Athletic Training and Sports Health Care

Original Research 

Preliminary Findings of Lower Extremity Injury Risk Categorization Through Lumbopelvic-Hip Endurance Screening of High School Basketball Players

Hillary A. Plummer, PhD, ATC; Gary B. Wilkerson, EdD, ATC, FNATA; Jeremy R. Bruce, MD; Richard J. Lamour, MD; Roger V. Ostrander III, MD

Abstract

Purpose:

To determine if three lumbopelvic-hip endurance tests can identify basketball players at risk for lower extremity injury.

Methods:

High school basketball players (n = 150) volunteered. The unilateral wall sit hold, trunk flexion hold, and horizontal trunk hold tests were administered prior to the season. Non-contact lower extremity injuries were tracked.

Results:

Players with wall sit hold times of 35 seconds or less had 2.6 times greater odds for occurrence of a lower extremity injury than those with hold times of longer than 35 seconds (90% confidence interval [CI]: 1.05 to 7.98). Females with wall sit times of 35 seconds or less were 2.75 times more likely to suffer a lower extremity injury than females with times of longer than 35 seconds (90% CI: 0.78 to 9.72). Males with wall sit hold times of 32 seconds or less had 2.38 times greater odds to sustain an injury compared to males with longer hold times (90% CI: 0.56 to 10.14). The horizontal trunk flexion hold and trunk flexion hold tests did not identify players at risk for injury.

Conclusions:

The wall sit hold identified participants with elevated risk for lower extremity injury during a basketball season. Participants at higher risk had shorter wall sit hold times.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Abstract

Purpose:

To determine if three lumbopelvic-hip endurance tests can identify basketball players at risk for lower extremity injury.

Methods:

High school basketball players (n = 150) volunteered. The unilateral wall sit hold, trunk flexion hold, and horizontal trunk hold tests were administered prior to the season. Non-contact lower extremity injuries were tracked.

Results:

Players with wall sit hold times of 35 seconds or less had 2.6 times greater odds for occurrence of a lower extremity injury than those with hold times of longer than 35 seconds (90% confidence interval [CI]: 1.05 to 7.98). Females with wall sit times of 35 seconds or less were 2.75 times more likely to suffer a lower extremity injury than females with times of longer than 35 seconds (90% CI: 0.78 to 9.72). Males with wall sit hold times of 32 seconds or less had 2.38 times greater odds to sustain an injury compared to males with longer hold times (90% CI: 0.56 to 10.14). The horizontal trunk flexion hold and trunk flexion hold tests did not identify players at risk for injury.

Conclusions:

The wall sit hold identified participants with elevated risk for lower extremity injury during a basketball season. Participants at higher risk had shorter wall sit hold times.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Approximately 1 million students per year play basketball at the high school level, making it one of the most popular sports in the United States.1 Lower extremity injuries are prevalent among basketball players, and they can have a long-term impact on sport participation and performance capabilities.2–4 High physical demands are placed on the lower extremities during basketball training and competition. These high physical demands may explain the high incidence of ankle and knee injuries.2–4 McKay et al.2 reported an ankle injury rate of 3.85 per 1,000 athlete-exposures. Among Australian basketball players, 53.7% of time lost from participation was due to ankle injuries.5 Among adolescent male and female basketball players, ankle injuries accounted for 48% of all reported injuries and 15% of injuries involved the knee.6 Previous research has identified intrinsic and extrinsic factors that relate to lower extremity injury.7–10 More evidence is needed to identify individuals with potentially modifiable risk factors that might be addressed to reduce injury susceptibility.

The musculature of the lumbopelvic-hip complex provides stability to the hip and trunk segments. Poor endurance of the lumbopelvic-hip musculature may increase susceptibility to excessive hip adduction, femoral internal rotation, and knee valgus during dynamic activities, which may contribute to lower extremity injury.11 The contribution of lumbopelvic-hip complex endurance and strength as a risk factor for injury has been examined in competitive athletes.10,12–17 Collegiate football players with deficient lumbopelvic-hip endurance have been found to be two to four times more likely to suffer a lower extremity injury during the season.13,14 However, Leetun et al.12 reported that lateral and posterior lumbopelvic-hip endurance were not significant risk factors for lower extremity injury in collegiate basketball and track athletes. Sports medicine clinicians use preparticipation examinations to identify athletes with deficits in movement patterns, strength, range of motion, endurance, and balance that may elevate injury susceptibility. The ability of lumbopelvic-hip endurance screening tests to identify high school basketball players at risk for lower extremity injury has not been examined. The lack of research with this population of athletes makes it difficult to understand the possible role of lumbopelvic-hip endurance on their injury risk.

