See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/244947717

Evaluation of the Lateral Step-Down Test as a Clinical Assessment of Hip

Musculature Strength

Article in Athletic Training and Sports Health Care · November 2009

DOI: 10.3928/19425864-20091019-06

CITATIONS READS

11 1,956

5 authors, including:

Marc Norcross Troy Blackburn

Oregon State University University of North Carolina at Chapel Hill
46 PUBLICATIONS 566 CITATIONS 195 PUBLICATIONS 2,769 CITATIONS

SEE PROFILE SEE PROFILE

Darin Padua
University of North Carolina at Chapel Hill
229 PUBLICATIONS 5,588 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Relationships Between Pre-Season Measurements, Internal Training Loads and Injury Risk in American Collegiate Soccer Athletes View
project

All content following this page was uploaded by Darin Padua on 16 March 2014.

The user has requested enhancement of the downloaded file.

 Evaluation of the Lateral Step-Down Test
as a Clinical Assessment of Hip Musculature
Strength
Marc F. Norcross, MA, ATC; S. Doug Halverson, MA, ATC; Tandice J. Hawkey, MA; J. Troy Blackburn, PhD, ATC;
and Darin A. Padua, PhD, ATC.
ABSTRACT
Gluteal musculature weakness is associated with lower extrem-
ity injury and greater frontal plane knee motion. A method for
functionally evaluating hip abduction and external rotation
strength by observing knee motion would be beneficial for
clinicians. This study evaluated the association between hip
abductor and external rotation strength and knee motion.
Peak isometric and eccentric hip abduction and external rota-
tion strength were assessed in 47 healthy participants before
analysis of knee kinematics during a lateral step-down test.
The relationships between each strength measure and frontal
plane knee kinematics were evaluated using bivariate Pearson
correlation coefficients. Frontal plane knee displacement was
not associated with hip musculature strength. Frontal plane
knee angle at peak knee flexion was not associated with exter-
nal rotation or eccentric abduction strength. Isometric abduc-
tion strength was negatively correlated with peak knee flexion.
Hip musculature strength is not indicative of the magnitude of
frontal plane knee motion during the lateral step-down test,
and this test is not recommended for clinical assessment of hip
muscle strength.
W
eakness of the hip abductors and external
rotators is associated with a variety of lower
extremity injuries as well as low back pain.1-5
Mr Norcross and Dr Blackburn are from the Neuromuscular Research
Laboratory, Mr Halverson is from Campus Health Services, and Dr Padua is from
Sports Medicine Research Library, the University of North Carolina at Chapel Hill,
Chapel Hill, NC; and Ms Hawkey is from the Department of Athletics, University of
California, Los Angeles, Los Angeles, Calif.
Originally submitted April 29, 2009.
Accepted for publication August 25, 2009.
The authors have no financial or proprietary interest in the materials presented
herein.
Address correspondence to Marc F. Norcross, MA, ATC, University of North
Carolina at Chapel Hill, Chapel Hill, NC 27599; e-mail: norcross@email.unc.edu.
doi:10.3928/19425864-20091019-06
272
ATSHC1109NORCROSS.indd 272
Specifically, decreased hip abduction and external rota-
tion strength has been reported in individuals with patel-
lofemoral pain syndrome,1,3,5 whereas lesser hip abduc-
tor strength has been observed in patients with iliotibial
band friction syndrome.2 Furthermore, a prospective
evaluation of collegiate athletes found individuals who
suffered a lower extremity or low back injury displayed
lesser hip abduction and external rotation strength com-
pared to their uninjured counterparts.4
In addition to strength deficits, a lower extremity kine-
matic pattern consisting of hip adduction and internal ro-
tation, and knee valgus has been proposed as a risk factor
for patellofemoral pain syndrome,3,6,7 iliotibial band fric-
tion syndrome,2 and anterior cruciate ligament injury.8,9
As a result, it has been suggested that greater eccentric re-
sistance to hip adduction and internal rotation provided
by the hip abductors and external rotators may attenuate
this kinematic pattern and result in an associated decrease
in knee valgus.2,3,10 This premise is supported by studies
reporting greater frontal plane knee motion during run-
ning11 and single-leg landing10 in individuals with weak
hip musculature. Accordingly, it has been recommended
that rehabilitation and prevention programs for these in-
juries should include evaluation and strengthening of the
hip musculature.3,12-14
The lateral step-down test is a clinically applicable
method of functional evaluation that potentially may
be used to evaluate hip abductor and external rotator
strength. This test, which demonstrates moderate inter-
tester reliability in patients with patellofemoral pain syn-
drome (0.67), evaluates patients’ quality of movement by
identifying characteristics of lower extremity function,
including medial knee deviation or knee valgus.15 As knee
valgus is reported to be coupled with hip adduction and
internal rotation,9,16 it may be plausible to interpret exces-
atshc.com
11/3/2009 2:57:22 PM

