The Relationship Between Static Posture and

ACL Injury in Female Athletes

)anice K. loudon, PhD, PT, ATC, SCS'
Walter )enkins, MS, PT, A T C ~
Karen I. loudon, MS, PT, A T C ~

he participation of

T
women in athletics has
steadily increased since
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Female participation in athletics has increased dramatically over the last decade.
Accompanying the increase in participation in sports is the increase incidence of anterior cruciate
ligament (ACL) injury. The purpose of this study was to examine the correlation between static

the advent of Title IX
(9). Due to the increase
in athletic participation by women,
the incidence of athletic injuries has
increased (9,19). In this population,
the knee is a common injury site,
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
postural faults in female athletes and the prevalence of noncontact ACL injury. Twenty ACL-injured
females and 20 age-matched controls were evaluated. Seven variables were measured: standing
pelvic position, hip position, standing sagittal knee position, standing frontal knee position,
hamstring length, prone subtalar joint position, and navicular drop test. A conditional step-wise
logistic regression analysis revealed the factors of knee recurvatum, an excessive navicular drop,
and excessive subtalar joint pronation to be significant discriminators between the ACL-injured and

and injuries to the anterior cruciate
ligament (ACL) are one of the most
common knee injuries (29). From
epidemiological studies, it appears
that female athletes have a higher
incidence of noncontact ACL injuries
than males (2). This type of injury
occurs due to deceleration of the
lower limb, forced hyperextension of
Journal of Orthopaedic & Sports Physical Therapy®
noninjured groups. These findings may have implications regarding rehabilitation techniques in
physical therapy.
Key Words: anterior cruciate ligament, female athletes, postural faults
' Assistant Professor, Department of Physical Therapy Education, University of Kansas Medical Center,
Kansas City, KS. Address for correspondence: 3056 Robinson, University of Kansas Medical Center, Kansas
City, KS 66 160-7601.
Associate Clinical Professor, Department of Physical Therapy, East Carolina University, Creenville, NC
' Staff Therapist, Watkins Memorial Hospital, University of Kansas, lawrence, KS

the knee, or forced tibial rotation

(6,21,24,28). The injury may be an
isolated tear of the ACL or a com-
bined injury also involving secondary
restraints.
Athletes with lower extremity bio-
mechanical deviations may be at
greater risk of injury to the ACL than
those without. Biomechanical abnor-
malities of the lower extremity are
related to knee pathologies (eg.,
patellofemoral pain) (26), but the
relationship between lower extremity
biomechanical faults and injuries to
the ACL has only briefly been investi-
gated, especially with the female ath-
lete. Beckett et al found that subjects
with ACL injuries had greater
amounts of subtalar joint pronation
than noninjured subjects and con-
cluded that hyperpronation of the
foot and ankle may increase the risk
of injury to the ACL (3). Woodford-
Rogers et al measured navicular
drop, calcaneal alignment, and ante-
rior knee joint laxity in an ACL
injured group and an age-matched
control group (31). The investigators
found that the ACLinjured group
had greater amounts of navicular
drop, suggesting increased subtalar
joint pronation and greater anterior
knee joint laxity in the uninvolved
limb. Coplan reported that abnormal
pronators were found to have in-
creased passive knee rotation at 5" of
knee flexion, and that there may be a
very important relationship between
pronation and rotational knee joint
laxity (7). Vogelbach and Combs as
well as Tiberio concluded that exces-
sively or prolonged subtalar joint pro-
nation results in increased internal
tibial rotation, which leads to in-
creased medial knee stress (26,27).
Since noncontact ACL injuries
may be produced by knee hyperex-
tension or forced internal tibial rota-
tion, abnormal postures that allow
these positions to occur may also in-
crease stress to the ACL and lead to
injury. Repeated forces on the ACL
may surpass the capacity and recovery
limits of the ligament, resulting in
disruption (21). A static posture, con-
sisting of anterior pelvic tilt, ante-
verted hips, tight hamstrings, genu
recurvatum, and subtalar joint prona-
tion, may place an individual in knee
hyperextension and increased inter-
nal tibial rotation during dynamic
movement, putting greater stress on
the anterior cruciate ligament and
exposing this ligament to forceful