The mechanisms contributing to lower extremity injury occurrence are almost always multifactorial. A lack of scientific evidence identifying potential lumbopelvichip risk factors that lead to lower extremity injury among high school basketball players limits clinicians' efforts to prevent such injuries. If clinicians can quantify impairments such as lumbopelvic-hip endurance, high-risk athletes can be identified and targeted interventions can be implemented. Lumbopelvic-hip endurance exercises can easily be added to a preventive training program or team warm-up period before practice sessions. Previous literature supports reduction of lower extremity injury risk through the performance of lumbopelvic-hip strength exercised,18 and neuromuscular training activities.19–21 As more contributing risk factors are identified, clinicians will be able to develop improved interventions to modify specific deficiencies.

Screening tests that identify a subset of athletes who possess elevated injury risk would allow for clinicians to concentrate time and resources on the individuals who are likely to receive the greatest benefit.13,14,22 There is a need to determine whether or not suboptimal lumbopelvic-hip muscular endurance is associated with lower extremity injury occurrence among high school basketball players. This evidence would support the development of training activities that might reduce injury risk. The purpose of this study was to determine the utility of three lumbopelvichip endurance tests for identification of basketball players possessing elevated risk for non-contact lower extremity injury. The hypothesis was that decreased lumbopelvichip muscular endurance would be associated with lower extremity injury occurrence among high school basketball players.

Methods

Participants

Data were collected on 150 basketball players (age: 16.1 ± 1.1 years; height: 175.7 ± 10.7 cm; weight: 70.5 ± 14.0 kg) from ten local high schools. This sample included 75 male and 75 female basketball players. All players were screened as part of the preseason testing. This study was approved by the Baptist Hospital Pensacola institutional review board. Prior to data collection, all testing procedures were explained to each participant and their parent(s)/legal guardian(s) and informed consent and participant assent were obtained. All players were screened as part of the preseason testing. Participant data were included for those: (1) with freedom from any lower extremity, trunk, or head injury at the time of testing and (2) who were on the team roster for the entire competitive season. Participant data were excluded if any of the following criteria were met: (1) history of back surgery and (2) currently receiving treatment for an injury that could limit performance during testing.

Sample Size

The number of high school basketball programs in the immediate geographical area and the availability of trained personnel to administer the screening tests limited the estimated size of the potential cohort to approximately 150 to 200 athletes. The following sample size assumptions were made: (1) 15% to 20% injury incidence over the course of the basketball season, (2) equal numbers of athletes classified as exposed versus unexposed to a given injury risk factor, and (3) three times more injury occurrences among exposed athletes. Detection of a difference at a confidence level of 90% was estimated by a web-based calculator (Open Source Epidemiologic Statistics for Public Health, Version 3.01, http://www.openepi.com/SampleSize/SSCohort.htm) to require 148 athletes for a power level of 0.65 and 222 athletes for a power level of 0.80. An injury incidence of 15% within a cohort of 200 athletes or 20% among 150 athletes was considered a reasonable expectation to permit inclusion of at least three predictor variables in logistic regression analysis at a 10:1 event-to-variable ratio.

Examiners

Data collection occurred in each team's athletic training facility or basketball gymnasium. Athletic trainers and team physicians assessed performance on the three lumbopelvic-hip endurance measures defined below. The examiners were all members of the same organization providing outreach services to each of the high school basketball programs. All examiners had previous experience assessing the lumbopelvic-hip endurance tests performed in this study, but neither intra-rater or inter-rater reliability data were assessed. Prior to collecting data, participating clinicians reviewed the testing procedures by a study investigator. This review session involved practice implementation of the tests in which the study investigator provided verbal feedback to the clinician regarding testing protocols.

