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The Effect of TheraBand Training on the Q Angle and Distance of Ankle Medial Malleolus in Individuals With Genu Valgum Deformity

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Purpose: Genu valgum deformity a common lower extremity deformity. The weakness of the lower limb muscles followed by the internal rotation of the femur and external rotation of the tibia, shift the gravitational pull to the outside of the knee. This lower limb alignment deformity could increase the distance of ankle medial malleolus and the Q angle. Therefore, the present study aimed to investigate the effect of TheraBand training on the Q angle and distance of ankle medial malleolus in individuals with genu valgum deformity. Methods: This was a quasi-experimental study with a pre-test and post-test and control group design. The study population consisted of girls in the age range of 9-13 years with genu valgum deformity. The study subjects were randomly divided into the experimental (n=15) and control (n=15) groups. The experimental group participated in TheraBand exercises for 8 weeks and 3 sessions per week. However, the control group received no training during this period. Before and after 8 weeks, the Q angle and distance of ankle medial malleolus were measured by goniometers and coulis, respectively. Analysis of Covariance (ANCOVA) was used to analyze the collected data in SPSS. The significance level was considered at 0.05. Results: The obtained statistical results suggested that TheraBand training significantly decreased the Q angle and the distance of ankle medial malleolus in the explored subjects with genu valgum deformity (P=0.001 & P=0.04, respectively). However, no significant difference was observed in the control group. Conclusion: The obtained data revealed that TheraBand training could improve the genu valgum position. Therefore, this training protocol could be implemented to improve the deformity in this population.
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117
July 2020. Volume 10. Number 3
Shiva Bahadori1, Hooman Fatahi1* , Mansooreh Ahmadpoor1
1. Department of Sports Injury and Corrective Exercises, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.
* Corresponding Author:
Hooman Fatahi, PhD.
Address: Department of Sports Injury and Corrective Exercises, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.
Phone:
+98 (903) 2485812
E-mail: hoomanfatahi92@yahoo.com
Research Paper: The Eect of TheraBand Training on
the Q Angle and Diance of Ankle Medial Malleolus
in Individuals With Genu Valgum Deformity
Purpose: Genu valgum deformity a common lower extremity deformity. The weakness of the
lower limb muscles followed by the internal rotation of the femur and external rotation of the
tibia, shift the gravitational pull to the outside of the knee. This lower limb alignment deformity
could increase the diance of ankle medial malleolus and the Q angle. Therefore, the present
udy aimed to inveigate the eect of TheraBand training on the Q angle and diance of ankle
medial malleolus in individuals with genu valgum deformity.
Methods: This was a quasi-experimental udy with a pre-te and po-te and control group
design. The udy population consied of girls in the age range of 9-13 years with genu valgum
deformity. The udy subjects were randomly divided into the experimental (n=15) and control
(n=15) groups. The experimental group participated in TheraBand exercises for 8 weeks and 3
sessions per week. However, the control group received no training during this period. Before and
after 8 weeks, the Q angle and diance of ankle medial malleolus were measured by goniometers
and coulis, respectively. Analysis of Covariance (ANCOVA) was used to analyze the collected
data in SPSS. The signicance level was considered at 0.05.
Results: The obtained atiical results suggeed that TheraBand training signicantly
decreased the Q angle and the diance of ankle medial malleolus in the explored subjects with
genu valgum deformity (P=0.001 & P=0.04, respectively). However, no signicant dierence
was observed in the control group.
Conclusion: The obtained data revealed that TheraBand training could improve the genu valgum
position. Therefore, this training protocol could be implemented to improve the deformity in this
population.
