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Reduced ankle dorsiflexion range may increase

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Journal of Science and Medicine in Sport (2006) 9, 304309

ORIGINAL PAPER

Reduced ankle dorsiexion range may increase

the risk of patellar tendon injury
among volleyball players
Peter Malliaras , Jillianne L. Cook, Peter Kent

School of Physiotherapy, La Trobe University, Vic. 3086, Australia

Received 27 January 2006 ; received in revised form 14 March 2006; accepted 16 March 2006

KEYWORDS Summary Patellar tendon injury, a chronic overuse injury characterised by pain
Tendinopathy; during tendon loading, is common in volleyball players and may profoundly restrict
Risk factors; their ability to compete. This cross-sectional study investigated the association
Range of motion; between performance factors and the presence of patellar tendon injury. These
Injury prevention performance factors (sit and reach exibility, ankle dorsiexion range, jump height,
ankle plantarexor strength, years of volleyball competition and activity level) were
measured in 113 male and female volleyball players. Patellar tendon health was
determined by measures of pain and ultrasound imaging. The association between
these performance factors and patellar tendon health (normal tendon, abnormal
imaging without pain, abnormal imaging with pain) was investigated using analy-
sis of variance. Only reduced ankle dorsiexion range was associated with patellar
tendinopathy (p < 0.05). As coupling between ankle dorsiexion and eccentric con-
traction of the calf muscle is important in absorbing lower limb force when landing
from a jump, reduced ankle dorsiexion range may increase the risk of patellar
tendinopathy.
2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Introduction and may be present in 25% of competing volleyball

Patellar tendon injury is characterised by abnor-
mal imaging, with or without pain. Abnormal imag-
ing may be present in 50% of competing volleyball
players.1,2 When tendon abnormality is accompa-
nied by pain it is classied as patellar tendinopathy,
Corresponding author. Tel.: +61 3 9479 5798;
fax: +61 3 9479 5768.
E-mail address: p.malliaras@latrobe.edu.au (P. Malliaras).
players.1,2 Patellar tendinopathy is often difcult to
treat and those affected may be unable to compete
for some time or may be at risk of early retirement
from sport.
Strength and exibility have been shown to be
associated with patellar tendon injury. Lian et
al.4 found that volleyball players with a greater
jump height, a functional measure of quadriceps
strength, were more likely to be affected by patel-
lar tendon injury. Recently, Cook et al.5 also showed
that greater jump height, as well as reduced sit and

