Deviating Running Kinematics and Hamstring Injury Susceptibility in Male Soccer Players: Cause or Consequence?

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Deviating running kinematics and hamstring injury susceptibility in male


soccer players: Cause or consequence?

Article  in  Gait & Posture · June 2017


DOI: 10.1016/j.gaitpost.2017.06.268

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Gait & Posture 57 (2017) 270–277

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Full length article

Deviating running kinematics and hamstring injury susceptibility in male MARK


soccer players: Cause or consequence?

Joke Schuermans , Damien Van Tiggelen, Tanneke Palmans, Lieven Danneels, Erik Witvrouw
Department of Rehabilitation Sciences and Physiotherapy Ghent, Ghent University, Ghent, Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Although the vast majority of hamstring injuries in male soccer are sustained during high speed
Hamstring injury running, the association between sprinting kinematics and hamstring injury vulnerability has never been in-
Aetiology vestigated prospectively in a cohort at risk.
Soccer Purpose: This study aimed to objectify the importance of lower limb and trunk kinematics during full sprint in
3D kinematics
hamstring injury susceptibility.
Sprinting coordination
Study design: Cohort study; level of evidence, 2.
Acceleration
Methods: At the end of the 2013 soccer season, three-dimensional kinematic data of the lower limb and trunk
were collected during sprinting in a cohort consisting of 30 soccer players with a recent history of hamstring
injury and 30 matched controls. Subsequently, a 1.5 season follow up was conducted for (re)injury registry.
Ultimately, joint and segment motion patterns were submitted to retro- and prospective statistical curve analyses
for injury risk prediction.
Results: Statistical analysis revealed that index injury occurrence was associated with higher levels of anterior
pelvic tilting and thoracic side bending throughout the airborne (swing) phases of sprinting, whereas no kine-
matic differences during running were found when comparing players with a recent hamstring injury history
with their matched controls.
Conclusion: Deficient core stability, enabling excessive pelvis and trunk motion during swing, probably increases
the primary injury risk. Although sprinting encompasses a relative risk of hamstring muscle failure in every
athlete, running coordination demonstrated to be essential in hamstring injury prevention.

1. Introduction -metabolic features, as well as neuro-dynamics and stretch tolerance


have been investigated in relation to hamstring injury vulnerability
Hamstring injuries are the single most frequent non-contact muscle [1–3,10,12]. In addition, because of the functional integrity of lower
injury in male soccer [1–3]. The vast majority of those occur during limbs and the lumbopelvic complex, joint mobility of the spine and
high speed running, where the muscle fails structurally or functionally lower limb as well as multiple other factors responsible for functional
[4], due to repetitive intense eccentric loading throughout the front- lumbopelvic control (postural control, coordination, strength, etc.) are
and (early) stance phases of the running cycle [5–9]. Because the me- thought to be crucial in rehabilitation and prevention [1,13–19].
chanical and metabolic demands imposed upon the hamstring unit Nonetheless, these potential hamstring injury correlates have only
during running acceleration are even more intense than is the case for rarely been scrutinized during explosive acceleration for full speed
constant speed sprinting, this posterior thigh unit is at highest risk of sprinting, during which the hamstring is at highest risk of injury
injury during explosive acceleration towards full speed sprint. Sufficient [20,21]. High amounts of negative work and tensile strain are in-
acceleration capacity and adequate starting speed are key motor com- herently present in acceleration and high speed running. Why some
ponents in soccer performance, necessitating optimal hamstring func- players manage to keep their hamstrings in optimal shape and others
tion. In trying to identify intrinsic risk factors for adequate injury pre- sustain (recurring) muscle injuries throughout those repeated sprint
vention, rehabilitation, and safe return to play, existing research tends (-acceleration)s, is a capital question that needs to be resolved in order
to be restricted to the investigation of functional and structural regional to adequately and sport specifically prevent these types of high speed
neuromuscular characteristics in resting state conditions [2,3,8,10,11]. running injuries. Besides, although lumbopelvic control training or
Among others, muscle strength and flexibility, morphologic and ‘core stability’ training has proven to be highly valuable in


