Sagittal Plane Hip, Knee, and Ankle Biomechanics and the Risk of Anterior Cruciate Ligament Injury: A Prospective Study

Background: Stiff landings with less knee flexion and high vertical ground-reaction forces have been shown to be associated with an increased risk of anterior cruciate ligament (ACL) injury. The literature on the association between other sagittal plane measures and the risk of ACL injuries with a prospective study design is lacking. Purpose: To investigate the relationship between selected sagittal plane hip, knee, and ankle biomechanics and the risk of ACL injury in young female team-sport athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 171 female basketball and floorball athletes (age range, 12-21 years) participated in a vertical drop jump test using 3-dimensional motion analysis. All new ACL injuries, as well as match and training exposure data, were recorded for 1 to 3 years. Biomechanical variables, including hip and ankle flexion at initial contact (IC), hip and ankle ranges of motion (ROMs), and peak external knee and hip flexion moments, were selected for analysis. Cox regression models were used to calculate hazard ratios (HRs) with 95% CIs. The combined sensitivity and specificity of significant test variables were assessed using a receiver operating characteristic (ROC) curve analysis. Results: A total of 15 noncontact ACL injuries were recorded during follow-up (0.2 injuries/1000 player-hours). Of the variables investigated, landing with less hip flexion ROM (HR for each 10° increase in hip ROM, 0.61 [95% CI, 0.38-0.99]; P < .05) and a greater knee flexion moment (HR for each 10-N·m increase in knee moment, 1.21 [95% CI, 1.04-1.40]; P = .01) was significantly associated with an increased risk of ACL injury. Hip flexion at IC, ankle flexion at IC, ankle flexion ROM, and peak external hip flexion moment were not significantly associated with the risk of ACL injury. ROC curve analysis for significant variables showed an area under the curve of 0.6, indicating a poor combined sensitivity and specificity of the test. Conclusion: Landing with less hip flexion ROM and a greater peak external knee flexion moment was associated with an increased risk of ACL injury in young female team-sport players. Studies with larger populations are needed to confirm these findings and to determine the role of ankle flexion ROM as a risk factor for ACL injury. Increasing knee and hip flexion ROMs to produce soft landings might reduce knee loading and risk of ACL injury in young female athletes.

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Stiff Landings Are Associated With Increased ACL Injury Risk in Young Female Basketball and Floorball Players

The American Journal of Sports Medicine ◽

10.1177/0363546516665810 ◽

2016 ◽

Vol 45 (2) ◽

pp. 386-393 ◽

Cited By ~ 95

Author(s):

Mari Leppänen ◽

Kati Pasanen ◽

Urho M. Kujala ◽

Tommi Vasankari ◽

Pekka Kannus ◽

...

Keyword(s):

Knee Flexion ◽

Injury Risk ◽

Acl Injury ◽

Young Female ◽

Flexion Angle ◽

Knee Flexion Angle ◽

Acl Injuries ◽

Increased Risk ◽

Peak Knee ◽

Acl Injury Risk

Background: Few prospective studies have investigated the biomechanical risk factors of anterior cruciate ligament (ACL) injury. Purpose: To investigate the relationship between biomechanical characteristics of vertical drop jump (VDJ) performance and the risk of ACL injury in young female basketball and floorball players. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, a total of 171 female basketball and floorball players (age range, 12-21 years) participated in a VDJ test using 3-dimensional motion analysis. The following biomechanical variables were analyzed: (1) knee valgus angle at initial contact (IC), (2) peak knee abduction moment, (3) knee flexion angle at IC, (4) peak knee flexion angle, (5) peak vertical ground-reaction force (vGRF), and (6) medial knee displacement. All new ACL injuries, as well as match and training exposure, were then recorded for 1 to 3 years. Cox regression models were used to calculate hazard ratios (HRs) and 95% CIs. Results: Fifteen new ACL injuries occurred during the study period (0.2 injuries/1000 player-hours). Of the 6 factors considered, lower peak knee flexion angle (HR for each 10° increase in knee flexion angle, 0.55; 95% CI, 0.34-0.88) and higher peak vGRF (HR for each 100-N increase in vGRF, 1.26; 95% CI, 1.09-1.45) were the only factors associated with increased risk of ACL injury. A receiver operating characteristic (ROC) curve analysis showed an area under the curve of 0.6 for peak knee flexion and 0.7 for vGRF, indicating a failed-to-fair combined sensitivity and specificity of the test. Conclusions: Stiff landings, with less knee flexion and greater vGRF, in a VDJ test were associated with increased risk of ACL injury among young female basketball and floorball players. However, although 2 factors (decreased peak knee flexion and increased vGRF) had significant associations with ACL injury risk, the ROC curve analyses revealed that these variables cannot be used for screening of athletes.