sive knee valgus observed during this test as an indication
of eccentric weakness of the hip abductors and external
rotators. To this effect, Mascal et al5 used an anterior step-
down task for evaluative and rehabilitative purposes in 2
case studies on the management of patellofemoral pain
syndrome, reporting increases in hip abduction and ex-
ternal rotation strength and decreased knee valgus dur-
ing the step-down test following a 14-week intervention
program.
These case reports coupled with the intertester reli-
ability of the lateral step-down test support the premise
that this technique may provide clinicians with a simple
method to evaluate the strength of the hip abductors
and external rotators during a functional task. The ap-
plications of this test could be 3-fold, with the test being
used to detect strength deficits, serve as a benchmark for
progression during rehabilitation, and identify individu-
als at risk for lower extremity and low back pathology.
Therefore, the purpose of this study was to evaluate the
association between knee valgus and hip abduction and
external rotation strength during the lateral step-down
test. It was hypothesized that individuals displaying less-
er hip abduction and external rotation strength would
demonstrate greater knee valgus during the lateral step-
down test.
Methods
Participants
Forty-seven healthy individuals (22 men, 25 women;
mean age, 21.3±2.0 years; mean mass = 71.6±14.8 kg;
mean height = 194.3±11.5 cm) volunteered to partici-
pate in this investigation. Participants were generally
healthy and had no history of lower extremity surgery,
anterior cruciate ligament injury, or lower extremity
injury within 3 months prior to data collection that
prevented participation in activity for more than 1 day.
All participants read and signed an approved informed
consent document prior to participation.
Experimental Procedures
Isometric and eccentric peak torque of the hip abductors
and external rotators of the dominant leg were collected
prior to kinematic analysis of the lateral step-down task
in all participants. The order of testing for hip abduc-
tion and external rotation was randomized. However,
the eccentric measure was always performed prior to
the isometric measure, with participants performing 5
Athletic Training & Sports Health Care | Vol. 1 No. 6 2009
ATSHC1109NORCROSS.indd 273
Lateral Step-Down Test
1
Figure 1. Starting (A) and ground contact (B) positions of the lateral
step-down test.
continuous concentric-eccentric isokinetic repetitions
and 3 isometric trials lasting 3 seconds each with 10 sec-
onds of rest between trials. All data were sampled from
the dominant leg, defined as the leg used to kick a ball
for maximal distance.
Following completion of the strength assessment,
participants performed the lateral step-down test, during
which knee kinematics of the dominant leg were mea-
sured. This test was performed at a standardized tempo
of 58 beats per minute via a metronome to standardize
movement velocity. Participants began in a single-leg
stance on their dominant leg atop a 30-cm high box with
the nonstance leg positioned just lateral to the box and
the hands placed on the hips. At the first beat of the met-
ronome, participants lowered themselves toward the
floor so that their nondominant heel made contact with
the ground at the time of the second beat; participants
returned to the starting position by the third beat of
the metronome (Figure 1). Participants were instructed
to maintain level hip position by not reaching for the
ground with the nonstance leg. Following proper dem-
onstration of the task by a certified athletic trainer (T.J.H.
or S.D.H.), participants were allowed to practice until
comfortable before performing 5 separate trials of the
lateral step-down test.
Instrumentation
Peak torque was measured using the Biodex System 3
Isokinetic Dynamometer (Biodex Medical Systems,
