better evidence-based practice in sports physical therapy, both authors and readers should examine assumptions in more detail, and report valid and adequate results. The PRISMA guideline should be used more extensively to improve reporting practices in sports physical therapy.
... If there is a range of motion (ROM) deficit in one segment of the lower limb system, there is usually compensation in the transverse and frontal planes. This situation can occur when the ROM of the ankle dorsal flexion is limited, which can force compensated movement of excessive pronation of the ankle, internal tibial rotation, adduction and internal rotation of the thigh and pelvic drop, which in turn leads to DKV [66][67][68]. Seven studies included in the meta-analysis of the researchers, Lima et al., allowed the publication of the claims, saying that the DF ROM restriction is associated with DKV (SMD −0.65, 95% CI −0.88 to -0.41), regardless of whether DF ROM was measured in a situation of foot loading (weight-bearing) or not (non-weight bearing), also with knee flexion or extension [68]. However, three studies in the meta-analysis were based on the lateral and forward step-down tasks [61][62][63], and only one study focused on the SLS test [12]. ...
... This situation can occur when the ROM of the ankle dorsal flexion is limited, which can force compensated movement of excessive pronation of the ankle, internal tibial rotation, adduction and internal rotation of the thigh and pelvic drop, which in turn leads to DKV [66][67][68]. Seven studies included in the meta-analysis of the researchers, Lima et al., allowed the publication of the claims, saying that the DF ROM restriction is associated with DKV (SMD −0.65, 95% CI −0.88 to -0.41), regardless of whether DF ROM was measured in a situation of foot loading (weight-bearing) or not (non-weight bearing), also with knee flexion or extension [68]. However, three studies in the meta-analysis were based on the lateral and forward step-down tasks [61][62][63], and only one study focused on the SLS test [12]. ...
Article
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Dynamic knee valgus (DKV) as an incorrect movement pattern is recognized as a risk factor for lower limb injuries. Therefore, it is important to find the reasons behind this movement to select effective preventive procedures. There is a limited number of publications focusing on specific tasks, separating the double-leg from the single-leg tasks. Test patterns commonly used for DKV assessment, such as single-leg squat (SLS) or single leg landings (SLL), may show different results. The current review presents the modifiable factors of knee valgus in squat and landing single-leg tests in healthy people, as well as exercise training options. The authors used the available literature from PubMed, Scopus, PEDro and clinicaltrials.gov databases, and reviewed physiotherapy journals and books. For the purpose of the review, studies were searched for using 2D or 3D motion analysis methods only in the SLL and SLS tasks among healthy active people. Strengthening and activating gluteal muscles, improving trunk lateral flexion strength, increasing ROM dorsiflexion ankle and midfoot mobility should be taken into account when planning training programs aimed at reducing DKV occurring in SLS. In addition, knee valgus during SLL may occur due to decreased hip abductors, extensors, external rotators strength and higher midfoot mobility. Evidence from several studies supports the addition of biofeedback training exercises to reduce the angles of DKV.
... The risk of bias for each study included was assessed by means of the modified version of the Quality Index Checklist by Downs&Black[17], as in previous literature reviews, including non-intervention studies [18][19][20]. The number of items of the modified version was reduced from 27 to 14 (1,2,3,5,6,7,10,11,12,16,18,20,21,22), for avoiding questions that are only applicable for intervention studies. ...
... The risk of bias for each study included was assessed by means of the modified version of the Quality Index Checklist by Downs&Black[17], as in previous literature reviews, including non-intervention studies [18][19][20]. The number of items of the modified version was reduced from 27 to 14 (1,2,3,5,6,7,10,11,12,16,18,20,21,22), for avoiding questions that are only applicable for intervention studies. For each item on the checklist, an answer of "yes", "no" or "unable to determine" was assigned. ...
Article
Background: It has been reported that individuals with chronic ankle instability (CAI) show motor control abnormalities. The study of muscle activations by means of surface electromyography (sEMG) plays a key role in understanding some of the features of movement abnormalities. Research question Do common sEMG activation abnormalities and strategies exists across different functional movements? Methods: Literature review was conducted on PubMed, Web-of-Science and Cochrane databases. Studies published between 2000 and 2020 that assessed muscle activations by means of sEMG during any type of functional task in individuals with CAI, and used healthy individuals as controls, were included. Methodological quality was assessed using the modified Downs&Black checklist. Since the methodologies of different studies were heterogeneous, no meta-analysis was conducted. Results: A total of 63 articles investigating muscle activations during gait, running, responses to perturbations, landing and hopping, cutting and turning; single-limb stance, star excursion balance task, forward lunges, ball-kicking, y-balance test and single-limb squatting were considered. Individuals with CAI showed a delayed activation of the peroneus longus in response to sudden inversion perturbations, in transitions between double- and single-limb stance, and in landing on unstable surfaces. Apparently, while walking on ground there are no differences between CAI and controls, walking on a treadmill increases the variability of muscles activations, probably as a “safety strategy” to avoid ankle inversion. An abnormal activation of the tibialis anterior was observed during a number of tasks. Finally, hip/spine muscles were activated before ankle muscles in CAI compared to controls. Conclusion: Though the methodology of the studies herein considered is heterogeneous, this review shows that the peroneal and tibialis anterior muscles have an abnormal activation in CAI individuals. These individuals also show a proximal muscle activation strategy during the performance of balance challenging tasks. Future studies should investigate whole-body muscle activation abnormalities in CAI individuals.
... Deficits in ankle dorsiflexion ROM may occur due to the decreased extensibility of the gastrocnemius/soleus complex and restricted posterior talar glide on the tibia, thus creating DKV [14]. A significant correlation was found between ankle dorsiflexion flexibility and the peak knee abduction angle (r = 0.355, p = 0.048) during landing [15]. Moreover, individuals with greater ankle dorsiflexion ROM demonstrated smaller GRFs and greater knee-flexion displacement during landing, which may be associated with a reduced risk of anterior cruciate ligament (ACL) injury [16]. ...
... Greater ankle mobility among females is due to the greater capacity of plantarflexors, as compared to males [31]. Greater passive ankle dorsiflexion ROM was associated with greater hip and knee flexion and lower GRFs during a jump-landing task in healthy individuals [15]. Dorsiflexion deficits may limit the ability to fully achieve a closed-packed, stable position of the ankle during dynamic activities, such as gait and jump-landing [17]. ...
Article
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The study investigated the influence of ankle strength and its range of motion (ROM) on knee kinematics during drop landing. Fifteen male and fifteen female university athletes with a normal range of dynamic knee valgus (DKV) (knee frontal plane projection angle: men = 3° to 8°, females = 7° to 13°) were recruited. They performed drop landing at height 30 cm and 45 cm with three-dimensional motion capture and analysis. Knee angles were compared at specific landing phases. Isokinetic ankle strength was tested at 60°/s angular velocity while the weight-bearing lunge test was conducted to evaluate ankle ROM. For males, strength for both plantarflexors and dorsiflexors were associated with knee kinematics at both heights (30 cm: r = −0.50, p = 0.03; 45 cm: r = −0.45, p = 0.05) during maximum vertical ground reaction force (MVGRF) phase. For females, ankle invertor strength and knee kinematics were associated at both 30cm (r = 0.53; p = 0.02,) and 45 cm landing heights (r = 0.49, p = 0.03), while plantarflexor strength and knee kinematics showed a significant association during initial contact (r = 0.70, p < 0.01) and MVGRF (r = 0.55, p = 0.02) phases at height 30 cm only. Male and female athletes with normal range of DKV showed a significant relationship between ankle strength and knee kinematics at specific landing phases. These relationships varied with increased landing height.
... Sixty-nine percent of physiotherapists adopted ankle mobilization/manipulation as an intervention, whereas 85.1 and 87.1% reported using sensorimotor and functional training, respectively. Some studies in the literature address the association between restricted ankle dorsiflexion and excessive dynamic knee valgus (Lima et al., 2018) and others found postural control deficits in individuals with PFP (Lee et al., 2012;Negahban et al., 2013). However, further studies are needed to lend support to certain interventions. ...
Article
Background No studies have evaluated whether interventions used by Brazilian physiotherapists for the treatment of patellofemoral pain (PFP) are in line with the best existing scientific evidence. Objectives Identify the interventions most commonly used by Brazilian physiotherapists for the rehabilitation of PFP and determine whether characteristics of physiotherapists and knowledge regarding evidence-based practice (EBP) influence the choice of interventions. Design Cross-sectional web-based survey. Methods Brazilian physiotherapists who treat patients with PFP participated in the study. Characteristics of the participants, information regarding EBP and interventions used in the treatment of PFP were collected through an online questionnaire. Descriptive analysis of the data was performed. Logistic regression analysis was employed to investigate associations between the interventions and both the characteristics of the physiotherapists and their knowledge regarding EBP. Results One hundred and ninety-four physiotherapists completed the questionnaire, 97.4% of whom reported using combined hip and quadriceps strengthening exercises, whereas only 25.3% reported using foot orthoses. A significant number of physiotherapists also reported using interventions that are not recommended (such as patellar mobilization, lumbar, hip and knee mobilization/manipulation and biophysical agents). Physiotherapists with a master's or doctoral degree and those who were aware of clinical practice guidelines were respectively 2.57-fold and 3.81-fold more likely to use recommended interventions. Conclusion Most Brazilian physiotherapists choose interventions that are in line with current scientific evidence. However, a significant number also use interventions that are not recommended for the treatment of PFP.
... As the coefficients of determination were not sufficiently high, it cannot be said that gluteal muscle and hamstring muscle activity fully explains peak knee FPPA. Other properties as muscle tone, stiffness, strength, flexibility, or range of motion could be related to knee FPPA In fact, limited ankle dorsiflexion range of motion has been significantly associated with higher dynamic knee valgus (Lima et al., 2018). Hip internal rotation has also been significantly correlated with knee FPPA (Nakagawa & Petersen, 2018). ...
Article
Objectives To assess a relationship between lower limb muscle activity and the frontal plane knee kinematics during a single-legged drop jump. Design Correlation study; Setting Functional Anatomy Laboratory. Participants 35 healthy collegiate male athletes. Main outcome measures Muscle activity (%MVIC) of gluteus maximus, gluteus medius, biceps femoris, semitendinosus, vastus medialis quadriceps, vastus lateralis quadriceps, medial gastrocnemius and lateral gastrocnemius; peak knee frontal plane projection angle; and Pearson's correlation coefficients between muscle activity and peak knee frontal plane projection angle. All outcomes were assessed for both dominant and non-dominant limbs. Results Significant correlations (r = 0.46–0.60, P < 0.05) were found between the muscle activities of the gluteus maximus, gluteus medius, biceps femoris, and semitendinosus, when compared to the knee frontal plane projection angle. Conclusion Gluteal muscles and hamstring muscles are associated with the peak knee frontal plane projection angle during a single-legged drop jump test. Thus, gluteal and hamstring muscle activities should be considered when developing rehabilitation or injury prevention programs.
... Dynamic knee valgus malalignment can be observed through performance in the jump-landing task [10]. Increased hip adduction, shallow knee flexion, and reduced ankle dorsiflexion are precipitating factors of knee valgus [1,13,14]. Studies have reported that excessive knee valgus during exercise increases the risk of the anterior cruciate ligament (ACL) injury [1,15,16]. ...
Article
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Flexibility, specifically that in the amplitude of sagittal-plane range of motion (ROM), can improve jump landing patterns and reduce the potential for sports injury. The use of floss bands (FLOSS) reportedly increases joint range of motion (ROM) in the shoulder, ankle, and elbow joints. However, little research on the effectiveness of FLOSS on the knee joint has been conducted. This study investigated the effects of FLOSS on knee ROM, static balance, single-leg-hop distance, and landing stabilization performance in women. This study had a crossover design. Twenty active female college students without musculoskeletal disorders were randomly assigned to receive a FLOSS intervention or elastic bandage (ELA) control on their dominant knees. The participants underwent FLOSS and ELA activities on two occasions with 48 h of rest between both sets of activities. The outcomes were flexibility of the quadriceps and hamstrings, how long one could maintain a single-leg stance (with and without eyes closed), distance on a single-leg triple hop, and score on the Landing Error Scoring System (LESS); these outcomes were evaluated at preintervention and postintervention (immediately following band removal and 20 min later). After the FLOSS intervention , the participants' hamstring flexibility improved significantly (immediately after: p = 0.001; 20 min later: p = 0.002), but their quadricep flexibility did not. In addition, FLOSS use did not result in worse single-leg stance timing, single-leg triple-hop distance, or landing stabilization performance relative to ELA use. Compared with the ELA control, the FLOSS intervention yielded significantly better LESS at 20 min postintervention (p = 0.032), suggesting that tissue flossing can improve landing stability. In conclusion, the application of FLOSS to the knee improves hamstring flexibility without impeding static balance, and improves single-leg hop distance and landing stabilization performance in women for up to 20 min. Our findings elucidate the effects of tissue flossing on the knee joint and may serve as a reference for physiotherapists or athletic professionals in athletic practice settings.