JOSPT Volume 24 Number 2 August 1W6

 RESEARCH STUDY
stretch. The purpose of this study was
to determine if static postural faults
correlate with noncontact ACL injury
in female athletes.
MATERIALS AND METHODS
Twenty females with one anterior
cruciate ligament-injured knee and
one normal knee were recruited for
this casecontrol study (age range =
16-41 years, X = 26.5 2 7.6 years).
Inclusion criteria included arthroscopic
examination of the ACL rupture and
injury occurrence within 2 years of test
date. The involved limb was either re-
constructed or the patient chose con-
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Since noncontact
anterior cruciate
ligament injuries may
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
be produced by knee
hyperextension or
forced internal tibial
rotation, abnormal
postures that allow
Journal of Orthopaedic & Sports Physical Therapy®
these positions to
occur may also
increase stress to the
anterior cruciate
ligament and lead
to injury.
semtive nonoperative management
(eight surgical, 12 nonsurgical). "Ath-
lete" was operationally defined as an
individual who participated in a sport
two to three times a week, which in-
volved start-stop running/jumping,
such as basketball, volleyball, tennis, or
soccer. Twenty age-matched athletic
females (age range = 16-41 years,
- orly tilted. For classification purposes,
X = 26.2 ? 7.8 years) with nonpathe
92
Anterior
Cmciate _,-,
Variables Ligamer
Group
- -
X SD X SD
Age (years) 26.5 7.6 26.2 7.8
Height (cm) 172.1 7.5 165.6 6.1
Weight (kg) 64.2 6.8 60.3 5.4
Activity (hourshueek) 11.5 2.9 10.8 3.7
TABLE 1. Characteristics of subjects.
logical knees were recruited as a con-
trol group. Descriptive information for
both groups is found in Table 1.
After obtaining informed consent
to take part in the study, seven mea-
sures were assessed on each subject,
including the involved side for the
ACLinjured group. The seven vari-
ables were pelvic position, femoral
anteversion, hamstring length, stand-
ing sagittal knee extension, standing
knee angle in the frontal plane, the
navicular drop test, and subtalar joint
neutral position. Each variable was
classified into three categories. The
categories were: normal range, low
range, and high range. The catego-
ries were determined prior to the
start of data collection and were de-
cided upon by normative data found
in the literature.
One of the three authors UKL)
was designated as the tester for all
subjects. Intrarater reliability was as-
sessed for each variable by the test-
retest method on 10 lower limbs.
Tilt of the pelvis was assessed by
the method described by Kendall et
al (15). The alignment of the ante-
rior superior iliac spine and pubic
syrnphysis was assessed in standing
using a straight edge. If these two
landmarks fell within the same verti-
cal plane, the subject's pelvis was clas-
sified as neutral; if the anterior supe-
rior iliac spine fell in front of the
pubic symphysis, the subject's pelvis
was classified as anteriorly tilted; and
if the anterior superior iliac spine fell
behind the pubic syrnphysis, the s u b
ject's pelvis was classified as posteri-
neutral was classified as normal, ante-
rior tilt was classified as high, and
posterior tilt was classified as low.
Testing for femoral anteversion
was performed with a manual goni-
ometer, according to the clinical
method described by Ruwe et al (25).
Subjects were placed in a prone posi-
tion, with the knee flexed to 90". The
greater trochanter was palpated,
while the hip was passively moved
from internal and external rotation
by the tester. At the point where the
greater trochanter was palpated in its
most lateral position, the angle of the
lower leg to the vertical plane was
measured. If the measurement was
greater than 15" of internal rotation,
the hip was designated to be ante-
verted. A retroverted position was
designated as less than 8" of internal
rotation in the test position. Ante-
verted hips were documented as a
positive number of degrees, with a
negative number designating a r e t r e
verted hip. Anteverted hips were clas-
sified as high, retroverted hips were
classified as low, and between 8 and
15" was considered normal.
Hamstring length was assessed,
with the subject in the supine position,
by measuring the angle of maximal hip
flexion with the knee placed in neutral
rotation (15). An angle between 80
and 95" was classified as normal, an
angle below 80" was classified as low,
and an angle greater than 95" was
high.
Standing knee extension in the
sagittal plane was measured with the
subject standing in an erect posture,
with the involved lower extremity
placed in a position of hip extension
and knee extension. The subject was
asked to shift her weight onto the
involved lower extremity and to bring
the knee into a maximal position of
knee extension. The knee extension
angle was measured using a standard
range of motion technique as de-
scribed by Norkin and Levangie (22).
An angle between 0 and 5" of hyper-
extension was classified as normal, an
angle greater than 5" of hyperexten-
sion was classified as high and
Volume 24 Number 2 August 1996 JOSPT

