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Original article
The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study
  1. Ruth Verrelst1,
  2. Dirk De Clercq2,
  3. Jos Vanrenterghem3,
  4. Tine Willems4,
  5. Tanneke Palmans5,
  6. Erik Witvrouw6
  1. 1Rehabilitation Sciences and Physiotherapy Ghent, Ghent University, Ghent, Belgium
  2. 2Department of Movement and Sports Sciences, Ghent University, Ghent, Belgium
  3. 3Rehabilitation Sciences and Physiotherapy, School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
  4. 4Department of Orthopedic Surgery and Physical Medicine, Ghent University, Ghent, Belgium
  5. 5Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
  6. 6Department of Physiotherapy, Aspetar, Doha, Qatar
  1. Correspondence to Ruth Verrelst, Rehabilitation Sciences and Physiotherapy Ghent, Ghent University, De Pintelaan 185 3B3, Ghent 9000, Belgium; ruth.verrelst{at}ugent.be

Abstract

Objective To prospectively determine risk factors contributing to the development of exertional medial tibial pain (EMTP).

Methods Data were prospectively collected on healthy female students in physical education, who were freshmen in 2010–2011 and 2011–2012. Eighty-six female students aged 19.38±0.85 years, were tested at the beginning of their first academic year. Kinematic parameters in the frontal and transverse plane were measured during a single-leg drop jump (SLDJ). For further analysis, the SLDJ task was divided in two phases: touchdown until maximal knee flexion (MKF) and then MKF until take-off, representing landing and push-off phase, respectively. The injury follow-up of the students was assessed using a weekly online questionnaire and a 3-monthly retrospective control questionnaire. EMTP was diagnosed by an experienced medical doctor. Cox regression analysis was used to identify the potential risk factors for the development of EMTP.

Results During injury follow-up (1–2 years), 22 participants were diagnosed with EMTP. The results of this study identified that increased range of motion (ROM) in the transverse plane of hip and thorax during landing (p=0.010 and 0.026, respectively) and during push off (p=0.019 and 0.045, respectively) are predictive parameters for the development of EMTP in women.

Conclusions Increased ROM values of hip and thorax in the transverse plane, which can be interpreted as impaired ability to maintain dynamic joint stability resulting in increased accessory movements, are significant contributors to the development of EMTP in women.

  • Lower extremity injuries
  • Sporting injuries
  • Women in sport
  • Core stability/pelvis/hips, ribs

https://doi.org/10.1136/bjsports-2012-092126

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    Introduction

    Approximately 50% of all sports injuries are secondary to overuse.1 One of the most common overuse injuries is exertional medial tibial pain (EMTP),2 especially in female athletes.3–5 EMTP is characterised by exertional pain along the posteromedial border of the middle and distal thirds of the tibia6 and can include diagnostic entities of medial tibial stress syndrome, tibial stress fracture, chronic exertional compartment syndrome and muscular and tendon injuries.7 ,8 As generally described in literature, EMTP results from repetitive microtrauma which causes local tissue damage,1 and commonly this mechanism occurs during regular physical activity like running. However, EMTP may also develop in athletes involved in jumping sports such as basketball, tennis and volleyball.9 Regular physical activity is generally known for its positive effects on physical and mental health,10 ,11 but brings along an increasing risk of sport injuries. Such sports injuries can lead to prolonged inactivity, a need for costly therapies12 and even to chronic disability.13 The development of prevention and rehabilitation strategies for lower extremity injuries including EMTP therefore is of great concern for researchers and healthcare professionals.

    Current literature has pointed out influences of distal and proximal factors in the development of EMTP, 3 ,14–16 suggesting that potential contributors can be found from the ground up and/or from the pelvis down. Concerning the distal parameters, generalised excessive or prolonged foot pronation has been described to result in numerous functional changes to the lower limb, affecting the lower leg and possibly resulting in EMTP.3 ,17 More recently, attention has turned to the role of proximal factors in the altered biomechanical function of the lower limb and in the development of lower extremity injuries like EMTP. 14 ,16 ,18–20 In order to control more distal movement, core stability has been described as being essential. 15 ,18 ,21 ,22 The impaired function of this lumbopelvic-hip complex is believed to increase vulnerability to uncontrolled joint displacements or accessory movements throughout the lower kinetic chain23 and has been shown to contribute to the development of EMTP. 24 These uncontrolled joint displacements can result in altered lower limb movements and in specific running or jumping styles. In addition to these possible altered movement strategies, Lawrence et al25 showed that participants with strong hip external rotators demonstrated significantly lower vertical ground reaction forces during single-leg landing, hence it can be speculated that decreased function of these hip muscles results in higher vertical ground reaction forces during single-leg landings.