... For instance, there is evidence showing that people with CAI adopt different movement strategies of the hip and the knee than subjects with no history of ankle sprains during functional tests such as the star excursion balance test (Hoch, Gaven, & Weinhandl, 2016). A recent meta-analysis found that reduced ankle dorsi flexion is associated with a dynamic knee valgus suggesting that deficits in knee control could be intrinsically related to the ankle (Lima, Ferreira, & de Paula Lima, 2018). In fact, patients with CAI exhibit decreased knee flexion than those without CAI (Theisen & Day, 2019). ...
Article
Objective: Chronic ankle instability (CAI) is reported after ankle sprain. Our aim was to assess differences in mechanical pain sensitivity of lower extremity nerve trunks and physical performance between amateur soccer players with and without CAI. Design: A cross-sectional case-control study. Setting: Amateur soccer teams. Participants: Fifty-five male soccer players, 28 with and 27 without CAI participated. Main outcome measures: The perceived instability was assessed with the Cumberland Ankle Instability Tool (CAIT). Pressure pain thresholds (PPTs) on the common peroneal and tibialis nerve trunks, vertical jump, lateral step-down test and joint position sense of the knee were assessed by a blinded assessor. Results: Soccer players with CAI showed lower PPTs over the common peroneal nerve than those without CAI (between-groups mean difference: 1.0 ± 0.8 kg/cm2, P < 0.001). No differences for PPT over the tibialis posterior (P = 0.078) or any physical performance outcome (knee joint positioning sense [P = 0.798], lateral step-down test [P = 0.580] and vertical jump variables [all, P > 0.310]) were found. PPT over the common peroneal nerve exhibited a significant moderate correlation with the CAIT score (r = 0.528, P < 0.001). Conclusion: Amateur soccer players with CAI have higher pressure pain sensitivity over the common peroneal nerve but exhibit similar physical performance to amateur soccer players without CAI.
... Besides that, the results reported in the literature are not consistent. As shown by Lima et al. in a systematic review [11], during jump landing, only one out of four studies available reported a significantand weakcorrelation between passive ankle dorsiflexion range and knee valgus [3]. For double-leg squats, two out of four studies reported that individuals with knee valgus presented less passive ankle dorsiflexion range than controls [8,9]. ...
Article
Background Limited passive ankle dorsiflexion range has been associated with increased knee valgus during functional tasks. Increased knee valgus is considered a contributing factor for musculoskeletal disorders in the lower limb. There is conflicting evidence supporting this association. The extent of passive ankle dorsiflexion range is associated with dynamic ankle dorsiflexion range and the way how these variables are related to lower limb or trunk kinematics is unclear. Research question What is the association between passive ankle dorsiflexion range or dynamic ankle dorsiflexion range with shank, thigh, pelvis or trunk movements during the single-leg squat? Methods This is a cross-sectional study with a convenience sample. Thirty uninjured participants performed the single-leg squat with their dominant limb. Ankle, shank, thigh, pelvis and trunk 3D kinematics were recorded. Passive ankle dorsiflexion range was assessed through the weight-bearing lunge test and the dynamic ankle dorsiflexion range was defined as the ankle dorsiflexion range of motion in the sagittal plane during the single-leg squat. Results Greater passive ankle dorsiflexion range was associated with smaller thigh internal rotation (r= -.38). Greater dynamic ankle dorsiflexion range was associated with smaller trunk flexion (r = .59) and pelvis anteversion (r= -.47). Passive ankle dorsiflexion range and dynamic ankle dorsiflexion range were not associated. Significance Greater passive ankle dorsiflexion range seems to be associated with a better lower limb alignment during the single-leg squat, while dynamic ankle dorsiflexion range seems to reflect different lower limb and trunk kinematic strategies.
... Additionally, different studies have identified ankle dorsiflexion range of motion (ROM) as a predictor of dynamic balance (Basnett et al., 2013). A deficit value of ankle ROM can lead to neuromuscular alterations in the knee (Lima et al., 2018), as well as kinetic alterations during a side cutting task (DosʼSantos et al., 2020;Simpson et al., 2020). Importantly, these alterations can lead to a decrease in performance in different soccer-related skills (DosʼSantos et al., 2020;Gonzalo Skok et al., 2015). ...
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In this study, we aimed to analyze the magnitude and direction of interlimb asymmetries in ankle dorsiflexion range of motion (ROM), power (using iso-inertial devices), and a neuromuscular skill (change of direction). Secondarily, we aimed to determine the relationship between interlimb asymmetry scores for each test and also between these scores and the scores for the different performance tests. Sixteen semi-professional male soccer players (age: 25.38  6.08 years; body height: 1.78  0.64 m; body mass: 79.5  14.9 kg) participated in this study. We calculated interlimb asymmetries using five tests: ankle dorsiflexion ROM, change of direction (COD 180º), and iso-inertial resistance tasks in the open (leg extension strength (LE), leg curl strength (LC)) and closed (crossover step (CRO)) kinetic chain. Our results showed that asymmetry magnitudes differed between all tests with highest interlimb asymmetries displayed during iso-inertial overloading. In addition, we observed that the direction of asymmetries varied depending on the test-specificity, and that the CRO asymmetries had a negative association with LE and CRO performance. These findings highlight the independent nature of asymmetries and that CRO could be an appropriate test to detect asymmetries related with the performance of soccer-specific actions (such as changes of direction). Practitioners are encouraged to use multiple tests to detect existing interlimb differences according to the specific characteristics of each sport.
... In this study, a recreational athlete was defined as a subject who participates in aerobic or sports activities at least three times a week for at least 30 min [19]. Inclusion criteria were: being a recreational athlete, aged 18-26 years, body mass index (BMI) between 18 and 24, normal ankle dorsiflexion range of motion at approximately 20°b ased on the ankle lunge test [21], the distance between the medial femoral condyles should be more than 3 cm in the static position and observed hip adduction and internal rotation in the functional tests (Single leg squat and step down tasks) [5]; evaluation by a corrective exercise specialist, and not participating in lower extremity rehabilitation programs in the last 6 months. Participants were excluded if they: had any lower-extremity injury in the previous six months, had a lower limb surgery or fractures within the past one year, and had any neurological and pathological conditions. ...
Article
Background The effect of the Posterior X Taping (PXT) used for subjects with Tibiofemoral Varus Malalignment (TFRV) aimed to control excessive tibiofemoral rotations is still unclear. Further, it is critical to use evidence-based therapeutic exercises to prevent non-contact injuries, especially in repetitive movements. Objective To investigate whether the PXT and real-time feedback (RTF) interventions would improve lower extremity functions during the pedaling task in subjects with TFRV. Methods Twenty-four male recreational athletes with TFRV participated in this study; Kinematic and muscle activity were synchronously recorded on ten consecutive pedal cycles during the last 30 s of 2-min pedaling. Results The present study indicated that the subjects at the post-intervention of the RTF group exhibited significant decreased hip adduction and internal rotation, significant decreased tibiofemoral external rotation between 144 and 216° of crank angle, significant increased vastus medialis activity between 144 and 288° of crank angle, and significant increased gluteus medius activity between 180 and 144° of crank angle; In contrast, the subjects at the post-intervention of the PXT group exhibited significant decreased tibiofemoral external rotation and increased ankle external rotation at all the crank angles. No between-group differences were observed in pre-and post-intervention. Significance These results suggest that the PXT and RTF interventions are recommended to immediately improve the functional defects of the subjects with TFRV during the pedaling task.
... It should be noted that the occurrence of DKV is more pronounced in the female gender [28], although this does not mean that there is no risk in the male population [29]. Several factors have been analyzed as triggers of this alteration in knee movement, but two of the recent factors that have shown some evidence have been a reduced ankle dorsiflexion [30] and a deficit of strength or impaired activation of the abductor and adductor hip muscles, in particular a weakness in the abductors and external rotators of the hip [31,32]. Recent evidence suggests that knee and ankle bracing may reduce DKV [33,34]. ...
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Childhood anterior cruciate ligament (ACL) injuries-which can pose a major risk to a child's sporting career-have been on the rise in the last few decades. Dynamic knee valgus (DKV) has been linked to an increased risk of ACL injury. Therefore, the aim of this study was to analyze the acute effects of an ACL injury prevention protocol (ACL-IPP) and a soccer-specific fatigue protocol (SSFP) on DKV in youth male soccer players. The research hypothesis was that DKV would be reduced by the ACL-IPP and increased by the SSFP. Eighteen youth male soccer players were divided according to baseline DKV. Those with moderate or large DKV performed a neuromuscular training protocol based on activation of the abductor and external rotator hip muscles. Those with little or no DKV performed a soccer-specific fatigue protocol. DKV was assessed using the single-leg squat pre-and post-protocols in both legs. The ACL-IPP significantly decreased DKV during single-leg squat (p < 0.01, effect size = 1.39), while the SSFP significantly increased baseline DKV in the dominant leg during single-leg squat (p = 0.012; effect size = 1.74). In conclusion, the ACL-IPP appears to acutely reduce the DKV in youth male soccer players, and the SSFP seems to acutely increase the DKV in those players who showed a light or no DKV in a non-fatigue situation. By using the SSFP, it may be possible to determine which players would benefit from injury prevention programs due to increased DKV during game scenarios, while hip abductor and external rotator neuromuscular training may be beneficial for players who have moderate and severe DKV during single-leg squat under non-fatigued scenarios.
... Inclusion criteria were: age between 18-30 years, body mass index (BMI) between 18 and 24 and presence of observable DKV during the pedaling with ergometer (visual assessment of the frontal plane knee angle (abduction) greater than 10•) [20]. Participants were excluded if they: had limited ankle dorsiflexion [21] and any musculoskeletal injury in the previous two months or lower-extremity injury in the previous six months, or had a lower-extremity surgery within the past one year, or any neurological and pathological conditions [22]. ...
Article
Background: Change in the lower extremity alignments in the frontal plane and muscle activation patterns have been associated with lower extremity injuries. Therefore, to prevent injuries, many therapeutic protocols focus on find ways to correct dynamic knee valgus (DKV). Methods: Thirty-one recreational male cyclists with DKV volunteered to participate in this study. Simultaneous recordings of kinematic and electromyography data were performed on ten consecutive pedal cycles which began during the last 30 seconds of each four test condition: with band at 0.5kg workload, with band at 2kg workload, without band at 0.5kg workload, and without band at 2kg workload. The paired t-test was used for statistical analysis (p < 0.05). Results: The results indicated significant differences in VM (band= 0.029, no band= 0.031) and VL (band= 0.015, no band= 0.035) activation between workloads in each condition. also there were significant differences in Gmed activation (0.5kg= 0.001, 2kg= 0.037), onset of Gmed (0.5kg= 0.048, 2kg= 0.012), offset of Gmed (0.5kg= 0.048, 2kg= 0.015), TFL activation (0.5kg= 0.001, 2kg= 0.041) and offset of TFL (0.5kg= 0.078, 2kg= 0.005) between the band and no band conditions. There was no different significant in VM/VL ratio between in each of four testing conditions (p>0.05). The Gmed/TFL ratio was significantly greater in band condition than no band at both 0.5 (p= 0.045) and 2kg (p= 0.001) workload. Knee abduction angle was affected by the band during the pedaling at two different workloads (0.5kg: p= 0.047, 2kg: p= 0.021) but mean (p= 0.027) and peak (p= 0.033) knee abduction angle significantly increased with increasing workload during the pedaling with band. Conclusions: pedaling with the band loop can be considered as an effective method to increase the Gmed, Gmed/TFL ratio, and control of DKV but increasing the workload during pedaling must be done with caution to prevent DKV.
