Baseline Time to Stabilization

Identifies Anterior Cruciate Ligament

Rupture Risk in Collegiate Athletes
Kevin M. DuPrey,*y DO, Kathy Liu,z§ PhD, Peter F. Cronholm,|| MD, Andrew S. Reisman,{ MD,
Steven J. Collina,y MD, David Webner,y MD, and Thomas W. Kaminski,§ PhD, ATC
Investigation performed at the Department of Kinesiology and Applied Physiology,
University of Delaware, Newark, Delaware, USA

Background: There is a need for successful screening methods to identify athletes at increased risk of anterior cruciate ligament
(ACL) injury. Previous research showed that collegiate athletes with ACL tears demonstrated slower time to stabilization during
jump landing after reconstruction.
Hypothesis: Collegiate athletes with baseline deficiencies in time to stabilization are at increased risk of subsequent ACL rupture.
Study Design: Case-control study; Level of evidence, 3.
Methods: A total of 278 National Collegiate Athletic Association Division I college athletes (166 men, 112 women; mean age, 18.5
years; height, 178.8 cm; mass, 79.9 kg) in the high-risk sports of men’s football; women’s volleyball and field hockey; and men’s
and women’s lacrosse, basketball, and soccer were measured to obtain baseline time to stabilization for backward, forward,
medial, and lateral single-legged jump landing tasks. Athletes were followed for ACL rupture over a 4-year period. Independent
t tests were used to evaluate differences in time to stabilization for each jump landing task between athletes with subsequent ACL
rupture and uninjured athletes. Logistic regression models were used to assess time to stabilization as a predictor for ACL
rupture.
Results: Nine athletes sustained noncontact ACL ruptures (5 men, 4 women). These 9 athletes took significantly longer to sta-
bilize compared with uninjured athletes during baseline backward jump landing (1.58 6 0.39 and 1.09 6 0.52 seconds, respec-
tively; P = .0052). The odds of ACL rupture increased 3-fold (odds ratio, 2.95; 95% CI, 1.28-6.77) for every second increase in
backward time to stabilization observed between injured and uninjured athletes.
Conclusion: Collegiate athletes with slower baseline backward time to stabilization were at increased risk of ACL rupture.
Keywords: dynamic postural stability; injury prevention; neuromuscular control; proprioception; anterior cruciate ligament; knee

Anterior cruciate ligament (ACL) injuries are common in
younger athletes participating in sports involving cutting,
*Address correspondence to Kevin M. DuPrey, DO, Department of
Sports Medicine, Crozer-Keystone Health System, 196 West Sproul Road,
Suite 110, Springfield, PA 19064, USA (e-mail: kevin.duprey@crozer.org).
y
Department of Sports Medicine, Crozer-Keystone Health System,
Springfield, Pennsylvania, USA.
z
Department of Exercise and Sport Science, University of Evansville,
Evansville, Indiana, USA.
§
Department of Kinesiology and Applied Physiology, University of
Delaware, Newark, Delaware, USA.
||
Department of Family and Community Health, Center for Public
Health Initiatives, and Leonard Davis Institute of Health Economics, Uni-
versity of Pennsylvania, Philadelphia, Pennsylvania, USA.
{
Department of Student Health Services, University of Delaware,
Newark, Delaware, USA.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 44, No. 6
DOI: 10.1177/0363546516629635
Ó 2016 The Author(s)
pivoting, and landing from a jump.1,10 Each year, approxi-
mately 2000 ACL injuries occur among National Collegiate
Athletic Association (NCAA) athletes.14 These injuries are
devastating and may lead to significant lost time to partic-
ipation, increased risk of osteoarthritis by 10-fold,4 concur-
rent meniscal and cartilage injury, rerupture, or tear of the
contralateral ACL.25,32,33 The financial burden of ACL
tears is estimated at nearly $1 billion in the United States
annually.7
Although research has shown that ACL injury preven-
tion programs can reduce injury incidence,8,10,11,22,24 the
rate of ACL injuries remains significant among collegiate
athletes.19 Reasons to account for this may include lack
of implementation or poor compliance with these injury
prevention programs. A recent meta-analysis regarding
compliance rates with ACL injury prevention programs
showed that studies with higher compliance led to
decreased ACL injury incidence. However, the authors
reported a wide variation in athlete compliance among
the studies, with 1 study reporting a compliance rate of

