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Association between knee-to-hip flexion ratio during single-leg vertical

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ISSN: 1476-3141 (Print) 1752-6116 (Online) Journal homepage: http://www.tandfonline.com/loi/rspb20

Association between knee-to-hip flexion ratio

during single-leg vertical landings, and strength
and range of motion in professional soccer players

Gustavo Leporace, Marcio Tannure, Gabriel Zeitoune, Leonardo Metsavaht,

Moacir Marocolo & Alex Souto Maior

To cite this article: Gustavo Leporace, Marcio Tannure, Gabriel Zeitoune, Leonardo Metsavaht,
Moacir Marocolo & Alex Souto Maior (2018): Association between knee-to-hip flexion ratio during
single-leg vertical landings, and strength and range of motion in professional soccer players, Sports
Biomechanics

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Sports Biomechanics, 2018
https://doi.org/10.1080/14763141.2018.1494207

Association between knee-to-hip flexion ratio during

single-leg vertical landings, and strength and range of
motion in professional soccer players
Gustavo Leporacea  , Marcio Tannureb, Gabriel Zeitounea,c  ,
Leonardo Metsavahta  , Moacir Marocolod  and Alex Souto Maiore 
a
Department of Research in Biomechanics, Institute Brazil of Technologies in Health, Rio de Janeiro, Brazil;
b
Performance Excellence Center, Flamengo Sport Club, Rio de Janeiro, Brazil; cBiomedical Engineering
Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; dDepartment of Physiology, Institute of
Biological Sciences, Universidade Federal de Juiz de Fora, Minas Gerais, Brazil; eDepartment of Rehabilitation
Sciences, University Augusto Mota, Rio de Janeiro, Brazil

ABSTRACT ARTICLE HISTORY

The aim of this study was to test the correlation between knee-to- Received 20 April 2017
hip flexion ratio during a single leg landing task and hip and knee Accepted 22 June 2018
strength, and ankle range of motion. Twenty-four male participants KEYWORDS
from a professional soccer team performed a continuous single leg Quadriceps dominance;
jump-landing test during 10s, while lower limb kinematics data were jumping; biomechanics;
collected using a motion analysis system. After biomechanical testing, injury; male
maximal isometric hip (abduction, extension, external rotation), knee
extension and flexion strength were measured. Maximum ankle
dorsiflexion range of motion was assessed statically using the weight
bearing lunge test. Pearson correlation coefficients were calculated
to determine the associations between the predictor variables (knee
and hip strength, and ankle ROM) and the main outcome measure
(knee-to-hip flexion ratio). Correlation between knee-to-hip flexion
ratio and hip abductors strength was significant (r = −0.47; p = 0.019).
No other significant correlations were observed among the variables
(p  >  0.05). These results demonstrated that a lower hip abductors
strength in male soccer players was correlated with a high knee-to-
hip flexion ratio during landing from a single leg jump, potentially
increasing knee overload by decreasing energy absorption at the hip.
The results provide a novel proposal for the functioning of hip muscles
to control knee overload.

Introduction
A high incidence of lower extremity injuries has been reported in professional soccer play-
ers, with an average of 8 injures/1000 h of exposure, and each player sustaining on average
two injuries per season (Ekstrand, Hägglund, & Waldén, 2011). The knee joint is one of
the most common injured sites, with a high prevalence of patellar tendinopathy (Ekstrand
et al., 2011; Falese, Della Valle, & Federico, 2016; Lian, Engebretsen, & Bahr, 2005).

CONTACT  Gustavo Leporace  gustavo@biocinetica.com.br

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2   G. LEPORACE ET AL.