termed genu recurvatum, and an an-
gle less than 0" was classified as low.
The relative position of the knee
in the frontal plane was measured by
the Qangle method as described by
Magee (18). Subjects were measured
in the standing position with the
knee fully extended and the axis of a
goniometer placed over the center of
the patella. The lever arms were
pointed toward the anterior superior
iliac spine proximally and the tibia1
TABLE 2. Variable components.
tubercle distally. Measures were re-
corded, with values between 18 and
22" designated as normal, values
greater than 22" were designated as
high, and values below 18" were des-
ignated as low.
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The navicular drop test was uti-
lized as a clinical measure of prona-
tion. Subjects were asked to begin
this test by sitting with their subtalar
joint palpated in the neutral position.
The subtalar joint neutral position is
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
defined as the position of maximum
congruency between the talus and
the calcaneus. Palpation of subtalar
neutral was performed by palpation
of the talar head on both the medial
and lateral side of the joint (1 1). The
height of the navicular was measured
from the floor to the distal most
point on the navicular bone. Subjects
Journal of Orthopaedic & Sports Physical Therapy®
then stood with the foot in a relaxed
position. The navicular distance was
FIGURE 1. Ndvrcubr drop test: d vertical measure- joint measurement was then recorded
ment from the navicular tubercle to the ground with in the number of degrees of varus
the ioot in subtalar joint neutral.
JOSPT Volume 24 Number 2 August 1W6
Normal
Variables
Value
Pelvic tilt Neutral
Hip position Neutral
Sagittal knee position 0-5"
Frontal knee position 18"
Hamstring length 80-95"
Navicular drop test 6-9 mm
Subtalar joint position Neutral
0-2" varus
remeasured (Figure 1). The differ-
ence between the two navicular dis-
tances was calculated. A difference
value of 6 mm was considered nor-
mal, greater or equal to 9 mm was
considered high, and values less than
6 mm were considered low. These
values were determined from a con-
sensus of the literature (5,20,31).
Measurement of rearfoot position
in subtalar joint neutral was accom-
plished by the palpation method de-
scribed by Hunt and McPoil (13).
Subjects were placed in the prone
position with the hip in neutral rota-
tion, the knee fully extended, and
the foot and ankle off the plinth.
The talus was then palpated on the
medial side at the talonavicular joint
when the foot was placed in a prona-
ted position. The lateral aspect of the
talus was then palpated in the sinus
tarsus when the foot was supinated.
When the talus was palpated equally
on medial and lateral sides, the foot
was gently dorsiflexed until there was
slight tension; this position was iden-
tified as subtalar joint neutral. The
rearfoot position was then observed
by assessing the angle between the
middle of the calcaneus and the mid-
dle of the lower leg. Measurement of
this angle can be performed by align-
ing the axis of the goniometer poste-
rior to the talus with the lever arms
of the goniorneter parallel to the
middle of the calcaneus and the mid-
dle of the lower leg. The subtalar
'from an ideal alignment in which the
RESEARCH STUDY
High Value
Anterior Posterior
Anteverted Retroverted
>15" internal <8" internal
rotation rotation
6" or greater Less than 0°
Greater than 18" Less than 18"
Greater than 95" Less than 80"
Greater than 9 mm Less than 6 mm
Varus deformity Valgus deformity
>2" varus
lower leg and calcaneus were parallel.
A normal value was 0-2", a value of
3" or greater varus was considered
high, and a value of 1" or greater
valgus was considered low. Table 2
lists the seven variables measured and
the classifications of each variable.
Data Analysis
Reliability of test measures is criti-
cal in any research project Intrarater
reliability was assessed for each inde-
pendent variable using a test-retest
method on 10 limbs. Each variable for
each limb was placed in a ca:egoIy
(eg., pelvis was anteriorly tilted and
classified as high). This was repeated
on the same subject on the same day
approximately 15 minutes apart. Co-
hen's kappa was used to assess in-
trarater reliability for all variables.
To address the purpose of the
study, univariate and multivariate statis
tics were used. Each variable was as-
sessed independently first. For statisti-
cal purposes, the low and high range
groups were collapsed to an abnormal
group. This was done because many of
the variables were only represented in
two of the three groups. The seven
independent variables present as cate-
gorical data (normal or abnormal);
therefore, the McNemar test of symme-
try was used to assess univariate signifi-
cance for each. Significance level was
set at cr < 0.05.
Next, a multivariate analysis was
undertaken to assess the combination
of the seven variables in discriminat-
ing between ACLinjured and nonin-
93
 RESEARCH STUDY