Procedures

The three lumbopelvic-hip endurance tests (unilateral wall sit hold, trunk flexion hold, and horizontal trunk hold) were assessed in each participant prior to the start of the season (Figure 1). Trained examiners in a station setting completed testing. Each participant was randomly assigned a station to begin and then rotated through the remaining stations.

Lumbopelvic-hip endurance screening tests. (A) Unilateral wall sit hold test position, (B) trunk flexion hold test position, and (C) horizontal trunk hold test position.

Figure 1.

Lumbopelvic-hip endurance screening tests. (A) Unilateral wall sit hold test position, (B) trunk flexion hold test position, and (C) horizontal trunk hold test position.

Unilateral Wall Sit Hold Test. The unilateral wall sit hold test has been shown to differentiate football players at risk for core and lower extremity sprains and strains.13 The methods described by Wilkerson and Colston13 were implemented. The participants then assumed a position of 90° of hip flexion and 90° of knee flexion with their trunk against the wall and their arms passively extended in a vertical position. Once this position was obtained, the participants lifted their non-dominant foot 2.54 cm so that their body was in single-leg support. A stopwatch was used to record the amount of time from foot lift off of the ground to the end of the test. Each trial had to meet the following criteria for the trial to be recorded: maintained a single-leg stance, stance foot remained flat and did not lift off the ground, and the non–weight-bearing foot did not touch the ground. The test was terminated when the participant could no longer maintain proper positioning or when the non–weight-bearing foot touched the ground. A stopwatch was used to record the amount of time from foot lift off of the ground to the end of the test. One trial was performed on each leg. The unilateral wall sit hold has excellent inter-rater reliability (intraclass correlation coefficient [ICC] = 0.89; 90% confidence interval [CI]: 0.73 to 0.96; minimal detectable change [MDC] = 16.03 seconds)23 and good intra-rater reliability (ICC (2,1) = 0.85; standard error of the mean [SEM] = 3.5 seconds) in healthy participants.13

Trunk Flexion Hold Test. The trunk flexion hold test was performed with the participant seated on the floor and the trunk at 45° of flexion, knees at 90° of flexion, elbows fully extended, and arms abducted to 90°.13 The feet and trunk were elevated off of the ground and only the pelvis/sacrum touched the ground during this test. The test was terminated when the participant could no longer maintain proper positioning or when any part of the legs/feet touched the ground. A stopwatch was used to record the amount of time from feet and trunk elevation to the end of the test. The trunk flexion hold test has excellent inter-rater reliability (ICC = 0.80; 90% CI: 0.54 to 0.92; MDC = 55.03 seconds).23

Horizontal Trunk Flexion Hold Test. The horizontal trunk flexion hold test was performed with the participants on their hands and knees. The feet were stabilized by a partner and participants then elevated their trunk to a horizontal position and abducted the fully extended arms to 90°. The trunk was positioned parallel to the floor and the hips and knees were at 90° of flexion. The palms of the hands faced forward and the thumbs were pointing upward. The test was terminated when the participant could no longer maintain proper horizontal trunk positioning or if the arms did not stay extended at 90° of abduction. A stopwatch was used to record the amount of time the participant could maintain proper positioning. The horizontal trunk flexion hold test has excellent inter-rater reliability (ICC = 0.89; 90% CI: 0.72 to 0.96; MDC = 58.76 seconds).23

Injury Tracking

All athletes who reported a lower extremity injury were examined and diagnosed by the team's sports medicine staff. Lower extremity injuries were defined as (1) occurred as a result of participating in basketball activities, (2) missed at least 1 day of practice or a game due to the injury, and (3) diagnosed as any non-contact lower extremity injury to a muscle, joint, ligament, tendon, or bone. Lower extremity injuries occurring outside of team-related events were excluded. After the season, a member of the sports medicine staff compiled lower extremity injury incidence data into a spreadsheet.

