Journal of Applied Biomechanics, 2023, 39, 10-14

https://doi.org/10.1123/jab.2022-0165
© 2023 Human Kinetics, Inc. ORIGINAL RESEARCH

The Effects of Increasing Trunk Flexion During Stair

Ascent on the Rate and Magnitude of Achilles Tendon
Force in Asymptomatic Females
Lee T. Atkins,1 Michael Lowrey,2 Sarah Reagor,3 Kirsten Walker,4 and Dhalston Cage5
1
Department of Physical Therapy, The University of North Texas Health Science Center, Fort Worth, TX, USA;
2
Sports Medicine and Orthopedic Center and Ivy Rehab, Chesapeake, VA, USA; 3Methodist Rehabilitation Hospital, Dallas, TX, USA; 4ClearSky Rehabilitation
Hospital of Flower Mound, Flower Mound, TX, USA; 5Children’s Health Andrews Institute, Plano, TX, USA

Research indicates that increasing trunk flexion may optimize patellofemoral joint loading. However, this postural change
could cause an excessive Achilles tendon force (ATF) and injury risk during movement. This study aimed to examine the
effects of increasing trunk flexion during stair ascent on ATF, ankle biomechanics, and vertical ground reaction force in
females. Twenty asymptomatic females (age: 23.4 [2.5] y; height: 1.6 [0.8] m; mass: 63.0 [12.2] kg) ascended stairs using
their self-selected and flexed trunk postures. Compared with the self-selected trunk condition, decreases were observed for
peak ATF (mean differences [MD] = 0.14 N/kg; 95% confidence interval [CI], 0.06 to 0.23; Cohen d = −1.2; P = .003),
average rate of ATF development (MD = 0.25 N/kg/s; 95% CI, 0.07 to 0.43; Cohen d = −0.9; P = .010), ankle plantar flexion
moment (MD = 0.08 N·m/kg; 95% CI, 0.03 to 0.13; Cohen d = −1.1; P = .005), and vertical ground reaction force
(MD = 38.6 N/kg; 95% CI, 20.3 to 56.90; Cohen d = −1.8; P < .001). Increasing trunk flexion did not increase ATF.
Instead, this postural change was associated with a decreased ATF rate and magnitude and may benefit individuals with
painful Achilles tendinopathy.

Keywords: trunk posture, stair ascent, Achilles tendon force

Patellofemoral pain is a multifactorial condition common
among young, physically active females.1–3 Recently, it was
suggested that increasing forward trunk flexion during movement
might be of benefit for individuals with patellofemoral pain as this
postural change has been associated with reduced patellofemoral
joint stress during stair ascent4 and running.5,6 Furthermore,
increasing trunk flexion during movement has been shown to
cause improvements in self-reported patellofemoral pain.7,8 How-
ever, despite these promising findings for patellofemoral joint
loading and individuals with patellofemoral pain, it is important
to understand how trunk flexion influences the mechanical load and
concomitant risk imposed on other anatomical structures com-
monly injured in active populations.
For example, Achilles tendinopathy is a lower-limb overuse
injury, characterized by tendon pain and edema, and altered
function9,10 that is common in athletes.11 Additionally, Achilles
tendinopathy has been attributed to an excessive Achilles tendon
force (ATF).12–14 Furthermore, the loading magnitude of the
Achilles tendon could influence healing following surgical repair
of a ruptured tendon. Thus, it is important to understand if and to
what extent changes in movement such as a flexed trunk posture
influence the mechanical loading and subsequent risks to structures
such the Achilles tendon.
When one increases their forward trunk flexion, the body’s
center of mass can shift anteriorly as evidenced by studies indicat-
ing that a flexed trunk posture is associated with increases and
decreases in the hip and knee extensor moments, respectively.15,16
Therefore, biomechanically speaking, one may conclude that
Atkins (lee.atkins@unthsc.edu) is corresponding author, https://orcid.org/0000-
0001-6596-8408
10
increasing forward trunk flexion (and shifting the body’s center
of mass anteriorly) is likely to also increase the ankle plantar
flexion moment and the ATF. Thus, increasing trunk flexion during
movement may increase one’s risk for exposure to an excessive
ATF and Achilles tendon injury.
Although research regarding the effect of changes in sagittal
plane trunk posture on the ATF is scarce, findings from studies that
examined the influence of trunk flexion on the ankle plantar flexion
moment (an important determinant of the ATF) are conflicting. For
example, trunk flexion has been associated with a decreased ankle
plantar flexion moment during walking16 and running,5 yet it was
reported that an increased ankle plantar flexion moment occurred
with greater trunk flexion during lunging15 and drop-landing17 tasks.
