Original researchThe reliability and validity of the measurement of lateral trunk motion in two-dimensional video analysis during unipodal functional screening tests in elite female athletes
Introduction
Female athletes are at increased risk for acute and overuse knee injuries, such as anterior cruciate ligament (ACL) injuries and patellofemoral pain syndrome (PFPS) (Agel, Arendt, & Bershadsky, 2005; Boling, Padua, Marshall, Guskiewicz, Pyne & Beutler, 2010). The underlying mechanisms of these injuries are multifactorial in nature. From an injury prevention perspective, biomechanical and neuromuscular factors are most important, as these can be modified by training (Hewett, Myer, Ford, Paterno, & Quatman, 2012).
Prospective studies have shown that increased knee abduction angles and moments are associated with an increased risk to sustain ACL (re-)injuries and PFPS (Hewett et al., 2005; Myer et al., 2010; Paterno et al., 2010). High risk knee loading may be the result of decreased whole body movement control, rather than a dysfunction of the knee itself, as it is recognized that the knee acts as an intermediate joint within a linked system of interdependent segments (Hewett & Myer, 2011; Mendiguchia, Ford, Quatman, Alentorn-Geli, & Hewett, 2011). Indeed, increasing evidence indicates that trunk control may have a large effect on knee injury risk (Hewett & Myer, 2011; Jamison, Pan, & Chaudhari, 2012; Mendiguchia et al., 2011; Zazulak, Hewett, Reeves, Goldberg, & Cholewicki, 2007). Movements of the trunk in the direction of the stance limb during unipodal tests may increase the external knee abduction moment (Jamison et al., 2012). Furthermore, increased lateral trunk motion (LTM) has been associated with the ACL injury mechanism in female athletes (Hewett, Torg, & Boden, 2009), and has been reported as a maladaptive movement strategy in subjects with PFPS (Nakagawa, Moriya, Maciel, & Serrao, 2012).
Assessment of movement quality during functional screening tests has been advocated to be important to evaluate (re-)injury risk (Chmielewski, Hodges, Horodyski, Bishop, Conrad & Tillman, 2007; Mottram & Comerford, 2008; Ortiz & Micheo, 2011; Sahrmann, 2011; Whatman, Hing, & Hume, 2011; Whatman, Hing, & Hume, 2012; Whatman, Hume, & Hing, 2012). Three-dimensional (3D) motion analysis is considered as the gold standard to identify poor biomechanical control of the lower extremity (McLean, Walker, Ford, Myer, Hewett & van den Bogert, 2005). However, due to the practical, temporal and spatial constraints of these methods, it is difficult to use in clinical settings and on larger scales. As a more time- and cost-effective alternative method, two-dimensional (2D) video analysis has been introduced. Despite the limitation that transverse movements cannot be measured (Ageberg, Bennell, Hunt, Simic, Roos & Creaby, 2010; Willson & Davis, 2008), 2D video analysis is considered as a useful method for measuring knee valgus (KV) angles during functional screening tests (Herrington & Munro, 2010; McLean et al., 2005; Miller & Callister, 2009; Mizner, Chmielewski, Toepke, & Tofte, 2012; Munro, Herrington, & Carolan, 2012; Stensrud, Myklebust, Kristianslund, Bahr, & Krosshaug, 2011; Willson & Davis, 2008).
However, focusing only on this angle and neglecting trunk motion may be too limited and may lead to misinterpretations when assessing knee injury risk, as it is recognized that LTM may play an important role in acute and overuse knee injury mechanisms by increasing the external knee abduction moment. In contrast with current practice where LTM is assessed during functional screening tests with visual observation (Chmielewski et al., 2007; Crossley, Zhang, Schache, Bryant, & Cowan, 2011; Whatman, Hing, et al., 2012) and 3D motion analysis (Jamison et al., 2012; Nakagawa et al., 2012; Whatman et al., 2011), LTM has not yet been measured with 2D video analysis.
The goal of the present study was to investigate the reliability and validity of the measurement of LTM in 2D video analysis during unipodal functional screening tests. Therefore, the reliability of this 2D LTM angle was first examined. Further, the correlations between 2D angles and 3D peak external knee abduction moment were calculated to validate this 2D method.
Section snippets
Participants
A total of 43 elite female athletes (22 soccer, 11 handball and 10 volleyball) were tested (mean ± SD: age = 21.1 ± 3.4 years; height = 170.0 ± 8.3 cm; weight = 65.2 ± 8.0 kg). Athletes were recruited from one soccer, one handball and one volleyball team of the highest national level. Participants were injury and pain free, and above 16 years old. Appropriate ethical approval had been granted by the local ethical committee prior to the commencement of the study. Before participating in the
Reliability
Excellent intratester reliability for the LTM angle was found, with small absolute differences (0.3–0.6°), high ICC values (0.99–1.00), and small SEM (0.3–0.5°) and SDD (0.8–1.3°) (Table 1). Intertester reliability was excellent with small absolute differences (0.5–0.7°), high ICC values (0.98–0.99), and small SEM (0.4–0.6°) and SDD (1.0–1.6°) (Table 2).
Differences between tests
Significantly smaller LTM and KVLTM angles were found during the SLDVJ compared to the SLS for both legs, while KV was not different between
Discussion
From an injury prevention perspective, it is important to have reliable and valid clinical assessment tools to identify those athletes at highest injury risk. The use of 2D video analysis to measure KV angles is supported in literature (Herrington & Munro, 2010; McLean et al., 2005; Miller & Callister, 2009; Mizner et al., 2012; Munro et al., 2012; Stensrud et al., 2011; Willson & Davis, 2008). Despite increasing evidence that the trunk may be important when assessing knee injury risk (Hewett &
Conclusion
The results of the current study show that LTM can be measured with excellent intra- and intertester reliability during unipodal functional screening tests using 2D video analysis. LTM and the combination of KV and LTM were significantly different between SLS and SLDVJ, while KV was not. The combination of KV and LTM was moderately correlated with the pKAM during the SLDVJ. Therefore, including the measurement of LTM in the 2D video analysis of unipodal functional screening tests may aid
Conflict of interest statement
All authors disclose that there are no financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work.
Ethical statement
Appropriate ethical approval had been granted by the local ethical committee of KU Leuven (S53369) prior to the commencement of the study. Participating subjects read and signed the informed consent form.
Funding
None delcared.
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