    In contrast to the well-identified distal contribution of an excessive or prolonged pronation pattern in EMTP, 3–5 ,14 no consensus on the specific contribution of proximal kinematic factors in lower extremity overuse injuries can be found in current literature.26 ,27 In a study by Souza and Powers26 increased internal femoral rotation was demonstrated in patients with patellofemoral pain syndrome, however another similar study by Willson and Davis27 revealed greater external femoral rotation. This inconsistency can be interpreted as an indication that it may be important to evaluate functional output measures like the ability to maintain dynamic joint stability (DJS) during functional activities, besides evaluating point output measures like peak kinematic parameters.26 ,27 DJS may operationally be defined as the ability of the joint to maintain position or intended trajectory.28–31 The maintenance of DJS along the entire kinetic chain seems to be important in the prevention of injuries.32

    For the purposes of this study, the single-leg drop jump (SLDJ) was chosen to evaluate this ability to maintain DJS. Increased range of motion (ROM) in the frontal and transverse plane during the SLDJ can be seen as accessory movements, since the lower limb and trunk movements during this jump are located in the sagittal plane.33

    The role of DJS factors in the development of EMTP remains unclear since no comprehensive and prospective research has been carried out on these parameters.3 ,14 ,15 Moreover, the link between vertical ground reaction forces during single-leg landings and the development of EMTP has not been identified so far.

    Therefore, the purpose of this prospective investigation was to identify risk factors for the development of EMTP. More specifically, we analysed DJS parameters of ankle, knee, hip and lumbo-pelvic joints in the frontal and transverse plane and vertical ground reaction forces during an SLDJ. We hypothesised that female athletes with less ability to control the lower extremity movement, which results in increased accessory movements in the evaluated joints, are at risk of developing EMTP. Additionally, we hypothesised that higher vertical ground reaction forces during SLDJ would be identified as a risk factor for EMTP.

    Methods

    Participants

    Participants were 86 female students, who were freshmen in 2010–2011(n=46) and 2011–2012(n=40) in Physical Education at Ghent University, Ghent University College and Ghent Artevelde University College, Belgium. Mean age of these students was 19.38±0.85 years. All signed informed consent and knew the goals of the study. Exclusion criteria for participating in the study were: (1) pain, ache or soreness in the lower extremity within the previous year (with specific attention for pain on palpation along the distal two-thirds of the tibia), (2) surgery of the lower extremity, (3) neurological problems that would affect lower extremity function.

    At the beginning of the academic year, full-body kinematics during SLDJ of the students was assessed. Freshmen in 2010–2011 were followed throughout two academic years and freshmen in 2011–2012 were followed throughout one academic year. During their education, the participants followed a similar sports programme, under similar environmental conditions, for 29 weeks per academic year. In addition to this basic sports programme, the amount of extramural (physical activities beyond sports lessons at school) and non-supervised practice activities was also registered. This individual amount of sport participation was then used as time at risk for every student.

    After the injury follow-up period, 79 of the 86 participants were taken into account for statistical analysis. Seven students developed other lower extremity injuries and therefore were excluded from the study.

    The injured leg of the participants who developed EMTP was used in the statistical analysis. If an injured participant developed bilateral symptoms, the ‘most painful’ leg based on visual analogue score was taken into account. Those 22 injured legs were matched with legs of the control group. The percentage of observed dominant legs in the control group was matched with the percentage of observed dominant legs in the injured group so that leg dominance would not play a role in the statistical outcome. Therefore, one leg per participant of the control group was eliminated at random until the number of non-dominant/dominant legs of the injured group was also present in the control group (figure 1).

    Figure 1
    Figure 1

    Restructure method in order to match the injured legs of the exertional medial tibial pain group with uninjured legs of the control group.

