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Associa ion be ween lowe ex emi y muscle s eng h and acu e ankle inju y in you h
eam-spo s a hle es
© 2021 Else ie
Accep ed e sion (Final d a )
Hie amo, J.; Pasanen, K.; Leppänen, M.; S e en, K.; Kannus, P.; Heinonen, A.;
Ma ila, V.; Pa kka i, J.
Hie amo, J., Pasanen, K., Leppänen, M., S e en, K., Kannus, P., Heinonen, A., Ma ila, V., &
Pa kka i, J. (2021). Associa ion be ween lowe ex emi y muscle s eng h and acu e ankle inju y
in you h eam-spo s a hle es. Physical The apy in Spo , 48, 188-195.
h ps://doi.o g/10.1016/j.p sp.2021.01.007
2021
1
Hie amo, J., Pasanen, K., Leppänen, M., S e en, K., Kannus, P., Heinonen, A., Ma ila, V., & Pa kka i, J.
1
(2021). Associa ion be ween lowe ex emi y muscle s eng h and acu e ankle inju y in you h eam-
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spo s a hle es. Physical The apy in Spo , 48, 188-195
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ABSTRACT
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Objec i es: To in es iga e lowe ex emi y muscle s eng h as isk ac o o an acu e ankle inju y
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in you h a hle es.
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Design: Coho s udy.
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Se ing: Baske ball and loo ball clubs.
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Pa icipan s: 188 you h (≤21) male and 174 emale a hle es.
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Main ou come measu es: 1RM leg p ess, maximal concen ic isokine ic quad iceps and
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hams ings as well as maximal isome ic hip abduc o s eng h we e measu ed and a hle es we e
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ollowed o an acu e ankle inju y up o h ee yea s. Cox eg ession models we e used in s a is ical
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analyses.
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Resul s: In males, g ea e 1RM leg p ess and maximal quad iceps s eng h inc eased he isk o any
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ype o acu e ankle inju y (Haza d a io [HR] o 1 SD inc ease, 1.63 [95% CI, 1.12‒2.39] and 1.43
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[95% CI, 1.01‒2.01], espec i ely). In emales, g ea e 1RM leg p ess and di e ence be ween legs
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in hip abduc ion s eng h inc eased he isk o acu e non-con ac ankle inju y (HR o 1 SD inc ease,
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1.44 [95% CI, 1.03‒2.02] and 1.44 [95% CI, 1.03‒2.00], espec i ely). Howe e , ROC cu e
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analyses showed AUC:s o 0.57-0.64 indica ing “ ail” o “poo ” combined sensi i i y and speci i y
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o hese es s.
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Conclusion: G ea e s eng h in bo h sexes along wi h asymme y in hip abduc o s eng h in
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emales inc eased he isk o acu e ankle inju y.
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2
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Keywo ds: SPORT INJURY; INJURY RISK; YOUTH SPORT
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1. INTRODUCTION
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Incidence o ankle inju y is high in you h eam spo s (Bo owski, Ya d, Fields, & Coms ock, 2008;
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Eme y, Ca olyn A., Meeuwisse, & Ha mann, 2005; Olsen, O-E, Myklebus , Engeb e sen, & Bah ,
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2006; Powell & Ba be -Foss, 2000). La e al ankle sp ain is obse ed mos equen ly (Sankey,
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B ooks, Kemp, & Haddad, 2008; S a key, 2000; Woods, Hawkins, Hulse, & Hodson, 2003a).
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Ankle sp ain can lead o a ma ked loss o p ac icing and playing ime (Cloke, Spence , Hodson, &
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Deehan, 2009) and o en e ol e pe sis en pain, weakness and ch onic ins abili y possibly esul ing
32
in lowe spo ac i i y le els o e en change o spo s (Anandacooma asamy & Ba nsley, 2005).
