Introduction: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

Why this Study is Important: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

How the Findings Apply to Practice: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

How Does this Relate to Brookbush Institute Content: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

Introduction: Impaired Core Stability is Predictor of Knee Injury Risk

Study Summary: Impaired Core Stability is Predictor of Knee Injury Risk

How this Study Contributes to the Body of Research: Impaired Core Stability is Predictor of Knee Injury Risk

How the Findings Apply to Practice: Impaired Core Stability is Predictor of Knee Injury Risk

How Does this Study Relate to Brookbush Institute Content: Impaired Core Stability is Predictor of Knee Injury Risk

Study Summary: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

Review and Commentary: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

How This Study Contributes to the Body of Research: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

How The Findings Apply to Practice: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

How Does this Relate to Brookbush Institute Content: Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

Introduction: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

Study Summary: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

How This Study Contributes to the Body of Research: Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

Does Movement Impairment Precede Knee Pain and Injury?

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Ramskov et al. (2015). Greater Eccentric Hip Abduction Strength Reduces Risk of Patellofemoral Pain in Novice Runners

Original Citation: Ramskov, D., Barton, C., Nielsen, R. O., and Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year <a id="observational-study" data-tip="1400" target="_blank" href="/glossary-term/observational-study" class="glossary">Observational Study</a>. Journal of orthopaedic and sports physical therapy, 45(3), 153-161. <a href="http://www.jospt.org/doi/abs/10.2519/jospt.2015.5091?journalCode=jospt#.VTfb7igvE20" target="_blank" rel="noopener">ABSTRACT</a>
<img src="https://strengthambassadors.com/wp-content/uploads/2014/11/running-knee-dropping-in.png" alt>
Why the study is relevant: Patellofemoral pain syndrome (PFPS) is a common injury in runners (1). It is frequently recurring and can become a chronic condition that limits activity (2). Previous research has been unclear about the relationship between <a href="https://brookbushinstitute.com/article/kinesiology-of-the-hip" target="_blank" rel="noopener">hip abduction</a> strength and PFPS. This 2015 study adds to the body of research on this topic specifically as it relates to eccentric hip abduction strength.
<a href="https://www.datocms-assets.com/25800/1646154416-gluteus-medius-mmt-copy.png"><img src="https://www.datocms-assets.com/25800/1646154416-gluteus-medius-mmt-copy.png"></a>
Gluteus Medius Manual <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing.

Introduction

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Observational prospective cohort study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Prospective cohort study</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>
 Sample:
 Demographics
 <ul>
 <li>Age (in years +/- standard deviation): 36.6 +/- 10.1 yrs</li>
 <li>Gender: 308 female (14 went on to develop PFPS); 321 male (10 went on to develop PFPS)</li>
 <li>Number of participants: 629</li>
 <li>Individuals structured their own running program during the 12 months of the study; all subjects utilized the same neutral running shoe (Adidas Supernova <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">Glide</a> 3).</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>Ages 18-65 years</li>
 <li>No injuries to the lower extremity in the 3 months leading up to data collection (injury defined as &quot;any musculoskeletal complaint of the lower extremity or back caused by running, resulting in a restriction of running for at least 1 week&quot;)</li>
 <li>Running less than 10km in the previous 12 months</li>
 <li>Individuals with high blood pressure (&gt;140 for systolic, &gt; 90 for diastolic) required clearance from a primary care physician to participate</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>At baseline 3 evaluators performed eccentric hip abduction strength tests on both limbs with a handheld dynamometer in random order.
 <ul>
 <li>Each participant was positioned in a side-lying with the testing limb in approximately 20&#xBA; of abduction.</li>
 <li>The tester applied resistance to build and isometric contraction, then increased the resistance to push the limb into approximately 10&#xBA; of adduction (30&#xBA; total excursion).</li>
 <li>The <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> was repeated until the subject performed 2 consecutive trials with a difference of 5% or less in force plateau between them (1-minute rest between each <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a>).</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>
 <ul>
 <li>Data was normalized by limb length and body weight.</li>
 <li>Age, sex, weight and height were taken into consideration when calculating the brackets for &quot;High&quot;, &quot;Normal&quot; and &quot;Low&quot; strength categories.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>The number of individuals and limbs developing Patellofemoral Pain Syndrome (PFPS) - as reported by participants and confirmed with <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> by physical therapist utilizing <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> diagnostic criteria for PFPS (pain with 2 of the following 4 tests: palpation of patella <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="gliding-joint" data-tip="1835" target="_blank" href="/glossary-term/gliding-joint" class="glossary">gliding</a> with the knee in full extension; patellar <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> with <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> and <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> gliding; eccentric resistance <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> of <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a>; isometric quadriceps strength <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>). Other tests were included to rule out other knee pathologies.</li>
 <li>Time to injury as calculated by the number of miles run (mileage tracked by GPS watch provided to all participants)
 <ul>
 <li>25 km</li>
 <li>50 km</li>
 <li>100 km</li>
 <li>250 km</li>
 <li>500 km</li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>629 participants were included (after 202 were excluded due to injury other than PFPS).</li>
 <li>Normalized mean eccentric hip abduction strength for women was 1.38 Nm/kg for the right leg and 1.44 Nm/kg for the left leg.</li>
 <li>Normalized mean eccentric hip abduction strength for men was 1.62 Nm/kg for the right leg and 1.64 Nm/kg for the left leg.</li>
 <li>605 remained injury-free; 24 were diagnosed with PFPS (14 female/10 male; 8 cases were <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a>).</li>
 <li>There were significant differences between the high, normal, and low strength groups for risk of PFPS at 25 km and 50 km.</li>
 <li>There were no significant differences between the strength groups at 100 km, 250 km or 500 km.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Conclusions</td>
 <td>Reduced eccentric hip abduction strength leaves an individual vulnerable to the development of PFPS in the early stages of a running program. It may be helpful to assess an individual&apos;s eccentric hip strength prior to him or her embarking on a running program.</td>
 </tr>
 <tr>
 <td>Conclusions of the Researchers</td>
 <td>Having &quot;greater than normal&quot; eccentric hip abduction strength reduced the risk of PFPS over the first 50 km of a self-structured running program in novice runners. Future research should examine the efficacy of hip abduction strengthening protocols on the treatment &amp; prevention of PFPS.</td>
 </tr>
 </tbody>
</table>
<img src="https://www.myweightlifting.com/online-courses/online-courses/image-files/gluteal-muscles-anatomy.jpg" alt>The <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteal Muscles</a> (along with <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">Tensor Fascia Latae (TFL)</a> and <a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Piriformis</a>) contribute to abduction strength - http://www.myweightlifting.com/online-courses/online-courses/image-files/gluteal-muscles-anatomy.jpg

