Accepted Manuscript

Test-retest reliability of two-dimensional video analysis during running

Bart Dingenen, Christian Barton, Tessa Janssen, Anke Benoit, Peter Malliaras

PII: S1466-853X(18)30095-6
DOI: 10.1016/j.ptsp.2018.06.009
Reference: YPTSP 921

To appear in: Physical Therapy in Sport

Received Date: 5 March 2018

Revised Date: 13 June 2018
Accepted Date: 30 June 2018

Please cite this article as: Dingenen, B., Barton, C., Janssen, T., Benoit, A., Malliaras, P., Test-retest
reliability of two-dimensional video analysis during running, Physical Therapy in Sports (2018), doi:
10.1016/j.ptsp.2018.06.009.

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 ACCEPTED MANUSCRIPT
1 Test-retest reliability of two-dimensional video analysis during running

3 Bart Dingenena (corresponding author), Christian Bartonb,c, Tessa Janssend, Anke

4 Benoitd, Peter Malliarase

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6 Rehabilitation Research Centre, Biomedical Research Institute, Faculty of Medicine

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7 and Life Sciences, UHasselt, Diepenbeek, Belgium. Telephone: +32 11 28 69 39. E-

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8 mail: bart.dingenen@uhasselt.be.

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9 La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La

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Trobe University, Bundoora, Victoria, Australia.
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11 Complete Sports Care, Hawthorn, Victoria Australia; Centre for Sport and Exercise
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12 Medicine, Queen Mary University of London, United Kingdom.

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13 Rehabilitation Research Centre, Biomedical Research Institute, Faculty of Medicine

and Life Sciences, UHasselt, Diepenbeek, Belgium.

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15 Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of
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16 Medicine, Nursing and Health Science, Monash University, Clayton, Victoria,

17 Australia.
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1 Test-retest reliability of two-dimensional video analysis during running

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2 ABSTRACT

3 Objectives: To examine test-retest reliability of two-dimensional measured frontal and

4 sagittal plane kinematics during running, and to determine how many steps to include

5 to reach and maintain a stable mean.

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6 Design: Reliability study

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7 Setting: Research laboratory

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8 Participants: Twenty-one recreational runners

9 Main Outcome Measures: Lateral trunk position, contralateral pelvic drop, femoral

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10 adduction, hip adduction, knee flexion and ankle dorsiflexion during midstance, and
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11 foot and tibia inclination at initial contact were measured with two-dimensional video

12 analysis during running for 10 consecutive steps for both legs. All participants were
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13 tested twice one week apart. A sequential estimation method was used to determine
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14 the number of steps needed to reach a stable mean. Intraclass correlation

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15 coefficients (ICC) and smallest detectable differences (SDD) were calculated.

16 Results: The minimal number of steps was 6.3±0.3. Lateral trunk position, femoral
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17 adduction and foot inclination showed excellent reliability (ICC 0.90-0.99;SDD 1.3°-

18 2.3°). Tibia inclination and ankle dorsiflexion showed good to excellent reliability (ICC
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0.73-0.92;SDD 2.2°-4.8°). Hip adduction and knee flexion showed good reliability
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20 (ICC 0.82-0.89;SDD 2.3°-3.8°). Contralateral pelvic drop showed moderate to good

21 reliability (ICC 0.59-0.77;SDD 2.7°-2.8°).

22 Conclusion: Two-dimensional video analysis is reliable to assess running kinematics

23 on different days. The mean of at least 7 steps should be included.

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25 KEYWORDS

26 Running, kinematics, two-dimensional video analysis, reliability

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27 HIGHLIGHTS

28 At least 7 steps should be used to reach and maintain a stable mean.

29 Good to excellent test-retest reliability was found for 2D video analysis.

30 2D video analysis of running kinematics can be used confidently on different days.

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32 INTRODUCTION

33 Increasing evidence supports the theory that altered lower extremity kinematics

34 during running may be related to a broad range of outcomes such as running

35 performance,17 running economy26 and running-related injuries.1, 5, 9, 25, 27, 30, 31, 35 In

36 addition, the ability to measure changes in lower extremity running kinematics is

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37 essential to further understand the effect of interventions. The majority of published

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38 studies reporting kinematics in runners,1, 25, 27, 30, 31, 35
have used three-dimensional

39 motion analysis systems, which are considered the gold standard for a detailed

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40 running analysis.23 However, this methodology requires expensive equipment, is

time-consuming and is currently not widely available in clinical settings where

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42 physical therapists or athletic trainers work with runners. Reliable, accurate and

43 inexpensive methods that are time-efficient and user-friendly are required to facilitate
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44 the evaluation of running kinematics in clinical settings.

45 Pipkin et al34 evaluated the inter- and intrarater reliability of a qualitative approach
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46 where running kinematics of 15 individuals were assessed with a visual categorical

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47 rating of two-dimensional video recordings with a high-speed camera in the frontal

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48 and sagittal plane. The intra- and interrater reliability was strongly dependent on the

49 kinematic variable of interest. Substantial to excellent intrarater reliability was found

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50 for 11/15 kinematic outcomes, whilst this was only the case for 5/15 kinematic
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51 outcomes for the interrater reliability.