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Iden i ying isk ac o s ha a e modi iable and clinically easy o es a e essen ial
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be o e planning inju y p e en ion p og ams (Bah & K osshaug, 2005). The ole o lowe ex emi y
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(LE) muscle s eng h as a isk ac o o spo inju y is con o e sial. Lowe quad iceps and
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hams ings s eng h o s eng h imbalances be ween hese muscles ha e shown o inc ease he isk
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o an e io c ucia e ligamen inju y and hams ing s ain (C oisie , Gan eaume, Bine , Gen y, &
38
Fe e , 2008; Mye e al., 2009; Sode man, Al edson, Pie ila, & We ne , 2001) al hough con a y
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esul s also exis (Bennell e al., 1998; Uho chak e al., 2003). In ou p e iously published s udy,
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lowe hip abduc ion s eng h inc eased he isk o acu e knee inju y in you h male a hle es (Hie amo
41
e al., 2020).
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The e a e se e al s udies in es iga ing ankle do si lexion, plan a lexion, in e sion,
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e e sion, do si lexion and plan a lexion s eng h as well as s eng h a ios be ween hese as isk
44
ac o s o ankle inju y (Beynnon, Rens om, Alosa, Baumhaue , & Vacek, 2001; Wang, Chen,
45
Shiang, Jan, & Lin, 2006; Willems, T. M. e al., 2005; Willems, Tine Ma ieke e al., 2005).
46
Howe e , based on kine ic chain heo ies, impai men s o p oximal co e and hip muscle unc ion
47
3
a e sugges ed o inc ease he likelihood o uncon olled join displacemen s dis ally and occu ence
48
o dis al LE inju y (Lee un, I eland, Willson, Ballan yne, & Da is, 2004; Willson, Doughe y,
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I eland, & Da is, 2005). Lowe hip abduc ion s eng h has ound o associa e wi h ch onic ankle
50
sp ains (F iel, McLean, Mye s, & Cace es, 2006), bu in ano he s udy, no associa ion be ween hip
51
muscle s eng h and he isk o non-con ac la e al ankle sp ain was epo ed in high school a hle es
52
(McHugh, Tyle , Te o, Mullaney, & Nicholas, 2006). In addi ion, al e a ions in knee kinema ics in
53
jump landing ask ha e ound in subjec s wi h ch onic ankle ins abili y (G ibble & Robinson, 2009)
54
and neu omuscula aining including quad iceps and hams ings s eng hening exe cises ha e
55
shown o dec ease he isk o acu e ankle inju y in you h a hle es (Eme y, C. A. & Meeuwisse,
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2010; Olsen, Odd-Egil, Myklebus , Engeb e sen, Holme, & Bah , 2005). The e o e, lowe
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quad iceps and hams ings s eng h may also be conside ed as isk ac o s o acu e ankle inju y.
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The pu pose o his s udy was hus o in es iga e selec ed LE muscle s eng h
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a iables as po en ial isk ac o s o an acu e ankle inju y in you h male and emale eam-spo
60
a hle es. We hypo hesized ha lowe muscle s eng h inc eases he isk o hese inju ies.
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62
63
64
65
66
67
68
69
4
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2. METHODS
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2.1. S udy design and pa icipan s
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This s udy is pa o he P edic o s o Lowe Ex emi y Inju ies in Team Spo s (PROFITS) s udy
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(Pasanen e al., 2015). The s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki and
74
was app o ed by he E hics Commi ee o he Pi kanmaa Hospi al Dis ic , Tampe e, Finland (ETL-
75
code R10169). The pa icipan s signed a w i en in o med consen be o e en e ing he s udy
76
(including pa en al consen o pa icipan s unde he age o 18).
