Jospt 2021 9302

Reduced 2D Frontal Plane Motion During Single Limb Landing Associated with Risk of
Future ACL Graft Rupture after ACL Reconstruction and Return to Sport: A Pilot Study
Grant R. Poston, PT 1
Laura C. Schmitt, PT, PhD 2,3
Matthew P. Ithurburn, PT, PhD 4
Downloaded from www.jospt.org at Asociación de Kinesiología del Deporte (AKD) on January 5, 2021. For personal use only. No other uses without permission.
Jason A. Hugentobler, PT 1
Staci Thomas, MS 5
Mark V. Paterno PT, PhD 1,5
1. Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s

Hospital, Cincinnati, OH, USA
2. Division of Physical Therapy, School of Health and Rehabilitation Sciences, Ohio
State University, Columbus, OH, USA
3. Jameson Crane Sports Medicine Research Institute, Ohio State University,
Columbus, OH, USA
4. Department of Physical Therapy and Center for Exercise Medicine, University of
Alabama at Birmingham, Birmingham, AL, USA
5. Division of Sports Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
This work was funded by support from the National Institutes of Health grants R21-
AR064923 and F32-AR055844 and the National Football League Charities Medical
Research Grants 2007, 2008, 2009, 2011
This study was approved by the Cincinnati Children’s Hospital Medical Center’s
Institutional Review Board.
Journal of Orthopaedic & Sports Physical Therapy®
Address correspondence to Grant Poston, 2765 Chapel Place, Crestview Hills, KY,
41017, Email: Grant.Poston@cchmc.org and Mark Paterno, 3333 Burnet Ave, MLC
10001, Cincinnati, OH, 45236. Email: mark.paterno@cchmc.org
Reduction in 2D Frontal Plane Motion During Single Limb Landing Identifies Risk
of Future ACL Graft Rupture after ACL Reconstruction and Return to Sport: A
Pilot Study
Financial Disclosure and Conflict of Interest. I (we) affirm that I (we) have no financial
affiliation (including research funding) or involvement with any commercial organization

that has a direct financial interest in any matter included in this manuscript, except as
disclosed in an attachment and cited in the manuscript. Any other conflict of interest (i.e.
personal associations or involvement as a director, officer, or expert witness) is also
disclosed in an attachment.
2
3
1 ABSTRACT
2 Objectives: To evaluate the association between 2D frontal plane movement and 2nd
3 anterior cruciate ligament (ACL) injury risk in young athletes at return to sport (RTS)
4 after ACL reconstruction (ACLR).
5 Design: Prospective Cohort
6 Methods: 49 participants after ACLR (16.0±3.0 yrs) performed a single leg drop-landing
7 from a 31 cm box at RTS. Frontal plane trunk, pelvis, and knee angles were measured
8 using 2D video analysis at the point of maximum depth during landing. Summated
9 frontal plane angles were calculated by adding trunk, pelvis, and knee angles.
10 Participants were grouped based on whether or not they sustained graft rupture over
11 the 24 months after RTS.
12 Results: Seven participants (14.3%) sustained an ipsilateral graft rupture within 24
13 months after RTS. Participants who suffered a 2nd ACL injury had a significant reduction
14 in summated frontal plane angle of trunk, pelvis, and knee (p=0.018) and trunk and
15 knee (p=0.02) compared to those who did not suffer a 2nd injury. For every 5 degree
16 increase in trunk, pelvis and knee (OR=0.537; 95%CI:0.31-0.94) and trunk and knee
17 (OR=0.484; 95%CI:0.25-0.94) summated motion the athletes were 46-52% less likely to
18 sustain a graft rupture.
19 Conclusions: Athletes who suffered an ACL graft rupture within 24 months of RTS had
20 a more rigid posture when landing compared to their uninjured peers. The results of this
21 pilot study should be replicated in a larger sample to determine if this method has merit
22 as a screening tool to identify patients at high risk for 2nd ACL injury.
4
23
Key Words: Return to Sport, Movement Analysis, Ipsilateral Injury
5
24 INTRODUCTION
25 Despite advances in surgical techniques and rehabilitation strategies, the
26 incidence of ipsilateral second ACL injury is as high as 10% in young athletes and 25-
27 33% when including both ipsilateral and contralateral injuries18, 25, 28. Altered movement
28 patterns are common after ACL reconstruction (ACLR)3, 8, 13, 15 as changes in joint
29 angles, joint moments and coordination of movement after ACLR have been reported in
30 low and high level functional tasks such as normal gait, hop tests, and jumping tasks8, 13,
31 27
. However, few movement-related variables are associated with second ACL injury.
32 One exception, noted greater frontal plane knee valgus, increased hip rotation moment
33 and asymmetries in internal knee extensor moments during the drop vertical jump
34 (DVJ), and deficits in single limb balance may be associated with second ACL injury24,
35 26
. Altered movement strategies and impaired proprioception may identify patients at
36 high risk for future ACL injury after ACLR and return to sport (RTS). However, this has
37 yet to be definitively confirmed.