1440-2440/$ see front matter 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2006.03.015
Risk factors for tendinopathy
reach exibility, were both associated with patellar
tendon injury.
Current or previous activity level also appear
to increase the risk of patellar tendon injury. Sev-
eral studies report an association between activity
level and patellar tendon injury.2,6,7 Ferretti et al.7
demonstrated that the number of years of volley-
ball competition is also associated with patellar
tendon injury.
Ankle dorsiexion range and ankle plantarexor
strength are important components in the absorp-
tion of lower limb load when landing from a jump.8
Increase in patellar tendon load subsequent to
impairment in these mechanisms may result in
injury. Although linked in theory, these factors have
not been empirically investigated as risk factors for
patellar tendon injury.
The aim of this study was to investigate whether
factors relating to muscle and joint exibility (sit
and reach exibility, dorsiexion range), strength
(jump height, ankle plantarexor strength) and
activity level (years of volleyball competition,
activity level) are associated with patellar ten-
don injury among volleyball players. Factors were
included based on their empirical and/or theoreti-
cal relationship with patellar tendon injury.
Materials and methods
Subjects
Male and female volunteers were recruited from
the Victorian State League competition in Australia.
All players in this competition were invited to par-
ticipate in the study. Players under 18 years of age
were not recruited in order to exclude juvenile dis-
orders such as Sinding-Larsen-Johansson syndrome.
Ethics approval was granted from the Human Ethics
Committee at La Trobe University and participants
provided informed consent before commencement
of the study.
Factors
The factors were measured over a 4-week period
spanning the commencement of the volleyball sea-
son. Assessors of these factors were blind to play-
ers imaging and pain status.
Ankle dorsiexion range was measured with a
weight-bearing lunge test.9 Sit and reach exibility
was measured by recording the centimeters of
reach, using the toes as a reference point.10 Jump
height was measured as the highest point players
displaced a marker on a jump height measure-
305
ment device during a maximal countermovement
jump from both feet (Swift Technologies, NSW,
Australia).11 Ankle plantarexor strength was
measured as the maximum number of single
leg heel raises a player could perform on at
ground.12 High levels of testretest reliability
have been demonstrated for the measurement
of ankle dorsiexion range (standard error of
measurement (S.E.M.) = 1.1 , 95% CI = 2.2 ),9 sit
and reach exibility (S.E.M. = 0.66 cm),10 jump
height (I.C.C. = 0.94)11 and ankle plantarexion
strength (S.E.M. = 2.07 repetitions).12
Years of volleyball competition was assessed via
questionnaire. Activity was measured prospectively
with fortnightly activity diaries that recorded the
weekly hours of training and playing performed in
the 7 months prior to the start of the season. Play-
ers posted the diaries to the researcher at the end
of each fortnight in reply-paid envelopes, and all
players returned most of their fortnightly diaries
(mean 94% of diaries, range 71100%). These activ-
ity diaries were used to determine the mean hours
of activity for each player.
Outcome measures
Pain and tendon abnormality on imaging were
assessed in the rst week of the volleyball season.
Pain was measured with the single leg decline squat
(SLDS) test, designed to optimally load the patel-
lar tendon.13 Players stood on a 25 decline board
and performed a single leg squat (60 of knee ex-
ion). Pain provoked was rated on a 100-point visual
analog scale. The S.E.M. for measuring patellar ten-
don pain twice within the same day using the SLDS
test has been shown to be approximately 5% (95%
CI 46%).13
An experienced musculoskeletal ultrasonogra-
pher who was blind to the risk factor scores and pain
status performed bilateral patellar tendon scans
using a high-resolution 12 MHz ultrasound imaging
machine (Siemens Accuson, Medical Solutions Inc.,
Malvern, PA, USA). Abnormal tendons were dened
as those containing a focal hypoechoic region evi-
dent in both the longitudinal and transverse images
and/or appeared diffusely hypoechoic and thick-
ened in the proximal tendon. Ultrasound imaging
was chosen as it has demonstrated perfect relia-
bility in detecting abnormality within the patellar
tendon (r = 1.00).14
The outcome variable comprised three groups
with different tendon health: (1) normal tendons
(no pain or tendon abnormality); (2) tendon abnor-
mality without pain; and (3) patellar tendinopathy
(tendon abnormality with pain). Painful tendons
without tendon abnormality were excluded as there
306
is a greater likelihood that pain in this group arises
from a non-tendon structure, such as the patello-
femoral joint.3
Data analysis
All data in this study were analysed using SPSS
for Windows (Version 13; SPSS, Chigaco, IL, USA).
Descriptive data (mean, S.D.) for age, weight,
height, average weekly activity and years of vol-
leyball competition were produced for the sample.
The mean (S.D.) was presented for each potential
risk factor across the three groups. One-way ANOVA
was used to investigate the relationship between
the potential risk factors and the outcome of ten-
don health. Post hoc tests (Student Newman-Keuls)
were performed to identify differences between
tendon health groups and their associations with
signicant risk factors. Right and left patellar ten-
don data were investigated separately to satisfy the
assumption of independent observations. The alpha
level was set at 0.05.
For each signicant association between a risk
factor and tendon health, receiver operator charac-
teristic (ROC) curves were calculated to investigate
the risk factor score that most accurately discrim-
inated between injured and uninjured tendons. A
ROC curve plots the true-positive rate (sensitiv-
ity) against the false-positive rate (one minus the
specicity) for each possible cut-off score. The area
under the ROC curve can be interpreted as the prob-
ability of the presence of a particular risk factor
correctly identifying an injured player from ran-
domly selected pairs of players who are injured and
uninjured. The area under the curve can range from
0.5 (no diagnostic accuracy) to 1.0 (perfect diag-
nostic accuracy).16
The prevalence of injury in the sample was
noted and used to determine the pre-test odds of
being injured. For each signicant risk factor, the
ROC curve-derived risk factor score was used to
calculate the relative risk of injury. For each of
these risk factors, the pre- and post-test probabil-
ity of injury were also calculated and the absolute
risk increase explained by the risk factor was
determined. Relative risk = probability of injury
in the presence of the risk factor/probability
of injury in the absence of the risk factor.
Table 1 Descriptive data for the sample
Age (years) Weight (kg) Height (m)
Right 25.8 (S.D. 4.9) 79.3 (S.D. 13.0) 1.81 (S.D. 0.1)
Left 26.1 (S.D. 5.4) 79.3 (S.D. 13.5) 1.81 (S.D. 0.1)
P. Malliaras et al.
Pre-test odds = pre-test probability/(1 pre-test
probability of injury). Post-test odds = pre-test
odds positive likelihood ratio or negative
likelihood ratio, where the positive likelihood
ratio = sensitivity/(1 specicity), and nega-
tive likelihood ratio = (1 sensitivity)/specicity.
Post-test probability = post-test odds/(post-test
odds + 1). Absolute risk increase = post-test proba-
bility if risk factor is present post-test probability
if risk factor is absent.17
Results
After excluding painful tendons that did not con-
tain tendon abnormality, data were available for 91
tendons (60 male, 31 female) on the right side and
99 tendons (64 male, 35 female) on the left side.
Descriptive data for age, height, weight, average
weekly activity level and years of volleyball com-
petition are shown in Table 1.
The mean (S.D.) for each factor across each
group are shown in Tables 2 and 3. More than 25%
of tendons had abnormal imaging without pain and
patellar tendinopathy on each side. The only poten-
tial risk factor that appeared to be associated with
tendinopathy was ankle dorsiexion range. There
was a signicant difference in ankle dorsiexion
range between the tendon health groups on the
right side (p = 0.03) and a trend towards a differ-
ence on the left side (p = 0.08). For the data on
both sides of the body, post hoc tests indicated
that players with patellar tendinopathy had signif-
icantly lower ankle dorsiexion range than players
with normal tendons.
The area under the ROC curves (Figs. 1 and 2)
was 0.70 on the right side and 0.65 on the left side.
Based on the coordinates of the ROC curves, the
ankle dorsiexion score that most accurately iden-
tied tendons with patellar tendinopathy was 45 .
There was a post-test probability of approximately
75% or more that tendons were normal in players
with greater than 45 of ankle dorsiexion range
(Table 4). In contrast, there was a post-test prob-
ability of approximately 50% or less that tendons
were normal in players with less than 45 of ankle
dorsiexion range (Table 4).
Average weekly Years of volleyball
activity (h) competition
4.7 (S.D. 1.6) 8.4 (S.D. 4.5)
4.5 (S.D. 1.6) 8.4 (S.D. 4.7)
Risk factors for tendinopathy 307

