Foot and hip contributions to high frontal plane knee projection angle in

athletes: a classification and regression tree approach

Natalia FN Bittencourt1,3, PT, Msc; Juliana M Ocarino2,3, PT, ScD; Luciana DM Mendonça3, PT;
Timothy E Hewett4, PhD; Sergio T Fonseca2,3, PT, ScD.

1- Minas Tênis Clube, Belo Horizonte, Minas Gerais, Brazil.

2- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
3- Laboratory of Prevention and Rehabilitation of Sports Injuries (LAPREV) – UFMG, Belo
Horizonte, Minas Gerais, Brazil
4- The Ohio State University, Sports Health and Performance Institute, Columbus, Ohio and
Cincinnati Children’s Hospital, Sports Medicine Biodynamics Center Cincinnati, Ohio,
USA

Corresponding author: Sergio T Fonseca,

Address: Escola de Educação Física, Fisioterapia e Terapia Ocupacional
Av. Pres. Antônio Carlos, 6627 - Pampulha - Belo Horizonte - MG CEP 31270-901 Universidade
Federal de Minas Gerais
Email: sfonseca@pib.com.br
 1
2 STUDY DESIGN: Cross-sectional.
3 OBJECTIVE: To investigate predictors of increased frontal plane knee projection angle (FPKPA)
4 in athletes.
5 BACKGROUND: The underlying mechanisms that lead to increased FPKPA are likely multi-
6 factorial and depend on how the musculoskeletal system adapts to the possible interactions between
7 its distal and proximal segments. Bivariate and linear analyses traditionally employed to analyze the
8 occurrence of increased FPKPA are not sufficiently robust to capture complex relationships among
9 predictors. Nonlinear interactions among biomechanical factors should be investigated to allow
10 understanding of lower limb segments interdependence and resultant dynamic knee alignment.
11 METHODS: The FPKPA was assessed in 101 athletes during single leg squat and in 72 athletes at
12 the moment of landing from a jump. The predictors were: sex, hip abductor isometric torque,
13 passive range of motion (ROM) of hip internal rotation (IR), and shank-forefoot alignment.
14 Classification and Regression Trees (CART) were used to investigate non-linear interactions among
15 predictors and their influence on the occurrence of increased FPKPA.
16 RESULTS: During single leg squatting, the occurrence of High-FPKPA was predicted by the
17 interaction between hip abductor isometric torque and passive hip IR ROM. At the moment of
18 landing, the shank-forefoot alignment together with abductor isometric torque and passive hip IR
19 ROM were predictors of High-FPKPA. In addition, the CART identified cut-off points that could be
20 used in clinical practice to identify athletes with potential risk for excessive FPKPA.
21 CONCLUSION: The models captured non-linear interactions between hip abductor isometric
22 torque, passive hip IR ROM, and shank-forefoot alignment.
23
24 KEY WORDS: anterior cruciate ligament, CART, dynamic knee alignment, hip strength,
25 patellofemoral joint
26 INTRODUCTION
27
28 Altered knee alignment during dynamic tasks, which is visually identified as increased

29 medial knee motion,1 seems to contribute to the occurrence of disorders such as anterior cruciate

30 ligament (ACL) injuries and patellofemoral pain (PFP).23 Two-dimensional (2D) frontal plane knee

31 projection angle (FPKPA) has been successfully used to assess dynamic knee alignment during

32 weight bearing activities in patients with PFP,28 to screen athletes that are at risk for ACL injury,22 to

33 identify asymmetries between limbs,12 and to identify individuals with altered knee alignment.27 As

34 an intermediate joint, the knee depends on the appropriate mechanical behavior of the hip and ankle

35 to maintain its proper dynamic alignment.9,24 Some studies have been performed to identify the

36 contribution of biomechanical factors to the occurrence of excessive dynamic frontal plane knee

37 motion during functional tasks.3,6,11,25,28 However, the majority had poor predictive capability.6,25,28

38 Increased hip internal rotation (IR) or hip adduction increase FPKPA during weight bearing

39 activities.6,28 These altered patterns may occur due to decreased hip passive resistance to motion

40 (stiffness)25 and weakness of the hip abductor muscles,11,14 respectively. In addition, excessive

