Article

Rethinking Dynamic Knee Valgus and Its Relation to Knee Injury: Normal Movement Requiring Control, Not Avoidance

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Abstract

The risk of knee injury in sport may be related to deviations in lower-limb alignment. An example of biomechanical deviation is dynamic knee valgus, considered by many to be one of the most important predictors of serious knee injury; however, the predictive validity of commonly used screening tests for dynamic knee valgus has recently been questioned. In this Viewpoint, the authors argue that assessing the risk of knee injury is complex and endeavor to present pelvic pronation and system tension as a 3-D construct to consider during physical assessments and exercise design, and to recognize dynamic knee valgus as a normal and necessary response to ground reaction forces. J Orthop Sports Phys Ther 2019;49(4):216-218. doi:10.2519/jospt.2019.0606.

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... 46 Primarily, this should include more intensive exercises designed to increase power 46 , as well as, additional eccentric loading across all planes of movement. 37,[49][50][51][52][53] Establishing triplanar control of the hip and pelvis is essential to improving both task specific neuromotor control of the proximal muscles, 27,46 and will limit contralateral pelvic drop, femoral adduction and internal rotation. 52 It is also essential that PFP rehabilitation include hip rotation, as this specifically reflects loading forces and can enhance the activity of key musculature such as the gluteus medius and minimis. ...
... 37,[49][50][51][52][53] Establishing triplanar control of the hip and pelvis is essential to improving both task specific neuromotor control of the proximal muscles, 27,46 and will limit contralateral pelvic drop, femoral adduction and internal rotation. 52 It is also essential that PFP rehabilitation include hip rotation, as this specifically reflects loading forces and can enhance the activity of key musculature such as the gluteus medius and minimis. 54 Optimal rehabilitation is underpinned by progression, whereby exercises become increasingly challenging by adding new stimuli. ...
Article
Objectives: Current best evidence has reported that therapeutic exercise programs that are designed to treat patellofemoral pain (PFP) should include both hip and knee specific exercises. The purpose of this review was to (1) examine the quality/comprehensiveness of exercise reporting in this field; (2) quantify the extent to which individual exercises comprised task-specific elements (single limb stance; eccentric control of the hip; rotational z-axis control) most likely to address key pathomechanics associated with PFP. Design: Systematic review: a systematic survey of RCTs. Methods: PubMed, CINAHL, Medline, Physiotherapy Evidence Database (PEDro) and SPORT Discus databases were searched for randomized controlled trials that addressed PFP utilizing a proximal control hip focused rehabilitation paradigm. The therapeutic exercise programs were evaluated, and each individual exercise was extracted for analysis. Quality assessments included the PEDro Scale and the Consensus on Exercise Reporting Template (CERT) was utilized to score the reporting of the interventions. Results: 19 studies were included in the final analysis. 178 total exercises were extracted from the proximal hip and knee rehabilitation programs. The exercises were analyzed for the inclusion of elements that align with reported underlying biomechanical mechanisms. Conclusions: The vast majority of the exercises were sagittal plane, concentric, non-weight bearing exercises, whereas multiplanar exercises, single limb weightbearing, and exercises where loading was directed around the longitudinal z-axis, were considerably under-represented. Current exercises for PFP utilize simplistic frameworks that lack progression into more task specific exercise, and are not reflective of the complex injury etiology.
... This release of stored elastic system tension transmits potential to kinetic energy at the ball release phase of throwing. [9][10][11][12][13][14] Musculoskeletal impairments at any point along the kinetic chain can have an impact on throwing performance and injury risk. 9 Empirical data show that the recruitment of the scapulothoracic muscles during throwing is sensitive to changes in lower extremity and trunk position, 15 and that the risk of shoulder and elbow injury is increased in athletes with reduced hip extension on the same side as the throwing shoulder 16 or internal rotation of the thrower's stride leg. ...
