sports
Article
Leg and Joint Stiffness of the Supporting Leg during Side-Foot
Kicking in Soccer Players with Chronic Ankle Instability
Akihiro Tamura 1, *, Keita Shimura 2 and Yuri Inoue 3
Citation: Tamura, A.; Shimura, K.;
Inoue, Y. Leg and Joint Stiffness of the
Supporting Leg during Side-Foot
Kicking in Soccer Players with
Chronic Ankle Instability. Sports 2023,
11, 218. https://doi.org/10.3390/
sports11110218
Academic Editor: Andrew Hatchett
Received: 1 October 2023
Revised: 2 November 2023
Accepted: 3 November 2023
Published: 7 November 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Sports 2023, 11, 218. https://doi.org/10.3390/sports11110218
1 Research Institute for Health and Sport Science, Nippon Sport Science University, Setagaya,
Tokyo 158-8508, Japan
2 School of Health Sciences, Tokyo International University, Saitama, Kawagoe 350-1197, Japan;
kshimura@tiu.ac.jp
3 Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women’s University, Hyogo,
Kobe 658-0001, Japan; y.inoue@konan-wu.ac.jp
* Correspondence: a-tamura@nittai.ac.jp; Tel.: +81-3-5706-0900
Abstract: Soccer players with chronic ankle instability (CAI) may stabilize their supporting leg by
the proximal joint to compensate for the ankle instability during kicking motion. This study aimed to
investigate the characteristics of leg and joint stiffness of the supporting leg during side-foot kicking
in soccer players with CAI. Twenty-four male collegiate-level soccer players with and without CAI
participated in this study. The kinematic and kinetic data were obtained using a three-dimensional
motion analysis system. Leg stiffness and joint (hip, knee, and ankle) stiffness in the sagittal and
frontal planes were calculated and analyzed. The results clarified that soccer players with CAI
(0.106 ± 0.053 Nm/◦ ) had greater knee stiffness in knee adduction during the kicking cycle compared
to those without CAI (0.066 ± 0.030 Nm/◦ ; p = 0.046), whereas no characteristic differences were
observed in knee stiffness in knee flexion and hip and ankle stiffness (p > 0.05). Knee stiffness is
believed to occur to compensate for ankle joint instability in the supporting leg. Therefore, adjusting
knee stiffness to accommodate ankle joint instability is crucial for maintaining kicking performance.
Based on results of this study, it may be important to consider training and exercises focused on joint
coordination to improve knee stiffness in soccer players with CAI.
Keywords: ankle sprain; joint instability; leg stiffness; joint stiffness
1. Introduction
In soccer, musculoskeletal injuries occur frequently during games and practice [1].
Among these injuries, ankle sprains are the most common, accounting for 11% of the total
injuries and 67% of all the ankle injuries in soccer players [2]. Ankle sprains often lead
to persistent ankle instability, a pathological condition known “chronic ankle instability”
(CAI) [3]. CAI is widespread and has two etiologies: mechanical ankle instability (MAI),
defined as ankle movement beyond the physiological limit of the ankle range of motion [4],
and functional ankle instability (FAI), defined as the subjective feeling of ankle instability
and/or recurrent symptomatic ankle sprains due to proprioceptive and neuromuscular
deficits [3,4]. These pathologies result from specific deficiencies in proprioception, neuro-
muscular control, postural control, strength, and other factors that affect the ankle complex
mechanics [5].
A previous prospective cohort study found that 40% of patients with first-time ankle
sprains developed CAI [6]. Therefore, it is essential to understand the causes of CAI after
ankle sprain and how its modulation can affect injury prevention. Individuals with CAI ex-
hibit postural control deficiencies and delayed muscle activation in the lower extremities [7].
Additionally, soccer players with CAI lack hip flexibility and have poor dynamic balance
ability of the non-dominant leg, which is the supporting leg during kicking [8]. These
findings suggest that soccer players with CAI may experience functional impairments and
https://www.mdpi.com/journal/sports
Sports 2023, 11, 218 2 of 12

