Asymmetric running is associated with pain during outdoor running in individuals with Achilles tendinopathy in the return-to-sport phase.

OBJECTIVES: To determine the relationships between (1) Achilles tendon pain and loading symmetry, and (2) number of running bouts and symptom severity, during two weeks of outdoor running in individuals with Achilles tendinopathy. DESIGN: Prospective, observational study. SETTING: Biomechanics laboratory and outdoors. PARTICIPANTS: Seventeen runners with Achilles tendinopathy in the return-to-sport phase of rehabilitation. MAIN OUTCOME MEASURES: Symptom severity was recorded with the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Running bouts and Achilles tendon pain during runs were recorded with daily training logs. Ground contact time was collected during runs with wearable sensors. Linear mixed modeling determined if the relationship between Achilles tendon pain and ground contact time symmetry during running was moderated by consecutive run days. Multiple regression determined the relationship between number of running bouts and change in VISA-A scores over two weeks, adjusted for run distance. RESULTS: Greater ground contact time on the contralateral leg corresponded to increased ipsilateral tendon pain for each consecutive run day (b = -0.028, p < 0.001). Number of running bouts was not associated with 2-week changes in VISA-A scores (p = 0.672). CONCLUSIONS: Pain during running is associated with injured leg off-loading patterns, and this relationship strengthened with greater number of consecutive run days. Number of running bouts was not related to short-term symptom severity.

Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy.

Background: Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function. Purpose: To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT). Study Design: Case series; Level of evidence, 4. Methods: Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance. Results: Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P < .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear. Conclusion: Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.

Measurement of Healthy and Injured Triceps Surae Morphology.

Achilles tendon injuries occur throughout the lifespan and can negatively affect quality of life and overall health. Achilles tendinopathy is generally classified as an overuse injury associated with fusiform tendon thickening, neovascularization, and interstitial tendon degeneration. Current literature suggests these structural changes are associated with symptoms and lower physical activity levels, as well as symptoms and lower extremity function in the long term. Surgically and non-surgically managed Achilles tendon ruptures result in increased tendon cross-sectional area (CSA) and a lengthened Achilles tendon. Both structural outcomes have clinical implications, as larger CSA positively predicts function, whereas increased tendon lengthening predicts reduced function after Achilles tendon rupture. Given the relationship between structural changes associated with Achilles tendon injuries for both injury severity and injury recovery, it is critical to be able to quantify Achilles tendon structure reliably and accurately. Silbernagel's group has established a valid and reliable method for efficiently evaluating triceps surae muscle and tendon structure. In this protocol, B-mode musculoskeletal ultrasound imaging is used to measure triceps surae structure, including Achilles tendon thickness and CSA, soleus thickness, and the presence of additional findings (calcifications and bursitis). B-mode extended field-of-view is used to measure Achilles tendon length and gastrocnemius anatomical CSA. Finally, power Doppler is used to identify intratendinous neovascularization. Quantification of triceps surae structure allows for comparison between limbs as well as longitudinal changes in response to exercise and treatment for healthy individuals and those with Achilles tendon injuries. This protocol has been used in many research studies to date and proves valuable in understanding the relationship between tendon structure and injury development, severity, and recovery. As ultrasound devices are becoming more affordable and portable, this protocol proves promising as a clinical tool, given its quick and efficient methods.

Markerless motion capture: What clinician-scientists need to know right now.

Markerless motion capture (mocap) could be the future of motion analysis. The purpose of this report was to describe our team of clinicians and scientists' exploration of markerless mocap (Theia 3D) and share data for others to explore (link: https://osf.io/6vh7z/?view_only=c0e00984e94a48f28c8d987a2127339d). Simultaneous mocap was performed using markerless and marker-based systems for walking, squatting, and forward hopping. Segment lengths were more variable between trials using markerless mocap compared to marker-based mocap. Sagittal plane angles were most comparable between systems at the knee joint followed by the ankle and hip. Frontal and transverse plane angles were not comparable between systems. The data collection experience using markerless mocap was simpler, faster, and user friendly. The ease of collection was in part offset by the added data transfer and processing times, and the lack of troubleshooting flexibility. If used selectively with proper understanding of limitations, markerless mocap can be exciting technology to advance the field of motion analysis.

Sex and Stride Impact Joint Stiffness During Loaded Running.