Article
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Background Traditional methods to measure rotational passive range of motion (PROM) in the throwing shoulder do not reflect the complexity of the throwing motion. Therefore, a sport specific shoulder rotation PROM test (FAST-SHDR) was developed and compared to traditional standard methods to measure shoulder internal and external rotational PROM in the throwing shoulder. Purpose The aim of this study was to determine the intra-rater reliability of the FAST-SHDR test in young, healthy, male Division 1 baseball players. Study Design Reliability and validity analysis Methods A study with 49 healthy participants (31 collegiate baseball players, 18 controls) examined a sport specific shoulder rotation PROM test (FAST-SHDR) and compared this to the standard supine 90/90 shoulder in a single session assessment. Intra-class correlation coefficient (ICC), standard error of measurement (SEM) and minimum detectable change (MDC) were calculated. Within and between group differences were based on t-tests (p<0.001), absolute differences and effect sizes (95% CIs). Results The novel test (FAST-SHDR) had good to excellent reliability with ICCs ranging from 0.95 (0.89 to 0.98) to 0.96 (0.92-0.98). MDC ranged from 7°-11° which is equivalent to 11-14% of mean PROM scores. In the dominant shoulder of baseballers, when FAST-SHDR IR/ER was compared to standard IR/ER testing the FAST-SHDR scores were lower for both IR (MD 23.3°; 95% CI 19.7-26.8) and ER (MD 50.7°; 95% 44.7 to 56.7). Comparing the shoulder rotation PROM in baseballers, the FAST-SHDR ER and IR measurements were significantly lower (p<0.0001) when compared to traditional standard PROM testing for shoulder IR and ER rotation. Conclusions FAST-SHDR testing shows good to excellent intra-rater reliability for measuring shoulder rotational PROM and demonstrates both face and discriminant validity. Level of Evidence 3
... The current study will also refine the intervention prior to a full-scale RCT. A secondary form of process modelling that was used prior to the feasibility study was the publication of three separate editorials [15][16][17]. The rationale behind these publications was to have the underpinning theory and the newly designed advanced exercises undergo a peer-review process. ...
Article
Anterior cruciate ligament (ACL) injuries and patellofemoral pain (PFP) continue to show high incidence rates, and poor long term outcomes. Key exercise elements were synthesized into an advanced hip focused exercise strategy and were administered to a sample of female athletes. This study examined the feasibility and impact of a 12-week advanced hip muscle strengthening program on physical performance measures and peak hip muscle torques. Thirteen female Division 1 collegiate volleyball players attended twelve twice-a-week advanced hip strengthening sessions. Outcome measures included subjective questionnaires of stakeholders, vertical, blocking and approach jumps, and peak isometric concentric and eccentric torque of hip muscles. Thirteen female athlete participants attended all 24 exercise sessions over the 12-week period, without adverse events, and all 13 participants responded favorably to the 35 question questionnaire, with all participants exceeding the a priori level of > 3/5 for perceived value of the intervention strategy. The mean jump scores increased across all three jumps (approach, vertical, blocking) with moderate to large effects noted. Hip extension peak torque increased bilaterally. The intervention paradigm presented could impact key variables of interest in an athletic population regarding both potential for injury reduction and improved athletic performance.
... Furthermore, patients instructed with EF appeared to have less knee valgus at initial contact and valgus displacement. In several studies, the position of dynamic knee valgus alignment of the lower extremity is described as the position in which the knee joint collapses medially, representing a coupled motion due to the combination of hip adduction, hip internal rotation, knee flexion, knee abduction, and tibial rotation [45,46]. This position has been shown to increase strain on the ACL and might have a relation with the prediction of a second ACL injury [47]. ...
