THE USE OF TWO-DIMENSIONAL MOTION ANALYSIS AND FUNCTIONAL PERFORMANCE TESTS FOR ASSESSMENT OF KNEE INJURY RISK BEHAVIOURS IN ATHLETES ALLAN G. MUNRO School of Health Sciences University of Salford, Salford, UK Submitted in Partial Fulfilment of the Requirements of the Degree of Doctor of Philosophy, July 2013 i Contents Page Title page Table of contents II Tables and figures VIII Acknowledgements XV Glossary of terms XVI Abstract XVIII Chapter 1 Introduction 1.1 Knee Injuries in Sport 1 1.2 Frequency and causes of knee injuries in men and women 2 1.3 Methods to identify high-risk athletes 2 1.4 2D motion analysis: reliability and validity 3 1.5 Functional Performance Tests: reliability, validity and clinical utility 5 1.6 Causative factors of dynamic valgus and potential interventions 7 1.7 Aims 10 Chapter 2 Literature Review 2.1 Introduction 11 2.1.1 Injuries in Sport 11 2.1.2 Anterior Cruciate Ligament Injuries 13 2.1.3 Patellofemoral Joint Injuries 14 ii 2.1.4 Incidence of Anterior Cruciate Ligament and Patellofemoral Joint Injury 14 2.2 Mechanisms of Knee Injury 16 2.2.1 Mechanisms of Anterior Cruciate Ligament Injury 16 2.2.2 Mechanisms of Patellofemoral Joint Injury 19 2.3 Risk Factors for Anterior Cruciate Ligament injuries 21 2.3.1 Extrinsic Risk Factors for Anterior Cruciate Ligament Injury 21 2.3.2 Intrinsic Factors for Anterior Cruciate Ligament Injury 21 2.3.2.1 Anatomical Risk Factors 22 2.3.2.2 Hormonal Risk Factors 25 2.3.2.2 Sagittal Plane Risk Factors 27 2.3.3 Risk Factors for Patellofemoral Joint Injury 31 2.3.3.1 Vastus Medialis Muscle Properties 31 2.3.3.2 The Illiotibial Band 33 2.3.4 Neuromuscular Control 34 2.3.4.1 Dynamic Knee Valgus and Anterior Cruciate Ligament and 35 Patellofemoral Joint Injury Risk 2.3.4.2 Differences in Dynamic Valgus between Men and Women 42 2.3.4.3 Muscle Strength 46 2.3.4.4 Muscular fatigue 49 2.3.4.5 Gender differences in muscle strength 50 2.4 Summary 50 2.5 Intervention Studies 53 2.5.1 ACL Intervention Studies 53 iii 2.5.2 PFPS Intervention Studies 64 2.5.3 Feedback 65 2.6 Screening for ACL and PFJ Injury Risk 67 2.6.1 Motion Analysis 70 2.6.2 Functional Performance Tests 74 2.6.2.1 Hop for Distance Tests 75 2.6.2.2 The Star Excursion Balance Test (SEBT) 79 2.7 Summary 81 Chapter 3 Reliability and Validity of Two-Dimensional Frontal Plane Projection Angle during common athletic screening tasks 3.1 Aim 82 3.2 Introduction 82 3.3 Methods 85 3.4 Results 96 3.5 Discussion 104 3.6 Conclusion 112 Chapter 4 Reliability of the Hop for Distance and Star Excursion Balance Tests 4.1 Aim 113 4.2 Introduction 113 4.3 Reliability of the Hop for Distance Tests 114 4.3.1 Introduction 114 iv 4.3.2 Aim 116 4.3.3 Methods 116 4.3.4 Results 119 4.3.5 Discussion 124 4.4 Reliability of the Star Excursion Balance Test 129 4.4.1 Introduction 129 4.4.2 Aim 131 4.4.3 Methods 131 4.4.4 Results 133 4.4.5 Discussion 137 4.5 Conclusion 141 Chapter 5 Factors Contributing to Dynamic Knee Valgus 5.1 Aim 142 5.2 Introduction 142 5.3 Methods 145 5.4 Results 154 5.5 Discussion 157 5.6 Conclusion 164 Chapter 6 The Use of Feedback to Modify Movement Patterns during Common Screening Tasks 6.1 Aim 165 v 6.2 Introduction 165 6.3 Methods 166 6.4 Results 170 6.5 Discussion 173 6.6 Conclusion 178 Chapter 7 Prospective Assessment of Anterior Cruciate Ligament injury Risk in a Women’s Football Player 7.1 Aim 179 7.2 Introduction 179 7.3 Methods 180 7.4 Results 183 7.4.1 Case Study Results 183 7.5 Discussion 186 7.6 Conclusion 189 Chapter 8 Summary, Conclusions and Recommendations for Future Work 8.1 Summary 190 8.2 Conclusions 195 8.3 Recommendations for future work 196 vi Appendices 198 Appendix 1: Feedback questions lists 199 Appendix 2: Basketball injury report form 201 Appendix 3: Football injury report form 202 Appendix 4: Anterior Cruciate Ligament injured athlete injury report form 203 References 204 Ethical Approval Forms 229 Publications 233 Herrington, L., & Munro, A. (2010). Drop jump landing knee valgus angle; normative data in a physically active population. Physical Therapy in Sport, 11 (2), pp. 56-59 Munro, A.G., & Herrington, L.C. (2010). Between-session reliability of the star excursion balance test. Physical Therapy in Sport, 11 (4), pp. 128-132 Munro, A.G., & Herrington, L.C. (2011). Between-session reliability of four hop tests and the agility T-test. Journal of Strength and Conditioning Research, 25 (5), pp. 1470-1477 Munro, A., Herrington, L., & Carolan, M. (2012). Reliability of 2-Dimensional Video Assessment of Frontal-Plane Dynamic Knee Valgus During Common Athletic Screening Tasks. Journal of Sport Rehabilitation, 21 (1), pp. 7-11 Munro, A., Herrington, L., & Comfort, P. (2012). Comparison of landing knee valgus angle between female basketball and football athletes: Possible implications for anterior cruciate ligament and patellofemoral joint injury rates. Physical Therapy in Sport, 13, 259-264 vii Tables and Figures Page Chapter 2 Figure 2.1: The knee joint muscles and direction of action. 