... However, none of the studies employed a soccer player sample suggesting that soccer players could have lower weightbearing ankle dorsiflexion compared to other sports. Limited ankle dorsiflexion range of motion is associated with dynamic knee valgus, anterior knee pain, patellar tendinopathy, chronic ankle instability, Achilles' tendinopathy, and metatarsal stress fractures [95]. Taking into account results from this study and previous literature, male and female elite youth soccer players may need to consider improving ankle dorsiflexion range of motion to decrease the risk for a variety of knee, ankle, and foot injuries. ...
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In soccer, injury epidemiology differs between males and females. It is clinically useful to know whether there are between-sex differences in selected characteristics relevant to primary injury risk and injury prevention practices. The purpose of this study was to explore between-sex differences in anthropometric, balance, and range-of-motion characteristics in Spanish elite male and female youth soccer players. This was a pre-season cross-sectional study. Sixty-nine males (age 16.8 ± 0.9 yr; height 175.9 ± 6.8 cm; mass 67.9 ± 6.3 kg) and thirty-seven females (age 17.2 ± 1.7 yr; height 164.0 ± 6.3 cm; mass 59.0 ± 5.8 kg) participated. Anthropometrics (standing/sitting height, bodymass, right/left leg length) and right/left anterior reach test (ART), hip internal/external active range of motion, active knee extension (AKE), and weightbearing lunge test (WBLT) were measured. Between-sex differences were assessed with Bonferroni-corrected Mann–Whitney U tests and Cliff’s delta (d). Between-sex significant differences (p < 0.003, d ≥ 0.50) were observed for anthropometric data and for hip internal rotation. No between-sex significant differences were observed for ART/AKE/WBLT measures. Between-sex significant differences with large effect sizes were identified for anthropometric data and right/left hip internal rotation. The present study adds new data to the literature for young Spanish male and female soccer players. The present findings will help inform clinical reasoning processes and future injury prevention research for elite male and female youth soccer players.
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Background: Dynamic knee valgus (DKV) is defined as a combination of excessive femoral adduction, internal rotation, tibial internal torsion, and the medial movement of the knee. It appears that the athletes with DKV are at higher risk of developing knee injuries. Objective: The aim of this study was to evaluate whether the reactive neuromuscular training would improve whole-body dynamic balance and knee joint position sense (JPS) in women with the dynamic knee valgus. Methods: A controlled laboratory study was conducted on 28 female athletes with DKV. The single leg squat test was used to assess the DKV. All participants performed the reactive neuromuscular training, stationary cycling and resting sessions on three different days in a random order. The knee JPS and balance in the participants were measured immediately before and after the interventions. Kinematic analysis was used to measure the knee JPS in sagittal and frontal planes. In this regard, captured photos in the sagittal and frontal planes were analyzed using Kinovea software. The Y-balance test was applied to measure the balance. The data were analyzed by the repeated measures analysis of variance with a Bonferroni correction. Results: The results of the repeated measures analysis of variance showed that there was a significant difference between the sessions with respect to knee JPS in sagittal (F(2, 54) = 3.323, p = .047) and frontal (F(2, 54) = 23.83, p = .001) planes, respectively. Also, a significant difference in Y-balance test scores was observed between the sessions (F(2, 54) = 9.12, p = .001). Conclusions: The results of this study showed that reactive neuromuscular training improved joint position sense and balance in individuals with DKV. The findings of this study may provide a basis for developing injury prevention and rehabilitation strategies in athletes with DKV.
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Objectives: The purpose of this study was to investigate the effect of transverse plane foot position on lower limb kinematics during a single leg squat. Methods: This was a cross-sectional study conducted among highly-trained male athletes. Only participants who showed normal knee valgus during a drop landing screening test were recruited. Twelve junior athletes performed single leg squats while maintaining a knee flexion angle of 60°. The squats were executed in three foot positions: neutral (0°), adduction (-10°), and abduction (+10°). Three-dimensional motion analysis was used to capture the lower extremity kinematics of the participants' preferred limb. The hip and knee kinematics in the sagittal, frontal, and transverse planes during squatting were compared across the three foot positions using one-way ANOVA. Results: The participants showed a normal range of dynamic knee valgus (5.3°±1.6). No statistically significant differences were observed in hip flexion (p = 0.322), adduction (p = 0.834), or internal rotation (p = 0.967) across different foot positions. Similarly, no statistically significant differences were observed in knee flexion (p = 0.489), adduction (p = 0.822), or internal rotation (p = 0.971) across different foot positions. Conclusion: Small changes in transverse plane foot position do not affect lower extremity kinematics during single leg squat in highly trained adolescent males with normal dynamic knee valgus. Our findings may provide guidance on safer techniques for landing, pivoting, and cutting during training and game situations.
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Background Deficits in neuromuscular control are common after anterior cruciate ligament (ACL) reconstruction and may be associated with further knee injury. The knee valgus angle during a single-leg squat (SLS) is one measure of neuromuscular performance. Purpose To determine whether the knee valgus angle during SLS changes between 6 and 12 months after ACL reconstruction and to assess how the operative knee valgus angle compares with that of the contralateral side. Study Design Case series; Level of evidence, 4. Methods A cohort of 100 patients with uninjured contralateral knees were assessed at 6 and 12 months after primary hamstring autograft ACL reconstruction. Participants performed the SLS on each leg, and the knee valgus angle was measured via frame-by-frame video analysis at 30° of flexion and at each patient’s maximum knee flexion angle. Results For the operative limb at 30° of flexion, a small but statistically significant reduction was noted in the valgus angle between 6 and 12 months (5.46° vs 4.44°; P = .002; effect size = 0.24). At 6 months, a slightly higher valgus angle was seen in the operative limb compared with the nonoperative limb (5.46° vs 4.29°; P = .008; effect size = 0.27). At maximum flexion, no difference was seen between limbs in the valgus angle at either 6 or 12 months, and no change was seen in the operative limb between 6 and 12 months. At 6 months and 30° of knee flexion, 13 patients had a valgus angle greater than 10°. This group also had a higher mean valgus angle in the contralateral limb compared with the contralateral limb in the other 87 patients (8.5° vs 3.65°; P < .001). Conclusion During a controlled SLS, the knee valgus angle remained essentially constant, and minimal limb asymmetries were present over the 6- to 12-month postoperative period, a time when athletes typically increase their activity levels. Whether changes or asymmetries will be seen with more dynamically challenging tasks remains to be determined. When present, high valgus angles were commonly bilateral.
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The objective of this review is to analyze some of the biomechanical factors involved in the most common running injuries: anterior knee pain, iliotibial band syndrome, Achilles tendinopathy, and medial tibial stress syndrome/tibial stress fracture. Eighteen studies met all inclusion criteria. Results showed that there is little consistent evidence in the literature to connect any biomechanical anomaly to any given running injury, except for female runners with patellofemoral pain who have an increased peak hip adduction angle at stance phase. This review suggests that assessing and treating hip mechanics could help to prevent knee injuries in female runners.
Chapter
Neben akuten Verletzungen können auch chronische Beschwerden am Sprunggelenk oder der Achillessehne die Trainings- und Wettkampffähigkeit beeinträchtigen. Zuletzt sind die Behandlungsstrategien bei tendinopathischen Beschwerden in den Fokus der Rehabilitation gerückt. Dieses Kapitel gibt einen Überblick über die Diagnostik- und Therapieprinzipien bei akuten und chronischen Beschwerden im Bereich des Sprunggelenkes und der Achillessehne.
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Objective: To explore the relationship between ankle dorsiflexion range of motion (ROM) and hip and knee muscle strength between patients with a history of patellar dislocation (PD) to healthy controls. Design: Case-control study. Setting: Orthopaedical specialty outpatient clinic at a tertiary hospital. Participants: 88 individuals were recruited; 44 individuals aged 16 years or older, of both sexes, with a history of at least one episode of atraumatic unilateral or bilateral PD requiring emergency care (14 males; 30 females; mean age 20 years) and 44 healthy (control) individuals (11 males; 33 females; mean age 21 years) matched for age, weight and height to the PD cases. Intervention: Assessment of hip and knee strength and ankle dorsiflexion ROM. Outcome measures: Ankle dorsiflexion ROM was assessed through the lunge test with a goniometer. Hip and knee muscle strength was evaluated through isometric hand-held dynamometry. Differences between healthy and control individuals were assessed using Student T-Tests and Mann-Whitney U Test. Results: PD individuals presented with a reduced ankle dorsiflexion ROM (mean difference (MD): 9°; effect size (ES): 1.39; p<0.001) and generalised hip and knee weakness (MD range: 4.74 kgf to 31.4 kgf; ES range: 0.52 to 2.35; p<0.05) compared to healthy subjects. Conclusion: Individuals with a history of PD have reduced ankle dorsiflexion ROM and hip and knee muscle strength compared to healthy controls.
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Injury rates in gymnastics are among the highest in men’s and women’s sports. Gymnastics requires full body utilization, as both the upper extremity and lower extremity are used for weight-bearing and experience repetitive exposure to high ground reaction forces. However, despite the increasing frequency of gymnastics participation among youth populations, and the unique physical demands required of the sport, there is very little evidence-based research on best practices for return to play (RTP) protocols for gymnasts following injury. General RTP principles and the extraordinary demands of gymnasts must be well understood in order to create an effective, but safe, RTP protocol that returns gymnasts to sport while minimizing the risk of reinjury or the development of new injuries.
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Dynamic knee valgus (DKV) is a frontal plane knee kinematic alteration that has been associated with patellofemoral pain (PFP) in female runners. DKV is commonly assessed in clinical practice by measuring frontal plane knee projection angle (FPPA) during squat tests. However, it remains unclear whether the DKV observed in these tests is similar to or correlates with that observed during running in female runners. The aims of this cross-sectional study were to correlate and compare DKV, by measuring FPPA values, in a lateral step-down (LSD) squat test and running in female runners with and without PFP. A two-dimensional (2D) video analysis of the LSD test and running was carried out for 21 asymptomatic female runners and 17 PFP female runners in order to determine FPPA values. A Pearson correlation test and a factorial ANOVA with Bonferroni post hoc correction were used for statistical analysis. The FPPAs recorded in the LSD test were significantly higher than those recorded during running in the asymptomatic (16.32° ± 5.38 vs. 4.02° ± 3.26, p < 0.01) and PFP groups (17.54° ± 7.25 vs. 4.64° ± 3.62, p < 0.01). No significant differences were found in FPPA values between asymptomatic and PFP runners during the LSD test (16.32° ± 5.38 vs. 17.54° ± 7.25, p = 0.55) and running (4.02° ± 3.26 vs. 4.64° ± 3.62, p = 0.58). There was a small (r < 0.3) and non-significant (p > 0.05) correlation in FPPAs between the LSD test and running in both groups. According to our results, DKV was not similar during the LSD test and running, and there was no significant correlation in FPPA values between the LSD test and running in both groups. Therefore, clinicians and therapists should be aware of these findings when using the LSD test in clinical practice to evaluate DKV in female runners with or without PFP.
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It is important to optimise the functional recovery process to enhance patient outcomes after major injury such as anterior cruciate ligament reconstruction (ACLR). Restoring movement quality during sporting-type movements is important prior to return-to-sport (RTS) after ACLR. Alterations in movement quality during an array of functional tasks are common amongst ACLR patients at or near the time of RTS and are associated with worse outcomes after ACLR. The inability to correct movement issues prior to RTS is likely due to the use of incomplete programmes or a lack of volume and intensity of movement re-training programmes. Although most clinicians and researchers understand that re-training movement after ACLR is important (e.g., the ‘why’), there is often a disconnect with understanding the ‘how’ and ‘what’ of movement re-training post ACLR. The aim of this paper was to discuss factors relevant to movement dysfunction and re-training after ACLR and provide recommendations for clinicians to restore movement quality of patients after ACLR, prior to RTS. The paper recommends: (i) considering the factors which influence the expression of movement quality, which revolve around individual (e.g., neuromuscular, biomechanical, sensorimotor and neurocognitive factors), task-specific and environmental constraints; (ii) incorporating a three-staged movement re-training approach aligned to the ACLR functional recovery process: (1) addressing the neuromuscular and biomechanical and sensorimotor control factors which affect movement quality and motor learning, (2) including a progressive movement re-training approach to re-learn an array of functional tasks optimising coordination and motor learning (3) performing the final aspect of rehabilitation and movement training on the field, in realistic environments progressively simulating the sporting movement demands and environmental constraints; and (iii) effectively designing the movement programme for optimal load management, employing effective coach and feedback techniques and utilising qualitative movement analysis for transition between exercises, stages and for RTS.
