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Lower Extremity Strength and Range of Motion in High School Cross-Country Runners

Lower Extremity Strength and Range of Motion in High School Cross-Country Runners Hindawi Applied Bionics and Biomechanics Volume 2018, Article ID 6797642, 5 pages https://doi.org/10.1155/2018/6797642 Research Article Lower Extremity Strength and Range of Motion in High School Cross-Country Runners 1 1 2 2 Jun G. San Juan , David N. Suprak, Sean M. Roach, and Marc Lyda Department of Health and Human Development, Western Washington University, 516 High St., MS 9067, Bellingham, WA 98225, USA Western Institute of Neuromechanics, 244 E. Broadway, Eugene, OR 97401, USA Correspondence should be addressed to Jun G. San Juan; jun.sanjuan@wwu.edu Received 1 February 2018; Accepted 30 July 2018; Published 8 August 2018 Academic Editor: Stefano Zaffagnini Copyright © 2018 Jun G. San Juan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cross-country running is becoming an increasingly popular sport, with a significant participation noted at the high school level. The aim of this study was to compare gender and bilateral hip extension range of motion and hip and knee extension strength of high school cross-country runners. 31 participants volunteered from a local high school cross-country team (16 males and 15 females). The modified Thomas test was utilized to measure hip extension range of motion bilaterally using a digital inclinometer. In order to measure hip and knee isometric strengths, an isokinetic dynamometer was employed. A mixed model approach revealed a statistically significant difference in peak hip extension strength between genders but not the side. Male athletes demonstrated a 29.2 Nm/kg (P <0 05) greater force production than females during isometric hip extension strength testing. There were no significant differences in peak knee extension isometric strength, hip extension range of motion, and the ratio of peak hip and knee strength between genders and the dominant and nondominant leg. Female cross-country runners should focus on increasing hip extension strength to help maintain hip stability during running. This may be beneficial in decreasing the chances of experiencing patellofemoral pain in long-distance runners. Patellofemoral pain (PFP) is a common orthopedic 1. Introduction problem in our society, accounting for up to 25% of all knee Running is becoming an increasingly popular activity in the problems addressed in sports medicine centers [4, 5]. The United States, with a significant participation noted at the presence of PFP can result in not only loss of participation high school level. According to the National Federation of in activity but also significant frustration when seeking appropriate diagnosis and management of the condition. State High School Associations, there were over 471,000 ath- letes who participated in high school cross-country in 2014, Current management strategies for the condition have been marking a 30% increase in participation over the past 10 met with limited success. The literature on PFP has recently years [1]. The increase in participation as well as increased focused attention on the importance of hip strength, in par- frequency of training can lead to significantly increased expo- ticular, the hip abductors and external rotators [6, 7]. Ireland sure to running-related injuries (RRI), most notably in the et al. [6] have demonstrated that active females with PFP lower extremities [2]. Several recent studies noted lower have significant weakness in the hip muscles, which may lead extremity injury rates in high school cross-country partici- to an alteration in lower extremity mechanics. Additionally, pants ranging from 19% to 79% and up to 92% when all Powers [8] has noted that most of the lower extremity inju- regions of the body were included [3]. The most common ries experienced with athletic participation could be the RRIs are reported to be patellofemoral pain syndrome, lower result of the same phenomena, which is excessive hip internal back pain, iliotibial band syndrome, plantar fasciitis, and rotation combined with adduction during the stance phase of lower leg injuries, followed by issues with the lower leg, activity. This pronation of the hip is required for proper Achilles/calf, and heel anatomy [4]. alignment of the leg segments for stability and appropriate 2 Applied Bionics and Biomechanics testing, participants did a five-minute warm-up on a Schwinn shock attenuation [7]. Further, it has been shown that PFP patients exhibited a decreased passive hip extension range Airdyne (Nautilus, Vancouver, WA, USA) upright exercise of motion [9]. bike. After the warm-up, participants had hip extension The importance of eccentric control of hip adduction (EXT) measurement on the dominant and nondominant during activity has been discussed as a factor in influencing hips. This ROM was measured using a digital inclinometer the health and function of the patellofemoral joint in partic- (Digital Protractor Pro 3600, Mitotoyo America, Aurora, ular [10]. A decrease in control of eccentric hip adduction IL, USA). The use of this instrument has been previously val- during activity results in an excessive internal rotation of idated and was reported to have a reliability of 0.9 [22]. To the femur, with the tibia in relative external rotation, result- measure hip extension ROM, the participants lay supine on ing in abnormal valgus