Structure, sex, and strength and knee and hip kinematics during landing.
Abstract: Context: Researchers have observed that medial knee collapse is a mechanism of knee injury. Lower extremity alignment, sex, and strength have been cited as contributing to landing mechanics.

Objective: To determine the relationship among measurements of asymmetry of unilateral hip rotation (AUHR); mobility of the foot, which we described as relative arch deformity (RAD); hip abduction-external rotation strength; sex; and medial collapse of the knee during a single-leg jump landing. We hypothesized that AUHR and RAD would be positively correlated with movements often associated with medial collapse of the knee, including hip adduction and internal rotation excursions and knee abduction and rotation excursions.

Design: Descriptive laboratory study.

Setting: Research laboratory.

Patients or Other Participants: Thirty women and 15 men (age = 21 [+ or -] 2 years, height = 171.7 [+ or -] 9.5 cm, mass = 68.4 [+ or -] 9.5 kg) who had no history of surgery or recent injury and who participated in regular physical activity volunteered.

Intervention(s): Participants performed 3 double-leg forward jumps with a single-leg landing. Three-dimensional kinematic data were sampled at 100 Hz using an electromagnetic tracking system. We evaluated AUHR and RAD on the preferred leg and evaluated isometric peak hip abductor-external rotation torque. We assessed AUHR by calculating the difference between internal and external hip rotation in the prone position (AUHR = internal rotation-external rotation). We evaluated RAD using the Arch Height Index Measurement System. Correlations and linear regression analyses were used to assess relationships among AUHR, RAD, sex, peak hip abduction-external rotation torque, and kinematic variables for 3-dimensional motion of the hip and knee.

Main Outcome Measure(s): The dependent variables were joint angles at contact and joint excursions between contact and peak knee flexion.

Results: We found that AUHR was correlated with hip adduction excursion (R = 0.36, P = .02). Asymmetry of unilateral hip rotation, sex, and peak hip abduction-external rotation torque were predictive of knee abduction excursion (adjusted [R.sup.2] = 0.47, P < .001). Asymmetry of unilateral hip rotation and sex were predictive of knee external rotation excursion (adjusted [R.sup.2] = 0.23, P = .001). The RAD was correlated with hip adduction at contact ([R.sup.2] = 0.10, R = 0.32, P = .04) and knee flexion excursion ([R.sup.2] = 0.11, R = -0.34, P = .03).

Conclusions: Asymmetry of unilateral hip rotation, sex, and hip strength were associated with kinematic components of medial knee collapse.

Key Words: anteversion, valgus, arch mobility, alignment, anterior cruciate ligament, biomechanics, lower extremity, risk factor, regression analysis
Article Type: Report
Subject: Kinematics (Research)
Knee (Physiological aspects)
Hip (Physiological aspects)
Biomechanics (Research)
Muscle strength (Physiological aspects)
Authors: Howard, Jennifer S.
Fazio, Melisa A.
Mattacola, Carl G.
Uhl, Timothy L.
Jacobs, Cale A.
Pub Date: 07/01/2011
Publication: Name: Journal of Athletic Training Publisher: National Athletic Trainers' Association, Inc. Audience: Academic Format: Magazine/Journal Subject: Sports and fitness Copyright: COPYRIGHT 2011 National Athletic Trainers' Association, Inc. ISSN: 1062-6050
Issue: Date: July-August, 2011 Source Volume: 46 Source Issue: 4
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 284551938
Full Text: Medial collapse of the lower extremity during landing often has been proposed and observed as a mechanism for knee injury. (1-3) Medial collapse or knee valgus can be characterized as the combined motions of knee abduction, hip adduction, and hip or knee rotation. It also might be accompanied by pronation. Risk for this mechanism of injury is believed to be heightened during frequently occurring single-limb landings. (1,4,5) Because of this perceived risk, recent injury-prevention protocols have focused on reducing the occurrence of medial collapse during landing and cutting activities. (6-9) Research regarding what factors might place a person at risk for medial collapse and potential knee injury is limited. Factors that warrant consideration might include nonmodifiable factors, such as lower extremity structural alignment and sex, or modifiable factors, such as strength.

Both distal and proximal structural alignment might influence knee motion. Understanding these relationships might help clinicians better identify factors that contribute to joint positions associated with medial collapse and potential knee injury. (1,3) Alignment of the femur in the transverse plane might be influenced by the degree of femoral anteversion present at the femoral head and neck. Whereas many authors (10-13) have suggested that femoral anteversion could influence the landing mechanics associated with anterior cruciate ligament (ACL) injuries, only Loudon et al (12) have attempted to measure femoral anteversion in patients with ACL injuries.

Researchers (14-22) have attempted to validate methods for measuring femoral anteversion; however, the findings have been variable. One of the most common methods, the Craig test, or the trochanteric prominence angle test, has been validated in a population with cerebral palsy. (19) However, similar attempts to validate these methods using accepted computed tomography and magnetic resonance imaging have been inconsistent. (14,22) Using an alternative method of measurement, Kozic et al (15) reported that differences in prone internal rotation (IR) and external rotation (ER) of the hip highly correlated (r = 0.93) with radiographic measures of femoral anteversion. Their method consisted of subtracting ER from IR range of motion. We define this measurement of IR and ER as asymmetry of unilateral hip rotation (AUHR) (IR-ER = AUHR). People with greater anteversion have been observed as having greater IR relative to ER. (15,16,18,23-25)

Distally, pronation might be associated with medial knee collapse and knee injury. Greater amounts of pronation have been observed in patients with ACL injuries. (12,26-29) In these same patients, no differences were found in mean measures of pronation between sexes. (26,29) These results suggest that pronation might be a risk factor for ACL injury that is unaffected by sex.

