Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes

Research Review: Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes

By: William Chancey Sumner, PTA, MS, CES, CAFS, HMS, FRCms, c-PT

Edited by: Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Leetun, D., Ireland, M., Willson, J., Ballantyne, B., Davis, I. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine and Science in Sports and Exercise, 36(6), 926-934. ABSTRACT

Introduction: Lower extremity injuries may impact between 30% and 50% of athletes during a competitive season, leading to missed time in practice, games, or an entire season (1-2). Many lower extremity injuries are associated with impaired core stability; especially, in female athletes (3-8). This 2004 prospective study by American researchers on collegiate athletes, shows that impaired core stability (lumbo pelvic hip complex ), specifically hip external rotation weakness, may increase lower-extremity injury risk. Human movement professionals should assess and address the hip external rotator  strength of athletes to reduce the risk of back and lower extremity injuries during the season.

Study Summary

Caption: Lateral hop to single leg sagittal plane hop to balance.

Lateral hop to single leg sagittal plane hop to balance.

How this study contributes to the body of research:

Inhibited core stability and hip strength are associated with increased injury risk of the lower-extremity; including, ankle sprains and anterior cruciate ligament sprains (1-9). This study investigated the rate of injury of male and female collegiate athletes for two years after a preparticipation evaluation including core muscle endurance and hip strength testing. This study adds to a relatively small number of prospective studies demonstrating a correlation between movement impairment and the risk of future injury. Further, this study includes males and females and multiple outcomes measures, demonstrating that both sexes may have increased risk of injury when external rotator strength is not sufficient. This last point, may also imply that risk of injury is more highly correlated with certain impairments. Future research should include collegiate athletes from other sports and additional tests/outcome measures to aid in determining additional impairments that may contribute to the risk of injury.

How the Findings Apply to Practice:

The findings of this study demonstrate correlations between core muscle endurance, insufficient hip strength and injury in collegiate athletes. Of the factors tested, insufficient hip external rotator strength had the strongest relationship. Human movement professionals may assist in injury prevention by assessing core muscle endurance and hip strength prior to the season. If limited by time or resources, the findings of this study suggest that hip external rotator strength would likely be the best screening tool. Human movement professionals should have a repertoire of exercises and techniques to address any identified deficits .

This study had many methodological strengths, including:

1. This was a prospective study with a two-year follow-up; prospective studies are relatively rare and desperately needed to aid in determining causation and sequence of events.
2. The sequence of the four strength measurements were randomized for all participants, reducing the impact fatigue may have on the aggregated outcome data for any one test.
3. Each university had a full-time staff of certified athletic trainers, improving compliance of reporting injury rates and aiding in the reliability of the findings.

Weaknesses and limitations that should be noted prior to clinical integration of the findings include:

1. Researchers changed how anterior core measurements were taken after the first year, reducing the reliability and validity of this measurement. This should be addressed in future studies.
2. Hip strength measurements were in units of force as a percentage of body weight, but height and limb length were not considered. Future research should consider height, limb length and relative torque in addition to force and body mass.
3. The two examiners were not tested for intratester reliability prior to data collection.

How the study relates to Brookbush Institute Content?

This study demonstrates an assumption made in the Brookbush Institute’s (BI) predictive models of Lower Extremity Dysfunction (LED) and Lumbo Pelvic Hip Complex Dysfunction (LPHCD) , that is, that dysfunction, injury and pain are often the result of impaired movement and compensation patterns. Although this assumption was made with knowledge of research studies like this, further research is needed to continue determining which signs, symptoms and patterns can be reliably assessed, and which have the highest correlation with future injury. Further, the BI recommends activation exercises for hip and core musculature, and this should be followed by integrated exercises targeting the anterior oblique subsystem (AOS) and posterior oblique subsystem (POS).

The following videos illustrate common assessment techniques for the LED and LPHCD , as well as interventions commonly used to facilitate hip external rotator activation.

Overhead Squat Assessment: Sign Clusters - Lumbo Pelvic Hip Complex Dysfunction

Overhead Squat Assessment: Sign Clusters - Lower Extremity Dysfunction

Gluteus Medius Isolated Activation

Side Plank - Core Stability

Bibliography:

1. Messina, D., Farney, W., DeLee, J. (1999). The incidence of injury in Texas high school basketball: a prospective study among male and female athletes. American Journal of Sports Medicine, 27, 294-299
2. Meeuwisse, W., Sellmer, R., Hagel, B. (2003). Rates and risk of injury during intercollegiate basketball. American Journal of Sports Medicine, 31, 379-385
3. De Blaiser, C., Roosen, P., Willems, T., Danneels, L., Bossche, L., De Ridder, R. (2018). Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy Sport, 30, 48-56
4. Araujo, S., Cohen, D., Hayes, L. (2015). Six weeks of core stability training improves landing kinetics among female capoeira athletes: a pilot study. Journal of Human Kinetics, 45, 27-37
5. Brown, T., Palmieri-Smith, R., McLean, S. (2014). Comparative adaptations of lower limbbiomechanics during unilateral and bilateral landings after different neuromuscular-based ACL injury prevention protocols. Journal of Strength and Conditioning Research, 28(10), 2859-2871
6. Jamison, S., McNally, M., Schmitt, L., Chaudhari, A. (2013). The effects of core muscle activation on dynamic trunk position and knee abduction moments: implications for ACL injury. Journal of Biomechanics, 46(13), 2236-2241
7. Hewett, T. Myer, G., Ford, K. (2005). Reducing knee and anterior cruciate ligament injuries among female athletes: a systematic review of neuromuscular training interventions. Journal of Knee Surgery, 18(1), 82-88
8. Nadler, S., Malanga, G., DePrince, M., Stitik, T., Feinberg, J. (2000). The relationship between lower extremity injury, low back pain, hip muscle strength in male and female collegiate athletes. Clinical Journal of Sport Medicine, 10(2), 89-97
9. Zazulak, B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., and Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk. The American Journal of Sports Medicine, 35(7), 1123-1130

© 2018 Brent Brookbush

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