Such findings highlight the lack of understanding and need for
additional research regarding the influence of trunk flexion on ankle
joint biomechanics (and ATF) during everyday functional tasks like
stair ascent which place an increased mechanical demand on the
plantar flexor muscles.18 This is especially true for individuals with
symptomatic Achilles tendinopathy or those in the early stages of
recovery following the repair of a ruptured Achilles tendon.
Increased understanding of the relationships between trunk
flexion, ankle joint biomechanics, and the ATF during stair ascent
will further inform clinicians about the cost-to-benefit ratio associ-
ated with teaching patients with patellofemoral pain, Achilles ten-
dinopathy, or other conditions to increase trunk flexion. Therefore,
the purpose of the present study was to examine the effects of
increasing trunk flexion during stair ascent on the rate and magnitude
of the ATF. A secondary purpose was to examine the effects of trunk
flexion on the ankle joint kinematics and kinetics and the vertical
ground reaction force at the time of peak ATF. It was hypothesized
that increasing trunk flexion would cause an increase in the ATF rate
and magnitude and the ankle plantar flexion moment.
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 Trunk Flexion Influence on Achilles Tendon Force 11

Methods
Subjects
Subjects in this study were a sample of convenience that included
20 asymptomatic females. The average (SD) age of subjects was
23.4 (2.5) years, and their average height (SD) and mass (SD) were
1.6 (0.8) m and 63.0 (12.2) kg, respectively. Only females partici-
pated as these subjects were initially recruited as part of earlier
studies4,19 that examined biomechanical variables related to pa-
tellofemoral pain which affects females more often than males.1
Using the effect size for changes in the ankle plantar flexion
moment impulse associated with increased trunk flexion (Cohen
d = 2.0) from a previous study,15 it was determined that fewer than
9 subjects would provide adequate statistical power of 0.80 with
α2 = 0.05. However, the ATF was the primary dependent variable
in the present study. Thus, given the scarcity of data regarding
changes in ATF with varying trunk postures, it was decided to use
all 20 of the subjects that, as mentioned previously, were recruited
for an earlier studies.4,19
Volunteers were included who were 18–45 years of age with a
body mass index less than 30 kg/m2 and reported no pain in their
lower limb or back. Volunteers were excluded from participating in
the present study if they reported having back or lower-limb
surgery, had sustained an injury to their back or lower limb within
the year prior to testing that was exacerbated by stair negotiation,
had a neuromuscular condition that prevented them from safely
negotiating stairs, or were pregnant. Prior to participation, all Figure 1 — Locations of reflective markers.
subjects provided written informed consent, and the institutional
review board at Angelo State University approved the pres-
ent study.

Procedures
Data for the present study were obtained as part of an earlier,
larger study that included an additional stair ascent condition.4
The specific procedures relevant to the present study are summa-
rized here. Upon arrival at the lab, subjects were provided with a
sports top, spandex shorts, and shoes (Asics, Gel-Contend 4) that
were intended to minimize the influence of different footwear
types on the dependent variables of interest. Next, 14-mm reflec-
tive markers were attached bilaterally to the anterior superior iliac
spines, posterior superior iliac spines, iliac crests, greater tro-
chanters, medial and lateral femoral condyles, medial and lateral
malleoli, and the first, second, and fifth metatarsal heads (Fig-
ure 1). Additionally, rigid plates consisting of 3 or 4 noncollinear
markers were attached to the trunk, thighs, legs, and feet (Fig-
ure 1). The trunk plate was attached at approximately the mid-
thoracic spine and aligned parallel to the frontal plane of the
Figure 2 — Subject demonstrating the (A) self-selected and (B) flexed
subject’s trunk (Figure 1). Following marker placement, a brief
trunk conditions.
standing trial was recorded and used to define local segment
coordinate systems and joint axes of rotation. All markers were
removed after the standing trial except those on the pelvis and the Subjects ascended the stairs to the beat of a metronome
rigid plates (Figure 2). (96 beats/min)20 to minimize the influence of changes in stair
Then, subjects ascended the stairs during 2 different conditions. ascent cadence on the dependent variables. Before data were
For the first condition, subjects were instructed to perform 5 stair collected, subjects performed several practice trials for each con-
ascent trials using their self-selected (SS) trunk posture (Figure 2). dition to minimize learning effects. Successful trials were those in
After the SS condition, subjects performed 5 additional stair ascent which the subject’s foot was supported entirely by the force plate
trials during the flexed condition (FLX) in which they were cued to embedded in the first step of the stairs (Figure 2).