suboptimal dynamic alignment during motion. Recent systematic reviews have shown
that CAI can impact lower extremity biomechanics during landings [9]. For instance, it can
lead to increased knee flexion and reduced potential energy dissipation during side-cutting
motions [10,11]. Moreover, due to compromised ankle sensorimotor function, individuals
with CAI demonstrate tend to rely more on the hip joint for balance and stability during
sports maneuvers [12]. These biomechanical findings highlight the necessity of assessing
physical function and dynamic alignment in soccer players with CAI.
Kicking motions such as shooting and passing are integral to soccer games and have a
significant effect on playing skills and performance [13]. Among these, side-foot kicking, in
which the large medial area of the foot makes contact with the ball, is the most frequently
used due to its power and accuracy. Successful side-foot kicking involves efficiently transfer-
ring energy from the supporting leg to the proximal-to-distal of the kicking-leg during the
inside kick [14,15]. Recently, the supporting leg kinematics and kinetics of side-foot kicking
have been noted as key factors in kicking performance and injury development [14,16,17].
A previous biomechanical study reported that the supporting leg generates a greater verti-
cal ground reaction of 2.28 body weight during the initial heel strike in the instep kick [18].
Inoue et al. reported that knee extension of the supporting leg immediately before ball
impact contributes to swing acceleration during kicking [14]. Furthermore, previous studies
have suggested that the balancing ability and muscle strength of the supporting leg affect
ball speed and kicking accuracy [19,20]. Therefore, maintaining adequate stability in the
supporting leg is essential to achieve efficient energy transfer to the kicking leg.
Previous studies have suggested that CAI in soccer players is associated with poor dy-
namic balance of the supporting leg [8] and foot eversion during foot strikes [17], indicating
potential difficulties in withstanding the impact during foot strike. However, individuals
with CAI have greater knee stiffness during jump landings than those without, suggesting
a possible compensatory mechanism for poor ankle joint stability and knee stiffness [21].
In addition, efficient kicking requires the transfer of energy from the ankle to the hip of
the supporting leg, and then to the proximal-to-distal of the kicking-leg [14,15]. Therefore,
soccer players with CAI may be required to maintain the entire stability of the supporting
leg during side-foot kicking by increasing knee and hip stiffness of the supporting leg.
To Identify stiffness properties of the lower extremities during kicking would provide a
more comprehensive understanding of the ideal kicking motion for soccer players and
would help to devise appropriate training methods. However, it is not clear whether soccer
players with CAI can withstand impact during foot strike, that is, effectively maintain the
stiffness of the supporting leg. This study aimed to investigate the stiffness characteristics
of the supporting leg during side-foot kicking in soccer players with CAI.

2. Materials and Methods

2.1. Participants
This study included 24 male collegiate-level soccer players (mean age, 20.8 ± 0.8 years;
height, 172.4 ± 5.3 cm; body mass, 65.1 ± 5.3 kg) with a soccer playing experience of
10.9 ± 2.0 years. For all participants, the preferred leg for kicking (kicking leg) was the
right leg, with the left leg acting as the supporting leg. Regarding their main position,
9 participants were strikers, 7 were midfielders, and 8 were defenders. The inclusion criteria
were (a) age > 18 years and (b) >6 years of soccer experience. We excluded participants
with (a) histories of orthopedic surgeries, (b) current injuries in the lower extremities, and
(c) pain in the lower extremities during daily activities and soccer practice.
This study was conducted between August 2019 and March 2020 at the Kinematics
Laboratory of the International University of Health and Welfare, Narita Campus, Chiba,
Japan.
Prior to testing, all participants volunteered to participate in this study and provided
written informed consent. The study protocol was approved by the International University
of Health and Welfare Ethics Committee (Approval No. 19-Io-59) and was conducted in
accordance with the tenets of the Declaration of Helsinki [22].
Sports 2023, 11, 218 3 of 12

2.2. Evaluation and Grouping of CAI

The participants completed a questionnaire regarding their physical characteristics,
medical history of ankle sprains, and current medical information before inclusion in this
study. The Cumberland Ankle Instability Tool (CAIT) was used to identify CAI [23]. The
CAIT is a valid and reliable measure of the severity of FAI and is widely used by researchers
and physicians [23–25], with a cutoff point of <27 [24,26].
The participants were divided into CAI and no-CAI (N-CAI) (CAIT score ≥ 28) groups.
Those who had a CAIT score of ≤27 [23,26], a history of at least one significant ankle sprain,
and a previously injured ankle joint “giving way,” recurrent sprain, and/or “feeling of
instability” [27] were included in the N-CAI group.