stress at the anterior medial knee a treatment table and a modified Thomas test was performed [23]. This maneuver was implemented with the participant joint, in addition to potentially excessive loading of the hip into internal rotation and the lower leg into excessive prona- holding their contralateral leg with the hip and knee flexed tion [11, 12]. It has, therefore, been suggested that interven- against their chest while the ipsilateral leg being measured tions for PFP should include a focus on influencing stability hung over the end of the treatment table. The investigator of the hip and the pelvis to control for this excessive valgus made sure that the hip was not in an abducted position. Fur- stress at the knee [13–15]. ther, the investigator provided both verbal and tactile cues to Previous literature had noted several biomechanical dif- maintain their lower back flat against the table to avoid lum- ferences between male and female runners. The variables bar extension and pelvic tilting during the evaluation. The most often examined include hip and knee kinematics, mus- inclinometer was positioned on the anterior aspect of the cle activation, and muscle strength. In particular, it has been thigh at the midpoint between the greater trochanter and demonstrated that female runners exhibit greater peak hip the lateral epicondyle of the femur. All of the measurements adduction and internal rotation and knee abduction angles for ROM, on the dominant and nondominant hips, were as compared to males [16]. This includes both healthy run- taken three times. An average was calculated for data analy- ners and those with either PFP or iliotibial band syndrome sis, and all the measurements were randomized. [17, 18]. In addition, clear differences are noted in both hip Participants then underwent isometric strength testing strength and muscle activation between the genders [19–21]. using a Biodex System 3 Isokinetic dynamometer (Biodex It is clear that hip kinematics and strength are related to Medical Systems, Shirley, NY, USA). Hip extension and knee the health and function of the patellofemoral joint, and that extension strengths were measured on both legs for each par- ticipant. Once again, the order was randomized to determine runners with certain biomechanical characteristics are sus- ceptible to faulty mechanics at this, and surrounding, joints. if testing would first be done on hip extension or knee exten- It is also known that male and female runners exhibit differ- sion and then if the dominant or nondominant leg would be ent hip and knee kinematic patterns during running gait. tested first. To measure hip extension strength, participants However, there currently exists a paucity of normative data were asked to stand in front of the Biodex chair while flexing pertaining to hip and knee kinematics and strengths in devel- their trunk to 45 with respect to the ground and with the oping male and female runners. Therefore, the purpose of the tested hip flexed to 30 . Participants were instructed to grasp study was to compare bilateral hip extension range of motion the chair handles for support. The thigh of the tested leg was and hip and knee extension strengths of high school runners secured distally above the medial and lateral epicondyle using before the start of the season. Additionally, we wanted to the thigh attachment that came with the dynamometer. The compare these variables between genders. We hypothesized contralateral foot was kept flat on the ground. The manufac- that there would be no statistically significant difference turer’s recommended protocol was utilized for isometric between genders in hip extension range of motion and hip knee extension strength testing. The knee was positioned at and knee strength bilaterally. 60 of flexion during the isometric testing, and the knee attachment was secured in the distal shank immediately superior to the malleoli. In each test position, participants 2. Materials and Methods performed a maximum voluntary isometric contraction The current study was conducted at the Biokinesiology Lab- (MVIC) for 5 seconds three times, and the average of the oratory at Western Institute of Neuromechanics in Eugene, three trials was utilized for analysis. Participants were given Oregon. A total of 31 participants (age: 15.6 ± 1.2 y/o, height: a minute rest in between testing positions to avoid fatigue. 169.1 ± 12.2 cm, mass: 58.3 ± 8.8 kg) were recruited from a All the strength data were normalized to participant’s body local high school cross-country team (16 males and 15 weight to account for differences in subjects’ stature. females). A priori estimate of the sample size revealed that A two-way mixed analysis of variance (ANOVA) was a total of 26 participants were needed to achieve a power of used to examine the effects of the gender and side (dominant 0.8 with an alpha level of 0.05. The study was approved by versus nondominant) on each dependent variable of interest, the Western Washington University human participants which included normalized peak hip extension strength, nor- review committee (#12-013). Before data collection, informed malized peak knee extension strength, the normalized peak consent was obtained from all participants and parents/ hip/knee extension strength ratio, and modified Thomas test guardians filled out the assent forms for minors. range of motion. Simple effects analyses were conducted in Participants were asked to come into the laboratory the event of a significant gender by side interaction. The sig- one time in which all testing was completed. During the nificance level for all statistical analyses was set at P <0 05. Applied Bionics and Biomechanics 3 3.5 3. Results and Discussion 3.0 The two-way mixed ANOVA revealed no significant side 2.5 by gender interaction effect on peak hip extension strength (F 1, 29 =0 059, P =0 81, η =0 002). In addition, there was 2.0 no significant main effect of the side on peak hip extension 1.5 strength (F 1, 29 =0 518, P =0 48, η =0 018). However, 1.0 peak hip extension strength (Figure 1) was significantly higher in males than in females across both sides (F 1, 29 = 0.5 5 96, P =0 02, η =0 171). 