Development of single-leg jump-landing tasks to predict noncontact anterior cruciate ligament injury risk

Priyankara Manoj Rajakaruna Rajakaruna Mudiyanselage

Noncontact anterior cruciate ligament (ACL) injuries in sports have surged in recent decades. Although three-dimensional (3D) motion analysis is the gold standard for ACL injury risk screening, its’ high cost, specialised equipment, and time demands limit its accessibility in community sports settings. Therefore, a cost-effective, field-based method for assessing wholebody techniques in noncontact ACL injury risk is essential. The double-leg Landing Error Scoring System (LESS), known for its reliability, validity, and predictive capability, evaluates biomechanics during double-leg jump-landing tasks. However, most noncontact ACL injuries occur during single-leg jump-landings. Research to assess single-leg landing tasks needs to be improved, highlighting the need for a reliable and ecologically valid tool. This PhD thesis investigates the reliability and validity of single-leg jump-landing tasks for assessing noncontact ACL injury risk. Chapter 2 (Study One) critically evaluated and summarised the reliability, validity, and predictability of noncontact ACL injury screening methods. The review identified various methods and tasks, highlighting a range of reliability and validity across intra-rater, inter-rater, and inter-session assessments. Notably, 3D motion analysis and force plate assessments demonstrated slightly better predictive accuracy and discriminative ability for noncontact ACL injury than two-dimensional (2D) video motion analysis, the LESS, the Functional Movement Screen (FMS), and Real-time Observational Screening. The limited availability of inter-session reliability data may contribute to inconsistencies in findings, as evidenced by the need for studies reporting such data for LESS and Real-time Observational Screening. Furthermore, the predominance of double-leg jump-landing tasks in most studies, despite the higher incidence of noncontact ACL injuries during single-leg jump-landing tasks, underscores the necessity for further research on single leg tasks. Specifically, future studies should investigate the inter session reliability of injury screening methods using ecologically valid tasks tailored to specific athlete populations which are appropriate for use in in field or clinical settings. Chapter 3 (Study Two) developed the and assessed the reliability of a single-leg version of the LESS, the Single-Leg Landing Error Scoring System (SLESS) and investigated the intersession, intra-rater, and inter-rater reliability of single-leg and double-leg jump-landing tasks using the SLESS and double-leg LESS. Inter-session reliability for the SLESS and LESS scores demonstrated good to excellent intraclass correlation coefficients (ICCs) (single dominant leg [SDL]: 0.89; single non-dominant leg [SNL]: 0.91; double-leg [DL]: 0.79) with moderate coefficients of variation (CVs) (SDL: 6.5%; SNL: 6.6%; DL: 7.9%). Intra-rater reliability for the SLESS and LESS scores also showed good to excellent ICCs (SDL: 0.94; SNL: 0.92; DL: 0.88) with moderate CVs (SDL: 5.0%; SNL: 6.0%; DL: 5.6%). Inter-rater reliability for the SLESS and LESS scores exhibited good ICCs (SDL: 0.82; SNL: 0.83; DL: 0.79) but poor CVs (SDL: 10.5%; SNL: 11.5%; DL: 11.5%). SLESS and LESS scores demonstrated small standard error of measurement (SEM) values (1.05–1.11) across all reliability measures. These findings suggest that the SLESS and LESS are reliable field-based tools for assessing jump-landing tasks among team sports players, enhancing confidence in sports and exercise science research. SLESS is a reliable and practical alternative to LESS, but further validation against goldstandard 3D measures is necessary. Chapter 4 (Study Three) investigated the inter-session, intra-rater, and inter-rater reliability of SLESS and LESS scores using seven common calculation methods. Inter-session reliability for SLESS and LESS scores across all seven calculation methods demonstrated moderate to excellent ICCs (0.63–0.91) and moderate to poor CVs (6.5%–11.5%). Intra-rater reliability showed moderate to excellent ICCs (0.74–0.94) and moderate CVs (5.0%–8.5%), while interrater reliability exhibited moderate to good ICCs (0.66–0.83) and poor CVs (10.5%–18.0%). Across all reliability measures, SLESS and LESS scores displayed small SEM values (1.05– 1.17). Additionally, the results revealed an inconsistent bias in the mean SLESS and LESS scores across the six alternative methods compared to the reference method. The averaging three trials