41 lower limb IR due to foot pronation has also been postulated to contribute to increased FPKPA.2,9,16

42 This contribution may be explained by the orientation of subtalar joint axis, which couples frontal

43 plane foot motion (calcaneal eversion) with transverse plane motion (talus and lower limb IR).21

44 Thus, changes in subtalar joint motion may lead to sub-optimal alignment at the knee joint.2

45 Because excessive pronation has been associated with the presence of forefoot varus alignment,19,26

46 foot alignment may also be related to excessive frontal plane knee motion. Therefore, during weight

47 bearing activities, altered passive and active stabilizing mechanisms of the hip and altered foot

48 alignment can influence dynamic knee alignment.

49 The contribution of biomechanical factors to the occurrence of excessive knee motion in the

50 frontal plane has been traditionally investigated by means of statistical analyses that assume a linear

51 scaling between outcome and predictors variables.6,25 The poor predictive capability observed in

52 these studies may be due to the multifactorial nature of increased FPKPA, which depends on

3
53 interactions among muscle strength, passive resistance, and lower limb alignment. The manner

54 these factors interact is essential to provide the required dynamic alignment during weight bearing

55 activities and to guide therapists in developing effective prevention and intervention strategies.

56 Therefore, the objectives of this study were: 1) to determine the predictive factors related to the

57 occurrence of increased FPKPA during single leg squatting (SLS) and at landing in athletes and 2)

58 to analyze how these predictors interact in a non-linear manner during functional tasks. To attain

59 these objectives, Classification and Regression Trees (CART) were used as statistical method.

60
61 METHODS
62
63 Participants
64
65 Initially, 173 basketball, soccer, volleyball, and gymnastics athletes (119 males, 54 females),

66 who trained 5 times a week, took part in the study. Mean ± SD age was 16.6 ± 5.0 years, body mass

67 was 67.2 ± 16.4 kg, and height was 176.9 ± 14.7 cm. The inclusion criteria were: absence of pain

68 and no history of lower extremity surgery in the previous 6 months. Pain or discomfort during the

69 performance of any test was the exclusion criterion. The Ethics in Research Committee of the

70 Universidade Federal de Minas Gerais approved the procedures of this study and all participants

71 signed an informed consent.

72

73 Procedures

74 Frontal Plane Knee Projection Angle (FPKPA)

75 The FPKPA of the athletes was assessed during single leg squatting and at the moment of

76 landing from a jump. A digital camera (SC-D385, Samsung®) was positioned parallel to the ground

77 and placed perpendicular to the frontal plane of the athlete. Reflective markers were attached to the

78 anterior superior iliac spines (ASIS), medial and lateral epicondyles of the knee, and to the midpoint

79 between the medial and lateral malleoli. The subjects were asked to single-leg squat to 60º of

80 flexion of the knee.6 This angle was previously determined by the examiner with a goniometer and

81 an adjustable apparatus was placed on the wall behind the subject to indicated how low he/she

4
82 should go to achieve 60° of knee flexion (FIGURE 1A). The subject performed 3 SLS, alternating

83 between limbs, to avoid fatigue. After a 5-minute rest period, the subject was asked to perform three

84 2-legged vertical jumps as high as possible with a 5-second interval between jumps. The SLS and

85 jumping were performed with subjects barefoot.

86 To determine the FPKPA, 30 Hz digital videos of SLS and jumping were analyzed using the

87 software Simi Motion Twinner ®. The FPKPA was defined by connecting the markers related to the

88 ASIS, the midpoint between the femoral epicondyles, and the midpoint between the malleoli

89 (FIGURE 1-B). The SLS FPKPA of the dominant limb was calculated at 60° of knee flexion and

90 during static single leg stance. The jumping FPKPA of both limbs was analyzed during landing,

91 which was defined as the second video frame after the visually identified foot contact. The FPKPA

92 mean of 3 trials was considered for analyses. A pilot study with 6 subjects and a 7 day interval

93 between assessments was conducted to determine the intrarater reliability of these measures. The

94 intraclass correlation coefficient (ICC3,3) for FPKPA during SLS was 0.83 and the standard error of