    Testing procedure

    The SLDJ was believed to be advantageous as evaluation tool because: (1) a single-leg task is adequate in order to evaluate lower extremity movement control in the transverse and frontal planes15 ,34; (2) numerous physical activities and athletic events require brief but dynamic moments of single-leg stance35; (3) the test had to be challenging concerning eccentric, concentric and dynamic stabilising demands36 in order to screen athletes for risk factors. (4) Moreover, there was no need for an expensive treadmill or a large room with standardised running distance in order to execute the SLDJ. Before the actual SLDJ testing procedure, weight, height and leg dominance were determined. The determination of leg dominance was operationally defined as the leg preferred to kick a ball. Subsequently, three-dimensional kinematic data were collected using six Oqus cameras and Qualisys Track Manager software (Qualisys AB, Sweden). The ground reaction force data were recorded by a 1 m force plate (AMTI, USA) that was mounted flush in the middle of the wooden running track on which the SLDJ was performed. Ground reaction force and kinematic data were collected synchronously at 1000 and 200 Hz, respectively.34

    Prior to the actual jump testing, the three following procedures took place: (1) marker placement, (2) standing calibration trial and (3) warming-up procedure. Marker placement during this protocol, was based on the Liverpool John Moores University lower limb trunk model (table 1 and figure 2).37

    View this table:
    Table 1

    X–Y–Z Euler rotation sequence

    Figure 2
    Figure 2

    Lower limb trunk model during single-leg drop jump. X, x-axis; Y, y-axis; Z, z-axis.

    After the standing calibration trial, a functional warm-up procedure protocol of 5 min of cycling on a cycle ergometer and 20 submaximal single-leg jumps was performed.

    Thereafter, the investigator demonstrated the actual SLDJ and the participants performed two practice trials per side so they would feel comfortable to complete the task. Participants were asked to stand on a box of 30.5 cm height, with both feet in a natural position. They were instructed ‘stand on your right/left leg and drop off the block, land on your left/right leg on the force plate and immediately jump as high as possible’. The SLDJ was executed three times per side. Height of the box was chosen based on previous literature38 and common use during rehabilitation and training exercises.

    Further analysis of kinematic data was carried out using Visual3D software (C-motion Inc, Germantown). Raw marker positioning was low-pass filtered at 15 Hz with a second order, bidirectional Butterworth filter with padded endpoint extrapolation. Joint angles of foot up to pelvis segments were calculated with reference to the proximal segments and additionally segment angles for the pelvis39 and thorax were referenced to the lab coordination system. An X–Y–Z Euler rotation sequence was used.40 The SLDJ was divided into two phases: touchdown (TD) until maximal knee flexion (MKF) and then MKF until take-off (TO), representing landing and push-off phase, respectively. Kinematic variables of interest were DJS parameters of foot, knee, hip, pelvis and thorax segment during TD-MKF and during MKF-TO. More specifically, ROM values were measured as the difference between maximum and minimum peak values in the frontal and transverse plane, during the SLDJ. An increased value of this ROM was described as an impaired ability to maintain DJS in this study.41 In addition, vertical ground reaction forces during SLDJ were analysed. Kinematic and force parameters analysed in this study were found to exhibit good to excellent reliability (intraclass correlation range 0.65–0.96).42

    Injury registration and diagnostic criteria

    Since injury registration method and diagnostic criteria are very important in the recording of injuries,43 a multilevel registration method and accurate diagnostic criteria were used.

    A primary online registration method was used to look for students with lower leg pain or dysfunction, but final diagnosis was always confirmed by an experienced medical doctor (MD). For this primary online method, the participants received a weekly reminder by email to register their injuries in an online questionnaire. In this online survey, the students could register their injuries, of which the localisation and other features could be specified. Once they registered lower leg for localisation of their injury, the participants were asked to visit the MD for further diagnosis. One fixed day every week the MD attended the university and the participants could ask for a free consult. As a secondary registration method, participant interviews were conducted one-on-one in a quiet and private surrounding to double-check for the occurrence of EMTP every 3 months.

    The diagnosis of EMTP was performed by the MD through the following criteria: (1) an atraumatic occurrence of at least 1 week of medial tibial pain, exacerbated by running, (2) the presence of focal or diffuse palpation tenderness at the distal two-thirds of the posteromedial tibial border, (3) pain, ache or soreness of the posteromedial tibial border with possible functional limitation during physical active participation.7 ,43

    Statistical analysis

    Cox regression analysis (enter method) was performed to look for significant contributors to the development of EMTP. Variables with p<0.05 in the Cox regression analysis, were seen as significant predictors for EMTP. This approach has been chosen because this regression analysis assumes that risk factors affect injury in a proportional manner across time. Moreover, this method can adjust the fact that the amount of sport participation can vary between participants.13 The time of sport exposure was measured from the start of the follow-up period until the injury, or the end of the follow-up period for students who were not injured or who dropped out of the education. In case of drop-out, the date of the drop-out was taken into the account for the individual time of exposure. Statistical analysis for this study was performed using SPSS (V.21.0), except for the calculation of the thresholds for altered ROM values, which may precipitate EMTP. To define these threshold values, a receiver operating characteristic (ROC)-curve analysis was performed using MedCalc—software.