1487
1488 DuPrey et al
10.7%.35 Reasons for lower compliance were cited as lim-
ited time, cost, and lack of motivation and supervision.
Thus, successful screening methods are needed to identify
athletes at increased risk of ACL injury. Once identified,
these athletes may be directed toward prevention pro-
grams with a focus on improving resource allocation, com-
pliance, and motivation.
Numerous studies have identified risk factors for ACL
injury, including female sex,8 decreased femoral notch width
size, generalized joint laxity, increased body mass index in
women,36 prior ACL tear,32 hormonal influences,12 and gen-
eralized fatigue.2,3 These anatomic, hormonal, and environ-
mental factors are often difficult or impossible to alter.
Thus, a screening method that evaluates modifiable risk fac-
tors, such as biomechanical forces that can be improved with
training, may be helpful for ACL injury prevention.
An estimated 80% of ACL injuries occur from noncon-
tact mechanisms,26 whereas jump landing contributes to
approximately 70% of noncontact ruptures.21 Maintaining
equilibrium while jump landing requires dynamic postural
stability, which is defined as the ability to transition from
a dynamic movement to a static state over one’s base of
support.5,6 An increasing amount of literature has recently
been published utilizing a functional measurement of
dynamic postural stability, known as time to stabilization
(TTS).2,27,31,34 TTS involves single-legged jump landing
onto a force platform to quantify dynamic postural stabil-
ity. A greater (slower) value represents poorer dynamic
postural stability.13 Slower TTS measurements were found
in athletes after muscular fatigue34 and in individuals with
functionally unstable ankles.31 Collegiate athletes with
ACL reconstruction were found to demonstrate slower
TTS compared with healthy controls an average of 2.5
years after surgery.38 Patterson and Delahunt27 found
similar results in female athletes after ACL reconstruction
but showed that evaluating TTS in multiple directions was
more sensitive to detect deficiencies in dynamic postural
stability. Further studies are needed to determine whether
these deficiencies were present before injury and if mea-
suring baseline TTS can identify athletes at increased
risk of ACL injury.
The purpose of this study was to evaluate the correla-
tion between baseline TTS and risk of subsequent ACL
rupture in collegiate athletes. Our hypothesis was that
athletes with deficiencies in dynamic postural stability,
represented by slower TTS, were at increased risk of
ACL rupture. To our knowledge, this is the first study to
analyze deficiencies in TTS as a risk factor for ACL injury.
METHODS
Participants
This investigation was a prospective cohort study conducted
from 2009 to 2013. An a priori sample size of 264 partici-
pants was calculated29 to obtain a minimum power of 80%
based on data reported by Patterson and Delahunt.27 Partic-
ipants were excluded if they had a history of ankle sprain or
lower extremity fracture within the past 6 months, an
The American Journal of Sports Medicine
existing neurological condition, current lower extremity
injury, previous ACL injury, contact mechanism of ACL
injury during the study, or \6 months of athlete exposure
after baseline measurements. An athlete exposure was
defined as participation in practice sessions and games
involving jump landing, pivoting, or cutting with their
team where the athlete was at risk of ACL injury.
Among the 322 participants initially enrolled, 278 met