95 measurement (SEM) was 1.65º. FPKPA measurements during landing had an ICC3,3 of 0.88 and

96 SEM of 1.93º.

97 Strength Testing

98 Isometric strength of the dominant limb hip abductors was measured using a hand held

99 dynamometer (Microfet2 ®), which was firmly positioned 5 centimeters above the knee joint. The

100 subject was positioned in side lying, with the arms in front of the body, the trunk stabilized with a

101 rigid strap and the tested hip was placed neutral in relation to abduction and extension (FIGURE

102 2A). After familiarization, the subject performed maximal hip abductors isometric contractions for 5

103 seconds. This procedure was repeated 3 times with intervals of 15 seconds between trials. Verbal

104 encouragement was provided to promote maximal effort by the participants. Hip abductor muscle

105 torque was calculated as the product of the mean of the 3 strength measures and the distance from

106 the greater trochanter to the location of the dynamometer. Torque values were normalized by body

107 mass (Nm/kg). Intrarater reliability analysis performed in a pilot study with 6 subjects and a 7 day

5
108 interval between assessments demonstrated an ICC3,3 of 0.94 and the SEM was 0.08 Nm/kg.

109

110 Passive Range of Motion (ROM) of Hip Internal Rotation (IR)

111 Passive ROM of hip IR was considered as the position in which the torque produced by the

112 mass of the lower leg and foot became equal to the passive resistance torque generated against

113 further hip IR. This measure was shown to be highly associated to hip stiffness.5 Specifically, the

114 greater hip IR stiffness, the lower the angle at which the passive resistance equals to segment’s

115 torque and smaller the measured IR ROM.5 The subject was positioned lying prone on a treatment

116 table with the pelvis stabilized and with the knee of the dominant limb flexed at 90º. The examiner

117 allowed the hip to move in IR, until the passive tension produced by the hip structures stopped the

118 movement. At this position, passive hip IR was measured with an inclinometer (FIGURE 2B). The

119 examiner carefully supported the lower leg of the athlete to maintain 90° of knee flexion, without

120 applying any additional force that could alter the hip position. If the examiner observed muscle

121 contractions, the measurement was disregarded and repeated. Three measurements were performed

122 and the mean, in degrees, was used for analysis. Intrarater reliability for passive hip IR ROM

123 measurements had an ICC3,3 of 0.99 and the SEM was 1.5º. These values were obtained in a pilot

124 study performed with 10 subjects with a 7 day interval between assessments.

125

126 Shank-Forefoot Alignment (SFA) Assessment

127 To assess the SFA, the athlete was positioned in prone with the dominant foot off the

128 treatment table. A digital camera (Nikon D5000®) was positioned on a tripod at 90º in relation to

129 the right end of the treatment table (FIGURE 3A). The examiner marked the midpoint between the

130 femoral condyles and the midpoint between the medial and lateral malleoli. The tibia was bisected

131 by joining these 2 points. A metal rod was positioned on the plantar aspect of the forefoot

132 (FIGURE 3B), following the orientation of a line connecting the metatarsophalangeal heads.10,20

133 With the aid of a universal goniometer (Carci®), the examiner positioned each subject’s foot at 90º

6
134 of ankle dorsiflexion, requested him/her to actively maintain this position and photographed the

135 subject’s foot (FIGURE 3B).10,20 This procedure was performed 3 times.

136 To determine the SFA, the photographs were analyzed with the software Simi Motion

137 Twinner®. The SFA was defined as the angle between the bisection of the tibia and the metal rod

138 positioned on the metatarsophalangeal region. The SFA was calculated in each of the 3 photos and

139 the mean was considered for analyses. This measure demonstrated intrarater reliability (ICC3,3) of

140 0.81 and a SEM of 3.9º. The reliability was assessed in a pilot study performed with 14 subjects

141 and a 7 day interval between the assessments.