Corresponding author at: Department of Rehabilitation Sciences and Physiotherapy, Ghent University, De Pintelaan 185, 3B3, 9000 Ghent, Belgium.
E-mail address: Joke.schuermans@ugent.be (J. Schuermans).

http://dx.doi.org/10.1016/j.gaitpost.2017.06.268
Received 9 August 2016; Received in revised form 16 June 2017; Accepted 26 June 2017
0966-6362/ © 2017 Elsevier B.V. All rights reserved.
J. Schuermans et al. Gait & Posture 57 (2017) 270–277

rehabilitation outcome and secondary injury prevention [15,22–29], its region during soccer participation or during the running protocol in this
exact role in the athlete’s primary injury vulnerability and its influence study.
on muscle mechanics during running and kicking, remains unclear.
After the example of Kibler et al., we define ‘core stability’ as ‘the 2.2. Testing procedure
ability to control the position and motion of the trunk and the pelvis to
allow optimum production, transfer and control of force and motion to All participants were informed about the content and the purpose of
the terminal segment in integrated athletic activities’ [30]. This implies the testing procedure and signed the Informed Consent, after which
a fairly broad functional interpretation, in which both the kinematic they were familiarized with the running protocol and the course of the
and kinetic features that add up to a controlled and coordinated gui- three-dimensional (3D) motion analysis. This information was con-
dance of the body center of mass throughout integrated activities, as sistently provided by the same qualified researcher (JS), who was in
there is running, are embedded. Because (high speed) running parti- charge of the entire testing procedure (participant preparation, data
cularly implies providing the body center of mass with acceleration and assembly and -processing) as well, which minimized the risk of inter-
velocity to achieve a fast horizontal displacement through horizontal tester bias. This study was approved by the Ethics Committee of the
force production, the functional integrity of the core is especially im- Ghent University Hospital (number of approval: EC/2013/118).
portant as regards the economy, sustainability and safety of running In order to get a valid impression of the participant’s running co-
and sprinting performances. Bearing in mind the evidence behind the ordination throughout acceleration towards full speed sprinting,
hamstring injury mechanism [8,9], it would seem merely logical that without bias of fatigue or muscle soreness, subjects were instructed not
running technique and the associated biomechanical features, as there to engage in intensive training or soccer competition 48 h prior to
is sufficient functional control of proximal lumbopelvic unit (containing testing.
the body center of mass), within the (high speed) running cycle could After testing, participants were informed about the online diary
be of substantial influence in the risk of sustaining a hamstring injury. which was put together for the purpose of injury registration during
The biomechanics of running have been subject of study repeatedly. follow up (http://www.hsi.ugent.be). This online survey contained
Strikingly however, high speed running kinematics have never been questions about weekly exposure (match and training) and the in-
investigated in direct association with hamstring injury occurrence. cidence/presence of soccer related injuries and complaints. The parti-
Therefore, this study intended to investigate the association between cipants were asked to complete this survey every Monday throughout
lower limb and trunk kinematics throughout maximal acceleration to- the entire 2013–2014 season, as well as the first half of the 2014–2015
wards full speed sprinting and hamstring injury susceptibility in a season, accounting for a follow up period of one entire and one half of a
sample at risk (male soccer players). This association was explored both soccer season.
retro- and prospectively, to allow strict differentiation between possible Follow up was terminated at the winter break of the 2014–2015
kinematical causes and consequences of hamstring injury. Although season, during which period all participants were contacted again for
both trunk and lower limb kinematics were taken into account, our final injury inquiry.
focus was particularly directed towards trunk- and pelvis function to
explore a possible association between running related hamstring injury 2.3. Three-dimensional kinematic testing protocol
risk and ‘core stability’.
When indicating having understood the content and course of the
2. Materials and methods testing procedure, participants were instructed to undress, wearing only
a pair of tight shorts and indoor soccer shoes. Afterwards, 40 passive
2.1. Participants infrared reflective markers (12 mm lightweight markers, Qualisys AB,
Sweden) were attached in accordance with the LJMU Lower limb and
Throughout the second half of the 2013 soccer season, 30 soccer Trunk Model for motion analysis (Van Renterghem J., Liverpool John
players with a recent history (last injury sustained within the past Moores University), representing respective bony landmarks and seg-
season or the prior one (past 24 months)) and 30 matched controls, all ment clusters (Fig. 1(a)). The kinematic analysis of the linear accel-
active in the same amateur competition series (Oost-Vlaanderen, eration to full speed sprinting was conducted on a 40 m (m) running
Belgium), were recruited. Players were excluded if they had track, which was surrounded by 8 cameras for 3D motion capturing
(Oqus, Qualisys AB, Göteborg, Sweden). These cameras were installed
– a history of severe lower limb injury, which could have influenced between meter 15 and 25 of the running track (resulting in a kinematic
kinematics measuring volume of 10 m), as this is the average distance over which
– a history of lower back complaints/lower back complaints at pre- maximal acceleration is achieved in attempting to reach maximal
sent, which could bias the intrinsic risk profile running speed (Fig. 1(b)) [31]. All reflective markers were attached to
– less than 5 years of competitive soccer experience, as this could the skin firmly by using double sided carpet tape, to prevent them from
induce selection bias coming loose or falling off. The entire 3D data assembly of the