    Results

    During the follow-up period, 22 (26%) of the 86 participants developed EMTP. Nine of them developed bilateral symptoms. A total of 57 (66%) participants did not sustain any overuse injury of the lower extremity and were used as a control group. During the study follow-up, four students dropped out of the education programme, none of whom presented with EMTP. Anthropometric data on the participants are listed in table 2.

    View this table:
    Table 2

    Means and SDs for demographic data for uninjured and EMTP group

    Cox regression analysis revealed several significant predictors for the development of EMTP. Especially DJS in the transverse plane (rotations around the Z-axis) seemed to be important, where ROM of hip referenced to the pelvis, pelvis referenced to the thorax and thorax referenced to the lab were found to be significant predictors for the development of EMTP. These parameters were found to be significant contributors during the two phases of the SLDJ. Descriptives and results for the Cox regression analysis are presented in table 3.

    View this table:
    Table 3

    Means, SDs and significance level by Cox regression analysis for accessory movement parameters in uninjured and EMTP group

    The strength of the predictive values of the significant contributors to the development of EMTP is presented in table 4.

    View this table:
    Table 4

    Contributors for EMTP by Cox regression analysis

    The Cox regression analysis revealed that the hazard of developing EMTP at any time, increases with 15% if thorax ROM in the transverse plane increases with 1° during landing phase. The hazard of developing EMTP at any time, increases with 9% if transverse thorax ROM increases with 1° during push-off phase. Similarly, the hazard of developing EMTP at any time, increases with 10% if transverse pelvis-thorax ROM increases with 1° during push-off phase.

    The hazard of developing EMTP at any time increases with 13% if transverse hip ROM increases with 1° during landing phase. If transverse hip ROM increases with 1° during push-off phase, the hazard of developing EMTP at any time increases with 10%.

    Mean and SD values of these predictive values are shown in figure 3.

    Figure 3
    Figure 3

    Mean and SD values for contributors for EMTP. EMTP, exertional medial tibial pain; MKF, maximal knee flexion; ROM, range of motion; TD, touchdown; TO, take off; Z, z-axis.

    The ROC-analysis revealed a cut-off value of >12.27° for transverse thorax ROM during landing phase, >13.24° for transverse thorax ROM during push-off phase, >16.76° for transverse pelvic-thoracic ROM during push-off phase, >8.93° for transverse hip ROM during landing phase and >6.12° for transverse hip ROM during push-off phase. These cut-off values are shown in table 5.

    View this table:
    Table 5

    Cut-off values for significant predictors of EMTP using ROC curve analysis

    Discussion

    This study is the first to prospectively identify the role of DJS parameters in the development of one of the most important overuse injuries, EMTP. More than 1/4 participants in this female population developed EMTP. This incidence (26%) is in accordance with a previous study.3

    The results of this study demonstrated that increased transverse movement of the hip and the thorax during a functional single-leg task, are significant risk factors for the development of EMTP in female athletes. These accessory movements of the hip and the thorax can be seen as the result of impaired neuromuscular control and therefore impaired ability to maintain DJS in the lumbopelvic-hip region.41

    As mentioned above, the literature reveals that potential contributors to LE injuries can be found distally and proximally in the kinetic chain.14 Nevertheless, comparison of this study with other studies is rather difficult, since no study prospectively examined the role of distal and proximal functional DJS factors in EMTP so far. In contrast to this study, other studies focused on peak outcome measures, rather than functional outcome measures.26 ,27 The results of this current study demonstrate that functional output measures like the ability to maintain DJS during functional activities, are indeed of great value since increased transverse ROM of hip and thorax were defined as risk factors for EMTP.

    In order to interpret the results of this study, it may be interesting to describe a possible relationship between decreased ability to maintain transverse DJS of the hip and the thorax and increased lower leg strains, since these strains are described to induce EMTP.3 ,44–46 The decreased ability to maintain transverse DJS of the hip and the thorax results in unneeded and therefore accessory movements. It is shown in this study that participants with increased accessory movements around the Z-axis in the transverse plane of the hip and the thorax while executing the SLDJ, are at a risk for the development of EMTP.

