Modeling of Ankle Joint Range of Motion and Landing Quality Scores in Female Soccer Players with Quantile Regression Approach

doi:10.21203/rs.3.rs-3876664/v1

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Modeling of Ankle Joint Range of Motion and Landing Quality Scores in Female Soccer Players with Quantile Regression Approach

https://doi.org/10.21203/rs.3.rs-3876664/v1

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Purpose

This study aimed to model the relationship between ankle dorsiflexion range of motion and landing quality during the Soccer-Specific Jump-Landing task (SSJL) on the non-dominant extremity in elite and amateur female soccer players using a quantile regression approach.

Methods

Fifty-five amateur and forty-seven professional female soccer players participated in the study. The relationship between ankle dorsiflexion range of motion (DF-ROM) and soccer-specific jump-landing landing technique quality was evaluated using Pearson's product-moment correlation analysis and linear regression analysis

Results

There was a statistically significant correlation between DF-ROM and SSJL landing quality in amateur female soccer players (r = − 0.63, p = 0.001), no significant correlation was found in elite female soccer players (r = 0.22, p = 0.13). QR model results for amateur female soccer players showed that ankle DF-ROM level affects landing quality more in the group with high SSJL landing quality scores (e.g., Q75 and Q90) compared to the group with low SSJL landing quality scores (e.g., Q10 and Q25).

Conclusions

Ankle DF-ROM level may be a functional clinical measurement for amateur female athletes in determining landing-related injury risk factors during SSJL.

Ankle joint

non-contact injuries

female soccer players

jump landing

Soccer is widely recognized as a prevalent sport worldwide and is increasingly attractive to female participation. Research has shown that female soccer has experienced rapid growth, encompassing professional, semi-professional, and amateur levels, and is considered the fastest-growing sport in the world [1]. Since soccer involves high-intensity technical tasks such as shooting, passing, dribbling, jumping, acceleration, deceleration, and stopping, researchers stated that as the number of soccer players increases, injury rates also increase [2]. While knee, ankle, shoulder, and head/neck injuries occur frequently in soccer, the studies reported that 86.8% of injuries related to this issue originate from lower extremity joints, such as the ankle and knee [3]. The ankle, the lowest component of the kinetic chain in the lower limb, can be negatively affected by sprains, Achilles tendon injuries, and plantar fascia injuries that occur during competition [4]. These external factors may limit ankle range of motion (ROM), and limited ankle range of motion may also identified as a significant risk factor for anterior cruciate ligament (ACL) injury [5].

Since 82% of ACL injury cases in soccer occur in non-contact situations [6], researchers have developed several testing protocols conducted in a non − contact environment to identify players at risk of injury [7]. One of these test protocols is the landing technique score. Limited ankle dorsiflexion range of motion (DF-ROM) may affect the landing technique score [5]. The relationship between stress on the knee joint during landing and ACL injury may also provide an evidence-based approach. Therefore, field experts and practitioners often interpret landing technique testing to predict anterior cruciate ligament injuries in soccer [8]. Although various protocols were improved for the landing technique, a general landing technique test protocol may not be suitable for interpreting sport-specific mechanical actions. For example, soccer players can focus on multiple tasks during a jumping motion, including both ball and landing mechanics. However, current landing technique tests may not be sufficient to interpret sport-specific landing quality [9]. Researchers claimed that the relationship between poor landing technique and DF-ROM could be better diagnosed with the soccer-specific jump-landing task (SSJL), and they reported a moderate negative correlation (r = − 0.450, p = 0.006) between DF-ROM levels and SSJL in male soccer players [9].