Shirley, NY). Hip abductor strength was assessed with
participants positioned on their side with their arms
crossed at the chest facing the dynamometer so that the
dominant leg was positioned on top of the nondominant
273
11/3/2009 2:57:23 PM
 Norcross et al.
2
Figure 2. Positioning of participants during hip abduction isokinetic
and isometric strength assessment.
leg (Figure 2). The nondominant leg and trunk were sta-
bilized by straps to control for trunk rotation, and the
axis of the dynamometer was aligned 0.5 inches medial
to the anterosuperior iliac spine at the level of the greater
trochanter.17 Resistance was applied by the lever arm to
the lateral aspect of the thigh just proximal to the lateral
femoral condyle. Participants were instructed to exert
maximally against the dynamometer in the direction of
abduction while keeping the dominant leg straight.
Peak eccentric torque was recorded during the mid-
dle 3 of 5 continuous concentric-eccentric repetitions at
60°/second through a range of 0° to 20° of hip abduction.
Isometric peak torque was then assessed 3 times for 3 sec-
onds each with 10 seconds of rest between trials. Partici-
pants’ positioning remained the same as in isokinetic test-
ing but with the hip fixed at 10° of abduction. A separate
reliability study established high intrasession reliability
for eccentric isokinetic intraclass correlation coefficient
(ICC) = 0.85, SEM = 11.34) and isometric (ICC = 0.95,
SEM = 6.41) hip abduction peak torque measures.
Hip external rotation strength was assessed with par-
ticipants seated with the hip and knee flexed to 90°. Par-
ticipants sat with the arms crossed at the chest, the thigh
and trunk stabilized by straps, and a rolled towel placed
between the knees (Figure 3) to act as a fulcrum for ex-
ternal rotation and to prevent compensatory hip adduc-
tion, which could have altered the peak external rotation
strength measured. The axis of rotation of the dynamom-
eter was aligned with the long axis of the femur, and resis-
tance was applied by the lever arm immediately superior
to the medial malleolus.
Peak eccentric torque was recorded during the middle
3 of 5 continuous concentric-eccentric repetitions at 60°/
second through a range of 15° of hip internal rotation and
274
ATSHC1109NORCROSS.indd 274
3
Figure 3. Positioning of participants during hip external rotation iso-
kinetic and isometric strength assessment.
5° of hip external rotation. Isometric peak torque was as-
sessed 3 times for 3 seconds each with 10 seconds of rest
between trials. Participants’ positioning remained the
same as in isokinetic testing but with the hip fixed in neu-
tral rotation (0°). Intrasession reliability for eccentric iso-
kinetic (ICC = 0.94, SEM = 3.61) and isometric (ICC =
0.93, SEM = 3.20) hip external rotation peak torque mea-
sures were established during pilot testing prior to data
collection.
Knee kinematics were assessed during the lateral
step-down test using an electromagnetic motion cap-
ture system (Flock of Birds, Ascension Technology
Corp, Burlington, Vt). Electromagnetic tracking sensors
were positioned directly on the skin of the anteromedial
shank, lateral thigh, and sacrum over areas of minimal
muscle mass to reduce motion artifact. Global and seg-
ment axis systems were established with the positive X
axis designated as forward/anteriorly, the positive Y axis
as leftward/medially, and the positive Z axis as upward/
superiorly. The dominant lower extremity was modeled
by digitizing the ankle, knee, and hip joint centers. Ankle
and knee joint centers were defined as the midpoint of
the digitized medial and lateral malleoli, and the medial
and lateral femoral condyles, respectively. The hip joint
center was estimated using a least squares method de-
scribed by Leardini et al.18 The Motion Monitor motion
analysis system (Innovative Sports Training, Chicago, Ill)
atshc.com
11/3/2009 2:57:24 PM