A B S T R A C T
Keywords:
TheraBand, Q Angle,
Deformity, Genu valgum
Citation
Bahadori Sh, Fatahi H, Ahmadpoor M. The Eect of TheraBand Training on the Q Angle and Diance of An-
kle Medial Malleolus in Individuals With Genu Valgum Deformity. Physical Treatments. 2020; 10(3):117-126. http://dx.doi.
org/10.32598/ptj.10.3.304.3
:
: http://dx.doi.org/10.32598/ptj.10.3.304.3
Use your device to scan
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Article info:
Received: 27 Dec 2019
Accepted: 27 May 2020
Available Online: 01 Jul 2020
118
July 2020. Volume 10. Number 3
1. Introduction
hysical poure is the alignment of dier-
ent body parts with each other. When an
individual is in a poor physical poure,
due to the high pressure on dierent body
parts, the body direction generates a de-
formity; this conant pressure, even if
relatively low, could cause non-anatomical compatibil-
ity. These changes alter individuals’ ability to perform
activities and aect the overall eciency of the body [1].
The knee joint, like all other joints in the body, is af-
fected by defects, injuries, and diseases. Moreover, un-
like the shoulder joint, the elbow and wri mu bear
the body weight while moving [2]. The mo frequent
deformities of the knee, due to the correctability and im-
provement in the range of corrective movements udied,
include the genu varum, genu valgum, at foot, hallux
valgus, cavus foot, and hammertoe [3].
The genu varum may be caused by weakness in the
lateral muscles, such as the Tensor fasciae latae, Biceps
femoris, and Fibular muscles, as well as the shortness of
the medial muscles, such as the Semimembranosus and
Semitendinosus muscles, Gracilis, and Tibialis anterior
[3]. In this deformity, when the individual is in and-
ing poure with the ankle medial malleolus of the foot
together, the knees remain completely separate [4]. Ac-
cording to previous udies, TheraBand could rengthen
weak muscles; accordingly, it improves the direction
of the femur, tibia, and ankles of individuals with genu
varum [5]. One of the mo prevalent deformities, i.e.
more common in females, is genu valgum deformity
[6]. In this condition, the weight line [Center of Gravity
(COG)] that descends from the center of the hip joint
tends to the outside of the knee joint. Subsequently, it
alters the pattern of body weight applied to the medial
and lateral parts of the knee joint [7]. Genu valgum also
increases the Q angle in this group. The Q angle is the
angle between the quadriceps muscle line and the patel-
lar tendon line, i.e. reported to be 10-14 degrees in men
and 14-18 in women. This dierence is due to the shape
of the females’ pelvic [4]. Wider pelvic, hip, and tibia
rotation, and genu valgum deformity aect Q angle, and
ultimately optimal poure [8]. Additionally, due to the
changes in the location of the gravity line and the abnor-
mal pressure on dierent parts of the joint surfaces, the
knee will be prone to premature erosive changes; subse-
quently, early arthritis could be expected [9]. Advanced
physiological valgus cases after the age of 8 years may
lead to patellar bone misalignment and the inability of
the knee ligaments. Such a condition lead to gait and run-
ning problems, as well as lower limb deformities [10].
Physical exercise, as a cheap, accessible, non-invasive,
and low-risk approach in maintaining health and mobil-
ity or improving the alignment of the lower limbs are
recognized [11]. TheraBand exercises are recently em-
ployed because they are more comfortable and safer. An
advanced resiance exercise is implementing Thera-
Band, which could increase muscle size and rength
in individuals [12]. TheraBand exercises, as a safe tool
are eective to improve the nervous-muscular syem,
muscle rength, and the ability to perform functional
tasks [11]. For approximately 25 years, researchers have
been using TheraBand resiance exercises to increase
rength and poure ability, and have achieved eec-
P
Highlights
The TheraBanddd exercise improves the Q angle in individuals with genu valgum abnormality.
● The TheraBand exercise improve diance of ankle medial malleolus in individuals with genu valgum abnormality.
Plain Language Summary
Physical poure is the alignment of dierent body parts with each other. When an individual is in a poor physical
poure,due to the high pressure on dierent body parts, the body direction generates a deformity. This conant pres-
sure, even if relatively low, could cause non-anatomical compatibility. Genu valgum also increases the Q angle in this
group. The Q angle is the angle between the quadriceps muscle line and the patellar tendon line, i.e. reported to be
10-14 degrees in men and 14-18 in women. TheraBandd exercises, as a safe tool, are eective to improve the neuro-
muscular syem, muscle rength, and the ability to perform functional tasks. The obtained atiical results suggeed
that TheraBandd training signicantly decreased the Q angle and the diance of ankle medial malleolus in the explored
subjects with genu valgum deformity.