52 Next to the visual categorical evaluation of running kinematics, measuring angles of

53 different joints of interest using two-dimensional video analysis might offer an

54 alternative approach to evaluate running kinematics in clinical settings. Dingenen et

55 al13 recently reported a significant relationship between peak two-dimensional

56 measured contralateral pelvic drop, femoral adduction and hip adduction, and the

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57 three-dimensional measured hip adduction kinematic profile during running. Peak

58 two-dimensional measured contralateral pelvic drop was also significantly related to

59 the three-dimensional measured contralateral pelvic drop kinematic profile across the

60 majority of the stance phase. In accordance with the study of Maykut et al23, excellent

61 intra- and intertester reliability was found for all frontal plane angles, including

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62 contralateral pelvic drop, femoral adduction and hip adduction, when the same

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63 videos were evaluated on different days. In the sagittal plane, different kinematic

64 outcomes resulting from two-dimensional video analysis have been reported at initial

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65 contact and midstance, such as foot inclination,3, 34, 41, 43 tibia inclination34, 41 and knee

66 flexion.8, 41
Damsted et al8 evaluated within and between day intra- and intertester

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reliability of two-dimensional video measures of knee and hip flexion angles at initial
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68 contact during running. However, the magnitude of change beyond measurement
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69 error was not calculated. Therefore, the test-retest reliability of two-dimensional

70 frontal and sagittal plane analysis when the runner is tested on different days remains
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71 unclear. This is important because assessment and re-assessment of running

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72 kinematics in a clinical setting often occur on different days.

73 The current limitation of unknown test-retest reliability when using two-dimensional

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74 video analysis collected on different days, as opposed to the same video being rated
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75 on different days, hampers the interpretation of changes in outcomes when retesting

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76 an individual runner. Based on the inter-session variability of running kinematics and

77 the increasing scientific support for running retraining to treat lower limb injuries,5 this

78 information is essential to use two-dimensional video analysis effectively before and

79 after interventions. Furthermore, given the intrinsic variability of human running,19 it is

80 not clear how many steps should be included and averaged when assessing two-

81 dimensional measured kinematic outcomes in order to obtain stable gait data.

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82 The purpose of this study was therefore twofold. First, we aimed to determine the

83 minimum number of steps required to obtain a stable mean to assess two-

84 dimensional measured running kinematics for lateral trunk position, contralateral

85 pelvic drop, femoral adduction, hip adduction, knee flexion and ankle dorsiflexion

86 during midstance, and foot and tibia inclination at initial contact. Second, we aimed to

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87 examine the test-retest reliability of these two-dimensional measured kinematics.

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METHODS

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90 Participants

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Twenty-one recreational runners (12 females, 9 males; age: mean ± SD = 28.1 ± 8.3
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92 years; weight: mean ± SD = 67.0 ± 12.2 kg; height: mean ± SD = 172.9 ± 9.7 cm; body

93 mass index: mean ± SD = 22.3 ± 2.1 kg/m2) were tested twice with a one week
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94 interval. Inclusion criteria for the study were (i) recreational runners: runners that run
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95 for enjoyment,20 with a running volume of at least 10 km per week, and (ii) aged 18-
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96 45 years. Exclusion criteria were (i) individuals with a current running-related injury or

97 a running-related injury over the past 6 months, which was defined as any running-
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98 related (training or competition) musculoskeletal pain in the lower limbs that causes a

99 restriction on or stoppage of running (distance, speed, duration, or training) for at

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100 least 7 days or 3 consecutive scheduled training sessions, or that requires the runner
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101 to consult a physician or other health professional;47 (ii) individuals with an injury

102 resulting from activities other than running; (iii) novice runners: runners without any

103 running experience or runners that did not perform their sport on a regular basis in

104 the last year;21, 28, 29 (iv) sprinters: runners who participate in running distances of 400

105 meters or less;21 (v) ultra-marathon runners; (vi) elite athletes; (vii) runners who

106 compete in other sports than running >6h/week; (viii) individuals with a history of
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107 major trauma and/or major orthopaedic surgery of the lumbopelvic region or lower

108 extremity; and (ix) the presence of the following conditions or constitutions:

109 neurological or vestibular impairments, pregnancy. Appropriate ethical approval was

110 granted by the local ethical committee prior to the commencement of the study.

111 Before participating in the study, all participants read and signed the informed

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112 consent form.

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113 Procedures

All participants wore tight-fitting running pants, their own running shoes (which were

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115 identical for both test sessions), and a sports bra for the female participants. Male

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116 participants were asked to undress their upper body. Reflective markers (diameter 14
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117 mm) were placed on the manubrium sterni and bilateral on the anterior superior iliac

118 spine (ASIS), greater trochanter, lateral femoral epicondyle, fibular head and lateral
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119 malleolus. The same investigator placed all markers on all participants at both test

120 sessions. All participants were instructed to run on a motorised treadmill (h/p/cosmos
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121 pulsar®, h/p/cosmos® sports & medical gmbh, Nusseldorf-Traunstein, Germany) at

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122 their preferred running speed (mean ± SD = 10.2 ± 1.2 km/h). A treadmill
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123 acclimatisation period of 6 minutes was used before running kinematics were

124 measured.22 After this acclimatisation period, digital videos were captured during 30
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125 seconds with 2 tablets (iPad Air ®) sampling at 120 frames per second. Then, the
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126 treadmill was stopped and the participant turned 180°. The running direction of the

127 treadmill was reversed at the same speed. As such, the camera position could

128 remain unchanged to capture sagittal plane videos of the other leg after a new

129 acclimatisation period of 2 minutes.

130 The frontal plane iPad was placed on a portable tripod perpendicular to the frontal

131 plane at a height of 1.05 m and a distance of 2.0 m from the treadmill (Figure 1). The

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132 sagittal plane iPad was also placed on a portable tripod, perpendicular to the sagittal

133 plane at a height of 0.80 m and a distance of 1.40 m from the treadmill (Figure 1).

134 These positions were chosen to optimize visualization of the body regions of interest,

135 and to minimize parallax error with our two-dimensional video analysis.

136 The video recordings were analyzed using a freely available software package

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137 (Kinovea® version 0.8.15, available at http://www.kinovea.org) by two raters (TJ,

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138 AB). Both raters were first trained by the principal investigator (BD). The test and

139 retest videos were analyzed with at least one week interval. The first 10 participants

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140 were analyzed by rater 1, and the remaining 11 participants were analyzed by rater 2.

