
==== Front
Int J Sports Phys Ther
Int J Sports Phys Ther
2159
International Journal of Sports Physical Therapy
2159-2896
NASMI Website: International Journal of Sports Physical Therapy

38835979
117775
10.26603/001c.117775
Original Research
Effect of Sex and Lateral Ankle Sprain History on Dorsiflexion Range Of Motion Asymmetry During the Weight Bearing Lunge Test
Cady kathrine P 1 2
De Ste Croix Mark 2
Deighan Martine 2
1 Sports Therapy University of Hertfordshire https://ror.org/0267vjk41
2 Education and Applied Science University of Gloucestershire https://ror.org/00wygct11
Corresponding author: Kathrine Cady School of Life and Medical Sciences, University of Hertfordshire Institute of Sport, De Havilland Campus, Hatfield, Hertfordshire, AL10 9EU k.cady2@herts.ac.uk 07810440728
1 6 2024
2024
19 6 714723
9 11 2023
24 4 2024
© The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (4.0) which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

Reduced dorsiflexion range of motion (DFROM) which is commonly seen following lateral ankle sprain (LAS) has the potential to influence lower extremity biomechanics which have been linked to increased injury risk in the female athlete. Current research on the effect of sex and LAS history on DFROM is limited.

Hypothesis/Purpose

This study had three aims 1) to determine the effect of sex, leg dominance and LAS history on DFROM, 2) to determine the effect of sex and LAS history on magnitude of DFROM symmetry and 3) to examine the association of sex on direction (whether dominant or non-dominant limb had the higher DFROM) of symmetry.

Study Design

Cross-Sectional Study

Methods

DFROM was measured bilaterally in 105 recreational athletes all participating in multidirectional sports using the tape measurement method during the weight bearing lunge test (WBLT). A mean of three measurements was used for analysis. A 3-way mixed ANOVA was carried out to determine the interaction between sex, LAS history and leg dominance on DFROM and a 2-way ANOVA for the effect of sex and LAS history on asymmetry. A chi-square test was used to determine the association of sex and direction of asymmetry.

Results

The results indicate no significant effect of sex, LAS history, and leg dominance on DFROM (p=0.65). Main effects were significant for sex and LAS on DFROM. The mean asymmetry for all participants was reported as 12.25±14.76cm. No significant effect of sex and LAS history on magnitude of asymmetry was reported. There was a significant association of sex and direction of asymmetry (χ2(1) = 11.26, p = 0.00). Sixty-five-point two percent of males were shown to have higher DFROM of their non-dominant limb compared to 75% of females who were higher in their dominant limb.

Conclusion

Findings from this study suggest that DFROM is affected by sex and LAS history. While females have increased DFROM compared to males, those with LAS history are more likely to have a decreased DFROM on the involved side. The results also indicate that interlimb asymmetries in DFROM are present in athletes, therefore practitioners should exercise caution when using bilateral comparisons in injury and return to play assessments.

Level of Evidence

2b.

Dorsiflexion
lateral ankle sprain
weight bearing lunge test
asymmetry
sex differences
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pmcINTRODUCTION

It has been well documented that the female athlete is at an increased risk of sustaining knee injuries such as patellofemoral pain (PFP)1 and anterior cruciate ligament (ACL) ruptures.2,3 Currently, two biomechanical patterns have been linked to knee injury risk: dynamic knee valgus (DKV) (adduction and internal rotation of the hip, knee abduction and rotation of the tibia) and reduced knee flexion.2,4 Females have been shown to demonstrate more knee valgus, less knee flexion and more femoral adduction when performing ‘at risk’ activities such as landing or cutting which could predispose them to a higher risk of injury.5–8 A plethora of research has focused on the influence of the kinetic chain on lower extremity biomechanics, with much of the research focusing on the hip,9–12 but there is a growing body of evidence linking decreased ankle dorsiflexion range of motion (DFROM) to these ‘at risk’ movement patterns.13–19 These kinetic chain patterns can be identified as the top-down approach (hip and trunk) and the bottom-up approach (ankle).20

Decreased DFROM is a common problem among athletes, especially after LAS, that has been shown to affect sagittal plane movement which may result in compensatory frontal and transverse plane motion and loading, especially at the knee. Individuals with DFROM limitations have been shown to have greater knee flexion displacement, increase knee valgus and greater ground reaction forces during bilateral and unilateral squatting,21,22 landing tasks,16,23,24 and change of direction tasks25 which have been linked to an increase in injury risk, especially in the female athlete. Furthermore, females have been shown to be more one-leg dominant in comparison to males and are more likely to injure their non-dominant limb.26–28 Therefore, understanding the effect of sex and leg dominance on DFROM may be useful to help inform future sex-specific prevention and rehabilitation strategies. Currently, the plethora of research which has investigated the effect of sex, limb dominance and LAS history on DFROM has found no effect of sex on DFROM29–32 in a variety of different sports and levels. Miller at al.29 and Senanayake et al.32 report a significant effect of previous ankle injury on DFROM but did not provide analysis on sex differences and so there exists a gap in the current evidence which will be explored further in this study.