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Single-Leg Landings Following a Volleyball Spike May Increase the Risk of Anterior Cruciate Ligament Injury More Than Landing on Both-Legs

Applied Sciences ◽

10.3390/app11010130 ◽

2020 ◽

Vol 11 (1) ◽

pp. 130

Author(s):

Datao Xu ◽

Xinyan Jiang ◽

Xuanzhen Cen ◽

Julien S. Baker ◽

Yaodong Gu

Keyword(s):

Anterior Cruciate Ligament ◽

Knee Flexion ◽

Sagittal Plane ◽

Cruciate Ligament ◽

Flexion Angle ◽

Ligament Injury ◽

Time Range ◽

Acl Injuries ◽

Volleyball Players ◽

Anterior Cruciate

Volleyball players often land on a single leg following a spike shot due to a shift in the center of gravity and loss of balance. Landing on a single leg following a spike may increase the probability of non-contact anterior cruciate ligament (ACL) injuries. The purpose of this study was to compare and analyze the kinematics and kinetics differences during the landing phase of volleyball players using a single leg (SL) and double-leg landing (DL) following a spike shot. The data for vertical ground reaction forces (VGRF) and sagittal plane were collected. SPM analysis revealed that SL depicted a smaller knee flexion angle (about 13.8°) and hip flexion angle (about 10.8°) during the whole landing phase, a greater knee and hip power during the 16.83–20.45% (p = 0.006) and 13.01–16.26% (p = 0.008) landing phase, a greater ankle plantarflexion angle and moment during the 0–41.07% (p < 0.001) and 2.76–79.45% (p < 0.001) landing phase, a greater VGRF during the 5.87–8.25% (p = 0.029), 19.75–24.14% (p = 0.003) landing phase when compared to DL. Most of these differences fall within the time range of ACL injury (30–50 milliseconds after landing). To reduce non-contact ACL injuries, a landing strategy of consciously increasing the hip and knee flexion, and plantarflexion of the ankle should be considered by volleyball players.

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Temporal Kinematic Differences between Forward and Backward Jump-Landing

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17186669 ◽

2020 ◽

Vol 17 (18) ◽

pp. 6669 ◽

Cited By ~ 1

Author(s):

Datao Xu ◽

Xuanzhen Cen ◽

Meizi Wang ◽

Ming Rong ◽

Bíró István ◽

...

Keyword(s):

Knee Flexion ◽

Cruciate Ligament ◽

Statistical Parametric Mapping ◽

Time Frame ◽

Biomechanical Analysis ◽

Acl Injuries ◽

Jump Landing ◽

Vertical Ground ◽

Anterior Cruciate ◽

Hip Flexion

Backward jump-landing during sports performance will result in dynamic postural instability with a greater risk of injury, and most research studies have focused on forward landing. Differences in kinematic temporal characteristics between single-leg and double-leg backward jump-landing are seldom researched and understood. The purpose of this study was to compare and analyze lower extremity kinematic differences throughout the landing phases of forward and backward jumping using single-leg and double-leg landings (FS and BS, FD and BD). Kinematic data were collected during the landing phases of FS and BS, FD and BD in 45 participants. Through statistical parametric mapping (SPM) analysis, we found that the BS showed smaller hip and knee flexion and greater vertical ground reactive force (VGRF) than the FS during 0–37.42% (p = 0.031), 16.07–32.11% (p = 0.045), and 23.03–17.32% (p = 0.041) landing phases. The BD showed smaller hip and knee flexion than the FD during 0–20.66% (p = 0.047) and 0–100% (p < 0.001) landing phases. Most differences appeared within a time frame during the landing phase at 30–50 ms in which non-contact anterior cruciate ligament (ACL) injuries are thought to occur and are consistent with the identification of risk in biomechanical analysis. A landing strategy that consciously increases the knee and hip flexion angles during backward landing should be considered for people as a measure to avoid injury during the performance of this type of physical activity.