the inclusion criteria (166 men, 112 women). The mean
(6SD) age, height, and mass were 18.5 6 0.9 years,
178.8 6 11.1 cm, and 79.9 6 18.8 kg, respectively. Athletes
participated in the following high-risk sports: men’s foot-
ball; women’s volleyball and field hockey; and men’s and
women’s lacrosse, basketball, and soccer. There were 3
additional studies conducted that utilized data obtained
from the same participants.16-18 All participants read and
signed the informed consent form approved by the Univer-
sity of Delaware institutional review board. Before partic-
ipation, each athlete was examined and cleared by the
university’s sports medicine physicians.
Testing Protocol
Baseline TTS data were obtained for all participants dur-
ing preseason on enrollment into the study. Before jump
testing, participants underwent a 5-minute warm-up on
a stationary bike, followed by a 5-minute period of guided
stretching of the lower extremity musculature.
The Multi-Directional Dynamic Stability Protocol18 was
used for the single-legged jump landing tasks of backward,
forward, medial, and lateral jumps onto a force platform
(Advanced Medical Technology Inc). Force platform data
were collected at a sampling rate of 100 Hz for a duration
of 5 seconds. Sampling rates as low as 60 Hz and durations
as low as 3 seconds have been found to be sensitive for
dynamic postural stability.30,39 Participants performed
the jump landing tasks barefoot to minimize the stability
from a shoe.
For the forward jump landing, participants were asked to
complete a ‘‘step, step, hop’’ protocol, previously described
by Liu and Heise.18 This protocol required participants to
take 2 comfortable steps before jumping and landing single
legged on the test leg. Participants jumped over a 15-cm
hurdle placed at a distance of 100% of their leg length
from the center of the force platform. Backward, forward,
medial, and lateral describe the direction of the jump with
respect to the participant. For these hop directions, partici-
pants were instructed to stand single legged on the test leg,
hop over a 5-cm hurdle placed directly next to the force plat-
form and land single legged on the force platform with the
test leg. Hurdles were placed for all landing directions to
normalize a minimal jump height among participants. All
participants were instructed to land in the middle of the
force platform on the test leg with eyes focused forward
and hands placed on their hips stabilizing as quickly as pos-
sible and to remain as motionless as possible for 5 seconds.
Participants were allowed to familiarize themselves with
the procedure with 3 practice trials. A total of 3 test trials
were performed, in a randomized order, for each of the 4
jump landings for each leg to total 24 jumps. If the
AJSM Vol. 44, No. 6, 2016
Injured Athletes Uninjured Athletes
3 3
2.5
Time to Stabilization, s
2 2
1.5
1 1
0.5
Backward Forward Lateral
0 0
Jump Landing Direction
Figure 1. Comparison of baseline mean time to stabilization
between anterior cruciate ligament (ACL)–injured and ACL-
uninjured athletes.
participant lost balance or touched the floor with the contra-
lateral leg, the trial was discarded and redone.
Injury Surveillance
After baseline testing, participants were followed for
a mean 3.1 6 0.76 years. All ACL injuries were reported
to and confirmed by the university’s sports medicine physi-
cian using magnetic resonance imaging. Injury type and
mechanism (contact or noncontact) were recorded using
