Effect of Lumbopelvic Control on Landing Mechanics and Lower Extremity Muscles’ Activities in Female Professional Athletes: Implications for Injury Prevention

doi:10.21203/rs.3.rs-250805/v1

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Effect of Lumbopelvic Control on Landing Mechanics and Lower Extremity Muscles’ Activities in Female Professional Athletes: Implications for Injury Prevention

https://doi.org/10.21203/rs.3.rs-250805/v1

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Background: Lumbopelvic control has recently been associated with function, kinesiology, and limb loading. However, poor lumbopelvic control has not been studied as a risk factor for lower limb injury in sports with frequent jump landings. The present study aimed to investigate the effects of lumbopelvic control on landing mechanics and lower limb muscle activity in professional athletes with frequent landing.

Methods: This study was conducted on 34 professional female athletes aged 18.29±3.29 years with the mean height and weight of 173.5±7.23 centimeters and 66.79±13.37 kilograms, respectively. The lumbopelvic control of the subjects was evaluated using the knee lift abdominal test, bent knee fall-out, active straight leg raising, and PRONE test by the pressure biofeedback unit. Based on the test results, the participants were equally divided into two groups of with and without lumbopelvic control (n=17). Landing mechanics were evaluated by an expert blinded to the procedures using the landing error scoring system (LESS) and two-dimensional video analysis. In addition, electrical muscle activity in single-legged standing skills was assessed via surface electromyography.

Results: The results of independent samples t-test indicated significant differences between the groups with and without lumbopelvic control in terms of the LESS test scores (P=0.0001), lateral trunk flexion (P=0.0001), knee valgus (P=0.0001), knee flexion (P=0.001), trunk flexion (P=0.01), and gluteus medius muscle activity (P=0.03). However, no significant differences were observed in the activity of the rectus femoris and semitendinosus muscles, and ankle dorsiflexion (P>0.05).

Conclusions: Poor lumbopelvic control affects the kinematics and electrical activity of the lower limb muscles and may be a risk factor for lower limb injuries, especially knee injury.

Sports Medicine and Kinesiology

Physical Medicine & Rehab

Lumbopelvic Control

Landing Mechanics

Lower Limb Injury

Jump-landing

The proper recognition of risk factors and injury mechanisms is essential to the successful prevention of injuries [1]. Injuries of the lower limbs (especially the knees) are common in athletes with long term consequences, such as premature osteoarthritis and poor performance [2]. Frequent jumps and landings impose extremely high loads on the lower limbs is in sports such as basketball, volleyball, and handball [3].

The lower limbs account for approximately 60% of all the injuries in these sports [4]: 45-86% of acute knee and ankle injuries in basketball and volleyball [5] and 70% of anterior cruciate ligament (ACL) ruptures in handball players [6] occur after a landing. The most important risk factors for these injuries include excessive knee valgus, lateral movements of the trunk, and poor pelvic stability [3, 7]. The National Institute of Sports Rehabilitation has recommended strength exercises, stabilization, and control of the lumbo-pelvic-hip complex in injury prevention programs [8]. Furthermore, core stability in lower limb function has been reported to be effective in this regard, with evidence suggesting that weakness in this area could predict the occurrence of lower limb injuries [9].

Lumbopelvic control is a risk factor for kinematic disruptions and upper limb injuries [10]. Lumbopelvic control is defined as the ability to move or stabilize the lumbopelvic region in response to internal or external perturbation [10]. Lumbopelvic control depends on the integrity of passive structures and appropriate dynamic neuromuscular control [11]. Although passive structures are partially responsible for the stability of this area, lumbopelvic control is responsible for muscular structures and neuromuscular control [12].

To date, only the isometric strength of the trunk and hip muscles has been evaluated in studies on the effects of core stability on the occurrence of lower extremities overuse injuries [9, 13]. In addition to the strength and endurance of the lumbopelvic-hip complex, optimal neuromuscular control is essential to the prevention of uncontrolled and compensatory movements [8]. Therefore, the poor neuromuscular control of the lumbopelvic-hip complex, which leads to trunk muscle imbalance, synergist dominance, and compensatory movements, is an important risk factor for lower extremity injuries in athletes. The stability of any system is the ability to limit displacements and maintain structural integrity [12]. On the other hand, poor lumbopelvic control may affect the muscle activity of the gluteus medius, rectus femoris, and hamstrings, as they insert or originate on the pelvis, thereby playing a role in knee and lower limb injuries [3, 14]. Therefore, it is essential to evaluate the activity of these muscles while standing on one leg.