Statistical Analysis

Receiver operating characteristic (ROC) curve analysis was used to determine the cut-point that optimally discriminated between injured and uninjured participants for each of the three lumbopelvic-hip endurance tests. Variables that demonstrated ROC area under the curve greater than 0.50, a clearly discernible cut-point, and a resultant binary classification risk ratio (RR) of 1.50 or greater were included in a logistic regression analysis to determine their relative predictive power for lower extremity injury occurrence. A 90% confidence interval lower limit of greater than 1.0 for the adjusted odds ratio (OR) was the standard used for retention of a given variable in a multivariable prediction model. Corresponding likelihood ratios were also reported to represent the magnitude of change in odds associated with a positive test result (+LR) versus a negative test result (−LR), which permits decomposition of the discriminatory power of a test (OR = +LR/−LR). The procedures were repeated for stratified analyses of the data for male and female players. Independent t tests were performed to assess differences between sexes for the three lumbopelvic-hip test results. Statistical Package for Social Science software (version 22; SPSS, Inc., Chicago, IL) was used for data analyses.

Results

The inclusion criterion for uninjured status at the time of testing was not met by 2 potential participants and 3 players declined to participate. None of the 150 participants who were screened prior to the start of preseason practice sessions were lost to follow-up. Fourteen basketball players (9.3%) sustained a lower extremity injury (Table 1). The wall sit hold mean value was 43.7 ± 32.6 seconds for 136 uninjured players and 38.4 ± 28.2 seconds for 14 injured players. The 5.3-second difference exceeded the intra-rater standard error of measurement value of 3.5 seconds, but did not exceed 90% confidence for a true difference (1.645 × 3.5 = 5.8 seconds). A wall sit hold cut-point of 35 seconds or less demonstrated a 2.6 times difference in injury incidence between the resulting binary risk classifications, with sensitivity of 71% and specificity of 54% (Figure 2). The +LR value of 1.54 indicates an increase in odds for injury with wall sit hold test results of 35 seconds or less, whereas the −LR value of 0.53 indicates a decrease in odds for injury results greater than 35 seconds (Table 2).

Lower Extremity Injuries Sustained by Study Participants Over the Course of the Season

Table 1:

Lower Extremity Injuries Sustained by Study Participants Over the Course of the Season

Receiver operating characteristic curve for the wall sit hold test. Area under the curve = .542.

Figure 2.

Receiver operating characteristic curve for the wall sit hold test. Area under the curve = .542.

Results of Univariable Analysis of Wall Sit Hold Durationa

Table 2:

Results of Univariable Analysis of Wall Sit Hold Duration

The other two lumbopelvic-hip endurance tests did not demonstrate substantial discriminatory power with the male and female data combined. Because female players sustained 1.8 times (sensitivity = 64% and specificity = 52%) more injuries than male players (9 [12%] vs 5 [6.7%]; +LR = 1.33, −LR = 0.69, sex was included as binary exposure variable with wall sit hold time of 35 seconds or less in a logistic regression analysis. The multivariable adjusted OR for sex was lower than that of the univariable value (1.36 vs 1.91) and the lower limit of its confidence interval (0.63) was less than 1.0. Thus, the logistic regression analysis yielded a single-factor model with an OR of 2.90 and 90% CI lower limit of 1.05, which did not differ from that of the wall sit hold univariable results.

Analyses stratified by sex were performed to assess the possibility that it may have affected associations of lumbo-pelvic hip test results with injury occurrence (Table 3). Although ROC analyses demonstrated clearly discernible cut-points for each of the tests, the reduction in statistical power resulting from data stratification precluded logistic regression analysis for development of sex-specific multivariable prediction models. The results of univariable analyses of sex-specific cut-points for wall sit hold duration were 7 injuries (incidence 16.6%) for 35 seconds or less and 2 injuries (incidence 6.1%) for greater than 35 seconds (+LR = 1.47, −LR = 0.47, RR = 2.75 [90% CI: 0.78 to 9.72], OR = 3.10 [90% CI = 0.78 to 12.32]) for females and 3 injuries (incidence 10.3%) for 32 seconds or less and 2 injuries (incidence 4.4%) for greater than 32 seconds (+LR = 1.62, −LR = 0.64, RR = 2.38 [90% CI: 0.56 to 10.14], OR = 2.54 [90% CI: 0.54 to 12.03]) for males. Female players with a wall sit hold duration of 35 seconds or less had 2.75 times greater injury incidence than those with a duration of longer than 35 seconds (sensitivity = 78% and specificity = 47%) (Figure 3). Male players with a wall sit hold duration of 32 seconds or less had 2.38 times greater injury incidence compared to those with longer hold times (sensitivity = 60% and specificity = 63%).

