Som J M5 prs 198-9. 76-81 Pineda red opyieh © Mksgord 109 WBIaNE LIEN webieine y SefeNce IN'seoRts. Active knee joint flexibility and sports activity Hann 1, Foldspang A. Vestergaard E, logemann-Hansen T. Active knee {joint Rexibility and sports activity Scand ) Med Sei Sports 1999-9. 14-80. © Munksgaard, 1999 “The aim of the study was to estimate active knee flexion and active ke extension in athletes ard to investigate the potential asociation of each to diferent ypes of sports activity. Active Ince extension and acive knee T.taha!, A. Feldapang?, E-Vestargaar’, r Ingemane-Hanson? "jr ine, Darina Reston, wines oma a Soc! Medios an *eparnet ot ots See, ea ‘ery Aa Dermat flexion was measured in 339 athletes, Active Knee extension was sigificant- ly higher im women tha in men and significantly positively associated swith weekly hours of swimming and weekly hours of competitive gym- Tics. Active Knee flexion was sinfcanl pos TOR ton Cnet ad sete gate an yy urs of sxe, Fron active knee extension. Flexibilay is generally defined as the maximum ablity to move 4 joist through a range of move- tment and it is believed to be an important aspect Of specific sports activity (1). Flexiility is limited by internal factors. eg.. bone structure, muscle vol- ‘une and elasticity of muscles, tendons. joint cap- ‘sue and ligaments, and external factors, ¢g.. oom Temperature, warm-up and physical exerese (2). In clinical practice. internal factors are usually divided into intra- and extraarticular components. Reduced Aexibility ie thus considered to be caused by either intra-articular joint disease, eg. arthrosis and men- itcal lesion, or by estra-erticular conditions, eg. reduced elasticity (tightness) of muscles, tendons and ligaments Kee joint flesbilty and sports activity seem to exert a reciprocal impact (2-5). Moreover, reduced and increased knee joint flexibility have both been as: sociated with knee joint and soft tissue injuries (6. 7) Furthermore, knee joint flexibility has been used to indicate rehabilitative 8-11) and surgical success (12 13), and itis possibly of importance for the aetiology and prevention of sport injury (4, 14) If itis possible to identify specific types of sports activity associated ‘with reduced knee joint flexibility, enhanced preven tive and rebabilitaive actions, eg. stretching exer cies. may take place. The investigation may thus be Important for the development of effective, sports specific strategies in the prevention of knee injuries a associated with ‘asociated with team handball and swimming, ‘esults point fo sport-spcific adaptation of active knee flexion and Ker wore: eso. ets, se et ‘tice ot sng pyres. asta soc Earp em aa ‘ras Hab, MO, Pa MPM prs Soares of sarang, Fs Un. ‘ang 8, doa, Ree ‘e400 fons, Dene ced uteation 9 Nowe 188 and for the continuous development of sports train- ing programmes in general “The aim of the present study was to estimate active ince flexion and active knee extension in athletes and to investigate the potential association of each to spe- tific sports activity. The study comprised active, competitive, non-preg- nant athletes, aged 14-24 years, who were members of one of two sports clubs in Aarius County, Denmark. One sports clab was suburban, near the city of Aarhus (204 000 inkabitants), and the other was situated in a rural area (Ebeltoft, 13 338 inhab- tants) (15)- During April-Deoember 1952, 339 (83%) of eligible athletes had their active knee Nexion and ‘active knee extension measured and answered a ques- Uionpaire about occupation and sports activity within, the preceding 12 months. ‘Active knee extension was measured, with the ath= lete placed in the supine positon, the hip stabilized at 90° flexion and the leg maximally extended, as the ‘upper angle between 1) the line from the fibular head 10 the lateral malleolus, and 2) a vertical line parallel 10 the longitudinal axis of the femur (16) (Fig. 1). A highangleis equivalent toa high active knee extension. Active eee flexion was measured with the athlete placed in the prone position and the leg maximallyFa. 