38 Although kinematic and kinetic data derived from three-dimensional (3D) motion
39 capture technology and force plates are precise and may have potential to be
40 associated to future injury risk, most clinicians do not have access to this technology.
41 Two-dimensional (2D) video analysis is a valid alternative for measuring trunk, hip and
42 knee joint angles during running, single leg squats, DVJ, and single leg landings10, 17, 19.
43 Joint angles measured with 2D video correlate with knee abduction moments when
44 evaluating knee valgus10, 19 and hip flexion5 individually, and when combining knee
45 valgus and lateral trunk lean6 during high level tasks, such as single leg squatting,
46 single leg drop landing, DVJ, and single leg drop vertical jump (SLDVJ). These 2D
6
47 methods have been used to establish lower extremity injury risk in previously uninjured
48 populations. Higher Landing Error Scoring System score (assessed using 2D video
49 analysis) in uninjured youth athletes was associated with increased risk of future ACL
50 injuries23. Increased 2D knee valgus was a risk factor for primary ACL injury in uninjured
51 female high school athletes22. Combined measures of frontal plane trunk and knee
52 motion predicted future non-contact knee injuries in uninjured female athletes4.
53 Therefore, evaluating individual joints22, 26 and combining joint angles4 appears to be
54 valuable in assessing movement patterns associated with lower extremity injury risk in
55 healthy populations.
56 We aimed to determine whether frontal plane motion during a single leg drop
57 landing (SLDL) at the time of RTS could identify subsequent ipsilateral ACL graft injury
58 risk. We hypothesized that patients with greater frontal plane trunk, pelvis and knee
59 movement would have a higher incidence of ACL graft ruptures compared to those with
60 less frontal plane movement.

61 METHODS
62 Study Design: Prospective, longitudinal cohort study
63 Participants
64 The participants were a subset of the larger, prospective, longitudinal ACL
65 ReLAY (ACL Reconstruction Long-term outcomes in Adolescents and Young adults)
66 cohort study performed at Cincinnati Children’s Hospital Medical Center. For the parent
67 study, all participants were recruited from the tristate region at the time of clearance for
68 RTS by their physician and rehabilitation team. A subset of forty-nine consecutively
7
69 recruited young athletes (32 female and 17 male) who completed rehabilitation following
70 a primary, unilateral ACLR with the intention to return to pivoting and cutting sports were
71 enrolled in the ACL ReLAY study and participated in an additional 2D assessment of

72 movement, which was included in this analysis. The participants engaged in level I/II
73 sports1 including soccer, basketball, football, volleyball and lacrosse.
74 Participants were included if they (1) were between 9 and 26 years, (2)
75 completed their post-ACLR rehabilitation program and were cleared by their treating
76 surgeon and rehabilitation specialist within the previous 4 weeks for return to all high-
77 level activities, and (3) intended to return to regular level I/II cutting and pivoting sports
78 (>50 hours/year)1, 2. Potential participants were excluded if they (1) had a history of low
79 back or other lower extremity injury (beyond ACL injury) requiring the care of a
80 physician in the past year, (2) had a concomitant knee ligament injury (beyond grade I
81 medial collateral ligament injury) to the involved limb, or (3) suffered a contact ACL
82 injury (direct contact to the affected knee).