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Effects of Sex and Fatigue on Biomechanical Measures During the Drop-Jump Task in Children

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967116679640 ◽

2017 ◽

Vol 5 (1) ◽

pp. 232596711667964 ◽

Cited By ~ 10

Author(s):

Kristín Briem ◽

Kolbrún Vala Jónsdóttir ◽

Árni Árnason ◽

Þórarinn Sveinsson

Keyword(s):

Knee Flexion ◽

Female Athletes ◽

Cruciate Ligament ◽

Pearson Correlation ◽

Reaction Force ◽

Acl Injury ◽

Initial Contact ◽

Drop Jump ◽

Increased Risk ◽

Movement Strategies

Background: Female athletes have a higher rate of anterior cruciate ligament (ACL) injury than males from adolescence and into maturity, which is suggested to result from sex-specific changes in dynamic movement patterns with maturation. Few studies have studied movement strategies and response to fatigue in children. Purpose: To evaluate the effect of fatigue on biomechanical variables associated with increased risk for ACL injury during a drop-jump (DJ) performance in children. Study Design: Controlled laboratory study. Methods: A total of 116 children (mean age, 10.4 years) were recruited from local sports clubs and performed 5 repetitions of a DJ task before and after a fatigue protocol. Kinematic and kinetic data from initial contact (IC) to the first peak vertical ground reaction force (vGRF) were analyzed for both limbs, including limb and fatigue as within-subject factors for analyses between boys and girls. Pearson correlation coefficients were calculated to identify associations between variables of interest. Results: Girls demonstrated greater peak vGRF values than boys (by 8.1%; P < .05), there were greater peak vGRF values for the right limb than the left (by 6.2%; P < .001), and fatigue led to slightly greater values ( P < .05). Although weak, the correlation between peak vGRF values and knee flexion excursion was stronger for girls ( r = –0.20) than boys ( r = –0.08) ( P < .006). Fatigue resulted in greater knee flexion angles at IC and less excursion during landing, more so for girls (by 6.1° vs 1.4°; interaction, P < .001), although the knee flexion moment was generally lowered by fatigue ( P < .001). Limb asymmetry in knee flexion moments was more pronounced for boys than for girls (interaction, P < .05), contrary to that seen in frontal plane knee moments, where asymmetry was much greater in girls than boys (interaction, P < .001). Conclusion: Even as young athletes, girls and boys seem to adopt dissimilar movement strategies and are differently affected by fatigue. Clinical Relevance: Injury prevention programs should be considered at an earlier age in an effort to lower the risk of ACL injury in athletes.

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Correlation Between Quadriceps, Hamstring, Tibialis Anterior, and Gastrocnemius Muscle Activation, With Knee Flexion Angle In Basketball Athlete While Performing Double-Leg Landing Task

Surabaya Physical Medicine and Rehabilitation Journal ◽

10.20473/spmrj.v2i1.2020.7-15 ◽

2020 ◽

Vol 2 (1) ◽

pp. 7

Author(s):

Ditaruni Asrina Utami

Keyword(s):