77
Junio -aged (≤21 y s) baske ball and loo ball a hle es we e ec ui ed om 9
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baske ball and 9 loo ball eams om 6 spo s clubs om Tampe e ci y dis ic . All a hle es played
79
a he wo highes junio o adul league le els. Al oge he 214 male (102 baske ball and 112
80
loo ball) and 189 emale (107 baske ball and 82 loo ball) a hle es en e ed he s udy du ing he
81
p eseason (Ap il‒May) in 2011, 2012 o 2013. Each a hle e comple ed a baseline ques ionnai e
82
including ques ions abou age, sex, p e ious inju ies and playing le el. S anding heigh (cm) and
83
body mass (kg) we e eco ded and muscle s eng h es s pe o med. A e baseline es s, inju y
84
egis a ion con inued un il he end o Ap il 2014. Twen y- ou male and 11 emale a hle es we e
85
excluded due o ongoing inju y. A hle es we e conside ed as inju ed i hey epo inju ies a
86
baseline ques ionnai e o we e no able o ully pa icipa e in muscle s eng h es s. In addi ion, 2
87
male and 4 emale a hle es we e excluded, because hey we e no o icial membe s o he eams
88
leading o a o al o 188 (88%) male and 174 (92%) emale a hle es in he inal analysis (Fig. 1).
89
The demog aphic da a and ankle inju y his o y o a hle es a e p esen ed in (Table 1).
90
2.2. Muscle s eng h es s
91

5
The muscle s eng h es s we e pa o a baseline es ba e y used o in es iga e po en ial
92
ana omical, biomechanical and neu omuscula isk ac o s o inju ies. The comple e es p o ocol
93
wi h s anda dised wa m-up p ocedu es be o e each es is desc ibed elsewhe e (Pasanen e al.,
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2015).
95
2.2.1. Maximal one- epe i ion leg p ess s eng h
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A sea ed leg p ess machine (Technogym®, Gambe ola, I aly) was used o measu e a combined
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maximal ex ension s eng h o LE muscles. The dis ance be ween ee was 20 cm and end o shoes
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we e 10 cm abo e om he lowes end o he oo pla e. The back o he sea was se on 30° angle
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ela i e o he loo . A e ical ba was placed a he poin whe e he knees eached he a ge knee
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angle o 80° (Fig. 2). The a ge knee angle was measu ed wi h a goniome e (HiRes, Baseline®
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E alua ion Ins umen s, Whi e Plains, NY, USA). A s anda dized wa m-up p o ocol consis ed h ee
102
se s wi h g adually inc easing weigh s (Pasanen e al., 2015). The one- epe i ion maximum (1RM)
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leg p ess es p o ocol s a ed wi h 80‒150 kg. App op ia e s a ing weigh s o each a hle e we e
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decided indi idually by asking abou a hle e’s expe ience o weigh aining in sea ed leg p ess
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machine. A he s a ing poin a hle e’s legs we e ex ended and he weigh s we e hen lowe ed un il
106
he knees o m he co ec angle and hen e u ned a he s a ing posi ion as ha d as possible. A e
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each success ul ial, he weigh s we e inc eased by maximum 30 kg a e he i s ials and by
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minimum 10 kg a e he las ials o he nex a emp . Reco e y pe iod be ween he a emp s was
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2 minu es (Ve dijk, an Loon, Meije , & Sa elbe g, Hans H C M., 2009) and he es ends when
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1RM was eached. Body mass no malized alue was used in he analysis. Simila es has been
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p o ed o be eliable ool o measu ing muscle s eng h (Le inge e al., 2009).
