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Journal of Science and Medicine in Sport xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Original research

Classification of lumbopelvic-hip complex instability on kinematics

amongst female team handball athletes
Gabrielle G. Gilmer, Sarah S. Gascon, Gretchen D. Oliver ∗
Auburn University, School of Kinesiology, Sports Medicine and Movement Laboratory, United States1

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The purpose of this study was to examine how lumbopelvic-hip complex (LPHC) stability, via
Received 14 July 2017 knee valgus, affects throwing kinematics during a team handball jump shot.
Received in revised form Design: LPHC stability was classified using the value of knee valgus at the instant of landing from the
13 December 2017
jump shot. If a participant displayed knee valgus of 17◦ or greater, they were classified as LPHC unstable.
Accepted 21 December 2017
Available online xxx
Stable and unstable athletes’ throwing mechanics were compared.
Methods: Twenty female team handball athletes (26.5 ± 4.7 years; 1.75 ± 0.04 m; 74.4 ± 6.4 kg; experience
level: 4.8 ± 4.1 years) participated. An electromagnetic tracking system was used to collect kinematic
Keywords:
Core stability data while participants performed three 9-m jump shots. The variables considered were kinematics of
Kinetic chain the pelvis, trunk, and shoulder; and segmental speeds of the pelvis, torso, humeral, forearm, and ball
Throwing mechanics velocities. Data were analyzed across four events: foot contact, maximum shoulder external rotation,
ball release, and maximum shoulder internal rotation.
Results: Statistically significant differences were found between groups in pelvis, trunk, humerus, and
forearm velocities at all events (p ≤ 0.05). Specifically, the unstable group displayed significantly slower
speeds.
Conclusions: These findings suggest the difference in throwing mechanics are affected by LPHC instability
for this select group of female team handball athletes. These differences infer an increased risk of injury in
the upper and lower extremities when landing from a jump shot because of the energy losses throughout
the kinetic chain and lack of utilization of the entire chain. It is recommended that further investigations
also consider muscle activation throughout the throwing motion.
© 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Throwing is a kinetic chain activity requiring coordinated
energy transfer from foot contact through the proximal segments
of the pelvis and trunk to the most distal segments of the arm
and hand.1 The summation of speed principle states that the total
energy in the kinetic chain is the sum of each segment’s individual
energy contribution.1,2 This principle can be applied to throw-
ing, and optimal energy transfer throughout the kinetic chain can
be achieved when the proximal segment reaches its maximum
speed then the next distal adjacent segment reaches its maximum
speed.1 Additionally, literature has shown inadequate strength and
stability throughout the kinetic chain may contribute to ineffi-
∗ Corresponding author.
E-mail address: gdo0001@auburn.edu (G.D. Oliver).
1
www.sportsmedicineandmovement.com.
cient force production and decrease energy transfer for throwing
performance.3,4
The lumbopelvic-hip complex (LPHC) connects the lower
extremity to the upper extremity and contributes approximately
50% of the energy and force during the dynamic motion of
throwing.4 LPHC stability is defined as the ability to control the
location of the torso over the pelvis that allows for uninter-
rupted energy transfer.4 In throwing, the LPHC stabilizes the upper
extremity by increasing intra-abdominal pressure and thus cre-
ating an optimized energy flow; however, the lower extremity
stabilizes the LPHC.4 Previous research has shown that proper sta-
bilization of the LPHC leads to higher rotational velocities of the
upper extremity segments during dynamic overhead throwing.5 It
is known that LPHC instability has been associated with knee injury
and is clinically recognized by an increase in hip varus, hip flexion,
and ultimately dynamic knee valgus.4
It has also been shown that 49% of athletes with a posterior-
superior labral tear in the shoulder have an unstable LPHC.6 During
rehabilitation from labral reconstructive surgery, lower extremity

https://doi.org/10.1016/j.jsams.2017.12.009
1440-2440/© 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Gilmer GG, et al. Classification of lumbopelvic-hip complex instability on kinematics amongst female
team handball athletes. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2017.12.009
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engagement has been found to activate the scapula and shoulder.7
Additionally, a 20% decrease in energy generation from the hips
leads to a 34% increase in demand on the shoulder and arm.4 When
specifically examining the effects of the kinetic chain in dynamic
movement, Elliot et al.8 found that tennis players who had a break
down in the lower extremities increased the load on their shoulder
and elbow by 23–27%. There has yet to be further investigation
of the effects of lower extremity and LPHC instability on upper
extremity motion in other sports, such as team handball.