The relationship between sex and knee biomechanics during cutting and landing activities has been studied extensively, with numerous authors (30-35) reporting differences between male and female participants. Similarly, less hip abduction strength has been associated with greater medial knee collapse among women. (36,37) Furthermore, femoral anteversion has been proposed to alter muscle mechanics and neuromuscular activity during hip abduction and ER. (13,38,39) Therefore, variations in hip strength and structure might result in a failure to maintain neutral lower extremity alignment during landing. Exploring the relationship among multiple factors that might influence landing mechanics provides additional information to the clinician for assessment and intervention. (6,40)

In addition to the previously studied factors of strength and sex, potential risk factors for medial knee collapse might include hip and foot structure. Therefore, the purpose of our study was to determine the relationship among measurements of AUHR; mobility of the foot, which we described as relative arch deformity (RAD); hip abduction-ER strength; sex; and medial collapse of the knee during a single-leg jump landing. We hypothesized that AUHR and RAD would be positively correlated with movements often associated with medial collapse of the knee, including hip adduction and IR excursions and knee abduction and rotation excursions.



We conducted a power analysis using pilot data from previous research in our laboratory, which demonstrated means for knee abduction displacement for male and female participants of 3.04[degrees] [+ or -] 3.50[degrees] and 7.33[degrees] [+ or -] 6.08[degrees], respectively. Assuming an [alpha] level of .05, the inclusion of 45 participants was expected to result in sufficient statistical power (0.80). We enrolled 30 women and 15 men in the study (age = 21 [+ or -] 2 years, height = 171.7 [+ or -] 9.5 cm, mass = 68.4 [+ or -] 9.5 kg). The participant pool consisted of recreationally active people recruited from the community as a sample of convenience. Inclusion criteria for participation were self-reported regular physical activity, no history of lower extremity injury in the 6 months before the study, no history of lower extremity surgery, age between 18 and 25 years, and willingness to participate in the study. We defined regular-physical activity as participation in activity for a minimum of 30 minutes 3 times per week.

Shoes (Air Max Challenge; Nike, Inc, Beaverton, OR) were provided for the participants to wear during the study to control for differences in footwear. Participants' height and mass were measured before we instructed them to perform 3 trials of a standing, 2-footed, forward jump landing on 1 lower extremity. The lower extremity on which a participant chose to land in 2 of 3 trials was considered the preferred leg and was the only lower extremity tested during our study. Participants then completed a 5-minute warm up on a stationary exercise bicycle at a self-determined intensity level. All participants provided written informed consent, and the study was approved by the Institutional Review Board of the University of Kentucky.

Evaluation of AUHR

We measured hip range of motion for IR and ER and considered the difference between the measurements to be an estimate of femoral anteversion. (15,16,18,23-25) Rotation was measured with participants lying prone on the examining table with the hips in extension and knees actively flexed to 90[degrees], with the patellae of both limbs lying even with the end of the table and with the knees spaced approximately 14 in (35.6 cm) apart (Figure 1). We used 14 in of spacing, which was novel to our study, to attempt to standardize limb position and control for variations in hip motion resulting from different amounts of abduction. This distance was chosen based on pilot testing in which we observed that participants often self-selected this position for comfort. A standard goniometer modified with the addition of a bubble level to ensure vertical alignment of the reference arm was used to measure IR and ER in degrees. Participants were instructed to actively flex their knees and to allow their hips to rotate internally and then externally under the force of gravity to their passive limit. (25) Both limbs were either internally or externally rotated simultaneously to aid in stabilization of the pelvis. (41) Each measurement was recorded 3 times to calculate an average measure of IR and ER from which AUHR was calculated. The same tester (J.S.H.) performed all hip rotation measurements. The intraclass correlation coefficients (2,1) were 0.99 (SEM = 0.5[degrees]) and 0.95 (SEM = 1.9[degrees]), respectively, for intratester between-days reliability (n = 10 with 1 day between tests) for measures of IR and ER a priori.


Evaluation of Longitudinal Arch Mobility

In our study, the foot and medial longitudinal arch were characterized by changes in dorsum height in response to loading. (42) Measurements were accomplished using the Arch Height Index Measurement System OAK Tool and Model, LLC, Matawan, NJ) (Figure 2). Arch height was recorded in 2 stance conditions: 10% (AH10%) of weight bearing and 90% (AH90%) of weight bearing. To calculate RAD during loading, we used the equation proposed by Nigg et a143 and modified by Williams and McClay (42):

RAD = (AH10% - AH90%)/AH10% BW [10.sup.4],

where body weight (BW) is expressed in newtons. Participants were weighed on a standard scale, and 10% and 90% of each participant's total weight were calculated. Participants stood with their hands resting on an examination table, which they used to assist in controlling their amount of weight bearing. The height of the examination table was raised or lowered as needed for participants to maintain balance. Participants then placed one foot on the scale and the other foot on an even, adjacent surface. The adjacent surface was the same height as the scale and was positioned just posterior and slightly medial to the stance limb being tested. This position was used to prevent leaning by the participants to one side, possibly influencing the foot height during the 2 weight-bearing conditions. The participants were instructed to control the amount of weight bearing by balancing directly over the scale and either touching the foot of the nontest limb to the adjacent surface or supporting their weight on the examination table until the scale showed that 90% of weight bearing had been achieved. The arch height then was recorded. The process was repeated for 10% of weight bearing. Participants were monitored carefully to ensure that their center of mass remained over the stance limb and that the knee was not bent. Intratester reliability of this instrument for calculating an arch height index using AH 10% and AH90% has been reported (intraclass correlation coefficient = 0.94). (42) The same examiner (J.S.H.) performed all measurements.