4 5
Figure 4. Scatterplot showing normalized isometric (Iso ABD) and ec-
centric (Ecc ABD) hip abduction strength and FPA ([-] valgus, [+] varus)
with associated simple linear regression trend lines. The solid line rep-
resents Iso ABD (r = -0.372, P = .011*), and the broken line represents
Ecc ABD (r = 0.103, P = .496). *Correlation is significant at p ≤ 0.05.
was used for model generation and calibration as well as
data acquisition.
Data Sampling and Reduction
Peak eccentric isokinetic and isometric torque values
for hip abduction and external rotation were gravity
corrected, normalized to the product of participants’
height and mass, and averaged across trials, resulting in
4 unitless expressions of relative strength:
l Eccentric hip abduction (Ecc ABD).
l Isometric hip abduction (Iso ABD).
l Eccentric hip external rotation (Ecc ER).
l Isometric hip external rotation (Iso ER).
Kinematic data were sampled at 50 Hz and filtered
using a zero-phase lag 4th-order Butterworth low-pass
filter with a cutoff frequency of 12 Hz. Kinematic an-
gles were calculated as the reference frame of the shank
relative to the reference frame of the thigh using Euler
angle sequences rotated in an order of flexion-extension
(Y-axis), valgus-varus (X-axis), and internal-external ro-
tation (Z-axis). By convention, knee flexion was indicat-
ed by positive values, and knee valgus was indicated by
negative values.
Values for knee varus-valgus and flexion-extension
were obtained at initial descent, defined as the time
when the knee flexion angle exceeded 10° and at peak
knee flexion. In addition, the peak knee varus-valgus
angle during this time period was calculated. All kine-
matic angle values were identified by computer algo-
rithms used via custom software (LabVIEW, National
Instruments, Austin, Tex). The variables of interest
for statistical analysis were frontal plane knee angle
at peak knee flexion (FPA) and frontal plane displace-
ment (FPD) during the lateral step-down test. Frontal
Athletic Training & Sports Health Care | Vol. 1 No. 6 2009
ATSHC1109NORCROSS.indd 275
Lateral Step-Down Test
Figure 5. Scatterplot showing normalized isometric (Iso ABD) and
eccentric (Ecc ABD) hip abduction strength and FPD ([-] valgus, [+]
varus) with associated simple linear regression trend lines. The solid
line represents Iso ABD (r = -0.132, P = .381), and the broken line rep-
resents Ecc ABD (r = 0.216, P = .149).
plane displacement was defined as the difference be-
tween the peak frontal plane knee angle during the test
and this same angle at initial descent.
Statistical Analysis
The relationships between each strength variable (Ecc
ABD, Iso ABD, Ecc ER, and Iso ER), and FPA and
FPD, respectively, were evaluated using bivariate Pear-
son correlation coefficients following the removal of
outliers. In total, the data for 3 participants were re-
moved from various analyses when their value on a de-
pendent variable involved in the correlation was more
than 2.5 standard deviations from the mean. This re-
sulted in slightly different sample sizes and composition
across analyses but maintained the assumption of nor-
mality for the statistical models. All analyses were con-
ducted using SPSS 16.0 software (SPSS Inc, Chicago,
Ill). Statistical significance was established a priori with
the alpha level set at P < .05.
Results
There were no significant relationships between Ecc
ABD and FPA (r = 0.103, P = .496, n = 46) and FPD
(r = 0.216, P = .149, n = 46); Ecc ER and FPA (r = 0.052,
P = .734, n = 45) and FPD (r = 0.050, P = .746, n = 45);
Iso ER and FPA (r = -0.179, P = .228, n = 47) and FPD
(r = -0.187, P = .208, n = 47); and Iso ABD and FPD
(r = -0.132, P = .381, n = 46) (Figures 4-7). However,
Iso ABD was significantly and negatively correlated
with FPA (r = -0.372, P = .011, n = 46), indicating
that participants with greater isometric hip abduction
strength demonstrated greater knee valgus ([-] angular
convention) motion (Figure 4). Descriptive statistics
for all outcome variables are presented in the Table.
275
11/3/2009 2:57:25 PM
 Norcross et al.
6 7
Figure 6. Scatterplot showing normalized isometric (Iso ER) and ec-
centric (Ecc ER) hip external rotation strength and FPA ([-] valgus, [+]
varus) with associated simple linear regression trend lines. The solid