112
2.2.2. Maximal isokine ic quad iceps and hams ings s eng h
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Maximal concen ic isokine ic quad iceps and hams ings s eng h was measu ed a i s s udy yea
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(2011) in non-comme cial dynamome e (name hidden). A he second s udy yea (2012) he
115
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dynamome e was eplaced by Biodex Mul i-Join Sys em P o dynamome e (Biodex Sys em 4,
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Biodex Medical Sys ems, Inc., Shi ley, NY, USA). The es p ocedu e was he same ei he o he
117
dynamome e s used. The es ange o mo ion was 90° h ough 15° o knee lexion wi h an angula
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eloci y o 60°/s (Fig. 2). A s anda dized es p o ocol (Pasanen e al., 2015) wi h g adually
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inc easing in ensi y we e pe o med and he inal es includes h ee epe i ions wi h maximum
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s eng h. The maximal s eng h was epo ed as peak o que (N‧m) eco ded and body mass
121
no malized alue was used in he analysis. The s eng h di e ence be ween legs as well as
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hams ings- o-quad iceps (HQ) s eng h a io we e calcula ed. Isokine ic s eng h es ing has been
123
es ablished as eliable ool o assessing muscle s eng h (B osky JA J , Ni z, Malone, Cabo n, &
124
Rayens, 1999).
125
To e alua e he ep oducibili y o measu emen s be ween he used wo dynamome e s,
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wel e 14‒15 yea s old male socce a hle es (24 legs) we e es ed wi h bo h dynamome e s by
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di e en es e s who collec ed he da a. In aclass co ela ion coe icien (ICC) alue (3,k) was 0.81
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(95% CI, 0.43‒0.93) o isokine ic quad iceps and 0.79 (95% CI, 0.47‒0.91) o isokine ic
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hams ing s eng h measu emen indica ing good es - e es eliabili y o he es s.
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2.2.3. Maximal hip abduc o s eng h
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Maximal isome ic hip abduc o s eng h (kg) was es ed wi h a hand-held dynamome e (Hyd aulic
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Push-Pull Dynamome e , Baseline® E alua ion Ins umen s, Whi e Plains, NY, USA). The es was
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pe omed wi h he a hle e lying legs ex ended in a supine posi ion on bench. The pel is and he
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con ala e al high we e ixed wi h a bel and he a hle e hold his o he a ms ac oss he ches du ing
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he es . The dynamome e was posi ioned app oxima ely 2 cm p oximal he la e al ankle malleolus
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wi h he leg in neu al posi ion and he oo in sligh do si lexion (Fig. 2). The dynamome e was
137
applied in a ixed posi ion and he a hle e hold muscle con ac ion agains he dynamome e o
138
app oxima ely wo seconds (make- es ). A e one es ial he a hle e pe o med wo maximal
139
7
con ac ions wi h a 10 second es be ween he a emp s (Johnson, Mille, Ma inez, C ombie, &
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Roge s, 2004). The highes esul was eco ded and body mass no malized alue was used in he
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analysis. The s eng h di e ence be ween legs was also calcula ed. Simila p ocedu e has been
142
showed o be eliable o assessing hip abduc o s eng h (Tho bo g, Pe e sen, Magnusson, &
143
Holmich, 2010).
144
2.3. Inju y and exposu e egis a ion
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Du ing a ollow-up pe iod (May 2011‒Ap il 2014), all acu e ankle inju ies we e egis e ed by wo
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s udy physicians. They con ac ed he eams once a week o check possible new inju ies and a e
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each inju y epo ed, he inju ed a hle e was in e iewed by elephone using he s uc u ed
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ques ionnai e (Pasanen e al., 2015). Inju y de ini ion was modi ied om de ini ion by Fulle and
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colleagues (Fulle e al., 2006). An inju y was eco ded i he a hle e was unable o ully pa icipa e
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in ma ches o aining du ing he nex 24 hou s. Only inju ies which occu ed in a eams’ scheduled
151
aining sessions o ma ches we e included in his s udy. The inju ies we e classi ied as con ac (ie.
152
di ec con ac o s ike o he in ol ed ankle) o non-con ac (ie. no di ec con ac o he in ol ed
153
ankle).