    These altered proximal-to-distal movement patterns may cause more eccentric activity of lower leg musculature in the attempt to control the motion and may therefore lead to excessive traction to the lower leg musculature.3 However, muscle origins do not frequently correspond to the site of symptoms in EMTP,47 so tractions to the tibia may not always be the direct result of traction of the lower leg musculature. In accordance with this finding, Stickley et al48 described the deep posterior crural fascia as a potential site of traction rather than the origins of lower leg. Furthermore, Bouche and Johnson49 described the link between lower leg muscles and fascia, in which fascial tenting with muscle tractions were demonstrated. The deep posterior crural fascia as a potential site of traction may thus be the explanation for traction conferred to the tibia.48 When each TD generates this traction on midtibial musculoskeletal structures, the musculoskeletal system may become overloaded and overuse injury of the lower leg such as EMTP may occur.3 However, further and thorough exploration of the specific link between the instability parameters identified in this study and the development of EMTP should be included in future research.

    Another interesting mechanism for the pathomechanics of EMTP could possibly be found in the link between altered movement patterns and therefore altered ground reaction forces.25 As aforementioned, Lawrence et al25 showed that participants with strong hip external rotators demonstrated significantly lower vertical ground reaction forces during single-leg landing. Nevertheless, in this study no significant differences were found in vertical ground reaction force between the uninjured and the EMTP group. The results in this study are thus not speculative for peak bone rates as an important risk factor in the development of EMTP.

    The results of this study contribute to the growing body of evidence that lumbopelvic-hip factors indeed play an important role in the development of EMTP.24 However, the overall screening instrument for core stability function, which can be described as motor control and muscular capacity,15 has not yet been identified. Recent study results reveal the important link between hip muscle weakness and EMTP,24 but Leetun et al15 found no link between trunk muscle strength and general lower limb injury. Therefore, the identification of the specific mechanism between decreased core stability function and the development of lower extremity injuries should be the focus of future studies.

    The results in this study only revealed proximal decreased DJS parameters, whereas in literature distal parameters are described to play an important role in EMTP.3–5 Riemann et al50 described an increasing role of the proximal joint musculature as the task difficulty increases. As more demanding tasks, like jumping, increase the need for appropriate proximal joint musculature function,50 less demanding tasks like marching and jogging may be more dependent on distal joint musculature function. This important statement may indicate the need for specific screening tools based on level of activity in order to develop comprehensive preventive and diagnostic screening tools.

    As a first and important limitation of this study, we note that these results concern female physical education students. Consequently, these findings cannot be generalised to a civilian setting. However, women suffer disproportionately higher rates of EMTP51 and therefore are an important population for studies on EMTP. Second, structural deformities of the lower extremity such as femoral anteversion and coxa vara, have significant effects on lower limb function.52 ,53 Nevertheless, the measurement of possible deformities was not part of this study's protocol. These parameters should be taken into account in future research, especially since they are common features of the female gender. Another limitation can be found in the difference between landing mechanics from a drop jump compared with landing from a jump, however, the practical advantages of the SLDJ (eg, standardising drop height vs jumping height) contribute to the value of this operative screening instrument. As a final but important limitation, muscle fatigue evaluation was not performed in this study. Muscle fatigue however has been described as playing an important role in the development of EMTP54 and therefore is of great interest in research concerning these lower extremity overuse injury.

    Conclusion

    The decreased ability to maintain transverse DJS of the hip and the thorax during SLDJ, was found to be a significant risk factor for the development of EMTP in female athletes. We suggest that the decreased ability to control the lower extremity movement during SLDJ resulted in increased risk for developing EMTP. Proximal stability seems to be an important factor to take into account for prevention and rehabilitation purposes.

    What are the new findings

    • This prospective study is the first to evaluate proximal dynamic joint stability (DJS) parameters as risk factors for the development of exertional medial tibial pain (EMTP) in women.

    • Since lower limb and trunk movements during the single-leg drop jump (SLDJ) are located in the sagittal plane, increased range of motion in the frontal and transverse plane can be seen as accessory movements. Decreased ability to maintain DJS can lead to accessory movements.

    • The results of this study identified that accessory movements of the hip and thorax in the transverse plane during SLDJ are predictive parameters for development of EMTP in women.

    • As only proximal DJS factors were identified as significant contributors for EMTP and as an increasing role of the proximal joint musculature is needed when task difficulty increases, level of activity may be a very important factor to take into account when developing screening tools for the prevention and revalidation of EMTP.

    Acknowledgments

    The authors gratefully acknowledge Fabienne Van De Steene and Roel De Ridder for their clinical point of view and assistance in analysis of the data, and Dr Vanden Boscche and Dr Steyaert for their assistance in data collection of the injuries.