The sport of team handball is unique in that it has side-to-side
cutting, jumping, and overhead throwing. The ability to transfer
energy and perform an accurate shot on goal is dependent on the
synchronization, stabilization, and strength of both the upper and
lower extremities. The objective of the game is to score more goals
than the opponent by throwing the ball into the opposing team’s
goal. Athletes throw a variety of shots in order to score.9–11 The
two most frequent shots are the run-up throw to a jump shot and
a run-up throw to a set shot.
In team handball, shoulder and knee injuries account for 44%
and 26.7% of all injuries, respectively.12 Even though the injury rates
and the importance of energy transfer throughout the kinetic chain
are known, there has yet to be a comparison examining the effects
of LPHC stability on throwing mechanics in female team handball
athletes. Therefore, the purpose of this study was to examine how
LPHC stability, via knee valgus, affects throwing kinematics during
a team handball jump shot. It was hypothesized that LPHC insta-
bility would affect kinematics of the pelvis, trunk, and shoulder;
and segmental sequencing of the pelvis, torso, humeral, forearm,
and ball velocities. Specifically, the authors expected the unstable
athletes to display significantly slower segmental speeds and ball
velocities and more pathomechanic kinematics.
2. Methods
Twenty female, team handball athletes (26.6 ± 4.7 years;
1.75 ± 0.04 m; 74.4 ± 6.4 kg; experience levels: 4.8 ± 4.1 years)
were recruited to participate. All participants were active on the
USA National Team residency program, in good physical condition,
and had no injuries within the last six months. Training for the USA
National Team includes 12 h per week of strength and conditioning
and 16 h per week of practice. The University’s Institutional Review
Board approved all testing protocols. Informed written consent was
obtained from each participant before testing.
Kinematic data were collected at 100 Hz using an electromag-
netic tracking system (trakSTARTM , Ascension Technologies, Inc.,
Burlington, VT, USA) synced with The MotionMonitorTM (Inno-
vative Sports Training, Chicago, IL, USA). The electromagnetic
tracking system used has been previously validated for measur-
ing humeral movements, and interclass correlation coefficients for
axial humeral rotation in both loaded and non-loaded conditions
have been reported greater than 0.96.13,14 In addition, the current
system was calibrated using previously established protocols prior
to the collection of any data.13,15,16 After calibration, the error in
determining position and orientation of the electromagnetic sen-
sors with the current calibrated world axis system was less than
0.01 m and 3◦ , respectively. A 40 cm × 60 cm Bertec force plate
(Bertec Corp., Columbus OH) was built into the surface from which
all jump shots were made such that the participant’s stride foot
would land on the force plate during the throwing motion. Force
plate data were only used to event mark the instance of stride foot
contact during the throwing motion and were sampled at a rate of
1000 Hz. If a participant did not land in the force plate, that trial
was repeated.