Study Summary

This study had many methodological strengths including:
<ul>
 <li>a prospective design and extensive one-year follow-up period.</li>
 <li>a large sample size</li>
 <li>a clearly defined definition for &quot;injury&quot; for the inclusion criteria, as well as clear diagnostic criteria for clinicians, to confirm a reported injury as patellofemoral pain syndrome (PFPS). PFPS can become a catch-all diagnosis. By performing differential testing to confirm PFPS and rule-out alternative sources of pain such as meniscal, cruciate, or collateral ligament pathologies, the authors precisely described the population they observed.</li>
 <li>moderate inter- and intra-tester <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in analysis of the eccentric strength testing procedure</li>
 <li>appropriate standardization procedures for data collection from participants. Each participant was issued a GPS watch to track their mileage. They uploaded data from the watch to an internet-based running diary. The authors also issued each participant a standard/neutral running shoe (Adidas Supernova <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">Glide</a> 3) to eliminate the potentially confounding variable of individually selected footwear.</li>
</ul>
Weaknesses that should be noted prior to the clinical <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of the findings include:
<ul>
 <li>a lack of external stabilization of the subjects during eccentric strength testing; it may have been possible for subjects to shift their position to <a id="compensation-pattern" data-tip="1697" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">compensate</a> during this <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>.</li>
 <li>multiple testers performed the strength testing. These factors may have contributed to the &quot;moderate&quot; inter- and intra-tester <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, noted above.</li>
 <li>a lack of participant subjective information in the diagnostic criteria for PFPS. A subjective history may have provided a more complete picture of the participants.</li>
 <li>a lack of re-measurement of hip abduction strength when participants reported to the clinic with injury. While the injured individuals may have started with reduced hip abduction strength, did they continue to have reduced strength up to the onset of injury?</li>
</ul>
Future research may want to consider the potential contributions of altered foot/ankle motion and its contribution to PFPS (e.g. lack of <a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener">tibialis anterior</a> strength). It may also seek to differentiate the recruitment of the muscles that perform hip abduction with respect to pain and <a id="movement-impairment" data-tip="1804" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctional movement</a> patterns during activity (e.g. <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fasciae latae (tfl)</a> <a id="synergistic-dominance" data-tip="1643" target="_blank" href="/glossary-term/synergistic-dominance" class="glossary">synergistic dominance</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> inhibition).

Review and Commentary

This study provides important information about hip abduction strength and its possible contribution to the development of patellofemoral pain syndrome (PFPS). This study highlights the importance of assessing the strength of the hip abductors during the eccentric phase of the movement, in addition to the concentric and isometric phases. <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">Optimal</a> control of eccentric hip abduction (as achieved by the <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">maximus</a> musculature) is key for maintaining pelvofemoral alignment during weight-bearing activities, such as running.

How This Study Contributes to the Body of Research

This study demonstrates that individuals who possess greater hip abduction strength at the start of a running program reduce their risk of patellofemoral pain syndrome (PFPS). This implies that adding hip abductor strengthening to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> warm-up or resistance training program may reduce an individual&apos;s risk of developing PFPS if they run as part of their regular exercise activity. As human movement professionals, our goal is to help more people move more. It can be disheartening for both client and coach to see an individual finally decide to get active, only to be quickly sidelined due to musculoskeletal pain. Injury prevention is an area of human movement science that must be expanded, and studies like this one provide essential information for creating effective programs.

How the Findings Apply to Practice

The Brookbush Institute recommends the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a> as a means of assessing movement quality during weight-bearing. Previous researchers have reported that patellofemoral pain syndrome (PFPS) has been related to <a href="https://brookbushinstitute.com/article/research-review-exercise-to-reduce-knee-valgus-in-squat" target="_blank" rel="noopener">reduced hip abduction</a> (3) and <a href="https://brookbushinstitute.com/article/research-review-lower-extremity-muscle-activation-patterns-in-individuals-with-knee-valgus" target="_blank" rel="noopener">external rotation strength</a> (4), as well as to increased <a href="https://brookbushinstitute.com/article/hip-internal-rotation-and-adduction-correlated-with-knee-pain" target="_blank" rel="noopener">hip internal rotation</a> and <a href="https://brookbushinstitute.com/article/hip-internal-rotation-and-adduction-correlated-with-knee-pain" target="_blank" rel="noopener">adduction</a> (5) during weight-bearing activities. These factors would manifest themselves as the sign &quot;Knees bow in&quot; in the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a>. This sign may occur as a result of <a href="https://brookbushinstitute.com/article/lower-extremity-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction</a>. For the purposes of this review, the interventions described below relate more to primary dysfunction at the hip as opposed to the ankle. The approach of the Brookbush Institute to creating a program to correct this maladaptive movement pattern would be to <a href="https://brookbushinstitute.com/?category=flexibility" target="_blank" rel="noopener">release and lengthen</a> short overactive muscles, <a href="https://brookbushinstitute.com/video/hip-mobilization" target="_blank" rel="noopener">mobilization of the hip</a> (when necessary) followed by <a href="https://brookbushinstitute.com/?category=activation" target="_blank" rel="noopener">activation and integration</a> of long under-active muscles. Below is a series of videos to provide a sample routine that may be used as an intervention to correct &quot;Knees bow in&quot;. This type of approach could be recommended to those contemplating starting a running program as a method of improving biomechanics and increasing hip strength to reduce the risk of developing PFPS.