142

143 Statistical Analyses

144 Descriptive statistics were used to characterize the sample in relation to the outcome

145 variable FPKPA and predictors: sex, normalized hip abductors torque, SFA, and passive hip IR

146 ROM. CART were used to determine which factors predicted the occurrence of High-FPKPA and

147 possible interactions among them. CART is a multivariate, nonparametric classification (regression)

148 model, which develops a decision tree by successive binary divisions of the initial set of data until

149 further divisions are not possible or until pre-established criteria for tree growth are reached.4 For

150 each of these divisions, all possible predictors and their respective cut-off points are considered to

151 establish the predictor that best classify the individuals into each of the outcome categories.4,7 The

152 order of entry of predictors in the model illustrates hierarchically the strength of association

153 between each predictor and outcome variable, and subsequent divisions identify possible interaction

154 among predictors. The choice of CART to analyze the data was based on its robust analysis that

155 captures non-linear relationships between predictors and produces results easily applied in clinical

156 practice.7,15

157 To facilitate clinical comprehension of prediction models produced by CART, the dependent

158 variable was dichotomized as the percentiles that corresponded to the lower (Low-FPKPA) and

159 higher (High-FPKPA) thirds of the sample’s distribution. Two models were developed to assess the

7
160 predictive factors of High-FPKPA of the dominant limb during SLS and at the moment of landing

161 from a jump. In the SLS model, the FPKPA of the dominant limb, assessed during the static

162 condition, was entered in the model as an influence variable. This procedure was adopted because

163 the amount of FPKPA during the static standing condition could influence the magnitude of this

164 measure during dynamic squatting. In the landing model, the influence variable was the dynamic

165 FPKPA of the contralateral limb because the behavior of one limb could influence the behavior of

166 the other in bilateral jump tasks. The area under the Receiver Operating Characteristics (ROC)

167 curve was calculated to verify the accuracy of the prediction models. A significance level of 0.05

168 was established to verify whether the area under the ROC curve of each model was different from

169 0.5, which indicates that the model is accurate to predict the outcome categories.

170

171 RESULTS

172 Only subjects with values below or above the cut-off values (4.69º and 8.16º for SLS and -

173 0.09º and 3.59º for landing) were included in the CART analyses. Subjects with values equal to the

174 inferior or superior cut-off values were also included in the analyses. The athletes with FPKPA

175 between these cut-off values were excluded from analyses. Thus, for the SLS, 50 subjects had High-

176 FPKPA (mean + SD, 11.79º+2.66) and 51 subjects had Low-FPKPA (2.86º + 1.36) for a total of 101

177 athletes. During the landing task, 33 athletes had High-FPKPA (7.59º+2.5) and 39 subjects had

178 Low-FPKPA (-3.93+4.2) for a total 72 athletes. Means and standard deviations of the sample’s

179 demographics characteristics and predictors are presented in the TABLE.

180
181
182
183 Predictive model for Single Leg Squat (SLS)
184
185 The classification tree for SLS selected hip abductor torque as the first predictor of High-

186 FPKPA. However, hip abductor torque alone did not explain total occurrence of High-FPKPA and

187 hip passive IR ROM was selected as the second predictor. Details about tree divisions with the

188 respective predictors’ cut-off points, and number and percentage of individuals classified in each

8
189 subgroup according to selected predictors are presented in FIGURE 4.

190

191 The predictive model, after pruning, correctly classified 36 of the 50 athletes with High-

192 FPKPA (72% sensitivity) and 47 of the 51 athletes with Low-FPKPA (92% specificity,) during SLS.

193 The area under the ROC curve (FIGURE 5A) was 0.74 (95% CI = 0.66-0.81; SE=0.40, P <

194 0.0001), which demonstrated that the classification of the individuals into High or Low FPKPA,

195 using this model, was not random.

196

197 Predictive model for Landing

198 The landing classification tree selected the SFA angle as the first predictor of High- FPKPA.

199 In the subgroup of individuals with lower values of SFA, hip abductor isometric torque was selected

200 as a second predictor. However, in individuals with greater values of SFA angles the CART model

201 selected passive hip IR ROM as the second predictor of High-FPKPA. Details about tree divisions

202 with the respective predictors’ cut-off points and number and percentage of individuals classified in

203 each subgroup according to selected predictors are presented in FIGURE 6.

204 The CART classified correctly 28 of the 33 athletes with High-FPKPA (sensitivity, 84%) and

205 32 of the 39 with Low-FPKPA (specificity, 82%) during landing. The area under the ROC curve

206 (FIGURE 5B) was 0.79 (95% CI = 0.70-0.88; SE= 0.46, P < 0.0001).