Independent t Test Results for Comparison of Female vs Male Performance on Lumbopelvic-Hip Endurance Tests

Table 3:

Independent t Test Results for Comparison of Female vs Male Performance on Lumbopelvic-Hip Endurance Tests

Comparison of injury incidence for male and female participants with wall sit hold (WSH) times greater than 35 seconds and 35 seconds or less.

Figure 3.

Comparison of injury incidence for male and female participants with wall sit hold (WSH) times greater than 35 seconds and 35 seconds or less.

Discussion

The primary objective of this study was to assess the potential predictive value of lumbopelvic-hip endurance tests for identification of players possessing elevated risk for lower extremity injury. The results suggest that the unilateral wall sit hold test may identify basketball players with a higher risk of lower extremity injury over the course of a competitive season. Participants with wall sit times of 35 seconds or less were 2.6 times more likely to sustain a lower extremity injury. The relatively high sensitivity of the test (71%) and the −LR = 0.53 support the “SNOUT” concept (high sensitivity − negative rules out), which suggests that players with test results of less than 35 seconds are substantially less likely to be injured than those with test results of longer than 35 seconds. The data suggest the unilateral wall sit hold test may be a valuable test to include in preseason screenings of basketball players and could support individualized preventive training programs for players with deficits during this test.13,14,22 It is important to note that these findings are preliminary in nature and should be interpreted with caution.

Core stability requires lumbopelvic-hip muscle strength, endurance, and neuromuscular control.24,25 Fatigue resistance, strength, and neuromuscular control are highly interrelated because fatigue decreases muscle force output and impairs motor coordination.25,26 Although the relative importance of core muscle strength versus endurance has not been clearly established,11,27 both weakness and fatigue appear to increase susceptibility to core and lower extremity injuries.12,13,28 Preparticipation administration of timed posture hold muscle endurance tests has been shown to provide good discriminatory power for binary categorization of risk for core or lower extremity injury among college football players.13,14 Among high school basketball players, the wall sit hold test was able to differentiate individuals who subsequently sustained a lower extremity injury from those who avoided such an injury. Female high school basketball players sustained 1.8 times more injuries than male players. Females had 2.75 times greater injury incidence if the wall sit hold duration was 35 seconds or less, whereas male players had 2.38 times greater injury incidence if the hold duration was 32 seconds or less. Male basketball players were able to perform the wall sit hold tests an average of 9 seconds longer than females. This difference between male and female players was not statistically significant (P = .089), but it did exceed 90% confidence for a true difference (5.8 seconds). The wall sit hold test was the only test of core muscle endurance that required coactivation of the quadriceps, hamstrings, and gluteus maximus muscles to simultaneously resist flexion at both the knee and hip joints. The trunk flexion hold and horizontal trunk flexion hold test primarily challenge the trunk flexor and extensor musculature, respectively.

Interpretation of a test's discriminatory value must consider both sensitivity and specificity. Without risk screening, neither high-risk (0% sensitivity) nor low-risk (0% specificity) individuals can be identified. A preparticipation physical examination provides an opportunity to identify potentially modifiable injury risk factors that have not been previously recognized and properly addressed.29 The feasibility for administration of any risk screening test to a cohort of athletes is highly dependent on its ease of administration and rapid completion. The preparticipation examination components currently administered by most athletic programs does not include the collection of data that can be used to quantify an individual athlete's injury risk. Consequently, relatively few athletic programs employ a systematic procedure to individualize training regimens for remediation of specific modifiable risk factors. Implementing lumbopelvic-hip endurance screening tests is time-efficient, does not require specialized equipment, and requires little training for clinicians or coaches to administer. The Functional Movement Screen (FMS) is a widely used battery of seven tests that yield a movement quality score used by many clinicians to assess musculo-skeletal injury risk.30 A recent prospective cohort study of 257 college athletes (n = 176 males) related an FMS score of 15 or less to subsequent musculoskeletal injury occur-rence, which resulted in an OR of 1.51.31 Considering the substantially greater time efficiency for administration of the wall sit hold test compared to the FMS, the observed OR of 2.90 clearly supports its potential value as a highly efficient method for injury risk screening of both male and female high school basketball players.