How Does This Study Relate to Brookbush Institute Content

Introduction to the Overhead Squat Assessment
<iframe src="https://player.vimeo.com/video/109420058?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Overhead Squat <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> 6 - Knees Bow In Breakdown
<iframe src="https://player.vimeo.com/video/109470711?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Tensor Fascia Lata (TFL) SA Static Release
<iframe src="https://player.vimeo.com/video/82875363?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Adductor SA Static Release
<iframe src="https://player.vimeo.com/video/76674522?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Kneeling Hip Flexor Stretch
<iframe src="https://player.vimeo.com/video/82860782" frameborder="0"></iframe>
Standing Adductor Stretch
<iframe src="https://player.vimeo.com/video/82874205?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Gluteus Medius Isolated Activation
<iframe src="https://player.vimeo.com/video/82856186?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Gluteus Medius <a id="exercise-progression" data-tip="1182" target="_blank" href="/glossary-term/exercise-progression" class="glossary">Progressions</a> - Activation Circuit
<iframe src="https://player.vimeo.com/video/82857653?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Sidestepping <a id="exercise-progression" data-tip="1182" target="_blank" href="/glossary-term/exercise-progression" class="glossary">Progressions</a> - Gluteus Medius Reactive Activation
<iframe src="https://player.vimeo.com/video/76716828?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>
Gluteus Medius Reactive Activation - Side Hop Progression
<iframe src="https://player.vimeo.com/video/76692013?title=0&amp;byline=0&amp;portrait=0" frameborder="0"></iframe>

Bibliography

Hewett et al. (2005). Increased Valgus During Landing Predicts ACL Injury in Adolescent Female Athletes

Original Citation: Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cruciate ligament injury risk in female athletes A <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a>. The American journal of sports medicine, 33(4), 492-501. <a href="http://ajs.sagepub.com/content/33/4/492.short" target="_blank" rel="noopener">ABSTRACT</a>
Why this study is relevant: Adolescent female athletes have higher rates of <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cruciate ligament (ACL) injuries than other active populations (1). Often these injuries are non-contact in nature and involve a moment of knee valgus; a <a id="compensation-pattern" data-tip="1699" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">dysfunctional movement pattern</a> where the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> femur excessively adducts and the <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> tibia excessively abducts. This 2005 study investigated whether excessive knee valgus during jumping and landing activities was a predictor of ACL injuries in female high school soccer, basketball, and volleyball players. The researchers found that excessive knee valgus during these activities predicted ACL injury with 73% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and 78% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a>. This information helps human movement professionals gain an understanding of the risk factors for this type of injury so that they may develop and implement screening tools and preventative intervention programs.
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/03/Melissa-Transverse-Plane.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/03/Melissa-Transverse-Plane.png" alt="Practicing Hop Down to Single Leg Touch Down in the Transverse Plane with a Soft Landing"></a>
Practicing Hop Down to Single Leg Touch Down in the Transverse Plane with a Soft Landing

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Prospective cohort study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Prospective cohort study</td>
 </tr>
 <tr>
 <td>Subject Characteristics</td>
 <td>
 Sample:
 Demographics
 <ul>
 <li>Age (in years +/- standard deviation): 15.8 +/- 1.0 (ACL - Injured group); 16.1 +/- 1.7 (ACL - Uninjured group)</li>
 <li>Gender: Female</li>
 <li>Number of participants: 205</li>
 <li>Adolescent female athletes playing soccer, basketball or volleyball
 <ul>
 <li> 9 ACL injuries occurred, all non-contact in nature (7 in soccer players, 2 in basketball players) and were confirmed by MRI or arthroscopic surgery. The 9 injured individuals made up the ACL-injured group (ACL-I).</li>
 <li>The remaining 196 athletes made up the ACL-uninjured group (ACL-U).</li>
 <li>There were no significant differences between groups with respect to age, height or weight.</li>
 </ul>
 