207

208 DISCUSSION

209 The results of the present study demonstrate that, during SLS, High-FPKPA was the result of

210 the interaction between hip abductor isometric torque and passive hip IR ROM. At the moment of

211 landing, high-FPKPA was due to an interaction between SFA, hip abductor isometric torque, and

212 passive hip IR ROM. These findings illustrate the interaction of biomechanical factors of the lower

213 limb distal and proximal segments in the production of increased FPKPA during functional

214 activities. The cutoff points defined by the CART analysis may help clinicians to plan treatment or

9
215 prevention programs for individuals with excessive frontal plane motion of the knee, as they offer

216 specific values for hip abductor isometric torque, passive hip IR ROM, and SFA that can be related

217 to the occurrence of increased FPKPA, during the analyzed tasks.

218 The SLS model indicated that low hip abductor isometric torque was the main predictor of

219 High-FPKPA. However, torque alone could not explain the occurrence of increased FPKPA.

220 Another predictor selected by the classification tree was passive hip IR ROM. The inclusion of this

221 variable allowed the understanding of how the available range of hip IR interacts with hip abductor

222 torque. Reduced hip abductor isometric torque (<1.03 Nm/kg) with increased range of passive hip

223 IR (>43°) contributed to the occurrence of High-FPKPA. Conversely, reduced hip abductor

224 isometric torque together with intermediate values of hip passive IR ROM (37 to 43o) was

225 associated with Low-FPKPA. These results demonstrate that the potential of the hip abductor

226 isometric torque to determine the occurrence of increased FPKPA depends on the available hip

227 ROM in IR. The observed relationship between hip IR ROM and knee alignment in the frontal

228 plane is consistent with the results by Wilson and Davis,28 who found that FPKPA was associated

229 with femoral internal rotation (r=0.42; P=0.007). As the ROM measurement used in the present

230 study was previously shown to inform about passive hip stiffness,5 our results indicate that

231 individuals with adequate hip stiffness may have better dynamic knee alignment in the frontal plane

232 despite the presence of reduced hip abductor torque.

233 The influence of hip abductor strength in the FPKPA was demonstrated by the fact that 91%

234 of the individuals with high abductor isometric torque (>1.48 Nm/Kg) did not demonstrate High-

235 FPKPA, even when they had passive hip IR ROM greater than 21°. However, it is important to note

236 that 7 individuals with torque between 1.39 and 1.48 Nm/kg and passive hip IR ROM greater than

237 21° had High-FPKPA. In this subgroup, it is possible that other factors not assessed in the present

238 study, such as a decreased hip external rotators strength or lack of familiarity with the task, could

239 help explaining the occurrence of High-FPKPA. Despite the existence of other possible contributors

240 to increased FPKPA, the interaction between hip abductor isometric torque and passive hip IR

10
241 ROM, shown in the present study, suggests that programs directed to the treatment or prevention of

242 injuries related to excessive frontal plane motion of the knee8,17, in athletes should focus on both the

243 contractile and passive elements of the hip joint.

244 The influence of reduced ROM of the hip in IR in the occurrence of High-FPKPA during

245 SLS was demonstrated by 7 individuals with hip abductor isometric torque greater than 1.03Nm/Kg

246 but with reduced passive hip IR ROM (<21°; mean angle of 17° in this subgroup). The lack of

247 appropriate range of hip IR, to allow for absorption of possible trunk and pelvis rotations resulting

248 from squatting, could cause the projection of the body’s center of gravity to move laterally relative

249 to the knee joint.23 This projection of body’s center of gravity relative to the knee could lead to an

250 increase in FPKPA. Therefore, this classification demonstrated that low hip isometric torque

251 associated with high or excessively low passive ROM of hip in IR are related to the occurrence of

252 increased FPKPA during functional activities. This non-linear relationship between hip abductor

253 isometric torque and passive resistance of the hip toward IR with FPKPA could not have been

254 explained by traditional analyses.