0.0 The two-way mixed ANOVA revealed no significant Hip Knee interaction effect between gender and side (F 1, 29 =2 63, Extension P =0 12, η =0 083) on peak knee extension strength, as well Male as no main effects of neither gender (F 1, 29 =1 19, P =0 28, Female 2 2 η =0 04) nor side (F 1, 29 =1 09, P =0 31, η =0 036). As with the effects of gender and side on peak knee Figure 1: Hip and knee extension peak isometric torque between genders. extension strength, the ratio between the peak hip and knee extension strengths was not significantly affected by the interaction between gender and side (F 1, 29 =0 677, P = exhibited a 40% greater peak gluteus maximus activation 0 42, η =0 023), nor by neither of the main effects of gender level compared to male runners. Additionally, Souza and (F 1, 29 =0 224, P =0 64, η =0 008) nor side (F 1, 29 = Powers [20] noted an increase in gluteus maximus activation 0 002, P =0 96, η <0 001). in female runners with PFP as opposed to female controls. According to the two-way mixed ANOVA, Thomas test The accumulating evidence lends credence to the hypothesis range of motion (Table 1) was not affected significantly by that the increased gluteus muscle activation in females with the interaction of gender and side (F 1, 29 =2 72, P =0 11, PFP, and even those without, may lead to earlier fatigue of η =0 086), nor by neither of the main effects of gender (F 1, the muscle and thus impaired control of frontal and trans- 29 =0 685, P =0 42, η =0 023) nor side (F 1, 29 =2 21, verse plane hip motion [20, 21]. The results of the current P =0 15, η =0 071). study revealed a marked difference in peak hip extension The primary purpose of this study was to compare the strength between male and female runners. A combination differences in bilateral hip and knee extension strengths of decreased overall strength and possible decreased endur- and hip extension mobility between high school cross- ance of the gluteus maximus in runners, particularly females, country runners. Additionally, the ratio of the average peak provides valuable information for better-designed condition- isometric strength of the knee extensors and hip extensors ing and rehabilitation programs for runners. This decreased was compared between genders. The results of the current hip strength observed in high school cross-country runners study support the hypothesis that there will be no statistically may lead to early fatigue and impaired lower extremity kine- significant differences between gender and side in both the matics. Runners may benefit from both aggressive isolated hip and the knee range of motion and strength except for hip extensor muscles strengthening (i.e., gluteus maximus) the peak hip extension strength. The current data indicated and endurance-type training to help normalize lower extrem- that males demonstrated significantly larger peak hip exten- ity mechanics during running activities. sion strength compared to females. This area of exploration In addition, females exhibited significantly lower peak was conducted in order to assist in further insights into com- hip strength values than males did, but no differences were mon RRI such as PFP and iliotibial band syndrome (ITBS). noted in knee extensor values between gender and sides. It has been increasingly documented that gluteal muscle Males exhibited 29.2 Nm/kg greater force production during strength is an important variable in control of the femur hip extension. Of most interest is that no significant differ- during functional tasks such as running and stair climbing ences were noted in knee-hip extensor strength ratios and descent [18, 20, 21]. The gluteus maximus main action between groups. With regard to RRI, there is strong evidence is to extend the hip joint, and it also plays a vital role in run- to support that females tend to use a more quadriceps- or ning by eccentrically controlling the hip during internal knee extensor- dominant pattern with landing activities rotation in upright tasks [24]. Notably, evidence shows that [25]. Stearns and colleagues [26] have documented that individuals with PFP have increased hip internal rotation in women tend to demonstrate a higher knee-hip extensor ratio running as compared to controls [20]. Souza and Powers than men during the deceleration phase of landing. One rea- [20] hypothesize that it is the increased internal rotation of son for the difference in findings could be the result of com- the femur relative to the tibia that creates a lateral position- paring a double leg drop jump task versus running. Although ing of the patella, and thus increased loading of the retro running certainly involves a deceleration phase during the patellar region. landing on one limb, increased control strategies may