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
119
July 2020. Volume 10. Number 3
tive results [13]. Elaic resiance (TheraBand) has been
proven to increase rength, mobility, and function, as
well as reduce joint pain. TheraBand is inexpensive,
portable, and versatile. Javanmehr et al. (2018) also
ated that muscle rength could be the mo eective
manner of preventing and treating deformities [14]. Park
et al. (2017) demonrated that TheraBand training and
retching exercises are eective methods to correct the
genu varum [15]. Lovell et al. (2010) argued that high-
intensity rength training increases the rength and
power of the elderly [16]. Delshad et al. (2011) ated
that TheraBand rength training could prevent muscle
disability in women [17]. Saki et al. (2019) documented
that plyometric exercises in women with dynamic knee
valgus could increase the rength of weakened muscles
in them [18]. Resiance training with TheraBand pro-
vides rength; this resiance is created by retching
force and could have a rengthening eect on weak-
ened muscles. Therefore, rengthening the weakened
muscles in the lower limbs to reduce the angle Q and
improve the genu valgum deformity is essential. Schol-
ars disregarded inveigating this training method and
the eect of TheraBand on the genu valgum deformity.
Thus, the present research aimed to inveigate the eect
of 8 weeks of TheraBand training on the Q angle and the
diance of ankle medial malleolus in individuals with
genu valgum deformity.
2. Materials and Methods
This was a quasi-experimental udy with a pre-te,
po-te and a control group design. The atiical pop-
ulation of the present udy consied of 13-9-year-old
udents of Parnian Girls’ Elementary School in Isfahan
City, Iran. After screening and initial evaluations involv-
ing 422 udents, 36 subjects with genu valgum deformi-
ty were selected by purposive and convivence sampling
method. The udy inclusion criteria included being girls
aged 9-13 years, the minimal diance of ankle medial
malleolus of 2.5 cm, the lack of receiving interventions
or exercises that aected the knee poure, no hiory of
visual, auditory, and neuromuscular disorders that aect-
ed balance, and no respiratory diress or injury and frac-
tures in the la 6 months. The individuals participated
voluntarily in this udy. An introductory meeting was
held for the selected udents’ parents on the subject of
methods, purposes, and interventions of the research. In
total, 30 volunteers were randomly selected and divided
into the udy groups of te and control (n=15/group).
The Q angle measurements were performed using a go-
niometer with a measuring accuracy of 0.1. Moreover,
we considered the diance of ankle medial malleolus by
the coulis with an accuracy of 1.1 mm.
To measure the Q angle, r, the subject ands with-
out exion, extension, or extra contraction in the lower
limbs and as the knees are facing. Then, the center of the
goniometer is placed on the center of the patella where
its xed armres on the tibial tuberosity and movable
arm are located along the femur and on the Anterior Su-
pinator Iliac Spine (ASIS). The measured angle shown is
the Q angle (Figure 1).
To measure the diance of the ankle medial malleo-
lus, the barefoot subject ood up raight and without
muscle contraction while the patella bones were facing
Figure 1. Measuring the angle Q with the goniometer Figure 2. Measuring the distance of ankle medial malleolus
by the coulis
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
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July 2020. Volume 10. Number 3
each other. By placing a coulis between the ankle medial
malleolus, the diance was recorded (Figure 2).
The experimental group performed exercises for 8
weeks, 3 sessions per week, and about 45-60 minutes
per session (5-10 minutes warm-up included move-
ments, such as speed walking, jogging, etc., followed
by retching exercises all over the body, especially the
lower limbs, such as hip, knee, and ankle retch; 40
minutes of TheraBand training; 10 minutes of cooling
down lower limbs retching exercises). However, the
control group received no training during this period.
The experimental group performed lower limb muscle
rengthening exercises on the hip, knees, and ankles
(Appendix 1). The training protocol is presented in the
Table 1 and 2 [19].
3. Results
The demographic characteriics of the udy partici-
pants are presented in Table 3.