Unilateral restrictions in DFROM may lead to asymmetrical loading and result in interlimb asymmetries which may influence lower extremity biomechanics. Current evidence is conflicting regarding the extent of asymmetries in DFROM. It has been previously suggested that a threshold of 10-15% asymmetry may increase risk of injury but the literature to support this focusses on return to sport after ACL reconstruction.33 This has since been challenged and no clear evidence which supports asymmetry and increased risk of injury,34,35 Furthermore the use of an arbitrary asymmetry threshold has limitations and it has been argued that asymmetry should be based on the metric, task, population, and muscle group studied in order to be useful.36 It has also been suggested that practitioners should monitor magnitude (% difference between dominant and non-dominant limbs) alongside direction of asymmetry (whether dominant or non-dominant limb had the larger DFROM) over several testing sessions as these have been to vary considerably over several test sessions using the same test. However, where data has only been collected during one single testing session, an inter-participant threshold can be established to determine what can be considered as a true asymmetry.37 To date there is no known study which investigates sex differences and LAS history on DFROM asymmetry. Normative data from Hoch and McKeon38 report interlimb asymmetries of 1-2cm in 35 healthy participants and Rabin et al.39 found asymmetries of 10° in 23% of male military recruits. Arede et al.40 and Işın et al.41 report frequent asymmetries of over 10% in male soccer players but argue that differences occur due to the functional demands of the sport. However, in comparison, other authors have found no asymmetry in DFROM,42,43 but this could be due to methodological differences between the studies and how asymmetry has been calculated. There is a dearth of literature on DFROM asymmetry in the female athlete. As DFROM has been postulated as a predisposing factor to influence lower extremity biomechanics, an understanding of between limb differences in DFROM is required to determine population and task specific asymmetry thresholds for asymmetry. Therefore, the aims of this study were to 1) to determine the effect of sex, leg dominance and LAS history on DFROM, 2) to determine the effect of sex and LAS history on magnitude of DFROM symmetry and 3) to examine the association of sex on direction (whether dominant or non-dominant limb had the higher DFROM) of symmetry.

MATERIALS AND METHODS

Participants

One hundred and five participants (68 females, 37 females) from recreational multidirectional sports volunteered for the study. All participants self-reported to be physically active and were participating in at least one training session and one match per week. All participants provided written, informed consent in the spirit of the Helsinki Declaration. Prior to testing, all participants completed an injury history questionnaire to assess previous lateral ankle injury on each leg, and leg dominance. Dominant leg was defined as the preferred leg for kicking a ball44 and LAS history was defined as at least one episode of an ankle sprain.45 Participants were excluded if they had a history of lower extremity surgery, any health conditions that may have influenced foot and ankle function, or a previous history of lower extremity injury in the prior six months. The participants were instructed to maintain their regular training regimens but were told not to exercise 48 hours prior to the day of testing. Ethical clearance was obtained by the institutional ethics review panel.

Procedure

DFROM measurements were obtained using the weight bearing lunge test (WBLT) where the back foot (BF) heel was raised off the floor.46 This method has been shown to have excellent intra-rater reliability.46 Participants were instructed to position themselves in a tandem stance position in front of a wall. The big toe and midline of the heel of both feet were maintained perpendicular to the wall and each participant was instructed to keep the BF knee straight during each test position. Their BF heel was raised off the floor so that the participant was on their toes. Participants were asked to place their hands against the wall in front so that their hands were flat, and no gripping was allowed. Measurements were taken using a tape measure (to the nearest 0.1cm) from the big toe to the wall (Figure 1). Once participants were able to maintain the position with the knee touching the wall, the test foot was then progressed away from the wall in 1cm increments until their reach their maximum range of dorsiflexion.38 The examiner ensured that front heel contact was made throughout the testing using manual contact alongside verbal instructions but did not control either pronation or supination of the foot during testing. The BF was maintained in the same position throughout the test. No warmup was performed prior to testing and all testing took place in the same place using the same instruments by the same examiner to standardize testing conditions. The WBLT was completed three times for each leg and the mean of the three measurements was used for analysis. Leg order was randomly selected prior to the testing session.