Previous findings have suggested an association between lumbopelvic-hip complex dysfunction and lower limb kinematics [15, 16]. For instance, athletes with weak core stability experience trunk displacement more frequently after receiving a perturbation and are more prone to ACL tears [17]. Furthermore, there is a link between weak core stability and lower limb injuries [1]. Although the effects of core stability on the incidence of lower limb injuries has been studied [12], core stability assessments have only been focused on static and one-dimensional lumbopelvic stability while lumbopelvic control assesses pelvic deviation from the neutral position [18].

In the present investigation, multidimensional lumbopelvic movements were evaluated using dynamic tests. Despite the high prevalence of lower limb injuries (especially knee injuries) among athletes with frequent landings, the main causes of these injuries remain unknown, and no studies have investigated the effects of weak lumbopelvic control on the landing mechanics of professional athletes.

The present study aimed to address the following hypotheses:

1) Landing mechanics differ between athletes with and without lumbopelvic control.

2) The activity of the muscles acting on the knee differs between athletes with and without lumbopelvic control.

2.1. Participants

A total of thirty-four female professional basketball, volleyball, and handball players (mean age: 18.29 ± 3.29 years; mean height: 173.5 ± 7.23 centimetres; mean body mass: 66.79 ± 13.37 kilograms) playing in the Iranian Pro League and Second Division volunteered to participate in the study.

The study was performed during September 10-November 6, 2020 at Razi University Sports Rehabilitation Laboratory.

The exclusion criteria of the study were the age of less than 17 years or more than 25 years, history of lower back injury or severe lower extremity injuries affecting the normal lower extremity function of the athletes, and neuromuscular disorders (Fig. 1). Since the present study was performed during the COVID-19 pandemic, the subjects were initially referred to the university health centre and excluded if diagnosed with abnormal symptoms, such as high body temperature (> 37) or hypoxia (< 93%). After each subject left the laboratory, the environment was completely disinfected with 70% alcohol.

2.2. Procedures

A case-control design was used to assess the differences in the test results between the athletes with and without lumbopelvic control. Data were collected on the age, weight, height, dominant lower limb, number of the years in high-performance sports, and duration of weekly training (hour). Lumbopelvic control was evaluated using the knee lift abdominal test (KLAT), bent knee fall-out (BKFO), active straight leg raising (ASLR), and PRONE test by the pressure biofeedback unit (PBU) (Stabilizer®, Chattanooga Group Inc., Hixson, TN, USA). In addition, the landing error scoring system (LESS) and ImageJ software were used to assess landing mechanics. Finally, wireless electromyography (EMG) (Noraxon, Scottsdale, AZ 85260) was recorded based on the activity of the gluteus medius (GM), rectus femoris (RF), and semitendinosus (ST). To prevent bias, lumbopelvic control diagnostic tests were performed at the end of the evaluations.