differ The present study was conducted to examine the differ- with double leg activities. ence between genders in hip and knee extension strengths. The current results did not show a difference in hip Willson et al. [21] found that healthy female runners extension mobility when compared bilaterally and between Peak torque (Nm/kg) 4 Applied Bionics and Biomechanics Table 1: Hip extension range of motion measured during the Conflicts of Interest modified Thomas test (mean ± SEM) between gender and the side (i.e., the dominant and nondominant leg). All authors declare that there is no conflict of interest. Hip extension range of motion ( ) Acknowledgments Gender Dominant Nondominant The authors would like to thank Heather Salzer for her Male 5.9 ± 1.5 6.0 ± 1.5 contribution to the data collection. The article processing Female 9.6 ± 2.5 7.1 ± 1.8 charge was provided by Western Washington University Research and Sponsored Programs. genders. This variable is important to help better understand References the influence of altering hip mobility in the sagittal plane, which could provide clues to differences in gender-specific [1] National Federation of State and High School Associations, injury rates. Given the importance of the gluteus maximus “2013-2014 High School Athletics Participation Survey to function within a full range of motion, it was important results,” 2015, May 2015; http://www.nfhs.org/Participation to determine if a lack of mobility existed with this population, Statics/ParticipationStatics.aspx/. since recent evidence demonstrated a difference in subjects [2] I. Buist, S. W. Bredeweg, K. A. P. M. Lemmink, W. van with PFP and controls [9]. Roach and colleagues [22] com- Mechelen, and R. L. Diercks, “Predictors of running-related pared hip mobility in healthy and PFP subjects. The authors injuries in novice runners enrolled in a systematic training program: a prospective cohort study,” The American Journal found out that PFP patients experienced decreased hip exten- of Sports Medicine, vol. 38, no. 2, pp. 273–280, 2010. sion ROM compared to controls. The combined gender aver- [3] R. N. van Gent, D. Siem, M. van Middelkoop et al., “Incidence age hip extension of runners in the current study was 6.6 on and determinants of lower extremity running injuries in long the nondominant and 7.7 on the dominant leg, which was distance runners: a systematic review,” British Journal of Sports consistent with that of the Roach et al. [9] study on healthy ° Medicine, vol. 41, no. 8, pp. 469–480, 2007, discussion 480. active individuals of 6.8 bilaterally. [4] J. E. Taunton, M. B. Ryan, D. B. Clement, D. McKenzie, D. R. There were a few limitations in this current study. First Lloyd-Smith, and B. D. Zumbo, “A retrospective case-control was the fact that the participants were uninjured, and there- analysis of 2002 running injuries,” British Journal of Sports fore, the findings may not be representative of injured run- Medicine, vol. 36, no. 2, pp. 95–101, 2002. ners. It may be valuable to investigate the differences [5] L. Wood, S. Muller, and G. Peat, “The epidemiology of patello- between healthy runners and injured runners to determine femoral disorders in adulthood: a review of routine general if these observations are consistent. The second limitation practice morbidity recording,” Primary Health Care Research was that the study examined isometric strength and did & Development, vol. 12, no. 2, pp. 157–164, 2011. not look at strength through a full dynamic range of [6] M. L. Ireland, J. D. Willson, B. T. Ballantyne, and I. M. C. motion. Future studies should examine the same variables Davis, “Hip strength in females with and without patellofe- within an injured population of high school-aged runners moral pain,” The Journal of Orthopaedic and Sports Physical for comparison. Therapy, vol. 33, no. 11, pp. 671–676, 2003. [7] C. M. Powers, “The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical 4. Conclusion perspective,” The Journal of Orthopaedic and Sports Physical Therapy, vol. 33, no. 11, pp. 639–646, 2003. [8] C. M. Powers, “The influence of abnormal hip mechanics on This study observed a significant difference in hip exten- knee injury: a biomechanical perspective,” The Journal of sion strength between genders in healthy high school cross- Orthopaedic and Sports Physical Therapy, vol. 40, no. 2, country runners. Males exhibited a higher hip extensor pp. 42–51, 2010. strength when tested isometrically than the female partici- [9] S. M. Roach, J. G. San Juan, D. N. Suprak, M. Lyda, and pants. However, it is worth noting that there are no signifi- C. Boydston, “Patellofemoral pain subjects exhibit decreased cant differences observed in the knee-hip extension strength passive hip range of motion compared to controls,” Interna- ratios and hip extension range of motion between genders. tional Journal of Sports Physical Therapy, vol. 9, no. 4, The results also presented that high school female cross- pp. 468–475, 2014. country runners do not exhibit a greater knee extensor [10] A. D. Nguyen, M. C. Boling, B. Levine, and S. J. Shultz, “Rela- strength when compared to their hip extensors. The results tionships between lower extremity alignment and the quadri- observed in the current study are all factors that can contrib- ceps angle,” Clinical Journal of Sport Medicine, vol. 19, no. 3, ute to decreasing or preventing the chance of suffering a pp. 201–206, 2009. running-related injury in high school cross-country