83 Rehabilitation progression, clearance criteria for RTS, and graft type were not
84 controlled in this study. Ipsilateral ACL injuries that occurred during the 24-month follow-
85 up period after RTS were confirmed with arthroscopic surgery or magnetic resonance
86 imaging. The study protocol was approved by the Cincinnati Children’s Hospital
87 Institutional Review Board and participants/parents gave written assent/consent and
88 parental permission, if applicable to participate. Stakeholder engagement has occurred
89 throughout the ACL-ReLAY study through the engagement of patients, families and
90 providers in formal and information conversations helping to identify and refine specific
91 research questions.
8
92 Data Collection
93 Participants were videotaped performing a single-leg drop landing task within 4
94 weeks following medical clearance to return to sport. Prior to the task, retroreflective
95 markers were placed to identify bony landmarks: proximal sternum, bilateral anterior
96 superior iliac spines, bilateral tibial tubercles, and bilateral distal anterior tibiae (Figure
97 1). Participants were allowed to wear a knee brace if they planned to use it during sport.
98 If a knee brace was worn, the marker was applied to the horizontal restraint just distal to
99 the knee joint instead of the tibial tubercle.
100 Participants stood on a 31 cm box and were instructed to stand on one leg, drop
101 off the box, and land on the same limb. Three trials were performed on each leg in a
102 random order determined by a random number generator. A standard video camera
103 (Sony HDR-CX240, 30 fps) was placed 10 ft in front of the box and 1.5 ft high to capture
104 frontal plane motion throughout landing. 2D motion analysis was executed simultaneous
105 with 3D motion capture.

106 Video analysis was performed by a single researcher (GP) who was blinded to
107 the future injury status of the participants. The analysis was performed using Dartfish
108 (Dartfish software 6.0, Fribourg, Switzerland). Data were analyzed at maximum depth,
109 defined as the time at which the midpoint between the ASIS markers was at its lowest
110 point. The maximum depth time point was determined by visually tracking the bisection
111 point until it was determined to be at its lowest point. Angles for each variable of interest
112 were then measured. We measured (1) knee valgus, (2) pelvis relative to a vertical line,
113 and (3) trunk lean relative to a vertical line. The markers used for each measured angle
114 are described in Table 1 and visually depicted in Figure 2. In pilot testing, there was
9
115 good to excellent inter-rater reliability with intraclass correlation coefficient (ICC) values
116 between 0.66-0.96 for variables of interest at initial contact and from 0.79-0.98 for
117 variable of interest at maximum depth with 66% of the VOI measures at initial contact
118 having ICC values greater than 0.88 and 83% of the VOI at maximum depth having ICC
119 values greater than 0.92.
120 Measures of knee valgus were subtracted from 180, measures of pelvis relative
121 to the vertical were subtracted from 90, and trunk measures were reported as the angle
122 of the trunk deviation from the vertical line. Therefore, a positive value indicated genu
123 valgus or a pelvis angle lower than 90 degrees, respectively. A negative value indicated
124 genu varus or a pelvis angle raised above 90 degrees, respectively. Trunk lean
125 measures were recorded as positive if the trunk was angled towards the landing leg and
126 negative if the trunk was angled away from the landing leg. Positive values were
127 operationally defined as a direction of “high-risk” movement11, 12. The average of the 3
128 trials was calculated for each individual joint angle variable of interest.
129 Summated joint angles were calculated by adding the values of all three
130 measures (knee valgus, trunk lean and pelvis angle) as well as looking at combinations
131 of any two joints (i.e. knee valgus and trunk lean, knee valgus and pelvis angle, trunk
132 lean and pelvis angle). Individual joint angles, a summated joint angle of knee, trunk
133 and pelvis and combinations of two joint angles were used for data analysis.
134 Following the initial testing session, participants were contacted via email, phone
135 and/or in person communication each month for the next 24 months. Any knee injury
136 that required a missed game or practice session was reported. Any participant who
137 suffered a noncontact or indirect contact graft rupture was included in the ipsilateral 2nd
10
138 injury group. The 2nd injury group was then compared to those who did not suffer a 2nd
139 ACL injury in the surveillance period.
140 Statistical Analysis