154
Du ing he ollow-up, he coach o each eam eco ded a hle es’ pa icipa ion in
155
ainings and ma ches. A hle e a endance in a aining session (yes/no), du a ion o a aining
156
session (h) and a endance in each pe iod o a ma ch (yes/no) we e eco ded indi idually on a eam
157
dia y. The dia ies we e e u ned a e each ollow-up mon h and he indi idual mon hly exposu e
158
ime (h) we e egis e ed o all a hle es. I an acu e ankle inju y occu ed, he exposu e hou s o ha
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mon h we e es ima ed by di iding he days om he beginning o he mon h o he inju y da e by all
160
days o he mon h and hen by mul iplying he esul by he a hle e’s egis e ed exposu e hou s o
161
ha mon h.
162
2.4. S a is ical analysis
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8
Desc ip i e da a a e p esen ed as he mean ± s anda d de ia ion (SD) o he median and
164
in e qua ile ange (IQR) depending on he no mali y o dis ibu ion o a iables. An independen -
165
samples es was used o compa e g oup di e ences o no mally dis ibu ed a iables and he
166
Mann-Whi ney U es o non-no mally dis ibu ed a iables. Depending on he dis ibu ion o he
167
a iables, Pea son’s and Spea man’s co ela ion coe icien s we e used o e alua e linea co ela ion
168
be ween wo a iables. Inju y incidences we e calcula ed as he numbe o inju ies pe 1000 playe -
169
hou s and epo ed wi h 95% CIs: ([Incidence a e – 1.96 * S anda d e o o incidence a e] *
170
1000 hou s) o ([Incidence a e + 1.96 * S anda d e o o incidence a e] * 1000 hou s). Recu en
171
inju ies we e included in incidence calcula ions.
172
Conside ing he s udy p ocedu e, Cox eg ession models we e chosen o analyse
173
s eng h a iables using he a hle e o he leg as a uni o analysis. The uni o analysis was de ined
174
acco ding o he s eng h a iable ep esen ing ei he he cha ac e is ic o he a hle e o o he leg
175
(Bah & Holme, 2003b). The ou comes we e a new acu e (con ac o non-con ac ) ankle inju y and
176
a new acu e non-con ac ankle inju y. Exposu e ime (h) om he s a o he ollow-up un il he
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i s inju y o he end o he ollow-up we e included in he models. Spo s club was included in all
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models as andom e ec and he leg in he models using i as he uni o analysis. Unadjus ed and
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adjus ed models wi h p ede ined adjus emen ac o s we e made sepa a ely o male and emale
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a hle es. The adjus emen ac o s ha migh mos ly in luence o he isk o ankle inju y we e
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selec ed in he ollowing o de : p e ious acu e ankle inju y, age, heigh , spo and playing a adul
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le el. These adjus emen ac o s we e included in he models acco ding o he numbe o inju ies in
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each model, using es ima ion o 10 inju ies needed pe included a iable (Peduzzi, Conca o,
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Feins ein, & Hol o d, 1995). In he models using he a hle e as he uni o analysis, p e ious inju ies
185
o ipsila e al o con ala e al side we e included, and in he models using he leg as a uni o
186
analysis, only inju ies o ipsila e al side we e included.
187
15
Rega dless o signi ican associa ions be ween he muscle s eng h and ankle inju y in
325
ou s udy, subs an ial o e lap be ween he es esul s in inju ed and uninju ed a hle es exis ed
326
leading “ ail” o “poo ” combined sensi i i y and speci i y o he s eng h es s meaning ha he
327
es s can co ec ly classi y <70% o inju ed and uninju ed a hle es. The e o e, in clinical p ac ice,
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he muscle s eng h es s as measu ed in he p esen s udy canno be ecommended alone as inju y
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sc eening ools o acu e ankle inju y in you h a hle es.
330
S udy s eng hs and limi a ions
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This s udy had se e al s eng hs. Fi s , all he da a was collec ed p ospec i ely. Second, he
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accu acy o ankle inju y da a collec ion was good, because s udy physicians con ac ed coaches once
333
a week. Thi d, indi idually collec ed exposu e da a enabled he use o Cox eg ession in s a is ical
334
analyses (Bah & Holme, 2003). Finally, he s eng h isk ac o s we e measu ed wi h s anda d and
335
simple p ocedu es easy o use in clinical p ac ice.