To exclude age related pathologies, soccer players aged beneath 18


or above 35 years were excluded from the study as well. All participants
were completely free from injury and ready to play at the moment of
testing.
A hamstring injury was defined as a soccer related injury in the
hamstring muscle region, preventing the player from participating in
training or competition for at least one entire week. The majority of
respective hamstring injuries within the injury group was diagnosed
clinically, with or without enclosed medical imaging (depending on the
decision of the medical staff). Actual recruitment and inclusion of for-
merly injured participants was mainly based on self-report, as we were
not able to get in touch with all physicians and physiotherapists in- Fig. 1. (a) Static – and tracking marker placement; Functional joint capture protocol of
volved in prior diagnosis and rehabilitation. At the time of testing, none the left knee; (b) 40 m sprinting track with [10*2]m 3D measuring volume in between the
of the players experienced any pain or discomfort in the hamstring step detection bars of the Optogait system.

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J. Schuermans et al. Gait & Posture 57 (2017) 270–277

acceleration phase in sprinting was carried out by the Qualisys Track the entire kinematic profile instead of the commonly used peak – or
Manager hard- and software systems. A 10 m Optogait system (Micro- mean amplitude comparison which only takes into account one or a
gate, Bolzano-Bozen, Italy) was used for step detection, as we wanted to couple of point estimates, irrespective of time. For more detail on the
perform kinematic analysis of one entire stride this would have been indications and benefits related to the use of SPM in biomechanical
impossible using a force plate. First, one static trial and 4 functional research, we refer the reader to previously published works of reference
joint trials (left and right knee and hip joints) were recorded to create a [32,33].
virtual model. Subsequently, 8 markers were removed (left and right Specifically, joint- and segment angle profiles were compared be-
acromion, greater Trochanters, left and right medial epicondyles of the tween groups, using SPM two-tailed independent t-tests. Firstly, the
knee joint and left and right medial malleolus at ankle level) as these SPM{t} statistic was calculated at each data point within a given time
were not necessary for motion capture (Fig. 1(a)). Hereafter, the par- frame (front swing, stance or backswing), then statistical inference was
ticipant was instructed to perform a 5 min warm up by running up and examined based on the behaviour of random curves with the same
down the running track at a self-chosen pace, alternated with short temporal smoothness. Besides taking into account the essential time-
sprint-intervals, as if they would perform starting speed drills. dependency of kinematic data behaviour, another advantage of using
After warm up, each participant was instructed to sprint up the SPM is that it provides better control of type I and type II statistical
track over a distance of (at least) 30m, trying to reach maximal error [34], enabling more valid risk estimation.
sprinting speed as soon as one could. 3D data collection and step de- For the SPM analysis within Matlab, α was set at 0.05. All statistical
tection were conducted simultaneously throughout the 10 m measuring analyses within the scope of this study were implemented using the
volume (meter 15–meter 25), as both software systems were synchro- open-source SPM1D code (http://spm1d.org).
nised within the QTM interface (Qualisys Track Manager). Every soccer
player had to perform 12 maximal sprints, because a minimum of six