runners. [11] J. T. Finnoff, M. M. Hall, K. Kyle, D. A. Krause, J. Lai, and J. Smith, “Hip strength and knee pain in high school runners: a prospective study,” PM&R, vol. 3, no. 9, pp. 792–801, 2011. Data Availability [12] R. L. Robinson and R. J. Nee, “Analysis of hip strength in females seeking physical therapy treatment for unilateral patel- The data used to support the findings of this study are lofemoral pain syndrome,” The Journal of Orthopaedic and available from the corresponding author upon request. Sports Physical Therapy, vol. 37, no. 5, pp. 232–238, 2007. Applied Bionics and Biomechanics 5 [13] R. Ferber, K. D. Kendall, and L. Farr, “Changes in knee biome- chanics after a hip-abductor strengthening protocol for run- ners with patellofemoral pain syndrome,” Journal of Athletic Training, vol. 46, no. 2, pp. 142–149, 2011. [14] K. Khayambashi, Z. Mohammadkhani, K. Ghaznavi, M. A. Lyle, and C. M. Powers, “The effects of isolated hip abductor and external rotator muscle strengthening on pain, health sta- tus, and hip strength in females with patellofemoral pain: a randomized controlled trial,” The Journal of Orthopaedic and Sports Physical Therapy, vol. 42, no. 1, pp. 22–29, 2012. [15] M. Shirey, M. Hurlbutt, N. Johansen, G. W. King, S. G. Wilkinson, and D. L. Hoover, “The influence of core muscu- lature engagement on hip and knee kinematics in women dur- ing a single leg squat,” International journal of sports physical therapy, vol. 7, no. 1, pp. 1–12, 2012. [16] R. Ferber, I. McClay Davis, and D. S. Williams III, “Gender differences in lower extremity mechanics during running,” Clinical Biomechanics, vol. 18, no. 4, pp. 350–357, 2003. [17] A. Phinyomark, S. Osis, B. A. Hettinga, R. Leigh, and R. Ferber, “Gender differences in gait kinematics in runners with ilioti- bial band syndrome,” Scandinavian Journal of Medicine & Science in Sports, vol. 25, no. 6, pp. 744–753, 2015. [18] E. S. Chumanov, C. Wall-Scheffler, and B. C. Heiderscheit, “Gender differences in walking and running on level and inclined surfaces,” Clinical Biomechanics, vol. 23, no. 10, pp. 1260–1268, 2008. [19] D. Ramskov, M. B. Pedersen, K. Kastrup et al., “Normative values of eccentric hip abduction strength in novice runners: an equation adjusting for age and gender,” International Jour- nal of Sports Physical Therapy, vol. 9, no. 1, pp. 68–75, 2014. [20] R. B. Souza and C. M. Powers, “Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain,” The Journal of Orthopaedic and Sports Physical Therapy, vol. 39, no. 1, pp. 12–19, 2009. [21] J. D. Willson, I. Petrowitz, R. J. Butler, and T. W. Kernozek, “Male and female gluteal muscle activity and lower extremity kinematics during running,” Clinical Biomechanics, vol. 27, no. 10, pp. 1052–1057, 2012. [22] S. Roach, J. G. San Juan, D. N. Suprak, and M. Lyda, “Concur- rent validity of digital inclinometer and universal goniometer in assessing passive hip mobility in healthy subjects,” Interna- tional Journal of Sports Physical Therapy, vol. 8, no. 5, pp. 680– 688, 2013. [23] F. P. Kendall, E. K. McCreary, and P. G. Provance, Muscles, Testing and Function: with Posture and Pain, Williams & Wilkins, Baltimore, Md., 4th ed edition, 1993. [24] D. E. Lieberman, D. A. Raichlen, H. Pontzer, D. M. Bramble, and E. Cutright-Smith, “The human gluteus maximus and its role in running,” Journal of Experimental Biology, vol. 209, no. 11, pp. 2143–2155, 2006. [25] C. D. Pollard, S. M. Sigward, and C. M. Powers, “Limited hip and knee flexion during landing is associated with increased frontal plane knee motion and moments,” Clinical Biomechan- ics, vol. 25, no. 2, pp. 142–146, 2010. [26] K. M. Stearns, R. G. Keim, and C. M. Powers, “Influence of relative hip and knee extensor muscle strength on landing biomechanics,” Medicine and Science in Sports and Exercise, vol. 45, no. 5, pp. 935–941, 2013. 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Lower Extremity Strength and Range of Motion in High School Cross-Country Runners

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Hindawi Applied Bionics and Biomechanics Volume 2018, Article ID 6797642, 5 pages https://doi.org/10.1155/2018/6797642 Research Article Lower Extremity Strength and Range of Motion in High School Cross-Country Runners 1 1 2 2 Jun G. San Juan , David N. Suprak, Sean M. Roach, and Marc Lyda Department of Health and Human Development, Western Washington University, 516 High St., MS 9067, Bellingham, WA 98225, USA Western Institute of Neuromechanics, 244 E. Broadway, Eugene, OR 97401, USA Correspondence should be addressed to Jun G. San Juan; jun.sanjuan@wwu.edu Received 1 February 2018; Accepted 30 July 2018; Published 8 August 2018 Academic Editor: Stefano Zaffagnini Copyright © 2018 Jun G. San Juan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cross-country running is becoming an increasingly popular sport, with a significant participation noted at the high school level. The aim of this study was to compare gender and bilateral hip extension range of motion and hip and knee extension strength of high school cross-country runners. 