2.3. Instrumentation
A three-dimensional motion analysis system (Vicon MX system, Oxford Metrics,
Oxford, UK) and AMTI force plates with an amplifier (MSA-6 Mini Amp, AMTI, Watertown,
MA, USA) were used to measure the kinetic data and GRF during testing, according to a
previous study [17]. The sampling rate was set to 250 Hz for the three-dimensional motion
analysis system and to 1000 Hz for the AMTI force plates.
All the participants wore closely fitted dark shorts, and the measurements were taken
barefoot to accurately measure the data. Thirty-nine reflective markers (14 mm) were
placed to create the coordinate systems of the head, torso, arm, pelvis, and leg segments,
according to the Vicon Plug-in Gait full-body model (Oxford Metrics, Oxford, UK) [28].
Reflective markers were placed on the head (left/right front head and back head), the
torso (7th cervical vertebrae, 10th thoracic vertebrae, clavicle, sternum, and right scapula),
the upper arm and forearm (left/right acromion, upper arm, lateral epicondyle, forearm,
radial styloid, ulnar styloid, and the head of the second metacarpal), the pelvis (left/right
anterior superior iliac spine and posterior superior iliac spine), and the thigh and tibial
segments (left/right lower lateral third of the thigh, lateral epicondyle, lower third of the
shank, second metatarsal head, calcaneus) [17,28]. This segment model was used to create
coordinate systems and to obtain the lower extremity kinematic and kinetic data.

2.4. Measurement Protocols

Prior to testing, all the participants performed the desired warm-up, including slow
jogging and/or stretching. Subsequently, the participants performed side-foot kicking trials
on the AMTI force plates. A ball (Adidas Telstar 18; Adidas, Germany) was placed at the
desired position on the AMTI force plates. All participants were instructed to perform
side-foot kicking with as much force as possible toward a net (width and height 0.6 m
each), positioned 2 m in front of the ball. The approach velocity was arbitrary for all
participants. The approach angle was set at 45◦ with respect to the direction of the net.
Side-foot kicking was conducted to obtain five successful trials. If the ball was off-target,
the trial was excluded. The intervals between trials were set at 3 min to check the acquired
data, reorganize the measurement settings, and consider the participant’s fatigue.

2.5. Data Analysis

The Vicon Nexus software (version 1.8.5; Oxford Metrics, Oxford, UK) was used to
calculate all variable outcome measures based on the biomechanical model of the Vicon
Plug-in Gait. The middle 3 trials of 5 successful kicking were used for data analysis. The
vertical GRF, joint angles, and moments (the hip, knee, and ankle) of the supporting leg
were obtained during a single side-foot kicking cycle. A single kicking cycle was defined
as the duration from heel strike (when the vertical GRF first exceeded 10 N) to the frame
in which the kicking leg reached its highest vertical position in the follow-through phase
after ball contact. The kicking cycle was normalized as a percentage, that is, 0% and 100%
represented the heel strike and frame of the highest vertical, respectively.
Joint angles were derived using the Cardan y-x-z rotation sequence of the distal
segment relative to that of the proximal segment. Positive joint angles represented flex-
Sports 2023, 11, 218 4 of 12

ion/dorsiflexion in the sagittal plane and abduction/inversion in the frontal plane. Joint
moments were calculated as external moments; positive joint moments represented flex-
ion/dorsiflexion in the sagittal plane and abduction/inversion in the frontal plane. The
whole-body center of mass (CoM) was calculated from the weighted sum of all centers of
mass of all segments defined by the markers.
Leg stiffness (Kleg ) was calculated as the ratio of the peak vertical GRF (vGRFpeak ) to
the change in vertical displacement of CoM (∆LCoM ) [29], and formulated as Equation
(1). vGRFpeak was obtained from the maximum value during the kicking cycle. ∆L was
calculated as the lowest and highest position of CoM during the kicking cycle. Leg stiffness
(Kleg ) was normalized to the body mass (kg) and height (mm) of the participants