Knee Flexion ◽

Tibialis Anterior ◽

Muscle Activation ◽

Sagittal Plane ◽

Cruciate Ligament ◽

Acl Injury ◽

Flexion Angle ◽

Knee Flexion Angle ◽

Cross Sectional ◽

Activation Ratio

ABSTRACTBackground: Anterior cruciate ligament (ACL) injury cause great disability for athlete. Recent focus of ACL injury management is on prevention by identifying the risk factors. Most of basketball injury mechanism is non-contact, related to landing process with small knee flexion angle. Muscle activation and its ratio, which control movement pattern in sagittal plane, are said to play a role in dynamic movement such as landing.Aims: The purpose of this study is to analyze the correlation between muscles activation and their activation ratio of quadriceps, hamstring, tibialis anterior and gastrocnemius with knee flexion angle of basketball athlete while performing double-leg landing task.Material and methods: This study was an observational analytic, cross sectional study. Study subjects was basketball athletes age 16 – 25 years in Surabaya. Measurements of knee flexion angle done with digital measurements of reflective marker, and muscle activation was measured with sEMG while performing double-leg landing task.Result: There was no significant correlation between maximum knee flexion angle and muscle activation of quadriceps (p=0,562), hamstring (p=0,918), tibialis anterior (p=0,394) and gastrocnemius (p=0,419). There was also no significant correlation between maximum knee flexion angle and the muscle activation ratio of quadriceps-hamstring (p=0,347), quadriceps-tibialis (p=0,139), quadriceps-gastrocnemius (p=0,626), hamstring-tibialis anterior (p=0,365), hamstring-gastrocnemius (p=0,867), and tibialis anterior-gastrocnemius (p=0,109).Conclusions: There was no correlation between muscle activation and muscle activation ratio of quadriceps, hamstring, tibialis anterior and gastrocnemius with maximum knee flexion angle in basketball athlete while performing double-leg landing task.

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Tendency of Driving to the Basket Is Associated With Increased Risk of Anterior Cruciate Ligament Tears in National Basketball Association Players: A Cohort Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211052953 ◽

2021 ◽

Vol 9 (11) ◽

pp. 232596712110529

Author(s):

Blake J. Schultz ◽

Kevin A. Thomas ◽

Mark Cinque ◽

Joshua D. Harris ◽

William J. Maloney ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Standard Deviation ◽

Cruciate Ligament ◽

Acl Injury ◽

National Basketball Association ◽

Acl Injuries ◽

Increased Risk ◽

Significant Difference ◽

Anterior Cruciate ◽

Level Performance

Background: Driving to the basket in basketball involves acceleration, deceleration, and lateral movements, which may expose players to increased anterior cruciate ligament (ACL) injury risk. It is unknown whether players who heavily rely on driving have decreased performance on returning to play after ACL reconstruction (ACLR). Hypothesis: Players with a greater tendency to drive to the basket would be more likely to tear their ACL versus noninjured controls and would experience decreased performance when returning to play after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: Season-level performance statistics and ACL injuries were aggregated for National Basketball Association (NBA) seasons between 1980 and 2017 from publicly available sources. Players’ tendency to drive was calculated using 49 common season-level performance metrics. Each ACL-injured player was matched with 2 noninjured control players by age, league experience, and style of play metrics. Points, playing minutes, driving, and 3-point shooting tendencies were compared between players with ACL injuries and matched controls. Independent-samples t test was utilized for comparisons. Results: Of 86 players with a total of 96 ACL tears identified in the NBA, 50 players were included in the final analysis. Players who experienced an ACL tear had a higher career-average drive tendency than controls ( P = .047). Players with career-average drive tendency ≥1 standard deviation above the mean were more likely to tear their ACL than players with drive tendency <1 standard deviation (5.2% vs 2.7%; P = .026). There was no significant difference in total postinjury career points ( P = .164) or career minutes ( P = .237) between cases and controls. There was also no significant change in drive tendency ( P = .152) or 3-point shooting tendency ( P = .508) after return to sport compared with controls. Conclusion: NBA players with increased drive tendency were more likely to tear their ACL. However, players who were able to return after ACLR did not underperform compared with controls and did not alter their style of play compared with the normal changes seen with age. This information can be used to target players with certain playing styles for ACL injury prevention programs.