336
One main limi a ion o he s udy was ha we measu ed only muscle s eng h, bu
337
ankle inju y is likely a esul o he complex in e ac ion be ween many in e nal (a hle e- ela ed) and
338
ex e nal (en i onmen al) isk ac o s (Bah & K osshaug, 2005; Meeuwisse, 1994). Howe e , we
339
ook in o analyses se e al o he po en ial isk ac o s as adjus emen ac o s. Ano he main
340
limi a ion was, ha s eng h measu emen s we e no epea ed and hus he s eng h alues migh
341
ha e been changed du ing he 3-yea ollow-up. In addi ion, we did no ake he in luence o le e
342
a m (limb leng h) in o accoun o 1RM leg p ess and hip abduc ion s eng h measu emen s
343
(Bakken e al., 2018; McHugh e al., 2006). Finally, because he s udy coho comp ised o you h
344
loo ball and baske ball a hle es, he indings may no be applicable o adul a hle es o a hle es
345
om o he you h spo s.
346
347
348

16
349
5. CONCLUSION
350
Ou 3-yea p ospec i e s udy showed ha g ea e 1RM leg p ess and maximal quad iceps s eng h
351
inc eased he isk o any ype o acu e ankle inju y in you h male a hle es while g ea e 1RM leg
352
p ess s eng h and g ea e di e ence be ween legs in maximal hip abduc ion s eng h inc eased he
353
isk o acu e non-con ac ankle inju y in you h emale a hle es. Howe e , acco ding o he ROC
354
cu e analysis, hese s eng h a iables as measu ed in he p esen s udy canno be used alone as
355
sc eening ools o acu e ankle inju y in you h eam-spo a hle es.
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Re e ences
370
Anandacooma asamy, A., & Ba nsley, L. (2005). Long e m ou comes o in e sion ankle inju ies.
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B i ish Jou nal o Spo s Medicine, 39(3), e14.
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Bah , R., & Holme, I. (2003a). Risk ac o s o spo s inju ies--a me hodological app oach. B i ish
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Jou nal o Spo s Medicine, 37(5), 384-392.
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Bah , R., & K osshaug, T. (2005). Unde s anding inju y mechanisms: A key componen o
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p e en ing inju ies in spo . B i ish Jou nal o Spo s Medicine, 39(6), 324-329.
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Bakken, A., Ta ge , S., Be e, T., Ei ale, C., Fa ooq, A., Mosle , A. B., e al. (2018). Muscle
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s eng h is a poo sc eening es o p edic ing lowe ex emi y inju ies in p o essional male
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socce playe s: A 2-yea p ospec i e coho s udy. Ame ican Jou nal o Spo s Medicine,
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46(6), 1481-1491.
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Bandholm, T., Tho bo g, K., Ande sson, E., La sen, T., To dahl, M., Bencke, J., e al. (2011).
381
Inc eased ex e nal hip- o a ion s eng h ela es o educed dynamic knee con ol in emales:
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Pa adox o adap a ion?. Scandina ian Jou nal o Medicine & Science in Spo s, 21(6), 215.
383
Bennell, K., Wajswelne , H., Lew, P., Schall-Riaucou , A., Leslie, S., Plan , D., e al. (1998).
384
Isokine ic s eng h es ing does no p edic hams ing inju y in aus alian ules oo balle s.
385
B i ish Jou nal o Spo s Medicine, 32(4), 309-314.
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Beynnon, B. D., Rens om, P. A., Alosa, D. M., Baumhaue , J. F., & Vacek, P. M. (2001). Ankle
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ligamen inju y isk ac o s: A p ospec i e s udy o college a hle es. Jou nal o O hopaedic
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Resea ch, 19(2), 213-220.
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Bo owski, L. A., Ya d, E. E., Fields, S. K., & Coms ock, R. D. (2008). The epidemiology o US
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