Kleg = vGRFpeak /∆LCoM (1)

Joint stiffness (Kjoint ) of the lower extremities was calculated by the ratio of the change
in joint moments (∆Mpeak ) to the change in joint angles (∆θ joint ) [29], and formulated as
Equations (2)–(4). Kjoint of the lower extremity joints were calculated as hip (Khip ), knee
(Kknee ), and ankle stiffness (Kankle ) in the sagittal and frontal planes. ∆Mjoint represented the
change in joint moments between the moment at the heel strike and the maximum value
during the kicking cycle. ∆θ joint represented the angular displacement between the angle
at the heel strike and the maximum value during the kicking cycle. Joint stiffness (Kjoint )
of the lower extremities was normalized to the body mass (kg) and height (mm) of the
participants
Khip = ∆Mhip /∆θ hip (2)

Kknee = ∆Mknee /∆θknee (3)

Kankle = ∆Mankle /∆θankle (4)

2.6. Statistical Analysis

Statistical analyses were conducted using the IBM® SPSS® Statistics for Windows
version 27.0. (IBM Corporation, Armonk, NY, USA) by an independent statistician. Prior to
statistical analysis, all outcome data were averaged for the middle three of five successful
trials, and the means and standard deviations were calculated. Normality of data was
assessed by the Shapiro–Wilk test, and homogeneity of variance was verified with Levene’s
test. The independent sample t-tests were used to identify differences in variables between
the CAI and N-CAI groups, depending on whether these variables were normally dis-
tributed. Statistical significance was set at p < 0.05. Effect sizes (ESs) were calculated using
Cohen’s d from raw data by all outcomes. ESs are considered small when d = 0.20, medium
when d = 0.50, and large when d = 0.80 [30]. Multiple regression analysis was performed to
identify the contributors to leg stiffness by the angular displacement of the lower extremity
joints during the kicking cycle. One-dimensional statistical parametric mapping (SPM[t])
unpaired t-tests were performed to compare each individual joint moment curve between
groups using the open-source SPM1d code (www.spm1d.org, accessed on 22 March 2022)
in MATLAB® R2020b (The Mathworks Inc., Boston, MA, USA).

3. Results
3.1. Partocipants Characteristics
Patient characteristics of both groups are shown in Table 1. There were no significant
differences in the physical characteristics or playing experiences between the groups
(p > 0.05).
Sports 2023, 11, 218 5 of 12

Table 1. Physical characteristics of the participants in the CAI and N-CAI groups.

CAI Group N-CAI Group

N 14 (58%) 10 (42%)
Main position
Striker, n 6 3
Midfielder, n 3 4
Defender, n 5 3
Age, years 20.8 ± 0.9 20.8 ± 0.8
Height, cm 172.8 ± 5.7 171.8 ± 5.0
Body mass, kg 65.8 ± 5.2 64.2 ± 5.6
Playing Experience, years 11.1 ± 1.7 10.6 ± 2.4
CAIT score 23.3 ± 4.1 29.6 ± 0.8
CAI, chronic ankle instability; N-CAI, no-CAI; CAIT, the Cumberland Ankle Instability Tool.

3.2. Joint Angles and Moments

The peak joint angles and moments of the supporting legs in the lower extremities are
shown in Tables 2 and 3. The peak knee adduction moment was significantly greater in the
CAI group than that in the N-CAI group (1.30 ± 0.58 vs. 0.86 ± 0.39 Nm/kg, p = 0.049).
There were no significant differences in the other variables during the kicking cycle between
the CAI and N-CAI groups (p > 0.05). The joint moment curves of the CAI and non-CAI
groups during the kicking cycle are shown in Figure 1. No between-group differences in
the lower extremity joint moments were observed at any time point during the kicking
cycle (p > 0.05).