227886 Figure 1. WBLT with back foot raised off the floor

Data Analysis

The mean of the three attempts were used for statistical analysis.47 For the first study aim, a three-way mixed ANOVA (IBM SPSS, version 29) was conducted to compare the effects of two between subject variables; lateral ankle sprain history (yes, no) sex (male or female) and a within subject’s variable: leg dominance (dominant or non-dominant) on DFROM. The assumption of normality for the data was checked using the Kolmogorov-Smirnov test with normative data obtained for all DFROM measurements (p>0.05). There was homogeneity of variances for dominant limb (p=0.90) and non-dominant limb (p=0.43) as assessed by the Levene’s test for equality of variances.

To determine interlimb asymmetry the calculation 100/(max value) x (min value) x -1 + 100 was used.48 To determine the direction of asymmetry (which ankle has higher DFROM) an ‘IF function’ was added to the end of the above formula: *IF(dominant <non-dominant,1,-1).49 An asymmetry threshold (AT%) was calculated for DFROM all participants and this was used to determine whether a participant can be considered as having a true asymmetry. This threshold was based on the population mean + smallest worthwhile change (SWC) using the calculation AT% = magnitude of asymmetry mean% + (0.2 x SD).50 The SD is the standard deviation of the mean magnitude of asymmetry. A high asymmetry threshold (HAT%) was calculated using population mean + (1.0 x between subject SD) for all participants.50 The assumption of normality for the data was checked for asymmetry data using the Kolmogorov Smirnov test and it was not normally distributed (p<0.05). There was homogeneity of variances as assessed by Levene’s test for equality of variances p=0.19). A two-way ANOVA was conducted to compare sex (male or female) and LAS history (yes or no) on magnitude of asymmetry (%). A Chi Square test of independence was conducted to determine whether there was an association between sex and direction of asymmetry.

RESULTS

One hundred and five participants (68 males, 37 females, age:27.8 ± 7.7 y, stature:175.5±9.4 cm, body mass:84.2± 17.4 kg, R dominant: n=92, L dominant: n=13) participated in the study. The descriptive statistics for all measurements for both dominant and non-dominant limb are presented in Table 1. Ninety-two (87.6%) participants (57 males, 35 females) reported their right leg to be their dominant leg while 13 (12.4%) participants (11 males, 2 females) reported their left leg to be the dominant leg. Seventy (66.6%) of participants reported a history of LAS in comparison to 35 (33.3%) of participants who reported no history of LAS.

227887 Table 1. Mean DFROM measurements by sex, LAS history and leg dominance. Data are reported as mean (+/- SD)

Sex	Participants (n)	LAS History (yes, no)	DFROM (cm) (Mean ± SD)	
Male Dominant Non-Dominant	
41
27

41
27	
Yes
No

Yes
No	
8.94 (3.25)
10.38 (3.45)

9.44 (3.23)
10.52 (3.46)	
Female Dominant Non-Dominant	
25
12
25
12	
Yes
No
Yes
No	
9.86 (3.31)
11.85 (3.09)
9.70 (3.15)
12.21 (2.39)	

There was no interaction between sex, LAS history, and leg dominance on DFROM (F(1,101) = 0.21, p = 0.65, η2 = 0.00) and no 2-way interactions between sex and leg dominance (p=0.82, η2=0.00), leg dominance and LAS history (p=0.94, η2= 0.00), or sex and LAS history (p=0.33, η2= 0.01). Significant main effects were found for sex (p=0.04, η2=0.43) and LAS history (p=<0.00, η2=0.10). No significant main effects were found for leg dominance (p=0.66, η2=0.00).

Magnitude of asymmetry values (%) are shown in Table 2. There was no interaction between sex and LAS history on magnitude of asymmetry F(1, 101)= .03, p=0.88, η2=0.00) and no main effects were found for sex (p=0.25, η2=0.00) or LAS history (p=0.82, η2=0.00).

227888 Table 2. Mean interlimb asymmetry values (%) and SD for sex and LAS history.

Sex	Participants (n)	LAS History	Asymmetry (% ±SD)	
Male	41
27	Yes
No	13.5 (18.2)
13.3 (13.7)	
Female	25
12	Yes
No	10.4 (11.8)
9.2 (8.5)	
Asymmetry Threshold (AT%) 11.8%	High Asymmetry Threshold (HAT%) 25.6%	

The asymmetry threshold was calculated as 11.8%. Twenty-six (24.7%) males (11 males LAS history, 15 no LAS history) 10 (9.5%) females (7 LAS history, 3 no LAS history) exhibited DFROM asymmetry magnitudes above the AT%. The HAT% was calculated as 25.6%. Twelve (11.4%) of males (6 LAS history, 6 no LAS history) and 3 (2.8%) females (2 LAS history, 1 no LAS history) exhibited asymmetry above the HAT%.