There are several limitations to this pilot study. Due to time constraints during testing, only three lumbopelvic-hip endurance tests were assessed. The screening tests used did not directly measure lumbopelvic-hip strength or neuro-muscular control, which may also contribute to lower extremity injury avoidance. Previous lower extremity injury was not controlled for and is a major predictor for injury. This study did not account for team and individual training, rehabilitation, and injury prevention programs that may have occurred after the preseason testing session. Some participants may have improved their lumbopelvic-hip endurance with training as the season progressed. The much lower than expected injury incidence of only 9.3% (14 of 150) may have affected the precision of the sensitivity and specificity values. Typically, at least 15% to 20% of a high school basketball cohort will be injured during a season.32 Lower extremity injury occurrence was defined as a traumatic event that resulted in at least 1 day of lost basketball participation, which probably excluded all non-significant injuries of minor severity. Conversely, some cases of substantial pathology that did not result in any time loss may have been excluded from the analysis.

The available injury records maintained by the athletic trainers were not sufficiently detailed to be able to report specific pathology, injury grade, or amount of time loss beyond one day. Another limitation of this study was a lack of exposure documentation (number of practices and games) for each participant. Some participants were clearly exposed to greater risk for lower extremity injury on the basis of a greater amount of playing time in games compared to other participants, which could have had a confounding influence on the results. Such a confounding effect seems unlikely, because players with the greatest performance capabilities (eg, muscle endurance) are generally those who have greatest exposure to game conditions. Although the key finding of this preliminary study closely corresponds to the previously reported uni-lateral wall sit hold cut-point of 30 seconds or less as an optimal threshold for classification of injury risk among college football players,13 a much larger dataset that includes volume of exposure to game conditions is needed to confirm the predictive value of the test for injury risk categorization of high school basketball players. Future research should aim to control for exposure, training programs, and history of lower extremity injury.

Implications for Clinical Practice

The unilateral wall sit hold screening test appears to provide a useful screening method for identification of high school basketball players who possess elevated risk for lower extremity injury risk. A cut-off value of 35 seconds or less allows clinicians and coaches to identify basketball players who may derive greatest benefit from an injury risk reduction training program. The unilateral wall sit hold screening test cut-off value of 35 seconds or less may allow clinicians to identify basketball players who have an increased risk of lower extremity injury. Caution should be used when interpreting the results of this study because the screening tests used did not directly measure lumbopelvic-hip strength or neuromuscular control and basketball exposure was not monitored by the athletic trainers.

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Lower Extremity Injuries Sustained by Study Participants Over the Course of the Season

Lower Extremity InjuryFemale InjuriesMale InjuriesInjured Players
Knee ligament sprain426
Knee anterior cruciate ligament tear101
Achilles tendon strain101
Ankle sprain4a25
Ankle fracture011
Total10514

Results of Univariable Analysis of Wall Sit Hold Durationa

TimebInjuryNo InjuryIncidenceTotalc
≤ 35 s106313.7%+LR = 1.54
> 35 s4735.2%−LR = 0.53
Total14136

Independent t Test Results for Comparison of Female vs Male Performance on Lumbopelvic-Hip Endurance Tests

TestFemales (Mean ± SD)Males (Mean ± SD)DifferenceP
Wall sit holda38.7 ± 31.447.7 ± 32.49.0.089
Trunk flexion hold105.8 ± 87.7104.1 ± 70.01.7.902
Horizontal trunk hold91.1 ± 70.989.7 ± 60.31.4.896
Authors

From the Andrews Research & Education Foundation (HAP, RVO) and Andrews Institute for Orthopaedics & Sports Medicine (RVO), Gulf Breeze, Florida; the Graduate Athletic Training Program (GBW) and Orthopaedic Surgery (JRB), University of Tennessee at Chattanooga, Chattanooga, Tennessee; and Olympia Orthopaedic Associates, Olympia, Washington (RJL).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Hillary A. Plummer, PhD, ATC, Andrews Research & Education Foundation, 1020 Gulf Breeze Parkway, Gulf Breeze, FL 32566. E-mail: hillary. plummer@andrewsref.org

Received: September 20, 2018
Accepted: January 24, 2019
Posted Online: June 13, 2019

10.3928/19425864-20190507-01

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