Article
Context: The authors hypothesized that in people with hip-related groin pain, less static ankle dorsiflexion could lead to compensatory hip adduction and contralateral pelvic drop during step-down. Ankle dorsiflexion may be a modifiable factor to improve ability in those with hip-related groin pain to decrease hip/pelvic motion during functional tasks and improve function. Objective: To determine whether smaller static ankle dorsiflexion angles were associated with altered ankle, hip, and pelvis kinematics during step-down in people with hip-related groin pain. Design: Cross-sectional Setting: Academic medical center. Patients: A total of 30 people with hip-related groin pain (12 males and 18 females; 28.7 [5.3] y) participated. Intervention: None. Main outcome measures: Weight-bearing static ankle dorsiflexion with knee flexed and knee extended were measured via digital inclinometer. Pelvis, hip, and ankle kinematics during forward step-down were measured via 3D motion capture. Static ankle dorsiflexion and kinematics were compared with bivariate correlations. Results: Smaller static ankle dorsiflexion angles were associated with smaller ankle dorsiflexion angles during the step-down for both the knee flexed and knee extended static measures. Among the total sample, smaller static ankle dorsiflexion angle with knee flexed was associated with greater anterior pelvic tilt and greater contralateral pelvic drop during the step-down. Among only those who did not require a lowered step for safety, smaller static ankle dorsiflexion angles with knee flexed and knee extended were associated with greater anterior pelvic tilt, greater contralateral pelvic drop, and greater hip flexion. Conclusions: Among those with hip-related groin pain, smaller static ankle dorsiflexion angles are associated with less ankle dorsiflexion motion and altered pelvis and hip kinematics during a step-down. Future research is needed to assess the effect of treating restricted ankle dorsiflexion on quality of motion and symptoms in patients with hip-related groin pain.
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Background Identifying risk factors for lower limb injury is an important step in developing injury risk reduction training and testing for player monitoring. Female athletes are distinct from male athletes, warranting separate investigation into risk factors. Objective To systematically review the literature and synthesise the evidence for intrinsic risk factors for lower limb injury in female team field and court sports. Methods Five online databases were searched from inception to April 2020. To be eligible for inclusion, studies were required to be a prospective study presenting intrinsic risk factors for lower limb injury in female team field or court sport athletes. Risk of bias was assessed using the Quality of Prognosis Studies tool. Results Sixty-nine studies, capturing 2902 lower limb injuries in 14,492 female athletes, and analysing 80 distinct factors met the inclusion criteria. Risk factors for any lower limb injury included greater body mass (standardised mean difference [SMD] = 0.24, 95% confidence interval [95% CI] 0.18–0.29), greater body mass index (BMI) (SMD = 0.22, 95% CI 0.05–040), older age (SMD = 0.20, 95% CI 0.09–0.31), greater star excursion balance test (SEBT) anterior reach distance (SMD = 0.18, 95% CI 0.12–0.24), and smaller single-leg hop distance (SMD = − 0.09, 95% CI − 0.12 to − 0.06). Lower knee injury and osteoarthritis outcome score (KOOS) increased the risk of knee injury. Anterior cruciate ligament (ACL) injury risk factors included prior ACL injury (odds ratio [OR] = 3.94, 95% CI 2.07–7.50), greater double-leg postural sway (SMD = 0.58, 95% CI 0.02–1.15), and greater body mass (SMD = 0.25, 95% CI 0.12–0.39). Ankle injury risk factors included smaller SEBT anterior reach distance (SMD = − 0.13, 95% CI − 0.14 to − 0.13), greater single-leg hop distance asymmetry (OR = 3.67, 95% CI 1.42–9.45), and slower agility course time (OR = 0.20, 95% CI 0.05–0.88). Remaining factors were not associated with injury or had conflicting evidence. Conclusion Prior injury, older age, greater body mass, and greater BMI are risk factors for lower limb injury in female athletes. Limited evidence showed an association between KOOS, SEBT anterior reach, single-leg hop distance and asymmetry, double-leg postural sway, agility, and lower limb injury. PROSPERO ID: CRD42020171973.
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Möchten Patienten oder Sportler ihre Beweglichkeit verbessern, liegt das Dehnen als Maßnahme nahe. Ein Krafttraining erhöht aber genauso, wenn nicht sogar stärker, das Bewegungsausmaß und bringt dazu noch andere positive gesundheitliche Effekte mit sich. Vor allem das exzentrische Training mobilisiert das Muskel- und Bindegewebe.
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Resumo Objetivo Avaliar o alinhamento do joelho no plano frontal e o equilíbrio pélvico durante a descida de um degrau comparando atletas de futebol feminino e masculino. Métodos Estudo transversal, realizado com atletas de futebol das categorias sub-15 e sub-17, de ambos os sexos, de um clube profissional do Sul do Brasil. Foi realizado o teste de descida de um degrau, o qual foi filmado por uma câmera de vídeo, e, em sua avaliação, traçaram-se as medidas angulares durante o movimento por meio do software Kinovea (código aberto), versão 0.8.24. Resultados A amostra foi composta por 38 indivíduos, 19 do sexo masculino e 19 do sexo feminino. As atletas do sexo feminino apresentaram maior ângulo em varo (9,42° ± 1,65°) quando comparadas com os atletas masculinos (3,91° ± 2,0°; p = 0,04). Não houve diferença em relação à queda unilateral da pelve (drop pélvico) entre os grupos, e a associação entre o drop pélvico do quadril e o ângulo de projeção no plano frontal do joelho foi fraca em ambos os sexos. Conclusão Apesar de ambos os sexos terem apresentado queda pélvica, as atletas de base do sexo feminino apresentaram maior angulação do joelho em varo no teste de descida do degrau, e necessitam maior atenção para minimizar o risco de lesão.
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Background A range of non-contact injuries such as anterior cruciate ligament tear, and patellofemoral pain syndrome are caused by disordered knee joint loading from excessive dynamic knee valgus (DKV). Previous systematic reviews showed that DKV could be modified through the influence of hip strength and ankle range of motion. Therefore, the purpose of this systematic review was to examine the effects of exercise intervention which involved either top-down or bottom-up kinetic chains on minimizing DKV in male and female adults and adolescents, with and without existing knee pain. Methodology Electronic searches were conducted in SAGE, Science Direct, SCOPUS, and Pubmed. The search strategy consisted of medical subject headings and free-text search keywords, synonyms and variations of ‘exercise intervention,’ ‘knee alignment,’ ‘dynamic knee valgus’, ‘knee abduction’ that were merged via the Boolean operator ‘AND’ and ‘OR’. The search was conducted on full-text journals that documented the impact of the exercise intervention program involving either the bottom-up or top-down DKV mechanism on the knee kinematics. Furthermore, exercise intervention in this review should last at least one week which included two or three sessions per week. This review also considered both men and women of all ages with a healthy or symptomatic knee problem. The risk of bias of the included studies was assessed by Cochrane risk assessment tool. The protocol of this review was registered at PROSPERO (registration number: CRD42021219121). Results Ten studies with a total of 423 participants (male = 22.7%, female = 77.3%; adults = 249, adolescents = 123; pre-adolescent = 51) met the inclusion criteria of this review. Seven studies showed the significant effects of the exercise intervention program (range from two weeks to ten weeks) on reducing DKV. The exercise training in these seven studies focused on muscle groups directly attached to the knee joint such as hamstrings and gastrocnemius. The remaining three studies did not show significant improvement in DKV after the exercise intervention (range between eight weeks to twelve weeks) probably because they focused on trunk and back muscles instead of muscles crossing the knee joint. Conclusion Exercises targeting specific knee-joint muscles, either from top-down or bottom-up kinetic chain, are likely to reduce DKV formation. These results may assist athletes and coaches to develop effective exercise program that could minimize DKV and ultimately prevent lower limb injuries.
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This study aimed to systematically review research investigating the association between hip muscle strength and dynamic knee valgus (DKV). Four databases (MEDLINE, PubMed, CINAHL, and SPORTDiscus) were searched for journal articles published from inception to October 2020. Seven studies investigating the association between hip muscle strength and DKV using a two-dimensional motion analysis system in healthy adults were included. The relationship between hip abductor muscle strength and DKV was negatively correlated in two studies, positively correlated in two studies, and not correlated in three studies. The DKV was associated with reduced hip extensor muscle strength in two studies and reduced hip external rotator muscle strength in two studies, while no correlation was found in three and five studies for each muscle group, respectively. The relationship between hip muscle strength, including abductors, extensors, and external rotators and DKV is conflicting. Considering the current literature limitations and variable methodological approaches used among studies, the clinical relevance of such findings should be interpreted cautiously. Therefore, future studies are recommended to measure the eccentric strength of hip muscles, resembling muscular movement during landing. Furthermore, high-demand and sufficiently challenging functional tasks revealing lower limb kinematic differences, such as cutting and jumping tasks, are recommended for measuring the DKV.
Article
Möchten Patient*innen oder Sportler*innen ihre Beweglichkeit verbessern, liegt das Dehnen als Maßnahme nahe. Ein Krafttraining erhöht aber genauso, wenn nicht sogar stärker, das Bewegungsausmaß und bringt dazu noch andere positive gesundheitliche Effekte mit sich. Vor allem das exzentrische Training mobilisiert das Muskel- und Bindegewebe.
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Objective: Stand-to-sit task is an important daily function, but there is a lack of research evidence on whether knee osteoarthritis (knee OA) affects the postural balance during the task. This study aimed to compare individuals with knee OA and asymptomatic controls in postural balance and identify kinematic and lower extremity muscle activity characteristics in individuals with knee OA during the stand-to-sit task. Methods: In total, 30 individuals with knee OA and 30 age-matched asymptomatic controls performed the 30-s Chair Stand Test (30sCST) at self-selected speeds. Motion analysis data and surface electromyography (sEMG) were collected while participants performed the 30sCST. To quantify postural balance, the displacement of the center of mass (CoM) and the peak instantaneous velocity of the CoM were calculated. The kinematic data included forward lean angles of the trunk and pelvic, range of motion (RoM) of the hip, knee, and ankle joints in the sagittal plane. The averaged activation levels of gluteus maximus, vastus lateralis, vastus medialis, rectus femoris, biceps femoris (BF), tibialis anterior (TA), and medial head of gastrocnemius muscles were indicated by the normalized root mean square amplitudes. Results: Compared with the asymptomatic control group, the knee OA group prolonged the duration of the stand-to-sit task, demonstrated significantly larger CoM displacement and peak instantaneous CoM velocity in the anterior-posterior direction, reduced ankle dorsiflexion RoM, greater anterior pelvic tilt RoM, and lower quadriceps femoris and muscles activation level coupled with higher BF muscle activation level during the stand-to-sit task. Conclusion: This study indicates that individuals with knee OA adopt greater pelvic forward lean RoM and higher BF muscle activation level during the stand-to-sit task. However, these individuals exist greater CoM excursion in the anterior-posterior direction and take more time to complete the task. This daily functional activity should be added Frontiers in Human Neuroscience | www.frontiersin.org 1 November 2021 | Volume 15 | Article 760960 Fu et al. Balance in Osteoarthritis During Stand-to-Sit to the rehabilitation goals for individuals with knee OA. The knee OA group performs reduced ankle dorsiflexion RoM, quadriceps femoris, and TA activation deficit. In the future, the rehabilitation programs targeting these impairments could be beneficial for restoring the functional transfer in individuals with knee OA.