The atiical indicators related to the Q angle and the
diance of ankle medial malleolus of the udy groups
are lied in Table 4.
According to Table 5, the covariance te assumptions
were met; therefore, a covariance analysis te was used
to analyze the collected data.
As per Table 6, ANCOVA data revealed a signicant
dierence between the udy groups (P<0.05). Based
on the mean scores, TheraBand exercises signicantly
impacted the Q angle and the diance of ankle medial
malleolus in the explored subjects.
4. Discussion
The present udy results suggeed that TheraBand
exercises signicantly reduced the Q angle and the dis-
tance of the ankle medial malleolus in the inveigated
individuals with genu valgum deformity.
Several factors, including the alignment of the lower
limbs, such as the femur, shin, and pelvic muscle rength
aected Q angle in the udy participants. A factor inu-
encing the Q angle is the alignment of the femur. The
internal rotation of the femur due to weakness of the hip
external rotator muscles increases the valgus in the knee
joint and creates malalignment in the lower limbs [20].
Accordingly, this condition could increase the Q angle
[21]. Previous udies also revealed that the rength of
the abductor and external rotator muscles could signi-
cantly aect the normal alignment of the hip, knee, and
ankles as well as the Q angle [22]. Increasing the Q angle
pulls the patella to the lateral, retching the quadriceps
muscle on the medial side of the knee, and causes muscle
imbalance. Biomechanically, the Q angle could change
an individual’s movement pattern, especially in the foot,
leading to internal rotation of the knee and the genera-
tion of the genu valgum [22]. Muscle imbalance in a
person can lead to the formation of this deformity [23,
24]. Mazidi et al. (2011) inveigated the eects of thera-
peutic exercises on the Q angle among 60 athletes with
patellofemoral pain syndrome [25]. They reported that
quadriceps rengthening exercises eectively reduced
the Q angle and pain in the udied samples. Delshad et
al. (2011) also reported that rengthening training could
prevent muscle disability [17].
In this udy, the Q angle was signicantly reduced in
the udied subjects after 8 weeks of intervention. Prop-
Table 1. The training protocol
Exercises Weeks 1 & 2 (R)Weeks 3 & 4 (R)Weeks 5 & 6 (R)Weeks 7 & 8 (R)
Squat with foot together 3×8 3×10 3×15 3×18
Knee exion with bia adducon (stance) 3×8 3×10 3×15 3×18
Hip abducon (bird dog) 3×8 3×10 3×15 3×18
Knee exion and extension with supinaon (prone) 3×8 3×10 3×15 3×18
Hip abducon (cross-leg) 3×8 3×10 3×15 3×18
Knee exion with bia adducon (prone) 3×8 3×10 3×15 3×18
Jugging 3×8 3×10 3×15 3×18
Hip abducon (lie on side) 3×8 3×10 3×15 3×18
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
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July 2020. Volume 10. Number 3
erly causes of reduced Q angle can mention increased
rength in the muscles around the knee and the mus-
cles of the femoral abductor. In this regard, Ismaili et
al. (2009) ated that factors, such as genu valgum, the
weakness of the muscles around the knee, and the exter-
nal rotation of the tibia increase the Q angle [26].