Kinematic Analysis

Three-dimensional joint kinematics of the hip and knee were collected at 100 Hz using Flock of Birds electromagnetic sensors (Ascension Technology Corporation, Burlington, VT) and The MotionMonitor software (Innovative Sports Training, Inc, Chicago, IL). Electromagnetic sensors were placed on the skin of the preferred landing leg using adhesive pads and tape. One sensor was placed on each participant's sacrum, lateral thigh, and medial tibial plateau. The posterior-superior iliac spine, lateral and medial knee joint lines, and lateral and medial malleoli were digitized per manufacturer recommendations. A standard right-hand coordinate system was used for all joints so that the positive x-axis projected anteriorly and the positive z-axis projected superiorly. The landing task, as described in the jump protocol, was performed by each participant. Time of initial contact was identified using a foot switch placed in the participant's shoe. Foot switches contained toe, midfoot, and heel sensors to accurately document ground contact regardless of landing technique. Foot-switch data were collected at 2000 Hz and synchronized with the kinematic data.


Jump Protocol

Participants performed a double-leg jump with a single-leg landing. Each participant started the task at a distance away from a designated target area that was equivalent to 40% of his or her height; the vertical component of the initial jump was equivalent to 115% of the participant's height. (37) To control for the vertical component of the jump, a foam block was hung at the appropriate height, and the participant was instructed to jump so the block just brushed the top of his or her head.37 The participants were instructed to use a single-leg landing strategy and to stabilize quickly. They also were instructed to perform several familiarization repetitions of the jump-landing task with the preferred leg. A minimum of 3 practice trials were performed to ensure comprehension of the task. Additional trials were permitted if a participant did not feel comfortable with the task. Three test trials from each participant were used for analysis. A trial was discarded and an additional one recorded if a participant did not meet the height or distance requirement or if the single-leg landing was not held stable. To be considered stable, participants had to maintain unilateral stance for a minimum of 5 seconds after landing.

Strength Testing

After completing the jump-landing task, all participants underwent isometric strength testing for a motion of combined hip abduction and ER. (13) Strength of the preferred leg was assessed with the PrimusRS dynamometer (BTE Technologies, Inc, Hanover, MD). Participants were positioned side lying on a table with the preferred leg on top. The trunk was in neutral alignment, with the hips flexed to 45[degrees] and the knees flexed to 90[degrees] (Figure 3). (13) Participants were allowed to support their heads using the contralateral hand and arm and could stabilize themselves on the table using the ipsilateral hand. Participants remained in this position for the duration of the strength testing.

The pad on the resistance arm of the dynamometer was placed over the lateral side of the preferred knee. Participants abducted and externally rotated the preferred leg against the pad. The foot of the preferred leg was not allowed to touch the other foot to prevent pushing off but was required to remain below the level of the knee to prevent internal hip rotation. Three maximal contractions of 5 seconds each with a 30-second rest between trials were averaged to establish the maximal voluntary isometric contraction torque (newton-meters) for each participant, which was then normalized to body mass (kilograms) for further analysis.

Data Analysis

Initial joint angles for 3-dimensional motion at the hip and knee were measured at the time of ground contact as detected by foot switches. Joint excursions for the hip and the knee were calculated as the difference between the joint angle at initial ground contact and the maximal joint angle occurring between contact and maximal knee flexion (maximal angle-initial contact angle = joint excursion). (33-34) Excursions were considered for each direction of motion within a plane. For example, for frontal-plane hip motion, excursions were calculated in abduction and adduction. All joint angles were calculated using a segmental, local coordinate system such that hip motion was defined as movement of the thigh sensor relative to the sacral sensor and knee motion was defined as movement of the shank sensor relative to the thigh. Euler angle equations were used to estimate joint angles, and the Leardini method was used to estimate the hip joint center. (44,45) Joint position data were processed using a fourth-order, dual-pass, Butterworth filter with a cutoff frequency of 9 Hz, which was confirmed by residual analysis. Datapac 2K2 (Run Technologies, Mission Viejo, CA) was used for the processing and analyzing all kinematic data.

Statistical Analysis

This was a single-occasion, descriptive laboratory study. Joint angles for 3-dimensional motion at the hip and knee at initial contact and maximal joint excursions were considered the response or dependent variables of interest for this study. The AUHR, RAD, sex, and hip strength were the explanatory or independent variables. Pearson product moment correlations were conducted to determine the relationship between continuous explanatory variables and hip and knee kinematics and to evaluate the relationship between AUHR and RAD. For kinematic variables for which a correlation was present, a multivariable linear regression model was used to determine which combination of factors (AUHR, RAD, sex, or hip abduction--ER isometric peak torque) were predictive of lower extremity kinematics of the hip and knee at ground contact and maximal excursion. All explanatory variables were included initially, then the models were backward reduced. The variables that contributed the least were removed at each step until all variables contributed to a concise model at the [alpha] level set a priori (.05). All statistical analyses were conducted with SPSS (version 15.0; SPSS Inc, Chicago, IL).



Descriptive values for strength and structural measures are presentedin Table 1, and means for all kinematic variables are presented in Table 2. Overall, participants demonstrated greater ER than IR, with a mean AUHR of -6[degrees] [+ or -] 15[degrees] (range, -35[degrees] to 26[degrees]). Correlations between AUHR, RAD, normalized peak isometric torque for hip abduction-ER, and kinematic variables are listed in Table 3. Regression models for which more than one explanatory variable was different are presented in Tables 4 and 5. Asymmetry of unilateral hip rotation, sex, and hip abduction-ER strength were predictive of knee abduction excursion during landing (Table 4). Greater AUHR ([beta] = 0.13), female sex ([beta] = 5.19), and lower hip abduction-ER strength ([beta] = -5.41) were predictive of greater knee abduction excursion. Asymmetry of unilateral hip rotation ([beta] = 0.08) and female sex ([beta] = 2.77) also were positively predictive of knee ER excursion (Table 5). Asymmetry of unilateral hip rotation was the only factor that contributed to a model for knee adduction excursion ([R.sup.2] = 0.10, P = .03, [beta] = -0.00) and to a model for hip adduction excursion ([R.sup.2] = 0.13, P = .02, [beta] = 0.13). Relative arch deformity was the only factor that contributed to a model for hip adduction at contact ([R.sup.2] = 0.10, P = .04, [beta] = 5.57) and to a model for knee flexion excursion ([R.sup.2] = 0.11, P = .03, [beta] = -6.59). Hip abduction-ER strength was the only factor that contributed to a model for knee extension excursion ([R.sup.2] = 0.09, P = .04, [beta] = 0.42). Finally, both lower hip abduction-ER strength ([beta] = -8.82) and female sex ([beta] = 4.01) were predictive of greater knee IR (Table 6). No issues with multicollinearity were present in any of the final models.