Article
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Background: Improving jump-landing technique during rehabilitation is important and may be achieved through different feedback techniques, i.e., internal focus of attention (IF) or external focus of attention using a target (EF). However, there is a lack of evidence on the most effective feedback technique after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to investigate the potential difference in jump-landing techniques between IF and EF instructions in patients after ACLR. Methods: Thirty patients (12 females, mean age 23.26 ± 4.91 years) participated after ACLR. Patients were randomly assigned into two groups that each followed a different testing sequence. Patients performed a drop vertical jump-landing test after receiving instructions with varying types of focus of attention. The Landing Error Scoring System (LESS) assessed the jump-landing technique. Results: EF was associated with a significantly better LESS score (P < 0.001) compared with IF. Only EF instructions led to improvements in jump-landing technique. Conclusion: Using a target as EF resulted in a significantly better jump-landing technique than IF in patients after ACLR. This indicates that increased use of EF could or might result in a better treatment outcome during ACLR rehabilitation.
... The three-dimensional position of the body affects the overall tension in the musculoskeletal system and, ultimately, the function [41]. Biomechanical changes due to the direction of the valgus dynamics may affect the loads applied to the joint [18]. ...
Article
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Objective Excessive dynamic knee valgus, as a defective movement pattern, predisposes patients to lower limb injuries. Therefore, the aim of the present study was to study dynamic knee valgus in male soccer players. Methods In this review article, an attempt was made to collect studies conducted on the subject of research from 2000 to June 2021. The websites Google Scholar, PubMed, Science Direct, SID, ISC and Magiran were used and keywords related to the topic were used to search for articles. Results According to the search method, 50 articles were found, which were finalized according to the inclusion and exclusion criteria of 12 articles. Finally, 7 articles were reported in the present study. Dynamic knee valgus condition is more common in women than men, and varus are more common with increasing age of male soccer players. Different situations during the game such as tackling, jumping, imbalance after strike to the ball and landing after jumping are also among the situations that are associated with increased dynamic knee valgus and players are exposed to knee injury. The first minutes of the halves due to the lower angle of flexion of the knee and also late in the game due to fatigue can increase the dynamic valgus and increase the risk of knee injury. Conclusion All studies have pointed to the role of dynamic valgus in the incidence of knee joint injuries, especially the anterior cruciate ligament, so it is necessary to identify the mechanism of injury and correct the direction of dynamic valgus among soccer players.
... 14 Furthermore, these exercises were often in isolation and were rarely combined with the other exercise elements recognized as being present during an ACL injury (flight, single-leg stance, or trunk and hip control) 18 This seems to represent a reductionist approach common to many areas of musculoskeletal rehabilitation, whereby simplistic frameworks are applied to complex injury pathologies. 7,8,10,15,16,29 It is well documented that a large proportion of ACL injuries occur in unilateral weightbearing, that is, some authors report as high as 70% of ACL injuries. 38,45,49,69 This is not yet fully reflected in current injury prevention program literature, with 25% of exercises undertaken in nonweightbearing and 41% in bilateral weightbearing. ...
Article
Context: Anterior cruciate ligament (ACL) injury risk reduction programs have become increasingly popular. As ACL injuries continue to reflect high incidence rates, the continued optimization of current risk reduction programs, and the exercises contained within them, is warranted. The exercises must evolve to align with new etiology data, but there is concern that the exercises do not fully reflect the complexity of ACL injury mechanisms. It was outside the scope of this review to address each possible inciting event, rather the effort was directed at the elements more closely associated with the end point of movement during the injury mechanism. Objective: To examine if exercises designed to reduce the risk of ACL injury reflect key injury mechanisms: multiplanar movement, single limb stance, trunk and hip dissociative control, and a flight phase. Data sources: A systematic search was performed using PubMed, Medline, EBSCO (CINAHL), SPORTSDiscus, and PEDro databases. Study selection: Eligibility criteria were as follows: (1) randomized controlled trials or prospective cohort studies, (2) male and/or female participants of any age, (3) exercises were targeted interventions to prevent ACL/knee injuries, and (4) individual exercises were listed and adequately detailed and excluded if program was unable to be replicated clinically. Study design: Scoping review. Level of evidence: Level 4. Data extraction: A total of 35 studies were included, and 1019 exercises were extracted for analysis. Results: The average Consensus on Exercise Reporting Template score was 11 (range, 0-14). The majority of exercises involved bilateral weightbearing (n = 418 of 1019; 41.0%), followed by single limb (n = 345 of 1019; 33.9%) and nonweightbearing (n = 256 of 1019; 25.1%). Only 20% of exercises incorporated more than 1 plane of movement, and the majority of exercises had sagittal plane dominance. Although 50% of exercises incorporated a flight phase, only half of these also involved single-leg weightbearing. Just 16% of exercises incorporated trunk and hip dissociation, and these were rarely combined with other key exercise elements. Only 13% of exercises challenged more than 2 key elements, and only 1% incorporated all 4 elements (multiplanar movements, single limb stance, trunk and hip dissociation, flight phase) simultaneously. Conclusion: Many risk reduction exercises do not reflect the task-specific elements identified within ACL injury mechanisms. Addressing the underrepresentation of key elements (eg, trunk and hip dissociation, multiplanar movements) may optimize risk reduction in future trials.