The test and retest of a participant were always analyzed by the same rater. Previous

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142 studies have shown excellent intra- and intertester reliability of measuring angles with

143 two-dimensional video analysis during running.13, 23

Ten consecutive steps of both
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144 the right and left leg were analyzed.

145 In the frontal plane, the deepest landing position (near midstance) was determined
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146 visually by slowly advancing the video frame by frame.13, 23 We defined this deepest
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147 landing position as the time point where there was maximal foot contact and no
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148 downward or upward movement occurred at the hip, knee and ankle.13, 23 The intra-

149 and interrater reliability of the detection of midstance in the frontal plane with two-
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150 dimensional video analysis has been shown to be excellent.34 We defined 3 different
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151 angles in the frontal plane. The lateral trunk position angle was the angle between

152 the vertical line starting at the ASIS of the stance leg, and a second line connecting

153 the ASIS of the stance leg and the manubrium sterni (Figure 2A).12 The smaller this

154 angle, the more the trunk is positioned in the direction of the stance leg. The

155 contralateral pelvic drop angle was the angle between the horizontal line starting at

156 the ASIS of the stance leg and a second line connecting the ASIS of the stance and

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157 swing leg (Figure 2A).13 The greater this angle, the greater the contralateral pelvic

158 drop. The femoral adduction angle was the angle between the horizontal line starting

159 at the ASIS of the stance leg and a second line connecting the ASIS of the stance leg

160 with the midpoint of the tibiofemoral joint (knee joint centre) (Figure 2A).13 Smaller

161 femoral adduction angles represent greater femoral adduction. The hip adduction

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162 angle was calculated as the difference between the femoral adduction angle and the

contralateral pelvic drop angle.13 Smaller hip adduction angles represent greater hip

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164 adduction. All frontal plane angles were drawn at the same digital picture, at the

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165 same time frame (midstance) (Figure 2A). The frontal plane angles were chosen

166 based on a combination of previous studies focusing on intra-tester and inter-tester

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reliability of two-dimensional measured angles,13, 23
the relationship between two-
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168 dimensional and three-dimensional measured angles,13, 23
and the evidence linking

trunk, hip and pelvis frontal plane mechanics to running-related injuries.1, 5, 9, 25, 27, 30,
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31, 35
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171 In the sagittal plane, we defined two angles at initial contact and two angles at
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172 midstance. The intra- and interrater reliability of the detection of these gait events in

the sagittal plane with a digital video camera capturing at 120 frames per second has
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174 been shown to be excellent when the same videos were rated on different days.34
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175 Initial contact was determined visually by slowly advancing the video frame by frame,
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176 and was defined as the first time that the foot touched the ground.34 The foot

177 inclination angle was defined as the angle between the horizontal and the sole of the

178 foot (Figure 2B).3, 34, 41, 43

Greater foot inclination angles represent greater foot

179 inclination. The foot inclination angle was negative when a forefoot strike was used.

180 The tibia inclination angle was defined as the angle between a vertical line starting at

181 the lateral malleolus and a second line connecting the lateral malleolus and the

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182 fibular head (Figure 2B).34, 41
Greater tibia inclination angles represent greater tibia

183 inclination. The foot and tibia inclination angles were drawn on the same digital

184 picture at initial contact (Figure 2B). Midstance in the sagittal plane was defined

185 visually in the same way as in the frontal plane, and was typically the point where the

186 swing leg crossed the stance leg.34 The ankle dorsiflexion angle was defined as the

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187 angle between the vertical line starting at the lateral malleolus and a second line

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188 connecting the lateral malleolus and the fibular head (Figure 2C). Greater ankle

189 dorsiflexion angles represent greater ankle dorsiflexion. The knee flexion angle was

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190 defined as the angle between the line formed by the greater trochanter and the

191 lateral femoral epicondyle, and a second line connecting the lateral femoral

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epicondyle and the lateral malleolus (Figure 2C).8, 11
Smaller knee flexion angles
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193 represent greater knee flexion. The ankle dorsiflexion and knee flexion angles were

drawn on the same digital picture (Figure 2C). Wille et al43 showed that a subset of
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195 different easily measurable sagittal plane kinematic outcomes, including foot
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196 inclination and peak knee flexion, can be used to estimate important kinetic outcomes
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197 during running such as peak knee extensor moment, mechanical energy absorbed

198 about the knee during loading response, peak patellofemoral joint reaction force,
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199 average vertical loading rate, peak vertical ground reaction force and braking

impulse. Tibia inclination is typically related to “overstride” mechanics, which is

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described as a running pattern in which the foot lands further in front of the person’s
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202 center of mass.41 An increased horizontal distance between the heel at initial contact

203 and the center of mass has been related to peak knee extensor moment and braking

204 impulse during running.43 In addition, knee flexion, tibia inclination and ankle

205 dorsiflexion have been related to running economy.26

206 Statistical analysis

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207 Sequential estimation method

208 The sequential estimation method is a technique used to calculate the number of

209 consecutive trials (steps) needed to obtain a stable mean for a certain variable,

210 participant and movement.18, 37

A sequential estimation was performed for each

211 participant’s block of 10 steps for each outcome variable (angle). We only used the

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212 data of both legs of the initial test. The cumulative mean was calculated by adding

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213 one trial at a time. The first data point was simply the angle of the first step. The

214 second data point was the mean of the first 2 steps, the third data point was the

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215 mean of the first 3 steps and so on. The last calculation was simply the mean of all

10 data points. The criterion to obtain a stable mean for each angle within each block

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217 of 10 steps was met when the cumulative mean fell within the bandwidth of the 10-

218 step mean ± 0.25 of the 10-step standard deviation and stayed there for the
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219 remaining steps (Figure 3).18 This procedure was performed for each block of 10

220 values of each angle of each individual. The mean and standard deviation of this
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221 outcome (the number of steps needed to reach and maintain a stable mean) was
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222 calculated for each angle (Table 1).