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Baseline testing was performed at the start of each respective season.</li>
 <li>A 25 marker and 8 camera motion analysis system was used to record participant movements during testing.</li>
 <li>All subjects performed a series of Drop Vertical Jumps where the athlete jumped off of a box 31 cm high onto a pair of force plates and then immediately performed a vertical jump.</li>
 <li>Participants were followed by athletic trainers who documented training/game schedules and injuries over the course of a season.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>
 <ul>
 <li>Means and standard deviations were calculated for each outcome measure.</li>
 <li>An analysis of variance was used to compare values between the injured and uninjured groups.</li>
 <li>Paired T-tests were used to compare the difference between limbs.</li>
 <li>A Pearson correlation coefficient was used to determine relationships between variables.</li>
 <li>To determine the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a> of their findings, the authors used linear <a id="exercise-regression" data-tip="1178" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regressions</a>, logistic <a id="exercise-regression" data-tip="1178" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regressions</a> and a repeated measure logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a>. An alpha level of .05 was set for statistical significance.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Knee flexion/extension angle at initial contact (IC; point of initial contact with force plate after landing out of jump).</li>
 <li>Knee adduction/abduction angle at IC.</li>
 <li>Vertical <a id="ground-reaction-force" data-tip="1395" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">Ground Reaction Force</a> (<a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a>) at IC.</li>
 <li>Vertical <a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> at toe off (TO; the moment just before feet left floor in jump).</li>
 <li>Peak knee abduction moment (defined as <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibia moving away from midline) during stance phase (period between IC &amp; TO)</li>
 <li>Peak knee flexion moment during stance phase</li>
 <li>Peak hip adduction moment during stance phase</li>
 <li>Peak hip flexion moment during stance phase</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>The mean time between screening and injury was 5.0 months (range .6 - 13.1 months).</li>
 <li>No difference in knee flexion angle between ACL-I &amp; ACL-U groups at IC.</li>
 <li>Significant correlation between knee flexion angle and peak <a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> was observed in ACL-U group, not in ACL-I group.</li>
 <li>Knee abduction angle was significantly different between ACL-I and ACL-U groups at both initial contact (8.4&#xBA; greater in ACL-I group) &amp; max abduction angle during stance (7.6&#xBA; greater in ACL-I group).</li>
 <li><a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> was observed to be increased by 20% in the ACL-I group (1266.1 +/- 149.9 N) as compared to ACL-U group (1057.8 +/- 289.9N)</li>
 <li>Knee abduction angle and peak <a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> values were correlated in ACL-I group, but not the ACL-U group.</li>
 <li>Peak knee abduction moment was greater in those in ACL-I group (45.3 +/- 28.5 N-m) as compared to ACL-U group (18.4 +/- 15.6 N-m).</li>
 <li>Peak knee flexion moment was not observed to be significantly different between groups.</li>
 <li>There was a correlation between knee flexion moment and peak <a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> in the ACL-U group.</li>
 <li>Significant correlations were present between knee abduction angle, knee abduction moment and peak <a id="ground-reaction-force" data-tip="1398" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">GRF</a> in the ACL-I group.</li>
 <li>Hip adduction moment was not significantly different between groups.</li>
 <li>Hip adduction moment was correlated with knee abduction moments in ACL-I subjects, but not in the ACL-U group.</li>
 <li>Peak hip flexion moment was significantly greater in ACL-I group (147.9 +/-33.5 N-m) as compared to ACL-U group (106.8 +/- 45.3 N-m).</li>
 <li>Members of the ACL-I group had a 16% shorter stance time than those in the ACL-U group.</li>
 <li>There were greater within subject asymmetries in knee abduction moment in ACL-I group, as compared to ACL-U groups (6.4 times greater).</li>
 <li>There was not a significant effect of leg dominance on ACL injury.</li>
 <li>Knee abduction moments &amp; angles were significant predictors of ACL injury status (p&lt;.0001). Knee abduction moment demonstrated <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of 78% and <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> of 73%.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Conclusions</td>
 <td>This research demonstrates that impaired frontal plane control of the knee may increase the risk of ACL injury in female adolescent athletes. Subjects who developed ACL injuries also demonstrated the following characteristics during a pre-season drop vertical jump screen: increased ground reaction forces with landing, increased hip flexion moment with landing, decreased stance time between landing and jump take off, and greater asymmetry between limbs in knee abduction moment.</td>
 </tr>
 <tr>
 <td>Conclusions of the Researchers</td>
 <td>Increased valgus observed during a drop vertical jump test may be used to predict ACL injury in adolescent female athletes. This test is useful to incorporate into a pre-season screen so that interventions can be implemented to reduce dynamic valgus during landing tasks.</td>
 </tr>
 </tbody>
</table>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/03/SL-Jump.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/03/SL-Jump.png" alt="SL Jump"></a>

This study continues to add to the growing body of research that is seeking to understand the relationship between <a id="movement-impairment" data-tip="1802" target="_blank" href="/glossary-term/movement-impairment" class="glossary">movement dysfunction</a> and injury. Long term prospective studies such as this are key to further enhancing our understanding of this relationship.
The study had many methodological strengths, including:
<ul>
 <li>a prospective design to follow the development of injuries over a thirteen-month surveillance period</li>
 <li>a clear definition of the <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> subset of <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cruciate ligament (ACL) injuries to observe (non-contact in nature and occurring in female adolescent athletes)</li>
 <li>a large sample size (200+ individuals)</li>
 <li>an appropriately provocative <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> for an athletic population.</li>
 <li>a well-designed motion analysis set-up</li>
</ul>
Weaknesses that should be noted prior to clinical <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of the findings include:
<ul>
 <li>a lack of follow-up on biomechanics measurements beyond baseline. It is impossible to know if the effects of training and the season altered the subjects&apos; movement patterns.</li>
 <li>no distinction of a cutoff value that would quantify &quot;excessive knee valgus&quot;.</li>
 <li>no use of EMG analysis to highlight the differences in recruitment relative to the amount of knee valgus, or the differences between the injured and uninjured groups.
 <ul>
 <li><a href="https://brookbushinstitute.com/article/research-review-exercise-to-reduce-knee-valgus-in-squat" target="_blank" rel="noopener">Bell et al. (2013)</a> looked at the neuromuscular activation patterns of individuals with knee valgus during a double leg squat, however did not include a full kinematic analysis of the lower extremity. The information provided in this article in addition to the research by <a href="https://brookbushinstitute.com/article/research-review-exercise-to-reduce-knee-valgus-in-squat" target="_blank" rel="noopener">Bell et al. (2013)</a> can be used together to expand our understanding of the characteristics of a maladaptive movement pattern of the lower extremity.</li>
 </ul>
 </li>
 <li>a lack of discussion of the role of the ankle as a potential contributor to knee valgus.
 <ul>
 <li>Based on the work of <a href="https://brookbushinstitute.com/article/research-review-exercise-to-reduce-knee-valgus-in-squat" target="_blank" rel="noopener">Bell et al. (2013)</a>, we know that dynamic knee valgus can be attributed to <a id="movement-impairment" data-tip="1802" target="_blank" href="/glossary-term/movement-impairment" class="glossary">movement dysfunction</a> at the ankle or the hip.</li>
 </ul>
 </li>
 <li>use of an equipment-reliant <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> without comparison to field tests used more commonly in athletic screening. Future research should compare the visual ability of clinicians to identify excessive knee valgus against that of a motion analysis system.
 <ul>
 <li>This would further validate the drop vertical jump <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> as a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> field <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> that may be used with minimal setup.</li>
 </ul>
 </li>
 <li>Future research may also wish to examine whether performance on the drop vertical jump <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> correlated with performance observations noted on the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a>. This would allow a clinician to have more options with which to evaluate individuals who may be at varying stages of recovery from injury (i.e. where performing a vertical drop jump might be too provocative of a <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> early in recovery and a double leg squat may not be provocative enough to fully <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> neuromuscular strategies in high impact activities).</li>
</ul>