In recent studies, researchers have suggested that sagittal-plane trunk and lower limb
posture may play important role in the development of knee injuries. It has been shown that
athletes with patellar tendon abnormalities, found by ultrasound, have greater knee flexion
at initial contact and lower hip flexion displacement during landing tasks in comparison to
participants without such tendon abnormalities (Mann, Edwards, Drinkwater, & Bird, 2013).
A more upright and stiff posture, described as a quadriceps dominant behaviour (Read,
Oliver, De Ste Croix, Myer, & Lloyd, 2016), has been correlated with higher knee-extensor
moments, leading to higher patellar tendon stresses (Van der Worp, de Poel, Diercks, van
den Akker-Scheek, & Zwerver, 2014). On the other hand, incorporating increased hip
flexion in relation to knee flexion during landing and cutting manoeuvres has been shown
to reduce knee-extensor moment, knee energy absorption and patellar tendon stress dur-
ing landing tasks (Blackburn & Padua, 2009; Scattone Silva, Ferreira, Nakagawa, Santos,
& Serrão, 2015). Therefore, the knee-to-hip flexion ratio during landings may be used as a
strategy to identify the contribution of knee and hip to load absorption and this may help
to potentially identify patients at risk for patellar tendon pathology.
Two factors that may influence the use of hip/knee motion is lower extremity strength and
ankle range of motion. It has been hypothesised that due to weakness of the posterolateral
hip complex and knee extensor musculature (Teng & Powers, 2016), athletes may use a stiffer
landing strategy, by decreasing hip and knee flexion during several tasks, overloading the
knee extensor mechanism and increasing the risk of patellar tendinopathy (Van der Worp
et al., 2014). Even though hip and knee weakness may have a role, it is unknown which
physical variables are related to a quadriceps dominant behaviour during lading tasks. It has
been also proposed that ankle dorsiflexion range of motion (ROM) may impair knee and
hip kinematics during different landing tasks (Dill, Begalle, Frank, Zinder, & Padua, 2014;
Fong, Blackburn, Norcross, McGrath, & Padua, 2011; Malloy, Morgan, Meinerz, Geiser, &
Kipp, 2015). However, it is not known if knee and hip kinematics are equally disturbed.
Limiting the amount of hip or knee flexion may influence knee-to-hip flexion ratio, leading
to an inadequate energy absorption by the lower limbs and potentially increasing the risk
of injuries.
This study aimed to test the correlation between knee-to-hip flexion ratio during sin-
gle-leg vertical landings and hip and knee strength, and ankle range of motion in male soccer
professional athletes. We hypothesised that all measures would be negative correlated with
knee-to-hip flexion ratio.

Methods
Twenty-four healthy male professional soccer players (24.4 ± 4.6 years; 179.9 ± 6.4 cm;
77.3 ± 7.7 kg; body fat 12.2 ± 4.3%) from a first division soccer league that participated
in national and international competitions volunteered in this study. Previous training
frequency was 6.3 ± 0.7 days/week and exclusion criteria included: (1) use of anabolic ster-
oids, drugs or medication with potential impact in physical performance (self-reported);
(2) presence of musculoskeletal injury in the past 6 months and (3) previous hip, knee or
ankle surgery. The study was approved by the State University of Rio de Janeiro Research
Ethics Committee. All participants signed an informed consent.
All participants performed the vertical hop power test (VHP) (Hickey et al., 2009),
wearing standardised shoes (Duramo Elite, Adidas) during pre season. Participants were
 SPORTS BIOMECHANICS   3

Figure 1. Vertical Hop Power Test. (A) Initial Position; (B) Maximum Flexion Position in the Propulsion
Phase; (C) End of the Propulsion Phase; (D) Highest Position of the Centre of Mass; (E) Ground Contact;
(F) Lowest Position of the Centre of Gravity. Knee-to-hip flexion ration was calculated in phase F. Every
athlete tried to achieve the highest number of repetitions of this jump task for 10 s.

instructed to repeatedly hop on the dominant leg ‘as high as possible while remaining under
control’ for ten seconds (Figure 1). Dominant leg was defined as the preferred to kick a ball.
Initially all participants did a sub-maximal test to warm-up. One-minute rest was allowed
between warm-up and tests. Standardised verbal stimulus was given during the test to
ensure maximal performance. If the task was not performed according to instructions or
data was unable to be recorded, the participant immediately stopped, rested for one minute,
and the test was repeated.
Kinematic data were collected using an 8 high-speed cameras motion analysis system
(Vicon, Oxford, UK) with a sample rate of 250 Hz. Markers were set according to Plug-In
Gait recommendations (Kainz et al., 2016) and segment definitions followed Kadaba,
Ramakrishnan, and Wootten (1990) recommendations. Data were filtered by a fourth order
zero-lag low pass Butterworth filter, with a cut-off frequency of 12 Hz, and lower limbs angles
were calculated using Nexus software (Vicon, Oxford, UK), based on the joint coordinate
system proposal (Grood & Suntay, 1983). A standing trial in a static position was used
for each participant to individualise marker position, calculate joint centres and segment
positions during the jump task. The variable of interest was the ratio between knee and hip
flexion in the lowest position of the centre of mass during the landing phase of the VHP
test (knee-to-hip flexion ratio, Figure 1). This ratio was calculated in each landing and the
average of the first three values was used in the analysis.
Maximal isometric hip strength was tested for the hip abductor, extensor and external
rotator, knee extensor and flexor muscle groups using a hand-held dynamometer on the
dominant leg (Lafayette Manual Muscle Tester Model 01163; Lafayette Instrument Company,
Lafayette, IN, USA). Participants were instructed to push into the dynamometer—a ‘make
test’—as this is a more reliable technique than traditional ‘break tests’ (Stratford & Balsor,
4   G. LEPORACE ET AL.