calculation method consistently proved to be the most reliable across all tasks and reliability measures and is recommended for use in future studies and practice. Precisely specifying the chosen calculation method is crucial for both practitioners and researchers. Therefore, sports and exercise science professionals should develop reliable, cost-effective, and time-efficient methods to obtain accurate SLESS and LESS scores for effective injury risk classification in community sports. Chapter 5 (Study Four) determined the relationship between SLESS and LESS scores and lower-extremity 3D kinematic and kinetic measures during jump-landing tasks. Individual SLESS item scores showed poor to excellent percent agreement with the 3D instrument’s dichotomised scores, ranging from 33% to 100%, while LESS item scores demonstrated poor to excellent percent agreement, ranging from 24% to 100%, during jump-landing tasks among all raters. SLESS scores exhibited small correlations, whereas LESS scores showed small to moderate correlations with 3D kinematic and ACL injury risk factors across all tasks and raters. Only the knee valgus angle at maximum displacement demonstrated a significant moderate correlation with LESS scores (rho = 0.37, P = 0.05) during double-leg jump-landings. The study highlights inconsistencies in the concurrent validity of SLESS scores during single-leg jump-landing tasks compared to the gold standard. While SLESS is reliable and provides a practical alternative to LESS, further validation is required, along with additional assessments to evaluate its ability to predict noncontact ACL injury risk. Chapter 6 (Study Five) examined the inter-session, intra-rater, and inter-rater reliability and validity of two double-leg jump-landing tasks using the LESS. The cognitive-loading drill with double-leg jump-landing (DC) demonstrated similar reliability to the standard double-leg (DL) landing. Inter-session reliability showed good to excellent ICCs (DC: 0.90; DL: 0.79) and moderate CVs (DC: 5.7%; DL: 7.9%), while intra-rater reliability had good to excellent ICCs (DC: 0.93; DL: 0.88) and good to moderate CVs (DC: 4.2%; DL: 5.6%). Inter-rater reliability exhibited good ICCs (DC: 0.82; DL: 0.79) but poor CVs (DC: 10.7%; DL: 11.5%) with small SEM values. No significant differences in LESS scores were found between tasks (P = 0.218). Individual LESS item scores showed poor to excellent agreement with 3D instrument dichotomised scores (11%–100%) across tasks and raters. LESS scores had small correlations with 3D kinematic and kinetic variables for DC (rho = 0.04–0.18) and small to moderate correlations for DL (rho = 0.01–0.37). Both tasks provide acceptable reliability for assessing landing biomechanics in sports and exercise science, particularly for noncontact ACL injury risk screening. However, due to inconsistencies in the concurrent validity of LESS scores compared to the gold standard, further validation against 3D kinematic and kinetic measures is needed before applying the DC task as a predictive tool for noncontact ACL injuries in practical settings. Chapter 7 (Study Six) examined whether sports and exercise science professionals and undergraduate students, using a 2D Visual Assessment Tool, could identify community-level team sports players at greater risk of noncontact ACL injury during jump-landing tasks, as assessed by gold-standard 3D kinematic and kinetic measures and SLESS and LESS scores. The study also evaluated the inter-rater reliability between expert and novice raters for the 2D Visual assessment during jump-landing tasks. The tool required minimal training and time for assessment. Kappa statistics indicated small to moderate agreement (κ = 0.095–0.429) between expert and novice raters. Additionally, 2D visual assessments by both groups showed small to moderate correlations (rho = 0.11–0.49) with overall SLESS and LESS scores and small correlations (r = 0.01–0.28) with 3D kinematic and kinetic risk factors for noncontact ACL injury. The 2D Visual Assessment Tool does not display sufficient reliability and validity to warrant further investigation. Overall, this thesis demonstrates that the SLESS is a reliable tool for assessing single-leg jumplanding tasks. However, more details are required regarding its validity, as the current study highlights inconsistencies. Additionally, further assessments are needed to evaluate whether the SLESS is effective in predicting injury.

Development of single-leg jump-landing tasks to predict noncontact anterior cruciate ligament injury risk

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