During analysis, an extreme statistical outlier (>3 SD above the mean) was discovered within the RAD data (RAD = 3.78) and removed. The exclusion of this participant did not influence any of the previously reported regression equations involving AUHR; therefore, the participant's AUHR and landing kinematic data were included in all analyses that did not involve RAD.


The primary purpose of our study was to identify relationships among clinical measures of lower extremity structure, sex, and hip strength with landing kinematics. Our main findings were that AUHR, sex, and hip strength were predictive factors for knee abduction excursion during landing; AUHR and sex were predictive of knee ER excursion; and AUHR alone was predictive of hip and knee adduction excursions. In addition, RAD was predictive of hip adduction at contact and knee flexion excursion, and sex and hip strength were predictive of knee IR at contact. These results suggest that AUHR, sex, and hip abduction-ER strength might be associated with medial collapse during landing characterized by hip adduction, knee abduction, and knee ER.

Sex, Hip Strength, and AUHR

Our results indicated that as AUHR increased (suggesting greater relative femoral anteversion), participants experienced greater knee abduction excursion during landing, with female participants and those with weaker hip abductors and external rotators experiencing the most knee abduction excursion. Femoral anteversion often is cited as a possible risk factor for ACL or other knee injuries (10-13); however, we were the first to attempt to include an estimate of femoral anteversion as a predictor of knee abduction, which is a kinematic position linked to ACL injury. (1,2,5,46)

As hypothesized, hip adduction excursion also was correlated with AUHR (R=0.36). Although not a primary aim of our study, the high correlation (R=0.70) observed between knee abduction excursion and hip adduction excursion was not surprising. Clinically, these combined motions are often called knee valgus. (47) When they occur in unison, these motions represent a medial collapse of the lower extremity. (47) Therefore, it would be functionally challenging for one to occur without the other in such a manner that balance between the hip and knee can be maintained.

To identify the functional influence of femoral anteversion, Nyland et al (13) studied the relationship between femoral anteversion and electromyographic (EMG) activation of hip musculature during an isometric exercise of combined hip abduction and ER. They reported that participants with greater IR had lower glutens medius/hip abductor and vastus medialis/hip abductor EMG ratios than did participants with less rotation. Although we did not collect EMG data, our results demonstrated a potential relationship between AUHR and the frontal-plane movements of hip adduction and knee abduction. Based on the findings of Nyland et al, (13) it might be theorized that the positive correlation observed between AUHR and hip adduction is a result of less relative gluteus medius activation. A decrease in relative gluteus medius activation in those with increased femoral anteversion (a deformity in the transverse plane) might result in a loss of frontal-plane hip control, sending the hip into adduction and a corresponding knee abduction position. (13) Although this pattern is plausible, further investigation involving structural measures, kinematics, and electromyography is needed to elucidate this potential biomechanical relationship.

The observed negative relationship between hip abduction--ER strength and knee abduction excursion also supports a potential link between AUHR and hip muscular strength and function. These results are supported by the work of Arnold et al, (39) in which computer modeling demonstrated that increasing femoral anteversion decreases the abduction moment arm of the gluteus medius. This decreased moment arm could contribute to both variations in activation and a loss of frontal-plane control. This potential biomechanical relationship between AUHR and frontal-plane knee motion is further supported by the observed negative relationship between AUHR and knee adduction excursion (R=-0.33). This result suggests that lower AUHR might have a protective effect against medial knee collapse by increasing knee adduction during landing.

The results presented in Tables 3 and 4 demonstrate that participants with greater AUHR went into more hip adduction and that as AUHR increased and hip abduction-ER strength decreased, participants experienced greater knee abduction excursion. Extreme valgus position (composed, at least in part, of knee abduction) has occurred in landing and cutting actions, resulting in subsequent injury to the ACL. (13) Our results showed a relationship among greater AUHR, female sex, lower hip strength, and greater knee abduction, which is an established position of risk.

Our observed trend of women experiencing greater knee abduction excursion during landing is consistent with the results reported by several researchers. (30-35) The role of hip strength during landing has not been studied extensively and is less understood. In women, a negative correlation between eccentric hip abductor peak torque and knee abduction (R=-0.61) has been reported during a landing activity similar to the one we used. (36,37) We observed a similar finding with hip abduction-ER strength and sex as predictors of knee abduction excursion. These same factors also were predictive of knee IR at contact. We found no differences in normalized hip strength between sexes (P=.7) (data not shown), which is a finding that other investigators (36) also have observed. However, this finding is in contrast to findings reported by other authors (37,48.49) documenting differences in hip abduction-ER strength between sexes. More study is needed to fully understand the role of hip strength and its relationship with sex and the possible implications of these factors for medial knee collapse,

We found a predictive relationship among AUHR, sex, and knee ER excursion (Table 5). Participants with greater AUHR went into more knee ER during landing, with women experiencing the greatest ER excursion. The observed ER excursion might be a function in part of the degree of knee IR at contact. Sex and hip strength were predictive of knee IR at contact, with women who had less hip strength landing in the most internally rotated position (Table 6). Landing in an internally rotated position might have contributed to the greater ER excursion associated with the female sex. It is important to note that the 2 kinematic variables were only moderately correlated ([R.sup.2] = 0.27) (data not shown), suggesting that in addition to contact position and sex, other factors, such as AUHR, might have contributed to knee ER excursion. Overall, this movement from a more internally rotated position at contact to a more externally rotated position during landing is consistent with a medial collapse knee injury mechanism, which might be exaggerated among women, especially those with lower hip ER-abduction strength.