This study determined changes in lower limb joint stiffness when running with body-borne load, and whether they differ with stride or sex. Twenty males and 16 females had joint stiffness quantified when running (4.0 m/s) with body-borne load (20, 25, 30, and 35 kg) and 3 stride lengths (preferred or 15% longer and shorter). Lower limb joint stiffness, flexion range of motion (RoM), and peak flexion moment were submitted to a mixed-model analysis of variance. Knee and ankle stiffness increased 19% and 6% with load (P < .001, P = .049), but decreased 8% and 6% as stride lengthened (P = .004, P < .001). Decreased knee RoM (P < .001, 0.9°-2.7°) and increased knee (P = .007, up to 0.12 N.m/kg.m) and ankle (P = .013, up to 0.03 N.m/kg.m) flexion moment may stiffen joints with load. Greater knee (P < .001, 4.7°-5.4°) and ankle (P < .001, 2.6°-7.2°) flexion RoM may increase joint compliance with longer strides. Females exhibited 15% stiffer knee (P = .025) from larger reductions in knee RoM (4.3°-5.4°) with load than males (P < .004). Stiffer lower limb joints may elevate injury risk while running with load, especially for females.

Lower-Limb Biomechanics Differ Between Sexes During Maximal Loaded Countermovement Jumps.

ABSTRACT: Fain, AC, Semore, KD, Lobb, NJ, and Brown, TN. Lower-limb biomechanics differ between sexes during maximal loaded countermovement jumps. J Strength Cond Res 35(2): 325-331, 2021-To improve military personnel's operational performance, this study determined the impact of heavy, military body-borne load on vertical jump performance. Twenty men and 17 women had lower-limb work and power quantified during a series of countermovement jumps with 4 body-borne loads (20, 25, 30, and 35 kg). For each jump, subjects stood in athletic position with feet shoulder-width apart, then squatted down and immediately performed a maximal-effort vertical jump. Subjects performed 3 successful jumps with each load. During each jump, limb and hip, knee and ankle work and power, each joint's contribution to limb work, as well as jump height and center of mass velocity were quantified. Each dependent measure was submitted to a 2-way repeated-meausres analysis of variance, with alpha level 0.05. Body-borne load reduced jump height (p = 0.001) but increased ankle work (p < 0.001). To jump higher (p < 0.001) with a greater center of mass velocity (p = 0.001), men produced more limb work (p < 0.001), hip (p = 0.001; p < 0.001), knee (p < 0.001; p < 0.001), and ankle (p < 0.001; p < 0.001) joint power and work. But, women produced a greater percentage of work at the ankle (p = 0.020) than men. Military practitioners may target different training adaptations to improve male and female personnel operational performance because lower-limb biomechanics differ between sexes during loaded vertical jumps.

Association Between Knee Anatomic Metrics and Biomechanics for Male Soldiers Landing With Load.

BACKGROUND: Anterior cruciate ligament (ACL) injury is a military occupational hazard that may be attributed to an individual's knee biomechanics and joint anatomy. This study sought to determine if greater flexion when landing with load resulted in knee biomechanics thought to decrease ACL injury risk and whether knee biomechanics during landing relate to knee anatomic metrics. HYPOTHESIS: Anatomic metrics regarding the slope and concavity of the tibial plateau will exhibit a significant relation to the increased anterior shear force on the knee and decreased knee flexion posture during landing with body-borne load. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty male military personnel completed a drop landing task with 3 load conditions: light (~6 kg), medium (15% body weight), and heavy (30% body weight). Participants were divided into groups based on knee flexion exhibited when landing with the heavy load (high- and low-Δflexion). Tibial slopes and depth were measured on weightbearing volumetric images of the knee obtained with a prototype cone beam computed tomography system. Knee biomechanics were submitted to a linear mixed model to evaluate the effect of landing group and load, with the anatomic metrics considered covariates. RESULTS: Load increased peak proximal anterior tibial shear force (P = .034), knee flexion angle (P = .024), and moment (P = .001) during landing. Only the high flexion group increased knee flexion (P < .001) during weighted landings with medium and heavy loads. The low flexion group used greater knee abduction angle (P = .030) and peak proximal anterior tibial shear force (P = .034) when landing with load. Anatomic metrics did not differ between groups, but ratio of medial-to-lateral tibial slope and medial tibial depth predicted peak proximal anterior tibial shear force (P = .009) and knee flexion (P = .034) during landing, respectively. CONCLUSION: Increasing knee flexion is an attainable strategy to mitigate risk of ACL injury, but certain individuals may be predisposed to knee forces and biomechanics that load the ACL during weighted landings. CLINICAL RELEVANCE: The ability to screen individuals for anatomic metrics that predict knee flexion may identify soldiers and athletes who require additional training to mitigate the risk of lower extremity injury.