“increase their forward trunk lean as much as comfortably possible” An 8-camera motion capture system (Vicon) was used during
(FLX; Figure 2). Initially, subjects performed the SS condition each stair ascent trial to record 3-dimensional kinematics (200 Hz).
followed by the FLX condition to ensure that trunk flexion increased Additionally, a floor-mounted force plate (Bertec) was used to
during the FLX condition. record 3-dimensional ground reaction forces.
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12 Atkins et al
Data Reduction
Three-dimensional position and ground reaction force data were
initially smoothed in Vicon Nexus (version 2.6.1, Vicon) using a
dual-pass, fourth-order Butterworth low-pass digital filter (6 Hz
cutoff). Next, in Visual3D (version 6, C-Motion), a 6-degrees-of-
freedom model was applied to these data in which the lower-limb
segments were modeled as frustums of cones, and the pelvis was
modeled as a cylinder. Trunk kinematics were calculated as
segment angle relative to the laboratory coordinate system, and
ankle kinematics were calculated as the foot segment relative to the
leg segment. The net internal ankle joint moment was calculated
using inverse dynamics and was normalized to body mass.
Next, the ATF was calculated using a 2-dimensional model that
included subject-specific and non-subject-specific model inputs
(Figure 3).21 Subject-specific model inputs included sagittal plane
ankle kinematic and kinetic data. An additional input variable not
specific to the subjects was the Achilles tendon moment arm length
obtained using data from a previous study.22 The first step in
estimating ATF was to calculate the Achilles tendon moment arm
length, which was achieved by fitting a linear equation to data from a
previous study that reported the length at varying sagittal plane ankle
angles22 (Figure 3). Next, the ATF was determined by calculating the
quotient of the net ankle plantar flexion moment divided by the
Achilles tendon moment arm length (Figure 3). The model output
variable of interest was the time-series ATF (normalized to body
mass) during the stance phase of the stair ascent trials.
The primary dependent variables for this study included the
peak ATF (N/kg) and the average rate of ATF development
(N/kg/s) from initial contact until the peak ATF. Additional
dependent variables calculated at the time of peak ATF included
the sagittal plane trunk segment and ankle joint angles (degrees),
ankle plantar flexion moment (N·m/kg), and vertical ground reac-
tion force (N/kg).
Statistical Analyses
Initially, descriptive statistics were calculated for each dependent
variable. Next, the parametric testing assumption of distribution
normality was confirmed for each dependent variable by calculat-
ing Kolmogorov–Smirnov and Shapiro–Wilk tests. Paired samples
t tests (α = .05) were then calculated to examine for differences
between conditions for each dependent variable. Additionally,
mean differences (MD) between conditions, 95% confidence inter-
vals (95% CIs), and Cohen d effect sizes for paired samples
(d: small = 0.20, medium = 0.50, large = 0.80)23 were calculated.
Figure 3 — Flow diagram of Achilles tendon force model. aSubject-
specific data obtained from motion capture system during the stance phase
of stair ascent. bData obtained from Maganaris.22
JAB Vol. 39, No. 1, 2023
Results
During the FLX condition, a decrease was observed for the peak
ATF (MD = 0.14 N/kg; 95% CI, 0.06 to 0.23; P = .003) and
average rate of ATF development (MD = 0.25 N/kg/s; 95% CI,
0.07 to 0.43; P = .010) compared with the SS trunk condition
(Table 1). Similarly, at the time of peak ATF, decreases were
observed for the ankle plantar flexion moment (MD = 0.08 N·m/kg;
95% CI, 0.03 to 0.13; P = .005) and vertical ground reaction force
(MD = 38.6 N/kg; 95% CI, 20.3 to 56.90; P < .001). In contrast, the
trunk flexion angle at the time of peak ATF increased during the
FLX condition (MD = −35.32 deg; 95% CI, −39.92 to −30.71; P <
.001) (Table 1). The ankle dorsiflexion angle at the time of peak
ATF was similar during both conditions (P = .125; Table 1).
Discussion
This study sought to determine the effects of trunk flexion on the
ATF. In contrast to the proposed hypothesis, increasing trunk
flexion caused a decrease in the ATF. Specifically, increasing
trunk flexion by approximately 35° resulted in a 10% decrease
in the rate and magnitude of the ATF experienced by subjects
during stair ascent. Based on these findings, increasing trunk
flexion during stair ascent does not increase one’s risk for exposure
to an excessive ATF rate or magnitude.