228773 Figure 2. Individual DFROM asymmetry scores for males.

Above 0 indicates asymmetry favours the dominant limb and below 0 indicates that asymmetry favours the non-dominant limb.

228774 Figure 3. Individual DFROM asymmetry scores for females.

Above 0 indicates asymmetry favours the dominant limb and below 0 indicates that asymmetry favours the non-dominant limb.

A chi-square test for independence was conducted between sex and direction of asymmetry (positive or negative). There were statistically significant association between sex and whether asymmetry favoured the dominant or non-dominant limb (χ2(1) = 11.26, p = .00). Sixty-five-point two percent of males were shown to have higher DFROM in their non-dominant limb compared to 75% of females who were shown to have higher DFROM in their dominant limb.

DISCUSSION

No statistically significant interactions existed between sex, leg dominance and LAS history and DFROM (F(1,101) = 0.21, p = 0.65, η2 = 0.00). Furthermore, there were no significant interactions found for sex and LAS history and DFROM, however, significant main effects were reported individually for sex (p=0.04, η2=0.43) and LAS history (p=0.00, η2=0.10) on DFROM. As this is the first known study to investigate the effect of sex, LAS history, and leg dominance on DFROM using the WBLT, these results cannot be compared to any previous published findings. The significant main effect of sex suggests that males demonstrated less DFROM (9.82cm) than females (10.91cm). It has been argued that females are shown to exhibit greater range of motion (ROM) due to lower muscle stiffness that allows a higher tolerance of muscle stretch,51 however, the findings from this study contradict Miller et al.29 and Llurda-Almuzara30 who found no significant effect of sex on DFROM in a group of elite level gymnasts and soccer players respectively. Differences between the studies could be attributed to the population tested as the athletes in this study were all recreational athletes from a range of multidirectional sports compared to elite athletes from a specific sport. Decreased DFROM has been linked to changes in lower extremity biomechanics which may increase risk of injury of non-contact ACL injuries especially in the female athlete. This study reported a significant difference in DFROM between males and females which may suggest that males may be more at risk of developing lower extremity biomechanics that may predispose them to injury, however, the difference was reported as 1.09cm (males 9.82cm, females 10.91cm) and it is unclear whether this is clinically relevant. More research is required to understand whether sex specific thresholds exist for DFROM, and how they influence lower extremity biomechanics or predispose an athlete to an increased risk of injury.

The results of this study indicate a significant main effect of LAS history on DFROM with those athletes with a history of LAS demonstrating less DFROM (LAS history 9.48cm, no LAS history 11.25cm, p=0.00). This supports findings from Miller et al.29 who reported similar findings in elite level gymnasts. However, Denegar et al.52 found no differences in DFROM in those with LAS history, but DFROM was measured passively in the prone position using an inclinometer which has been shown to be less reliable. These findings suggest that those with previous LAS history have less DFROM which may predispose them injury. However, there is a need to understand what constitutes decreased DFROM and whether there is a specific DFROM or threshold of loss that may predispose an individual to adverse lower extremity biomechanics.

The results of this study indicated that sex or LAS did not affect magnitude of asymmetry for DFROM. The mean magnitude of asymmetry ranged from 13.3%-13.5% in males and 9.2% -10.4% in females (males: LAS history: 13.6%±18.2%, No LAS history: 13.3%±13.7%; Females: LAS history: 10.4%±11.9%; No LAS history: 9.2%±8.6%). Magnitude of asymmetry values reported in this study are much higher compared to Madruga–Parera et al.53 who reported asymmetry of 5.88% ± 3.42 and Gonzalo Skok et al25 who reported asymmetry 9.6% in fifteen youth elite male basketball players, however they are consistent with findings from Arede et al.40 and Işın et al.41 who reported magnitude of asymmetries over 10% in semi-professional male soccer players. Large SDs have been reported in this study which indicates a large inter-individual variation however, this is a common finding in most asymmetry related research and may explain why relationships between asymmetry and performance are often insignificant.54 The AT% for this study population of recreational athletes was calculated as 11.8%. Of the 105 athletes tested 28 (41.17%) of the males (16.17% LAS history and 22.05% no LAS history) and 13 (35.13%) of the females (27.02% LAS history and 8.10% no LAS history) exhibited DFROM asymmetries which exceeded the AT%. Furthermore, 12 (17.6%) males and only 3 (8.1%) females exhibited asymmetry values above HAT%. This suggests that symmetries are present in males and females and supports findings from Hoch and McKeon,38 Rabin et al.,39 Howe et al.,42 and Arede et al.40 who all reported differences in DFROM between dominant and non-dominant limbs in healthy populations. Therefore, clinicians should exercise caution when using bilateral comparisons during injury assessment. However, in the current study true asymmetries (above the AT% for that population) were only seen in 41.17% of males and 35.13% of females and high asymmetry in 17.6% of males and 8.1% of females. It is important to recognise that these values are only specific to this population for this specific testing period and should not be used as a threshold for other studies as asymmetry has been shown to be metric, population, and test specific.52 Furthermore, it is not known how DFROM asymmetry influences lower extremity biomechanics and more research is needed in this area.