Effect of Sex and Ankle Brace Design on Knee Biomechanics During a Single-Leg Cut.

BACKGROUND: Despite success at preventing ankle sprain, prophylactics that restrict ankle plantarflexion motion may produce deleterious knee biomechanics and increase injury risk. PURPOSE: To determine if ankle prophylactics that restrict plantar- and dorsiflexion motion produce changes in knee biomechanics during a single-leg cut and whether those changes differ between sexes. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 17 male and 17 female participants performed a single-leg cut with 4 conditions: Ankle Roll Guard (ARG), lace-up brace, nonelastic tape, and an unbraced control. Peak stance knee flexion, abduction, and internal rotation joint angle and moment; total knee reaction moment (TKM) and its components (sagittal, frontal, and transverse); and ankle plantarflexion and inversion range of motion (ROM) and peak stance joint moments were tested with a repeated measures analysis of variance to determine the main effect and interaction of condition and sex. RESULTS: Brace and tape restricted plantarflexion ROM as compared with ARG and control (all P < .001). With the brace, women had increased peak knee abduction angle versus ARG (P = .012) and control (P = .009), and men had decreased peak knee internal rotation moment as compared with ARG (P = .032), control (P = .006), and tape (P = .003). Although the restrictive tape decreased inversion ROM when compared with ARG (P = .004) and brace (P = .017), it did not change knee biomechanics. Neither brace nor tape produced significant changes in TKM or components, yet sagittal TKM increased with ARG versus control (P = .016). Women exhibited less ankle inversion ROM (P = .003) and moment (P = .049) than men, while men exhibited significantly greater frontal TKM (P = .022) and knee internal rotation moment with the ARG (P = .029), control (P = .007), and tape (P = .016). CONCLUSION: Prophylactics that restrict ankle plantarflexion motion may elicit knee biomechanical changes during a single-leg cut, but these changes may depend on prophylactic design and user's sex and may increase women's injury risk. CLINICAL RELEVANCE: Sex-specific ankle prophylactic designs may be warranted to reduce knee injury during sports.

Effectiveness of Novel Ankle Prophylactic Compared With Lace-Up Brace or Tape.

CONTEXT: Conventional ankle prophylactics restrict harmful ankle inversion motions that lead to injury. But these existing prophylactics also limit other ankle motions, potentially leading to detriments in functional joint capacity. The ankle roll guard (ARG) may alleviate the prevailing issues of existing ankle prophylactics and prevent harmful ankle inversion, while allowing other joint motions. OBJECTIVE: This technical report sought to compare the ARG's ability to prevent ankle inversion, but not restrict other ankle motions with existing prophylactics. DESIGN: Repeated-measures study. SETTING: Motion capture laboratory. PARTICIPANTS: Thirty participants. INTERVENTION: Each participant had dominant limb ankle kinematics recorded during 5 successful trials of a sudden inversion event and 30-cm drop landing task with each of 4 conditions (ARG, ASO ankle stabilizer [brace], closed-basket weave athletic tape [tape], and unbraced [control]). MAIN OUTCOME MEASURES: Peak ankle inversion angle, range of inversion motion (ROM), and time to peak inversion during the sudden inversion event, and ankle plantar- and dorsiflexion ROM during the drop landing were submitted to a 1-way repeated-measures analysis of variance to test the main effect of prophylaxis. RESULTS: Participants exhibited greater inversion ROM with control compared with tape (P = .001), and greater plantar- and dorsiflexion ROM with ARG and control compared with brace (P = .02, P = .001) and tape (P = .02, P < .001). It took significantly longer to reach peak ankle inversion with brace and tape compared with ARG (P < .001, P = .001) and control (P = .01, P = .01). No significant difference in peak ankle inversion was observed between any condition (P > .05). CONCLUSION: The ARG may prevent ankle inversion angles where injury is thought to occur (reportedly >41°), but is less restrictive than existing prophylactics. The less restrictive ARG may make its use ideal during rehabilitation as it allows ankle plantar- and dorsiflexion motions, while preventing inversion related to injury.

Sex and limb differences during a single-leg cut with body borne load.