The decreased ATF observed in the present study during FLX is
largely due to an 8% decrease in the ankle plantar flexion moment as
ankle kinematics were similar during both conditions. The decreased
ankle plantar flexion moment that occurred during the FLX condi-
tion is consistent with findings from previous studies that examined
this relationship during activities that are predominantly performed
on a single limb including walking16 and running.5
However, this finding of a decreased ankle plantar flexion
moment during FLX is not in agreement with some studies. For
example, Farrokhi et al15 proposed that the increased ankle plantar
flexion moment that occurred while lunging with greater trunk
flexion was likely due to increased loading of the lead limb (as
evidenced by an increased vertical ground reaction force) and
decreased loading of the trailing limb. In the present study,
contralateral initial contact was not assessed, and therefore, it
could not be ascertained whether the peak ATF occurred during
single- or double-limb stance of the stair ascent. However, it is
conceivable the peak ATF in the present study occurred during
single-limb stance, which would have prevented subjects from
employing a compensatory strategy with their contralateral limb.
In another study, Scattone Silva et al17 reported an increase in
the plantar flexion moment (on the painful, affected limb) in subjects
with patellar tendinopathy during double-limb landing with a flexed
trunk posture. In this study, during the more painful SS landing, the
vertical ground reaction force (on the painful, affected limb) was
decreased compared to that experienced during the less painful
flexed trunk landing. Although speculative, it is possible that during
the more painful SS landing, these subjects increased the loading of
their unaffected contralateral limb. Similarly, because of reduced
pain during flexed trunk landing, these subjects likely tolerated
greater lower-limb loading of their affected limb, as evidenced by
an increased vertical ground reaction force. Regardless, the compar-
ison of findings from the present study to earlier research highlights
the task-specific nature of the relationship between sagittal plane
trunk posture during movement and the ankle plantar flexion
moment. In particular, a key task characteristic appears to be whether
the activity is predominantly single or double limb. Additional
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Table 1 Influence of Forward Trunk Lean on Biomechanical Variables of Interest During Stair Ascenta
Biomechanical variables Self-selected trunk condition
Peak ATF, N/kg 1.96 (0.14)
Average rate of ATF development, N/kg/s 2.95 (0.28)
Ankle plantar flexion moment,b N·m/kg 1.21 (0.08)
Vertical ground reaction force,b N/kg 667.78 (117.39)
Ankle dorsiflexion angle,b deg 6.21 (5.08)
Trunk flexion angle,b deg 15.33 (6.62)
Abbreviation: ATF, Achilles tendon force. Note: Negative effect size indicates a decrease during flexed trunk condition compared with self-selected trunk condition.
a
Values represent mean (SD). bMeasured at time of peak ATF. cP is less than alpha.
research is needed that examines this relationship during other
movements such as stair descent and inclined and declined walking.
Excessive loading can cause a painful tendon maladaptation
that may require reduced loading to optimize symptoms and restore
tendon homeostasis.14,24 However, it is difficult to discern the
magnitude of change in tendon load necessary for effecting an
improvement in self-reported symptoms for individuals with con-
ditions such as symptomatic tendinopathy. To date, few if any
studies have examined the effects of a decreased ATF during
movement on self-reported Achilles tendinopathy pain. However,
one study examined the immediate effects of decreasing the patellar
tendon force during landing on self-reported patellar tendinopathy
pain.17 In this study, a significant decrease in self-reported patellar
tendinopathy pain during landing was associated with a decrease in
the tendon force of nearly 10%.17 Based on this finding, the 10%
decrease in ATF rate and magnitude observed in the present study
may represent clinically relevant changes, at least in regard to self-
reported tendinopathy pain. However, it should be noted that an
ATF change of this magnitude may not be feasible during stair
ascent for individuals with painful Achilles tendinopathy. For
example, it was recently reported that during stair ascent, indivi-
duals with Achilles tendinopathy do not use their plantar flexor
muscles to the same extent as asymptomatic control subjects as
evidenced by reduced plantar flexion power.25 These authors
suggested that this difference may represent an attempt to minimize
Achilles tendon loading and pain. If true, this compensatory pain
avoidance strategy may constrain or limit the ability of these
individuals to decrease the ATF. Future studies are needed that
examine the effect of trunk flexion on the ATF and self-reported
pain in individuals with Achilles tendinopathy.