    References

    1. ↵
      1. Wilder RP,
      2. Sethi S
      . Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med 2004;23:55–81.
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. Jarvinen M
      . Lower leg overuse injuries in athletes. Knee Surg Sports Traumatol Arthrosc 1993;1:126–30.
      OpenUrlCrossRefPubMed
    3. ↵
      1. Willems TM,
      2. De Clercq D,
      3. Delbaere K,
      4. et al
      . A prospective study of gait related risk factors for exercise-related lower leg pain. Gait Posture 2006;23:91–8.
      OpenUrlCrossRefPubMedWeb of Science
    4. ↵
      1. Bennett JE,
      2. Reinking MF,
      3. Pluemer B,
      4. et al
      . Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther 2001;31:504–10.
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      1. Yates B,
      2. White S
      . The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 2004;32:772–80.
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. Bhatt R,
      2. Lauder I,
      3. Finlay DB,
      4. et al
      . Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sports Med 2000;34:49–53.
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Burne SG,
      2. Khan KM,
      3. Boudville PB,
      4. et al
      . Risk factors associated with exertional medial tibial pain: a 12 month prospective clinical study. Br J Sport Med 2004;38:441–5.
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. Touliopolous S,
      2. Hershman EB
      . Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Med 1999;27:193–204.
      OpenUrlCrossRefPubMedWeb of Science
    9. ↵
      1. Edwards PH,
      2. Wright ML,
      3. Hartman JF
      . A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med 2005;33:1241–9.
      OpenUrlAbstract/FREE Full Text
    10. ↵
      1. Kujala UM,
      2. Kaprio J,
      3. Sarna S,
      4. et al
      . Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. JAMA 1998;279:440–4.
      OpenUrlCrossRefPubMedWeb of Science
    11. ↵
      1. Pate RR,
      2. Pratt M,
      3. Blair SN,
      4. et al
      . Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402–7.
      OpenUrlCrossRefPubMedWeb of Science
    12. ↵
      1. Parkkari J,
      2. Kujala UM,
      3. Kannus P
      . Is it possible to prevent sports injuries? Review of controlled clinical trials and recommendations for future work. Sports Med 2001;31:985–95.
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Bahr R,
      2. Holme I
      . Risk factors for sports injuries—a methodological approach. Br J Sports Med 2003;37:384–92.
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Chuter VH,
      2. Janse de Jonge XA
      . Proximal and distal contributions to lower extremity injury: a review of the literature. Gait Posture 2012;36:7–15.
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      1. Leetun DT,
      2. Ireland ML,
      3. Willson JD,
      4. et al
      . Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004;36:926–34.
      OpenUrlCrossRefPubMedWeb of Science
    16. ↵
      1. Niemuth PE,
      2. Johnson RJ,
      3. Myers MJ,
      4. et al
      . Hip muscle weakness and overuse injuries in recreational runners. Clin J Sports Med 2005;15:14–21.
      OpenUrlCrossRefPubMedWeb of Science
    17. ↵
      1. Willems TM,
      2. Witvrouw E,
      3. De Cock A,
      4. et al
      . Gait-related risk factors for exercise-related lower-leg pain during shod running. Med Sci Sports Exerc 2007;39:330–9.
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Ireland ML,
      2. Willson JD,
      3. Ballantyne BT,
      4. et al
      . Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 2003;33:671–6.
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. Willson JD,
      2. Dougherty CP,
      3. Ireland ML,
      4. et al
      . Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg 2005;13:316–25.
      OpenUrlAbstract/FREE Full Text
    20. ↵
      1. Willson JD,
      2. Ireland ML,
      3. Davis I
      . Core strength and lower extremity alignment during single leg squats. Med Sci Sports Exerc 2006;38:945–52.
      OpenUrlCrossRefPubMedWeb of Science
    21. ↵
      1. Fredericson M,
      2. Cookingham CL,
      3. Chaudhari AM,
      4. et al
      . Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10:169–75.
      OpenUrlCrossRefPubMedWeb of Science
    22. ↵
      1. Nadler SF,
      2. Malanga GA,
      3. DePrince M,
      4. et al
      . The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clin J Sport Med 2000;10:89–97.
      OpenUrlCrossRefPubMedWeb of Science