An interesting finding of the current study is that there was a significant association between sex and direction of asymmetry (χ2(1) = 11.26, p = 0.00). Sixty-five-point two percent of males were shown to have higher DFROM in their non-dominant limb compared to 75% of females who were more likely to have higher ROM in their dominant limb. It has been argued that athletes should have greater DFROM in their non-dominant (stance) limb as this limb needs to provide stability and balance when cutting and landing which is needed in sports requiring frequent change of direction,40 but this needs to be explored further. It is not known how direction and magnitude of asymmetry affects lower extremity biomechanics during specific activities as previous research has only investigated performance measures.53 Females have been shown to favour one limb more than another (leg dominance) in sports compared to males who have been shown to have less reliance on one limb which may predispose them to injury risk,2 and several studies have found that females are a higher risk of injury of injuring their non-dominant limb which suggests that leg dominance is a factor.26–28

This study is not without its limitations, although a large sample size was used for this study (n=105), the athletes used were from a variety of different university and recreational level multidirectional sports which required changes of direction and athletes were participating at different levels. Previous research54–57 shows that asymmetry differs depending on both sport, level, task, and population studied and therefore it is not known whether these sex differences would be seen if the tested on one sport and from athletes participating at the same level. Furthermore, the data from this study was collected during one single data collection point and caution must be taken when interpreting this data as both magnitude and direction has been shown to vary considerably across several testing sessions. This study also did not measure the effect of DFROM asymmetry on a specific performance variable and so it is not known how asymmetries may influence a variety of difference sports specific activities.

CONCLUSION

The results of this study indicate no significant interaction between sex, leg dominance and LAS history on DFROM in university and recreational level athletes from a range of multidirectional sports. However, females were had significantly higher DFROM values compared to males. Furthermore, those with LAS history had less DFROM compared to those without. This study reported interlimb asymmetry, however this was not affected by sex or LAS history. There was a difference in association of sex on direction of asymmetry as females were shown to have direction in favor of their dominant limb compared to males which favored the non-dominant limb. Caution should be exercised in interpreting these results as thresholds for asymmetry are metric, population, and test specific. Future research would be useful to determine the sex differences in magnitude and direction of asymmetry in DFROM while performing specific sports specific maneuvers. Further investigations of sex differences in the magnitude and direction of asymmetry on lower extremity biomechanics may help inform sex specific rehabilitation and prevention strategies.