Participants had a series of 11 electromagnetic sensors affixed to
the skin using PowerFlex cohesive tape (Andover Healthcare, Inc.,
Please cite this article in press as: Gilmer GG, et al. Classification of lumbopelvic-hip complex instability on kinematics amongst female
team handball athletes. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2017.12.009
Salisbury, MA) to ensure the sensors remained secure throughout
testing. Sensors were attached to the following locations: (1) pos-
terior aspect of the trunk at the first thoracic vertebrae (T1) spinous
process; (2) posterior aspect of the pelvis at the first sacral verte-
brae (S1); (3) flat, broad portion of the acromion on the throwing
scapula; (4) lateral aspect of the throwing upper arm at the del-
toid tuberosity; (5) posterior aspect of the distal throwing forearm,
centered between the radial and ulnar styloid processes; (6–7) lat-
eral aspect of each thigh, centered between the greater trochanter
and the lateral condyle of the knee; (8–9) lateral aspect of each
shank, centered between the head of the fibula and lateral malle-
olus; (10–11) dorsal aspect of each foot on top of the shoe.15 A
twelfth, moveable sensor was attached to a plastic stylus used for
the digitization of bony landmarks.16–18 Joint centers were digi-
tized using previously established and tested protocols.19–21 Raw
data regarding sensor position and orientation were transformed
to locally based coordinate systems for each of the representative
body segments using previously described methods.17–19 All data
were time stamped through The MotionMonitorTM and passively
synchronized using a data acquisition board.
Even though dynamic knee valgus is known to indicate LPHC
instability, no standard method has been described on how to mea-
sure LPHC instability within a throwing motion.5 For the current
study, knee valgus at landing was used for classification due to
the large number of knee injuries that occur at this point in the
throw.12 In arthroscopy, knee valgus between 17◦ and 26◦ is con-
sidered grade II valgus deformation, and knee valgus greater than
26◦ is considered grade III valgus deformation.26,22 Knee valgus
around 7◦ is considered normal.22 For the purpose of this study,
LPHC instability was defined by a knee valgus of 17◦ or greater
at landing because valgus deformation classification begins at this
point and a large portion of knee injuries occur when landing from
a throw.
Based on the aforementioned stability groups, the LPHC stable
athletes (27.8 ± 3.2 years; 1.73 ± 0.05 m; 76.8 ± 5.5 kg; experience
level: 5.6 ± 4.6 years; n = 9) had a knee valgus of 6 ± 5◦ , and the LPHC
unstable athletes (24.9 ± 6.62 years; 1.74 ± 0.04 m; 73.66 ± 6.73 kg;
experience level: 3.9 ± 3.5 years; n = 11) had a knee valgus of
19 ± 5◦ .
After sensor attachment and digitization, each participant was
allotted an unlimited amount of time to warm-up (average warm-
up time: 5 min) and become familiar with all testing procedures.
The testing began only when the participant was self-declared
ready to partake in the shots. For testing, each participant was
instructed to throw the ball (Internation Handball Federation (IHF)
Size 2) into a modified team handball goal at 9 m distance. The
participants were required to accomplish three successful shots on
goal of the run-up to a jump shot. A successful shot was defined as
an athlete shooting the team handball goal.
Kinematic data (pelvis anterior/posterior and lateral tilt; trunk
flexion/extension, lateral flexion, and rotation; shoulder plane of
elevation, elevation, and rotation; and segmental sequencing of
the pelvis, torso, humeral, forearm, and ball velocities) were col-
lected across three trials of the jump shot for analysis. The throwing
motion was defined by four events, as shown in Fig. 1: (1) foot con-
tact (FC), (2) maximal shoulder external rotation (MER), (3) ball
release (BR), and (4) maximal shoulder internal rotation (MIR).
All data were processed using a customized MATLAB (MATLAB
R2010a, MathWorks, Natick, MA, USA) script. Statistical analyses
were performed using IBM SPSS Statistics 22 software (IBM Corp.,
Armonk, NY) for normally distributed data and a customized MAT-
LAB script for non-normally distributed data with an alpha level
set a priori at ˛ = 0.05. Prior to analysis, a Jarque–Bera test of
Normality was run. Results showed normal distribution of the kine-
matic data and non-normal distribution for the segmental speeds.
All kinematic variables were analyzed using repeated measure
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Fig 1. Throwing events of jump shot. A. foot contact, B. maximum external rotation, C. ball release, D. maximum internal rotation.