An exercise used in this udy was the rengthening of
the femoral abductor muscles. Strengthening this muscle
in the hip joint causes the femur to be rotated to external
and prevents it from excessive internal rotation. A fac-
tor that increases the Q angle is femoral adduction; thus,
it could reduce the Q angle by increasing the rength
of the hip abductor muscles. Furthermore, increasing
Table 4. Statistical indexes of the study groups
Variable Group Trial Mean±SD Depended Samples t-test P
Q angle (deg)
Experimental Pre-test 25.1±2.81 29.1 0.001
Post-test 18.9±2.66
Control Pre-test 25.6±3.46 2.2 0.12
Post-test 25.8±3.32
Distance of ankle malleolus
(cm)
Experimental Pre-test 6.2±1.32 8.2 0.04
Post-test 2.9±0.66
Control Pre-test 5.1±1.1 2.2 0.13
Post-test 5.9±0.66
Table 5. Covariance test assumptions
Variable Group Trial
Shapiro-Wilk test Levene’s test Regression
F P F P F P
Q Angle
Experimental
Pre-test 0.65 0.18
0.396 0.476 0.427 0.24
Post-test 0.71 0.12
Control
Pre-test 0.67 0.9
Post-test 0.74 0.27
The distance of ankle medial
malleolus
Experimental
Pre-test 0.76 0.29
0.429 0.417 0.512 0.43
Post-test 0.8 0.1
Control
Pre-test 0.74 0.14
Post-test 0.79 0.12
Table 2. The training program with thera band
Week 1 & 2 Week 3 & 4 Week 5 & 6 Week 7 & 8
Yellow Red Red Blue
Table 3. Demographic characteristics of the study subjects (n=15)
Variable
Mean±SD
P
Experimental Group Control Group
Age (y) 10.76±1.19 11.1±1.17 0.3
High (cm) 148±2.24 149.19±2.18 0.17
Weight (kg) 56±2.84 57.36±2.24 0.19
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
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July 2020. Volume 10. Number 3
the
rength of the quadriceps muscle abilizes the patella;
therefore, another possible reason for the decrease in Q an-
gle was the increase in quadriceps muscle rength. Sadeghi
et al. (2012) examined the eects of corrective exercises on
lower extremity deformities in female udents [27]. They
concluded that a period of rengthening exercises using
free weights and retching exercises to correct the abnor-
malities of the lower limbs of female udents improved the
deformities of their lower limbs, including the genu valgum.
Moreover, Ashouri et al. (2018) explored the eects of cor-
rective exercises on genu valgum deformity. They argued
that 8 weeks of corrective exercises improved the knee and
ankle alignment in female high school udents [28].
Lee et al. (2016) also indicated that 12 weeks of corrective
exercises signicantly impacted genu valgum deformity
and the proper alignment of the lower limbs [29]. Ghasemi
et al. (2017) also reported that the TheraBand rengthen-
ing program provided a signicant eect on girls’ genu
varum deformity and has improved the alignment of their
hip, knee, and ankles due to the weakening of weakened
muscles [5]. Park et al. (2017) revealed that TheraBand re-
siance training improved knee deformity and reduced the
diance between the knees in this group [15]. Haddadnejad
et al. (2011) examined the relationship between genu val-
gum deformity and lower limb rength in adolescent males
[30]. The relevant results demonrated that the genu val-
gum deformity group had a weaker performance, compared
to the genu varum and healthy knee groups. Besides, the
genu varum group had a weaker performance, compared to
the healthy knee group. They ated that joint muscles play
a greater role in performing various jumping tes; thus,
these dierences in function could be attributed to these
muscles and the biomechanical changes in the joints, due to
the disruption of the proper alignment of the joints.
The reasons for the increased diance between the an-
kle’s malleolus and the Q angle in the control group was
the incorrect habits of these udents over time. Besides,
the sensitivity of the age of the amulets was important in
this regard, because the bones are more formable during
the age of growth.
Considering the eects of TheraBand exercises on
lower limb muscle rength and the signicance of quad-
riceps and hamring muscles in the alignment of femur
and tibia, the possible etiologies for the diance between
the two ankles malleolus could be corrected by rength-
ening the lower limb muscles. Individuals with a genu
valgum deformity encounter weakness in the muscles
of the femoral abductor and internal hamrings, includ-
ing the semitendinosus and semimembranosus muscles;
the exercises used in this protocol were rengthening
training for these muscles. The weakness of the adduc-
tor muscles and external rotator leads to hip adduction,
as well as internal hamring muscle weakness. Subse-
quently, this condition causes tibial abduction, followed
by the removal of the internal ankles of the ankles. The
benets of TheraBand exercises include variable re-
siance; these exercises enhance muscle rength and
endurance in weakened lower limb muscles. As the
rength in the hip abductor muscles increases, the rate
of internal rotation and adduction in the hip decreases.