Conflict of interest

The authors report no conflict of interest.
==== Refs
Gender differences in the incidence and prevalence of patellofemoral pain syndrome Scand J Med Sci Sports Boling M. Padua D. Marshall S. Guskiewicz K. Pyne S. Beutler A. 2010
20 5 725 30 10.1111/j.1600-0838.2009.00996.x 10.1111/j.1600-0838.2009.00996.x 19765240
Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors Am J Sports Med Hewett T.E. Myer G.D. Ford K.R. 2006
34 2 299 311 10.1177/0363546505284183 16423913
Understanding and preventing ACL injuries current biomechanical and epidemiologic considerations- update 2010 N Am J Sports Phys Ther Hewett T. E. Ford K. R. Hoogenboom B. J. Myer G. D. 2010
5 4 234 251 21655382
Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study Am J Sports Med Hewett T.E. Myer G.D. Ford K.R.. 2005
33 4 492 501 10.1177/0363546504269591 15722287
The anterior cruciate ligament injury controversy: is "valgus collapse" a sex-specific mechanism? Br J Sports Med Quatman C.E. Hewett T.E. 2009
43 5 328 35 10.1136/bjsm.2009.059139 10.1136/bjsm.2009.059139 19372087
Sex differences in unilateral landing mechanics from absolute and relative heights Knee Weinhandl J.T. Irmischer B.S. Sievert Z.A. 2015
22 4 298 303 10.1016/j.knee.2015.03.012 10.1016/j.knee.2015.03.012 25910453
Sex differences in lower extremity stiffness and kinematics alterations during double-legged drop landings with changes in drop height Sports Biomech Wang I. L. Wang S. Y. Wang L. I. 2015
14 4 404 12 10.1080/14763141.2015.1062129 10.1080/14763141.2015.1062129 26271402
Gender differences in hip joint kinematics and kinetics during side-step sutting maneuver Clin J Sport Med Pollard C. D. Sigward S. M. Powers C. M. 2007
17 38 42 10.1097/JSM.0b013e3180305de8 10.1097/JSM.0b013e3180305de8 17304004
What's my risk of sustaining an ACL injury while playing sports? A systematic review with meta-analysis Br J Sports Med Montalvo A. M. Schneider D. K. Yut L.. 2019
53 16 1003 1012 10.1136/bjsports-2016-096274 10.1136/bjsports-2016-096274 29514822
The effect of weak hip abductors or external rotators on knee valgus kinematics in healthy subjects: A Systematic Review J Sport Rehab Cashman G. E. 2012
21 273 284 10.1123/jsr.21.3.273 10.1123/jsr.21.3.273
Is hip muscle strength associated with dynamic knee valgus in a healthy adult population? A systematic review Int J Environ Res Public Health Alzahrani A. M. Alzhrani M. Alshahrani S. N. Alghamdi W. Alqahtani M. Alzahrani H. 2021
18 14 10.3390/ijerph18147669 10.3390/ijerph18147669
The influence of gluteal muscle strength deficits on dynamic knee valgus: a scoping review J Exp Orthop Rinaldi V. G. Prill R. Jahnke S. Zaffagnini S. Becker R. 2022
9 1 81 10.1186/s40634-022-00513-8 10.1186/s40634-022-00513-8 35976534
The relationship of foot and ankle mobility to the frontal plane projection angle in asymptomatic adults J Foot Ankle Res Wyndow N. De Jong A. Rial K.. 2016
9 3 10.1186/s13047-016-0134-9 10.1186/s13047-016-0134-9 26816531
Dynamic knee valgus in single-leg movement tasks. Potentially modifiable factors and exercise training options. A literature review Int J Environ Res Public Health Wilczynski B. Zorena K. Slezak D. 2020
17 21 10.3390/ijerph17218208 10.3390/ijerph17218208
Anterior cruciate ligament injury and ankle dorsiflexion Knee Surg Sports Traumatol Arthrosc Wahlstedt C. Rasmussen-Barr E. 2015
23 11 3202 7 10.1007/s00167-014-3123-1 10.1007/s00167-014-3123-1 24923690
Ankle dorsiflexion affects hip and knee biomechanics during landing Sports Health Taylor J. B. Wright E. S. Waxman J. P. Schmitz R. J. Groves J. D. Shultz S. J. 2021 19417381211019683 10.1177/19417381211019683 10.1177/19417381211019683
Ankle Dorsiflexion displacement is associated with hip and knee kinematics in females following anterior cruciate ligament reconstruction Res Sports Med Stanley L. E. Harkey M. Luc-Harkey B.. 2019
27 1 21 33 10.1080/15438627.2018.1502180 10.1080/15438627.2018.1502180 30084269
The association of visually-assessed quality of movement during jump-landing with ankle dorsiflexion range-of-motion and hip abductor muscle strength among healthy female athletes Phys Ther Sport Rabin A. Einstein O. Kozol Z. 2018
31 35 41 10.1016/j.ptsp.2018.01.004 10.1016/j.ptsp.2018.01.004 29525640
The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and meta-analysis Phys Ther Sport Lima Y. L. Ferreira V. de Paula Lima P. O. Bezerra M. A. de Oliveira R. R. Almeida G. P. L. 2018