Article
This study sought to determine whether the inclusion of an opponent on an isoinertial crossover step task influenced the post-activation response and power production. Twenty adult male team-sports athletes participated in a randomized crossover trial. We used a novel design in which the performance of an isoinertial flywheel exercise was tested with or without the inclusion of sport-specific constraints (inclusion of an opponent vs. no opponent) in one of the two sequences (sequence one: constraint manipulation followed by no constraint manipulation; and sequence two: no constraint manipulation followed by constraint manipulation). Maximal power was recorded during exercise; then the coefficient of variation of maximal power was estimated. Post-activation responses were measured using unilateral jump height and change-of-direction time. Also, ankle dorsiflexion range of motion was measured. The use of an isoinertial flywheel resulted in improved ankle dorsiflexion and the capacity to repeat change-of-direction. Furthermore, the inclusion of an opponent was associated with a higher variability of the power output in the concentric phase of the movement. Importantly, performing the crossover step task in front of an opponent was also linked to a positive correlation between unilateral countermovement jump and power output. We conclude that the inclusion of typical constraints of the performance environment may have induced movement adaptations to accommodate the unpredictability associated with the actions of the opponent.
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Background Dynamic knee valgus (DKV) is a common lower extremity movement disorder among females. This study aimed to investigate kinematic couplings between lower extremity joints in female junior athletes with DKV during single and double-leg landing and gait. Methods Twenty-six physically active female junior athletes (10–14 years old) with DKV were recruited. Kinematic couplings between rearfoot, tibia, knee, and hip were extracted using eight Vicon motion capture cameras and two force plates. Zero-lag cross-correlation coefficient and vector coding were used to calculate kinematic couplings between joints during physical tasks. Paired t-test and Wilcoxon tests were run to find significant couplings between joint motions and coupling strengths. Bonferroni posthoc was used to determine significance with α ≤ 0.05. Results The results showed that the strongest kinematic relationship existed between rearfoot eversion/inversion and tibial internal/external rotation during all three tasks. Correlations of the rearfoot supination/pronation with tibial rotations, knee, and hip motions in sagittal, frontal, and transverse planes were very strong to strong during double-leg landing and moderate to weak during gait. A weak correlation was observed between rearfoot supination/pronation and hip adduction/abduction during single-leg landing. Conclusions Coupling relationships between rearfoot, knee, and hip vary by the task intensity and alignment profiles in female juniors with DKV.
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The 4-Element Movement System Model describes primary elements (motion, force, motor control, and energy) essential to the performance of all movements. The model provides a framework or scaffolding which allows for consistent processes to be used in examination and intervention decisions. The process starts with task identification followed by a systematic observation of control, amount, speed, symmetry, and symptoms during movement. Testable hypotheses are generated from the observations which inform the examination and the interventions. This commentary describes the use of the 4-Element Movement System Model in entry level and post-graduate residency educational programs and in clinical care with three common sports-related diagnoses. Level of evidence: 5.
Article
Resumo A presente atualização foi embasada nas novas evidências científicas das principais tendinopatias relacionadas ao quadril. Foram abordadas temáticas que envolvem os princípios do aparecimento das tendinopatias através, principalmente, do princípio da capacidade versus demanda e os aspectos biomecânicos envolvidos no seu aparecimento, suas principais características e apresentações clínicas. Associadas a isso, foram expostas as atualizações voltadas ao tratamento, com a terapia por exercício sendo o foco do tratamento conservador e as abordagens cirúrgicas necessárias para o controle ou resolução desses casos.
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Background Foam rolling has been shown to acutely improve joint range of motion (ROM). However, limited knowledge exists on the chronic and residual effects. The primary purpose of this study was to examine the chronic and residual effects of a 2-week roller–massager intervention on ankle dorsiflexion ROM and dynamic balance.Methods Forty-two participants (24.3 ± 2.5 years, 33 males, 9 females) were randomly assigned to either roller-massage (RM) or control group (= no intervention). Ankle ROM was assessed with the weight-bearing lunge test (WBLT) and dynamic balance with the Y-Balance test for both limbs. The RM group was instructed to roll their calf muscles for three sets of 60 s per leg on 6 days a week over 2 weeks. Acute effects were measured during baseline testing for dorsiflexion ROM and dynamic balance immediately after foam rolling. Chronic and residual effects were measured 1 day and 7 days after the intervention period. Multivariate ANOVA was performed for post-hoc comparisons to determine acute, chronic, and residual effects.ResultsSignificant acute and chronic foam rolling effects (p <0.05) were found for ankle dorsiflexion ROM. The chronic increase in ROM slightly decreased 7 days post-intervention but remained significantly above baseline (p < 0.05). Regarding dynamic balance, there were no acute but chronic (p < 0.05) and residual (p < 0.05) effects.Conclusion Using a roller–massager for a 2-week period chronically increases ROM and dynamic balance. These increases are still significant 7 days post-intervention emphasizing the sustainability of foam rolling effects.
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Objectives To investigate the association between sensorimotor function and visual assessment of postural orientation during execution of weight-bearing activities in patients with anterior cruciate ligament reconstruction (ACLR). Design Cross-sectional study. Setting Laboratory. Participants Fifty-two individuals (23 women and 29 men, mean (SD) age 26.5 (6.4)) approximately 7 months after ACLR. Main outcome measures Sensorimotor function (proprioception, ankle dorsiflexion range of motion, and isometric muscle strength of the hip, knee, and trunk) were recorded on the injured leg. Postural orientation errors (POEs) were visually scored from video-recordings of the injured leg during execution of 5 functional tasks, and POE subscales activities of daily living (ADL) and Sport, and Total POE score were used in the analysis. Results Lower hip external rotation strength was associated with higher Total POE score (B = −24.4, p = 0.041) and higher POE subscale ADL score (B = −24.9, p = 0.03). No associations between sensorimotor function and POE subscale Sport were found. Conclusions Decreased hip external rotation strength might contribute to higher scores on the POE subscale ADL and the Total POE score, in men and women following ACLR. Future studies will reveal if strengthening of hip external rotation strength improves postural orientation.
Article
This prospective study in youth football examined the relationship between frontal plane knee projection angle (FPKPA) during the single‐leg squat and sustaining an acute lower extremity injury or acute non‐contact lower extremity injury. Secondly, side‐to‐side asymmetry in FPKPA and sex as injury risk factors were explored. In addition, we investigated the influence of age, sex and leg dominance on the FPKPA. A total of 558 youth football players (U11 to U14), participated in the single‐leg squat test and prospective injury registration. FPKPA was not found as a risk factor for injuries at this age. There was no difference in the mean FPKPA between sexes. However, FPKPA was associated with age; oldest subjects displayed the smallest FPKPA. Among boys, the frontal plane knee control improved by age. Among girls, the relationship between age and FPKPA was not as clear but the oldest girls displayed the smallest mean FPKPA in the study (12.2°+ 8.3°). The FPKPA was greater on the dominant kicking leg compared to the non‐dominant support leg (P<0.001 for boys, P=0.001 for girls). However, side‐to‐side asymmetry in FPKPA was not associated with future injuries. In conclusion, frontal plane knee control in the single‐leg squat was not associated with lower extremity injuries among young football players. As the single‐leg squat to 90° knee flexion was too demanding for many subjects, easier single‐leg squat test procedure or a different movement control test, such as a double‐legged squat, could be more suitable for the young football players. This article is protected by copyright. All rights reserved.
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The final publication is available at link.springer.com http://link.springer.com/article/10.1007/s40279-016-0519-8
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BACKGROUND: Prospective studies have reported that abnormal movement patterns at the trunk, hip, and knee are associated with noncontact anterior cruciate ligament (ACL) injuries. Impaired hip strength may underlie these abnormal movement patterns, suggesting that diminished hip strength may increase the risk of noncontact ACL injury. PURPOSE: To determine whether baseline hip strength predicts future noncontact ACL injury in athletes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Before the start of the competitive season, isometric hip strength (external rotation and abduction) was measured bilaterally by use of a handheld dynamometer in 501 competitive athletes (138 female and 363 male athletes) participating in various sports. During the sport season, ACL injury status was recorded, and injured athletes were further classified based on the mechanism of injury (noncontact vs contact). After the season, logistic regression was used to determine whether baseline hip strength predicted future noncontact ACL injury. Receiver operating characteristic (ROC) curves were constructed independently for each strength measure to determine the clinical cutoff value between a high-risk and low-risk outcome. RESULTS: A total of 15 noncontact ACL injuries were confirmed (6 females, 9 males), for an overall annual incidence of 3.0% (2.5% for males, 4.3% for females). Baseline hip strength measures (external rotation and abduction) were significantly lower in injured athletes compared with noninjured athletes (P = .003 and P < .001, respectively). Separate logistic regression models indicated that impaired hip strength increased future injury risk (external rotation: odds ratio [OR] = 1.23 [95% CI, 1.08-1.39], P = .001; abduction: OR = 1.12 [95% CI, 1.05-1.20], P = .001). Clinical cutoffs to define high risk were established as external rotation strength ≤20.3% BW (percentage of body weight) or abduction strength ≤35.4% BW. CONCLUSION: Measures of preseason isometric hip abduction and external rotation strength independently predicted future noncontact ACL injury status in competitive athletes. The study data suggest that screening procedures to assess ACL injury risk should include an assessment of isometric hip abduction and/or external rotation strength.
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Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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To examine the evidence for effect of restricted ankle dorsiflexion range of motion on lower-extremity landing mechanics. Literature review. Systematic search of the literature. Articles critiqued by two reviewers. Six studies were identified that investigated the effect of restricted DF ROM on landing mechanics. Overall, results suggest that landing mechanics are altered with restricted DF ROM, but studies disagree as to the particular mechanical variables affected. There is evidence that restricted dorsiflexion range of motion may alter lower-extremity landing mechanics in a manner, which predisposes athletes to injury. Interpretation of results was made difficult by the variation in landing tasks investigated and the lack studies investigating sport-specific landing tasks. The focus of studies on specific mechanical variables rather than mechanical patterns and the analysis of pooled data in the presence of different compensation strategies between participants also made interpretation difficult. These areas require further research. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Achilles tendinopathy (AT) is a prevalent condition among runners and military personnel. Although ankle dorsiflexion (DF) range of motion (ROM) as measured with the knee bent has not been previously associated with AT, the literature concerning its role is limited. In addition, the role of lower extremity movement pattern in the pathogenesis of AT has not been studied prospectively. The purpose of this study was to further explore the role of ankle DF ROM as measured with the knee bent and that of lower extremity movement pattern as risk factors for mid-portion AT. Seventy healthy male military recruits (mean ± SD age, height and body mass of 19.6 ± 1.0 years, 176.0 ± 10.0 cm, and 71.5 ± 7.4 kg) participated in this study. Ankle DF ROM as measured with the knee bent in weight-bearing (WB) and non-weight-bearing (NWB), as well as lower extremity quality of movement during a lateral step down (LSD) test were measured at baseline. Participants were then followed for a 6-month period of army basic training with recording of the development of AT. Five participants developed AT during training. Participants that developed AT had a more limited NWB ankle DF ROM (27.4(0) versus 21.1(0), p = 0.025). The quality of lower extremity movement did not differ between injured and uninjured participants (p = 0.361). A more limited ankle DF ROM as measured in NWB with the knee bent increases the risk of developing AT among military recruits taking part in intensive physical training.
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Context: Ankle-dorsiflexion (DF) range of motion (ROM) may influence movement variables that are known to affect anterior cruciate ligament loading, such as knee valgus and knee flexion. To our knowledge, researchers have not studied individuals with limited or normal ankle DF-ROM to investigate the relationship between those factors and the lower extremity movement patterns associated with anterior cruciate ligament injury. Objective: To determine, using 2 different measurement techniques, whether knee- and ankle-joint kinematics differ between participants with limited and normal ankle DF-ROM. Design: Cross-sectional study. Setting: Sports medicine research laboratory. Patients or other participants: Forty physically active adults (20 with limited ankle DF-ROM, 20 with normal ankle DF-ROM). Main outcome measure(s): Ankle DF-ROM was assessed using 2 techniques: (1) nonweight-bearing ankle DF-ROM with the knee straight, and (2) weight-bearing lunge (WBL). Knee flexion, knee valgus-varus, knee internal-external rotation, and ankle DF displacements were assessed during the overhead-squat, single-legged squat, and jump-landing tasks. Separate 1-way analyses of variance were performed to determine whether differences in knee- and ankle-joint kinematics existed between the normal and limited groups for each assessment. Results: We observed no differences between the normal and limited groups when classifying groups based on nonweight-bearing passive-ankle DF-ROM. However, individuals with greater ankle DF-ROM during the WBL displayed greater knee-flexion and ankle-DF displacement and peak knee flexion during the overhead-squat and single-legged squat tasks. In addition, those individuals also demonstrated greater knee-varus displacement during the single-legged squat. Conclusions: Greater ankle DF-ROM assessed during the WBL was associated with greater knee-flexion and ankle-DF displacement during both squatting tasks as well as greater knee-varus displacement during the single-legged squat. Assessment of ankle DF-ROM using the WBL provided important insight into compensatory movement patterns during squatting, whereas nonweight-bearing passive ankle DF-ROM did not. Improving ankle DF-ROM during the WBL may be an important intervention for altering high-risk movement patterns commonly associated with noncontact anterior cruciate ligament injury.