the university’s electronic medical record database, Point
and Click (Point and Click Solutions, Burlington, MA).
Participants were divided into 2 groups: injured (athletes
who sustained a noncontact ACL rupture) and uninjured
(athletes with no ACL rupture).
Statistical Analysis
TTS was quantified by methodology from McKinley and
Pedotti20 as the time required for the vertical force compo-
nent of the ground reactive force to reach and remain
within 65% of the participant’s body weight after landing.
TTS results were averaged for left and right legs creating
a mean TTS score for forward, backward, medial, and lat-
eral jump landing tasks. Mean TTS scores were compared
between injured and uninjured athletes using unpaired
independent t testing.
Conducting 4 separate independent t tests may result in
erroneous significant effects with an alpha set at the
traditional level of .05. Thus, a more conservative Bonfer-
roni adjustment procedure was conducted to control the
experiment-wise error rate.23 The adjustment procedure
resulted in a new level of significance (a = .013).
With subsequent ACL injury as a dichotomous outcome,
associations with mean TTS scores were assessed using
logistic regression. The logit link was used to estimate
the odds ratios (ORs) and CIs for the association between
Stabilization Deficiencies Identify ACL Injury Risk 1489
Injured Limb Uninjured Limb
2.5
Time to Stabilization, s
1.5
0.5
Medial Backward Forward Lateral Medial
Jump Landing Direction
Figure 2. Comparison of baseline mean time to stabilization
between anterior cruciate ligament (ACL)–injured and ACL-
uninjured limbs in athletes with ACL tears.
ACL rupture and TTS scores. Stata 13 software (Stata-
Corp) was used for all statistical analyses.
RESULTS
Nine participants sustained noncontact ACL ruptures (5
men, 4 women). Two athletes sustained contact ACL rup-
tures and were excluded. The remaining 267 participants
were uninjured. Mean baseline backward TTS scores
were significantly different between injured and uninjured
groups. Specifically, injured athletes took 0.49 seconds lon-
ger to stabilize during baseline backward jump landing
compared with uninjured athletes (1.58 6 0.39 seconds
and 1.09 6 0.52 seconds, respectively; P = .0052). Although
the absolute mean baseline forward, medial, and lateral
TTS scores were slower for injured athletes, they were
not statistically significant (forward TTS: 1.31 6 0.51
and 1.14 6 0.49 seconds, P = .33; medial TTS: 1.38 6
0.36 and 1.10 6 0.51 seconds, P = .11; and lateral TTS:
1.35 6 0.47 and 1.15 6 0.54 seconds, P = .28) (Figure 1).
Among injured athletes, there was no significant difference
between injured- and noninjured-leg TTS baseline scores
during each jump landing task (Figure 2).
Logistic regression analysis demonstrated that mean
baseline backward jump landing score was a significant
predictor of ACL injury status (P = .010). For every second
increase in backward TTS observed between injured and
uninjured athletes, the odds of ACL rupture increased 3-
fold (OR, 2.95; 95% CI, 1.28-6.77). ORs were increased
for mean baseline forward, lateral, and medial jump land-
ing directions but were not statistically significant. Base-
line backward time to stabilization 1.19 seconds (mean
injured backward TTS 2 1 SD) predicted ACL rupture
with 89% sensitivity and 70% specificity.
Injured athlete demographics and mean baseline TTS
scores for each jump landing task are shown in Table 1.
1490 DuPrey et al The American Journal of Sports Medicine