line represents Iso ER (r = -0.179, P = .228), and the broken line repre-
sents Ecc ER (r = 0.052, P = .734).
Discussion
These findings show eccentric strength of the hip ab-
ductors and eccentric and isometric strength of the hip
external rotators are not related to frontal plane knee
motion during the lateral step-down test. Isometric hip
abduction strength was weakly correlated with frontal
plane knee angle at peak knee flexion. Individuals with
greater isometric hip abduction strength demonstrated
greater knee valgus with Iso ABD strength explaining
approximately 14% of the variation in FPA (r2 = 0.138).
However, the low strength of the association in the di-
rection contrary to what would be expected from a bio-
mechanical framework makes the clinical significance of
this result unclear.
Prior to comparing our results to previous research, it
is important to note how the use of either 2-dimensional
(2-D) or 3-dimensional (3-D) methods of motion anal-
ysis changes the strict interpretation of the measured
“knee valgus” motion. Although 3-D motion analysis
yields pure frontal plane knee angles, 2-D motion analy-
sis results in dynamic knee valgus, or medial knee dis-
placement, angles in which the specific contributions of
femoral adduction and internal rotation, and knee valgus
motions to this composite angle are not known. As a re-
sult, it is difficult to directly compare the magnitudes of
the frontal plane knee angles reported in the literature.
Therefore, it is necessary to compare studies based on the
premise that during closed kinetic chain activities, knee
valgus, femoral adduction, and femoral internal rotation
are associated,9,16 and increased movement into these po-
sitions would result in greater measured 2-D dynamic
knee valgus or 3-D pure knee valgus angles.
Our findings are consistent with a number of previous
studies examining the relationship between hip strength
and frontal plane knee kinematics during dynamic tasks
276
ATSHC1109NORCROSS.indd 276
Figure 7. Scatterplot showing normalized isometric (Iso ER) and ec-
centric (Ecc ER) hip external rotation strength and FPD ([-] valgus, [+]
varus) with associated simple linear regression trend lines. The solid
line represents Iso ER (r = -0.187, P = .208), and the broken line repre-
sents Ecc ER (r = 0.050, P = .746).
that imposed similar demands. Thijs et al19 evaluated hip
strength in individuals performing a single-leg forward
lunge and found no significant differences in peak hip
abduction (Cohen’s d effect size [d] = 0.36) or external
rotation (d = 0.30) strength between a group that moved
into dynamic knee valgus during the lunge compared to a
group that moved into dynamic knee varus as measured
using 2-D video analysis. In addition, they found no sig-
nificant relationships between hip abductor and external
rotator strength and the magnitude of frontal plane knee
motion in either group. Bell et al20 found that participants
who displayed medial knee displacement during an over-
head squat test exhibited greater normalized isometric
hip external rotation strength than participants who did
not demonstrate medial knee displacement using 2-D
video analysis. However, they also found no differenc-
es between groups in isometric hip abduction strength
(d = 0.34), and concluded hip musculature weakness did
not contribute significantly to frontal plane knee motion
during this functional task. Lawrence et al21 also showed
no significant difference in the frontal plane knee angle
of participants with high and low hip isometric external
rotation strength (d = 0.21) during a single-leg drop land-
ing using 3-D motion analysis.
Two studies have reported a significant relationship
between hip musculature strength and frontal plane
knee angle that are inconsistent with our results. Willson
et al22 demonstrated a significant association between
greater isometric hip external rotation strength and lesser
frontal plane projection angle (r = 0.40), defined as the
angle between lines drawn between the anterosuperior
iliac spine to the middle of the tibiofemoral joint and the
mid-tibiofemoral joint to the middle of the ankle mor-
tise, derived using 2-D kinematic analysis. Claiborne et
atshc.com
11/3/2009 2:57:26 PM