1. Active knee extemion test. Reprinted fom Physical ‘Therapy. Gajdosik R, Lon G. Hamtring muss tightness olan acthe-kne-eteson tes. 1983: 65 1085-1090 wih the persion ofthe APTA. flexed. Active knee flexion was measured as the angle between 1) the line, from the fibular head tothe lateral ‘malleolss, nd 2)1 horizontal line parallel tothe longi- tudinal axis of the femur (17) Fig. 2). A high angle is ‘equivalent to a high active knee flexion. Room tem- perature was measured, and the athletes were not Allowed to take physical exercise orto warm-up for the last 30 min before the tests. Each athlete was measured ‘once on ac le by the same investigator. Data of active knee extension, actve kaee flexion and body length were approximately normally dis- ributed, whereas data of sports participation and oc- ‘cupation, xcept for duration of sports participation, ‘vere non-normally distributed. Neither active knee ‘extension nor active knee fexion test results showed significant difference between left and right knee and ‘Active knee joint flexibility and sports activity were analysed by use of the mean of the two sides “st results more than 3 iterquardle ranges from the 25th and 75th perceatiles (1.5% of the active knee ‘exion das) were removed in order to improve est- ‘mates of means. The statisical analysis applied Pear son’ ext, Stadents test and multiple linear e- tresion performed by a combination of forward Selection ad backward elimination (18). All mltiple Tear regreiontinciaded age sex sportsclub sport (ype and number of different types; years and mean numbers of wetly hours of participation within the receding 12 months), and occupation (ears; mean Trumbers of weely and daily hous of standing. walh- ing and siting work within the preceding 12 months). 1P=O.5 was Wed a8 « general vel of significance. The profet was approved by the Regional Com nittes of Ethes of Medical Science, Aarhus, Denmark, and bythe National Registry Inspectorate Results Questionnaie response ‘Among responders, 125 (37%) were female and 214 (63%) male, aged 14-24 years (mean 18 years, median 17 years). Response was independent of sex and sports club but decreased with age (OR 0.84 (0.76- 0.93) per year of age, P<0,001). Among gymnasts, ‘the response was 47% ws. 84% in other athletes (2<0001). Among swimmers, the response was 100% vs. 82% in other athletes (P<0.05) Sports partipation and occupation ‘The mean duration of sports participation was 10 years (SD 3.7}; mean amount of sports participation, ' h/week (median 7 b, range 0-32 hy; mean duration of oocupational work, 2 years (median 1 year, range ‘We 1 Ata eas (A) dat is son Eby sx an ge 59 alts, asus, Deak 1382 Se No ME ayes) ARF ene) peed won tw 80 ws 8 ms 8 ww to o1r wm 8 a au 8 8h jt az) orn Yes =m z ms wy @ mB sme ho "em ue ie 7 ae on OM a om 7 Soro tatHaha et al. (0-13 yearsy; mean amount of occupational work, 13, Iweck (median 6 h. range 0-60 h)- Active knee extension, active knee flexion and body height Mean active knee extension was ~35*, without sig- nificant difference between left and right knee, but ‘was higher in women than in men (mean difference "Wl 2 Ace oe esteson (AE an ete ein (AK) by He TT, P<0.001) (Table 1). Active knee extension was positively associated with participation in competitive ‘gymnastics and swimming (Table 2). Active knee ex: Tension was also positively associated with weekly hours of competitive gymnastics and weekly hours of ‘swimming, but negatively associated with weekly hhours of soccer (Table 3). Moreover, active knee ex- tension was positively associated with years of swim- ‘ming and jogging (Table 4). fpr? in 39th, Ars, Orman, 1982 Type d spon ie? AE (gre) AF eres) ee eT) ‘once 7 He a8 sa ai 220 08 opin wan tania «w= ODS] aN? 086 ‘eaten © ms ML i127 Sar ast Boman @ we - 1 in 0M tor Tens @ 18-3 228 2 OL 13 Compete ymmanes = «6B TOH AL Semnng O 6-0 gi 1m 123-80 116 sana Rome "fee oss "For ations et? Wen pcan 17 mnt Ashe aie arco moran ae ptf sr. te numbers km uD tro tan 339" Sex: and agora ratio near ees estima (8) and standard wor SE) of Spee NPE Seans « Peto Poot. ‘tort vs oes. "We 3, Ace oe eso (Ea ave heen (A) by tours cf po per wen 330 ales, ars, Denna, 182 “pe ot poe ows of pct per weet? ARE Gey) MF (res) ve Fae * =o & se Sacer “aC OR ame OT ns Earoean a hardba ao “os 138 | “ow ot ‘suet s2 oR 00 127 ose ON Baameton 2 os 0% 168-05 a Teen 188 “0m om 0a Ost Conti aynnastis a4 bo hie or OB om Seemng aout om 021-021 On pod hte -0@ 949 009 amt "Fos otens ne ta? Wain be prcding 12 mows. "Amen aes paricoaeg in 2 soe ‘tiple reson esate (8) an stand er (SE) per hour ‘Th 4 Ave eve san (an ch he tin (A by ‘Won of sar. “Sex at apecorecne oor pe weet P08 * AcOH,” PDO i spon in 29 aha, Aas, Oa, 1982 ‘Woe oso Years spor ARE (epnes) ARF (ores) Meant Rage EG) SEB) scar soo | 07 on | Oat 0@ foropen tam antes = AG ONO -tatt On beset 45 01 os Oe anton a5 yO 025, ‘es 24 ti oar 08 ste ast Conpettve grasics «42S OMB, OOM OT Seong 1% oe Gwe oz oo =m M4 soot oe oss "Fer tinting, ser tt Anang aes paring a spi peo por. * Sac nd pcos regrsion eit 8) 1 Sana ear (0 per war sor. POS. * AO * PB 83 €@ nas Ope F152, 15323, POO; Ate F018 * Wine pending ¥2 monte 006, * “ODN? PO. Mean active knee fleion was 123°, without signifi- cant difference betweea lefl and right side, and un- associated with sex (Table 1). Active knee flexion was negatively associated with participation in socer and European tcam handball, but positively associated with participation in basketball (Table 2). These as- sociations were abo found in respect of weekly hours of sports participation (Table 3). Active knee flexion ‘was negatively associated with years of soocer and years of European team handball but positively as- Sociated with years of basketball, tennis and competi- tive gymnastics (Table 4. ‘Mean female body beight was 168 em (range 154— 190 cm), and mean male body height was 179 cm (range 161-199 em). Active knee extension (AKE) land active knee fexion (AKF) were both negatively aswociated with body height (AKE=—2.69- ‘O.19xbody height, P<0.05, AKF=139-0.10xbody hight, P<005). ‘In multiple linear regressions, active knee extension 1was found to be significantly higher in women than in men and positively associated with weekly hours of swimming and weekly hours of competitive gym- nastics (Table 5, Fig. 3). Active knee flexion was found to be positively associated with participation in basketball, and negatively associated with age and ‘weekly hours of soccer, European team handball and ‘swimming (Table 5, Fig. 4). Discession Kee joint flexiility consists of flerion, extension ‘and rojation in flexion (19). Flexion and extension Of the knee can be measured by simple and reliable ‘methods (16, 17), whereas rotation is difficult to measure, Although rotational movements ofthe knee Active knee joint Mlexibility and sports activity ‘may be important for both the performance of sport ‘and the development of knee symptoms (20), this study focuses on knee flexion and knee extension. ‘Knee flexion and hace extension can be measured by active movements of the investigated athlete and by passive movements made by the investigator. As knee flexitilty is limited by extraarticular con ditions, the test result is dependent on the body pos: tion, eg., are the hamstring muscles tightened by in- ‘creased flexion of the hip, which reduces Knee joint fexibiity. A standardized testis thus important for the reliability of the method. Ta the present investigation one test each of active AKE (degress) ‘Hours of awinming per week Fi, 5 Observed snd estimated’ mean active knee extension (Akin by hours of sports partciption yer seek in 339th tes, Aarhus, Dermat, 1982." By linear reresion. Model: Akin S66+2ss3chours of competitve gomnasie per eek, POD, AKE="35.66+0.xXhous of swimming fet ‘eek, P<0.05, For defaition, see ext. 7Hahn et al. AKE (degrees) AXE (degrees) Eatimated +) + Observed Hours of swimming per week 7 Fe 4 Observed snd eximatt! mean active knee flexion (csp by tows ot sperm peipston perme a 39a tees, Abus Denar 1982 "By Inca mgreson. Mode IREFO001. AKF=12281-0.18shours of Tk Boon Rr aetnitom ete nee extension and active knee flexion were chosen as thee active tts ave « high reliability, are more Standardized and better documented than the passive {ests (16, 21-25). The tess of ative knee extension and active knee flexion are standardized 0 thatthe atblete i i a position where the hamstring muscles respecively the quadriceps muscle generally ae the limiting factors. Accordingly, these tests are often wed a indicators for hamstring muscle respectively quadreeps muscle tightness. Hower, when inter- ‘ectating the results tis important to recognize that both intra-articular and other extra-artcular compo- rents may influence the tet result At active tests de- ‘rnd on the force production of the athlete, athletes ‘with high muscular strength may appear to have higher knee flexibility than athctes with low musey- Jar strength. However, afer multivariate analyses ac- tie knee extension and active fexion were not asoci- Mod with body height, which the foree production ‘of the quadriceps and hamstring muscles ae highly ‘ependent on. {nthe present study of young, competitive athletes, setive knee extension was found to be psinely as ‘ociated with weekly hours of swimming and com petitive gymnastics, whereas active knee flexion was Positively associated with participation in basketball, nd negatively associated wit weekly hours of swim thing, soccer