When comparing the rate of anterior cruciate ligament injuries between genders, a study by researchers found that female soccer players were 5.36 times more likely to experience an acute injury [10]. These results emphasized the importance of optimal ankle joint range of motion for female soccer players and the existence of mechanical differences between genders. Although the relationship between DF-ROM and SSJL has been evaluated in male soccer players [9], the relationship between DF-ROM levels and soccer-specific landing quality in female soccer players has not been investigated. Moreover, considering the physical performance differences between elite and amateur female athletes [11], the level of relationship between DF-ROM and SSJL may also vary depending on the athlete profiles. On the other hand, evaluating the current subject area with traditional correlation tests may hinder interpreting the relationship between DF-ROM and SSJL in elite and amateur female soccer players. Standard correlation tests are based on average values in a data set and may limit variables' results that involve non-linear relationships with predictive variables. Therefore, researchers have proposed alternative methods, such as quantile regression, to comprehensively evaluate predictors in a data set [12].

The effect of DF-ROM on the soccer-specific landing quality score of elite and amateur females can provide empirical evidence to field experts and practitioners. The aim of this study was to model the relationship between non-dominant ankle DF-ROM and landing quality during the SSJL task in elite and amateur female soccer players with a quantile regression approach. We hypothesized a statistically significant relationship between ankle DF-ROM and landing quality in the non-dominant limb.

Study design

This study was based on the correlational model, which is a quantitative research method, to evaluate the relationship between DF-ROM and the SSJL task. The study was conducted using a single-blind cross-sectional study design. The Quality Output Checklist and Content Assessment (QuOCCA) checklist was used to enhance the methodological quality of the study [13], and it is presented in Appendix 2. Additionally, The study protocol was pre-registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/KP7XA accessed date: 11.12.2023), and details of the study files are presented on the website (https://osf.io/mtney/ accessed date: 11.12.2023).

Participants

102 female soccer players (age: 21.30 ± 2.14 years, height: 165.10 ± 6.05 cm, weight: 56.56 ± 3.97 kg, BMI: 20.91 ± 2.25 kg∙m²) from Iran's Shahin and Khatoon soccer clubs were included in the study. The participants consisted of 55 amateur and 47 elite-level female soccer players. The participants were selected based on the following criteria in the study: (i) being over 18 years of age, (ii) having at least three years of experience in the field for amateur players, (iii) having competed in the premier, first, or second leagues for professional players (iv) participating in at least two training sessions per week, (v) not having suffered any severe lower limb injuries in the past year (such as ankle or knee sprains, or ACL tears), (vi) being out of the menstrual cycle.

The study sample was determined using the simple random method, and the sample size was determined based on the results of a previous study [9]. A priori power analysis was performed using G*Power software (version 3.1, University of Dusseldorf, Germany) based on the following reference values: α = 0.05, β = 0.80, r = 0.35, two-tailed, and bivariate normal model test. The results showed that the minimum sample size should be 61 participants, while the study included 102 female soccer players. This study was approved by the Vasile Alecsandri University Ethics Committee (decision no: 42/2, 14.12.2023) and was conducted by the Declaration of Helsinki. All subjects provided signed informed consent before being included.

Experimental Procedure

While this study was conducted in Kerman, Iran, measurements were performed on the natural grass fields at the Kargar and Fajr stadiums. A track and field coach with seven years of experience in sports carried out the study protocol. The study protocol was explained to the participants before the measurements to prevent any potential bias caused by learning. Participants were asked to refrain from eating for two hours before taking measurements. Additionally, they were allowed to drink water 30 minutes before measurements. Since the study protocol included jumping and landing tasks that required a high biomechanical load, a standardized 15-minute warm-up protocol was implemented to prevent injuries to the athletes. This warm-up protocol consisted of a 7-minute jog, double-leg squats (2 sets x 10 reps), and dynamic stretches for the hamstrings, quadriceps, and calves (2 sets x 10 reps). Before commencing the measurements, the device calibrations were verified, and all participants underwent the tests while wearing identical attire. Then non-dominant limb test, weight-bearing lunge test, vertical jump test, and soccer-specific jump landing test were performed, respectively. The best test results of the soccer players were used for statistical analysis.

Measurements

Non-dominant limb test.

The non-dominant leg of female soccer players was assessed to measure the DF-ROM level. The ball strike test was used to determine the dominant foot. This test was carried out according to the instructions specified by the researchers, and female soccer players kicked the ball into a target located four meters away. The leg used when hitting the target was considered the dominant leg. Researchers reported 100% agreement between the dominant leg reported by participants and the leg used during the ball-striking test (van Melick et al., 2017).