31 participants volunteered from a local high school cross-country team (16 males and 15 females). The modified Thomas test was utilized to measure hip extension range of motion bilaterally using a digital inclinometer. In order to measure hip and knee isometric strengths, an isokinetic dynamometer was employed. A mixed model approach revealed a statistically significant difference in peak hip extension strength between genders but not the side. Male athletes demonstrated a 29.2 Nm/kg (P <0 05) greater force production than females during isometric hip extension strength testing. There were no significant differences in peak knee extension isometric strength, hip extension range of motion, and the ratio of peak hip and knee strength between genders and the dominant and nondominant leg. Female cross-country runners should focus on increasing hip extension strength to help maintain hip stability during running. This may be beneficial in decreasing the chances of experiencing patellofemoral pain in long-distance runners. Patellofemoral pain (PFP) is a common orthopedic 1. Introduction problem in our society, accounting for up to 25% of all knee Running is becoming an increasingly popular activity in the problems addressed in sports medicine centers [4, 5]. The United States, with a significant participation noted at the presence of PFP can result in not only loss of participation high school level. According to the National Federation of in activity but also significant frustration when seeking appropriate diagnosis and management of the condition. State High School Associations, there were over 471,000 ath- letes who participated in high school cross-country in 2014, Current management strategies for the condition have been marking a 30% increase in participation over the past 10 met with limited success. The literature on PFP has recently years [1]. The increase in participation as well as increased focused attention on the importance of hip strength, in par- frequency of training can lead to significantly increased expo- ticular, the hip abductors and external rotators [6, 7]. Ireland sure to running-related injuries (RRI), most notably in the et al. [6] have demonstrated that active females with PFP lower extremities [2]. Several recent studies noted lower have significant weakness in the hip muscles, which may lead extremity injury rates in high school cross-country partici- to an alteration in lower extremity mechanics. Additionally, pants ranging from 19% to 79% and up to 92% when all Powers [8] has noted that most of the lower extremity inju- regions of the body were included [3]. The most common ries experienced with athletic participation could be the RRIs are reported to be patellofemoral pain syndrome, lower result of the same phenomena, which is excessive hip internal back pain, iliotibial band syndrome, plantar fasciitis, and rotation combined with adduction during the stance phase of lower leg injuries, followed by issues with the lower leg, activity. This pronation of the hip is required for proper Achilles/calf, and heel anatomy [4]. alignment of the leg segments for stability and appropriate 2 Applied Bionics and Biomechanics testing, participants did a five-minute warm-up on a Schwinn shock attenuation [7]. Further, it has been shown that PFP patients exhibited a decreased passive hip extension range Airdyne (Nautilus, Vancouver, WA, USA) upright exercise of motion [9]. bike. After the warm-up, participants had hip extension The importance of eccentric control of hip adduction (EXT) measurement on the dominant and nondominant during activity has been discussed as a factor in influencing hips. This ROM was measured using a digital inclinometer the health and function of the patellofemoral joint in partic- (Digital Protractor Pro 3600, Mitotoyo America, Aurora, ular [10]. A decrease in control of eccentric hip adduction IL, USA). The use of this instrument has been previously val- during activity results in an excessive internal rotation of idated and was reported to have a reliability of 0.9 [22]. To the femur, with the tibia in relative external rotation, result- measure hip extension ROM, the participants lay supine on ing in abnormal valgus stress at the anterior medial knee a treatment table and a modified Thomas test was performed [23]. This maneuver was implemented with the participant joint, in addition to potentially excessive loading of the hip into internal rotation and the lower leg into excessive prona- holding their contralateral leg with the hip and knee flexed tion [11, 12]. It has, therefore, been suggested that interven- against their chest while the ipsilateral leg being measured tions for PFP should include a focus on influencing stability hung over the end of the treatment table. The investigator of the hip and the pelvis to control for this excessive valgus made sure that the hip was not in an abducted position. Fur- stress at the knee [13–15]. ther, the investigator provided both verbal and tactile cues to Previous literature had noted several biomechanical dif- maintain their lower back flat against the table to avoid lum- ferences between male and female runners. The variables bar extension and pelvic tilting during the evaluation. The most often examined include hip and knee kinematics, mus- inclinometer was positioned on the anterior aspect of the cle activation, and muscle strength. In particular, it has been thigh at the midpoint between the greater trochanter and demonstrated that female runners exhibit greater peak hip the lateral epicondyle of the femur. All of the measurements adduction and internal rotation and knee abduction angles for ROM, on the dominant and nondominant hips, were as compared to males [16]. This includes both healthy run- taken three times. An average was calculated for data analy- ners and those with either PFP or