BACKGROUND: Military personnel don body borne loads that produce maladaptive lower limb biomechanics, increasing risk of musculoskeletal injury during common training tasks. Female personnel have over twice the injury risk as males, but it is unknown if a sex dimorphism in lower limb biomechanics exists during common training-related tasks. RESEARCH QUESTION: To determine whether lower limb biomechanics exhibited during a single-leg cut with military body borne loads differ between sexes. METHODS: Sixteen females and 20 males had lower limb biomechanics quantified during five single-leg cuts off each limb with four loads (20, 25, 30 and 35 kg). Each cut required participants run 4 m/s, before planting their foot on a force platform and cut 45° towards the opposite limb. Lower limb biomechanics related to musculoskeletal injury were submitted to a repeated measures ANOVA to test for main and interaction effects of load, sex, and limb. RESULTS: During the cut, load increased peak proximal anterior tibial shear force (p < 0.001) and peak hip flexion (p = 0.010) and knee abduction (p = 0.045) moments, but decreased peak knee flexion angle (p = 0.032). Females exhibited greater peak proximal anterior tibial shear (p = 0.014), and peak hip adduction (p < 0.001) and knee external rotation (p = 0.001) moment than males. Dominant limb exhibited larger peak hip adduction (p = 0.002); whereas, the non-dominant limb exhibited greater peak hip internal (p = 0.002) and knee external (p = 0.007) rotation moments. Only the non-dominant limb increased peak knee abduction moment (p = 0.001) with additional load. SIGNIFICANCE: During the cut, adding body borne load produced maladaptive biomechanics that may increase knee musculoskeletal injury risk. Load increased peak proximal tibial shear and potential strain of knee's soft-tissues. Females exhibited a sex dimorphism in lower limb biomechanics that may further elevate their injury risk. Both limbs exhibited biomechanics that may increase injury risk, but only the non-dominant limb further increased injury risk with load.

Sex and stride length impact leg stiffness and ground reaction forces when running with body borne load.

This study quantified leg stiffness and vGRF measures for males and females using different stride lengths to run with four body borne loads (20, 25, 30, and 35 kg). Thirty-six participants (20 males and 16 females) ran at 4.0 m/s using either: their preferred stride length (PSL), or strides 15% longer (LSL) and shorter (SSL) than PSL. Leg stiffness and vGRF measures, including peak vGRF, impact peak and loading rate, were submitted to a RM ANOVA to test the main effect and interactions of load, stride length, and sex. Leg stiffness was greater with the 30 kg (p = 0.016) and 35 kg (p < 0.001) compared to the 20 kg load, but decreased as stride lengthened from SSL to PSL (p < 0.001) and PSL to LSL (p < 0.001). Males exhibited greater leg stiffness than females with SSL (p = 0.029). Yet, males decreased leg stiffness with each increase in stride length (p < 0.001; p < 0.001), while females only decreased leg stiffness between PSL and LSL (p = 0.014). Peak vGRF was greater with the addition of body borne load (p < 0.001) and increase in stride length (p < 0.001). Both impact peak and loading rate were greater with the 30 kg (p = 0.034; p = 0.043) and 35 kg (p = 0.004; p = 0.015) compared to the 20 kg load, and increased as stride lengthened from SSL to PSL (p = 0.001; p = 0.004) and PSL to LSL (p < 0.001; p < 0.001). Running with body borne load may elevate injury risk by increasing leg stiffness and vGRFs. Injury risk may further increase when using longer strides to run with body borne load.

Sex and limb impact biomechanics associated with risk of injury during drop landing with body borne load.

Increasing lower limb flexion may reduce risk of musculoskeletal injury for military personnel during landing. This study compared lower limb biomechanics between sexes and limbs when using normal and greater lower limb flexion to land with body borne load. Thirty-three participants (21 male, 12 female, age: 21.6±2.5 years, height: 1.7±0.1 m, weight: 74.5±9.0 kg) performed normal and flexed lower limb landings with four body borne loads: 20, 25, 30 and 35 kg. Hip and knee biomechanics, peak vertical ground reaction force (GRF), and the magnitude and direction of the GRF vector in frontal plane were submitted to two separate repeated measures ANOVAs to test the main and interaction effects of sex, load, and landing, as well as limb, load, and landing. Participants increased GRFs (between 5 and 10%) and hip and knee flexion moments when landing with body borne load, but decreased vertical GRF 19% and hip adduction and knee abduction joint range of motion and moments during the flexed landings. Both females and the non-dominant limb presented greater risk of musculoskeletal injury during landing. Females exhibited larger GRFs, increased hip adduction range of motion, and greater knee abduction moments compared to males. Whereas, the non-dominant limb increased knee abduction moments and exhibited a more laterally-directed frontal plane GRF vector compared to the dominant limb during the loaded landings. Yet, increasing lower limb flexion during landing does not appear to produce similar reductions in lower limb biomechanics related to injury risk for both females and the non-dominant limb during landing.