In our study, greater anteversion resulted in greater knee external excursion during landing. In a previous study, (50) greater anteversion resulted in less tibial IR excursion (tibial IR excursion=22.009+l.09 [navicular drop]-l.083 [body mass index]-0.0771 [anteversion]). Although the terminology is different, the motions described are similar. The results of our study and the study by Carcia and Houglum (50) suggest that femoral anteversion might influence transverse-plane knee motion during landing. Despite these similarities, several differences exist between our study and that of Carcia and Houglum. (50) For example, the landing task was different, the method for evaluating anteversion was not reported, and although the overall model (including femoral anteversion) was predictive of tibial IR, the contribution of femoral anteversion to the model was not at the [alpha] level established a priori (P=.06). (50) Each study provided additional information for better elucidating the roles of structure, strength, and function in neuromuscular patterns, such as landing, but additional research clearly is needed to identify consistent relationships between hip asymmetry/structure and knee position during landing tasks.

Despite these findings, the clinical applications of our results are influenced by the limitations of the instrumentation used to measure biomechanical movement. In our experimental design, a segmental local coordinate system was used such that knee IR was identified as rotation of the shank relative to the thigh. With this design, IR of the femur relative to a stable tibia would be reported as external knee rotation. This type of kinematic assessment makes drawing distinct conclusions regarding transverse-plane knee motion difficult because which segment of the kinetic chain is moving is not known. This method might explain our lack of findings in the transverse plane at both the hip and knee despite examining factors thought to primarily influence transverse kinematics.

Arch Mobility

Our hypothesis that RAD would predict medial collapse during landing was not supported by our results. We observed a correlation between RAD and hip abduction at contact. This negative relationship is consistent with the potential for medial collapse of the lower extremity. (51) However, the absence of a relationship with hip adduction or knee abduction excursion suggests that RAD does not relate to a medial collapse actually occurring during landing. No factors associated with medial collapse during landing were correlated with RAD. Although RAD might have influenced frontal-plane hip position at contact, this relationship did not continue throughout the landing process.

We observed a negative correlation between RAD and knee flexion excursion, suggesting that those experiencing greater arch deformation moved through a smaller range of knee flexion during landing. This relationship might represent a tradeoff in force absorption between knee flexion and arch mobility. If the impact of landing can be attenuated by arch collapse, knee flexion excursions might be lessened. Gross and Nelson (52) suggested that attenuation processes during landing might be learned muscular responses. However, Hargrave et al (53) did not report lower ground reaction forces or differences in knee flexion among participants with increased pronation. Further research with kinetic analysis is needed to determine whether this relationship is consistent and how it might influence ground reaction forces and subsequent risk for injury during landing activities.


Our results are presented with the assumption that AUHR is an appropriate estimate of femoral anteversion. Although this method has been validated successfully in the literature, it was tested predominantly among 8- and 9-year-old children. (15) It is well documented that femoral anteversion decreases with growth from birth to age 16 years. (24) The smaller variation in degree of anteversion seen in normal, healthy adults possibly limits the accuracy of a test originally designed to evaluate the larger angles of anteversion seen in youth. In addition, this method was validated using biplane radiography, which is a technique documented as being less valid and more variable than computed tomography imaging. (54) We examined screening measures that could be performed in a clinical setting without extensive training or expensive equipment. We believe this is a reasonable method of examining the proposed risk factor for knee injury because greater IR relative to ER has been observed consistently in participants with above-average femoral anteversion. (15,16,18,23-25)

The strength of any conclusions drawn from our study is limited by the inability to fully understand what factors influence static measures of hip rotation. We have not found documentation of the percentage of hip range of motion determined by skeletal structure compared with soft tissue laxity. The ability to differentiate soft tissue laxity from bony structure at the hip or to control for soft tissue laxity at the hip could improve the use of AUHR as an estimate of femoral anteversion. Our use of 14 in (35.6 cm) as a standard spacing between knees during range-of-motion assessment similarly might have influenced hip rotation; in subsequent research, this spacing might need to be normalized to participant height or thigh length.

We defined AUHR as IR-ER. The mean of our sample groups was -6[degrees], suggesting that, on average, they demonstrated more ER. Swanson et al (55) suggested that 30[degrees] of asymmetry is necessary to produce abnormal alignment. Why our participants demonstrated greater ER than IR is not clear. It might be a function of the age of our participants. Femoral anteversion and AUHR are documented to decrease with age. (19) Although we anticipated greater IR than ER, reports of rotational differences have varied in the literature, with AUHR (as defined in our study) reported as low as -21.9[degrees]. (56) The use of the term AUHR is specific to the equation and does not necessarily imply pathologic asymmetry in our sample.

Finally, an additional limitation of our study was the size and health of our sample. The sample size did not allow a robust comparison between sexes, which might have been helpful to fully eliminate sex as a confounding factor in our results. Because sex-related differences have been reported for hip strength and femoral anteversion, fully controlling for the effect of sex on these variables is difficult. However, we have accounted for sex by including it in the regression model and believe that review of the standardized parameter estimates supports our conclusion that the relationship among AUHR, strength, and landing kinematics is not due to sex alone. One limitation with investigating predictive relationships is that the variability of the data for moderate to small samples is compressed. In our sample, the variables of interest might not have been varied enough to detect some relationships. Although our standard deviations did not suggest this was the case with AUHR or RAD, it might have been the case for hip strength (Fable 1). Despite these potential limitations of our sample, we believe our participants represented a physically active population that is clinically relevant.