Variable Kappa Value Step Chi-square

Term Entered df p value
Number Value
1 Sagittal knee position 1 13.45 0.0001
2 Navicular drop 1 8.73 0.003
3 Subtalar joint position 1 4.07 0.044
Significant level set at p < 0.05.
TABLE 5. Conditional stepwise logistic regression.

TABLE 3. Kappa values for intrarater reliability of

seven variables.
jured groups. A conditional stepwise
logistic regression was used to assess
for multivariate significance of all
seven variables. From the logistic re-
gression, the variables that were sig-
nificant contributors to determining
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position, frontal knee position, and
hamstring length. In the normal
group, all three categories were r e p
resented in two of the seven variable
groups, including hip position, sagit-
tal knee position, frontal knee posi-
tion, hamstring length, and navicular
drop test. Because so many variable
regression are found in Table 5. Re-
sults indicate that excessive sagittal
knee position, excessive navicular
drop, and excessive subtalar joint
pronation were predictors of group
classification. All other variables did
not significantly contribute to deter-
mination of group membership.

group membership were identified. groups only had representation in

Significance level was set at P < 0.05.
RESULTS
lntrarater Reliability
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
two categories, it was decided to di-
vide the variables into a normal and
abnormal class for statistical testing.
The McNemar test of symmetry
was used to determine the signifi-
DISCUSSION
Injuries to the female athlete have
escalated with increasing participation
in competitive sports. Malone et al

cance of individual variables as a dis- found that female intercollegiate

Results of the Cohen's kappa
analysis are listed in Table 3. These
values exceeded 0.61 for each vari-
able, indicating substantial agreement
(16,17). With these results, the study
was then undertaken using the same
tester for all subjects.
Journal of Orthopaedic & Sports Physical Therapy®
criminator between ACLinjured sub-
jects and normals. Chi-square values
are generated from this analysis, and
these values are listed in Table 4. Sig-
nificant values included the variables
of anterior pelvic tilt, knee recurva-
tum, excessive navicular drop, and
excessive subtalar joint pronation.
NCAA basketball players are signifi-
cantly more likely than their male
counterparts to have an ACL injury
(19). Reasons for this increase in fe-
male injuries range from the theory of
femoral notch size and shape to in-
creased speed and aggressiveness of
play (12). This present study was un-

Univariate Measures dertaken because the authors clinically

Table 4 lists the distribution of
the two groups into one of three cat-
egories for each of the seven inde-
pendent variables. In the ACL-
injured group, only two categories
were represented for the variables of
pelvic tilt, hip position, sagittal knee
Multivariate Measure
The purpose of using a logistic
regression model is to identify the
variables which contribute signifi-
cantly to group membership (ACL
injured and noninjured). The results
of the conditional stepwise logistic
found a specific postural pattern
present in the female athletes with
ACL injuries. An n postural
model was developed, which included
postural characteristics that may predis-
pose the anterior cruciate ligament to
abnormal stress. Figure 2 is an exam-
ple in the sagittal view of this posture