3. Results
left – and six right side strides was needed for post hoc data processing
and analysis within the Visual 3D interface (Visual 3D v5 Professional,
We assessed the possible association between (deviant) sprinting
C-Motion Research Biomechanics, Germantown, USA). A sprinting trial
kinematics and hamstring injury vulnerability with strict differentiation
could only be taken along for data analysis when it consisted of three
as regards kinematical cause or consequences of increased injury risk.
full stance phases within the measuring volume.
To do so, we performed both baseline statistics within the entire cohort
(kinematic consequences of previous hamstring injury?), and pro-
2.4. Data analysis
spective statistical analysis within a cohort consisting of only those that
reported never having sustained a hamstring injury at initial intake
For each participant, a virtual model was created according to his
(kinematical cause of hamstring injury?). Average age, height and
specific anthropometric features, on the basis of which 3D segment
weight within the group of players with an injury history was 24.7
coordinates and joint angles could be calculated throughout an entire
( ± 3.4) years, 1.80 ( ± 0.06) m and 75.2 ( ± 6.8) kg. This was 23.7
stride. To serve this purpose, the static-, functional joint- and sprinting
( ± 4.5) years, 1.81 ( ± 0.05) m and 74.4 ( ± 7.1) kg within the group
trials were labelled within the QTM interface (marker identification).
of matched controls.
Afterwards, sprinting trials were divided into swing- and stance phases
Of the 30 healthy controls submitted to the 3D sprinting analysis,
using 4 events: left toe off, right touch down, right toe off and left touch
only 1 was lost to follow up. As mentioned above, mostly to prevent a
down in the left stride trials; right toe off, left touch down, left toe off
biasing influence of injury history and to validly verify to what extent
and right touch down in the right stride trials. Labelled trials were
running kinematics effectively influence hamstring loading by means of
exported to the ‘C3D’ format, after which they could be imported in
injury vulnerability, only the data of this group (original control group)
Visual 3D (V3D, C-Motion Inc., USA) to quantify joint kinematics in the
were included for prospective analysis. Within this original control
ankle-, knee- and hip joints, as well as segment kinematics for the pelvis
group (n = 29), 4 players sustained an index injury, resulting in an
and the thorax. For each phase (front-swing, stance and backswing),
(index) injury incidence of 13.8% during the 1.5 season follow up.
kinematic data were normalized to 101 data frames, enabling in-be-
Details on study course are illustrated in Fig. 2.
tween-subject comparison. Ultimately, kinematics were prepared for
Because we wanted to compare the trunk- and lower limb kine-
statistical analysis by subcategorizing all processed data into excel files
matics during full acceleration based on the presence of an injury his-
in function of
tory or the incidence of a hamstring injury during our 1.5 season follow
up period, without leg dominance being a biasing covariate, we verified
– phase: “front swing”, “stance” or “backswing”
the ratio of dominant/non-dominant leg involvement both retro- and
– group: “Injury History” or “Control” for the retrospective analysis;
prospectively in the injury groups, and randomly elected the same ratio
“Injury” or “Control” for the prospective analysis
in the control groups.
– joint (or segment), and
– plane (Sagittal, X; Coronal, Y; Transverse, Z).
3.1. Retrospective analysis: hamstring injury history and running
2.5. Statistical analysis kinematics?