Lumbopelvic Control Tests

For the KLAT, the subjects were in a crook lying position, and the pressure biofeedback unit (PBU) was placed horizontally under the spine of the participants, with the lower edge at the level of the posterior superior iliac spines (PSIS); the basal pressure of the PBU was adjusted to 40 mmHg. The participants were asked to lift one foot off the examination table until reaching the hip and knee flexion of 90° and hold for 4–6 seconds. Following that, the maximal pressure deviation was recorded and used for further analysis (Fig. 2-A).
For the BKFO test, the subjects were supine position, and the PBU was placed vertically under the lumbar spine with the lower edge two centimeters caudal of the PSIS on the contralateral side of the flexed knee. In addition, a folded towel was placed near the PBU to keep both sides of the lumbar spine at the same height. The basal pressure of the PBU was adjusted to 40 mmHg. Afterwards, one hip was flexed, and the knee was also flexed to 120°, with the foot resting on the surface of the examination couoch. The participants were asked to slowly bend their hip to approximately 45° of the abduction/lateral rotation while keeping their foot supported beside their straight knee and return to the starting position. The maximal pressure deviation was recorded and used for further analysis (Fig. 2-B).
The ASLR was also executed in the supine position, and the PBU placed horizontally under the lumbar spine of the participants, with the lower edge at the level of the PSIS; the calf of PBU was adjusted to 40 mmHg. The participants lifted one extended leg 20 centimeters above the examination bed and held it for 20 seconds. The maximal pressure deviation was recorded and used for further analysis (Fig. 2-C).
In the PRONE test, the participants were positioned prone on the examination table. The PBU was placed between the anterior superior iliac spine and navel and inflated to 70 mmHg. Afterwards, the subjects were asked to breathe deeply using their abdominal wall. After the completion of two normal breaths, the inflatable bag was readjusted to 70 mmHg. The subjects were requested to perform three contractions with the following verbal command: “Draw in your abdomen without moving your lumbar spine or pelvis and hold the position until you are told otherwise.” Using palpation, the examiner determined whether the participants were moving their spine/pelvis over 10 seconds (Fig. 2-D). Pressure changes of equal to or lower than 8 mmHg (up or down) were recorded as successful completion [11, 19, 20].

2.4. Landing Mechanics

In this study, jump-landing tasks were simultaneously recorded by two standard cameras (frontal-sagittal plane views; model: Canon Eos 80D EFS 18-135mm f/3.5–5.6 IS USM Kit Digital Camera). The markers were placed on the anterior superior iliac spine (ASIS) bilaterally, center of the patella, and center of the talocrural joint in the frontal plane, and some markers were placed on the dominant side greater trochanter, lateral femoral epicondyle, and lateral malleolus in the sagittal plane for 2D kinematic analysis.

The LESS is used to evaluate the landing technique of an individual based on 17 easily observable criteria. The participants were asked to jump forward from a 30-centimeter-tall box, land on a marked spot on the ground that was half their height away from the box, and immediately jump vertically as high as possible (Fig. 3). At this stage, the score of the subjects was calculated out of a total of 17, and was inversely proportional to the LESS performance. The scoring criteria and description of the LESS have been previously reported [21]. The LESS provides a valid, two-dimensional assessment of lower extremity and trunk kinematics and has excellent intraclass correlation-coefficient (ICC) (SEM = 0.42) and good interrater reliability ICC (SEM = 0.71) [22]. In the present study, ImageJ software was used to measure knee flexion, trunk flexion, and ankle dorsiflexion in the sagittal plane and trunk inclination and knee valgus in the frontal plane. None of the participants were instructed on proper landing techniques.

2.5. Electromyography of Muscles (EMG)

Wireless surface EMG electrodes were oriented parallel to the muscle fibres and placed on the GM, RF, and ST muscles of the dominant leg in accordance with the SENIAM recommendations. The GM was positioned 50% on the line from the iliac crest to the trochanter, RF was placed at 50% of the distance on a straight line between the ASIS and the proximal patellar margin, and ST placed at 50% of the distance on a straight between the ischial tuberosity and medial epicondyle [23].

After shaving and cleaning the sites with 70% alcohol to reduce skin impedance, gel-type Ag/AgCl electrodes (diameter: 20 mm; Skintact, Austria) were attached to the muscles belly of the dominant leg. The surface EMGs were amplified 500 times, sampled at 1500 Hz, and digitized using a 16-bit analog to a digital converter. The signals were filtered at the bandwidth of 10–500 Hz to eliminate the noise recorded during data collection, and the root mean square window of 50 milliseconds was used for signal smoothing. The mean value of each period was also calculated during the test [2]. The subjects performed the one-leg stance for 30 seconds, and the EMG data were normalized to the peak muscle activity (maximum voluntary isometric contraction).