141 Independent samples t-tests were used to compare demographic variables and
142 the mean values of each individual joint angle measured between those who did and did
143 not sustain an ipsilateral ACL graft rupture. Summated frontal plane joint angle and
144 combinations of frontal plane joint angles were compared between groups using
145 independent samples t-tests. Univariable binary logistic regression was used to
146 determine the ability of 2D biomechanical variables to predict 2nd ACL injury risk after
147 ACLR and RTS.
148 RESULTS
149 Of the 49 patients included, 7 (14%; 5 female) sustained a graft rupture within the
150 first 24 months after RTS. No significant group differences in age, gender, height,
151 weight, or time from surgery to RTS were identified between the injured group (graft
152 rupture) and those who did not suffer a 2nd ACL injury (p>0.05) (Table 2).
153 There were no significant differences in knee valgus [1.3° (95%CI = -8.4, 11.1),
154 6.6° (95%CI = 4.3, 9.0), p=0.11], trunk lean [9.3° (95%CI = 3.3, 15.2), 11.3° (95%CI =
155 9.3, 13.3), p=0.39], or frontal plane pelvis angle [-5.0 (95%CI = -8.8, 1.2), -3.5(95%CI =-
156 5.0, -1.9), p=0.44) between groups (see Table 3).
157 The injured group had a lower summated frontal plane alignment of the knee,
158 pelvis and trunk relative to a vertical line [5.6° (-3.5, 14.6)] at MD compared to the group
159 with no ACL graft injury [14.5° (11.8, 17.2), p=0.018). The injured group had a lower
11
160 summated frontal plane combination of the knee and trunk alignment [10.5° (4.8, 16.3)]
161 at maximum depth compared to the group with no ACL graft injury [17.9° (15.5, 20.3),
162 p=0.02]. There were no statistically significant differences between groups in summated
163 frontal plane angles of the knee and pelvis (p=0.12) or of the pelvis and trunk (p=0.18).
164 For every 5 degree increase in summated frontal plane knee and trunk motion,
165 athletes were 52% less likely [OR=0.48 (95% CI: 0.25, 0.94) p=0.03] to sustain an ACL
166 graft rupture. For every 5 degree increase in summated frontal plane knee, pelvis and
167 trunk motion, athletes were 46% less likely [OR=0.54 (95% CI: 0.31, 0.93) p=0.03] to
168 sustain an ACL graft rupture.

169 DISCUSSION
170 Lower summated 2D frontal plane motion of the trunk, knee, and pelvis during a
171 single-leg drop landing was associated with ACL graft rupture risk within the first 24
172 months following RTS after ACLR. There was no association between individual joint
173 angles during the SLDL and ipsilateral ACL injury risk. Two combinations of joint angles
174 were associated with graft rupture: (1) the sum of trunk lean and knee valgus and (2)
175 trunk lean, knee valgus, and pelvic drop. Therefore, the addition of the pelvis angle may
176 not provide further value in determining potential risk of an ACL graft rupture.
177 Summated Joint Angles
178 We measured individual joint angles and combinations of angles to identify the
179 relationship between 2D measured joint angles at the trunk, hip and knee (both
180 independently and collectively) and injury risk as previously described in the literature12,
181 22, 26
. Prior reports of two-dimensional measures of knee valgus and trunk lean
12
182 independently did not correlate to knee abduction moments6, but combining these
183 values may correlate to knee abduction moments6 and may be predictive of future soft
184 tissue injuries of the lower extremity4. Evaluating the motion of the trunk and knee in a
185 combined manner may provide a more comprehensive picture of global movement and
186 may be more useful than evaluating a single joint in a clinical setting using 2D video
187 analysis.
188 Reduction in Frontal Plane Movement
189 Excessive frontal plane motion at the knee is a risk factor for primary and second
190 ACL injury9, 11, 16, 26. Conversely, in our study, athletes who suffered a graft rupture
191 tended to have a more rigid posture while landing, with a reduction in frontal plane
192 movement compared to those who did not. Previous work has described stiff landing
193 mechanics in the sagittal plane before and after ACLR13, 14. Athletes often demonstrate
194 decreased knee flexion excursion during a single leg drop landing task at the time of
195 RTS following ACLR13. Although our primary aim was not to measure sagittal plane
196 movement, it is possible that the reduction in frontal plane movement may be occurring
197 in tandem with a reduction in sagittal plane motion13. Reduced knee flexion and
198 increased ground reaction forces during drop vertical jump may be associated with
199 primary ACL injury risk 14.
200 Methodological Variation Between Studies
201 Other investigations using 2D video analysis have reported associations between
202 increased frontal plane motion and lower extremity injury risk using dynamic single leg
203 tasks in healthy populations. In comparison to our study, differences in methods and
13
204 populations may explain the varying results. Previous studies have reported prospective
205 evidence for an association between increased frontal plane motion and risk for primary
206 injury.4, 22 Increased frontal plane motion during plyometric tasks may identify higher risk
207 for a primary ACL injury. Reduced motion while landing may identify a higher risk for
208 ipsilateral graft rupture after ACLR. However, both studies used a higher-level
209 plyometric task and employed novel measurement methods focused on the contribution
210 of knee valgus more than other variables such as trunk lean. Our single-leg drop
211 landing task requires the athlete to stick the initial landing as opposed to preparing to
212 perform another jump. The athlete may focus attention exclusively on the landing
213 component during the SLDL, resulting in a rigid movement pattern.