Table 2. Peak lower extremity joint angles in the sagittal and frontal planes of the CAI and N-
CAI groups.

Mean
Variables Groups Mean ± SD 1 Difference t Value p Value Effect Size 3
(95% CI 2 )
Sagittal Plane
CAI 29.3 ± 9.4 −1.1
Hip Flexion, deg −0.24 0.81 −0.10
N-CAI 30.4 ± 12.5 (−10.3–8.2)
CAI 33.3 ± 9.0 −3.4
Knee Flexion, deg −1.01 0.32 −0.42
N-CAI 36.7 ± 6.9 (−10.5–3.6)
CAI 23.9 ± 8.9
Ankle Dorsi-Flexion, deg −0.7 (−7.3–5.9) −0.23 0.82 −0.10
N-CAI 24.6 ± 5.5
Frontal Plane
CAI 8.3 ± 5.3
Hip Adduction, deg −2.0 (−5.8–1.8) −1.09 0.29 −0.42
N-CAI 10.3 ± 2.6
CAI 14.2 ± 13.7
Knee Adduction, deg 7.9 (−2.8–18.5) 1.53 0.14 0.63
N-CAI 6.3 ± 10.4
CAI 6.3 ± 8.4
Ankle Dorsi-Flexion, deg 3.0 (−2.8–8.8) 1.09 0.29 0.45
N-CAI 3.2 ± 3.3
CAI, chronic ankle instability; N-CAI, no-CAI. 1 SD, standard deviation; 2 CI, confidence interval; 3 effect sizes
were calculated using Cohen’s d.
Sports 2023, 11, 218 6 of 12

Table 3. Peak lower extremity joint moments in the sagittal and frontal planes of the CAI and
N-CAI groups.

Mean
Variables Groups Mean ± SD 1 Difference t Value p Value Effect Size 3
(95% CI 2 )
Sagittal Plane
CAI 1.60 ± 1.61 0.28
Hip Flexion, Nm/kg 1.14 0.27 0.47
N-CAI 1.32 ± 0.58 (−0.23–0.80)
CAI 1.44 ± 0.82 −0.37
Knee Flexion, Nm/kg −0.94 0.36 −0.39
N-CAI 1.81 ± 1.13 (−1.20–0.45)
CAI 2.54 ± 0.62 0.20
Ankle Dorsi-Flexion, Nm/kg 0.84 0.41 0.35
N-CAI 2.34 ± 0.49 (−0.29–0.69)
Frontal Plane
CAI 1.40 ± 0.63 0.01
Hip Adduction, Nm/kg 0.04 0.97 0.02
N-CAI 1.39 ± 0.41 (−0.46–0.48)
CAI 1.30 ± 0.58
Knee Adduction, Nm/kg 0.44 (0.00–0.88) 2.09 0.049 * 0.86
N-CAI 0.86 ± 0.39
CAI 0.29 ± 0.37 0.04
Ankle Dorsi-Flexion, Nm/kg 0.28 0.79 0.11
N-CAI 0.25 ± 0.23 (−0.24–0.31)
Sports 2023, 11, x FOR PEER REVIEW 6 of
3 12
CAI, chronic ankle instability; N-CAI, no-CAI. 1 SD, standard deviation; 2 CI, confidence interval; effect sizes
were calculated using Cohen’s d. * Statistically significant at p < 0.05.

Figure 1. Cont.
Sports 2023, 11, 218 7 of 12

Figure
Figure Time-series
1. 1. Time-seriesdata
dataofofthe
the hip,
hip, knee, and ankle
knee, and anklejoint
jointmoments
momentsofof the
the supporting
supporting leg leg during the
during
the kicking
kicking cycle.cycle.
The The means
means andand standard
standard deviationsof
deviations of the
the CAI
CAIand
andN-CAI
N-CAI groups were
groups expressed
were expressed as
redaswith
red with the shaded
the shaded areas
areas andand black
black lineswith
lines withthe
thediagonal
diagonal lines.
lines.AAkicking
kickingcycle was
cycle defined
was as as the
defined
the duration from the heel strike (0%) to the frame in which the kicking leg reached the highest
duration from the heel strike (0%) to the frame in which the kicking leg reached the highest vertical
vertical position in the follow-through phase after the ball contact (100%). CAI, chronic ankle insta-
position in the follow-through
bility; N-CAI, no-CAI. phase after the ball contact (100%). CAI, chronic ankle instability;
N-CAI, no-CAI.

