First-time anterior cruciate ligament injury in adolescent female elite athletes: a prospective cohort study to identify modifiable risk factors.

PURPOSE: To identify modifiable biomechanical and neuromuscular anterior cruciate ligament (ACL) injury risk factors for first-time ACL injury in adolescent female elite football and team handball players. METHODS: Adolescent female elite football and handball players with no previous ACL injury participated in the present study. At baseline, players were tested during side-cutting manoeuvres performed in a 3-dimensional motion analysis laboratory with concomitant electromyography (EMG) measurements. Maximal isometric lower limb muscle strength was assessed by handheld dynamometry. Players were prospectively followed for 2 years after baseline testing, and all magnetic resonance imaging (MRI) verified ACL injuries were registered. The effect of 16 risk factor candidates on the relative risk (RR) of ACL injury was estimated using Poisson regression analysis. RESULTS: Ninety players (age 16.9 ± 1.2 years) were included in the analyses. Nine first-time ACL injuries (injury incidence 10.0% (95% confidence interval (CI) 5.4-18.6%)) were registered during the 2-year follow-up period. Four risk factor candidates were significantly associated with the risk of ACL injury: (1) hip flexion angle at initial contact (IC) [RR 0.56, 95% confidence interval (CI) 0.34-0.92], (2) internal knee rotation angle at IC [RR 1.13, 95% CI 1.08-1.19], (3) semitendinosus EMG activity 50 ms prior to IC [RR: 0.62, 95% CI 0.43-0.89], and (4) external hip rotator strength [RR: 0.77, 95% CI 0.66-0.89]. CONCLUSION: Four distinct ACL injury risk factors related to the side-cutting manoeuvre were identified in a population of adolescent female elite football and team handball players with no previous ACL injury. As ACL injury typically occur during side-cutting, intervention programmes to modify these risk factors pose a promising strategy for ACL injury prevention in adolescent female elite football and team handball. LEVEL OF EVIDENCE: II.

Acute Neuromuscular Activity in Selected Injury Prevention Exercises with App-Based versus Personal On-Site Instruction: A Randomized Cross-Sectional Study.

INTRODUCTION: A significant step towards sport-related injury prevention is the introduction of easily accessible smartphone applications (apps). However, it is unknown whether this type of app-based instruction facilitates similar acute neuromuscular and biomechanical characteristics of the preventive exercises as achieved when instructed on-site by an expert. Thus, the aim was to evaluate acute neuromuscular characteristics observed during a single bout of selected lower extremity injury preventive exercises instructed by an on-screen app versus on-site individual instruction provided by a physiotherapist. METHODS: In a cross-sectional study design, 47 female football and handball players were randomly assigned to receive app instruction (APP group) or on-site instruction provided by a physiotherapist (PHY group) while performing five lower extremity injury preventive exercises. The exercises performed comprised (1) one-legged balance on Airex, (2) vertical drop jump, (3) one-legged horizontal jump onto floor, (4) one-legged horizontal jump onto Airex, and (5) two-hand Kettlebell Swing. Primary outcome was hamstring (biceps femoris and semitendinosus) muscle activity. Secondary outcomes were quadriceps (vastus lateralis and medialis) muscle activity, as well as hip and knee joint angles. Muscle activity was monitored by surface electromyography (EMG) and normalized to the peak amplitude obtained during a maximal voluntary isometric contraction (MVC). Hip and knee joint angles were recorded by a 3D motion analysis system. A linear mixed model was used to evaluate the differences between experimental conditions for each outcome variable. RESULTS: Medial hamstring (semitendinosus) muscle activity was significantly higher during one-legged jump onto Airex (17 percentage points (95% CI 7 to 27)) and Kettlebell Swing (19 percentage points (95% CI 2 to 36)) in the PHY group than the APP group. Likewise, the PHY group demonstrated 18 percentage points (95% CI 1 to 35) and 19 percentage points (95% CI 0 to 38), greater lateral quadriceps muscle (vastus lateralis) activity during one-legged jump onto floor and one-legged jump onto Airex, respectively, compared with that of the APP group. CONCLUSIONS: Complex exercises, i.e., Kettlebell Swing and one-legged jump onto Airex, are characterized by lower neuromuscular activity when using app-based instructions compared with on-site instruction provided by a physiotherapist. However, the effectiveness of app-based instruction versus on-site individual instruction in injury prevention interventions remains to be investigated in future longitudinally studies.