For every joint- and segment angle, the entire kinematic curve Comparing the three-dimensional joint angles of the ankle-, knee-
throughout each of the three phases was submitted to both retro- and and hip complexes (i.e. the angles between adjacent segments) as well
prospective in between group comparison based on the presence or as the segment angles of pelvis and thorax in reference to the global
absence of injury history on one hand and injury incidence during laboratory (i.e. the position of participant’s pelvis and the thorax re-
follow-up on the other. Curve analysis was conducted using Statistical lative to the testing environment) during front swing-, stance- and
Parametric Mapping (SPM, version M.03) in Matlab (R2014a, The backswing phases of full acceleration between the 30 participants with
Mathworks Inc, Natick, MA). This method retrieves results on statistical a recent hamstring injury history and the same amount of healthy
inference, based on the Random Field Theory. Whilst commonly used controls, no significant in between group differences could be demon-
for the analysis of functional brain images it is becoming commonplace strated. The ankle-, knee-, hip-, pelvis- and thorax kinematics in the
in biomechanical data analysis as well [32,33]. Using the mean joint- or coronal, sagittal and transverse planes did not present significant dif-
segment angle and its corresponding standard deviation at each of the ferences based on the presence or absence of a history of hamstring
101 data frames within one phase, it allows statistical comparison of injuries.

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J. Schuermans et al. Gait & Posture 57 (2017) 270–277

Fig. 2. Flowchart study trajectory.

3.2. Prospective analysis: running kinematics and hamstring injury kinematics for hamstring injury risk detection prospectively, however,
susceptibility during follow up? demonstrated significant biomechanical differences in trunk- and pelvis
kinematics between the participants that sustained a (first) hamstring
Assessing the kinematic curves of the soccer players that sustained a injury during follow up and those who did not. Index hamstring injury
first time hamstring injury during follow up (n = 4) in reference to the occurrence was associated with significantly more anterior pelvic tilting
healthy controls (n = 25), statistical parametric mapping revealed and thoracic side-bending during the back- and front swing phases of
significant differences in pelvis – and thorax motion patterns. In par- acceleration, respectively. Hip-, knee-, nor ankle kinematics, presented
ticular, players that sustained a hamstring injury presented sub- a prospective association with hamstring injury occurrence.
stantially more anterior pelvis tilt throughout the entire stride, with a Similar to the results of the retrospective biomechanical research of
statistically significant difference during the backswing phase Lee et al. [25], we found no association in between previous hamstring
(p = 0.0445), compared to the healthy controls (Figs. 3 and 4). injury and any of the kinematic features in the trunk nor the lower limb.
Moreover, the index injury group presented significantly more thoracic They did not include a control group and just compared the kinematic
side bending throughout the front-swing phase, compared to the behaviour of the previously injured limb with the contralateral side. We
healthy controls (p = 0.028) (Figs. 3 and 5, ). Additionally, thoraco- did include healthy controls but found no differences in kinematic
pelvic kinematics of the participants that sustained a first time ham- patterns when comparing theirs with the ones of the formerly injured
string injury appeared to be less stable throughout the entire running participants. Nonetheless, original hamstring injury susceptibility
stride, displaying more fluctuations and discontinuity, compared to the might just very well be influenced by running technique. Opposite to
quite neutral thoraco-pelvic motion pattern demonstrated by the our retrospective findings and those of Lee et al., the recent study re-
healthy controls (Fig. 3). sults of Daly et al. [36] did reveal a possible association in between
previous injury and running kinematics. In their cohort of Gaelic foot-
ball players (9 with previous hamstring injury and 9 controls) presented
4. Discussion increased amounts of hip flexion, anterior pelvic tilt and external tibia
rotation throughout the front swing an early stance phases of the gait
In this study, the association between lower limb and trunk kine- cycle in running, compared to the healthy controls. We cannot compare
matics during maximal acceleration to full speed sprinting, and ham- our study results with theirs unfortunately, as they assessed steady
string injuries was assessed both retro- and prospectively in male soccer treadmill running instead of over-ground sprinting acceleration (should
players. Comparison of the running kinematics of the participants with imply lower amounts of anterior pelvic tilting due to smaller strides and
a recent history of hamstring injuries and their matched controls, re- more forward trunk lean compared to constant speed running) and used
vealed no in between group differences for any of the joints, planes or completely different methods of statistical analysis (discrete measure
phases throughout the captured stride. Assessing the running