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223 Test-retest reliability

224 Based on the results of the sequential estimation method, the mean of 7 consecutive
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225 steps was calculated for each angle. The absolute differences between test and
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226 retest, and intraclass correlation coefficients (ICC2,2) were calculated. The ICC values

227 were interpreted as poor (<0.50), moderate (0.50-0.74), good (0.75-0.89) or excellent

228 (0.90-1.00).36 The standard error of measurement (SEM) and smallest detectable

229 difference (SDD) were calculated using the formulas SD*√(1-ICC) and 1.96*SEM*√2

230 respectively.42 The range of each angle within this study population was also

231 calculated as reliability will improve as the total variance increase.36

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232 All data were normally distributed, except for foot inclination (Shapiro-Wilk).

233 Differences between angles at test and retest were compared with paired t tests.

234 Foot inclination was compared with the Wilcoxon rank means test. Statistical

235 significance was set at P < .05. All statistical analyses were performed using SPSS

236 (SPSS Science, version 24 for Windows, USA).

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237

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238 RESULTS

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239 Sequential estimation method

240 The minimal number of steps needed to reach and maintain a stable mean ranged

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between 5.8 and 7.0 (Table 1). Across all angles of both legs, mean ± SD = 6.3 ± 0.3
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242 steps.
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243 Test-retest reliability

244 Based on the mean of 7 steps, lateral trunk position, femoral adduction and foot
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245 inclination showed excellent reliability (ICC 0.90-0.99; SDD 1.3°-2.3°). Tibia
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246 inclination and ankle dorsiflexion showed good to excellent reliability (ICC 0.73-0.92;

SDD 2.2°-4.8°). Hip adduction and knee flexion showed good reliability (ICC 0.82-
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248 0.89; SDD 2.3°-3.8°). Contralateral pelvic drop showed moderate to good reliability
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249 (ICC 0.59-0.77; SDD 2.7°-2.8°). The absolute differences, ICC, SEM and SDD values
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250 of all angles are presented in Table 2. All angles were not significantly different

251 between test and retest (P > .05), except for lateral trunk position for the left leg (P =

252 .004) (Table 3).

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254 DISCUSSION

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255 The purpose of this study was to determine the minimum number of steps required to

256 obtain a stable mean to assess two-dimensional measured running kinematics and to

257 examine the test-retest reliability of these two-dimensional measured kinematics. The

258 most important findings are that two-dimensional video analysis can be used

259 confidently in clinical settings on different days, and that the mean of at least 7 steps

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260 should be evaluated to reach and maintain a stable mean of a two-dimensional

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261 measured angle.

262 Even in a highly repetitive activity such as running, a certain amount of variability can

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263 be expected between consecutive steps. However, the number of steps needed to

reliably assess an individual runner was previously unknown. Other studies using

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265 two-dimensional video analysis during running made arbitrary decisions to include

266 four13 or five8, 23

steps. In the current study, we calculated the number of steps
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267 needed to achieve a stable mean for each outcome with the sequential estimation

268 method. For most of the two-dimensional measured kinematic outcomes, the
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269 minimum number of steps was 6.3. This implies that future studies using the same
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270 two-dimensional video analysis methodology should include at least 7 steps to

271 analyze the angles in the frontal and sagittal plane.

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272 The evaluation of between-day reliability is essential to provide an indication of the

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273 magnitude of change needed in longitudinal studies to be considered meaningful.

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274 Without these analyses, it is impossible to ascertain whether a change measured

275 with two-dimensional video analysis can be attributed to an intervention or to

276 measurement error. Between-day variability in kinematic measurements can be

277 driven by a number of factors, which can be categorized as intrinsic or extrinsic to the

278 individual.7 The intrinsic variability can be attributed to the variability that naturally

279 occurs as a result of movement variability. Extrinsic sources of test-retest variability in

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280 the current study were mainly related to the methodology being used, including

281 marker placement, gait event detection and the drawing of the angles. Despite these

282 potential sources of variability, the good to excellent ICCs suggest that two-

283 dimensional video analysis, based on the mean of 7 steps, can be used reliably to

284 test and retest running kinematics in the frontal and sagittal plane.

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285 We did observe some differences in reliability between certain angles. For example,

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286 the ICC of contralateral pelvic drop was lower compared to the other frontal and

287 sagittal plane angles. However, it is important to note that despite this, contralateral

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288 pelvic drop produced similar absolute test-retest differences (1.3°-1.4°) compared to

other angles (0.8°-2.8°). By definition, statistical variance in the test scores is the

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basis for reliability estimates.36 Therefore, reliability will improve as the total variance
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291 increase, as the error component will account for a smaller proportion of it.36 The
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292 smaller ICCs for contralateral pelvic drop may therefore also be attributed to the

293 smaller range of this kinematic outcome.

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294 Considering ICCs provide only a relative estimate of reliability, and limited indication
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295 of the precision of the measurement,10, 42

we also calculated SEM and SDD to
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296 provide absolute measures of reliability, expressed in the same unit (degrees) as the

297 original measure. The determination of these outcomes allows clinicians to define
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298 whether changes in kinematic outcomes at retest can be considered as real

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299 alterations in running kinematics, or measurement error. For example, lateral trunk

300 position was significantly different between test and retest for the left leg, but the

301 mean absolute difference between measures (1.0°) was smaller than the SDD (1.8°).