Do we need a gender-specific total knee replacement? A randomised controlled trial comparing a high-flex and a gender-specific posterior design.

The purpose of this study was to investigate whether a gender-specific high-flexion posterior-stabilised (PS) total knee replacement (TKR) would offer advantages over a high-flex PS TKR regarding range of movement (ROM), 'feel' of the knee, pain and satisfaction, as well as during activity. A total of 24 female patients with bilateral osteoarthritis entered this prospective, blind randomised trial in which they received a high-flex PS TKR in one knee and a gender-specific high-flexion PS TKR in the other knee. At follow-up, patients were assessed clinically measuring ROM, and questioned about pain, satisfaction and daily 'feel' of each knee. Patients underwent gait analysis pre-operatively and at one year, which yielded kinematic, kinetic and temporospatial parameters indicative of knee function during gait. At final follow-up we found no statistically significant differences in ROM (p = 0.82). The median pain score was 0 (0 to 8) in both groups (p = 0.95). The median satisfaction score was 9 (4 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.98). The median 'feel' score was 9 (3 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.66). Gait analysis showed no statistically significant differences between the two prosthetic designs in any kinematic, kinetic or temporospatial parameters. Both designs produced good clinical results with significant improvements in several gait parameters without evidence of any advantage in the gender-specific design.

Increased external hip-rotation strength relates to reduced dynamic knee control in females: paradox or adaptation?

The purpose of the present study was to examine the relationship between hip muscle strength (abduction and external rotation) and frontal-plane knee control during drop jumping in recreational female athletes. Thirty-three healthy young recreational female athletes were included. Maximal isometric hip abduction and external rotation torque were measured using hand-held dynamometry, and frontal-plane knee control during drop jumping was assessed using three-dimensional motion analysis. Frontal-plane knee control during drop jumping was expressed as the absolute (cm) and relative (cm/cm body height) change in distance between lateral knee markers from foot-ground contact to the time of minimal marker distance during the contact phase of the jump. Greater maximal external hip-rotation torque correlated significantly with greater absolute (r=0.48, P=0.005) and relative (r=0.43, P=0.012) change in knee marker distance during drop jumping. Maximal hip-abduction torque did not correlate with the absolute (r=0.18, P=0.31) or relative (r=0.19, P=0.29) change in knee marker distance during drop jumping. Contrary to our expectations, greater maximal external hip-rotation torque was related to greater change in knee marker distance during drop jumping (reduced frontal-plane knee control) in recreational female athletes.

Acute fatigue impairs neuromuscular activity of anterior cruciate ligament-agonist muscles in female team handball players.

In sports, like team handball, fatigue has been associated with an increased risk of anterior cruciate ligament (ACL) injury. While effects of fatigue on muscle function are commonly assessed during maximal isometric voluntary contraction (MVC), such measurements may not relate to the muscle function during match play. The purpose of this study was to investigate the effect of muscle fatigue induced by a simulated handball match on neuromuscular strategy during a functional sidecutting movement, associated with the incidence of ACL injury. Fourteen female team handball players were tested for neuromuscular activity [electromyography (EMG)] during a sidecutting maneuver on a force plate, pre and post a simulated handball match. MVC was obtained during maximal isometric quadriceps and hamstring contraction. The simulated handball match consisted of exercises mimicking handball match activity. Whereas the simulated handball match induced a decrease in MVC strength for both the quadriceps and hamstring muscles (P<0.05), a selective decrease in hamstring neuromuscular activity was seen during sidecutting (P<0.05). This study shows impaired ACL-agonist muscle (i.e. hamstring) activity during sidecutting in response to acute fatigue induced by handball match play. Thus, screening procedures should involve functional movements to reveal specific fatigue-induced deficits in ACL-agonist muscle activation during high-risk phases of match play.