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Purpose: While previous studies have examined the association between ankle dorsiflexion flexibility and deleterious landing postures, it is not currently known how landing kinetics are influenced by ankle dorsiflexion flexibility. The purpose of this study was to examine whether ankle dorsiflexion flexibility was associated with landing kinematics and kinetics that have been shown to increase the risk of anterior cruciate ligament (ACL) injury in female athletes. Methods: Twenty-three female collegiate soccer players participated in a preseason screening that included the assessment of ankle dorsiflexion flexibility and lower-body kinematics and kinetics during a drop vertical jump task. Results: The results demonstrated that females with less ankle dorsiflexion flexibility exhibited greater peak knee abduction moments (r = -.442), greater peak knee abduction angles (r = .355), and less peak knee flexion angles (r = .385) during landing. The range of dorsiflexion flexibility for the current study was between 9° and 23° (mean = 15.0°; SD 3.9°). Conclusion: Dorsiflexion flexibility may serve as a useful clinical measure to predict poor landing postures and external forces that have been associated with increased knee injury risk. Rehabilitation specialists can provide interventions aimed at improving dorsiflexion flexibility in order to ameliorate the impact of this modifiable factor on deleterious landing kinematics and kinetics in female athletes. LEVEL OF EVIDENCE: II.
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Objective: To determine range of motion (ROM), postural alignment, and dynamic motion differences between those with and without medial knee displacement (MKD) during the overhead squat (OHS). We hypothesized those with MKD would have restricted ROM, differing postural alignment, and poorer quality dynamic motion than those without MKD. Design: Observational. Setting: University Research Laboratory. Participants: Ninety-seven healthy recreationally active college-aged individuals. Independent Variables: Groups were determined by the presence (MKD group) or absence (control group) of MKD during an OHS. Main Outcome Measures: Range of motion measures were active and passive ankle dorsiflexion with the knee straight and bent, hip internal and external rotation, and hip abduction. Postural alignment measures were Q angle, navicular drop, and genu recurvatum. Quality of dynamic motion was measured using total Landing Error Scoring System (LESS) score. Results: The MKD group had significantly less active (P = 0.017) and passive (P = 0.045) ankle dorsiflexion with the knee straight, as well as significantly increased Q angle (P = 0.004) and decreased navicular drop (P = 0.009). There were no significant differences in total LESS score or the other outcome measures. Conclusions: There is select ROM, such as ankle dorsiflexion, and postural measures clinicians can screen for that may be related to increased MKD and theoretically elevated risk of injury.
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Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes. Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains. This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination 'ankle', 'sprain', 'injuries', 'lateral', 'manual therapy', and 'joint mobilisation'. The methodological quality of individual studies was assessed using the PEDro scale. After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed. For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.
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Study design: Cross-sectional. Objective: To investigate the interrater reliability of movement-quality ratings for the forward step-down (FSD) test and to compare hip muscle strength and lower extremity joint range of motion and muscle flexibility among asymptomatic women with different levels of movement quality. Background: The interrater reliability of the FSD test has not yet been investigated. Additionally, it is not known whether differences in musculoskeletal measures exist among individuals with different levels of movement quality during the FSD test. Methods: Two physical therapists assessed movement quality during the FSD test in 26 asymptomatic women (mean ± SD age, 22.7 ± 0.9 years). Hip muscle strength and lower extremity joint range of motion and muscle flexibility were also assessed. The interrater reliability of the FSD test was estimated by using the kappa coefficient and percent agreement. Differences in musculoskeletal measures based on movement quality were assessed by independent t tests. Results: The kappa coefficient and percent agreement for rating the quality of movement on the FSD test were 0.80 (95% confidence interval: 0.57, 1.00) and 85%, respectively. The subjects with moderate movement quality had significantly less strength of the hip abductors, less knee flexion range of motion measured in prone (quadriceps flexibility), and less hip adduction range of motion measured in sidelying (iliotibial band/tensor fascia latae flexibility) compared to those with good movement quality. Conclusion: There was good agreement for the rating of movement quality during the FSD test, and there were physical attributes that distinguished those with moderate from those with good quality of movement.
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Context: Two-dimensional (or medial knee displacement [MKD]) and 3-dimensional (3D) knee valgus are theorized to contribute to anterior cruciate ligament injuries. However, whether these displacements can be improved in the double-legged squat (DLS) after an exercise intervention is unclear. Objective: To determine if MKD and 3D knee valgus are improved in a DLS after an exercise intervention. Design: Randomized controlled clinical trial. Setting: Research laboratory. Patients or other participants: A total of 32 participants were enrolled in this study and were randomly assigned to the control (n = 16) or intervention (n = 16) group. During a DLS, all participants demonstrated knee valgus that was corrected with a heel lift. Intervention(s): The intervention group completed 10 sessions of directed exercise that focused on hip and ankle strength and flexibility over a 2- to 3-week period. Main outcome measure(s): We assessed MKD and 3D knee valgus during the DLS using an electromagnetic tracking system. Hip strength and ankle-dorsiflexion range of motion were measured. Change scores were calculated for MKD and 3D valgus at 0%, 10%, 20%, 30%, 40%, and 50% phases, and group (2 levels)-by phase (6 levels) repeated-measures analyses of variance were conducted. Independent t tests were used to compare change scores in other variables (α < .05). Results: The MKD decreased from 20% to 50% of the DLS (P = .02) and 3D knee valgus improved from 30% to 50% of the squat phase (P = .001). Ankle-dorsiflexion range of motion (knee extended) increased in the intervention group (P = .009). No other significant findings were observed (P > .05). Conclusions: The intervention reduced MKD and 3D knee valgus during a DLS. The intervention also increased ankle range of motion. Our inclusion criteria might have limited our ability to observe changes in hip strength.
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Because of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers. Twenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention. We conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods. From the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed. The proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.
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Knee valgus is a potential risk factor for lower extremity (LE) injuries. Clinical movement screenings and passive range of motion (PROM) measurements may help identify neuromuscular patterns, which contribute to knee valgus. The purpose of this study was to compare LE muscle activation and PROM between subjects who display visual medial knee displacement (MKD) during a single leg squat (SLS) and those who do not. We hypothesized that muscular activation and PROM would differ between the groups. Forty, physically active adults (20 control, 20 MKD) participated in this study. Subjects completed ten LE PROM assessments and performed five SLS trials while EMG data were collected from eight LE muscles. Three separate MANOVAs were utilized to identify group differences in EMG data, muscle co-activation, and PROM. Results, during the SLS, indicated hip co-activation ratios revealed smaller gluteus medius to hip adductor (GMed : Hip Add) (P = .028) and gluteus maximus to hip adductor (GMax : Hip Add) co-activation ratios (P = .007) compared to the control group. Also, the MKD group displayed significantly less passive ankle dorsiflexion with the knee extended (P = .047) and flexed (P = .034), and greater talar glide motion (P = .012). The findings of this study indicate that MKD during a SLS appears to be influenced by decreased co-activation of the gluteal to the hip adductor muscles and restricted dorsiflexion. Therefore, conditioning, rehabilitation, and injury prevention programs should focus on decreasing hip adductor activity, increasing hip abductor and external rotator activity, and increasing ankle dorsiflexion in hopes to decrease the incidence of these injuries.
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Functional movement analyses are commonly performed to evaluate for the risk of developing a knee or lower extremity injury. Conclusions are drawn about muscle strength, flexibility, and activation during these screenings based upon observed movement patterns. The purpose of this project was to compare range of motion (ROM), isokinetic strength, and muscle activity in individuals with and without excessive medial knee displacement (MKD) during a double-leg squat. Seventeen control participants and 14 participants with MKD had ankle and hip ROM and hip isokinetic peak torque assessed. Participants also had muscle activity of the gluteus maximus and adductor complex assessed during the descending and ascending phases of 5 consecutive double leg squats. The MKD group demonstrated decreased dorsifl exion ROM with the knee straight (P � .001), and increased adductor activation (P = .02) during the squat. These results indicate that gastrocnemius muscle tightness and increased adductor activity may cause excessive MKD.
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Limitations in gastrocnemius/soleus flexibility that restrict ankle dorsiflexion during dynamic tasks have been reported in individuals with patellofemoral pain (PFP) and are theorized to play a role in its development. To determine the effect of restricted ankle-dorsiflexion range of motion (ROM) on lower extremity kinematics and muscle activity (EMG) during a squat. The authors hypothesized that restricted ankle-dorsiflexion ROM would alter knee kinematics and lower extremity EMG during a squat. Cross-sectional. 30 healthy, recreationally active individuals without a history of lower extremity injury. Each participant performed 7 trials of a double-leg squat under 2 conditions: a no-wedge condition (NW) with the foot flat on the floor and a wedge condition (W) with a 12° forefoot angle to simulate reduced plantar-flexor flexibility. 3-dimensional hip and knee kinematics, medial knee displacement (MKD), and ankle-dorsiflexion angle. EMG of vastus medialis oblique (VMO), vastus lateralis (VL), lateral gastrocnemius (LG), and soleus (SOL). One-way repeated-measures ANOVAs were performed to determine differences between the W and NW conditions. Compared with the NW condition, the wedge produced decreased peak knee flexion (P < .001, effect size [ES] = 0.81) and knee-flexion excursion (P < .001, ES = 0.82) while producing increased peak ankle dorsiflexion (P = .006, ES = 0.31), ankle-dorsiflexion excursion (P < .001, ES = 0.31), peak knee-valgus angle (P = .02, ES = 0.21), and MKD (P < .001, ES = 2.92). During the W condition, VL (P = 0.002, ES = 0.33) and VMO (P = .049, ES = 0.20) activity decreased while soleus activity increased (P = .03, ES = 0.64) compared with the NW condition. No changes were seen in hip kinematics (P > .05). Altering ankle-dorsiflexion starting position during a double-leg squat resulted in increased knee valgus and MKD, as well as decreased quadriceps activation and increased soleus activation. These changes are similar to those seen in people with PFP.
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We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24-48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre-intervention measures or between the post-intervention and 1-week follow-up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1798-1804, 2012.
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A smaller amount of ankle-dorsiflexion displacement during landing is associated with less knee-flexion displacement and greater ground reaction forces, and greater ground reaction forces are associated with greater knee-valgus displacement. Additionally, restricted dorsiflexion range of motion (ROM) is associated with greater knee-valgus displacement during landing and squatting tasks. Because large ground reaction forces and valgus displacement and limited knee-flexion displacement during landing are anterior cruciate ligament (ACL) injury risk factors, dorsiflexion ROM restrictions may be associated with a greater risk of ACL injury. However, it is unclear whether clinical measures of dorsiflexion ROM are associated with landing biomechanics. To evaluate relationships between dorsiflexion ROM and landing biomechanics. Descriptive laboratory study. Research laboratory. Thirty-five healthy, physically active volunteers. Passive dorsiflexion ROM was assessed under extended-knee and flexed-knee conditions. Landing biomechanics were assessed via an optical motion-capture system interfaced with a force plate. Dorsiflexion ROM was measured in degrees using goniometry. Knee-flexion and knee-valgus displacements and vertical and posterior ground reaction forces were calculated during the landing task. Simple correlations were used to evaluate relationships between dorsiflexion ROM and each biomechanical variable. Significant correlations were noted between extended-knee dorsiflexion ROM and knee-flexion displacement (r  =  0.464, P  =  .029) and vertical (r  =  -0.411, P  =  .014) and posterior (r  =  -0.412, P  =  .014) ground reaction forces. All correlations for flexed-knee dorsiflexion ROM and knee-valgus displacement were nonsignificant. Greater dorsiflexion ROM was associated with greater knee-flexion displacement and smaller ground reaction forces during landing, thus inducing a landing posture consistent with reduced ACL injury risk and limiting the forces the lower extremity must absorb. These findings suggest that clinical techniques to increase plantar-flexor extensibility and dorsiflexion ROM may be important additions to ACL injury-prevention programs.