2.6. Statistical Analysis

Data analysis was performed using SPSS version 21.0 (SPSS Inc., Chicago, USA) employing the Shapiro-Wilk test to assess the normality of data distribution and Levene’s test for the homogeneity of data. In addition, descriptive statistics were calculated for all variables, and mean and standard deviation (SD) and 95% confidence interval (CI) were reported. The homogeneity of the demographic data at baseline was evaluated using independent samples t-test, which was also employed to compare the means of the landing mechanics and muscle EMG variables between the participants with and without lumbopelvic control. In all the statistical analyses, the significance level was set at 0.05.

The sample size of the study was estimated at 17 participants per group based on the study by Grosdent et al. [11], and the effect size (ES) was calculated using the following formula:

ES with d < 0.2 was considered to be small, while d > 0.5 was moderate, and d > 0.8 was considered large [11].

In total, 34 female basketballs, volleyball, and handball players completed the study. The results of the Shapiro-Wilks and Levene’s tests confirmed both research hypotheses (P > 0.05). In addition, the comparison of the participants with and without lumbopelvic control indicated no significant differences regarding age, weight, height, body mass index, activity hours in the week, and duration of activity (P > 0.05) (Table 1).

Table 1

Descriptive statistics of participants with and without lumbopelvic control.
	Without-LPC (n = 17) Mean SD		With-LPC (n = 17) Mean SD		P-Value
Age (years)	18.29	2.41	18.29	4.10	1.00
Weight (kg)	67.76	16.79	65.82	9.25	0.62
Height (cm)	173.23	8.26	173.76	6.24	0.84
BMI(kg.m^− 2)	22.33	4.13	21.72	2.47	0.66
Activity (h.wk^− 1)	5.27	1.92	5.55	2.14	0.67
Duration of activity (years)	7.47	2.42	7.17	1.81	0.79
KLAT (mmHg)	10.17	2.65	3.76	2.99	0.0001
BKFO(mmHg)	14.47	2.85	2.94	2.13	0.0001
ASLR(mmHg)	10.88	2.28	3.76	2.99	0.0001
PRONE(mmHg)	17.76	3.88	6.35	3.25	0.0001
Note: LPC, lumbopelvic control; SD, standard deviation; BMI, body mass index; h, hours; wk, week. KLAT, Knee Lift Abdominal Test; BKFO, Bent Knee Fall Out; ASLR, Active Straight Leg Raising.

3.1. Muscle Activity

A significant difference was observed between the subjects with and without lumbopelvic control only in terms of the GM activity (t₃₂ = 2.26; 95% CI: 0.26–4.89; P = 0.032; ES = 0.13). However, no significant differences were observed between the groups in terms of the RF and ST muscle activity (P > 0.05) (Table 2 & Fig. 4).

Table 2

Comparison in muscles activity during single-leg standing and landing mechanic between with and without lumbopelvic control groups.
	Without-LPC (n = 17) Mean SD		With-LPC (n = 17) Mean SD		P-Value	ES
Electromyography^*
GM	5.89	2.22	8.47	4.12	0.032^*	0.13
RF	3.23	1.52	5.21	6.06	0.20	0.05
ST	7.61	5.36	7.42	6.14	0.92	0.00
Landing mechanic
Trunk lateral flexion	29.40	3.78	22.60	2.77	0.0001^**	0.37
Knee valgus	23.26	8.02	9.40	5.70	0.0001^**	0.48
Trunk flexion	74.66	11.17	87.40	15.49	0.015^*	0.16
Knee flexion	71.40	15.52	92.40	16.70	0.001^**	0.28
Ankle dorsiflexion	79.86	10.58	78.26	9.88	0.67	0.00
LESS	8.20	2.11	2.00	1.25	0.0001^**	0.74
Note: LPC, lumbopelvic control; SD, standard deviation; ES, effect size; GM, gluteus medius; RF, rectus femoris; ST, semitendinosus; MVIC, maximum voluntary isometric contraction; LESS, landing error scoring system. ^* Percent activation relative to MVIC. P < 0.05 & *P < 0.001.