214 Bilateral vs. Unilateral Landing Tasks
215 Movement assessments following ACLR often consist of bilateral lower extremity
216 tasks such as the DVJ.14, 23, 26 However, bilateral tasks may hide high-risk compensation
217 patters. There are important differences between bilateral and unilateral movements. A
218 unilateral movement isolates one limb as it makes contact with the ground, A bilateral
219 movement requires coordination between limbs to attenuate forces. There were
220 significant correlations between the knee valgus displayed by athletes performing a
221 single leg squat, SLDL, and DVJ 20. However, lesser degrees of valgus occurred in the
222 DVJ as compared to the single limb tasks, suggesting that the double limb task may not
223 elicit the magnitude of existing deficits. It is possible that reduced trunk control during
224 dynamic tasks will not be quantified using a bilateral task. Land-based sports require
225 both unilateral and bilateral movement patterns and therefore both may warrant
226 inclusion in RTS assessment.
14
227 Limitations
228 Our study is a pilot evaluation with a relatively small sample and 2nd injury
229 frequency. Although the second ACL injury rate in our study is comparable to work
230 recently included in a systematic review and meta-analysis,28 our results are at risk of
231 Type II error. We compared multiple variables of interest. To balance the risk of Type I
232 and Type II error, and avoid further reducing the power of our analyses, we did not
233 correct for multiple comparisons. Future work must focus on validating these results in
234 larger populations. We only evaluated ipsilateral injury risk. Therefore, our results may
235 not generalize to populations such as those with contralateral tears or applied to primary
236 injury prevention.

237 We included males and females in our analysis. Previous research has identified
238 differences in landing mechanics between sexes,7 and therefore could alter the group
239 means. Inherent limitations of 2D video analysis methods used in this study included
240 retroreflective makers intermittently being blocked from view by clothing or body tissues
241 and limbs, the inability to detect rotational movements. Only one plane of motion was
242 evaluated due to the use of one camera.
243 Future Directions
244 We aimed to investigate frontal plane movement. Future studies should include
245 analysis of both frontal and sagittal plane motions. Future investigations should also aim
246 to validate our findings in a larger sample, and evaluate the association between 2D
247 frontal plane motion during SLDL and contralateral injuries following ACLR. Additional
248 variables of interest and standardized methods of 2D frontal plane motion should be
15
249 established with an emphasis on reliability and validity when compared to 3D methods.
250 With respect to task, other dynamic single leg movements such as the SLDVJ, broad
251 jumps, hop tests, and lateral and transverse motions should be evaluated using 2D
252 video analysis to determine their association with second injuries following ACL
253 reconstruction. Finally, incorporating clinically feasible, 2D screening tools which identify
254 high risk movements into a RTS decision algorithm represents an area of future
255 investigation.
256
257 CONCLUSION
258 Athletes who ruptured their ACL graft in the 24 months following RTS after ACL
259 reconstruction, had a rigid landing posture in the frontal plane, characterized by reduced
260 summated frontal plane knee, pelvis and trunk angles at the maximum depth of a single
261 leg drop landing task.