Changes in AH in response to loading (RAD) were weakly correlated with hip adduction at contact and knee flexion excursion. These results suggested that participants with greater arch mobility made contact with the ground in greater hip adduction and experienced less knee flexion during landing. The RAD was not correlated with any kinematic motions associated with medial collapse of the hip or knee (hip adduction excursion and knee abduction and rotation excursion) during landing.

The factors of being a woman, having greater AUHR, and having less hip abduction-ER strength were linked with various movements associated with medial collapse during landing, including hip adduction, knee abduction, and knee ER. Further research is warranted to evaluate the possible relationships among femoral anteversion, hip range of motion, and dynamic knee abduction and to evaluate how these values might be incorporated prospectively into a multifactorial approach for knee injury screening and prevention.

Key Points

* Asymmetry of unilateral hip rotation, sex, and hip abduction-external rotation strength were predictive factors for knee abduction excursion during landing.

* Asymmetry of unilateral hip rotation and sex were predictive of knee external rotation excursion during landing.

* Asymmetry of unilateral hip rotation alone was predictive of hip and knee adduction excursions during landing.

* Relative arch deformity was correlated with hip adduction at contact and knee flexion excursion but did not predict medial knee collapse during landing.

* Greater asymmetry of unilateral hip rotation, female sex, and lower hip abduction-external rotation strength might be associated with a medial collapse during landing characterized by greater hip adduction, knee abduction, and knee external rotation.


This study was fully funded by Osternig Master's Research Grant 505MGP4004 from the National Athletic Trainers' Association Research & Education Foundation, Dallas, Texas. We thank Robert Shapiro, PhD, for his contribution to the conception and design of this study.


(1). Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23(6):573-578.

(2.) Ireland ML. Anterior cruciate ligament injury in female athletes: epidemiology. J Athl Train. 1999;34(2): 151)-154.

(3.) Olsen, OE Myklebust G, Engerbretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32(4): 1002-1012.

4.) Tillman MD, Hass CJ, Brunt , Bennett . umping and landing techniques in elite women's volleyball. J Sports Sci Med. 2004;3(1):30-36.

(5.) Hewlitt TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.

(6.) Hewlitt, TE, Lindenfield TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med. 1999;27(6):699-706.

(7.) Myklebust G, Engebretsen L, Braekken IH Skjolberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13(2):71-78.

(8.) Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7): 1003-1010.

(9.) Myer G, Ford, Brent J, Hewett T. Differential neuromuscular training effects on ACL injury risk factors in "high-risk" versus "low-risk" athletes. BMC Musculoskelet Disord. 2007;8:39.

(10.) Arendt EA, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med. 1995;23(6):694-701.

(11.) Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34(2):86-92.

(12.) Loudon JK, Jenkins WJ, Loudon KL. The relationship static posture and ACL injury in female athletes. J Orthop Sports Phys Ther. 1996;24(2):91-97.

(13.) Nyland J Kuzemchek S, Parks M, Caborn DN. Femoral anteversion influences vastus medialis and gluteus medius EMG amplitude: composite hip abductor EMG amplitude ratios during isometric combined hip abductionexternal rotation. J Electromyogr Kinesiol. 2004;14(2):255-261.

(14.) Davids JR, Benfanti P. Blackhurst , DW, Allen Bl. Assessment of femoral anteversion in children with cerebral palsy: accuracy of the trochanteric prominence angle test. J Pediatr Orthop. 2002;22(2): 173-178.

(15.) Kozic S, Gulan G, Matovinovic D, Nemec B, Sestan B, Ravlic-Gulan J. Femoral anteversion related to side differences in hip rotation: passive rotation in 1,140 children aged 8-9 years. Acta Orthop Scand. 1997;68(6):533-536.

(16.) Braten M, Terjesen T, Rossvoll I. Femoral anteversion in normal adults: ultrasound measurements in 50 men and 50 women. Acta Orthop Scand. 1992;63(1):29-32.

(17.) Murphy SB Simon RS, Kijewski PK, Wilkinson RH, Griscom NT. Femoral anteversion. J Bone Joint Surg Am. 1987;69(8): 1169-1176.

(18.) Gelberman RH, Cohen MS, Desai SS, Griffin PP, Salamon PB, O'Brien TM. Femoral anteversion: a clinical assessment of idiopathic intoeing gait in children. J Bone Joint Surg Br. 1987;69(1):75-77.

(19.) Ruwe PA, Gage JR, Ozonoff MB, DeLuca PM. Clinical determination of femoral anteversion: a comparison with established techniques. J Bone Joint Surg Am. 1992;74(6):820-830.

(20.) Svenningsen S, Terjesen T, Auflem M, Berg V. Hip rotation and in-toeing gait: a study of normal subjects from four years until adult age. Clin Orthop Relat Res. 1990;251:177-182.

(21.) Ryder CT, Crane L. Measuring femoral anteversion: the problem and a method. J Bone Joint Surg Am. 1953;35(2):321-328.

(22.) Souza RB, Powers CM. Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. J Orthop Sports Phys Ther. 2009;39(8):586-592.

(23.) Crane L. Femoral torsion and its relation to toeing-in and toeing-out. J Bone Joint Surg Am. 1959;41(3):421--428.

(24.) Fabry G, MaeEwen GD, Shands AR Jr. Torsion of the femur: a follow-up study in normal and abnormal conditions. J Bone Joint Surg Am. 1973;55(8): 1726-1738.

(25.) Staheli LT. Medial femoral torsion. Orthop Clin NorthAm. 1980;11(1):39-50.

(26.) Allen MK, Glasoe WM. Metrecom measurement of navicular drop in subjects with anterior eruciate ligament injury. J Athl Train, 2000;35(4):403406.