302 Therefore, one can conclude that this statistical significant difference is not clinically

303 meaningful with the current methodology.

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304 Overall, our results show that the SDDs ranged between 1.3°-4.8° (Table 2). The

305 clinical value of these numbers should be interpreted within the total range of each

306 angle and the clinical reasoning processes of a clinician. For example, the SDD of

307 contralateral pelvic drop was 2.7°-2.8°, but the total range across all participants was

308 only 6.1° for the right leg and 9.6° for the left leg. This SDD corresponds to 44.0%

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309 and 29.2% of the range of respectively the right and left leg. In contrast, the SDD of

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310 foot inclination corresponds to only 6.5% and 7.9% of the range of respectively the

311 right and left leg. As a consequence, differences between test and retest are

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312 probably easier to identify in angles where the SDD is a smaller proportion of the total

313 range with the current two-dimensional video analysis methodology.

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314 This is the first study to our knowledge to evaluate the test-retest reliability of two-

315 dimensional video running analysis in the frontal and sagittal plane across different
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316 days, limiting our ability to compare findings to previous literature. Despite the

317 widespread use of three-dimensional motion analysis in gait laboratories, only a

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318 relative small amount of studies have evaluated test-retest reliability of three-
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319 dimensional measured running kinematics.2, 16, 32, 38

The diversity in study

320 participants, methods, biomechanical modelling techniques, outcomes, statistical

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321 analyses and results impedes a general consistent conclusion of these studies.24
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322 Noehren et al32 studied the between-session reliability of three-dimensional

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323 measured peak angles, extracted from a series of 10 individual curves (landing

324 phases) in a group of 4 male and 6 female participants during treadmill running at

325 approximately 12 km/h. These authors reported SEMs of 0.9° for hip adduction, 1.9°

326 for knee flexion and 0.9° for ankle dorsiflexion, which corresponds to SDDs of

327 respectively 2.5°, 5.3° and 2.5°. Interestingly, the results of our two-dimensional

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328 video analysis methodology are very similar to test-retest reliability outcomes

329 reported with these three-dimensional motion analyses systems.

330 Given the validity of two-dimensional video analysis compared to three-dimensional

331 video analysis,13, 23 the results of the previously published intervention studies14, 33, 39,
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332 and the relative small SDDs reported in this study, the current methodology

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333 offers possibilities to identify differences in running kinematics after interventions in

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334 future studies and clinical practice. Previously published intervention studies focusing

335 on running retraining and/or strengthening have mainly used three-dimensional

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336 motion analysis systems to evaluate alterations in running kinematics.14, 33, 39, 40, 44-46

To the best of our knowledge, only two previously published intervention studies

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used two-dimensional video analysis. Breen et al6 performed a 6-week individualized

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339 running retraining intervention in a case series of 10 patients with exercise related
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340 running pain in the anterior compartment of the lower leg. Coaching cues were used

341 to increase hip flexion during swing, increase cadence, maintain an upright torso and
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342 to achieve a midfoot strike pattern. By using two-dimensional video analysis in the
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343 sagittal plane, statistical significant changes were found in the kinematic outcomes of

344 interest (foot inclination and tibia inclination at initial contact, maximum hip flexion
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345 during the swing phase and ankle dorsiflexion during midstance). Ferber et al15 could
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346 not find a statistical significant difference in knee valgus after a 3-week hip abductor
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347 strengthening program in runners with patellofemoral pain. Considering the good to

348 excellent reliability of two-dimensional video analysis of kinematics found in this

349 study, these inconsistencies are likely the result of differing interventions rather than

350 the measurement properties of testing methods. Importantly, the findings of the

351 current study can be used as a solid scientific base to interpret the results of future

352 intervention studies.

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353 Some important clinical implications can be formulated based on the results of this

354 study. The mean of at least 7 steps should be used to reach and maintain a stable

355 mean. Although the current approach is more time-consuming than visual categorical

356 rating of two-dimensional video recordings,34 the good to excellent test-retest

357 reliability outcomes allow clinicians to make better informed interpretations of

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358 kinematic changes after an intervention in clinical practice. Nevertheless, we want to

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359 emphasize that the clinical reasoning skills of a clinician within a multifactorial

360 approach remain essential when aiming to address running kinematics of an

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361 individual.4, 5

A few limitations of the current study need to be considered. We only included non-

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363 injured participants in the study, limiting the generalizability of findings to clinical

364 populations. Although the extrinsic sources of test-retest variability remain the same,
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365 the intrinsic running repeatability might be different in pathological populations.19

366 However, based on the inclusion of both males and females in this study, we believe
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367 that the diversity within the study population was large enough to confidentially
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368 generalize the test-retest reliability results to a broad range of movement patterns.

369 The two-dimensional videos were captured with high-speed videos (120 frames per
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370 second) and analyzed using a freely available specific software program (Kinovea). It
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371 is unclear whether cameras with lower sampling frequencies, or assessment using
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372 other software programs will produce similar reliability. Based on the finding to

373 include 7 steps when analyzing two-dimensional angles, the current method with

374 manual drawing of the angles can still take some time to perform. Another inherent

375 limitation of two-dimensional video analysis is that movement patterns are reduced to

376 two dimensions. Three-dimensional motion analysis remains the gold standard to

377 perform a detailed running analysis. However, based on the results of this study and

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378 other studies, two-dimensional video analysis can be used as a reliable and valid

379 alternative to assess running kinematics when three-dimensional motion analysis is

380 not available.

381

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382 CONCLUSION

383 This is the first study to report test-retest reliability of running kinematics with two-

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384 dimensional video analysis in the frontal and sagittal plane. First, we found that at

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385 least 7 steps should be included to reach and maintain a stable mean of a two-

386 dimensional measured angle during running analysis. Second, good to excellent test-

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387 retest reliability was found, but the outcomes can differ between angles being
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388 measured. These findings further support the implementation of two-dimensional

389 video analysis to assess running kinematics confidently in clinical settings.