262
263 KEY POINTS
264 Findings: Young athletes who ruptured their ACL graft within 24 months of returning to
265 sport following ACL reconstruction, had reduced motion in the frontal plane with
266 decreased motion of the trunk, pelvis and knee during a single limb drop landing.
267 Implications: Reduced motion observed in the frontal plane during the single leg drop
268 landing performed at the time of return to sport following ACLR may be a risk factor for
269 a future ipsilateral ACL injury. Clinicians might consider evaluating trunk lean, hip drop,
16
270 and knee valgus in the single leg drop landing prior to discharge as a component of
271 return to sport assessment.
272 Caution: These data cannot be generalized to contralateral ACL injures or uninjured
273 populations.
274 STUDY DETAILS

275
276 Author Contributions:
277
278 Grant R. Poston, PT, was the Sports Resident at CCHMC at the time of the study
279 completion. Dr. Poston was involved in study design, data analysis, data interpretation,
280 manuscript preparation and revision.
281
282 Laura C. Schmitt, PT, PhD is co-PI on the ACL-RELAY project and contributed to all
283 aspect of study design and development, data collection, analysis and interpretation,
284 manuscript preparation and revision

285
286 Matthew P. Ithurburn, PT, PhD participated in data collection, analysis and
287 interpretation as well as manuscript preparation and revision.
288
289 Jason A. Hugentobler, PT participated in data interpretation and manuscript preparation
290 and revision
291
292 Staci Thomas, MS participated in data collection, analysis and interpretation as well as

294
295 Mark V. Paterno PT, PhD is co-PI on the ACL-RELAY project and contributed to all
296 aspect of study design and development, data collection, analysis and interpretation,
298
299 Data Sharing: All data relevant to the study are included in the article or are available
300 as supplementary files.
301
302 Patient and Public Involvement: We engaged patients, families and providers in formal
303 and informal conversations to help identify and refine specific research questions for the
304 ACL-ReLAY study. Participants were not involved in developing the specific research
305 question for this study.
306 Acknowledgements
307
308 We would like to thank the staff within the Division of Occupational Therapy and
309 Physical Therapy and the Division of Sports Medicine at Cincinnati Children’s Hospital
310 medical Center, including Jamie Kronenberg for her contributions to this work.
17
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392
TABLE 1. Retroreflective Markers Used to Measure Joint Angles
393
Angle Markers Used During Measurement
Knee Valgus 394
Ipsilateral ASIS – tibial tubercle – anterior distal tibia
Pelvis Relative to a Vertical Contralateral ASIS – ipsilateral ASIS – inferiorly 395
Line directed vertical line

396
Trunk Lean Relative to a Midpoint between the shoulders on the chest where
Vertical Line 397
the sternum was thought to be – midpoint between
the ASIS’ – superiorly directed vertical line 398
399 Abbreviations: ASIS, anterior superior iliac spine

400
TABLE 2. Demographic characteristics of patients based on injury category
401
All Patients Ipsilateral Injury Uninjured
p-value
(n=49) (n=7) (n=42) 402
Age, yrs (SD) 16.5 (3.0) 16.2 (0.9) 16.6 (3.2) 0.73
403
Height, cm (SD) 166.9 (11.1) 169.6 (6.2) 166.4 (11.7) 0.49

404
Weight, kg (SD) 65.6 (14.5) 63.3 (8.3) 65.9 (15.4) 0.66

405
Time from 406

Surgery to RTS, 7.6 (2.2) 6.5 (1.4) 7.7 (2.3) 0.19
407
mo (SD)
408
Sex, F/M (%F) 32/17 (65%) 5/2 (71%) 27/15 (64%) 0.54
409
Graft Type
36/11/2 7/0/0 29/11/2 0.09
(HS/PT/Allo) 410
Brace use at
10 (20.4) 1 (14.3) 9 (21.4) 0.56
testing (%)
411 Abbreviations: SD, Standard deviation; yrs, years; cm, centimeters; kg, kilograms; RTS,
412 Return to Sport; mo, months; F = female; M = male; PT = patellar tendon graft; HS =
413 Hamstrings graft; Allo = allograft
414 * Statistically significant value (p<0.05)
415
416
417
418
419
20
420
421
TABLE 3. Individual and aggregate frontal plane range of motion of the knee, pelvis,
and trunk during a single leg drop landing
All Ipsilateral Injury Uninjured p-value
(n=49) (n=7) (n=42)