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J. Schuermans et al. Gait & Posture 57 (2017) 270–277

Fig. 3. (a) Sagittal plane pelvis kinematics throughout different running phases in full acceleration – Control versus Index Injury, displaying significantly more anterior tilting at the end
of backswing – p = 0.045; (b) Side bending kinematics throughout different running phases in full acceleration – Control versus Index Injury, displaying significantly more side-bending
throughout front swing – p = 0.028.

Fig. 4. (a) Controls versus (b) Index Injuries: Sagittal plane Pelvis-Lab
segment Angle in late Front swing phase (taking into account the back-
swing of the left leg in the control group, and the right left in the injury
group).

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J. Schuermans et al. Gait & Posture 57 (2017) 270–277

Fig. 5. (c) Controls versus (d) Index Injuries: Coronal plane Pelvis-Thorax
Angle in late Front swing phase (taking into account the front swing of the
left leg in the control group, and the right left in the injury group).

comparison instead of looking at the overall kinematical behaviour pelvis and hip joints during the swing phase of running, warranting
throughout the gait cycle in running). proper ground contact for forceful propulsion, is of capital importance
As concerns our prospective findings, in particular trunk and pelvis in running performance [2,8,39]. Indeed, as functional kinetic chain
kinematics, presented to be associated with the risk of sustaining a integrity throughout the swing phases is key for the safety and the
hamstring injury, contrary to lower limb motion patterns. As respective adequacy of subsequent touch down and propulsion, poor control in the
increments in sagittal and coronal plane movement of the core-region proximal core might induce both an increased injury risk and weaker
(trunk and pelvis) were also associated with more variability within the acceleration capacity/running economy. Next to exerting excessive
kinematic trajectory over the course of the airborne phase, our findings tensile strain on the (posterior) thigh muscles [31], reduced proximal
might suggest that players appearing to be more vulnerable for ham- control could also imply higher loading of the bi-articular thigh mus-
string injury, suffer from lacking proximal control and insufficient cles, in an attempt to increase kinematic efficacy throughout both the
dissociative capacity within the lumbo-pelvic-hip complex. As such, swing- and stance phases [13,14,35]. Interestingly, predominantly the
these kinematic alterations might imply that the kinematic quality of airborne phase was observed to be subject to a lack of proximal control.
the core and the ability to dissociate lower limb movement (hip-ex- Certainly in high speed running, where the airborne phase (flight time)
tension and -flexion) from compensatory contribution of the trunk and represents up to 80% of the entire stride time [2,8,39], adequate core
pelvis, is essential in primary hamstring injury prevention. Certainly stability seems to be important in (primary) hamstring injury preven-
given the fact that the increments in anterior tilting were particularly tion. Several authors have investigated the relation between core sta-
objectified during the backswing phase of running, where pelvic control bility and hamstring injuries in soccer, however, mainly indirectly and
is challenged the most, as sufficient hip extension is needed for pro- in association with the efficacy of rehabilitation (association between
pulsion. Because these kinematical differences in pelvis- and trunk exercise protocol allocation, time to return-to-play (RTP) and sub-
compartments were specifically found in the index injury group, we sequent injury recurrence without investigating actual core function)
believe that these kinematic characteristics fundamentally contribute to [15,19,22,23,40]. Accordingly, Sherry and colleagues compared the
a less safe running pattern, making the running athlete more prone to effectiveness of a rehabilitation protocol consisting of isolated ham-
sustaining (repeated) hamstring injuries, when not recognized and string stretch and strengthening exercises with the one of integrated
corrected. kinetic chain training including core stability and agility exercises
Although suggested to be key in sports injury prevention [40,41]. They found the recurrence rates and the time to RTP to be
[1,3,15,22,23,26,27,29,37], the actual scientific background of the significantly lower in players allocated to the core stability training
functional integrity of the core (trunk and pelvis) has not been objec- protocol. Yet, they did not measure core function nor functional co-
tified in a sport- and injury specific research setting. The present study ordination so the direct link with hamstring injury susceptibility could
is the first giving rise to actual scientific evidence concerning the im- not be deducted. In contrast, Silder and colleagues found no significant
portance of functional control of the proximal lumbo-pelvic unit (‘core differences in clinical presentation, functional performance or medical
stability’)in injury prevention. Adequate control in the lower back, imaging at time to RTP between players [19] allocated to a “Progressive