1994). Peak isometric strength was assessed three times for each participant and highest,
single value of the three trials was used in the analyses. All measures were performed by
a single researcher. Intra and inter-rater reliability of hand held isometric dynamometers
has been proven previously (Ieiri et al., 2015; Kim & Lee, 2015; Thorborg, Bandholm, &
Hölmich, 2013).
The hip abductor muscle group was tested in lateral decubitus with the hip to be tested
placed in the neutral position. The hand-held dynamometer was placed 5 cm proximal to
the lateral epicondyle of the femur in a perpendicular position to the thigh. The hip extensor
and external rotator muscle groups were tested in a prone position with the hip placed in
neutral position. For hip extensors, the hand-held dynamometer was placed 5 cm proxi-
mal to the posterior joint line of the knee in a perpendicular position to the thigh. For hip
external rotators the dynamometer was placed 5 cm proximal to the medial malleolus of
the ankle with the knee at 90° of flexion (Figure 2(A)). Knee flexors strength was assessed
in the same position, but with the dynamometer placed 5 cm proximal to the posterior pro-
jection of the medial malleolus of the ankle with the knee at 90°. The knee extensors were
tested in a seated position with the hip placed in neutral rotation on frontal and transverse
planes and knees flexed at 90°, while the dynamometer was placed 5 cm proximal to the
anterior projection of the medial malleolus of the ankle (Malloy, Morgan, Meinerz, Geiser,
& Kipp, 2016) (Figure 2(B)).
Participants were requested to perform maximal effort against the dynamometer avoiding
sudden movements, in order to build to maximal effort over a 5-s period (Malloy et al.,
2016). Maximal hip abductor, extensor and external rotator, and knee extensor and flexor
isometric torques were calculated as the product of the respective segment lever arm and
the isometric force measured with the hand-held dynamometer and normalised to body
mass (newton-meters per kilogram). Lever arm, for torque calculation of thigh muscles,
was measured considering the distance between the proximal tip of the greater trochanter
of femur and a horizontal line drawn five centimetres above lateral knee joint line. For the
shank it was set a site midway the medial knee joint line and five centimetres above medial
malleolus.
Maximum weight-bearing ankle dorsiflexion range of motion (ADROM) was assessed
statically using the weight bearing lunge test (WBLT) on the dominant leg, as described by
Hoch and McKeon (2011), using a digital inclinometer (ACUMAR, USA). To perform the
WBLT, the participant was positioned facing a wall with the involved foot in front, and the
great toe touching the wall (Figure 2(B)). Participants initially were progressed backward
in 1-cm increments until heel or knee contact could no longer be maintained during the
lunge. Subsequent changes in distance from the wall were made in smaller increments until
the maximum lunge distance was identified. Maximum ADROM was assessed three times
for each participant and maximal value was used for analysis (Hoch & McKeon, 2011).

Statistical analysis
Kolmogorov-Smirnov test was applied to verify the distribution of data. Pearson correlation
coefficients were calculated to determine the associations between the predictor variables
(knee and hip strength, and ADROM) and the interest variables (knee-to-hip flexion ratio).
Statistical significance was set at p < 0.05. All statistical analyses were performed using
MATLAB (version 8.6.0, The Mathworks, USA).
 SPORTS BIOMECHANICS   5

Figure 2.  A, Top: Hip Abductor Strength test; A, Middle: Hip Extensor Strength test; A, Bottom: Hip
External Rotator Strength test; B, Top: Knee Extensors Strength test; B, Middle: Knee Flexors Strength
test; B, Bottom: Weight Bearing Lunge test (Dorsiflexion range of motion).