29 61 69 10.1016/j.ptsp.2017.07.003 10.1016/j.ptsp.2017.07.003 28974358
Bottom-Up Kinetic Chain in Drop Landing among University Athletes with Normal Dynamic Knee Valgus Int J Environ Res Public Health Jamaludin N. I. Sahabuddin F. N. A. Raja Ahmad Najib R. K. M. Shamshul Bahari M. L. H. Shaharudin S. 2020
17 12 10.3390/ijerph17124418 10.3390/ijerph17124418
Altered knee and ankle kinematics during squatting in those with limited weight-bearing-lunge ankle-dorsiflexion range of motion J Athl Train Dill K. E. Begalle R. L. Frank B. S. Zinder S. M. Padua D. A. 2014
49 6 723 732 10.4085/1062-6050-49.3.29 10.4085/1062-6050-49.3.29 25144599
Restricted unilateral ankle dorsiflexion movement increases interlimb vertical force asymmetries in bilateral bodyweight squatting J Strength Cond Res Crowe M. A. Bampouras T. M. Walker-small K. Howe L. P. 2020
34 2 332 336 10.1519/JSC.0000000000003345 10.1519/JSC.0000000000003345 31425458
Ankle-dorsiflexion range of motion and landing biomechanics J Athl Train Fong C. Blackburn J. T. Norcross M. F. McGrath M. Padua D. 2011
46 1 5 10 10.4085/1062-6050-46.1.5 10.4085/1062-6050-46.1.5 21214345
Weight-bearing dorsiflexion range of motion and landing biomechanics in individuals with chronic ankle instability J Athl Train Hoch M. C. Farwell K. E. Gaven S. L. Weinhandl J. T. 2015
50 8 833 9 10.4085/1062-6050-50.5.07 10.4085/1062-6050-50.5.07 26067428
Relationships between functional movement tests and performance tests in young elite male basketball players Int J Sports Phys Ther Gonzalo-skok O. Serna J. Rhea M. R. Marin P. J. 2015
10 5 628 638 26491613
Lower limb dominance as a possible etiologic factor in noncontact anterior cruciate ligament tears J Strength Cond Res Negrete R. J. Schick E. A. Cooper J. P. 2007
21 1 270 273 10.1519/00124278-200702000-00048 10.1519/00124278-200702000-00048 17313288
Gender influences: the role of leg dominance in ACL injury among soccer players Br J Sports Med Brophy R.H. Silvers H.J. Gonzales T. Mandelbaum B.R. 2010
44 10 694 7 10.1136/bjsm.2008.051243 10.1136/bjsm.2008.051243 20542974
Leg dominance is a risk factor for noncontact anterior cruciate ligament injuries in female recreational skiers Am J Sports Med Ruedl G. Webhofer M. Helle K.. 2012
40 6 1269 73 10.1177/0363546512439027 10.1177/0363546512439027 22427619
Does gender and ankle injury history affect weightbearing dorsiflexion in elite artistic gymnasts? Phys Ther Sport Miller H. Fawcett L. Rushton A. 2020
42 46 52 10.1016/j.ptsp.2019.12.003 10.1016/j.ptsp.2019.12.003 31884244
Sex differences in pre-season anthropometric, balance and range-of-motion characteristics in elite youth soccer players Healthcare Llurda-Almuzara L. Perez-Bellmunt A. Labata-Lezaun N. Lopez-de-Celis C. Moran J. Clark N.C. 2022
10 5 10.3390/healthcare10050819 10.3390/healthcare10050819
Normative Functional Performance Values in High School Athletes: The functional pre-participation evaluation project J Athl Train Onate J. A. Starkel C. Clifton D. R. 2018
53 1 35 42 10.4085/1062-6050-458.16 10.4085/1062-6050-458.16 29314871
Influence of weight bearing dorsiflexion (WBDF) on ankle injury history among semi-professional recreational basketball players Adv J Grad Res Senanayake S. Premakumara T. Kodagoda P. Jayasekara H. 2021
11 1 45 51 10.21467/ajgr.11.1.45-51 10.21467/ajgr.11.1.45-51
Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study Br J Sports Med Grindem H. Snyder-Mackler L. Moksnes H. Engebretsen L. Risberg M.A. 2016
50 13 804 8 10.1136/bjsports-2016-096031 10.1136/bjsports-2016-096031 27162233
Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture Br J Sports Med Kyritsis P. Bahr R. Landreau P. Miladi R. Witvrouw E. 2016
50 15 952 10.1136/bjsports-2016-096410 10.1136/bjsports-2016-096410 27432854
Does lower-limb asymmetry increase injury risk in sport? A systematic review Phys Ther Sport Helme M. Tee J. Emmonds S. Low C. 2021
49 204 213 10.1016/j.ptsp.2021.03.001 10.1016/j.ptsp.2021.03.001 33770741
Interlimb Asymmetries: Are thresholds a usable concept? Strength Cond J Bishop C. 2020
0 0 1 5 10.1519/SSC.0000000000000554 10.1519/SSC.0000000000000554
Validity and reliability of the rear foot elevated split squat 5 repetition maximum to determine unilateral leg strength symmetry J Strength Cond Res Helme M. Bishop C. Emmonds S. Low C. 2019