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390 CONFLICT OF INTEREST STATEMENT

391 None declared.

392

393 ETHICAL APPROVAL

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394 The work has been approved by the appropriate ethical committees related to the

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395 institution in which it was performed (S60108 BE322201731705). Participants gave

396 informed consent to the work.

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397

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398 FUNDING
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399 This research did not receive any specific grant from funding agencies in the public,
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400 commercial, or not-for-profit sectors.

401
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402 REFERENCES

403 1. Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band

404 syndrome in runners: a systematic review. BMC Musculoskelet Disord.

405 2015;16:356.

406 2. Alenezi F, Herrington L, Jones P, Jones R. How reliable are lower limb

PT
407 biomechanical variables during running and cutting tasks. J Electromyogr

RI
408 Kinesiol. 2016;30:137-142.

409 3. Allen DJ, Heisler H, Mooney J, Kring R. The Effect of Step Rate Manipulation

SC
410 on Foot Strike Pattern of Long Distance Runners. Int J Sports Phys Ther.

2016;11:54-63.

U
411 AN
412 4. Barton CJ. Managing RISK when treating the injured runner with running

413 retraining, load management and exercise therapy. Phys Ther Sport.
M

414 2018;29:79-83.

415 5. Barton CJ, Bonanno DR, Carr J, et al. Running retraining to treat lower limb
D

416 injuries: a mixed-methods study of current evidence synthesised with expert

TE

417 opinion. Br J Sports Med. 2016;50:513-526.

418 6. Breen DT, Foster J, Falvey E, Franklyn-Miller A. Gait re-training to alleviate

EP

419 the symptoms of anterior exertional lower leg pain: a case series. Int J Sports
C

420 Phys Ther. 2015;10:85-94.

AC

421 7. Chau T, Young S, Redekop S. Managing variability in the summary and

422 comparison of gait data. J Neuroeng Rehabil. 2005;2:22.

423 8. Damsted C, Nielsen RO, Larsen LH. Reliability of video-based quantification of

424 the knee- and hip angle at foot strike during running. Int J Sports Phys Ther.

425 2015;10:147-154.

21
 ACCEPTED MANUSCRIPT
426 9. Davis IS, Futrell E. Gait retraining: altering the fingerprint of gait. Phys Med

427 Rehabil Clin N Am. 2016;27:339-355.

428 10. Denegar CR, Ball DW. Assessing reliability and precision of measurement: an

429 introduction to intraclass correlation and standard error of measurement. J

430 Sport Rehabil. 1993;2:35-42.

PT
431 11. Dingenen B, Malfait B, Vanrenterghem J, Robinson MA, Verschueren SM,

RI
432 Staes FF. Can two-dimensional measured peak sagittal plane excursions

433 during drop vertical jumps help identify three-dimensional measured joint

SC
434 moments? Knee. 2015;22:73-79.

435 12. Dingenen B, Malfait B, Vanrenterghem J, Verschueren SM, Staes FF. The

436
U
reliability and validity of the measurement of lateral trunk motion in two-
AN
437 dimensional video analysis during unipodal functional screening tests in elite
M

438 female athletes. Phys Ther Sport. 2014;15:117-123.

439 13. Dingenen B, Staes FF, Santermans L, et al. Are two-dimensional measured
D

440 frontal plane angles related to three-dimensional measured kinematic profiles

TE

441 during running? Phys Ther Sport. 2018;29:84-92.

442 14. Earl JE, Hoch AZ. A proximal strengthening program improves pain, function,
EP

443 and biomechanics in women with patellofemoral pain syndrome. Am J Sports

Med. 2011;39:154-163.
C

444

15. Ferber R, Kendall KD, Farr L. Changes in knee biomechanics after a hip-
AC

445

446 abductor strengthening protocol for runners with patellofemoral pain

447 syndrome. J Athl Train. 2011;46:142-149.

448 16. Ferber R, McClay Davis I, Williams DS, 3rd, Laughton C. A comparison of

449 within- and between-day reliability of discrete 3D lower extremity variables in

450 runners. J Orthop Res. 2002;20:1139-1145.

22
 ACCEPTED MANUSCRIPT
451 17. Folland JP, Allen SJ, Black MI, Handsaker JC, Forrester SE. Running

452 technique is an important component of running economy and performance.

453 Med Sci Sports Exerc. 2017;49:1412-1423.

454 18. Hamill J, McNiven SL. Reliability of selected ground reaction force parameters

455 during walking. Hum Mov Sci. 1990;9:117-131.

PT
456 19. Hamill J, Palmer C, Van Emmerik RE. Coordinative variability and overuse

RI
457 injury. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:45.

458 20. Hespanhol Junior LC, De Carvalho AC, Costa LO, Lopes AD. Lower limb

SC
459 alignment characteristics are not associated with running injuries in runners:

460 Prospective cohort study. Eur J Sport Sci. 2016;1-8.

461 21.
U
Kluitenberg B, van Middelkoop M, Diercks R, van der Worp H. What are the
AN
462 differences in injury proportions between different populations of runners? A
M

463 systematic review and meta-analysis. Sports Med. 2015;45:1143-1161.

464 22. Lavcanska V, Taylor NF, Schache AG. Familiarization to treadmill running in
D

465 young unimpaired adults. Hum Mov Sci. 2005;24:544-557.

TE

466 23. Maykut JN, Taylor-Haas JA, Paterno MV, DiCesare CA, Ford KR. Concurrent

467 validity and reliability of 2d kinematic analysis of frontal plane motion during
EP

468 running. Int J Sports Phys Ther. 2015;10:136-146.