3.3. Leg Stiffness

Leg stiffness did not differ significantly between the CAI (19.67 ± 2.85 kN/m) and
N-CAI groups (22.21 ± 9.67 kN/m, p = 0.36, Table 4). The multiple regression model for
the prediction of leg stiffness based on the angular displacement of the lower-extremity
joints is presented in Table 5. Angular displacement in the sagittal plane was 32.9 ± 4.6◦ in
hip flexion, 20.0 ± 3.6◦ in knee flexion, and 35.7 ± 7.0◦ in ankle dorsi-flexion. According to
the multiple regression results, both angular displacements in the knee flexion and ankle
dorsi-flexion were significant predictors of leg stiffness among the participants (R2 = 0.429,
adjusted R2 = 0.344, p = 0.009).

Table 4. Leg stiffness of the lower extremity joints in the CAI and N-CAI groups.

Mean
Variables Groups Mean ± SD 1 Difference t Value p Value Effect Size 3
(95% CI 2 )
Leg stiffness, CAI 19.67 ± 2.85 −2.52
Kleg , kN/m −0.80 0.36 −0.38
N-CAI 22.21 ± 9.67 (−8.16–3.11)
CAI, chronic ankle instability; N-CAI, no-CAI. 1 SD; standard deviation, 2 CI; confidence interval, 3 effect sizes
were calculated using Cohen’s d.

Table 5. Multiple regression analysis of leg stiffness and angular displacements in the sagittal plane.

Unstandardized Standardized
Angular Coefficients Coefficients t p
Displacements Value Value 95% CI 1
B Std. Error Beta
Hip Flexion,
0.17 0.26 0.14 0.66 0.52 −0.37–0.71
deg
Knee Flexion,
−0.77 0.34 −0.48 −2.28 0.03 * −1.49–0.07
deg
Ankle
Dorsi-Flexion, −0.32 0.15 −0.39 −2.19 0.04 * −0.63–0.02
deg
1 CI, confidence interval; Std., standard; * statistically significant at p < 0.05.
Sports 2023, 11, 218 8 of 12

3.4. Joint Stiffness of the Lower Extremity

The joint stiffness of the lower extremity joints is shown in Table 6. In the frontal plane
analysis, the CAI group (0.106 ± 0.053 Nm/deg) showed significantly greater knee stiffness
than the N-CAI group (0.066 ± 0.030 Nm/deg, p = 0.046), whereas there was no significant
difference in the sagittal plane (p > 0.05). Regarding hip and ankle stiffness, these variables
showed no significant differences in either the sagittal or frontal planes (p > 0.05).

Table 6. Joint stiffness of the lower extremity in the CAI and N-CAI groups.

Mean
Variables Groups Mean ± SD 1 Difference t Value p Value Effect Size 3
(95% CI 2 )
Sagittal plane

Hip stiffness, Khip , Nm/deg

CAI 0.034 ± 0.012 −0.002
−0.35 0.73 −0.14
N-CAI 0.036 ± 0.008 (−0.011–0.008)
CAI 0.061 ± 0.040 0.002
Knee stiffness, Kknee , Nm/deg 0.16 0.88 0.06
N-CAI 0.059 ± 0.025 (−0.028–0.032)
Ankle stiffness, Kankle , CAI 0.037 ± 0.014 −0.003
−0.56 0.58 −0.23
Nm/deg N-CAI 0.039 ± 0.009 (−0.013–0.008)
Frontal plane
CAI 0.111 ± 0.058 0.017
Hip stiffness, Khip , Nm/deg 0.80 0.43 0.33
N-CAI 0.095 ± 0.035 (−0.026–0.060)
CAI 0.106 ± 0.053 0.040
Knee stiffness, Kknee , Nm/deg 2.12 0.046 * 0.88
N-CAI 0.066 ± 0.030 (0.001–0.0780)
Ankle stiffness, Kankle , CAI 0.057 ± 0.045 0.014
0.87 0.40 0.37
Nm/deg N-CAI 0.043 ± 0.024 (−0.019–0.046)
CAI, chronic ankle instability; N-CAI, no-CAI. 1 SD; standard deviation, 2 CI; confidence interval, 3 effect sizes
were calculated using Cohen’s d. * Statistically significant at p < 0.05.