This study has several limitations that should be acknowledged.
First, the ATF was estimated using a 2-dimensional model that did
not account for changes in frontal and transverse plane kinematics
that could have affected the ATF. Additionally, this model did not
account for cocontraction of the ankle dorsiflexor muscles, which
also may have influenced the ATF. Furthermore, the subjects
examined in the present study were asymptomatic females, so
extrapolation of these findings to patient populations or males is
limited. Additionally, it is plausible that the observed changes in
movement biomechanics in the present study are not permanent.
Further research is needed to determine whether these changes are
lasting or if they transfer to other functional tasks such as stair
descent as ankle biomechanics can vary between tasks. Continued
research is also needed to determine if changes in ATF and ankle
biomechanics observed in the present study also occur in other
populations such as males and individuals with orthopedic condi-
tions. Finally, increasing trunk flexion may increase an individual’s
risk of exposure to excessive lumbar spine loads. Thus, studies are
needed that examine how trunk flexion during stair ascent influences
JAB Vol. 39, No. 1, 2023
Trunk Flexion Influence on Achilles Tendon Force 13
Flexed trunk condition P Cohen d
1.81 (0.23) .003c −1.2
2.71 (0.41) .010c −0.9
1.13 (0.14) .005c −1.1
629.18 (141.59) <.001c −1.8
7.78 (5.46) .125 0.5
50.64 (9.17) <.001c 5.1
the loading of the lumbar spine. Additionally, it may be possible to
effect a significant change in ATF with less trunk flexion. Thus, it
would be worthwhile to examine the effects of incremental increases
in trunk flexion (ie, 15°, 20°, 25°) on the ATF.
In summary, increasing trunk flexion during stair ascent does
not increase one’s risk for excessive Achilles tendon loading.
Instead, this postural change during stair ascent is associated
with a decreased ATF rate and magnitude, and may be of benefit
for individuals with painful Achilles tendinopathy.
References
1. Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A.
Gender differences in the incidence and prevalence of patellofemoral
pain syndrome: epidemiology of patellofemoral pain. Scand J Med
Sci Sports. 2010;20(5):725–730. PubMed ID: 19765240 doi:10.
1111/j.1600-0838.2009.00996.x
2. Devereaux MD, Lachmann SM. Athletes attending a sports injury
clinic—a review. Br J Sports Med. 1983;17(4):137–142. PubMed ID:
6661608 doi:10.1136/bjsm.17.4.137
3. Powers CM, Witvrouw E, Davis IS, Crossley KM. Evidence-based
framework for a pathomechanical model of patellofemoral pain: 2017
patellofemoral pain consensus statement from the 4th international
patellofemoral pain research retreat, Manchester, UK: part 3. Br J
Sports Med. 2017;51(24):1713–1723. PubMed ID: 29109118 doi:10.
1136/bjsports-2017-098717
4. Atkins LT, Smithson C, Grimes D, Heuer N. The influence of sagittal
trunk posture on the magnitude and rate of patellofemoral joint stress
during stair ascent in asymptomatic females. Gait Posture. 2019;74:
121–127. PubMed ID: 31499406 doi:10.1016/j.gaitpost.2019.08.016
5. Teng HL, Dilauro A, Weeks C, et al. Short-term effects of a trunk
modification program on patellofemoral joint stress in asymptomatic
runners. Phys Ther Sport. 2020;44:107–113. PubMed ID: 32504959
doi:10.1016/j.ptsp.2020.05.002
6. Teng HL, Powers CM. Sagittal plane trunk posture influences
patellofemoral joint stress during running. J Orthop Sports Phys
Ther. 2014;44(10):785–792. PubMed ID: 25155651 doi:10.2519/
jospt.2014.5249
7. Atkins LT, James CR, Yang HS, et al. Immediate improvements in
patellofemoral pain are associated with sagittal plane movement training
to improve use of gluteus maximus muscle during single limb landing.