This study provides information on factors that may help predict <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cruciate ligament (ACL) injury in a population that is particularly vulnerable, female adolescent athletes. The high incidence of these injuries results in significant medical costs (including rehabilitation), in addition to the psychological impact of being off the field on the athletes. In the introduction to this research, Hewett et al. describe three types of factors that may contribute to the high rate of ACL injury in female athletes - anatomical, hormonal or neuromuscular. Of the 3 types, only neuromuscular factors are conservatively modifiable. This is an area that the human movement professional can potentially have a large impact via accurate <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> selection of corrective interventions.

Why this Study is Important

This data provides information that the human movement professional can use to screen <a id="movement-impairment" data-tip="1804" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctional movement</a> patterns and design interventions to correct excessive valgus noted during a drop vertical jump. A lack of frontal plane control of the knee implicates certain muscles as being short, long, overactive or under-active (for example, the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">hip adductors</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">abductors</a>). The ACL-Injury (ACL-I) group also demonstrated an increased hip flexion moment when compared to the ACL-Uninjured (ACL-U) group. This may imply that decreased eccentric <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">hip extensor strength/control</a> may also play a role in ACL injury. Adolescent female athletes were the subjects of this study; the relative generalizability is unknown. However, it may be reasonable to consider individuals with excessive valgus during landing tasks as &quot;at risk for ACL injury.&quot; Finally, this article provides an <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> platform for the human movement professional to advocate for screening &amp; prevention programs for their athletes.

The Brookbush Institute uses the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a> to identify knee valgus, otherwise known as &quot;knees in&quot;. This sign can be interpreted as indicative of <a href="https://brookbushinstitute.com/article/lower-extremity-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>. Furthermore, the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a> allows the human movement professional to differentiate between knee valgus resulting from dysfunction at the foot/ankle or at the hip/pelvis/spine, using a <a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">modification of the original test</a>. The Drop Vertical Jump <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> is a more provocative <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> than the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a>. The forces produced during the movement is far greater; however, a squat is contained within the drop vertical jump <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> and it may be reasonable to assume that if an individual demonstrates valgus during an <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a>, they will also demonstrate valgus during a Drop Vertical Jump <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>. Below are videos that provide detailed explanations of how to use the <a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment</a> as a method of choosing to target interventions at the hip or ankle in order to correct excessive knee valgus.

Overhead Squat Assessment: Knees Bow In
<iframe src="https://player.vimeo.com/video/109470711" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Overhead Squat Assessment: Lower Extremity Dysfunction
<iframe src="https://player.vimeo.com/video/109546175" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<ol>
 <li>Arendt, E., and Dick, R. (1995). Knee injury patterns among men and women in collegiate basketball and soccer NCAA data and review of literature. The American journal of sports medicine, 23(6), 694-701.</li>
 <li><a href="https://brookbushinstitute.com/article/research-review-exercise-to-reduce-knee-valgus-in-squat" target="_blank" rel="noopener">Bell, D. R., Oates, D. C., Clark, M. A., &amp; Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. Journal of athletic training,48(4), 442-449.</a></li>
</ol>

Zazulak et al. (2007). Impaired Core Stability is Predictor of Knee Injury Risk

Original Citation: 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. <a href="https://www.researchgate.net/profile/Norman_Reeves/publication/6362341_Deficits_in_Neuromuscular_Control_of_the_Trunk_Predict_Knee_Injury_Risk_A_Prospective_Biomechanical-Epidemiologic_Study/links/00b7d525bf496c69d7000000/Deficits-in-Neuromuscular-Control-of-the-Trunk-Predict-Knee-Injury-Risk-A-Prospective-Biomechanical-Epidemiologic-Study.pdf" target="_blank" rel="noopener">ARTICLE</a>
The <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> joint is the second most commonly injured body part, and <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> surgeries account for as much as 60% of all sports-related surgeries (1-2). Research is starting to imply that dynamic <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> of the <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> depends on the ability to react to changes in trunk position during cutting, stopping, and landing movements (3-4). This 2007 study by U.S. researchers demonstrated a correlation between the amount of trunk displacement after a significant isometric force was suddenly removed, and the risk of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury during a 3-year follow-up. Human movement professionals should consider screening for and addressing any noted impairments in core <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> prior to the beginning of a season.
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kneeling-Chop.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kneeling-Chop.jpg" alt="Dr. Brookbush instructs model, Melissa Ruiz, on proper form during a Kneeling Chop"></a> Kneeling Chop. (Image: Courtesy of www.BrentBrookbush.com)

