Literature ReviewIs core stability a risk factor for lower extremity injuries in an athletic population? A systematic review
Introduction
Participation in sports and physical activity entails a considerable risk for musculoskeletal injury for both elite and recreational athletes (Bahr & Krosshaug, 2005). Athletic injuries generally affect the lower extremity, including hip, knee, lower leg and ankle injuries. (Murphy, Connolly, & Beynnon, 2003). A clear understanding of intrinsic risk factors, extrinsic risk factors and injury mechanisms is essential for providing successful injury prevention (Bahr and Holme, 2003, Gissane et al., 2001, Meeuwisse, 1994, van Mechelen et al., 1992). Many risk factors for lower extremity injury have already been studied thoroughly. For example, altered biomechanics including increased knee abduction angle and knee abduction moment during movement are found to be predictors for anterior cruciate ligmant injuries in female athletes (Hewett et al., 2005).
In addition to these locally defined biomechanical alterations, the role of core stability related factors in the altered function of the lower extremity and the development of injuries has gained widespread attention over the last decade (Chuter and Janse de Jonghe, 2012, Raschner et al., 2012, Wilkerson and Colstan, 2015, Willson et al., 2006). From an anatomical point of view, the musculoskeletal core of the body refers to the osseous and soft tissue structures of the spine, pelvis, and the abdomen (Bergmark, 1989, Borghuis et al., 2008, Kibler et al., 2006). Numerous muscles cross the spine and abdomen and contribute to core stability (Colston, 2012). Core stability is generally defined as the foundation of lumbopelvic dynamic control that allows for optimal production, transfer and control of force and motion, which is transferred throughout the kinetic chain during functional movement (Ireland et al., 2003, Kibler et al., 2006). (Cholewicki and McGill, 1996, Ebenbichler et al., 2001, Hammill et al., 2008, Hibbs et al., 2008, Leetun et al., 2004). Core stability is instantaneous and efficient functioning requires the successful integration of adequate muscular characteristics defined by strength and endurance (Borghuis et al., 2008, Leetun et al., 2004) and sensorimotor control, which relies on proprioception and neuromuscular control (Borghuis et al., 2008, Zazulak et al., 2007a, Zazulak et al., 2007b). This integration is essential to guarantee sufficient core stability (Cholewicki and McGill, 1996, Ebenbichler et al., 2001, Hammill et al., 2008, Hibbs et al., 2008).
Core stability has been implied numerous times to influence lower limb functioning (Dierks et al., 2008, Hewett et al., 2006, McGill, 2010). Abdominal and multifidus muscles are proven to contract in anticipation of reactive forces produced by lower limb movement (Hodges & Richardson, 1997), and preparatory motion of the trunk was demonstrated prior to asymmetric limb movement (Hodges, Cresswell, Daggfeldt, & Thorstensson, 2000). As such, core musculature could provide a stable foundation, which allows for safe and controlled movement distal to the core, and is considered as an important contributor in maintaining dynamic joint stability in the kinetic chain during locomotion (Akuthota and Nadler, 2004, Barr et al., 2007, Borghuis et al., 2008, Kibler et al., 2006). Furthermore, core training has been established to influence lower extremity biomechanics (Earl and Hoch, 2011, Sato and Mokha, 2009) and it was found to modify and enhance sports performance (Butcher et al., 2007, Jamison et al., 2012, Willardson, 2007). Therefore, it is hypothesized that impaired core stability increases vulnerability in the development of general lower extremity injuries through uncontrolled joint displacements or accessory movements throughout the kinetic chain (Chuter and Janse de Jonghe, 2012, Kibler et al., 2006).
As it is still unclear to this day whether impaired core stability could lead to injuries, researching and identifying the relationship between impaired core stability and lower extremity injuries could have important implications in the fields of injury prevention and rehabilitation. A first step towards gaining insight into this relationship is to research whether core stability can be considered as a risk factor in the development of lower extremity injuries. As of this day, an overview of the current existing evidence for core stability as a risk factor for these injuries is lacking. Therefore, the main purpose of this systematic review is to summarize the available literature on the role of core stability as a risk factor in the development of lower extremity injuries in a healthy athletic population. Secondary to this main purpose, this review will discuss the findings and explore the association between various aspects attributed to core stability and lower extremity injuries.
Section snippets
Methods
This review follows the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines. Literature search, screening, data collection and quality assessment was performed by 2 researchers independently at the University of Ghent, Belgium. Afterwards, the results were compared and differences were discussed to reach consensus. If no agreement could be reached, a third researcher would ultimately decide on the outcome.
Study selection
The search of PubMed, Web of Science and Embase databases provided a total of 1580 citations. After deduplication, 1253 citations remained. After selection on title and abstract based on the modified – PICO criteria, fourteen full texts were withheld. Four studies were discarded based on intervention; one study was discarded based on outcome. No extra studies were identified from the reference lists using the systematic search strategy. This lead to a total of nine studies used for data
Discussion
To the authors' knowledge, this is the first systematic literature review regarding the link between core stability and lower extremity injury. The hypothesis for this review was that inadequate core stability is associated with lower extremity injuries and consequently, that core stability could be considered as risk factor for musculoskeletal injuries. This review revealed that various core stability related components can be considered as risk factors in the development of different types of
Conclusion
The results of this systematic review provide preliminary evidence for the association between impaired core stability measures and the development of lower extremity injuries in healthy athletes. Deficits in aspects of core stability such as core strength, core endurance, core proprioception and neuromuscular control of the core were identified as potential risk factors for lower extremity injuries. The results could have an important impact in the field of injury prevention and
Funding
None.
Conflict of interest
The authors affirm that no financial affiliation or involvement with any commercial organization that has a direct financial interest in any matter included in this review.
PCME: Posterior core muscle endurance; LCME: Lateral core muscle endurance; ACME: Anterior core muscle endurance; ABS FF: Absolute flexion force; ABS EF: Absolute extension force; REL FF: Relative flexion force; REL EF: Relative extension force; FLE:EXT R: Ratio of absolute flexion to extension ratio; ASLR: Active straight
Acknowledgements
None.
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