Phys Ther. 2021;101(10):pzab165. doi:10.1093/ptj/pzab165
8. dos Santos AF, Nakagawa TH, Lessi GC, et al. Effects of three gait
retraining techniques in runners with patellofemoral pain. Phys Ther
Sport. 2019;36:92–100. doi:10.1016/j.ptsp.2019.01.006
9. Maffulli N, Longo UG, Kadakia A, Spiezia F. Achilles tendinopathy.
Foot Ankle Surg. 2020;26(3):240–249. PubMed ID: 31031150
doi:10.1016/j.fas.2019.03.009
Unauthenticated | Downloaded 02/11/23 12:23 PM UTC
14 Atkins et al
10. Ogbonmwan I, Kumar BD, Paton B. New lower-limb gait bio-
mechanical characteristics in individuals with Achilles tendinopathy:
a systematic review update. Gait Posture. 2018;62:146–156. PubMed
ID: 29550694 doi:10.1016/j.gaitpost.2018.03.010
11. Ackermann PW, Renström P. Tendinopathy in sport. Sports Health.
2012;4(3):193–201. PubMed ID: 23016086 doi:10.1177/19417381
12440957
12. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology
model to explain the clinical presentation of load-induced tendino-
pathy. Br J Sports Med. 2009;43(6):409–416. PubMed ID: 18812414
doi:10.1136/bjsm.2008.051193
13. Matthews W, Ellis R, Furness J, Hing WA. The clinical diagnosis of
Achilles tendinopathy: a scoping review. PeerJ. 2021;9:e12166.
PubMed ID: 34692248 doi:10.7717/peerj.12166
14. Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a
proposed “physical stress theory” to guide physical therapist practice,
education, and research. Phys Ther. 2002;82(4):383–403. PubMed
ID: 11922854 doi:10.1093/ptj/82.4.383
15. Farrokhi S, Pollard CD, Souza RB, Chen YJ, Reischl S, Powers CM.
Trunk position influences the kinematics, kinetics, and muscle activ-
ity of the lead lower extremity during the forward lunge exercise. J
Orthop Sports Phys Ther. 2008;38(7):403–409. PubMed ID:
18591759 doi:10.2519/jospt.2008.2634
16. Kluger D, Major MJ, Fatone S, Gard SA. The effect of trunk flexion
on lower-limb kinetics of able-bodied gait. Hum Mov Sci. 2014;
33:395–403. PubMed ID: 24423389 doi:10.1016/j.humov.2013.
12.006
17. Scattone Silva R, Purdam CR, Fearon AM, et al. Effects of altering
trunk position during landings on patellar tendon force and pain. Med
Sci Sports Exerc. 2017;49(12):2517–2527. PubMed ID: 28704344
doi:10.1249/MSS.0000000000001369
JAB Vol. 39, No. 1, 2023
18. DiLiberto FE, Nawoczenski DA, Tome J, DiGiovanni BF. Patient
reported outcomes and ankle plantarflexor muscle performance fol-
lowing gastrocnemius recession for Achilles tendinopathy: a pro-
spective case-control study. Foot Ankle Surg. 2020;26(7):771–776.
PubMed ID: 31727534 doi:10.1016/j.fas.2019.10.001
19. Atkins LT, Reid J, Zink D. The effects of increased forward trunk lean
during stair ascent on hip adduction and internal rotation in asymp-
tomatic females. Gait Posture. 2022;97:147–151. PubMed ID:
35961131 doi:10.1016/j.gaitpost.2022.08.001
20. Salsich GB, Brechter JH, Powers CM. Lower extremity kinetics
during stair ambulation in patients with and without patellofemoral
pain. Clin Biomech. 2001;16(10):906–912. PubMed ID: 11733129
doi:10.1016/S0268-0033(01)00085-7
21. Willy RW, DeVita P, Meardon SA, Baggaley M, Womble CC,
Willson JD. Effects of load carriage and step length manipulation
on Achilles tendon and knee loads. Mil Med. 2019;184(9–10):e482–
e489. doi:10.1093/milmed/usz031
22. Maganaris CN. Imaging-based estimates of moment arm length in
intact human muscle-tendons. Eur J Appl Physiol. 2004;91(2–3):
130–139. PubMed ID: 14685871 doi:10.1007/s00421-003-1033-x
23. Portney LG, Watkins MP. Foundations of Clinical Research: Ap-
plications to Practice. 3rd ed. Prentice Hall; 2009.
24. Davenport TE, Kulig K, Matharu Y, Blanco CE. The edurep model
for nonsurgical management of tendinopathy. Phys Ther. 2005;
85(10):1093–1103. PubMed ID: 16180958 doi:10.1093/ptj/85.10.
1093
25. Chimenti RL, Flemister AS, Tome J, McMahon JM, Houck JR.
Patients with insertional Achilles tendinopathy exhibit differences in
ankle biomechanics as opposed to strength and range of motion. J
Orthop Sports Phys Ther. 2016;46(12):1051–1060. PubMed ID:
27796197 doi:10.2519/jospt.2016.6462
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