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Correlation Between Quadriceps, Hamstring, Tibialis Anterior, and Gastrocnemius Muscle Activation, With Knee Flexion Angle In Basketball Athlete While Performing Double-Leg Landing Task

Surabaya Physical Medicine and Rehabilitation Journal ◽

10.20473/spmrj.v2i1.17051 ◽

2020 ◽

Vol 2 (1) ◽

pp. 7

Author(s):

Ditaruni Asrina Utami

Keyword(s):

Knee Flexion ◽

Tibialis Anterior ◽

Muscle Activation ◽

Sagittal Plane ◽

Cruciate Ligament ◽

Acl Injury ◽

Flexion Angle ◽

Knee Flexion Angle ◽

Cross Sectional ◽

Activation Ratio

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Sexual Dimorphisms in Anterior Cruciate Ligament Injury: A Current Concepts Review

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211025304 ◽

2021 ◽

Vol 9 (12) ◽

pp. 232596712110253

Author(s):

Tayt M. Ellison ◽

Ilexa Flagstaff ◽

Anthony E. Johnson

Keyword(s):

Female Athletes ◽

Cruciate Ligament ◽

Acl Injury ◽

Extrinsic Factors ◽

Male Athletes ◽

Acl Injuries ◽

Sexual Dimorphisms ◽

Increased Risk ◽

Anterior Cruciate ◽

Postsurgical Outcomes

Background: Although most anterior cruciate ligament (ACL) injuries occur in male athletes, female athletes are consistently observed to be at a higher risk for sports-specific ACL injury. Purpose: To provide a thorough review of what is known about the sexual dimorphisms in ACL injury to guide treatment and prevention strategies and future research. Study Design: Narrative review. Methods: We conducted a comprehensive literature search for ACL-related studies published between January 1982 and September 2017 to identify pertinent studies regarding ACL injury epidemiology, prevention strategies, treatment outcomes, and dimorphisms. By performing a broad ACL injury search, we initially identified 11,453 articles. After applying additional qualifiers, we retained articles if they were published in English after 1980 and focused on sex-specific differences in any of 8 different topics: sex-specific reporting, difference in sports, selective training, hormonal effects, genetics, neuromuscular and kinematic control, anatomic differences, and outcomes. Results: A total of 122 articles met the inclusion criteria. In sum, the literature review indicated that female athletes are at significantly higher risk for ACL injuries than are their male counterparts, but the exact reasons for this were not clear. Initial studies focused on intrinsic differences between the sexes, whereas recent studies have shifted to focus on extrinsic factors to explain the increased risk. It is likely both intrinsic and extrinsic factors contribute to this increased risk, but further study is needed. In addition to female patients having an increased risk for ACL injuries, they are less likely than are male patients to undergo reconstructive surgery, and they experience worse postsurgical outcomes. Despite this, reconstructive surgery remains the gold standard when knee stability, return to sports, and high functional outcome scores are the goal, but further research is needed to determine why there is disparity in surgical rates and what surgical techniques optimize postsurgical outcomes for female patients. Conclusion: Male athletes often predominated the research concerning ACL injury and treatment, and although sex-specific reporting is progressing, it has historically been deficient. ACL injuries, prevention techniques, and ACL reconstruction require further research to maximize the health potential of at-risk female athletes.

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A Tomahawk Shaped Femur is a Risk Factor for Anterior Cruciate Ligament Injury

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00016 ◽

2018 ◽

Vol 6 (4_suppl2) ◽

pp. 2325967118S0001

Author(s):

Thomas Pfeiffer ◽

Jeremy Burnham ◽

Elmar Herbst ◽

Sven Shafizadeh ◽

Volker Musahl

Keyword(s):