... They tested flexibility of soft tissue connecting the adjacent body segments in a 3D fashion rather than testing isolated movement directions in single joints. This way of looking at body biomechanics is increasingly valued, as with the patient positioned in trunk rotation, the tension in the entire kinetic chain is assessed (Dischiavi et al., 2019;Wilke et al., 2016). We developed a 2-step approach of (1) evaluating LLROM and classifying patients with PFP into one of four subgroups and (2) selecting and applying an intervention targeting LLROM. ...
Article
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Introduction Patellofemoral pain (PFP) is a common and often long-standing musculoskeletal condition. Evidence of the effectiveness of interventions addressing soft tissue flexibility is conflicting and of inconsistent scientific quality. However, reduced soft tissue flexibility can negatively affect patellofemoral joint kinematics. Lower limb range of motion (LLROM) reflects soft tissue flexibility throughout the kinetic chain. The aim was to evaluate the short-term effectiveness of an intervention targeting LLROM on pain and disability in patients with PFP. Methods A randomized, non-concurrent, multiple-baseline single-case design with a two-week intervention phase and baseline and postintervention phase with varying length was conducted. Eight participants (5 females, 3 males) of age 19(±1.6) years, weekly sports participation 12(±3.1) hours and 17(±14) months symptom duration were included. The Anterior Knee Pain Scale – Dutch Version (AKPS-DV) and the Patient Specific Complaint Scale (PSCS) were administered twice a week. After allocating participants to one of four subgroups of reduced LLROM the intervention was applied. The intervention consisted of soft tissue techniques (mobilization, taping, and stretching). Results Participant 3 and 6 showed a medium and small but statistically significant positive effect on the AKPS-DV. Participant 2 showed a large and statistically significant positive effect on the PSCS. Conclusions This study provides moderate evidence that an intervention targeting LLROM in patients with PFP reduces pain and disability in the short-term. Further research is needed to evaluate the long-term effectiveness and optimize individual treatment outcomes.
... The exercise uses simple elastic resistance to generate torque which pulls the pelvis into a position of relative contralateral drop, adduction and internal rotation which the subject is attempting to control eccentrically; thereby specifically addressing contributory pathomechanics associated with FAI syndrome. This supports previously proposed mechanisms whereby the triplanar position of the pelvis on the femur is the target of the exercise, a top-down approach (Dischiavi et al., 2019). Treating FAI syndrome as a pelvic and hip dysfunction would create a paradigm shift in exercise prescription. ...