3.2. Landing Kinematics

The analysis of the knee valgus indicated a significant difference between the subjects with and without lumbopelvic control (t₃₂=-5.45; 95% CI: -19.07–8.66; P = 0.0001; ES = 0.48). Furthermore, a significant difference was observed between the subjects with and without lumbopelvic control regarding the lateral flexion angle of the trunk in the frontal plane (t₃₂ = 7.09; 95% CI: 5.54–10.05; P = 0.0001; ES = 0.61). Significant differences were also denoted between the two groups in terms of the trunk flexion angle (t₃₂ = 2.58; 95% CI: 2.63–22.83; P = 0.015; ES = 0.16) and knee flexion angle in the sagittal plane (t₃₂ = 3.56; 95% CI: 8.93–33.06; P = 0.001; ES = 0.28), while no significant difference was observed in ankle dorsiflexion (P > 0.05). In the LESS test, a significant difference was also observed between the subjects with and without lumbopelvic control (t₃₂=-9.78; 95% CI: -7.49–4.90; P = 0.0001; ES = 0.74) (Table 2 & Fig. 4).

The present study aimed to evaluate the status of lumbopelvic control in professional athletes with frequent jump-landing skills and compare the mechanical status of the landing and lower limb muscle activity of the athletes with and without lumbopelvic control to recognize the associated risk factors. Lumbopelvic control was assessed by four tests using a PBU in which pressure changes of more than 8 mmHg indicated poor lumbopelvic control. Based on these results, the athletes participating in the study were divided into two groups of poor lumbopelvic control and adequate lumbopelvic control.

The current study indicated that professional female basketball, volleyball, and handball players have poor lumbopelvic control. The lumbopelvic region provides dynamic stability for the movement of the extremities [18]. Recent findings have demonstrated that the risk of injury increases with the disruption of the elements within the kinetic chain, which in turn causes alterations in the biomechanics of the extremities. Poor control of the lumbopelvic area is associated with upper limb injuries [8, 20, 24]. Furthermore, trunk muscle activity precedes lower limb muscle activity, and the central nervous system provides a stable foundation for lower limb movements [13]. Therefore, the disrupted stability of this foundation could lead to inefficient landing and predispose the individual to lower limb injury. In jump landing, 50% of knee injuries occur following landing on the opposite, and the other 50% arise from improper landing [4].

According to finding in the current research, landing mechanics (i.e., LESS test scores) in the subjects without lumbopelvic control were significantly weaker compared to those with lumbopelvic control, which confirms the research hypothesis. This may result from poor control of the lumbopelvic region as weaknesses or delays in the activation of the muscles involved in lumbopelvic control could cause compensatory and unpredictable movements. For instance, GM is one of the main lumbopelvic muscles, as well as the main abductor of the hip joint. Dysfunction of this muscle could cause the femur to move to the midline of the body and increase the dynamic knee valgus moment [25]. A LESS test score greater than 5 increases the relative risk of ACL injury 10.7 times. On the other hand, core exercises could reduce the LESS score by up to three points [26]. In other words, the increased stability of the trunk could decrease the mechanical errors of landing, which is consistent with our findings. Also, impaired neuromuscular control of core stability during dynamic movements may expose athletes to lower limb injuries [13].

According to the results of the present study, the lateral flexion of the trunk and knee valgus were significantly higher in the subjects without lumbopelvic control compared to those who had adequate control. Landing on the knee at the frontal plane imposes high strains on the medial collateral ligament and ACL. Furthermore, maintaining and controlling the trunk plays a key role in reducing the pressure on the knees, and the risk of lower limb injuries. In particular, the combination of knee valgus and lateral trunk flexion on the frontal plane is highly sensitive in the identification of women at risk of ACL injuries [27]. In this regard, individuals with lateral trunk flexion have increased knee valgus, and lateral flexion of the trunk could cause the ground reaction force to pass through the lateral compartment of the knee and increase the abduction torque exerted on it [28]. Similarly, poor neuromuscular control of the trunk can be associated with knee injuries in women [13]. Dynamic knee valgus of more than eight degrees while landing is reliable predictor ACL injury [29].

According to the results of the study, the flexion of the knee and trunk at the sagittal plane was higher in the subjects with lumbopelvic control compared to those without lumbopelvic control, which confirmed the research hypothesis. Knee flexion angle has been associated with knee injuries, with several studies reporting that and increased knee flexion angle could decrease the anterior shear force on the knee joint and strain the ACL [30–32]. In this regard, with the knee flexed, lower anterior shear forces are applied to the knee joint compared to the extension position: trunk flexion with knee flexion at the moment of landing could cause decrease the ACL strain [33]. These findings are in line with the results of the present study.