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J. Schuermans et al. Gait & Posture 57 (2017) 270–277

Agility and Trunk Stability” training group and those submitted to a control for both type 1 and type 2 errors, associated risk is limited as
“Progressive Running and eccentric Strength” training group. Un- well [34]. Second, we did not have medical records of the injury history
fortunately, similar to the before mentioned study, this study did not of the participants that entered this study, nor did we have any medical
include measures of core muscle strength capacity either nor did they documentation on the injuries sustained during follow up (physician’s
include a control group that did not receive a customized rehabilitation report, records of medical imaging). Therefore, we were reliant on the
protocol. Assuming them to have a beneficial influence, many other participant’s reporting and study compliance, which might have in-
interventional studies incorporated core stability exercises in their duced a certain degree of recall bias. Moreover and because of the same
(secondary) prevention protocols as well [1,3,15,22,23,42,43,26,38]. reason, we decided not to take along information on the exact location
However, it is impossible to compare or link our study results and of the lesion (muscle belly, distance from the ischial tuberosity and
possible clinical implications to this kind of retrospective interventional tissue involvement (muscle-tendon ratio)). Adding those covariates to
studies, as both research hypothesis and statistical approaches differ the analysis, might have yielded towards more detailed and possibly
substantially. Indeed, due to differing or poor methodological design somewhat different insights in the running related hamstring injury
and lack of participant compliance, the exact influence of incorporating risk. The strength of this study is however that it is the first study that
functional and isolated core training in (secondary) injury prevention, investigated the association between running coordination and ham-
remains unknown [3,15,22,23,26,42,43]. In particular, the evidence to string injury risk in male soccer players. More so, in performing both
validly link functional core stability with running related hamstring retro- and prospective analyses, it enabled differentiation as regards the
injury susceptibility is non-existing to date. direction of the association between running kinematics and hamstring
Interestingly, previous research also demonstrated that the magni- injury risk, which appeared to be the cause rather than the consequence
tude of anterior pelvic tilting is highly correlated with the amount of of hamstring injury vulnerability in our cohort.
lumbar lordosis and hip-extension range of motion during backswing
[42]. Franz and colleagues suggest that the increase in anterior pelvic 5. Conclusion
tilt with increasing running velocity is predominantly due to increases
in lumbar lordosis and trunk kinematics, as they found no statistical Surprisingly, this was the first study to relate lower limb and trunk
differences in hip extension range of motion with increasing running kinematics during sprinting to (primary) hamstring injury risk. Our
speed. More so, they could demonstrate that running athletes presented findings indicate that running coordination might actually be highly
higher anterior tilting amplitudes, when hip extension range of motion associated with the risk of sustaining a hamstring injury. Lacking con-
during stance and backswing was decreased. Albeit not related to soccer trol of the lumbopelvic unit (core stability), presented by excessive
or hamstring injury susceptibility in their observational study, the au- pelvis and trunk motion during the swing phases of running is related to
thors pointed out the importance of lumbar spine and hip kinematics in the primary injury risk. Therefore, assessing and addressing sprinting
lower back and hamstring injury vulnerability. Because the hamstrings, kinematics/running technique seem to be indispensable in primary
particularly the long head of the Biceps Femoris, originate on the sciatic hamstring injury prevention. Clinicians should acknowledge the im-