Article
Objective Research reports limited, mixed evidence on the effectiveness of physiotherapy management in the treatment of femoroacetabular impingement (FAI) syndrome. The purpose of this review was to (1) identify what therapeutic exercises are being utilized in the non-surgical management of patients with FAI syndrome; (2) map the extent to which reported exercises reflect contributory pathomechanics associated with FAI syndrome. Design Scoping Review. Methods MEDLINE, PubMed, CINAHL, SPORTDiscus, and PEDRO electronic databases were searched for studies that implemented a non-surgical, exercise-based treatment approach in patients with FAI syndrome. Exercises were extracted and analyzed according to elements recognized as contributing to the pathomechanics associated with FAI syndrome. Results 24 studies fulfilled the inclusion criteria. 453 exercises were extracted. Uniplanar exercises accounted for 338/453 or 74.6% of all reported exercises whereas triplanar exercises accounted for 21/453 or 4.6% of all exercises. Non-weight bearing exercises accounted for 220/453 or 48.6% of all exercises. Conclusion The majority of therapeutic exercises were classified as sagittal, uniplanar exercises, utilizing a concentric exercise approach. These findings highlight that exercises utilizing triplanar, eccentric hip control, in a single limb weightbearing position are considerably underrepresented.
... Dynamic knee valgus (DDV) is a biomechanical deviation occurring in 3 movement plans and involving contralateral pelvis fall simultaneously with the internal rotation and adduction of the femur [1]. For activities on one leg, hip abductors prevent pelvic fall and hip adduction [2]. ...
... Since no significant increase was observed in knee flexion and adduction angular velocities, it could be stated that decreased ankle external rotation angular velocities lead to such an increment in movement ratios toward knee movement, particularly in frontal plane, which resulted in excessive knee valgus and might end up with damages to the knee joint in a long-term run. 48 Similarly, increased knee internal movement angular velocities simultaneously along with decreased ankle external rotation angular displacements rates resulted in considerably higher external rotation to knee internal rotations ratios in the landing phase following Kinesio-tape application. These findings, similar to those observed for ankle ...
Article
Background: Ankle Kinesio-taping (KT) is being globally used an intervention to provide the ankle joint complex with sufficient support against sudden excessive mechanical stress during various activities. However, its effects on proximal joints are unclear. This study investigated the impact of ankle KT on ankle-knee joint coupling in sagittal, frontal and transverse planes. Methods: Adopting a pre-test post-test study design, 30 collegiate athletes with chronic ankle instability performed 3 single-leg drop landings in each non-taped and Kinesio-taped conditions and their movement kinematics were recorded using 6 optoelectronic cameras. Results: The ankle angular velocities in sagittal (p=0.038, d=0.64) and transverse planes (p=0.001, d=0.95) decreased after KT application, while the knee internal rotation velocities increased (p=0.020, d=0.51). The coupling angles revealed that the ankle movement ratios significantly decreased in 3 planes in comparison with knee movement ratios. Conclusions: Outcomes of this study illustrated that application of ankle KT leaves the individuals with a stiffer ankle joint, which increases the mechanical stresses to this joint and decreases its stiffness in absorbing the applied shocks. Further, ankle KT application resulted in more knee internal rotation moments and may increase the risk of knee injuries during landing after a long-term usage in patients with instability ankle sprain.
... Considering risk factors for injury, knee valgus seemed unaffected by the interventions as assessed in the TJA and the DVJs. While some argue that knee valgus is a natural movement, which needs to be controlled rather than avoided 22 , decreasing lower extremity valgus and increasing knee flexion angles in jumping/landing and cutting are often seen as important targets for IPEPs 79,86 . Hence, it is positive that the knee flexion angles improved in the girls in Study IV. ...
... Movement patterns that are coupled to high knee valgus moment and valgus angles have been shown to be associated with an increased risk of ACL injury [14], although other subsequent studies have not confirmed these results [18,19]. While some argue that knee valgus is a natural movement, that needs to be controlled rather than avoided [7], decreasing lower extremity valgus and increasing knee flexion angles in jumping/landing and cutting are often seen as important targets for IPEPs [17,19] and in the current study the girls' knee flexion angles improved. It should be noted that even though the effect size was large, the minimal clinically relevant change in knee flexion angle is not known. ...