    23. ↵
      1. Wilkerson GB,
      2. Giles JL,
      3. Seibel DK
      . Prediction of core and lower extremity strains and sprains in collegiate football players: a preliminary study. J Athl Train 2012;47:264–72.
      OpenUrlPubMed
    24. ↵
      1. Verrelst R,
      2. Willems TM,
      3. Clercq DD,
      4. et al
      . The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. Br J Sports Med Published Online First: 8 Feb 2013 doi:10.1136/bjsports-2012-091710
    25. ↵
      1. Lawrence RK,
      2. Kernozek TW,
      3. Miller EJ,
      4. et al
      . Influences of hip external rotation strength on knee mechanics during single-leg drop landings in females. Clin Biomech 2008;23:806–13.
      OpenUrlCrossRefWeb of Science
    26. ↵
      1. Souza RB,
      2. Powers CM
      . Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain. Am J Sports Med 2009;37:579–87.
      OpenUrlAbstract/FREE Full Text
    27. ↵
      1. Willson JD,
      2. Davis IS
      . Lower extremity strength and mechanics during jumping in women with patellofemoral pain. J Sport Rehabil 2009;18:76–90.
      OpenUrlPubMedWeb of Science
    28. ↵
      1. Bendjaballah MZ,
      2. Shirazi-Adl A,
      3. Zukor DJ
      . Finite element analysis of human knee joint in varus-valgus. Clin Biomech 1997;12:139–48.
      OpenUrlCrossRefWeb of Science
    29. ↵
      1. Hewett TE,
      2. Myer GD,
      3. Ford KR,
      4. 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;33:492–501.
      OpenUrlAbstract/FREE Full Text
    30. ↵
      1. Markolf KL,
      2. Burchfield DM,
      3. Shapiro MM,
      4. et al
      . Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res 1995;13:930–5.
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      1. Zazulak BT,
      2. Ponce PL,
      3. Straub SJ,
      4. et al
      . Gender comparison of hip muscle activity during single-leg landing. J Orthop Sports Phys Ther 2005;35:292–9.
      OpenUrlCrossRefPubMedWeb of Science
    32. ↵
      1. Riemann BL,
      2. Lephart SM
      . The sensorimotor system, Part II: the role of proprioception in motor control and functional joint stability. J Athl Train 2002;37:80–4.
      OpenUrlPubMedWeb of Science
    33. ↵
      1. Lees A,
      2. Barton G,
      3. Robinson M
      . The influence of Cardan rotation sequence on angular orientation data for the lower limb in the soccer kick. J Sports Sci 2010;28:445–50.
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      1. Earl JE,
      2. Monteiro SK,
      3. Snyder KR
      . Differences in lower extremity kinematics between a bilateral drop-vertical jump and a single-leg step-down. J Orthop Sports Phys Ther 2007;37:245–52.
      OpenUrlCrossRefPubMedWeb of Science
    35. ↵
      1. Coventry E,
      2. O'Connor KM,
      3. Hart BA,
      4. et al
      . The effect of lower extremity fatigue on shock attenuation during single-leg landing. Clin Biomech 2006;21:1090–7.
      OpenUrlCrossRefWeb of Science
    36. ↵
      1. Ortiz A,
      2. Olson S,
      3. Libby CL,
      4. et al
      . Landing mechanics between noninjured women and women with anterior cruciate ligament construction during 2 jump tasks. Am J Sports Med 2008;36:149–57.
      OpenUrlAbstract/FREE Full Text
    37. ↵
      1. Vanrenterghem J,
      2. Gormley D,
      3. Robinson M,
      4. et al
      . Solutions for representing the whole-body centre of mass in side cutting manoeuvres based on data that is typically available for lower limb kinematics. Gait Posture 2010;31:517–21.
      OpenUrlCrossRefPubMedWeb of Science
    38. ↵
      1. Fagenbaum R,
      2. Darling WG
      . Jump landing strategies in male and female college athletes and the implications of such strategies for anterior cruciate ligament injury. Am J Sports Med 2003;31:233–40.
      OpenUrlAbstract/FREE Full Text
    39. ↵
      1. Willy RW,
      2. Davis IS
      . The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther 2011;41:625–32.
      OpenUrlCrossRefPubMed
    40. ↵
      1. Wu G,
      2. Siegler S,
      3. Allard P,
      4. 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 Biomechanics. J Biomech 2002;35:543–8.
      OpenUrlCrossRefPubMedWeb of Science
    41. ↵
      1. Panjabi MM
      . The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 1992;5:390–6.
      OpenUrlCrossRefPubMedWeb of Science
    42. ↵
      1. Fleis JL
      . Analysis of data from multiclinic trials. Control Clin Trials 1986; 7:267–75.
      OpenUrlCrossRefPubMedWeb of Science
    43. ↵
      1. Bahr R