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Prospective cohort study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Prospective cohort study</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Age (years +/- standard deviation):
 <ul>
 <li>19.4 +/- 1.0 (female)</li>
 <li>19.3 +/- 1.8 (male)</li>
 </ul>
 
 </li>
 <li>Gender: 140 female, 137 male</li>
 <li>Number of participants: 227</li>
 <li>Collegiate athletes participating in various sports</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>No history of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>N/A</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Participants filled out a questionnaire with demographic data, athletic experience, and a history of any injury that prompted a visit to a physician</li>
 <li>Baseline trunk <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> was tested</li>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> injuries were tracked over a 3-year period</li>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> injury was defined as &quot;ligament, meniscal or patellofemoral injury to the <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> joint&quot;
 <ul>
 <li>All <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injuries were confirmed by magnetic resonance imaging (MRI)</li>
 <li>Fractures and contusions were not classified as <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injuries.</li>
 </ul>
 
 </li>
 <li>Core <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> was evaluated by observing the response of the trunk to the sudden removal of an isometric force</li>
 <li>Testing was performed with the participant&apos;s pelvis and lower extremities stabilized in a wooden apparatus
 <ul>
 <li>Participants were semi-seated with their lumbar spine in a self-determined &quot;comfortable position&quot;
 <ul>
 <li>The hips were in approximately 20&#xBA; of flexion, <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knees</a> in approximately 90&#xBA; of flexion, and the feet were free</li>
 </ul>
 
 </li>
 <li>Each participant wore a chest harness at the T5 spinal level that was connected via a pulley to an electromagnet and supplied the resistance for the isometric contraction for the trunk</li>
 <li>Resistance was &quot;30% of the maximal isometric trunk exertion for an average healthy man (108 N) or woman (72 N)&quot; as determined by a pilot study</li>
 </ul>
 
 </li>
 <li>Resistance was provided from 3 different directions:
 <ul>
 <li>Flexion (cable directed <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> from harness)</li>
 <li>Extension (cable <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> from harness)</li>
 <li>Lateral bending (cable right from harness)</li>
 </ul>
 
 </li>
 <li>Each participant performed 5 trials in which:
 <ul>
 <li>The electromagnet gradually increased direction-specific resistance</li>
 <li>Participants were instructed to maintain their position and were provided with a visual of the target resistance level</li>
 <li>The electromagnet was abruptly disengaged at random</li>
 </ul>
 <ul>
 <li>Trunk motion was recorded via sensor at T5 after the <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of the isometric force
 <ul>
 <li>At 150 milliseconds (ms) after release</li>
 <li>At maximal trunk displacement</li>
 </ul>
 
 </li>
 </ul>
 
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>
 <ul>
 <li>A 3-factor analysis of variance and Tukey post hoc <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> identified significantly different values (force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> direction, gender, and history of injury) between injured and uninjured participants</li>
 <li>The variables were combined with demographic data to create a multiple logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> that predicted <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury in the sample as a whole, the type of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury, and the difference between male and female participants
 <ul>
 <li>Data from a parallel study were also included, in which the Active Trunk Re-positioning (APR) <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> was used to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> trunk proprioception (2).
 <ul>
 <li>Each participant&apos;s trunk was slowly rotated from neutral to 20&#xBA; then slowly back to neutral.</li>
 <li>Participants pressed a switch to stop the return rotation when they believed they had returned to neutral.</li>
 <li>APR error was determined as the difference in degrees between neutral and where the apparatus was stopped.</li>
 </ul>
 
 </li>
 </ul>
 
 </li>
 </ul>
 <ul>
 <li>The <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> was performed multiple times with minimally contributing variables removed each time until only variables with P&lt; 0.1 remained</li>
 <li>A binary logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> analysis was used to determine if the <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> direction of trunk displacement was predictive of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury type and if there were differences between male and female participants</li>
 <li>A priori <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> analysis determined that 21 injuries over the 3-year period were needed to achieve a statistical <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> of 0.8</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>History of low back pain</li>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> injuries and type over a 3-year period</li>
 <li>Trunk displacement at 150 milliseconds for flexion, extension, and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> displacement</li>
 <li>Maximal trunk displacement for flexion, extension, and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> displacement</li>
 <li>Active trunk re-positioning (APR) error</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>During the 3-year follow-up period, 25 <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injuries occurred
 <ul>
 <li>11 female and 14 male participants reported injuries</li>
 <li>11 injuries were ligament injuries (5 female, 6 male)</li>
 <li>6 injuries were ACL ruptures (4 female, 2 male)</li>
 </ul>
 
 </li>
 <li>Trunk displacement at 150 milliseconds (ms) was greater in <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>-injured than in uninjured athletes
 <ul>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> injury P&lt;.05</li>
 <li>Ligament injury P&lt;.001</li>
 <li>ACL injury P&lt;.05</li>
 </ul>
 
 </li>
 <li>Maximal trunk displacement was significantly greater in <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>-injured than in uninjured athletes
 <ul>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> injury P&lt;.001</li>
 <li>Ligament injury P&lt;.05</li>
 <li>ACL injury P&lt;.001</li>
 <li>Uninjured P&lt;.05</li>
 </ul>
 