The three important muscles investigated in the current research were RF, ST, and GM, which originate from the pelvis and are involved in the occurrence of knee injuries [17, 18, 28, 34]. According to our findings, only the GM muscle activity was significantly different between the subjects with and without lumbopelvic control regarding the ability to stand on one leg. Many lower limb injuries occur in a single-legged position, especially in sports such as handball, basketball, and volleyball, which involve frequent jumps and landings [35, 36]. The GM muscle plays a vital role in lumbopelvic control, and, given its abduction torque, it influences the mechanics of the lower limb, especially knee valgus. This finding is in line with the study by Laudner et al., which demonstrated that the GM muscle is a primary pelvic stabilizer during single-legged standing and also plays a key role in lumbopelvic control [24]. In this regard, optimal strengthening of the gluteal muscles to enhance the stability of the lumbopelvic region [37]. The decreased activity of the GM muscle and instability of the lumbopelvic-hip complex was associated with lower limb injuries [38].

One of the limitations of our study was that, given our country sharia laws, it was not possible to evaluate men and women, and the women evaluator was only allowed to study women. In addition, we could not study more muscles due to economic issues and lack of time during the COVID-19 pandemic. Therefore, it is recommended that further investigations be focused on more muscles to achieve more accurate results and make comparisons with our findings.

Poor lumbopelvic control in the professional athletes with frequent jump-landings affected the scores of the mechanical landing test (LESS), lateral flexion angle of the trunk, angle of dynamic knee valgus, knee flexion angle, flexion angle of the trunk, and EMG of the GM muscle. Therefore, the increased risk of lower limb injuries could be predicted by impaired lumbopelvic control. It is recommended that sports rehabilitation specialists, physiotherapists, and coaches use appropriate strategies to strengthen the lumbopelvic control of athletes to prevent possible injuries.

ACL: anterior cruciate ligament; KLAT: knee lift abdominal test; BKFO: bent knee fall-out; ASLR: active straight leg raising; PBU: pressure biofeedback unit; LESS: landing error scoring system; EMG: electromyography; GM: gluteus medius; RF: rectus femoris; ST: semitendinosus; PSIS: posterior superior iliac spines; ASIS: anterior superior iliac spine; ICC: intraclass correlation-coefficient; SD: standard deviation; CI: confidence interval; ES: effect size.

Ethics approval and consent to participate

The objectives and procedures of this study were explained to the participants, and written informed consent was obtained from all participants before the beginning of the study that was in accordance with the Declaration of Helsinki. The research protocol was approved by the Ethics Committee of Razi University of Iran (code: IR.RAZI.REC.1399.007).

Consent for publication

The person on the pictures has provided written consent for publication.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The present study was financially supported by Razi University.

Authors’ contributions

PF recruited the patients, collected the data and designed the idea, FG was supervisor, designed the idea, and assessed the outcomes of the research. NM assessed the outcomes of the research and reviewed the paper. All the authors contributed to the writing of the paper.

Acknowledgments

Hereby, we extend our gratitude to the athletes for participating in this study, their coaches who coordinated their participation, and the expert of the Sports Rehabilitation Laboratory for assisting us in this research process.

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No competing interests reported.

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Editorial decision: Major revision
12 Apr, 2021
Reviewers agreed at journal
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Reviewers agreed at journal
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Reviewers invited by journal
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Editor assigned by journal
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Editor invited by journal
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Effect of Lumbopelvic Control on Landing Mechanics and Lower Extremity Muscles’ Activities in Female Professional Athletes: Implications for Injury Prevention

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Abstract

Figures

1. Background

2. Methods

2.1. Participants

2.2. Procedures

2.4. Landing Mechanics

2.5. Electromyography of Muscles (EMG)

2.6. Statistical Analysis

3. Results

3.1. Muscle Activity

3.2. Landing Kinematics

4. Discussion

5. Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgments

References

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Version 1