Intra-rater repeatability of the Oxford foot model in healthy children in different stages of the foot roll over process during gait.

BACKGROUND: The repeatability of the Oxford foot model has been reported, but possible variations in the repeatability during the foot roll over process have not been examined. The aim of this study was to determine the relative and absolute repeatability of the model for each stage of the foot roll over process during gait and to compare foot kinematic data from this study with that from another centre as a preliminary examination of the model's inter-centre repeatability and validity. METHOD: Eight healthy children were tested twice at the gait laboratory. Foot kinematics from this study were plotted against those from an earlier repeatability study and repeatability statistics calculated for the three rockers of stance phase and swing phase. RESULTS: Foot kinematics from this study and an earlier repeatability study produced similar kinematic patterns and joint angle ranges, but there were offsets in the absolute joint angles in the frontal and transverse planes. Relative and absolute repeatability were best in the sagittal plane (flexion/extension) with the poorest repeatability in the transverse plane (rotation and abduction/adduction). There was little difference in repeatability between the three rockers. Typical error of measurement varied between planes and segments from 0.9 degrees for maximum forefoot dorsiflexion in second rocker to 8.6 degrees for maximum hindfoot internal rotation in first rocker. DISCUSSION: Repeatability varied markedly between planes and segments but was consistent throughout the gait cycle. Further studies are needed to determine the inter-centre repeatability and validity of the model.

Anaerobic power and muscle strength characteristics of 11 years old elite and non-elite boys and girls from gymnastics, team handball, tennis and swimming.

The aim of the present investigation was to study the possible effects of specificity of training on muscle strength and anaerobic power in children from different sports and at different performance levels in relation to growth and maturation status. Hundred and eighty-four children of both gender participating either in swimming, tennis, team handball or gymnastics were recruited from the best clubs in Denmark. Within each sport, the coach had divided the children into an elite (E) and non-elite (NE) group according to performance level and talent. Tanner stage assessment and body weight and height measurements were performed by a physician. The anaerobic performances were assessed by Wingate tests and jumping performance in squat jump (SJ), countermovement jump (CMJ) and drop jump (DJ) from two heights. Most of the differences between groups in Wingate performance disappeared when the data were normalised to body mass. The gymnasts were the best jumpers and their superiority were increased in the more complex motor coordination tasks like DJ. The results may indicate some influence of training specificity, especially on the more complex motor tasks as DJ and there may be an effect of training before puberty. The performance in the less complex motor tasks like cycling and SJ and CMJ may also be influenced by specific training, but not to the same extent, and heritance may be an important factor for performance in these anaerobic tasks.

Body proportions, body composition and pubertal development of children in competitive sports.

The aim of this study was primarily to investigate anthropometric variables, body composition and pubertal development in children aged 9-13 participating in competitive sports. Secondly, the influence of age, sport, training hours and pubertal development/maternal menarcheal age on body composition and pubertal development was explored. A total of 183 (96 girls, 87 boys) children performing swimming (Sw), tennis (Te), European team handball (TH), and gymnastics (Gy) took part in the study. Anthropometric measurements and pubertal development were determined. The participants completed a questionnaire regarding hours of training per week and maternal menarcheal age. Significant differences in stature (z-scores) were found in both boys (Sw=0.06; Te=0.04; TH=0.05; Gy=-0.66, P<0.004) and girls (Sw=0.12; Te=0.19; TH=0.25; Gy=-0.96, P<0.004). In girls, sum of skinfolds in millimetres (Sw=33.4; Te=33.3; TH=41.0; Gy= 27.2, P<0.02) and body mass index z-scores (SW=0.00; Te=-0.27; TH=0.35; Gy=-0.25, P<0.001) were different between the sports. A regression analysis revealed that in girls, age and maternal menarcheal age were significantly associated with pubertal development (P<0.005 and P<0.01), respectively, and sport was associated with the sum of skinfolds (P<0.05). In boys, only age was significantly associated with pubertal development (P<0.005). In conclusion, anthropometric and body composition differences exist in athletes of both sexes from different sports but are more evident in females. Most importantly, we did not find any effect of training on body composition or pubertal development, confirming previous data that children in competitive sports are selected due to constitutional factors.