Acl Reconstruction ◽

Roc Analysis ◽

Cruciate Ligament ◽

Acl Injury ◽

Control Group ◽

Acl Injuries ◽

Injury Group ◽

Increased Risk ◽

The Mean ◽

Anterior Cruciate

Bony morphologic characteristics have been demonstrated to increase the risk of anterior cruciate ligament (ACL) injury. The purpose of the study was to examine distal femoral morphology relative to ACL injury, reconstruction failure, and contralateral ACL injury. It was hypothesized that an increased posterior femoral condylar depth, quantified as the tomahawk ratio, would correlate with increased risk of primary ACL ruptures, ACL reconstruction failures, and contralateral ACL injuries. Consecutive patients undergoing arthroscopic knee surgery at an academic medical center from 2012-2016 with minimum 24-month follow-up were retrospectively reviewed. Subjects were stratified into four groups: a control group consisting of patients with no ACL injuries and three groups of patients with a primary ACL injury, failed ACL reconstruction, or previous ACL injury with subsequent contralateral ACL injury. Using lateral radiographs, the ratio of posterior condylar depth over total condylar distance was defined as the tomahawk ratio. Analysis-of-variance (ANOVA) and post-hoc testing were used to test for differences in the mean tomahawk ratio between study groups (p<0.05). Receiver Operating Characteristic (ROC) analysis was performed to determine the optimal tomahawk ratio cut-off for detecting increased risk for ACL injury 175 patients met inclusion criteria. The mean tomahawk ratios in the control group, primary ACL injury group, failed ACL reconstruction group, and contralateral ACL injury group were 61.1% (± 2.1), 64.2% (± 3.8), 64.4% (± 3.6), and 66.9% (± 4.0), respectively. Patients with a primary ACL injury, failed ACL reconstruction, or contralateral ACL injury had a significantly higher tomahawk ratio compared to the control group (p<0.008). ROC analysis demonstrated a tomahawk ratio of 63% or greater to be associated with an increased risk for ACL injury with a sensitivity of 83% and a specificity of 71%. The data from this study show that an increased posterior femoral condylar depth, or tomahawk ratio, is associated with increased risk of ACL injury, including primary ACL injury, failed ACL reconstruction, and contralateral ACL injury. Readily identifiable risk factors, such as an increased tomahawk ratio, could assist clinicians in identifying at-risk individuals who may experience greater benefit from targeted ACL injury prevention counseling and intervention. The presence of the tomahawk-shaped femur could also be used to guide treatment decisions and identify ACL reconstruction patients who may benefit from additional surgical procedures such as extra articular tenodesis.

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Rapid Posterior Tibial Reduction After Noncontact Anterior Cruciate Ligament Rupture: Mechanism Description From a Video Analysis

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120936673 ◽

2020 ◽

Vol 12 (5) ◽

pp. 462-469 ◽

Cited By ~ 1

Author(s):

Alberto Grassi ◽

Filippo Tosarelli ◽

Piero Agostinone ◽

Luca Macchiarola ◽

Stefano Zaffagnini ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Video Analysis ◽

Knee Flexion ◽

Cruciate Ligament ◽

Acl Injury ◽

Soccer Players ◽

Initial Contact ◽

Acl Injuries ◽

Posterior Tibial ◽

Anterior Cruciate

Background: The mechanisms of noncontact anterior cruciate ligament (ACL) injuries are an enormously debated topic in sports medicine; however, the late phases of injury have not yet been investigated. Hypothesis: A well-defined posterior tibial translation can be visualized with its timing and patterns of knee flexion after ACL injury. Study Design: Case series. Level of Evidence: Level 4. Methods: A total of 137 videos of ACL injuries in professional male football (soccer) players were screened for a sudden posterior tibial reduction (PTR) in the late phase of noncontact ACL injury mechanism. The suitable videos were analyzed using Kinovea software for sport video analysis. The time of initial contact of the foot with the ground, the foot lift, the start of tibial reduction, and the end of tibial reduction were assessed. Results: A total of 21 videos exhibited a clear posterior tibial reduction of 42 ± 11 ms, after an average of 229 ± 81 ms after initial contact. The tibial reduction occurred consistently within the first 50 to 60 ms after foot lift (55 ± 30 ms) and with the knee flexed between 45° and 90° (62%) or more than 90° (24%). Conclusion: A rapid posterior tibial reduction is consistently present in the late phases of noncontact ACL injuries in some male soccer players, with a consistent temporal relationship between foot lift from the ground and consistent degrees of knee flexion near or above 90°. Clinical Relevance: This study provides insight into the late phases of ACL injury. The described mechanism, although purely theoretical, could be responsible for commonly observed intra-articular lesions.

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