Anterior Cmciate Ligament-Injured Normals

Chi-
Abnormal Abnormal p value
Norm Norm Square
High Low High Low
Pelvic position 3 17 0 12 6 2 9.00* 0.003
Hip position 11 0 9 6 0 14 2.78 0.096
Sagittal knee position 2 18 0 15 5 0 11.27' 0.001
Frontal knee position 2 0 18 2 0 18 1.00 0.31 7
Hamstring length 6 0 14 11 0 9 2.27 0.1 32
Navicular drop 4 15 1 14 6 0 7.1 4* 0.008
Subtalar joint position 5 14 1 15 4 1 8.33* 0.004
- - -

* Significant value (p < 0.05) included the variables of pelvis, knee position, navicular drop test, and subtalar joint position.
TABLE 4. Classification of anterior cruciate ligament-injuredand normals for seven variables (N = 20 for each group).

94 Volume 24 Number 2 August 1996 JOSPT


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Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 2. Faulty static posture: sagittal view of faulty
posture, including anteriorly tilted pelvis and knee
joint hyperextension.
type. The posture includes an anterior
pelvic tilt, internal rotation of the hip,
increased valgus at the knee, recurva-
tum of the knee, and excessive subtalar
joint pronation.
Journal of Orthopaedic & Sports Physical Therapy®
The results of this study suggest
there is a strong association between
noncontact injuries to the anterior
cruciate ligament in female athletes
and females who display a standing
posture of genu recurvatum with s u b
talar joint overpronation. Static pos-
ture is the starting point for dynamic
movement. The proprioceptive sys-
tem of the individual who presents
with knee recurvatum and excessive
subtalar joint pronation will recog-
nize this position as normal. When
this individual is placed in a dynamic
situation in which the knee is stressed
beyond normal, the ACL may be at
greater risk.
Pelvic Position
According to Kendall et al, the
pelvic position dictates lower ex-
JOSPT Volume 24 Number 2 August 1996
tremity alignment (15). An exces-
sive anterior tilt of the pelvis causes
tightening of the hip flexors, posi-
tioning the femur in relative flex-
ion. A flexion moment at the hip is
counteracted with an extensor mo-
ment at the knee, leading to hyper-
extension of the knee joint (15). In
the present study, a significant rela-
tionship was found between pelvic
position and incidence of ACL in-
jury when pelvic position was ana-
lyzed as a univariate measure, but
not when the multivariate test was
used for analysis.
Hip Position
Hip anteversion is characterized
by excessive internal rotation of the
shaft of the femur in stance. Ac-
cording to Tiberio, internal rota-
tion of the femur predisposes an
individual to pronation of the foot
(26). Feagin et a1 discussed the im-
portance of femoral rotation in the
transverse plane as a mechanism of
injury to the ACL and found that,
in tibia1 internal rotation, the ACL
is stretched over the lateral femoral
condyle (10). Arms et a1 found that
internal rotation and varus move-
ments increase ACL strain. In the
present study, however, hip position
did not discriminate between ACL
injured and normal knees (1). Per-
haps if the total range of internal
rotation had been analyzed or if the
measure had been taken in weight
bearing, this factor may have been
significant.
Frontal Knee Position
An excessive Qangle has fre-
quently been associated with knee
pathology, such as patellofemoral
pain (14). An increased Qangle may
be caused by increased femoral ante-
version (8). Since our model in-
cluded the anteversion measurement,
we decided to include Qangle as a
variable. Also, patellofemoral pain is
a complaint of individuals with ACL
injury (4). In the present study, the
RESEARCH STUDY
Hip position did not
discriminate bet ween
anterior cruciate
ligament-injured and
normal knees.
Qangle variable did not significantly
affect the predisposition to ACL in-
jury. Surprisingly, most of the s u b
jects in both groups fell into the a b
normal (low) category for frontal
knee position. Woodall and Welsh
report that the Qangle is a "less reli-
able physical finding than was previ-
ously believed" (30). If the patella sits
laterally, this would introduce error
into the measurement. Also, if the
subject stands in a pronated position,
this may affect the Qangle value.
Sagittal Knee Position
Norwood and Cross demon-
strated in cadavers that the ACL im-
pinges on the anterior intercondylar
notch with the knee in full extension
(23). Injury to the ACL usually re-
sults from the leg being in a position
of internal rotation and hyperexten-