 </li>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a> ligament injured females demonstrated significantly greater maximal trunk displacement than uninjured females (P=.005)
 <ul>
 <li>No significant differences in maximal trunk displacement were noted between injured and uninjured males</li>
 </ul>
 
 </li>
 <li>The multiple logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> determined:
 <ul>
 <li>Trunk displacement in all 3 directions at 150 ms (maximal trunk displacement variable eliminated because it correlated with displacement at 150 ms), absolute error in the APR <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, and the history of low back pain predicted <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury with 83% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and 63% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> (P&lt;.0001).</li>
 <li>Trunk displacement at 150 ms and a history of low back pain predicted ligament injury with 91% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and 68% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> (P=.001)</li>
 <li>Trunk displacement in all directions at 150 ms was the sole predictor of ACL injury with 83% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and 76% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> (P=.002)</li>
 <li>The strongest predictor of injuries in females were the trunk displacement variables (85% accurate for <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injuries, 91% for ligament, 89% for ACL)
 <ul>
 <li>Active Proprioceptive Re-positioning (APR) error and history of low back pain were also predictors</li>
 </ul>
 
 </li>
 <li>The strongest predictor of injuries in male participants was a history of low back pain (P=.015).</li>
 </ul>
 
 </li>
 <li>The binary logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> determined:
 <ul>
 <li>Excessive <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> displacement was the strongest predictor of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>, ligament, and ACL injuries in all athletes
 <ul>
 <li>It was a significant predictor of ligament injury in female athletes (100% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, 72% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a>, P=.024)</li>
 <li>It did not predict injury in male athletes</li>
 </ul>
 
 </li>
 </ul>
 
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The results of this study demonstrate that greater trunk displacement following the sudden removal of a significant isometric force is correlated with increased risk of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury. This may imply that descriptions of <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> should include re-activity as well as changes in alignment.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>Athletes with a history of low back pain, increased trunk displacement following release of an isometric force, and errors in trunk APR demonstrated an increased risk of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury. Males and females exhibited different predisposing factors for injury. The implementation of interventions that incorporate core stability training, including proprioceptive exercise, perturbation, and correction of body sway, has the potential to reduce <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>, ligament, and ACL injury risk in male and female athletes.</td>
 </tr>
 </tbody>
</table>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kill-The-Trainer.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kill-The-Trainer.jpg" alt="Single Leg &lt;a id=" balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">Balance</a> Reactive Drill (Kill the Trainer)&quot;&gt; Single-Leg <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">Balance</a> Reactive Drill (Kill the Trainer). (Image: Courtesy of www.BrentBrookbush.com)

The relationship between core <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> and lower extremity (LE) injury highlights the interdependence of the trunk and LE (5-8). Previous research has shown a correlation between decreased neuromuscular control of the core, hamstrings, and <a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">ankle</a> injuries (9-11). Unique to this study, the researchers prospectively investigated an athlete&apos;s trunk displacement following the sudden removal of a significant isometric force and correlation with future <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury. This study demonstrates that decreased core reactivity is correlated with future <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury.

The findings of this study demonstrate a correlation between decreased core reactivity and increased risk of future <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury in athletes. This may imply interdependence between the trunk and leg and suggest that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> should include <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> for <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a>, <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>, and <a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">ankle</a> impairments and trunk <a href="https://brookbushinstitute.com/glossary/compensation-pattern/" target="_blank" rel="noopener">compensation patterns</a>. Further, human movement professionals should have a repertoire of techniques for addressing decreased core reactivity, and potentially <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> techniques for addressing coordination between the trunk/pelvis and lower extremity.
This study had many methodological strengths, including:
<ul>
 <li>Prospective studies are relatively rare in human movement science. This study followed athletes for 3 years after testing and provides evidence that impairment may be a cause, and/or predictive of injury.</li>
 <li>The researchers tested the trunk from multiple directions, which mimicked the potential variability in <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> perturbations during sports activities.</li>
 <li>An athlete&apos;s ability to generate a trunk stabilizing motor response (sudden trunk unloading <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>) and his or her ability to accurately perceive the position of their trunk in space (Active Trunk Repositioning <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>) were included in the <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> in this study. Both accurate sensory input and efficient motor output are needed for <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> dynamic <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>.</li>
 <li>Statistical analysis was performed on male and female participants together and separately. This allowed for observation of whether different variables predicted injury in different sexes.</li>
 <li>The researchers performed an a priori <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> analysis based on pilot testing to achieve a statistical <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> of 0.80, and exceeded the number of needed injuries in the study.</li>
</ul>
Weaknesses that should be noted prior to the clinical <a href="https://brookbushinstitute.com/glossary/integration/" target="_blank" rel="noopener">integration</a> of the findings include:
<ul>
 <li>The participants&apos; baseline injury history was not reported. Such data would have provided more information about the sample prior to observation.</li>
 <li>A significant amount of equipment was required to position participants and record perturbations. Future research should consider the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a> of core <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> &quot;field tests&quot; that can be performed with minimal or no equipment.</li>
 <li>A functional athletic position was not tested. While the authors noted this was done to avoid compensation by any lower extremity muscles, this limits the generalization of the findings to functional activity.</li>
 <li>A young, athletic population was studied. Findings may not generalize to older or more sedentary populations.</li>
</ul>

The Brookbush Institute (BI) has developed predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction, such as the <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>, to aid human movement professionals in selecting <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, manual interventions, and exercise. This study demonstrates that decreased core reactivity is correlated with an increased risk of <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a> injury in athletes. The findings of this study were <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> with additional studies demonstrating a correlation between trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> weakness, <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>. In a comprehensive treatment and/or training program, the BI recommends including core stability/reactivity exercises to ensure <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> with the affected/addressed segment. The BI continues to pursue <a href="https://brookbushinstitute.com/glossary/optimal/" target="_blank" rel="noopener">optimal</a> practice by refining <a href="https://brookbushinstitute.com/article/introduction-to-postural-dysfunction-and-movement-impairment" target="_blank" rel="noopener">predictive </a><a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction and looks forward to the <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of more insightful studies like the one reviewed here.