Table 2 Descriptive data for the factors and signicance on the right Side
Tendon health p-value
Normal Imaging abnormality Imaging abnormality
without pain with pain
N 40 (44%) 24 (26%) 27 (30%)
Sit and reach exibility (cm) 4.1 (S.D. 9.0) 4.8 (S.D. 9.4) 7.2 (S.D. 10.1) .58
Ankle dorsiexion range ( ) 47.2 (S.D. 6.5) 44.4 (S.D. 6.1) 42.7 (S.D. 7.5) .03
Jump height (cm) 484.5 (S.D. 99.6) 527.3 (S.D. 84.5) 501.3 (S.D. 86.2) .35
Ankle plantarexor strength 26.2 (S.D. 12.5) 25.4 (S.D. 10.6) 26.3 (S.D. 13.3) .95
(frequency)
Off-season activity (hours) 3.2 (S.D. 1.7) 3.2 (S.D. 1.9) 3.1 (S.D. 1.6) .77
Years of volleyball (years) 7.5 (S.D. 3.8) 8.4 (S.D. 4.2) 9.6 (S.D. 5.6) .39
Signicant p-values are bold.

Table 3 Descriptive data for the factors and signicance on the left side
Tendon health p-value
Normal Imaging abnormality Imaging abnormality
without pain with pain
N 47 (48%) 26 (26%) 26 (26%)
Sit and reach exibility (cm) 5.7 (S.D. 8.8) 4.8 (S.D. 9.4) 6.7 (S.D. 10.4) .51
Ankle dorsiexion range ( ) 45.1 (S.D. 6.1) 44.3 (S.D. 7.5) 41.8 (S.D. 6.8) .08
Jump height (cm) 494.2 (S.D. 96.1) 507.7 (S.D. 104.3) 501.7 (S.D. 90.3) .94
Ankle plantarexor strength 25.7 (S.D. 10.7) 23.1 (S.D. 14.1) 23.4 (S.D. 12.1) .59
(frequency)
Off-season activity (hours) 3.0 (S.D. 1.6) 3.4 (S.D. 2.0) 2.7 (S.D. 1.3) .33
Years of volleyball (years) 7.4 (S.D. 3.5) 8.6 (S.D. 5.5) 10.1 (S.D. 5.4) .14

Figure 1 ROC curve for the possible cut-off points in Figure 2 ROC curve for the possible cut-off points in left
right ankle dorsiexion range. ankle dorsiexion range.