iliotibial band syndrome sis, and all the measurements were randomized. [17, 18]. In addition, clear differences are noted in both hip Participants then underwent isometric strength testing strength and muscle activation between the genders [19–21]. using a Biodex System 3 Isokinetic dynamometer (Biodex It is clear that hip kinematics and strength are related to Medical Systems, Shirley, NY, USA). Hip extension and knee the health and function of the patellofemoral joint, and that extension strengths were measured on both legs for each par- ticipant. Once again, the order was randomized to determine runners with certain biomechanical characteristics are sus- ceptible to faulty mechanics at this, and surrounding, joints. if testing would first be done on hip extension or knee exten- It is also known that male and female runners exhibit differ- sion and then if the dominant or nondominant leg would be ent hip and knee kinematic patterns during running gait. tested first. To measure hip extension strength, participants However, there currently exists a paucity of normative data were asked to stand in front of the Biodex chair while flexing pertaining to hip and knee kinematics and strengths in devel- their trunk to 45 with respect to the ground and with the oping male and female runners. Therefore, the purpose of the tested hip flexed to 30 . Participants were instructed to grasp study was to compare bilateral hip extension range of motion the chair handles for support. The thigh of the tested leg was and hip and knee extension strengths of high school runners secured distally above the medial and lateral epicondyle using before the start of the season. Additionally, we wanted to the thigh attachment that came with the dynamometer. The compare these variables between genders. We hypothesized contralateral foot was kept flat on the ground. The manufac- that there would be no statistically significant difference turer’s recommended protocol was utilized for isometric between genders in hip extension range of motion and hip knee extension strength testing. The knee was positioned at and knee strength bilaterally. 60 of flexion during the isometric testing, and the knee attachment was secured in the distal shank immediately superior to the malleoli. In each test position, participants 2. Materials and Methods performed a maximum voluntary isometric contraction The current study was conducted at the Biokinesiology Lab- (MVIC) for 5 seconds three times, and the average of the oratory at Western Institute of Neuromechanics in Eugene, three trials was utilized for analysis. Participants were given Oregon. A total of 31 participants (age: 15.6 ± 1.2 y/o, height: a minute rest in between testing positions to avoid fatigue. 169.1 ± 12.2 cm, mass: 58.3 ± 8.8 kg) were recruited from a All the strength data were normalized to participant’s body local high school cross-country team (16 males and 15 weight to account for differences in subjects’ stature. females). A priori estimate of the sample size revealed that A two-way mixed analysis of variance (ANOVA) was a total of 26 participants were needed to achieve a power of used to examine the effects of the gender and side (dominant 0.8 with an alpha level of 0.05. The study was approved by versus nondominant) on each dependent variable of interest, the Western Washington University human participants which included normalized peak hip extension strength, nor- review committee (#12-013). Before data collection, informed malized peak knee extension strength, the normalized peak consent was obtained from all participants and parents/ hip/knee extension strength ratio, and modified Thomas test guardians filled out the assent forms for minors. range of motion. Simple effects analyses were conducted in Participants were asked to come into the laboratory the event of a significant gender by side interaction. The sig- one time in which all testing was completed. During the nificance level for all statistical analyses was set at P <0 05. Applied Bionics and Biomechanics 3 3.5 3. Results and Discussion 3.0 The two-way mixed ANOVA revealed no significant side 2.5 by gender interaction effect on peak hip extension strength (F 1, 29 =0 059, P =0 81, η =0 002). In addition, there was 2.0 no significant main effect of the side on peak hip extension 1.5 strength (F 1, 29 =0 518, P =0 48, η =0 018). However, 1.0 peak hip extension strength (Figure 1) was significantly higher in males than in females across both sides (F 1, 29 = 0.5 5 96, P =0 02, η =0 171). 0.0 The two-way mixed ANOVA revealed no significant Hip Knee interaction effect between gender and side (F 1, 29 =2 63, Extension P =0 12, η =0 083) on peak knee extension strength, as well Male as no main effects of neither gender (F 1, 29 =1 19, P =0 28, Female 2 2 η =0 04) nor side (F 1, 29 =1 09, P =0 31, η =0 036). As with the effects of gender and side on peak knee Figure 1: Hip and knee extension peak isometric torque between genders. extension strength, the ratio between the peak hip and knee extension strengths was not significantly affected by the interaction between gender and side (F 1, 29 =0 677, P = exhibited a 40% greater peak gluteus maximus activation 0 42, η =0 023), nor by neither of the main effects of gender level compared to male runners. Additionally, Souza and (F 1, 29 =0 224, P =0 64, η =0 008) nor side (F 1, 29 = Powers [20] noted an increase in gluteus maximus activation 0 002, P =0 96, η <0 001). in female