ANOVAs that included event (FC, MER, BR, MIR) and group (sta-
ble versus unstable) as a between-subject factor. All segmental
speeds were analyzed using a Wilcoxon rank-sum test. Repeated
measure ANOVAs and Wilcoxon rank-sum testing were employed
to examine differences in pelvis anterior/posterior and lateral
tilt; trunk flexion/extension, lateral flexion, and rotation; shoulder
plane of elevation, elevation, and rotation; as well as pelvis, torso,
humerus, and forearm segmental velocities between LPHC stable
and unstable female team handball athletes. A between-subjects
2 (groups) × 4 (events) design was utilized for pelvis, trunk, and
shoulder kinematics. Mauchly’s test of sphericity was conducted
prior to all normal analyses, and a Greenhouse–Geisser correction
was imposed when sphericity was violated.
3. Results
Repeated measure ANOVAs results revealed no significant dif-
ferences in kinematics between groups in the run-up to jump
shot (p > 0.05). Means and standard deviations are presented in
Table 1. Wilcoxon rank-sum test results revealed significant dif-
ferences between groups in the segmental sequencing (p < 0.05).
Statistical data from Wilcoxon rank-sum test are shown at the
bottom of Table 1. Median event results were statistically signif-
icant between groups at all events for pelvis, torso, humerus, and
forearm velocities. Fig. 2 outlines the changes in velocities of each
segment throughout the course of the throw. Wilcoxon rank-sum
test revealed significant differences in ball speeds between groups
(p = 0.0324, U = 154, z = 3.5950). The median speed for LPHC unsta-
ble athletes was 16.17 mph, and the median speed for LPHC stable
athletes was 18.19 mph.
4. Discussion
The purpose of this study was to examine how LPHC stability, via
knee valgus, affects full body kinematics and segmental sequencing
amongst American female team handball athletes during a jump
shot. It was hypothesized that lower extremity instability would
affect kinematics of the pelvis, trunk and shoulder; and segmental
sequencing of the pelvis, torso, humerus, and forearm velocities.
However, no kinematic differences were found between groups.
Both groups displayed similar kinematic patterns across most
throwing events. However, there were different trends in kine-
matics from FC to MER in that upon observation, the LPHC stable
Please cite this article in press as: Gilmer GG, et al. Classification of lumbopelvic-hip complex instability on kinematics amongst female
team handball athletes. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2017.12.009
3
athletes decreased in pelvis lateral flexion and increased in trunk
flexion and shoulder elevation; whereas LPHC unstable athletes
increased in lateral flexion, and decreased in trunk flexion and
shoulder elevation. Previous research has found that amongst
male team handball players, trunk flexion and shoulder elevation
increase from FC to MER.23 In addition, Lintner et al. found that
tennis players who displayed “pull-through” (i.e. increased lateral
flexion and shoulder elevation) are more prone to injury.24 These
movements are most similar to that of the stable athletes, however,
since no significant differences were found, it is unclear on whether
or not this difference indicates instability. The lack of kinematic
differences between the classified LPHC stable and unstable ath-
letes may originate from compensations within the kinetic chain.
As members of the USA National Team residency program, these
athletes train five days per week and perform weight lifting activ-
ities with a strength and conditioning coach three days per week.
Because of this advanced training, these athletes’ muscles may be
able to re-stabilize the body in order to perform a shot without
injury.
When examining segmental speeds, differences were found
between LPHC stable and unstable athletes. These findings sup-
port the hypothesis as well as previously reported data.1,4,5 As seen
in Fig. 2, the LPHC unstable athletes displayed slower segmental
speeds across all investigated throwing events. These results agree
with the summation of speeds principle because the median ball
speed for LPHC unstable athletes was 16.17 mph, and the median
speed for stable athletes was 18.19 mph.1,2 Though LPHC unstable
athletes were slower, they still followed the summation of speed
theory. As stated previously, approximately 50% of the energy from
the throwing motion is generated from the LPHC, and the lower
extremity acts as a base for the LPHC.4 The current results imply
that with a lack of LPHC stability, unstable athletes were unable to
generate as much force during the throwing motion. Saeterbakken
et al.5 examined exercises intended to minimize energy loss due
to instability and found that specific core activities increased the
ball speed amongst female team handball athletes. The unstable
athletes of this study may benefit from core engaging exercises.