Knee Valgus (95% CI) 5.9° 1.3° 6.6° 0.11
(3.5, 8.2) (-8.4, 11.1) (4.3, 9.0)
Trunk Lean (95% CI) 11.0° 9.3° 11.3° 0.39
(9.1, 12.8) (3.3, 15.2) (9.3, 13.3)
Pelvis (95% CI) -3.7° -5.0° -3.5° 0.44
(-5.1, -2.3) (-8.8, -1.2) (-5.0, -1.9)
Trunk and Knee 16.9° 10.5° 17.9° 0.02*
(95% CI) (14.6,19.1) (4.8, 16.3) (15.5,20.3)
Pelvis and Knee 2.2° -3.7° 3.2° 0.12
(95% CI) (-.09, 5.3)] (-16.9, 9.5)] (0.1, 6.3)
Trunk and Pelvis 7.3° 4.3° 7.8° 0.18
(95% CI) (5.5, 9.2) (-0.3, 8.9) (5.8, 9.9)
Trunk, Pelvis, and 13.2° 5.6° 14.5° 0.018*

Knee (95% CI) (10.5, 15.9) (-3.5, 14.6) (11.8, 17.2)
422
423 Abbreviations: 95% CI, 95% Confidence Interval; yrs, years; cm, centimeters; kg,
424 kilograms; RTS, Return to sport; mo, months
425 * Statistically significant value (p<0.05)
426
21
432
431
430
429
428
427
FIGURE 1. Markers used during video analysis.
values used for data analysis are listed in gray boxes.

FIGURE 2. Labeled joint angles of trunk lean, hip drop, and knee valgus are in red. The
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Reduced 2D Frontal Plane Motion During Single Limb Landing Associated with Risk of

1. Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s

affiliation (including research funding) or involvement with any commercial organization

4 after ACL reconstruction (ACLR).

5 Design: Prospective Cohort

11 the 24 months after RTS.

12 Results: Seven participants (14.3%) sustained an ipsilateral graft rupture within 24

18 sustain a graft rupture.

37 yet to be definitively confirmed.

52 motion predicted future non-contact knee injuries in uninjured female athletes4.

53 Therefore, evaluating individual joints22, 26 and combining joint angles4 appears to be

60 less frontal plane movement.

62 Study Design: Prospective, longitudinal cohort study

64 The participants were a subset of the larger, prospective, longitudinal ACL

65 ReLAY (ACL Reconstruction Long-term outcomes in Adolescents and Young adults)

68 RTS by their physician and rehabilitation team. A subset of forty-nine consecutively

71 enrolled in the ACL ReLAY study and participated in an additional 2D assessment of

73 sports1 including soccer, basketball, football, volleyball and lacrosse.

82 injury (direct contact to the affected knee).

87 Institutional Review Board and participants/parents gave written assent/consent and

88 parental permission, if applicable to participate. Stakeholder engagement has occurred

93 Participants were videotaped performing a single-leg drop landing task within 4

99 the knee joint instead of the tibial tubercle.

105 with 3D motion capture.

119 values greater than 0.92.

139 ACL injury in the surveillance period.

140 Statistical Analysis

147 ACLR and RTS.

156 5.0, -1.9), p=0.44) between groups (see Table 3).

168 sustain an ACL graft rupture.

177 Summated Joint Angles

188 Reduction in Frontal Plane Movement

199 primary ACL injury risk 14.

200 Methodological Variation Between Studies

213 component during the SLDL, resulting in a rigid movement pattern.

214 Bilateral vs. Unilateral Landing Tasks

226 inclusion in RTS assessment.

236 injury prevention.

242 evaluated due to the use of one camera.

243 Future Directions

261 leg drop landing task.

263 KEY POINTS

271 return to sport assessment.

274 STUDY DETAILS

284 manuscript preparation and revision

293 manuscript preparation and revision

315 Patient:A Prospective Outcome Study. 1994;22(5):632-644.

329 male basketball players. Med Sci Sports Exerc. 2003;35(10):1745-1750.

338 prospective study. Am J Sports Med. 2005;33(4):492-501.

375 in Elite-Youth Soccer Athletes. J Athl Train. 2015;50(6):589-595.

384 reconstruction and return to sport. Am J Sports Med. 2010;38(10):1968-1978.

Line directed vertical line

399 Abbreviations: ASIS, anterior superior iliac spine

Height, cm (SD) 166.9 (11.1) 169.6 (6.2) 166.4 (11.7) 0.49

Weight, kg (SD) 65.6 (14.5) 63.3 (8.3) 65.9 (15.4) 0.66

Time from 406

(n=49) (n=7) (n=42)

Trunk, Pelvis, and 13.2° 5.6° 14.5° 0.018*

values used for data analysis are listed in gray boxes.

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