255 In the landing model, the main predictor selected by the CART was the SFA. Considering

256 that the ankle-foot complex is the first segment to contact the ground when landing from a jump,

257 changes of ankle-foot alignment appear to be important for kinematic alignments of the other joints

258 of the lower limb.9,26 The present study demonstrated that in individuals with small SFA (below

259 10.9º), the hip abductor isometric torque was the second predictor selected by the model. However,

260 for those individuals with SFA angle greater than 10.9º, passive hip IR ROM was the next predictor

261 selected to explain the occurrence of High-FPKPA. These findings demonstrated a complex inter-

262 segmental relationship, because the contribution of one factor to occurrence of outcome variable

263 depends on the presence of another factor. The identification of these complex interactions could

264 guide clinical reasoning during the management of athletic injuries.

265 Although small SFA was initially predictive of Low-FPKPA in 24 individuals, the presence

266 of reduced hip abductor isometric torque (< 1.09 Nm/kg) was predictive of High-FPKPA in 75% of

11
267 individuals in the subgroup with good foot alignment. McLean et al18 demonstrated that the knee

268 motion in the frontal plane assessed in 2D occurs due to the combination of hip adduction and

269 internal rotation.18 In the present study, individuals with lower forefoot varus angle (SFA<10.9°)

270 may have had a lower demand for lower limb internal rotation. In this case, hip adduction may have

271 become more relevant to altering knee kinematics. Heinert el al11 also found lower values of hip

272 abductor torque in athletes who had higher knee abduction (valgus) angles compared with athletes

273 with higher values of torque. The contribution of hip abductor torque to the FPKPA can be

274 demonstrated by the fact that large abductor isometric torque (> 1.09 Nm/kg) associated with small

275 SFA was predictive of Low-FPKPA in 95% of the individuals with these characteristics.

276 In the subgroup with greater SFA (>10.9º), an increase in the demand of lower limb internal

277 rotation may have occurred, which explain the fact that high SFA values were predictive of High-

278 FPKPA in 61% of these individuals. However, during landing, in the case of decreased ROM of the

279 hip in IR (increased stiffness), transverse plane hip motion would be more restricted. This scenario

280 could prevent the occurrence of increased FPKPA even in the presence of high SFA. This happened

281 in 71% of the individuals with SFA greater than 10.9º and range of hip IR of less than 34o. On the

282 other hand, when individuals showed high SFA and passive hip IR ROM between 34º and 47º there

283 was an increase in the occurrence of High-FPKPA. In addition, in individuals with greater hip IR

284 ROM (>47º) and high SFA angle (>17°), the demand for lower limb internal rotation seemed to be

285 more pronounced and it was related to the occurrence of High-FPKPA in a higher percentage of the

286 individuals. Therefore, the findings of the present study indicated the influence of foot alignment

287 and hip passive characteristics to FPKPA.

288 Several studies have indicated that women have a higher prevalence of excessive knee

289 valgus than men during squatting and landing tasks.12,27 However, in the present study, sex was not

290 selected as predictor of FPKPA in any of the CART models. Hip abductor strength production

291 capability, foot alignment, and passive ROM of the hip in IR were the most relevant factors related

292 to increased knee excursion in the frontal plane. Because hip abductor isometric torque was

12
293 significantly lower in women than men (P = 0.015, t = -2.45), the higher prevalence of increased

294 FPKPA in women may have been mediated by this variable.

295 The areas under the ROC curves indicated how well the classification rules of both models

296 differentiated between distributions of two categories of the outcome variables. In SLS model, the

297 area was 0.74, which indicates that, based on the classification rules, a randomly selected athlete

298 with increased FPKPA has 74% of chance of being correctly classified as belonging to the High-

299 FPKPA group than an athlete with measured low FPKPA In the landing model, the same would

300 occur 79% of the time. These results indicate that both models had high accuracy to predict the

301 target category: High-FPKPA. In addition, the identification of cutoff values by the CART models

302 indicates that the relationship between predictors and outcome variable was non-linear. Differently

303 from traditional analysis, a specific value (not a continuum) of a given predictor variable determines

304 the occurrence of 1 of the categories of the outcome variable.

305 One limitation of the present study was the lack of inclusion of other possible variables that

306 could also influence the occurrence of increased FPKPA, such as hip external rotator strength.