Results
Table 1 presents mean and standard deviation of the biomechanical variables of the athletes.
There was a significant association between knee-to-hip flexion ratio in landing and hip
adductor strength (Figure 3). None of the other variables were correlated with knee-to-hip
flexion ratio (Table 2).
6   G. LEPORACE ET AL.

Table 1. Mean (standard deviation) of knee and hip strength, ankle dorsiflexion range of motion (ROM)
and knee-to-hip flexion ratio.
Mean (SD)
Hip extensors strength (Nm/kg) 1.79 (0.38)
Hip abductors strength (Nm/kg) 1.72 (0.27)
Hip external rotators strength (Nm/kg) 0.87 (0.14)
Knee extensors strength (Nm/kg) 2.43 (0.55)
Knee flexors strength (Nm/kg) 0.95 (0.17)
Dorsiflexion ROM (°) 36.0 (5.4)
Knee-to-hip flexion ratio 1.40 (0.44)
Note: ROM: Range of Motion.

Figure 3. Scatter plot between knee-to-hip flexion ratio and hip abductors strength. The continuous line
represents the regression curve between variables.

Table 2. Pearson correlation coefficient (r), coefficient of determination (r2) and p value between knee/
hip flexion ratio and: hip and knee strength, and dorsiflexion range of motion (ROM)
r r2 p value
Hip extensors strength −0.11 0.01 0.599
Hip abductors strength −0.47 0.22 0.019*
Hip external rotators strength 0.11 0.01 0.600
Knee extensors strength −0.10 0.01 0.650
Knee flexors strength −0.05 0.00 0.807
Dorsiflexion ROM −0.25 0.06 0.242
Note: ROM: Range of Motion.

Discussion and implications

Knee-to-hip flexion ratio during landing tasks is related to increased knee and/or hip
overload, and considered a potential risk factor for patellar tendinopathy (Mann et al.,
2013) and other injures, therefore it is an important variable to be measured during bio-
mechanical landing. A higher knee-to-hip flexion means that the amount of knee flexion
during the landing task is higher than hip flexion, increasing knee energy absorption. The
 SPORTS BIOMECHANICS   7

most important finding of this study was the significant association between this ratio and
hip abductors strength, confirming partially our hypothesis. Those male soccer players
with weaker hip abductors presented higher knee-to-hip flexion, increasing quadriceps
dominance.
The results of this study confirm that hip abductor muscle strength and sagittal planed
dynamic control of the knee and hip are related. This adds to the hip abductors role of con-
trolling frontal plane knee and pelvic motion (Jacobs, Uhl, Mattacola, Shapiro, & Rayens,
2007; Malloy et al., 2016). Our observation supports the proposal by Powers (2010) that indi-
viduals with hip-muscle weakness adopt altered movement strategies to reduce mechanical
demands on the hip, subjecting the knee joint to higher loading in the sagittal and frontal
planes. This observation may also help to further explain why patients who complete pos-
terolateral hip muscle strengthening program report a decrease in knee pain (Fox, Bonacci,
McLean, Spittle, and Saunders (2016), as strengthening these muscles may cause a change
in hip-knee flexion ratio, ultimately reducing the load placed on the patellar tendon. This
theory cannot be confirmed from our observations, but should be investigated in future
research. 
Despite the similar correlation coefficient with other studies that assessed the rela-
tion between biomechanical variables and isometric strength (ranging from 0.20 to 0.50)
(Malloy et al., 2016; Shultz, Nguyen, Leonard, & Schmitz, 2009), hip abductor strength only
explained 22% of the variability of knee-to-hip flexion ratio. Some previous authors did not
find significant correlations between hip strength and knee kinematic (Baldon et al., 2011;
Jacobs et al., 2007), while some other did find (Suzuki, Omori, Uematsu, Nishino, & Endo,
2015; Teng & Powers, 2016). Although hip external rotators strength have been related to
better dynamic control of the lower extremity during unanticipated single-leg landing and
cutting tasks in female athletes (Malloy et al., 2016), on this study, hip external rotators
strength was not associated to any changes on sagittal plane coupling in male soccer play-
ers. Suzuki et al. (2015) found a positive correlation between hip extensors strength and
maximum knee flexion angle during single-legged medial drop landing in males and could
possibly be related to the different biomechanical tasks performed. Other authors found no
significant relationship between hip strength and knee kinematics during single leg squat
and single leg landing task in male participants (Baldon et al., 2011; Jacobs et al., 2007).
The results of this study showed a lack of relationship between knee extensors and flexors
strength and sagittal plane knee and hip kinematics, in accordance to some previous studies,
despite different biomechanical tasks used (Shultz et al., 2009; Van der Worp et al., 2014;
Wojtys, Ashton-Miller, & Huston, 2002). The low correlation between strength measures
and kinematics during the single-leg landing task might be related to the nature of strength
tests used in the present study. Strength was measured as the peak value during an isomet-
ric test, while during landing tasks eccentric muscle contraction is required (Malloy et al.,
2016; Shultz et al., 2009). Also, it is possible that the single-leg landing performed was not
demanding enough to elicit a high amount of strength of male professional soccer players,
since different results has been found for studies comparing strength and kinematics using
a low demand test (i.e. single leg squat) and high demand task (i.e. landing tasks) (Baldon
et al., 2011; Jacobs et al., 2007; Suzuki et al., 2015). Other neuromuscular variables may
influence sagittal plane biomechanics during landing tasks. Shultz et al. (2009) proposed
that more focus should be placed on positional differences of trunk, hip and knee during
landing for their potential to increase sagittal plane knee joint loads. There are evidences
8   G. LEPORACE ET AL.