24. McGinley JL, Baker R, Wolfe R, Morris ME. The reliability of three-dimensional
C

469

kinematic gait measurements: a systematic review. Gait Posture.

AC

470

471 2009;29:360-369.

472 25. Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female

473 runners with a history of tibial stress fracture. J Orthop Sports Phys Ther.

474 2010;40:59-66.

23
 ACCEPTED MANUSCRIPT
475 26. Moore IS. Is there an economical running technique? A review of modifiable

476 biomechanical factors affecting running economy. Sports Med. 2016;46:793-

477 807.

478 27. Neal BS, Barton CJ, Gallie R, O'Halloran P, Morrissey D. Runners with

479 patellofemoral pain have altered biomechanics which targeted interventions

PT
480 can modify: A systematic review and meta-analysis. Gait Posture. 2016;45:69-

RI
481 82.

482 28. Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with

SC
483 increased injury risk in novice runners wearing a neutral shoe: a 1-year

484 prospective cohort study. Br J Sports Med. 2014;48:440-447.

485 29.
U
Nielsen RO, Parner ET, Nohr EA, Sorensen H, Lind M, Rasmussen S.
AN
486 Excessive progression in weekly running distance and risk of running-related
M

487 injuries: an association which varies according to type of injury. J Orthop

488 Sports Phys Ther. 2014;44:739-747.

D

489 30. Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006
TE

490 prospective study of the biomechanical factors associated with iliotibial band

491 syndrome. Clin Biomech (Bristol, Avon). 2007;22:951-956.

EP

492 31. Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in

patellofemoral pain. Med Sci Sports Exerc. 2013;45:1120-1124.

C

493

32. Noehren B, Manal K, Davis I. Improving between-day kinematic reliability

AC

494

495 using a marker placement device. J Orthop Res. 2010;28:1405-1410.

496 33. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip

497 kinematics, pain and function in subjects with patellofemoral pain syndrome.

498 Br J Sports Med. 2011;45:691-696.

24
 ACCEPTED MANUSCRIPT
499 34. Pipkin A, Kotecki K, Hetzel S, Heiderscheit B. Reliability of a qualitative video

500 analysis for running. J Orthop Sports Phys Ther. 2016;46:556-561.

501 35. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical

502 predictors of retrospective tibial stress fractures in runners. J Biomech.

503 2008;41:1160-1165.

PT
504 36. Portney LG, Watkins MP. Foundations of clinical research: applications to

RI
505 practice. New Jersey: Prentice Hall. 2000.

506 37. Preatoni E, Hamill J, Harrison AJ, et al. Movement variability and skills

SC
507 monitoring in sports. Sports Biomech. 2013;12:69-92.

508 38. Queen RM, Gross MT, Liu HY. Repeatability of lower extremity kinetics and

509
U
kinematics for standardized and self-selected running speeds. Gait Posture.
AN
510 2006;23:282-287.
M

511 39. Roper JL, Harding EM, Doerfler D, et al. The effects of gait retraining in

512 runners with patellofemoral pain: A randomized trial. Clin Biomech (Bristol,
D

513 Avon). 2016;35:14-22.

TE

514 40. Snyder KR, Earl JE, O'Connor KM, Ebersole KT. Resistance training is

515 accompanied by increases in hip strength and changes in lower extremity

EP

516 biomechanics during running. Clin Biomech (Bristol, Avon). 2009;24:26-34.

41. Souza RB. An evidence-based videotaped running biomechanics analysis.

C

517

Phys Med Rehabil Clin N Am. 2016;27:217-236.

AC

518

519 42. Weir JP. Quantifying test-retest reliability using the intraclass correlation

520 coefficient and the SEM. J Strength Cond Res. 2005;19:231-240.

521 43. Wille CM, Lenhart RL, Wang S, Thelen DG, Heiderscheit BC. Ability of sagittal

522 kinematic variables to estimate ground reaction forces and joint kinetics in

523 running. J Orthop Sports Phys Ther. 2014;44:825-830.

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524 44. Willy RW, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson JD. In-field

525 gait retraining and mobile monitoring to address running biomechanics

526 associated with tibial stress fracture. Scand J Med Sci Sports. 2016;26:197-

527 205.

528 45. Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics

PT
529 during running and during a single-leg squat. J Orthop Sports Phys Ther.

RI
530 2011;41:625-632.

531 46. Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of

SC
532 patellofemoral pain in female runners. Clin Biomech (Bristol, Avon).

533 2012;27:1045-1051.

534 47.
U
Yamato TP, Saragiotto BT, Lopes AD. A consensus definition of running-
AN
535 related injury in recreational runners: a modified Delphi approach. J Orthop
M

536 Sports Phys Ther. 2015;45:375-380.

537
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FIGURE CAPTIONS

Figure 1:

Experimental set-up.

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Figure 2:

An example of the two-dimensional measurement of lateral trunk position,

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contralateral pelvic drop and femoral adduction (A), tibia inclination and foot

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inclination at initial contact (B) and knee flexion and ankle dorsiflexion during
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midstance (C).
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Figure 3:
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Graphical representation of the sequential estimation method for the contralateral

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pelvic drop angle of one leg of one participant across 10 steps.

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TABLE 1. Number of steps needed to measure two-dimensional angles based on the sequential estimation method.

Right leg* Left leg*

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Lateral trunk motion 6.1 ± 1.8 6.3 ± 1.8

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Contralateral pelvic drop 5.8 ± 2.3 6.1 ± 1.8
Femoral adduction 5.8 ± 2.5 6.0 ± 2.0

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Hip adduction 6.2 ± 2.0 6.2 ± 1.3
Foot inclination 6.1 ± 2.1 6.2 ± 1.7
Tibia inclination 6.6 ± 1.4 6.3 ± 1.8

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Knee flexion 6.4 ± 2.1 6.5 ± 1.9
Ankle dorsiflexion 6.4 ± 1.7 7.0 ± 1.8

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* Mean ± standard deviation.