TVA and Gluteus Maximus Activation and Progressions
<iframe src="https://player.vimeo.com/video/82877282" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Quadruped Crawl
<iframe src="https://player.vimeo.com/video/133934741" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Quadruped Crawl 2
<iframe src="https://player.vimeo.com/video/263787607" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Resisted Quadruped Crawl
<iframe src="https://player.vimeo.com/video/306488004" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Kneeling Chop Pattern
<iframe src="https://player.vimeo.com/video/267500518" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Single-Leg Standing Chop Pattern
<iframe src="https://player.vimeo.com/video/267503968" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Crunch and Catch
<iframe src="https://player.vimeo.com/video/82849084" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<ol>
 <li>Ingram, J. G., Fields, S. K., Yard, E. E., and Comstock, R. D. (2008). Epidemiology of knee injuries among boys and girls in US high school athletics. The American journal of sports medicine, 36(6), 1116-1122.</li>
 <li>Powell, J. W., &amp; Barber-Foss, K. D. (1999). Injury patterns in selected high school sports: a review of the 1995-1997 seasons. Journal of athletic training, 34(3), 277.</li>
 <li>Hewett, T. E., Paterno, M. V., &amp; Myer, G. D. (2002). Strategies for enhancing proprioception and neuromuscular control of the knee. Clinical Orthopaedics and Related Research&reg;, 402, 76-94.</li>
 <li>Hewett, T. E., Zazulak, B. T., Myer, G. D., &amp; Ford, K. R. (2005). A review of electromyographic activation levels, timing differences, and increased anterior cruciate ligament injury incidence in female athletes. British journal of sports medicine, 39(6), 347-350.</li>
 <li>Zazulak, B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., and Cholewicki, J. (2007). The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study. The American journal of sports medicine.</li>
 <li>Heiderscheit, B. C. (2010). Lower extremity injuries: is it just about hip strength? journal of orthopaedic &amp; sports physical therapy, 40(2), 39-41.</li>
 <li>Leetun, D. T., Ireland, M. L., Willson, J. D., Ballantyne, B. T., &amp; Davis, I. M. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine &amp; Science in Sports &amp; Exercise, 36(6), 926-934.</li>
 <li><a href="https://brookbushinstitute.com/article/role-of-the-diaphragm-in-stabilization" target="_blank" rel="noopener">Hodges, P. W., Butler, J. E., McKenzie, D. K., and Gandevia, S. C. (1997). Contraction of the human diaphragm during rapid postural adjustments. The Journal of physiology, 505(Pt 2), 539-548.</a></li>
 <li>Cholewicki, J., Silfies, S. P., Shah, R. A., Greene, H. S., Reeves, N. P., Alvi, K., &amp; Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine, 30(23), 2614-2620.</li>
 <li>Devlin, L. (2000). Recurrent posterior thigh symptoms detrimental to performance in rugby union. Sports Medicine, 29(4), 273-287.</li>
 <li>Beynnon, B., Vacek, P. M., Abate III, J. A., Murphy, D., &amp; Paller, D. (2006, July). A prospective study of risk factors for first time ankle inversion ankle ligament trauma. In 32nd annual meeting of the American Orthopaedic Society for Sports Medicine</li>
</ol>

&copy; 2018 Brent Brookbush
Questions, comments and criticisms are welcomed and encouraged

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Accuracy - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

Adenosine triphosphatase (ATPase): is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

Adenosine triphosphate (ATP): The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

Algometry - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

All-or-none principle - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the anterior aspect of the head

Appendicular Skeleton - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

Arthrokinematic Motion - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

Assessment - is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li>"Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li>Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li>Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin axis "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

Case-control Study - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology, 134(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed cephalad.

Cohort Study - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

Comparable Sign: A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

Concave (Concavity) - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

Conductivity: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

Convex (Convexity) - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

Correlational Research - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

Crossover (Study) Design - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. Journal of Human Kinetics, 58, 197-206. </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength.  Journal of Manual &amp; Manipulative Therapy. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the distal end of the leg.

An arthrokinematic motion - a force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the dorsal surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an alteration of normal kinematics.

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

Elasticity: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0">Evidence-based medicine (practice) is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

Exercise Progression - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

Exercise regression - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

Experimental Research - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

False Negative - the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

False Positive - the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain, 27(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. PAIN®, 145(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

H-Band - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (biological holism) - (from Greek holos "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. Holism and evolution. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

Hormone: Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. Scandinavian journal of clinical and laboratory investigation, 60(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

Hyperplasia is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

Muscular hypertrophy is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

I-Band - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: <a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An isoform, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior kinetic chain, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

Latent Trigger Point - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is lateral to the pectoralis major

Length/Tension Relationship - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. The Journal of physiology, 184(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. The Journal of Physiology, 183(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. Journal of neurophysiology, 71(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). Skeletal muscle structure, function, and plasticity. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

Levels of Evidence - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.


The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. Western Journal of Medicine, 170(6), 348.</li>
</ol>

Likelihood Ratios - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li>Positive Likelihood Ratio (LR+) - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li>Negative Likelihood Ratio (LR-) - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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