33 12 3269 3275 10.1519/JSC.0000000000003378 31524778
Normative range of weight-bearing lunge test performance asymmetry in healthy adults Man Ther Hoch M.C. McKeon P.O. 2011
16 5 516 9 10.1016/j.math.2011.02.012 10.1016/j.math.2011.02.012 21429784
Weight-bearing ankle dorsiflexion range of motion-can side-to-side symmetry be assumed? J Athl Train Rabin A. Kozol Z. Spitzer E. Finestone A.S. 2015
50 1 30 5 10.4085/1062-6050-49.3.40 10.4085/1062-6050-49.3.40 25329350
Assessing asymmetries and predicting performance in semiprofessional soccer players Int J Sports Sci Coach Arede J. Fernandes J. F. T. Singh H. Bishop C. Romero-Rodriguez D. Madruga Parera M. 2023
10.1177/17479541221146220 10.1177/17479541221146220
Associations between differing magnitudes of inter-limb asymmetry and linear and change of direction speed performance in male youth soccer players Biomed Hum Kinet Işın A. Akdağ E. Özdoğan E.Ç. Bishop C. 2022
14 1 67 74 10.2478/bhk-2022-0009 10.2478/bhk-2022-0009
Within-session reliability for inter-limb asymmetries in ankle dorsiflexion range of motion measured during the weight-bearing lunge test Int J Sports Phys Ther Howe L. P. Bampouras T. M. North J. S. Waldron M. 2020
15 1 64 73 10.26603/ijspt20200064 32089959
Reliability of three different measurements of ankle dorsiflexion Int J Sports Phys Ther Konor M. M. Morton S. Eckerson J. M. Grindstaff T. L. 2012
7 3 279 287 22666642
Eccentric hip adduction and abduction strength in elite soccer players and matched controls: a cross-sectional study Br J Sports Med Thorborg K. Couppe C. Petersen J. Magnusson S.P. Holmich P. 2011
45 1 10 3 10.1136/bjsm.2009.061762 10.1136/bjsm.2009.061762 19850576
The evaluation of joint mobilization dosage on ankle range of motion in individuals with decreased dorsiflexion and a history of ankle sprain J Sport Rehab Meyer J. E. Rivera M. J. Powden C. J. 2020
30 3 347 352 10.1123/jsr.2020-0114
Back foot influence on dorsiflexion using three different positions of the weight bearing lunge test Phys Ther Sport Cady K. De Ste Croix M. Deighan M. 2020
47 1 6 10.1016/j.ptsp.2020.10.005 10.1016/j.ptsp.2020.10.005 33099092
Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion Aust J Physiother Bennell K. Talbot R. Wajswelner H. Techovanich W. Kelly D. Hall A.J. 1998
44 3 175 180 10.1016/s0004-9514(14)60377-9 10.1016/s0004-9514(14)60377-9 11676731
Interlimb asymmetries:Understanding how to calculate differences rrom bilateral and unilateral tests Strength Cond J Bishop C. Read P. Lake J. Chavda S. Turner A. 2018
40 4 1 6 10.1519/JSC.0000000000002729
Using unilateral strength, power and reactive strength tests to detect the magnitude and direction of asymmetry: A test-retest design Sports Bishop C. Read P. Chavda S. Jarvis P. Turner A. 2019
7 3 10.3390/sports7030058 10.3390/sports7030058
Assessing interlimb asymmetries: Are we heading in the right direction? Strength Cond J Dos'Santos T. Thomas C. Jonea P. A. 2021
43 3 91 100 10.1519/SSC.0000000000000590
Functional performance of ankles between male and female practitioners of resistance exercise Muscl Ligament Tendon J Braz M. Souto Maior A. 2021
11 04 10.32098/mltj.04.2021.13 10.32098/mltj.04.2021.13
Interlimb asymmetries: The need for an individual approach to data analysis J Strength Cond Res Bishop C. Lake J. Loturco I. Papadopoulos K. Turner A. Read P. 2018 1 7 10.1519/JSC.0000000000002729 10.1519/JSC.0000000000002729
Multidirectional leg asymmetry assessment in sport Strength Cond J Hewit J.K. Cronin J.B. Hume P.A. 2012
34 1 82 86 10.1519/SSC.0b013e31823e83db 10.1519/SSC.0b013e31823e83db
Seasonal variation of physical performance and inter-limb asymmetry in professional cricket Athletes J Strength Cond Res Bishop C. Weldon A. Hughes G. 2021
35 4 941 948 10.1519/JSC.0000000000003927 10.1519/JSC.0000000000003927 33752220
Magnitude or direction? Seasonal variation of interlimb asymmetry in elite academy soccer players J Strength Cond Res Bishop C. Read P. shyam C. 2022
36 4 1031 1037 10.1519/JSC.0000000000003565 32149878
Inter-limb asymmetry during rehabilitation. Understanding formulas and monitoring the magnitude and direction Aspetar Sports Med J Bishop C. Turner A. Gonzalo-skok O. Read P. 2021
9 19 22
Effects of maturation on lower limb neuromuscular asymmetries in elite youth tennis players Sports Madruga-Parera M. Romero-Rodriguez D. Bishop C.. 2019
7 5 10.3390/sports7050106 10.3390/sports7050106