sion (4). The resting position of knee
hyperextension may produce a pre-
loading effect on the ACL since it
increases the tension on the ligament
(3). If an athlete starts or ends a
jump or decelerates with the knees
hyperextended, any additional exten-
sion force to the knee could lead to
failure of the anterior cruciate liga-
ment. A predisposition to noncontact
injuries of the ACL may exist in fe-
male athletes with knee recurvatum
as found in this study.
Hamstring length
Harner et a1 (12) found a signifi-
cant difference in hamstring tight-
ness in ACLinjured and normal fe-
males, in which the ACLinjured
 RESEARCH STUDY
possessed short hamstrings. It has
been stated in the literature that
tightness in the hamstrings will help
prevent increased anterior translation
of the tibia in the absence of the
ACL (6). Our study found no signifi-
cant difference between groups and
hamstring length. The majority of
the female athletes tested had tight-
ness in the hamstrings.
Subtalar Joint Pronation and
Navicular Drop Test
Subtalarjoint pronation and tibial
internal rotation occur together during
the contact phase of the gait cycle. The
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anterior cruciate ligament becomes
taut with tibial internal rotation. P r e
longed pronation of the foot produces
excessive internal tibial rotation and
may produce a preloading effect on
the ACL (7). Since abnormal prona-
tion leads to increased strain on the
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ACL, athletes who abnormally pronate
may be more prone to injury of this
ligament, particularly with running,
cutting, or twisting activities. Two inde-
pendent studies have found a signifi-
cant difference in the navicular drop
test in individuals with ACL injury and
matched controls (3,31). Beckett et al
examined two groups of 50 athletes, a
Journal of Orthopaedic & Sports Physical Therapy®
Previous investigations
concluded that injury
to the anterior
cruciate ligament
usually results from
the femur being in a
position of internal
rotation and
hyperextension in
relationship to the
fixed tibia.
group with ACL injury and a group
with normal knees (3). The ACL
injured subjects had greater navicular
drop test scores than noninjured s u b
jects. Woodford-Rogers et a1 examined
14 football players and eight gymnasts
with ACL injuries and compared them
with an agesex-sportsmatched control
group (31).They also found an in-
crease in navicular drop in the ACL
injured group, suggesting increase in
subtalarjoint pronation. The results of
both studies are consistent with the
finding in the current study.
A combination of genu recurva-
tum and subtalar joint pronation
would cause greater strain to the an-
terior cruciate ligament than a single
postural fault. Several previous inves-
tigations concluded that injury to the
ACL usually results from the femur
being in a position of internal rota-
tion and hyperextension in relation-
ship to the fixed tibia (3,4,25).
Therefore, it is not surprising that
athletes in this study with knee recur-
vatum and subtalar joint pronation
had a greater prediction for ACL in-
jury than those with only pronation
or no postural faults.
Clinical Implications
Treatment for female athletes
with postural faults should focus on
optimal positioning of the joints to
decrease stress on soft tissue, includ-
ing ligaments. Appropriate footwear
and orthotics would help with over-
pronation. Also, training the athlete
to stand and move in optimal p o s
tural patterns should carry over to
dynamic situations.
SUMMARY
The purpose of this study was to
explore the relationship between se-
lected static posture variables and
prevalence of ACL injury in female
athletes. The combination of knee
hyperextension with excessive subta-
lar joint pronation proved to be a
strong discriminator between injured
and noninjured groups. As a result of
the findings in this study, training to
prevent hyperextension of the knee
and correction of excessive pronation
are worth addressing in this popula-
tion.
Future Study
Further studies should investigate
the cause and effect relationship be-
tween static posture and ACL injury
in the female athlete, perhaps using
a prospective design. Also, only static
postures were examined in this
present study and one cannot ignore
the importance of motor control on
movement. Continued studies need
to focus on dynamic posture and its
effect on ACL injury. JOSPT
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