307 Another limitation was the use of 2D analysis, which has a limited relationship to 3D measures and

308 is insensitive to tibial rotation.28 Thus, it is important to stress that 2D analysis does not reflect 3D

309 joint motion. In fact, the FPKPA used in the present study does not inform about valgus motion of

310 the knee, but instead it is an overall measure of dynamic lower limb alignment, that has also been

311 shown to be sensitive to identify changes in knee alignment during a drop-jump task after a

312 neuromuscular training program in athletes.22 It is also important to consider that the cross-sectional

313 design of this study imposes limitations on the cause and effect relationship among predictors and

314 outcomes. Another aspect to consider is the fact that the results of the study were obtained with the

315 subjects being barefoot. Therefore, in shod condition, the relationships found could be different

316 depending on the characteristics of the shoes.

317 The results of the present study showed that increased FPKPA during weight bearing

318 activities depends on biomechanical factors of the distal and proximal joints of the lower limb. In

13
319 addition, the 2 models indicated different interactions between variables to predict High-FPKPA.

320 Furthermore, CART analysis separated the athletes with and without High-FPKPA into meaningful

321 subsets of clinical features. The identification of interactions among predictors and the non-linear

322 nature of these interactions may help practitioners to efficiently plan preventive and treatment

323 programs for lower extremity injuries related to excessive medial displacement of the knee. For

324 example, the finding that hip abductor weakness contributes to High-FPKPA is consistent with

325 recent work showing the effectiveness of hip strengthening programs for individuals with knee

326 dysfunctions, such as PFP.13 In this context, measures of forefoot alignment, hip abductor torque,

327 and passive ROM of the hip in IR should be included in the assessment of athletes, and

328 interventions programs should be directed to address identified deficits.

329
330 CONCLUSION
331
332 During SLS the occurrence of High-FPKPA was the result of the interaction between hip

333 abductor torque and passive ROM of the hip in IR. During landing, the SFA together with hip

334 abductor torque and passive hip IR ROM were the predictors of high FPKPA. In addition, CART

335 analysis captured non-linear and complex interactions between proximal and distal lower limb

336 segments, which indicated that the contribution of one biomechanical factor to occurrence altered

337 knee motion in the frontal plane depends on the presence of other factors.

338 KEY POINTS

339
340 FINDINGS: During SLS, High-FPKPA was predicted by decreased hip abductor isometric torque

341 related to increase passive hip IR ROM. During landing, excessive forefoot varus alignment

342 together with increased passive hip IR ROM and decreased hip abductor isometric torque were the

343 predictors of High-FPKPA.

344 IMPLICATIONS: CART analyses captured non-linear interactions among predictors and

345 identified cutoff points of hip stiffness, hip abductor strength and foot alignment that can be used to

346 screen athletes with increased FPKPA.

347 CAUTION: The cross-sectional nature of the study imposes limitations to establish causal

14
348 relationship among predictors and outcomes. It is also important to stress that FPKPA does not

349 inform about true knee joint 3D motion. Many other potential factors that could contribute to

350 FPKPA were not considered in this study.

351
352 Acknowledgements:

353 We would like to thank the Minas Tenis Clube's Health Manager, Deborah Rocha da Costa Reis for
354 supporting this study, o Núcleo de Integração de Ciências do Esporte (NICE- Minas Tênis
355 Clube/Brazil) for their help with logistic during data collection. Finally, we thank Giovanna Mendes
356 Amaral, Mayara Nize and Barbara Murta for their help with data processing.
357
358

359

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 TABLE. Means (SD) for demographics characteristics and independents variables.

Single Leg Squat Activity Landing Activity

Variable (n = 101) (n= 72 )

Age (years) 17.1 (5.3) 16.7 (4.6)

Body Mass (kg) 68.9 (17.3) 68.6 (16.9)

Sex (n, %)
Female 32 (31%) 22 (30%)
Male 69 (69%) 50 (70%)

Height (cm) 176.5 (15.0) 179.7 (14.7)

Shank-Forefoot Alignment (o) 11.8 (8.2) 11.9 (8.9)

Passive ROM of Hip IR (o) 43.01 (15.1) 45.7 (14.9)

Hip Abductor Torque (Nm/Kg) 1.17 (0.39) 1.27 (0.35)