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Case-control study of females with patellofemoral pain syndrome (PFPS) and a control group. Three different approaches were used to examine the utility of a 2-dimensional (2-D) frontal plane projection angle (FPPA) measure of knee alignment. First, we measured the FPPA association with respect to 3-dimensional (3-D) lower extremity joint rotations during single-leg squats. Second, we determined the correlation of the FPPA during single-leg squats with hip and knee joint rotations during running and single leg jumping. Third, we compared the FPPA between females with and without PFPS. PFPS is associated with altered lower extremity kinematics during weight-bearing activities that decrease retropatellar contact area and increase retropatellar stress. An objective and simple procedure to quantify altered kinematics during weight-bearing activities may help clinicians identify individuals who may likely benefit from interventions to improve lower extremity kinematics. Twenty females with PFPS and 20 healthy female controls performed single-leg squats, running, and repetitive single-leg jumps while 3-D lower extremity kinematics were recorded. The FPPA was recorded by a digital camera during single-leg stance and single-leg squats. Correlation coefficients were used to quantify the association between the FPPA and transverse and frontal plane hip and knee angles for all activities. Independent t tests were used to compare FPPA values between groups. FPPA values representing medial displacement of the knee during single-leg squats were associated with increased hip adduction (r = 0.32 to 0.38, P<.044) and knee external rotation (r = 0.48 to 0.55, P<.001) across activities. FPPA values for the PFPS group reveal greater medial displacement of the knee compared with those of the control group during single-leg squats (P = .012). The association between the FPPA and lower extremity kinematics that are associated with PFPS suggest that the FPPA during single-leg squats may be a useful clinical measure. However, these methods should not be used to quantify 3-D joint rotations.
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Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our purpose in this study to determine the intrinsic risk factors for the development of anterior knee pain in an athletic population over a 2-year period. Before the start of training, 282 male and female students enrolled in physical education classes were evaluated for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters. During this 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses revealed a significant difference between those subjects who developed patellofemoral pain and those who did not concerning quadriceps and gastrocnemius muscle flexibility, explosive strength, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. However, only a shortened quadriceps muscle, an altered vastus medialis obliquus muscle reflex response time, a decreased explosive strength, and a hypermobile patella had a significant correlation with the incidence of patellofemoral pain. We concluded that the latter four parameters play a dominant role in the genesis of anterior knee pain and we therefore deem them to be risk factors for this syndrome.
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Editor's Note: PTJ's Editorial Board has adopted PRISMA to help PTJ better communicate research to physical therapists. For more, read Chris Maher's editorial starting on page 870. Membership of the PRISMA Group is provided in the Acknowledgments. This article has been reprinted with permission from the Annals of Internal Medicine from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med. Available at: http://www.annals.org/cgi/content/full/151/4/264. The authors jointly hold copyright of this article. This article has also been published in PLoS Medicine, BMJ, Journal of Clinical Epidemiology, and Open Medicine. Copyright © 2009 Moher et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Article
Study Design Cross-sectional. Background Altered hip and knee kinematics have been associated with several knee disorders including anterior cruciate ligament tear, patellofemoral pain, and iliotibial band syndrome. Limited ankle dorsiflexion (DF) range of motion (ROM), which has been linked with some of these disorders, has also been associated with altered knee kinematics. Objective Explore the association of ankle DF ROM with hip and knee kinematics during a step down task. Methods Thirty healthy participants underwent a 3-dimensional analysis of hip and knee kinematics during a lateral step down test, followed by measurement of ankle DF ROM in weight-bearing (WB) and non-weight-bearing (NWB). Participants were dichotomized using the median values into low- and high-DF subgroups within both WB and NWB. Hip and knee kinematics were compared between the low- and high-DF subgroups. Results Participants in the low-DF subgroups exhibited greater peak hip adduction (WB, P=.01; NWB, P<.01) and greater peak knee external rotation (WB, P=.01; NWB, P<.01) compared with participants in the high-DF subgroups. In addition, participants in the low-DF WB subgroup exhibited decreased peak knee flexion compared with participants in the high-DF WB subgroup (P<.01). Conclusion Individuals with a less ankle DF ROM exhibited hip and knee kinematics previously associated with several knee disorders suggesting this impairment may be involved in the pathogenesis of the same disorders. Assessment of ankle DF ROM may be useful as part of a pre-participation screening. Furthermore, deficits in ankle DF ROM may need to be addressed in individuals with altered movement patterns. J Orthop Sports Phys Ther, Epub 29 Sep 2016. doi:10.2519/jospt.2016.6621.
Article
Background: The frontal plane projection angle (FPPA) is frequently used as a measure of dynamic knee valgus during functional tasks, such as the single leg squat. Increased dynamic knee valgus is observed in people with knee pathologies including patellofemoral pain and anterior cruciate injury. As the foot is the primary interface with the support surface, foot and ankle mobility may affect the FPPA. This study investigated the relationship between foot and ankle mobility and the FPPA in asymptomatic adults. Methods: Thirty healthy people (aged 18-50 years) performed 5 single leg squats. Peak FPPA and FPPA excursion were determined from digital video recordings. Foot mobility was quantified as the difference in dorsal midfoot height or midfoot width, between non-weightbearing and bilateral weightbearing positions. Ankle joint dorsiflexion range was measured as the maximum distance in centimetres between the longest toe and the wall during a knee-to-wall lunge. Linear regressions with generalised estimating equations were used to examine relationships between variables. Results: Higher midfoot width mobility was associated with greater peak FPPA (β 0.90, p < 0.001, odds ratio [OR] 2.5), and FPPA excursion (β 0.67, p < 0.001, OR 1.9). Lower midfoot height mobility was associated with greater peak FPPA (β 0.37, p = 0.030, OR 1.4) and FPPA excursion (β 0.30, p = 0.020, OR 1.3). Lower ankle joint dorsiflexion was also associated with greater peak FPPA (β 0.61, p = 0.008, OR 1.8) and greater FPPA excursion (β 0.56, p < 0.001, OR 1.7). Conclusions: Foot and ankle mobility was significantly related to the FPPA during the single leg squat in healthy individuals. Specifically, higher midfoot width mobility, or lower ankle joint dorsiflexion range and midfoot height mobility, were associated with a greater FPPA. These foot mobility factors should be considered in the clinical management of knee-related disorders that are associated with a high FPPA.
Article
Altered movement patterns including contralateral pelvic drop, increased hip adduction, knee abduction and external rotation have been previously implicated in several lower extremity pathologies. Although various methods exist for assessing movement patterns, real-time visual observation is the most readily available method. The purpose of this study was to determine whether differing visual ratings of trunk, pelvis and knee alignment, as well as overall quality of movement, are associated with differences in 3-dimensional trunk, pelvis, hip, or knee kinematics during a lateral step down test.Trunk, pelvis, and knee alignment of 30 healthy participants performing the lateral step down were visually rated as "good" or "faulty" based on previously established criteria. An additional categorization of overall quality of movement as either good or moderate was performed based on the aggregate score of each individual rating criterion. Three-dimensional motion analysis of trunk, pelvis, hip, and knee kinematics was simultaneously performed.Participants with a faulty pelvis alignment displayed a greater peak contralateral pelvic drop (Effect size [ES]: 1.65, p<0.01), and a greater peak hip adduction (ES: 1.04, p=0.01) compared with participants with a good pelvis alignment. Participants with a faulty knee alignment displayed greater peak knee external rotation compared with participants with a good knee alignment (ES: 0.78, p=0.02). Participants with an overall moderate quality of movement displayed increased peak contralateral pelvic drop (ES: 1.07, P=0.01) and peak knee external rotation (ES: 0.72, P=0.04) compared with those with an overall good quality of movement.Visual rating of quality of movement during a lateral step down test, as performed by an experienced physical therapist, is associated with differences in several kinematics previously implicated in various pathologies.
Article
Background Musculoskeletal symptoms limit adherence to exercise interventions for individuals with type 2 diabetes. People with diabetes may be susceptible to tendinopathy due to chronically elevated blood glucose levels. Therefore, we aimed to investigate this potential association by systematically reviewing and meta-analysing case–control, cross-sectional, and studies that considered both of these conditions. Methods Nine medical databases and hand searching methods were used without year limits to identify all relevant English language articles that considered diabetes and tendinopathy. Two authors applied exclusion criteria and one author extracted data with verification by a second author. Meta-analysis was conducted using a random effects model. Results were expressed as odds ratio (OR), mean difference or standardised mean difference with a confidence intervals (95% CI). Heterogeneity was assessed by I2. Findings 31 studies were included in the final analysis of which 26 recruited people with diabetes and five recruited people with tendinopathy. Tendinopathy was more prevalent in people with diabetes (17 studies, OR 3·67, 95% CI 2·71 to 4·97), diabetes was more prevalent in people with tendinopathy (5 studies, OR 1·28, 95% CI 1·10 to 1·49), people with diabetes and tendinopathy had a longer duration of diabetes than people with diabetes only (6 studies, mean difference 5·26 years, 95% CI 4·15 to 6·36) and people with diabetes had thicker tendons than controls (9 studies, standardised mean difference 0·79 95% CI 0·47 to 1·12). Interpretation These findings provide strong evidence that diabetes is associated with higher risk of tendinopathy. This is clinically relevant as tendinopathy may affect adherence to exercise interventions for diabetes.
Article
A pattern of excessive hip adduction and internal rotation with medial deviation of the knee has been associated with numerous musculo-skeletal dysfunctions. Research into the role that ankle dorsiflexion (DF) range of motion (ROM) play in lower limb kinematics is lacking. The objective of this cross-sectional, observational study was to investigate the relationship between ankle DF ROM and hip adduction and hip internal rotation during a step down test with and without heel elevation in a healthy female population. Hip and ankle ROM was measured kinematically using a ten-camera Optitrack motion analysis system. Thirty healthy female participants (mean age=20.4 years; SD=0.9 years) first performed a step-down test with the heel of the weight bearing foot flat on the step and then with the heel elevated on a platform. Ankle DF, hip adduction and hip internal rotation were measured kinematically for the supporting leg. Participants who had 17⁰ or less of ankle DF ROM displayed significantly more hip adduction ROM (p=0.001; Cohen’s d effect size=1.2) than the participants with more than 17⁰ of DF during the step-down test. Participants with limited DF ROM showed a significant reduction in hip adduction ROM during the elevated-heel step-down test (p=0.008). Hip internal rotation increased in both groups during the EHSD compared to the step-down test (p>0.05) Reduced ankle DF ROM is associated with increased hip adduction utilised during the step-down test. Ankle DF should be taken into account when assessing patients with aberrant frontal plane lower limb alignment.
Article
Landing and squat tasks have been utilized to assess lower extremity biomechanics associated with anterior cruciate ligament loading and injury risks. The purpose of this study was to identify the differences and correlations in knee and hip mechanics during a single-leg landing, a single-leg squat, a double-leg landing, and a double-leg squat. Seventeen male and 17 female recreational athletes performed landings and squats when kinematic and kinetic data were collected. ANOVAs showed significant differences (p < 0.00001) for maximum knee flexion angles, maximum hip flexion angles, maximum knee abduction angles, maximum hip adduction angles, and maximum external knee abduction moments among squats and landings. For maximum knee and hip flexion angles, significant correlations (r ≥ 0.5, p ≤ 0.003) were observed between the two landings and between the two squats. For maximum knee abduction and hip adduction angles and maximum external knee abduction moments, significant correlations were mostly found between the two landings, and between the single-leg squat and landings (r ≥ 0.54, p ≤ 0.001). Individuals are likely to demonstrate different profiles of injury risks when screened using different tasks. While a double-leg landing should be considered as a priority in screening, a single-leg squat may be used as a surrogate to assess frontal plane motion and loading.