12 Figure 2.2: The knee joint ligaments - a) anterior view; b) posterior view. 12 Figure 2.3: Comparison of overall Anterior Cruciate Ligament injury rates per 15 1000 exposures between men and women across a number of sports and levels of competition. Figure 2.4: Comparison of non-contact Anterior Cruciate Ligament injury rates 16 per 1000 exposures between men and women across a number of sports and levels of competition. Figure 2.5: Dynamic knee valgus during the plant and cut mechanism of ACL 17 injury in Team Handball Figure 2.6: Dynamic knee valgus during the one-legged landing mechanism of 18 ACL injury in Team Handball. Figure 2.7: Dynamic knee valgus 18 Figure 2.8: The effect of changes in patella, tibial or femoral position on the load 20 bearing surface of the patella – a) neutral position with equal load bearing at both the medial and lateral patella facets; b) increased lateral displacement with resultant increase load bearing of the lateral patella facet; c) increased medial displacement with resultant increase load bearing of the medial patella facet Table 2.1: Summary of section content for intrinsic risk factors for Anterior 22 Cruciate Ligament injury. Figure 2.9: Femoral condyle notch width measures. A - femoral intercondylar 22 notch width; B – femoral bicondylar width: A:B – notch width index viii Figure 2.10: ACL impingement on the femoral condyle caused by tibial external 24 rotation and knee valgus Figure 2.11: A free-body diagram of the quadriceps (Q) and hamstring (H) forces 28 acting upon the proximal tibia in the sagittal plane during different degrees of knee flexion (a) with the knee at full extension; (b) with the knee is a moderately flexed position Figure 2.12: Muscles affecting motion of the patella. 31 Figure 2.13: Dynamic valgus of the lower limb 35 Figure 2.14: The influence of femoral rotation on a) position of the patella and b) 36 contact pressures of the patella facets Figure 2.15: The influence of tibial rotation on a) position of the patella and b) 41 contact pressures of the patella facets Table 2.2: Summary of the studies using 2D motion analysis that have shown 44 differences in the dynamic knee valgus between men and women. Table 2.3: Summary of the studies using 3D motion analysis that have shown 45 differences in the dynamic valgus kinematics and kinetics between men and women. Figure 2.16: Summary of the potential risk factors for Anterior Cruciate Ligament 52 and Patellofemoral Joint injury. Table 2.4: Summary of prevention programmes aimed at reducing ACL injury 59-60 rates Table 2.5: Summary of prevention programmes aimed to modify risk factors for 61-63 ACL injury. Table 2.6: Summary of the studies assessing the reliability of the four hop tests. 78 Chapter 3 Figure 3.1: The Drop Jump task. 87 ix Figure 3.2: The Single Leg Land task. 88 Figure 3.3: The Single Leg Squat task. 89 Figure 3.4: 3D anatomical and rigid marker setup. 89 Figure 3.5: 3D tracking marker setup. 90 Figure 3.6: Lower extremity segment and joint rotation denotations. 92 Figure 3.7: 2D marker placement for measurement of Frontal Plane Projection 93 Angle. Figure 3.8: Frontal Plane Projection Angle during drop jump, single leg land and 94 single leg squat tasks. Figure 3.9: A flow diagram showing statistical analyses undertaken. 96 Table 3.1: Mean, standard deviation (SD) for session 1 (S1) and session 2 (S2) 97 and within-day intraclass correlation coefficient (ICC), 95% confidence intervals (CI) for ICC, standard error of measurement (SEM), and smallest detectable difference (SDD). Table 3.2: Mean and standard deviation (SD) values for sessions 1 (S1) and 3 97 (S3), between-day intraclass correlation coefficient (ICC), 95% confidence intervals (CI) for ICC, standard error of measurement (SEM), and smallest detectable difference (SDD). Table 3.3: Mean and standard deviation (SD) values for test 1 (T1) and test 2 98 (T2) and intra-tester intraclass correlation coefficient (ICC), 95% confidence intervals (CI) for ICC, standard error of measurement (SEM), and smallest detectable difference (SDD).