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TABLE 2. Test-retest reliability of two-dimensional measured angles based on 7 steps.

Absolute difference
Right leg ICC2,2 (95% CI) SEM (°) SDD (°) SDD/range (%)
between measures (°)*

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Lateral trunk position 1.1 ± 0.7 0.90 (0.75 – 0.96) 0.7 1.8 19.4

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Contralateral pelvic drop 1.3 ± 1.1 0.59 (0.03 – 0.83) 1.0 2.7 44.0
Femoral adduction 0.9 ± 0.6 0.91 (0.79 – 0.97) 0.5 1.5 16.7

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Hip adduction 1.4 ± 1.3 0.82 (0.57 – 0.93) 1.0 2.8 28.4
Foot inclination 1.1 ± 1.0 0.99 (0.97 – 0.99) 0.7 2.0 6.5
Tibia inclination 1.3 ± 0.8 0.92 (0.82 – 0.97) 0.8 2.2 20.5

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Knee flexion 1.6 ± 1.3 0.87 (0.68 – 0.95) 1.0 2.9 19.5
Ankle dorsiflexion 1.3 ± 0.8 0.90 (0.76 – 0.96) 0.8 2.2 23.0

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Absolute difference
Left leg ICC2,2 (95% CI) SEM (°) SDD (°) SDD/range (%)

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between measures (°)*

Lateral trunk position 1.0 ± 0.7 0.91 (0.67 – 0.97) 0.6 1.8 20.3

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Contralateral pelvic drop 1.4 ± 1.2 0.77 (0.44 – 0.90) 1.0 2.8 29.2

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Femoral adduction 0.8 ± 0.5 0.94 (0.86 – 0.98) 0.5 1.3 15.7
Hip adduction 1.3 ± 0.9 0.87 (0.69 – 0.95) 0.8 2.3 22.4
Foot inclination 1.4 ± 0.9 0.98 (0.95 – 0.99) 0.8 2.3 7.9
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Tibia inclination 2.1 ± 1.2 0.87 (0.67 – 0.95) 1.3 3.5 25.3
Knee flexion 2.1 ± 1.6 0.89 (0.71 – 0.96) 1.4 3.8 22.5
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Ankle dorsiflexion 2.8 ± 1.4 0.73 (0.33 – 0.89) 1.7 4.8 35.0
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Abbreviations: ICC, intraclass correlation coefficients; CI, confidence interval; SEM, standard error of measurement; SDD,
smallest detectable difference.
* Mean ± standard deviation.
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TABLE 3. Differences between test and retest based on 7 steps.

Right leg Test (°)* Test (°)† Retest (°)* Retest (°)† P value

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Lateral trunk position 13.5 ± 2.3 8.3 (10.6 – 18.9) 13.3 ± 1.9 8.7 (9.6 – 18.3) .418

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Contralateral pelvic drop 5.3 ± 1.4 4.6 (3.0 – 7.6) 4.7 ± 1.6 5.7 (1.4 – 7.1) .126
Femoral adduction 80.4 ± 2.0 9.0 (75.7 – 84.7) 80.5 ± 1.8 6.4 (76.4 – 82.9) .843

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Hip adduction 75.1 ± 2.4 9.9 (69.4 – 79.3) 75.7 ± 2.5 9.4 (69.9 – 79.3) .148
Foot inclination 12.9 ± 5.8 27.0 (-5.9 – 21.1) 12.8 ± 6.6 30.3 (-9.9 – 20.4) .667
Tibia inclination 5.7 ± 2.8 10.4 (0.9 – 11.3) 6.0 ± 3.0 10.6 (1.0 – 11.6) .406

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Knee flexion 136.3 ± 3.0 13.6 (129.1 – 142.7) 135.8 ± 2.8 11.4 (127.9 – 139.3) .180
Ankle dorsiflexion 29.4 ± 2.8 9.6 (23.9 – 33.4) 29.4 ± 2.3 7.9 (25.4 – 33.3) 1.000

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Left leg Test (°)* Test (°)† Retest (°)* Retest (°)† P value

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Lateral trunk position 13.0 ± 2.1 8.0 (8.8 – 16.8) 13.8 ± 2.2 9.0 (8.7 – 17.7) .004‡

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Contralateral pelvic drop 5.2 ± 2.1 9.7 (0.7 – 10.3) 5.7 ± 2.0 7.2 (1.8 – 9.0) .223

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Femoral adduction 82.3 ± 2.2 8.7 (77.8 – 86.5) 82.4 ± 1.7 6.8 (78.5 – 85.3) .434
Hip adduction 77.0 ± 2.5 10.7 (70.7 – 81.3) 76.7 ± 2.3 8.7 (71.5 – 80.2) .361
Foot inclination 12.7 ± 5.7 25.6 (-5.4 – 20.1) 12.2 ± 6.1 28.4 (-8.9 – 19.6) .140
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Tibia inclination 7.8 ± 3.3 13.9 (0.6 – 14.4) 8.2 ± 3.6 11.9 (2.6 – 14.4) .404
Knee flexion 138.6 ± 4.4 16.9 (130.4 – 147.3) 138.9 ± 3.9 14.9 (131.3 – 146.1) .735
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Ankle dorsiflexion 26.2 ± 3.3 11.9 (21.6 – 33.4) 26.4 ± 3.4 11.7 (19.7 – 31.4) .709
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* Mean ± standard deviation.

†
Range (minimum – maximum).
‡
Significant (P < .05).
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