Furthermore, as the rength in the internal hamring
muscles increases, the external rotation of the tibia bone
decreases and rotates to the medial side. As a result, it re-
duces the diance between the medial ankles. Addition-
ally, when the alignment of the femur and tibia is correct-
ed after exercise, the knees close together are somewhat
apart, and the medial ankles also become closer.
Table 6. ANCOVA results concerning the effects of the training intervention
Variable Source Some of Squares Ds Mean Squares F P
Q angle
Corrected model 16746.1 28.109 14.603 0.012
Intercept 6.84 14.478 7.409 0.002
Pre-test score of Q angle 19.21 19.254 16.326 0.004
Group 7.204 25.105 17.258 0.003
The distance of ankle medial
malleolus
Corrected model 17256.07 27.009 15.712 0.003
Intercept 4.39 12.499 6.625 0.01
Pre-test score of the distance of ankle malleolus 15.74 110.85 19.208 0.004
Group 6.617 14.231 20.039 0.002
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
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July 2020. Volume 10. Number 3
The udy limitations included goniometer measure-
ment error; the faulty habits of the udy subjects, e.g.
walking or sitting incorrectly, and the eect of psycho-
logical factors on the evaluated subjects’ performance.
5. Conclusion
The present udy data suggeed that performing 8
weeks of TheraBand exercises demonrated a signi-
cant improvement in both research variables. Comparing
the two research groups, it could be concluded that the
experimental group improved due to rengthening exer-
cises with TheraBand. Besides, by increasing rength in
weakened muscles, the alignment of the femur and tibia
improved and reduced the Q angle and approached the
ankle medial malleolus.
Considering the results obtained during 8 weeks of the
training intervention, therapis and trainers in sports
environments could use rength training exercises to
reduce the Q angle and the diance of ankle medial mal-
leolus in individuals with cruciate knee deformity.
Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this article. The par-
ticipants were informed about the purpose of the research and
its implementation ages; they were also assured about the
condentiality of their information; moreover, they were al-
lowed to leave the udy whenever they wish, and if desired,
the results of the research would be available to them. After
describing teprotocol to all subjects before participating in
the udy, they all signed an informed consent form.
Funding
This udy was approved by the Ethics Committee of the
University of Isfahan (Khorasgan) Branch, Islamic Azad
University, Department of Sports Injury and Corrective
Exercises.
Authors' contributions
All authors contributed equally in preparing all parts of
the research.
Conict of interest
The authors declare no conicts of intere related to this
article.
Acknowledgments
The authors would like to thank the ocials of the Fac-
ulty of Physical Education at the University of Khorasgan
for their valuable cooperation and all udents participated in
this udy.
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Appendix 1
Scott’s r exercise was called a pair of legs, in which the person ood with the legs raight and, while lowering the
center of gravity by exing the knees, placed the trampoline on the hips, trying to move the hip away and rotate them
outward. In this exercise, the upper body is raight and the knees move apart as you move. The second exercise was
knee exion movement with leg adduction. In this movement, the person is anding, sitting on a chair or lying on his
omach with his thighs in line and the bandage on his leg, exing his knee and at the same time bringing his leg in.
Exercise 3 In order to rengthen the abductors and external rotators of the thigh, the person is placed on all fours and
while the bandage is on the thigh, he tries to turn the thigh and rotate it externally, alternating with left and right legs.
The fourth movement of knee exion and extension, while the person was lying on his back and trampling the sole
of the foot, with 90-degree exion and knee extension, both leg adduction and ankle supination were performed. The
fth movement of sitting on 4 knees while the bandage was closed on the person’s thigh was performed by external
rotation and abduction of the thigh, rengthening of the abductors, external rotation of the thigh and retching of the
thigh adapters. The sixth move was a jugging walk, which was performed at the same time with 120° knee exion, in
order to rengthen the rotators and abductors of the thigh and knee exors. The seventh movement was hip abduction
movement that was performed lying on one side, unilaterally, and in the middle with the left and right legs. In this
movement, the theraband was closed on the subject’s thigh.
Bahadori Sh, et al. TheraBand Training on the Q Angle and Diance, Ankle Medial Malleolus, Individuals With Genu Valgum Deformity. PTJ. 2020; 10(3):117-126.
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