Individuals with varus thrust do not increase knee adduction when running with body borne load.

Osteoarthritis (OA) is a common occupational hazard for service members. This study quantified how body borne load impacts knee biomechanics for participants who do and do not present varus thrust (range of knee adduction motion exhibited from heel strike to mid-stance (0-51%)) during over-ground running. Eighteen (9 varus thrust and 9 control) military personnel had knee biomechanics recorded when running with three load conditions (light, ∼6 kg, medium, 15% BW, and heavy, 30% BW). Subject-based means for knee biomechanics were calculated and submitted to a RM ANOVA to test the main effects and possible interactions between load and varus thrust group. The varus thrust group exhibited greater varus thrust (p = .001) and peak stance (PS, 0-100%) knee adduction (p = .009) posture compared to the control group with the light load, but not for the medium (p = .741 and p = .825) or heavy loads (p = .142 and p = .429). With the heavy load, varus thrust group reduced varus thrust (p = .023), whereas, the control group increased varus thrust (p = .037) compared to the light load, and increased PS knee adduction moment compared to light (p = .006) and medium loads (p = .031). The varus thrust group, however, exhibited no significant difference in knee adduction moment between any load (p = .174). With the addition of body borne load, varus thrust participants exhibited a significant reduction in knee biomechanics related to OA; whereas, control participants adopted knee biomechanics, including greater varus thrust and knee adduction moment, related to the development of OA.

Dual-task and anticipation impact lower limb biomechanics during a single-leg cut with body borne load.

This study quantified how a dual cognitive task impacts lower limb biomechanics during anticipated and unanticipated single-leg cuts with body borne load. Twenty-four males performed anticipated and unanticipated cuts with and without a dual cognitive task with three load conditions: no load (∼6 kg), medium load (15% of BW), and heavy load (30% of BW). Lower limb biomechanics were submitted to a repeated measures linear mixed model to test the main and interaction effects of load, anticipation, and dual task. With body borne load, participants increased peak stance (PS) hip flexion (p = .004) and hip internal rotation (p = .001) angle, and PS hip flexion (p = .001) and internal rotation (p = .018), and knee flexion (p = .016) and abduction (p = .001) moments. With the dual task, participants decreased PS knee flexion angle (p < .001) and hip flexion moment (p = .027), and increased PS knee external rotation angle (p = .034). During the unanticipated cut, participants increased PS hip (p = .040) and knee flexion angle (p < .001), and decreased PS hip adduction (p = .001), and knee abduction (p = .005) and external rotation (p = .026) moments. Adding body borne load produces lower limb biomechanical adaptations thought to increase risk of musculoskeletal injury, but neither anticipation nor dual task exaggerated those biomechanical adaptations. With a dual task, participants adopted biomechanics known to increase injury risk; whereas, participants used lower limb biomechanics thought to decrease injury risk during unanticipated cuts.

The effect of Nordic hamstring strength training on muscle architecture, stiffness, and strength.

PURPOSE: Hamstring strain injury is a frequent and serious injury in competitive and recreational sports. While Nordic hamstring (NH) eccentric strength training is an effective hamstring injury-prevention method, the protective mechanism of this exercise is not understood. Strength training increases muscle strength, but also alters muscle architecture and stiffness; all three factors may be associated with reducing muscle injuries. The purpose of this study was to examine the effects of NH eccentric strength training on hamstring muscle architecture, stiffness, and strength. METHODS: Twenty healthy participants were randomly assigned to an eccentric training group or control group. Control participants performed static stretching, while experimental participants performed static stretching and NH training for 6 weeks. Pre- and post-intervention measurements included: hamstring muscle architecture and stiffness using ultrasound imaging and elastography, and maximal hamstring strength measured on a dynamometer. RESULTS: The experimental group, but not the control group, increased volume (131.5 vs. 145.2 cm3, p < 0.001) and physiological cross-sectional area (16.1 vs. 18.1 cm2, p = 0.032). There were no significant changes to muscle fascicle length, stiffness, or eccentric hamstring strength. CONCLUSIONS: The NH intervention was an effective training method for muscle hypertrophy, but, contrary to common literature findings for other modes of eccentric training, did not increase fascicle length. The data suggest that the mechanism behind NH eccentric strength training mitigating hamstring injury risk could be increasing volume rather than increasing muscle length. Future research is, therefore, warranted to determine if muscle hypertrophy induced by NH training lowers future hamstring strain injury risk.