Discussion than that reported in the literature (5052%).1,2

However, the prevalence of patellar tendinopathy
In this sample of volleyball players, the prevalence in the current sample (2630%) was similar to that
of abnormal imaging without pain (26%) was lower previously reported (2627%).1,2
308 P. Malliaras et al.

In the current study, patellar tendinopathy was

associated with reduced range of ankle dorsiex-
75.0% (6086%)
70.2% (5681%)

ion when compared with normal tendons. Less than

45 of ankle dorsiexion range appeared to be the
Specicity
(95% CI)

score that best differentiated normal tendons and

patellar tendinopathy. Having less than 45 of ankle
dorsiexion range increased the risk of patellar
tendinopathy by 1.82.8 times.
70% (5284%)
54% (3671%)

Reduced ankle dorsiexion range may be a risk

Sensitivity

factor for the development of patellar tendinopa-

(95% CI)

thy due to its contribution to lower limb force

absorption. When landing from a jump, the fore-
foot usually contact the ground and then the ankle
moves into dorsiexion.18 This movement is cou-
2.8 (1.65.1)
1.8 (1.03.2)
Relative risk

pled with eccentric calf muscle contraction that

accounts for between 37 and 50% of the total kinetic
(95% CI)

energy absorbed by the muscular system during

landing.18 Restricted dorsiexion range may lead
to altered lower limb landing biomechanics that
potentially increase patellar tendon load and the
Absolute risk

risk of tendon injury.

Relative risk, pre- and post-test probability, absolute risk increase, sensitivity and specicity

Maintenance of ideal ankle dorsiexion range

increase

among volleyball players may have implications

44%
23%

for prevention of patellar tendinopathy. Dorsiex-

ion range can be reduced after inversion ankle
sprains, the most common acute injury among vol-
(<45 ankle dorsiexion)

leyball players.19 Players without previous ankle

injury can have reduced ankle dorsiexion range
Post-test probability

due to tightness of the calf muscle-tendon unit20

or inherent ankle joint stiffness. Effective manage-
ment to regain dorsiexion range among volleyball
players who suffer ankle injuries and attention to
calf stretching and joint mobilising among players
66%
50%

with inherent restrictions may reduce the risk of

patellar tendinopathy.
In these data, calf muscle strength was not asso-
(>45 ankle dorsiexion)

ciated with patellar tendinopathy, despite impair-

Post-test probability

ment in the coupling between ankle dorsiexion

movement and eccentric contraction of the calf
muscle being hypothesised to lead to an increased
risk of patellar tendinopathy.8 This may be due to
lack of specicity in type of calf strength mea-
sured. The current study measured calf endurance
21%
27%

at a rate of one calf raise every 2 s. This may not

appropriately mimic the calf muscles capacity to
rapidly contract eccentrically when landing from a
Pre-test probability

jump.18
Jump height4,5 and activity level2,7 have been
(prevalence)

reported to be associated with patellar tendon

injury in previous studies but were not signicant in
the current study. This may be due to varying deni-
40%
36%

tions of patellar tendon injury in the current study

and in previous studies. The current study consid-
Table 4

ered pain and tendon abnormality when dening

Right
Left

patellar tendon injury, whereas previous studies

only considered pain 4,21 or tendon abnormality.5
 Risk factors for tendinopathy
There are some limitations to the current study
that need to be considered. The cross-sectional
design of the current study cannot exclude that
reduced ankle dorsiexion range may be a con-
sequence of patellar tendon injury. Longitudinal
studies are required to conrm whether reduced
ankle dorsiexion range precedes patellar tendon
injury. There is also the possibility that if ankle dor-
siexion does precede injury, it has an inuence
on injury via a third unknown factor. A randomized
controlled trial with ankle dorsiexion range as the
intervention is required to investigate whether this
ankle dorsiexion range has a causal inuence on
injury. In addition, these risk factor ndings in adult
male and female volleyball players may not apply
to younger players or participants in other sports.
Practical implications
Ankle dorsiexion range is associated with
patellar tendinopathy among adult volleyball
players.
Players with less than 45 of ankle dorsiexion
range appear to have a greater risk of patellar
tendinopathy.
Improving dorsiexion range among players
with reduced range may have implications for
the prevention of patellar tendon injury.
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