Limitations of this study include the total number of American
female team handball athletes. Team handball is not a popular sport
in the USA; however, it is a popular sport in Europe. Thus, all of
the current publications as of December 2016 concerning female
team handball are based on European athletes. This is a notable
difference because of the cultural differences in team handball.
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Table 1
Jump shot kinematics and segmental velocities means and standard deviations for stable and unstable groups at the throwing events. Significant differences were found
amongst all speeds at all events. The statistical results from the Wilcoxon rank sum test are listed below each significant finding. Throwing events include: foot contact (FC),
maximum external rotation of the shoulder (MER), ball release (BR), and maximum internal rotation of the shoulder (MIR).

FC MER BR MIR

Trunk flexion
Stable 3.44 ± 9.41 3.31 ± 9.03 2.37 ± 13.63 −0.41 ± 28.71
Unstable −0.63 ± 13.62 2.83 ± 13.67 −1.00 ± 7.46 −7.84 ± 6.18
Trunk lateral flexion
Stable 3.48 ± 9.58 −2.37 ± 21.09 −32.21 ± 21.86 −27.67 ± 26.03
Unstable 3.48 ± 10.73 −3.30 ± 13.32 −31.28 ± 8.86 −29.38 ± 12.11
Trunk rotation
Stable −62.62 ± 46.19 −33.25 ± 37.53 25.31 ± 33.70 23.14 ± 51.42
Unstable −60.38 ± 28.28 −31.52 ± 28.47 24.51 ± 13.43 17.01 ± 11.85
Pelvis flexion
Stable −12.55 ± 9.52 −9.60 ± 6.69 −9.14 ± 7.72 −5.14 ± 9.46
Unstable −15.33 ± 8.67 −13.53 ± 9.40 −10.62 ± 10.68 −5.00 ± 10.18
Pelvis lateral flexion
Stable −17.35 ± 6.23 −17.45 ± 5.37 15.61 ± 8.69 −12.43 ± 9.13
Unstable −12.82 ± 9.59 −11.75 ± 7.18 −12.03 ± 6.61 −7.36 ± 6.76
Pelvis rotation
Stable −37.80 ± 17.21 −15.71 ± 15.20 4.12 ± 20.49 −4.41 ± 19.38
Unstable −34.14 ± 21.56 −7.57 ± 25.99 7.09 ± 15.49 −1.26 ± 12.58
Shoulder plane of elevation
Stable −2.34 ± 34.33 6.49 ± 21.76 34.31 ± 14.24 57.97 ± 25.95
Unstable −9.65 ± 22.54 8.41 ± 29.38 48.17 ± 21.52 77.10 ± 19.65
Shoulder elevation
Stable −62.27 ± 20.62 −61.31 ± 64.95 −74.95 ± 21.97 −64.81 ± 24.16
Unstable −62.95 ± 25.59 −98.84 ± 15.39 −88.11 ± 17.23 −59.17 ± 18.74
Shoulder rotation
Stable −41.38 ± 19.75 −80.49 ± 19.23 −60.82 ± 21.48 −29.83 ± 25.45
Unstable −39.91 ± 49.29 −103.10 ± 25.06 −80.29 ± 22.85 −47.76 ± 23.25
Pelvis rotation velocity
Stable 152.99 345.01 241.97 182.64
Unstable 104.68 301.08 182.87 127.07
p 0.036 0.008 0.028 0.011
U 642 632 627 617
Z 5.9037 5.6689 5.3168 5.3168
Torso rotation velocity
Stable 156.81 662.09 232.24 234.35
Unstable 118.07 549.66 136.93 163.41
p 0.048 0.019 0.006 0.014
U 619 634 632 487
Z 5.3637 5.7159 5.6689 2.2652
Humerus rotation velocity
Stable 364.56 1103.03 1180.63 711.52
Unstable 281.94 823.9 1052.19 607.91
p 0.047 0.020 0.028 0.050
U 601 646 677 619
Z 4.9412 5.9975 5.5515 5.3638
Forearm rotation velocity
Stable 551.56 1064.2 2018.75 674.64
Unstable 462.17 861.8 1666.93 563.41
p 0.048 0.047 0.039 0.046
U 627 637 635 631
Z 5.551 5.7863 5.6454 5.6454

Pelvis ant/post tilt: (−) anterior tilt, (+) posterior tilt; pelvis lateral tilt: (−) away from throwing side, (+) toward throwing side; trunk flexion/extension: (−) flexion, (+)
extension; trunk lateral flexion: (−) away from throwing side, (+) toward throwing side.