TABLE 1
ACL-Injured Athlete Demographics and Mean TTS Scoresa

TTS Score, s
Time From Baseline
Participant Sex Sport Injured Leg to Injury, mo Backward Forward Lateral Medial

1 Female Lacrosse Left 6.8 2.02 0.81 1.57 1.47

2 Female Field Hockey Left 8.8 1.20 1.43 2.06 2.18
3 Female Lacrosse Right 13.2 1.68 1.22 1.32 1.15
4 Female Volleyball Left 19.2 1.26 1.27 0.71 1.19
5 Male Lacrosse Left 44.1 1.40 1.26 1.52 1.46
6 Male Soccer Left 13.5 0.98 0.58 0.65 0.94
7 Male Lacrosse Left 15.4 2.13 1.21 1.78 1.58
8 Male Football Right 24.2 1.71 1.56 1.06 1.12
9 Male Football Right 25.6 1.84 2.40 1.48 1.29

a
ACL, anterior cruciate ligament; TTS, time to stabilization.

ACL tears occurred a mean of 19.0 6 10.7 months after
baseline TTS measurements were obtained (range, 6.8-
44.1 months). ACL tears occurred in a variety of sports,
with a similar mean age, height, and mass in the injured
and uninjured athletes (18.5 6 0.8 and 18.4 6 0.9 years,
177.5 6 12.8 and 178.9 6 11.0 cm, and 76.5 6 17.6 and
80.0 6 18.8 kg, respectively). ACL injury incidence was
1.1% per player season.
DISCUSSION
The findings of our study support the tested hypothesis that
athletes with baseline deficiencies in dynamic postural sta-
bility, measured by slower TTS, were at increased risk of
ACL rupture. Athletes who went on to rupture their ACL
took 50% longer, on average, to stabilize during baseline
backward jump landing compared with uninjured athletes
(1.58 seconds compared with 1.09 seconds, respectively).
The odds of ACL rupture increased 3-fold for each second
increase in backward TTS observed between injured and
uninjured athletes. Among injured athletes, TTS measure-
ments were similar between the injured and uninjured
limbs, suggesting a global deficiency in dynamic postural
stability in athletes at increased risk for ACL rupture.
It is important to understand the limitations in our cur-
rent study and the existing literature regarding identifica-
tion of athletes at increased risk of ACL injury. ACL tears
are likely multifactorial in origin, with numerous variables
that may act as possible confounders. There are multiple
potential confounding variables that were not controlled
for in our study design that have been previously corre-
lated with increased risk of ACL injury, including femoral
notch width, joint laxity, body mass index,36 menstrual
cycle history and hormonal levels,12 generalized fatigue,2,3
quadriceps and hamstring muscle strength,28 measures of
static balance,37 and dynamic valgus and knee abduction
loads on jump landing.9 Attempts to limit confounders
were taken by excluding athletes with previous ACL inju-
ries, history of ankle sprain or lower extremity fracture
within the past 6 months, an existing neurological condi-
tion, or current lower extremity injury. Retrospective
analysis revealed that our groups were similar in age,
mass, height, proportion of male and female athletes, and
type of sport. Thus, baseline TTS screening appears to be
a generalizable method to stratify injury risk in both
male and female collegiate athletes in high-risk sports for
ACL injuries; however, further longitudinal studies are
needed to evaluate additional confounding variables.
In our study, baseline TTS scores were measured only
once for all athletes, which may lead to variability in ath-
lete exposure. Our results indicate that the majority of ath-
letes were exposed for a significant duration of the 4-year
study with a small standard deviation (mean 3.1 6 0.76
years). Attempts to minimize athlete exposure variation
were taken by excluding athletes with \6 months of partic-
ipation. During the study period, athlete TTS scores may
have changed as a result of training effects. Although pre-
vious research has shown that TTS can be improved with
training programs,15 athletes in our study did not partici-
pate in such programs. Additional studies involving multi-
ple TTS measurements at various time points are needed
to determine the effects of training on TTS scores.
Our findings suggest that baseline backward TTS can
be utilized as a screening method to identify collegiate ath-
letes at increased risk of ACL injury. We suggest using
a baseline backward TTS cutoff score of 1.19 seconds to
identify those athletes at increased risk of ACL rupture.
On the basis of our results, this score will allow identifica-
tion of 89% of athletes at increased risk of ACL rupture
with 70% specificity. Once identified, these athletes could
be directed toward an ACL injury prevention program.
Huang et al15 showed that TTS could be improved after
a 6-week program that involved plyometric and balance
training. Although the authors primarily investigated ankle
instability, they reported that improvements in TTS were
attributable to modulating the knee joint rather than the
ankle. They found that training allowed participants to
regain knee extension faster and improved TTS by decreas-
ing the knee-flexion angle. Further studies may be helpful
to determine the effects of improving TTS in athletes with
slower baseline TTS and risk of subsequent ACL injury.
To our knowledge, this is the first study to report defi-
ciencies in TTS and increased risk of ACL injury. Thus,
AJSM Vol. 44, No. 6, 2016
our findings may lead to a better understanding of the
underlying biomechanical factors that contribute to ACL
injuries. We recognize that TTS screening is not feasible
in clinical settings where force plate technology is unavail-
able. With an increasing amount of literature utilizing force
plate technology in collegiate and other institutional set-
tings,15,16,18,30,34 we hope that this study will lead to further
investigation and utilization of TTS and injury prevention.
CONCLUSION
Collegiate athletes with baseline deficiencies in dynamic
postural stability, represented by slower backward TTS,
were at greater risk of ACL injury. These findings may
allow clinicians to identify athletes at increased risk of
ACL ruptures and direct them toward ACL injury preven-
tion programs.
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