Article
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Purpose To evaluate changes in jump-landing technique in football-playing boys and girls after 8 weeks of injury prevention training. Methods Four boys’ and four girls’ teams (mean age 14.1 ± 0.8 years) were instructed to use either the original Knee Control injury prevention exercise programme (IPEP) or a further developed IPEP, Knee Control + , at every training session for 8 weeks. Baseline and follow-up testing of jump-landing technique included drop vertical jumps (DVJ), assessed subjectively and with two-dimensional movement analysis, and tuck jump assessment (TJA). Results Only minor differences in intervention effects were seen between the two IPEPs, and results are therefore presented for both intervention groups combined. At baseline 30% of the boys showed good knee control during the DVJ, normalised knee separation distances of 77–96% (versus hip) and a median of 3 flaws during the TJA. Among girls, 22% showed good knee control, normalised knee separation distances of 67–86% and a median of 4 flaws during the TJA. At follow-up, boys and girls performed significantly more jumps during TJA. No changes in jump-landing technique were seen in boys, whereas girls improved their knee flexion angle at initial contact in the DVJ (mean change + 4.7°, p < 0.001, 95% CI 2.36–6.99, d = 0.7) and their TJA total score (− 1 point, p = 0.045, r = − 0.4). Conclusion The study showed small positive effects on jump-landing technique in girls, but not in boys, after 8 weeks of injury prevention training. Level of evidence Level II. Trial registration Clinical Trials gov identifier: NCT03251404
Article
Background and Aims Dynamic knee valgus, as a poor movement pattern, may increase the risk of injury in the knee joint. This condition, which is related to a deviation in the lower limb alignment, can cause serious damage to the knee joint during tasks such as jump-landing, especially when bearing weight. The present study aims to investigate the role of dynamic knee valgus (DKV) in occurrence of knee injuries. Methods This is a review study. A search was conducted for the related articles published in English or Persian using the keywords Dynamic Knee Alignment, Dynamic Knee Valgus, Knee Joint Kinematics, Medial Collapse, Medial Knee Displacement, Frontal Plane Knee Excursion, Projection Angle, Dynamic Lower Extremity Valgus and Knee Injury in Science Direct, Scopus, PEDro, Google Scholar, PubMed, SID, ISC, Medlib, MagIran and IranDoc databases published from 2005 to May 2021. Initial search yielded 230 articles. After examining their full texts, 67 related articles were remained. Finally, 34 articles in the field of the role of DKV in occurrence of common knee injuries were selected for the review. Results Most of the studies were conducted on women and young people (aged 16-25 years). The DKV cause knee injuries such as anterior cruciate ligament injury (21 studies), patellofemoral pain syndrome (7 studies), tibiofemoral osteoarthritis (4 studies) and patellofemoral osteoarthritis (one study) as well as other cases such as osteoarthritis of the inner knee, chronic pain injuries in the hip and knee joints, and cartilage injuries. Conclusion DKV, as a poor movement pattern, put a person at risk of lower limb injuries. Muscle imbalance, muscle weakness, and impairment in the static alignment and its effect on dynamic alignment are among the most important mechanisms of DKV. Due to the structural and biomechanical characteristics, the most injuries caused by DKV occur in women.