that plyometric training focusing on technique using real-time feedback is effective to

reduce knee and hip overload (Dallinga et al., 2017; Scattone Silva et al., 2015), proposing
that motor control, instead of only peak strength, might be an important variable to be
trained to decrease joint stress.
A decreased ADROM has been described as a potential risk factor for patellar tendinopa-
thy in male athletes (Backman & Danielson, 2011), possibly because of the relation between
this variable and knee and hip angular displacement during landing tasks. Fong et al. (2011)
found that reduced ADROM is correlated to a decreased knee flexion displacement during
landing tasks. Dowling, McPherson, and Paci (2018) showed that ADROM and peak hip
flexion during landing tasks are also positively correlated. However, the present study did not
find association between knee-to-hip flexion ratio during landing from a single leg jump and
WBLT. Although, there is a clear positive association between knee and hip flexion during
squats and drop landing tasks and ADROM (Dill et al., 2014; Dowling et al., 2018; Fong et
al., 2011), the latter seems not to influence the knee and hip coupling in the sagittal plane
in healthy participants during a single leg vertical jump-landing task. Therefore, ADROM
may not be sensitive variable when a single leg task is used. 
A limitation of present study is that the sample consisted only of highly skilled, athletic
and healthy males soccer players and may limit the generalisability of the results to other
populations, since strength measures may be clustered and therefore the ability to see a linear
correlation amongst variables may have been compromised. Furthermore, the results of a
cross-sectional correlational study do not allow a cause-and-effect relationship.

Conclusion
This study found that greater hip abductors strength in male soccer players was correlated
with a lower knee-to-hip flexion ratio during single leg vertical landing, showing a better
control of sagittal plane movements during single-leg landings. This finding provides a
novel proposal of hip abductors muscles importance on knee sagittal plane overloading,
rather than solely controlling dynamic knee valgus. On the other hand, ADROM and knee
strength had no influence on sagittal plane mechanics during landing from vertical jumps
in male soccer players. Longitudinal studies are needed to clarify if male soccer athletes
without dynamic knee valgus would benefit from hip abductors strengthening into their
conditioning program to increase sagittal plane coupling during landings.

Disclosure statement
No potential conflict of interest was reported by the authors.

ORCID
Gustavo Leporace   http://orcid.org/0000-0002-7265-4658
Gabriel Zeitoune   http://orcid.org/0000-0002-0019-8112
Leonardo Metsavaht   http://orcid.org/0000-0001-9263-1309
Moacir Marocolo   http://orcid.org/0000-0002-7715-2534
Alex Souto Maior   http://orcid.org/0000-0003-0346-0750
 SPORTS BIOMECHANICS   9

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