al23 evaluated hip strength and frontal plane knee motion
in individuals performing a single-leg squat using 3-D
analysis. Peak knee valgus and frontal plane knee mo-
tion, defined as the difference between peak knee valgus
during the squat and standing frontal plane knee angle,
were not significantly correlated with either eccentric hip
abduction (r = -0.249) or external rotation peak torque
(r = -0.356). However, concentric hip abduction was sig-
nificantly correlated with the magnitude of frontal plane
knee motion (r = -0.365). The authors concluded greater
hip abduction strength resulted in decreased motion in the
valgus direction during a single-leg squat. It is important
to note, however, that greater knee valgus is associated
with greater hip adduction.9,16 As a result, it is expected
that eccentric, not concentric, force production from the
hip abductors would be important in limiting knee valgus
motion as these muscles would be lengthened during hip
adduction motion. Therefore, it remains unknown how
concentric strength of the hip abductors would influence
knee valgus motion.
Although the findings of this study are contrary to
our hypotheses, we propose the following possible ex-
planation for the obtained results. The lateral step-down
test used in this study may not have placed a sufficient
functional demand on our participant sample to elicit the
response suggested by earlier research. Previous studies
on healthy individuals that identified lesser hip strength
in participants displaying greater frontal plane knee mo-
tion involved more demanding tasks such as running11
and single-leg landing from a jump.10 It may be that the
single leg step-down test used in our study, similar to the
forward lunge19 and single-leg squat,23 was not demand-
ing enough dynamically and allowed participants to use
compensatory mechanisms they would not be able to use
in a more difficult task. For instance, participants with
greater strength may have been able to go into greater
knee valgus knowing they had the requisite strength to
return from that position, whereas the task may have
been slow enough for those with lesser strength to make
a compensatory knee varus movement to successfully
complete the task. These potential compensatory mecha-
nisms help to illustrate the multifactorial nature of the
strategies used to complete a dynamic task, which makes
it difficult to draw conclusions regarding individual per-
formance and just a limited number of those factors.
Nonetheless, the results suggest the use of the lateral
step-down test is not indicative of hip abduction or exter-
nal rotation strength in asymptomatic individuals. Fur-
Athletic Training & Sports Health Care | Vol. 1 No. 6 2009
ATSHC1109NORCROSS.indd 277
Lateral Step-Down Test
Tab l e
Descriptive Statistics for FPA and FPDa,
and Normalized Isometric and Eccentric
Hip Abduction and External Rotation
Strength
Mean±SD
FPA 7.28°±8.70°
FPD 5.66°±0.23°
Eccentric hip abduction 0.053±0.180
Isometric hip abduction 0.052±0.015
Eccentric hip external rotation 0.038±0.009
Isometric hip external rotation 0.030±0.007
Abbreviations: FPA, frontal plane knee angle at peak knee flexion; FPD, frontal plane
displacement.
a
(-) valgus, (+) varus.
thermore, based on the results of this study, it is unclear
how this test may be applied to a pathologic population.
Although hip abductor1-3,5 and external rotator1,3,5 weak-
ness has been demonstrated in individuals with patholo-
gies associated with increased frontal plane motion, such
as patellofemoral pain syndrome and iliotibial band fric-
tion syndrome, it is unknown whether this weakness
would manifest in increased frontal plane motion dur-
ing the lateral step-down test or potentially be obscured
via the same compensatory mechanisms that were likely
present in this study.
Limitations and Future Research
Future research is necessary to assess the utility of the
lateral step-down test to evaluate hip abductor and ex-
ternal rotator strength in a patient population actively
experiencing symptoms related to chronic lower ex-
tremity pathologies. Our study was limited in that it
evaluated healthy individuals who may have exhibited
strength and neuromuscular control mechanisms that
are not congruent with patients currently experiencing
symptoms. Evaluation of an adapted version of the lat-
eral step-down test from a greater height or at a greater
velocity so as to increase the dynamic demands placed
on a healthy population also is warranted for its possible
use in identifying individuals at risk for lower extremity
and low back injuries.
In addition, because all participants performed ec-
centric strength testing prior to isometric strength testing
as we considered the eccentric measure to be the most
important, we cannot rule out the possibility that test-
277
11/3/2009 2:57:27 PM
 Norcross et al.
ing order may have impacted the strength measures.
Furthermore, although our methods allowed for assess-
ment of maximal torque production capacity of the hip
abductors and external rotators, it is unclear to what ex-
tent this capacity was used during the lateral step-down