(27.) Beckett ME, Massie DL, Bowers KD, Stoll DA. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train. 1992;27(1):58-62.

(28.) Woodford-Rogers B, Cyphert L, Denegar CR. Risk factors for anterior cruciate ligament injury in high school and college athletes. J Arid Train. 1994;29(4):343-346.

(29.) Hertel J, Dorlman JH, Brahman RA. Lower extremity malalignments and anterior cruciate ligament injury history. J Sports Sci Med. 2004;3(4):220-225.

(30.) Ford KR, Myer GD, Hewlitt TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003;35(10): 1745-1750.

(31.) Ford KR, Myer GD, Smith RL, Vianello RM, Seiwert SL, Hewlitt TE. A comparison of dynamic coronal plane excursion between matched male and female athletes when performing single leg landings. Clin Biomech (Bristol, Avon). 2006;21(1):33-40.

(32.) Hewlitt TE, Myer GD, Ford KR. Decrease in neuromuscular control about the knee with maturation in female athletes. J Bone Joint Surg Am, 2004;86(8): 1601-1608.

(33.) Kernozek TW, Torry MR, Van Hoof H, Cowley H, Tanner S. Gender differences in frontal and sagittal plane biomecharties during drop landings. Med Sci Sports Exerc. 2005;37(6): 1003-1012.

(34.) Lephart SM, Ferris CM, Riemann BL, Myers JB, Fu FH. Gender differences in strength and lower extremity kinematics during landing. Clin Orthop Relat Res. 2002;401:162-169.

(35.) Russell KA, Palmieri RM, Zinder SM, Ingersoll CD. Sex differences in valgus knee angle during a single-leg drop jump. J Athl Train. 2006;41(2): 166-171.

(36.) Jacobs CA, Mattacola CG. Sex differences in eccentric hip-abductor strength and knee-joint kinematics when landing from a jump. J Sport Rehabil. 2005;14(4):346-355.

(37.) Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: sex differences. J Athl Train. 2007;42(1):76-83.

(38.) Derek T, Cooke V. Lengths of hamstrings and psoas museles during crouch gait: effects of femoral anteversion. J Orthop Res. 1998;16(4):518-519.

(39.) Arnold AS, Komattu AV, Delp SL. Internal rotation gail; a compensatory mechanism to restore abduction capacity decreased by bone deformity. Dev Med Child Neurol. 1997;39(1):40-44.

(40.) Harmon KG, Ireland ML., Gender differences in noncontact anterior cruelate ligament injuries. Clin Sports Med. 2000;19(2):287-302.

(41.) Simuneau GG, Hoenig KJ, Lepley JE, Papanek PE. Influence of hip position and gender on active hip internal and external rotation. J Orthop Sports Phys Ther. 1998;28(3): 158-164.

(42.) Williams DS, McClay IS. Measurement used to characterize the foot and the medial longitudinal arch: reliability and validity. Phys Ther. 2000;80(9): 864-871.

(43.) Nigg BM, KhanA, Fisher V, Stefanyshyn D. Effect of shoe insert construction on foot and leg movement. Med Sci Sports Exerc. 1998;30(4):550-555.

(44.) Wu G, Siegler S, Allard P, et al. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion. Part I: ankle, hip, and spine. International Society of Biomeehanics. J Biomech. 2002;35(4):543-548.

(45.) Leardini A, Cappozzo A, Catani F, et al. Validation of a functional method for the estimation of hip joint centre location. J Biomech. 1999;32(1):99-103.

(46.) Tillman MD, Bauer JA, Cauraugh JH, Timble MH. Differences in lower extremity alignment between males and females: potential predisposing factors for knee injury. J Sports Med Phys Fitness. 2005;45(3):355-359.

(47.) Zazulak BT, Ponce PL, Straub SJ, Medvecky MJ, Avedisian L, Hewlitt TE. Gender comparison of hip muscle activity during single-leg landing. J Orthop Sports Phys Ther. 2005;35(5):292-299.

(48.) Willson JD, Ireland ML., Davis I. Core strength and lower extremity alignmcnt during single leg squats. Med Sci Sports Exerc. 2006;38(5):945-952.

(49.) Cahalan TD, Johnson ME, Liu S, Chao EY. Quantitative measurements or hip strength in different age groups. Clin Orthop Relat Res. 1989;246:136-145.

(50.) Carcia CR, Houglum PA. Prediction of tibial rotation during landing and hopping in females. J Athl Train. 2004;39(suppl 2):S-29-S-30.

(51.) Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639-646.

(52.) Gross TS, Nelson RC. The shock attenuation role of the ankle during landing from a vertical jump. Meal Sci Sports Exerc. 1988;20(5):506-514.

(53.) Hargrave MD, Carcia CR, Gansneder BM, Shuitz SJ. Subtalar pronation does not influence impact forces or rate of loading during a single-leg landing. J Athl Train. 2003;38(I): 18-23.

(54.) Kuo TY, Skedros JG, Bloebaum RD. Measurement of femoral anteversion by biplane radiography and computed tomography imaging: comparison with an anatomic reference. Invest Radiol. 2003;38(4):221-229.

(55.) Swanson AB, Greene PW Jr, Allis HD. Rotational deformities of the lower extremity in children and their clinical significance. Clin Orthop Relat Res. 1963;27:157-175.

(56.) Hamill J, Bates BT, Knutzen KM, Kirkpatrick GM. Relationship between selected static and dynamic lower extremity measures. Clin Biomech (Bristol, Avon). 1989;4(4):217-225.