Article
The single leg squat and single leg step down are two commonly used functional tasks to assess movement patterns. It is unknown how kinematics compare between these tasks. The purpose of this study was to identify kinematic differences in the lower extremity, pelvis and trunk between the single leg squat and the step down. Fourteen healthy individuals participated in this research and performed the functional tasks while kinematic data were collected for the trunk, pelvis, and lower extremities using a motion capture system. For the single leg squat task, the participant was instructed to squat as low as possible. For the step down task, the participant was instructed to stand on top of a box, slowly lower him/herself until the non-stance heel touched the ground, and return to standing. This was done from two different heights (16 cm and 24 cm). The kinematics were evaluated at peak knee flexion as well as at 60° of knee flexion. Pearson correlation coefficients (r) between the angles at those two time points were also calculated to better understand the relationship between each task. The tasks resulted in kinematics differences at the knee, hip, pelvis, and trunk at both time points. The single leg squat was performed with less hip adduction (p ≤ 0.003), but more hip external rotation and knee abduction (p ≤ 0.030), than the step down tasks at 60° of knee flexion. These differences were maintained at peak knee flexion except hip external rotation was only significant in the 24 cm step down task (p ≤ 0.029). While there were multiple differences between the two step heights at peak knee flexion, the only difference at 60° of knee flexion was in trunk flexion (p < 0.001). Angles at the knee and hip had a moderate to excellent correlation (r = 0.51-0.98), but less consistently so at the pelvis and trunk (r = 0.21-0.96). The differences in movement patterns between the single leg squat and the step down should be considered when selecting a single leg task for evaluation or treatment. The high correlation of knee and hip angles between the three tasks indicates that similar information about knee and hip kinematics was gained from each of these tasks, while pelvis and trunk angles were less well predicted.
Article
Study design: Cross-sectional. Objective: To determine what physical measures are associated with visually assessed quality of movement among patients with patellofemoral pain (PFP). Background: An altered movement pattern has been implicated as a risk factor for PFP. An understanding of physical measures associated with an altered movement pattern could potentially help guide prevention and management efforts in patients with PFP. Methods: Seventy-nine (40 women) Israel Defense Forces soldiers referred to physical therapy with a diagnosis of PFP were included. Movement pattern was assessed visually during a lateral step-down test and rated as "good" or "moderate," based on previously established criteria. Weight-bearing and non-weight-bearing ankle dorsiflexion (DF) range of motion (ROM); hip internal and external rotation ROM; and hip abduction, hip external rotation, and knee extension strength were also assessed. Differences in physical measures between those with good versus moderate quality of movement were assessed. Results: Weight-bearing DF ROM was more limited among participants with a moderate quality of movement compared to those with a good quality of movement (P<.01). Among men, non-weight-bearing DF ROM was more limited in those with a moderate quality of movement as well (P<.01). In addition, quality of movement was associated with weight-bearing DF ROM for both women (r = -0.39, P = .01) and men (r = -0.46, P<.01), and with non-weight-bearing DF ROM for men (r = -0.66, P<.01). When the subgroup of participants who exhibited more than 25° of non-weight-bearing DF ROM was assessed, those with a good quality of movement displayed greater hip external rotator and knee extensor muscle strength compared with those with a moderate quality of movement (P<.01). Conclusion: Ankle DF ROM should be assessed when patients with PFP demonstrate a lower quality of movement during a lateral step-down test. Lower hip muscle strength may be associated with lower quality of movement among patients with relatively greater ankle DF ROM.
Article
Context: Lower extremity movement patterns have been implicated as a risk factor for various knee disorders. Ankle-dorsiflexion (DF) range of motion (ROM) has previously been associated with a faulty movement pattern among healthy female participants. Objective: To determine the association between ankle DF ROM and the quality of lower extremity movement during the lateral step-down test among healthy male participants. Design: Cross-sectional study. Setting: Training facility of the Israel Defense Forces. Patients or other participants: Fifty-five healthy male Israeli military recruits (age = 19.7 ± 1.1 years, height = 175.4 ± 6.4 cm, mass = 72.0 ± 7.6 kg). Intervention(s): Dorsiflexion ROM was measured in weight-bearing and non-weight-bearing conditions using a fluid-filled inclinometer and a universal goniometer, respectively. Lower extremity movement pattern was assessed visually using the lateral step-down test and classified categorically as good or moderate. All measurements were performed bilaterally. Main outcome measure(s): Weight-bearing and non-weight-bearing DF ROM were more limited among participants with moderate quality of movement than in those with good quality of movement on the dominant side (P = .01 and P = .02 for weight-bearing and non-weight-bearing DF, respectively). Non-weight-bearing DF demonstrated a trend toward a decreased range among participants with moderate compared with participants with good quality of movement on the nondominant side (P = .03 [adjusted P = .025]). Weight-bearing DF was not different between participants with good and moderate movement patterns on the nondominant side (P = .10). Weight-bearing and non-weight-bearing ankle DF ROM correlated significantly with the quality of movement on both sides (P < .01 and P < .05 on the dominant and nondominant side, respectively). Conclusions: Ankle DF ROM was associated with quality of movement among healthy male participants. The association seemed weaker in males than in females.
Article
Background Knee injuries are one of the most common types of injuries in team ball sports, and prevention is crucial because of health and economic implications. To set up effective prevention programs, these programs must be designed to target potential, modifiable risk factors. In addition, it is essential to evaluate the effects of these prevention programs. Objective The purpose of this study was to provide an overview of the effect of prevention programs on potential, modifiable risk factors for knee injuries in team ball sports. Method A systematic review was performed in PUBMED (1978 to December 2013), EMBASE (1973 to December 2013), and CINAHL (1992 to December 2013). The titles, abstracts, and full texts were analyzed according to predefined inclusion criteria to find relevant studies. Results Neuromuscular control training with plyometric and agility exercises with addition of instructions reduced knee valgus angles and moments in female athletes. Knee flexion angles and moments were enhanced by plyometric and resistance exercises with augmented feedback (verbal or video). The specificity of the exercises must match the task that needs to be improved. Hamstring/quadricep strength ratio and hamstring strength may be improved by isolated hamstring exercises. Conclusion Various training components are required to reduce the risk of knee injury. Neuromuscular control training and the use of instructions/feedback (verbal or video) seem promising. However, attention should be given to the target populations and the specificity of the programs. More research is needed with respect to reducing risk factors in male athletes as well as in children.
Article
Aim Restrictions in range of ankle dorsiflexion (DF) motion can persist following ankle injuries. Ankle DF is necessary during terminal stance of gait, and its restricted range may affect knee joint kinematics and kinetics. The purpose of this study was to investigate the acute influence of varied levels of restricted ankle DF on knee joint sagittal and frontal plane kinematics and kinetics during gait. Methods and materials Thirty healthy volunteers walked with a custom-designed ankle brace that restricted ankle DF. Kinematics and kinetics were collected using a 7-camera motion analysis system and two force plates. Ankle dorsiflexion was restricted in 10-degree increments, allowing for four conditions: Free, light (LR), moderate (MR) and severe restriction (SR). Knee angles and moments were measured during terminal stance. Results Real peak ankle DF for Free, LR, MR, and SR were 13.7 ± 4.8°, 11.6 ± 5.0°, 7.5 ± 5.3°, and 4.2 ± 7.2°, respectively. Peak knee extension angles under the same conditions were − 6.7 ± 6.7°, -5.4 ± 6.4°, -2.5 ± 7.5°, and 0.6 ± 7.8°, respectively, and the peak knee varus moment was 0.48 ± 0.17 Nm/kg, 0.47 ± 0.17 Nm/kg, 0.53 ± 0.20 Nm/kg, and 0.57 ± 0.20 Nm/kg. The knee varus moment was significantly increased from MR condition with an 8-degree restriction in ankle DF. Conclusion Knee joint kinematics and kinetics in the sagittal and frontal planes were affected by reduced ankle DF during terminal stance of gait. Differences were observed with restriction in ankle DF range of approximately 8 degrees.
Article
Study design Systematic literature review. Objectives To investigate whether quadriceps atrophy is present in the affected limb of individuals with patellofemoral pain (PFP). Background PFP is a common condition. Atrophy of the quadriceps femoris, in particular the vastus medialis oblique (VMO), is often assumed to be present by clinicians and its resolution may underpin the reported effectiveness of quadriceps strengthening intervention in PFP rehabilitation. Methods A systematic search of the literature was conducted to identify studies that measured the size of the quadriceps in individuals with PFP. Meta-analyses were performed to determine whether a difference was present in quadriceps size between the limb with PFP and comparison limbs. Separate meta-analyses were performed for quadriceps size measured as girth and quadriceps size measured with imaging (thickness, cross sectional area, and volume). Results Ten studies were included in this review. Meta-analysis of girth measurements (3 studies) found no atrophy in limbs with PFP (P=.638). Meta-analyses for imaging (thickness, cross sectional area, or volume measurements) showed atrophy in the limb with PFP compared to both the asymptomatic limb (3 studies) (P=.036) and limbs from a comparison group (3 studies) (P=.001). The single study that compared VMO and vastus lateralis (VL) in individuals with PFP found atrophy of both VMO and VL but no significant difference in the amount of atrophy between them (P=.179). Conclusion Quadriceps muscle atrophy was shown to be present in PFP when analysed by imaging, but not girth measures. Insufficient data were available to determine if there is greater atrophy of VMO than VL. These findings support the rationale for use of quadriceps strengthening as part of the rehabilitation for PFP. Level of evidence Therapy, Level 2a J Orthop Sports Phys Ther, Epub XXX 2013. doi:10.2519/jospt.2013.4833.
Article
Context Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective. Objective To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain. Data Sources We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles. Study Selection Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions. Data Extraction We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale. Data Synthesis In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39). Conclusions Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation.
Article
It has been postulated that subjects with weak hip abductors and external rotators may demonstrate increased knee valgus, which may in turn raise risk of injury to the lower extremity. Recent studies have explored the potential link between hip strength and knee kinematics, but there has not yet been a review of this literature. To conduct a systematic review assessing the potential link between hip-abductor or external-rotator strength and knee-valgus kinematics during dynamic activities in asymptomatic subjects. An online computer search was conducted in early February 2011. Databases included Medline, EMBASE, CINAHL, SPORTDiscus, and Google Scholar. Inclusion criteria were English language, asymptomatic subjects, dynamometric hip-strength assessment, single or multicamera kinematic analysis, and statistical analysis of the link between hip strength and knee valgus via correlations or tests of differences. Data were extracted concerning subject characteristics, study design, strength measures, kinematic measures, subject tasks, and findings with regard to correlations or group differences. Eleven studies were selected for review, 4 of which found evidence that subjects with weak hip abductors or external rotators demonstrated increased knee valgus, and 1 study found a correlation to the contrary. There is a small amount of evidence that healthy subjects with weak hip abductors and perhaps weak external rotators demonstrate increased knee valgus. However, due to the variation in methodology and lack of agreement between studies, it is not possible to make any definitive conclusions or clinical recommendations based on the results of this review. Further research is needed.
Article
Patellar tendinopathy (PT) is one of the most common reasons for sport-induced pain of the knee. Low ankle dorsiflexion range might predispose for PT because of load-bearing compensation in the patellar tendon. The purpose of this 1-year prospective study was to analyze if a low ankle dorsiflexion range increases the risk of developing PT for basketball players. Cohort study (prognosis); Level of evidence, 2. Ninety junior elite basketball players were examined for different characteristics and potential risk factors for PT, including ankle dorsiflexion range in the dominant and nondominant leg. Data were collected over a 1-year period and follow-up, including reexamination, was made at the end of the year. Seventy-five players met the inclusion criteria. At the follow-up, 12 players (16.0%) had developed unilateral PT. These players were found to have had a significantly lower mean ankle dorsiflexion range at baseline than the healthy players, with a mean difference of -4.7° (P = .038) for the dominant limb and -5.1° (P = .024) for the nondominant limb. Complementary statistical analysis showed that players with dorsiflexion range less than 36.5° had a risk of 18.5% to 29.4% of developing PT within a year, as compared with 1.8% to 2.1% for players with dorsiflexion range greater than 36.5°. Limbs with a history of 2 or more ankle sprains had a slightly less mean ankle dorsiflexion range compared to those with 0 or 1 sprain (mean difference, -1.5° to -2.5°), although this was only statistically significant for nondominant legs. This study clearly shows that low ankle dorsiflexion range is a risk factor for developing PT in basketball players. In the studied material, an ankle dorsiflexion range of 36.5° was found to be the most appropriate cutoff point for prognostic screening. This might be useful information in identifying at-risk individuals in basketball teams and enabling preventive actions. A history of ankle sprains might contribute to reduced ankle dorsiflexion range.