Trunk rotation: (−) toward throwing side, (+) away from throwing side; shoulder plane of elevation: (−) abduction, (+) adduction.

In Europe, most team handball athletes begin playing when they
are children.25 In this particular study and most USA team hand-
ball athletes, athletes do not start playing team handball until they
are adults. Literature has yet to show kinematic data comprised
of American female team handball players, therefore the literature
was restricted to European female team handball athletes. Adults
learning new skill sets respond differently than adults who have
learned a skill set as children so comparing American and European
athletes is not justified.26
In addition, the literature as of December 2016 does not include
methods on how to classify LPHC instability within a throwing
motion. Landing is only a part of throwing motions that require
jumping, and the methods for classifying LPHC instability in this
study could not be repeated for sports, such as softball and baseball,
that do not demand a combined jumping and throwing mecha-
nism. Most stabilization tests are movements that are outside of the
dynamics of a specific sport or sport movement. It may be benefi-
cial to athletes to investigate classification methods that are sports
specific since most injuries occur within a dynamic movement.
5. Conclusions
Throwing requires engagement of the entire kinetic chain to
efficiently transfer energy to the upper extremities. The current
study reiterates the importance of proximal stability through LPHC
stabilization and strength in the efficiency of the dynamic work of
the kinetic chain. The main findings suggest that athletes who have
LPHC instability, defined by knee valgus at landing greater than 17◦ ,

Please cite this article in press as: Gilmer GG, et al. Classification of lumbopelvic-hip complex instability on kinematics amongst female
team handball athletes. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2017.12.009
G Model
JSAMS-1781; No. of Pages 6 ARTICLE IN PRESS
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Fig. 2. The segmental speeds were plotted versus the throwing events. Significance was found in the pelvis rotational, torso rotational, humeral, and forearm velocities
between the two groups at all four events. **denotes significant findings (p < 0.05).
have significantly lower segmental speeds throughout the throw-
ing motion of a jump shot. This interruption in the kinetic chain may
cause these athletes to further compensate and put more strain on
their shoulder and elbow. While this study only focused on upper
extremity kinematics, previous research has clearly shown that
high knee valgus indicates high risk of lower extremity injury.27
In addition, it is crucial for the sports medicine community to stan-
dardize how LPHC stability is classified to ease applications for
coaches and players and keep the literature consistent. It is rec-
ommended that future research consider muscle activation when
studying kinetic chain activities.
Practical implications
• Instability in the hip area leads to slowed body movement
amongst female team handball athletes.
• Instability in the hip area does not result in altered movement
patterns amongst female team handball athletes.
• There is a need for a practical and reproducible method for clas-
sifying hip instability.
Acknowledgments
The authors would like to acknowledge the assistance of all the
members of the Sports Medicine and Movement lab for assisting
with data collection, the US National Team Residency Program for
agreeing to participate in this study, and the statistical expertise of
Dr. Keith Lohse.
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5
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Please cite this article in press as: Gilmer GG, et al. Classification of lumbopelvic-hip complex instability on kinematics amongst female
team handball athletes. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2017.12.009