Address correspondence to Jennifer S. Howard, PhD, ATC, Rehabilitation Sciences, 210 Wethington Health Sciences Building, 900 South Limestone Street, University of Kentucky, Lexington, KY40536. Address e-mail to

Jennifer S. Howard, PhD, AT C*; Melisa A. Fazio, MS, ATC ([dagger]); Carl G. Mattacola, PhD, ATC, FNATA *; Timothy L. Uhl, PhD, PT, ATC, FNATA *; Cale A. Jacobs, PhD ([double dagger])

* Department of Rehabilitation Sciences, University of Kentucky, Lexington; ([dagger]) University of Colorado, Boulder; ([double dagger]) ERMI, Inc, Atlanta, GA
Table 1. Descriptive Values for the Structural and Strength

Measure                                    Mean [+ or -] SD

Average hip internal rotation, [degrees]     29 [+ or -] 11
Average hip external rotation, [degrees]     35 [+ or -] 7
Asymmetry of unilateral hip                  -6 [+ or -] 15
rotation (a), [degrees]
Arch height in 10% of weight bearing, cm   6.58 [+ or -] -0.58
Arch height in 90% of weight bearing, cm   6.16 [+ or -] -0.51
Relative arch deformity (b), [N.sup.-1]    0.96 [+ or -] 0.52
Peak hip abduction-external rotation       1.07 [+ or -] 0.30
torque (c), Nm/kg

(a) Calculated by subtracting average external rotation from average
internal rotation.

(b) Calculated as [(AH10%-AH90%)/(AH10% BW)]* [10.sup.4], where AH90%
is arch height in 90% of weight bearing, AH10% is arch height in
10% of weight bearing, and BW is body weight.

(c) Indicates normalized to body weight.

Table 2. Mean Joint Angles at Contact and Excursion
from Contact to Peak Knee Flexion [degrees]

                           Mean Angle at               Mean
Motion                  Contact [+ or -] SD   Excursion (a) [+ or -] SD

Hip flexion              18.40 [+ or -] 6.97      18.40 [+ or -] 6.97
Hip extension                     NA               0.07 [+ or -] 0.24
Hip adduction                     NA              10.58 [+ or -] 5.32
Hip abduction             7.49 [+ or -] 5.41       0.91 [+ or -] 1.76
Hip internal rotation             NA               7.59 [+ or -] 4.65
Hip external rotation    12.14 [+ or -] 6.88       1.29 [+ or -] 1.87
Knee extension                    NA               0.12 [+ or -] 0.41
Knee flexion              4.04 [+ or -] 5.43      41.29 [+ or -] 6.34
Knee adduction            3.90 [+ or -] 5.87       1.32 [+ or -] 2.08
Knee abduction                    NA               8.48 [+ or -] 5.77
Knee internal rotation    1.66 [+ or -] 6.68       4.39 [+ or -] 4.38
Knee external rotation            NA               4.92 [+ or -] 3.91

Abbreviation: NA, not applicable.

(a) Calculated by subtracting peak angle from contact angle.

Table 3. Relationship Between Structural or Strength and Kinematic

Variables                                     R Value   P Value

Asymmetries of unilateral hip rotation (a)      0.36      0.02
and hip adduction excursion
Asymmetries of unilateral hip rotation (a)      0.51      <.001
and knee abduction excursion
Asymmetries of unilateral hip rotation (a)     -0.33      0.03
and knee adduction excursion
Asymmetries of unilateral hip rotation (a)      0.41      0.005
and knee extemal rotation excursion
Relative arch deformity and hip adduction       0.32      0.04
at contact
Relative arch deformity and knee flexion       -0.34      0.03
Peak hip abduction-external rotation            0.31      0.04
torque and knee extension excursion
Peak hip abduction-external rotation torque    -0.37      0.02
and knee abduction excursion
Peak hip abduction-external rotation torque    -0.41      0.005
and knee internal rotation at contact

(a) Calculated by subtracting average external rotation from average
internal rotation.

Table 4. Regression Models Predicting Knee Abduction Excursion

                              Parameter   Standard   95% Confidence
Variable                      Estimate,     Error       Interval

Asymmetries of unilateral        0.13       0.05       0.04, 0.22
hip rotation
Peak hip abduction-external     -5.41       2.17      -9.79, -1.03
rotation torque
  Male                        Reference
  Female                         5.19       1.39       2.39, 8.83

Variable                        Estimate     P Value

Asymmetries of unilateral         0.336       0.006
hip rotation
Peak hip abduction-external      -0.278       0.02
rotation torque
  Female                          0.374       0.001

(a) Knee abduction excursion = 11.63 + 0.13 (asymmetries of unilateral
hip rotation)-5.39 (peak hip abduction-external rotation torque) +5.09
(sex=female). Adjusted [R.sup.2] = 0.47, P<.001.

Table 5. Regression Model (a) Predicting Knee Eternal Rotation

                                Parameter      Standard
Variable                    Estimate, [beta]     Error

Asymmetries of unilateral         0.08           0.04
hip rotation
  Male                         Reference
  Female                          2.77           1.12

                            95% Confidence   Standardized
Variable                       Interval        Estimate     P Value

Asymmetries of unilateral     0.01, 0.15         0.313       0.03
hip rotation
  Female                      0.50, 5.04         0.338       0.02

(a) External rotation excursion = 3.58+0.08 (asymmetries of unilateral
hip rotation)+2.77 (sex=female). Adjusted [R.sup.2]=0.23, P=.001.

Table 6. Regression Models Predicting Knee Internal Rotation at Contact

                                  Parameter      Standard
Variable                      Estimate, [beta]     Error

Peak hip abduction-external        -8.82            3.01
rotation torque
  Male                           Reference
  Female                            4.01            1.88

                              95% Confidence   Standardized
Variable                         Interval        Estimate     P Value

Peak hip abduction-external   -14.90, -2.73        -0.39       0.006
rotation torque
  Female                        0.22, 7.79          0.29       0.04

(a) Knee internal rotation at contact = 8.46-8.82 (peak hip
abduction-external rotation torque)+4.01 (sex=female).
Adjusted [R.sup.2]=0.214, P=.002.
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