      . No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med 2009;43:966–72.
      OpenUrlAbstract/FREE Full Text
    44. ↵
      1. Yoshikawa T,
      2. Mori S,
      3. Santiesteban AJ,
      4. et al
      . The effects of muscle fatigue on bone strain. J Exp Biol 1994;188:217–33.
      OpenUrlAbstract/FREE Full Text
    45. ↵
      1. Milgrom C,
      2. Finestone A,
      3. Ekenman I,
      4. et al
      . The effect of shoe sole composition on in vivo tibial strains during walking. Foot Ankle Int 2001;22:598–602.
      OpenUrlAbstract/FREE Full Text
    46. ↵
      1. Burr DB,
      2. Milgrom C,
      3. Fyhrie D,
      4. et al
      . In vivo measurement of human tibial strains during vigorous activity. Bone 1996;18:405–10.
      OpenUrlCrossRefPubMedWeb of Science
    47. ↵
      1. Beck BR,
      2. Osternig LR
      . Medial tibial stress syndrome. The location of muscles in the leg in relation to symptoms. J Bone Joint Surg Am 1994;76:1057–61.
      OpenUrl
    48. ↵
      1. Stickley CD,
      2. Hetzler RK,
      3. Kimura IF,
      4. et al
      . Crural fascia and muscle origins related to medial tibial stress syndrome symptom location. Med Sci Sports Exerc 2009;41:1991–6.
      OpenUrlCrossRefPubMedWeb of Science
    49. ↵
      1. Bouche RT,
      2. Johnson CH
      . Medial tibial stress syndrome (tibial fasciitis): a proposed pathomechanical model involving fascial traction. J Am Podiatr Med Assoc 2007;97:31–6.
      OpenUrlPubMed
    50. ↵
      1. Riemann BL,
      2. Myers JB,
      3. Lephart SM
      . Comparison of the ankle, knee, hip, and trunk corrective action shown during single-leg stance on firm, foam, and multiaxial surfaces. Arch Phys Med Rehabil 2003;84:90–5.
      OpenUrlCrossRefPubMedWeb of Science
    51. ↵
      1. Macleod MA,
      2. Houston AS,
      3. Sanders L,
      4. et al
      . Incidence of trauma related stress fractures and shin splints in male and female army recruits: retrospective case study. BMJ 1999;318:29.
      OpenUrlFREE Full Text
    52. ↵
      1. Iglic A,
      2. Antolic V,
      3. Srakar F,
      4. et al
      . Biomechanical study of various greater trochanter positions. Arch Orthop Trauma Surg 1995;114:76–8.
      OpenUrlCrossRefPubMedWeb of Science
    53. ↵
      1. Nyland J,
      2. Kuzemchek S,
      3. Parks M,
      4. et al
      . Femoral anteversion influences vastus medialis and gluteus medius EMG amplitude: composite hip abductor EMG amplitude ratios during isometric combined hip abduction-external rotation. J Electromyogr Kinesiol 2004;14:255–61.
      OpenUrlCrossRefPubMedWeb of Science
    54. ↵
      1. Milgrom C,
      2. Radeva-Petrova DR,
      3. Finestone A,
      4. et al
      . The effect of muscle fatigue on in vivo tibial strains. J Biomech 2007;40:845–50.
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Contributors RV was responsible for the overall content as guarantor and was involved in the conception and design of the study, acquisition of data, analysis and interpretation of data, and writing and drafting the article or revising it critically for important intellectual content, describing clinical implications of the results, and final approval of the version to be published. DDC was involved in the conception and design of the study, acquisition of data, revising it critically for important intellectual content, and final approval of the version to be submitted. JV was involved in conception and design of the lower limb trunk model used during data collection and further analysis, conception of analysing methods concerning the biomechanical data, and revising the manuscript critically for important intellectual content. TW was involved in the conception and design of the study, acquisition of data, analysis and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. TP was involved in acquisition of data, conception of analysing methods concerning the biomechanical data and revising the manuscript critically for important intellectual content. EW was involved in the conception and design of the study, acquisition of data, analysis and interpretation of data, describing clinical implications of the results, revising the manuscript critically for important intellectual content, and final approval of the version to be published.

    • Funding This research was funded by BOF-UGent 05V00910.

    • Competing interests None.

    • Patient consent Obtained.

    • Ethics approval The Ethical Committee of Ghent University Hospital.

    • Provenance and peer review Not commissioned; externally peer reviewed.