4. Discussion
This study aimed to investigate the stiffness characteristics of the supporting leg
during side-foot kicking in soccer players with CAI. The results of this study showed that
soccer players with CAI exhibit greater knee stiffness in the frontal plane during the kicking
cycle compared to those without CAI; however, there were no characteristic differences in
knee stiffness in the sagittal plane and hip and ankle stiffness. These results indicate that
soccer players with CAI exhibit greater knee stiffness in knee adduction during kicking,
potentially compensating for CAI-associated ankle instability.
Previous studies have revealed that leg stiffness is adjusted to accommodate differ-
ent surfaces [31,32], increasing to accommodate reductions in surface stiffness. Thus, a
reduction in surface stiffness results in increased joint stiffness of the lower extremities.
The ankle, as the joint that absorbs the load after landing, plays a significant role in energy
absorption [33–35], and therefore ankle instability causes poor alignment of the lower
extremities during landing [36,37]. Li et al. reported that participants with CAI exhibit
knee stiffness owing to ankle joint instability as a result of a protective strategy utilized to
effectively absorb energy during landing [21], meaning that the stiffness and stability of the
entire lower extremity may be maintained in legs with CAI. Using a similar mechanism,
the soccer players with CAI in this study also had greater knee stiffness in the frontal
plane during the kicking cycle and could compensate for ankle joint instability. Therefore,
adjusting knee stiffness to accommodate ankle joint instability is considered to be very
important for maintaining kicking performance, with properly managing CAI and learning
the correct motion also being essential strategies. Previous studies have demonstrated that
muscle recruitment can enable autonomously control joint stiffness, thereby enhancing
dynamic joint stability by adjusting the joint stiffness [38,39]. Considering training and
Sports 2023, 11, 218 9 of 12