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Introduction Volleyball requires jumping and strenuous movements and certain sports injuries inevitably occur during the sport. The surface of the knee joint is considerably large and shallow, making the lever effect strong and negative, easily targeted for injury in the unstable movements caused by this sport. Objective Investigate the main causes of knee joint injuries in volleyball players and evaluate the effect of treatment with intervention through aquatic therapy. Methods Eight volleyball players from a university with different degrees of knee joint injury were randomly divided into an experimental group and a control group. The experimental group used intervention training with aquatic exercise therapy, while the control group did not include additional rehabilitation measures. The knee condition of the subjects before and after the experiment was analyzed and compared. Results The knee joint injury in the subjects in the experimental group was significantly improved, and the recovery from the knee joint injury of the subjects in the experimental group was better than that of the subjects in the control group. Conclusion Water sports therapy can significantly improve the knee joint injury of volleyball players, leading to the belief that water sports therapy can effectively improve the agility, strength, and endurance of muscles adjacent to knee joints in patients, reducing their pain, and increasing the range of motion of these joints. Level of evidence II; Therapeutic studies - investigation of treatment outcomes. Keywords: Aquatic Therapy; Volleyball; Exercise Therapy; Knee Injuries
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My PhD thesis at a glance: 9 studies, 763 subjects, 1000+ PROM scores, 189 x-rays, 240 pages in 1 infographic. Produced and published together with @paramedisch and @BJSM_BMJ
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Injury prediction is one of the most challenging issues in sports and a key component for injury prevention. Sports injuries aetiology investigations have assumed a reductionist view in which a phenomenon has been simplified into units and analysed as the sum of its basic parts and causality has been seen in a linear and unidirectional way. This reductionist approach relies on correlation and regression analyses and, despite the vast effort to predict sports injuries, it has been limited in its ability to successfully identify predictive factors. The majority of human health conditions are complex. In this sense, the multifactorial complex nature of sports injuries arises not from the linear interaction between isolated and predictive factors, but from the complex interaction among a web of determinants. Thus, the aim of this conceptual paper was to propose a complex system model for sports injuries and to demonstrate how the implementation of complex system thinking may allow us to better address the complex nature of the sports injuries aetiology. According to this model, we should identify features that are hallmarks of complex systems, such as the pattern of relationships (interactions) among determinants, the regularities (profiles) that simultaneously characterise and constrain the phenomenon and the emerging pattern that arises from the complex web of determinants. In sports practice, this emerging pattern may be related to injury occurrence or adaptation. This novel view of preventive intervention relies on the identification of regularities or risk profile, moving from risk factors to risk pattern recognition.
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Background: The evidence linking knee kinematics and kinetics during a vertical drop jump (VDJ) to anterior cruciate ligament (ACL) injury risk is restricted to a single small sample. Still, the VDJ test continues to be advocated for clinical screening purposes. Purpose: To test whether 5 selected kinematic and kinetic variables were associated with future ACL injuries in a large cohort of Norwegian female elite soccer and handball players. Furthermore, the authors wanted to assess whether the VDJ test can be recommended as a screening test to identify players with increased risk. Study design: Cohort study; Level of evidence, 2. Methods: Elite female soccer and handball players participated in preseason screening tests from 2007 through 2014. The tests included marker-based 3-dimensional motion analysis of a drop-jump landing. The authors followed a predefined statistical protocol in which they included the following candidate risk factors in 5 separate logistic regression analyses, with new ACL injury as the outcome: (1) knee valgus angle at initial contact, (2) peak knee abduction moment, (3) peak knee flexion angle, (4) peak vertical ground-reaction force, and (5) medial knee displacement. Results: A total of 782 players were tested (age, 21 ± 4 years; height, 170 ± 7 cm; body mass, 67 ± 8 kg), of which 710 were included in the analyses. The authors registered 42 new noncontact ACL injuries, including 12 in previously ACL-injured players. Previous ACL injury (relative risk, 3.8; 95% CI, 2.1-7.1) and medial knee displacement (odds ratio, 1.40; 95% CI, 1.12-1.74 per 1-SD change) were associated with increased risk for injury. However, there was an association with medial knee displacement among the 643 players with no history of previous injury. A receiver operating characteristic curve analysis of medial knee displacement showed an area under the curve of 0.6, indicating a poor-to-failed combined sensitivity and specificity of the test, even when including previously injured players. Conclusion: Of the 5 risk factors considered, medial knee displacement was the only factor associated with increased risk for ACL. However, receiver operating characteristic curve analysis indicated a poor combined sensitivity and specificity when medial knee displacement was used as a screening test for predicting ACL injury. For players with no previous injury, none of the VDJ variables were associated with increased injury risk. Clinical relevance: VDJ tests cannot predict ACL injuries in female elite soccer and handball players.
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Application of complex systems science to systems engineering
  • L P Beckerman
Beckerman LP. Application of complex systems science to systems engineering. Systems Eng. 2000;3:96-102. https://doi.org/10.1002/1520-6858(2000)3:2<96::AID-SYS4>3.0.CO;2-7