and Europesn team handball. Mean ac- tive hace extension and mean ative knee flexion as S33" and 123, respectively. These results rein cement with revously published ste showing mean active knee extension ranging from ~ "(161,22 and mem tes et eon an ing fom 110" to 134 (17,24, 25) Variation between the studies may reflect differences in methods and study population. Room and body temperature may Affect the flexibility (26). In the present study. room temperature was not correlated with active knee et tension and active knee flexion, and physical exerci and warm-up were ot allowed before the tei. This Aspect it not addressed in all previously pubiched studies (21, 22, 24, 25), which may explin some of the variation betwosn the studies The study may have been biased by “heathy athlete selection” ie, athletes with knee’ problems associated with Knee joint flexiiity may have changed to other types of Sport. or they may have stopped sports particpation However, thee was no association between priorcessation or pause with sport due to knee symptoms and present type of sport. Among 49 eigible gym tasts, the questionnaire response was only 47%; ac- condingly, conclusions about gymnasts are ten‘ative "The joint capsule, the muscles and tendons are the ‘ost important tissue forthe imitation of fleibilty (27). In the proveat study, active knee extension wae found o be higher in women than in men, which may te due to « lower muscular volume ands higher lax- lity ofthe musces, tendons and joint capsules in f- male athetes. Active knee flexion was negatively a sociated with age, which may be caused by increasing stiffs ofthe knee int capsules and the surround ing tendons and muscles (28, or it may be con founded by an incessing risk of posttranmate knee damage with age. The associations with age and sex are in accordance with previous studies (2, 29- 3D. ‘As flexibility seems to be enhanced by steady, uri- form elongation ofthe tissue at low loads (32), our @ priori expectation was that stimming would be a tocintd with a high flexibility of the koee joint, As traning of flexibility isa specie part of competiine symmstis, we, furthermore, expecied that compet- {ve gymnastics would be associated with a high flexiility of the Knee jont. This was i part con- firmed by the increased active knee extension by hours of swimming and competitive gymnastics. “Moreover, the results arein agreement with previo studies (3, 34). Active kee flexion was unexpectedly negatively associated with hours of swimming. This may reflect exercise-induced inflammation of the ‘quadcioops muscles, duo to the repetitive and monot- ‘onous quadriceps activity in swimming, but is never- theless surprising. Tn ball games, the knees are prone to acute injury, 2g. meniicus ksions, which may reduce flexibility Furthermore, the quadriceps musles may develop ia- flammation an increased stifiess duc to exces kick- ing and jumping, which may induce decreased knce joint flexion. According our inital expectation was that participation in ball games would be associated with a reduced flexibility of the Knee joint. This was in put cosfirmed by the negative asociation between active knee fleion and weekly hours of soocer and European team handball, Moreover, the rel rein accordance with a previous finding of reduced knee fexiility in soccer players in contrat 1 other ath- Jetes (35). Participation in basketball was associated vith «high acive hee flexion, which may indiate that basketball has higher demands oa knee joint flexibility, as compared to other types of sport. The spor'-specfic associations could reflect exercise-n- duced adaptation. However, the findings may pos ibly be biased by selection asociated withthe ath- Jets initial ehoice of spore. athletes may choose to partciate in competitive gymnastics because they ‘Active knce joint flexibility and sports activity hhave high knce joint flexibility. This point of view is sustained by the lack of multivariate association with years in sport. ‘Most of the associations between knee join flex- bility and sport have not been documented pre- Viously. Not least, the association with gymnastics shouldbe further investigated in future research with hopefully less non-partiipation among gymnasts. In view of the associations between soocer, European team handball, swimming and reduced active knee {cxion, the question arises whether athletes should be aadvired to do stretching exercises of the quadriceps muscles (36). 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