test. It is probable that muscle activation (ie, % maximal
effort) in combination with strength of the gluteus maxi-
mus, gluteus medius, and associated hip musculature is
more important in explaining dynamic control of frontal
plane knee motion than absolute strength alone. In other
words, the fact that individuals possess a high level of
strength does not necessitate that they use that strength
during a given task. Future research should incorporate
electromyography to determine the relative activation
levels and contributions of these muscle groups during
this task.
Conclusion
These findings indicate the use of the lateral step-down
test in a healthy population to draw conclusions relat-
ed to hip abductor and external rotator strength is not
justified. There appear to be no clinically significant
relationships between isometric and eccentric strength
of the hip abductors and external rotators and frontal
plane knee motion during this test. n tive intensity of hip extensor and abductor muscle action during
References
1. Bolgla LA, Malone TR, Umberger BR, Uhl TL. Hip strength and hip
and knee kinematics during stair descent in females with and
without patellofemoral pain syndrome. J Orthop Sports Phys Ther.
2008;38:12-18.
2. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oes-
treicher N, Sahrmann SA. Hip abductor weakness in distance run-
ners with iliotibial band syndrome. Clin J Sport Med. 2000;10:169-
175.
3. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in fe-
males with and without patellofemoral pain. J Orthop Sports Phys
Ther. 2003;33:671-676.
4. Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core sta-
bility measures as risk factors for lower extremity injury in athletes.
Med Sci Sports Exerc. 2004;36:926-934.
5. Mascal CL, Landel R, Powers C. Management of patellofemoral
pain targeting hip, pelvis, and trunk muscle function: 2 case re-
ports. J Orthop Sports Phys Ther. 2003;33:647-660.
6. Powers CM. The influence of altered lower-extremity kinematics
278
ATSHC1109NORCROSS.indd 278
on patellofemoral joint dysfunction: A theoretical perspective. J
Orthop Sports Phys Ther. 2003;33:639-646.
7. Fredericson M, Yoon K. Physical examination and patellofemoral
pain syndrome. Am J Phys Med Rehabil. 2006;85:234-243.
8. Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate
ligament injuries: Risk factors and prevention strategies. J Am Acad
Orthop Surg. 2000;8:141-150.
9. Ireland ML. Anterior cruciate ligament injury in female athletes:
Epidemiology. J Athl Train. 1999;34:150-154.
10. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abduc-
tor function and lower extremity landing kinematics: Sex differ-
ences. J Athl Train. 2007;42:76-83.
11. Heinert BL, Kernozek TW, Greany JF, Fater DC. Hip abductor weak-
ness and lower extremity kinematics during running. J Sport Reha-
bil. 2008;17:243-256.
12. Fredericson M, Weir A. Practical management of iliotibial band fric-
tion syndrome in runners. Clin J Sport Med. 2006;16:261-268.
13. McConnell J. The physical therapist’s approach to patellofemoral
disorders. Clin Sports Med. 2002;21:363-387.
14. Lephart SM, Abt JP, Ferris CM, et al. Neuromuscular and biome-
chanical characteristic changes in high school athletes: A plyomet-
ric versus basic resistance program. Br J Sports Med. 2005;39:932-
938.
15. Piva SR, Fitzgerald K, Irrgang JJ, et al. Reliability of measures of im-
pairments associated with patellofemoral pain syndrome. BMC
Musculoskelet Disord. 2006;7:33.
16. Padua DA, Marshall SW, Beutler AI, et al. Predictors of knee valgus
angle during a jump-landing task. Med Sci Sports Exerc. 2005;37(5):
S398.
17. Lyons K, Perry J, Gronley JK, Barnes L, Antonelli D. Timing and rela-
level and stair ambulation: An EMG study. Phys Ther. 1983;63:1597-
1605.
18. Leardini A, Cappozzo A, Catani F, et al. Validation of a functional
method for the estimation of hip joint centre location. J Biomech.
1999;32:99-103.
19. Thijs Y, Van Tiggelen D, Willems T, De Clercq D, Witvrouw E. Rela-
tionship between hip strength and frontal plane posture of the
knee during a forward lunge. Br J Sports Med. 2007;41:723-727.
20. Bell DR, Padua DA, Clark MA. Muscle strength and flexibility char-
acteristics of people displaying excessive medial knee displace-
ment. Arch Phys Med Rehabil. 2008;89:1323-1328.
21. Lawrence RK III, Kernozek TW, Miller EJ, Torry MR, Reuteman P.
Influences of hip external rotation strength on knee mechanics
during single-leg drop landings in females. Clin Biomech (Bristol,
Avon). 2008;23:806-813.
22. Willson JD, Ireland ML, Davis I. Core strength and lower extrem-
ity alignment during single leg squats. Med Sci Sports Exerc.
2006;38:945-952.
23. Claiborne TL, Armstrong CW, Gandhi V, Pincivero DM. Relationship
between hip and knee strength and knee valgus during a single
leg squat. J Appl Biomech. 2006;22:41-50.
atshc.com
11/3/2009 2:57:27 PM
Copyright of Athletic Training & Sports Health Care: The Journal for the Practicing Clinician is the property of
SLACK Incorporated and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print, download, or email
articles for individual use.

View publication stats