runners with PFP as opposed to female controls. According to the two-way mixed ANOVA, Thomas test The accumulating evidence lends credence to the hypothesis range of motion (Table 1) was not affected significantly by that the increased gluteus muscle activation in females with the interaction of gender and side (F 1, 29 =2 72, P =0 11, PFP, and even those without, may lead to earlier fatigue of η =0 086), nor by neither of the main effects of gender (F 1, the muscle and thus impaired control of frontal and trans- 29 =0 685, P =0 42, η =0 023) nor side (F 1, 29 =2 21, verse plane hip motion [20, 21]. The results of the current P =0 15, η =0 071). study revealed a marked difference in peak hip extension The primary purpose of this study was to compare the strength between male and female runners. A combination differences in bilateral hip and knee extension strengths of decreased overall strength and possible decreased endur- and hip extension mobility between high school cross- ance of the gluteus maximus in runners, particularly females, country runners. Additionally, the ratio of the average peak provides valuable information for better-designed condition- isometric strength of the knee extensors and hip extensors ing and rehabilitation programs for runners. This decreased was compared between genders. The results of the current hip strength observed in high school cross-country runners study support the hypothesis that there will be no statistically may lead to early fatigue and impaired lower extremity kine- significant differences between gender and side in both the matics. Runners may benefit from both aggressive isolated hip and the knee range of motion and strength except for hip extensor muscles strengthening (i.e., gluteus maximus) the peak hip extension strength. The current data indicated and endurance-type training to help normalize lower extrem- that males demonstrated significantly larger peak hip exten- ity mechanics during running activities. sion strength compared to females. This area of exploration In addition, females exhibited significantly lower peak was conducted in order to assist in further insights into com- hip strength values than males did, but no differences were mon RRI such as PFP and iliotibial band syndrome (ITBS). noted in knee extensor values between gender and sides. It has been increasingly documented that gluteal muscle Males exhibited 29.2 Nm/kg greater force production during strength is an important variable in control of the femur hip extension. Of most interest is that no significant differ- during functional tasks such as running and stair climbing ences were noted in knee-hip extensor strength ratios and descent [18, 20, 21]. The gluteus maximus main action between groups. With regard to RRI, there is strong evidence is to extend the hip joint, and it also plays a vital role in run- to support that females tend to use a more quadriceps- or ning by eccentrically controlling the hip during internal knee extensor- dominant pattern with landing activities rotation in upright tasks [24]. Notably, evidence shows that [25]. Stearns and colleagues [26] have documented that individuals with PFP have increased hip internal rotation in women tend to demonstrate a higher knee-hip extensor ratio running as compared to controls [20]. Souza and Powers than men during the deceleration phase of landing. One rea- [20] hypothesize that it is the increased internal rotation of son for the difference in findings could be the result of com- the femur relative to the tibia that creates a lateral position- paring a double leg drop jump task versus running. Although ing of the patella, and thus increased loading of the retro running certainly involves a deceleration phase during the patellar region. landing on one limb, increased control strategies may differ The present study was conducted to examine the differ- with double leg activities. ence between genders in hip and knee extension strengths. The current results did not show a difference in hip Willson et al. [21] found that healthy female runners extension mobility when compared bilaterally and between Peak torque (Nm/kg) 4 Applied Bionics and Biomechanics Table 1: Hip extension range of motion measured during the Conflicts of Interest modified Thomas test (mean ± SEM) between gender and the side (i.e., the dominant and nondominant leg). All authors declare that there is no conflict of interest. Hip extension range of motion ( ) Acknowledgments Gender Dominant Nondominant The authors would like to thank Heather Salzer for her Male 5.9 ± 1.5 6.0 ± 1.5 contribution to the data collection. The article processing Female 9.6 ± 2.5 7.1 ± 1.8 charge was provided by Western Washington University Research and Sponsored Programs. genders. This variable is important to help better understand References the influence of altering hip mobility in the sagittal plane, which could provide clues to differences in gender-specific [1] National Federation of State and High School Associations, injury rates. Given the importance of the gluteus maximus “2013-2014 High School Athletics Participation Survey to function within a full range of motion, it was important results,” 2015, May 2015; http://www.nfhs.org/Participation to determine if a lack of mobility existed with this population, Statics/ParticipationStatics.aspx/. since recent evidence demonstrated a difference in subjects [2] I. Buist, S. 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