Is prepubertal growth adversely affected by sport?

PURPOSE: To study the effect of genetic factors, birth weight, early childhood growth, sport, hours of training, and pubertal status on the stature and body mass index (BMI) of children aged 9-13 participating in sports at a competitive level. METHODS: A total of 184 children (96 girls, 88 boys), competing in swimming, tennis, team handball, and gymnastics, were investigated, assessing their height, weight, pubertal development, and BMI. Of these, 137 (76 girls, 61 boys) returned a questionnaire, which enabled us to determine height and BMI at age 2-4, birth weight, and parental heights. RESULTS: Significant differences in standard deviation scores (SDS) for actual height and for height at age 2-4 were found in both sexes between the four sports. In girls, BMI SDS was significantly different between the four sports, whereas no difference was found in boys. Each sport investigated separately showed no change in height SDS and BMI SDS between ages 2-4 and 9-13. A regression analysis showed that target height, height at age 2-4, and pubertal status had a significant impact on actual height. Interestingly, the type of sport and hours of training per week had no effect on height SDS. In boys, BMI at age 2-4 and pubertal status had a significant effect on actual BMI, whereas in girls, only BMI at age 2-4 was significant. CONCLUSIONS: The results suggest that prepubertal growth is not adversely affected by sport at a competitive level and that constitutional factors are of importance for choice of sport in children.

Motor pattern of the knee joint muscles during side-step cutting in European team handball. Influence on muscular co-ordination after an intervention study.

The incidence of anterior cruciate ligament (ACL) injuries is reported to be high in many popular team sports The most risky movement in European team handball is reported to be the side-step cutting manoeuvre. Well-rehabilitated ACL-deficient athletes have been shown to have increased co-contraction about the knee joint with this manoeuvre. The aim of this study was to examine the effect of a prophylactic training programme on the co-contraction of the knee joints of non-injured European team handball players The subjects performed 'match-like' cutting manoeuvres on a force platform. EMG-signals from the involved knee joint muscles and force platform signals were simultaneously stored on a personal computer. The data collected before and after a 12-week prophylactic training program were compared. The results demonstrated that rehabilitation exercises cannot increase co-contraction about the knee joint in healthy athletes during side-step cutting. This is contradictory to the reported effect on ACL-deficient athletes.

Can the hamstring muscles protect the anterior cruciate ligament during a side-cutting maneuver?

Because anterior cruciate ligament (ACL) injuries are common in European handball the present study assessed knee joint shear forces to estimate ACL loading in six elite female handball players during a side-cutting maneuver. A pilot investigation in three dimensions showed that peak moments occurred in the sagittal plane at a high velocity. Therefore, analysis of the movement was performed in two dimensions using high-speed cinematography, ground reaction forces, and electromyography (EMG). Film and force plate data allowed for calculation of net joint moments (inverse dynamics), estimates of instantaneous muscle-tendon lengths, contraction velocities, and peak loading of the ACL. During the breaking phase of the maneuver the peak knee joint moment was 239 Nm (99-309), which yielded an ACL-load of 520 N (215-673). The corresponding peak EMG amplitudes for the hamstring muscles were 34-39% of maximum EMG. During the breaking phase the quadriceps muscle contracted eccentrically with a velocity of 216-253% fiber length/s. In contrast, the hamstring muscles contracted concentrically with a velocity of 222-427% fiber length/s. These results suggest that a side-cutting maneuver produces loads that are insufficient to rupture the ACL. Furthermore, the rapid concentric hamstring contraction suggests that even during maximal activation, the ability of the hamstrings to reduce the ACL load is marginal.