tuberosity and its stabilizing ligamentous structures, hamstring function portance of proper running technique in muscle injury rehabilitation
depends on pelvic posture and kinematics, just as much as lumbopelvic and prevention in soccer, in which a bilaterally symmetrical, decently
function is reliant on hamstring features and function (flexibility, angle aligned running technique should be aspired, with adequate proximal
of optimal force output etc.) [6]. Another study investigated the effects neuromuscular control.
of intentionally inducing forward trunk lean throughout sprinting
versus regular sprinting in a sample of eight healthy male sprinters Conflict of interest
[31]. Their results indicate that both the amount of hamstring muscle
stretch and the lengthening velocity significantly increased when All authors – Joke Schuermans, Damien Van Tiggelen, Tanneke
adopting a forward lean in running. As intentional forward trunk lean Palmans, Lieven Danneels and Erik Witvrouw – declare to have no
induces more anterior pelvic tilt as well, these could possibly explain conflicts of interest regarding the scientific content of the paper nor
why the players presenting an increased pelvic tilt, were subject of regarding the sources of funding. All authors explicitly disclose not to
hamstring muscle failure during follow up in our study. have any financial or personal relationships with other people or or-
Although repeatedly suggested to be of potential importance for the ganizations, that could inappropriately influence the present work.
prevention of lower limb injuries, our findings confirm the association
between core kinematics/control and hamstring injury risk. In order to Acknowledgements
get an even better insight in this interplay, future research should at-
tempt an integrated investigation of lower limb and trunk kinematics, The authors gratefully acknowledge the assistance of their collea-
surface electromyography (sEMG) and muscle mechanics. Interestingly, gues at the department of Rehabilitation Sciences and Physiotherapy in
our research group recently published a study looking at the muscle Ghent (Belgium), as well as the staff members of Bloso, Topsporthal
activation patterns during the exact same sprinting acceleration test Vlaanderen (Belgium). In particular Steven Heyndrickx, for his assis-
protocol. In very close coherence with the findings of this kinematic tance during the installation of the running track with surrounding
study, it was established that lower amounts of normalized EMG ac- measuring systems, as well as for the assembly of the online diary for
tivity of the trunk muscles and the gluteus maximus during the airborne injury registration during follow up and the post hoc data processing.
phase of running, were associated with a greater hamstring injury oc- Additionally, sincere appreciation goes out to Jos Vanrenterghem
currence during follow up [44]. How these valuable scientific data (Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven,
might be translated into more adequate primary injury prevention Leuven, Belgium), Mark van (School of Sport and Exercise Sciences,
strategies, is yet to be determined. LJMU, Liverpool, United Kingdom) and Todd Pataky (Shinshu
University, Dept. Bioengineering, Matsumoto, Nagano, Japan), for their
4.1. Limitations support during the SPM analyses. Their sincere appreciation is also
oriented towards the participants of this study, without whom this
There were some limitations to this study. First, we must bear in paper could not have been accomplished. For their financial support,
mind that the sample size for prospective statistical analysis was small. our gratitude goes out to the Agency for Innovation by Science and
This might have compromised the potential predictive validity of the Technology in Flanders (IWT – Brussels, Belgium). All authors declare
kinematic outcome measures. However, as the statistical procedures to have no conflicts of interest regarding the scientific content of the
(Statistical Parametric Mapping) attributed within this study, strongly paper nor regarding the sources of funding.

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