exercises focused on joint coordination may be useful to improving knee stiffness in soccer
players with CAI.
Although the kicking motion was in the sagittal plane, the results of this study repre-
sented affected knee stiffness in the frontal plane. In a previous biomechanical study, the
medial and lateral GRF components were generated in the supporting leg during the kick-
ing cycle [17]. In addition, players with CAI had greater knee varus and hindfoot eversion
angles at the flat-foot contact point [17]. This is because ankle instability in the frontal plane
tends to be residual owing to anterior talofibular ligament sprain. Furthermore, this study
showed that the peak knee adduction moment was significantly greater in the CAI group
than in the N-CAI group. Therefore, players with CAI may be able to compensate for ankle
joint instability by increasing knee stiffness in the frontal plane rather than in the sagittal
plane. If knee stiffness cannot be increased to accommodate the ankle joint instability, it
could lead to a reduction in the stiffness of the entire lower limb, possibly resulting in a
lack of energy transfer in the kicking motion.
There was no difference in leg stiffness, which represents stiffness of the entire lower
extremity, between the CAI and N-CAI groups. This may be the result of ankle joint
instability being compensated for by increased knee stiffness. Through the investigation
of the angular displacements affecting leg stiffness among all players, it became clear that
those at the hip and knee joints in the sagittal plane were the major contributors to leg
stiffness. This suggests that knee and hip flexion are the most important factors in increasing
leg stiffness during the kicking motion, similar to previous studies that investigated the
main contributors of energy absorption during jump landing or side-stepping [34,40,41].
Therefore, it is important to recognize that knee and hip flexion are important factors that
influence the stability of the supporting leg and efficiently transfer energy to the kicking
leg during the kicking motion.
Changes in the knee stiffness and kinematic/kinematic properties of the knee joint
during landing motion are closely related to severe knee joint disorders such as anterior
cruciate ligament injuries and knee osteoarthritis [42–45].In individuals with CAI, it has
been reported that ankle instability with CAI is compensated for by increasing the knee stiff-
ness with the less knee flexion, potentially resulting in inadequate energy attenuation and
increased stress on the knee joint structures [9,46,47]. In addition, it has also been pointed
out that increased knee adduction moment during landing, as in the results of this study,
may lead to medial meniscus tears or future medial component knee osteoarthritis because
of the large compressive load on medial tibial plateau due to forced knee varus [43,48].
Therefore, improvement of knee stiffness and a decrease in knee adduction moment would
contribute to the prevention of secondary knee disorders. However, previous reports have
been limited to biomechanical studies during jump landing and side-step movements,
leaving unanswered questions regarding whether knee angular displacement in the sagittal
plane or the knee stiffness in the frontal plane during kicking motion are associated with
secondary severe knee injuries. Consequently, future research is warranted to determine if
stiffness properties and kinematic/kinetics characteristics during kicking motion in soccer
players with CAI are associated with future secondary disabilities.
This study had some limitations. Firstly, a previous study found that the CAIT
measures the severity of CAI due to MAI, FAI, or a combination of these two phenomena [3].
As a result, CAIT scores may be affected by CAI severity and score. Hence, although the
score has been validated as a reliable indicator for the severity of functional instability of
the ankle, it should be considered as a self-reported evaluation tool and not equivalent to a
physician’s evaluation. Secondly, kinematic and kinetic measurements with a multisegment
foot model are hampered by measurement limitations and modeling assumptions [49,50].
All kicking trials were conducted barefoot to minimize measurement errors by shifting
the reflective markers during kicking and in the laboratory, unlike in daily practice and
games. Therefore, these results did not consider the effects of shock absorption by shoes
or protection/fixation of the foot shape and the measurement environment differences
from actual sports situations. Thirdly, this study had a small sample size per group after
Sports 2023, 11, 218 10 of 12

group categorization; therefore, it could be argued that the results might not provide
accurate findings of the difference in stiffness properties between the CAI and Non-CAI
groups. Considering the effects of the less sample size, we provided effect sizes for all
the analyses to illustrate more meaningfully the magnitude of the differences between
the groups. Primary outcomes resulted in a medium effect size of more than 0.3, which
indicates that, despite the small sample size, our results provide a useful comparison of the
differences in stiffness properties between groups.

5. Conclusions
The results of this study clarified that soccer players with CAI exhibited greater knee
stiffness in the frontal plane of the supporting leg during the kicking cycle, while no
characteristic differences were observed in the sagittal plane, compared to those without
CAI. This finding indicated a potential link between ankle instability in CAI with knee
stiffness of the supporting leg during side-foot kicking. Therefore, adjusting knee stiffness
to accommodate ankle joint instability may be a crucial mechanism for maintaining kicking
performance. These findings have relevance for the development of training programs and
exercises centered around joint coordination to enhance knee stiffness in soccer players
with CAI.

Author Contributions: Conceptualization, A.T.; methodology, A.T. and K.S.; software, A.T. and
K.S.; validation, A.T., K.S. and Y.I.; formal analysis, A.T.; investigation, A.T. and K.S.; resources, A.T.
and K.S.; data curation, A.T. and K.S.; writing—original draft preparation, A.T.; writing—review
and editing, K.S.; visualization, A.T. and K.S.; supervision, Y.I.; project administration, A.T. and
Y.I.; funding acquisition, none. All authors have read and agreed to the published version of the
manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was conducted according to the guidelines of the
Declaration of Helsinki and was approved by the ethics committee of the International University of
Health, Narita, Chiba, Japan (19-Io-59).
Informed Consent Statement: Written informed consent has been obtained from all participants to
publish this paper.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to privacy concerns.
Acknowledgments: The authors would like to thank all participants and all assistants in this study.
Conflicts of Interest: The authors declare no conflict of interest.

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