Weight − bearing lunge Test.

The weight − bearing lunge test was used in the study to determine the DF-ROM level of female soccer players. Researchers stated that the test has high validity (r = 0.71) and reliability (ICC = 0.80 to 0.99) for evaluating DF-ROM [14, 15]. This test was performed using the Inclinometer & Bubble Level (InclineSense Technologies, Iran) mobile app, which has high validity and reliability [16]. Measurements were performed according to instructions in previous study protocol [17]. Before measurement, each device was placed with its long axis on the ground and calibrated to 0° next to the participant. The closed kinetic chain test, which simulates ankle and knee joint loading during the landing mission and provides complete DF-ROM measurement, was chosen to perform the measurement. Participants were asked to place their hands shoulder-width apart on the wall. The non-dominant leg was placed 10 cm from the wall with the knee in line with the second toe. The dominant was placed behind the non-dominant leg with the knee extended. A mobile phone was placed on the flat surface behind the Achilles tendon, approximately one centimeter above the posterior calcaneal tuberosity and perpendicular to the tibia. An inclinometer application called Inclinometer & Bubble Level (or BublePro App) was installed on the Samsung Galaxy A72 to measure ankle DF-ROM. The subjects continued the test by flexing the knee until the heel lifted off the ground. DF-ROM measurement was completed before the heel was lifted off the ground. The test was repeated three times for the non-dominant leg, and the maximum value was used for data analysis. The details of the test protocol are presented in Fig. 1.

Vertical jump test.

The vertical jump height of female soccer players was determined with a traditional vertical jump test to perform the soccer-specific jump test. The vertical jump was measured by having each participant stand beside a wall with their non-dominant side. With feet firmly planted on the ground and hips positioned as close as possible to the wall, the participant extended the arm nearest the wall and reached as high as possible. This point of maximum reach was then marked on the wall. Throughout the exercise, it was essential to ensure that no part of the feet lost contact with the ground (Burkett et al., 2005). After marking the wall, the players jumped as high as possible. The wall was marked again at the highest point reached by the participants. The difference between these two measurements was recorded as the participant's maximum vertical jump. Participants were allowed to perform a maximum of three jumps, and the height of the ball was determined by taking the average of the two highest measurements.

Soccer-specific jump landing test (SSJL)

The SSJL test, an adapted version of the Landing Error Scoring System (LESS), was utilized to assess the landing biomechanics of soccer players. The reliability of the test was confirmed in previous studies [18]. The measurement protocol suggested by the literature was considered to increase the validity and reliability of the test [19, 20]. The test was recorded with an external video, and all female football players continued regular football training that activated the neuromuscular system. Since the age factor affects the LESS score, female soccer players of similar ages were included in this study [19, 20].

To perform the test, participants had to jump over a 7.5 − centimeter cone with the landing point positioned at a distance equal to half their height. Participants were instructed to jump vertically after landing on both feet and head a soccer suspended at a point equivalent to half of their maximum vertical jump height, landing approximately at the same location [9]. Additionally, the test was performed without shoes since footwear can impact the jumping performance of the participants. To record the tests, two digital video cameras (GoPro HERO 9, USA) were positioned 3 meters in front and to the right of the participants [9]. The test was performed three times, and the best result was used for data analysis. Each participant's landing technique was evaluated using Kinovea (version 0.7.10, USA), a valid and reliable software [21]. The evaluation was based on the criteria outlined in Appendix 1, adapted from the Landing Error Scoring System (LESS) introduced by researchers [22]. The LESS test was administered to evaluate each participant's landing technique. It was assessed 17 items on a scale ranging from 0 to 19. A higher score indicating more landing errors suggested potentially high − risk movement patterns. All participants were evaluated by an assessor trained in LESS. Movements of the lower extremities and trunk were analysed at two specific moments: (i) between the first contact of the foot with the ground and (ii) between the first contact with the land and maximum knee flexion. Because several studies suggest that the non-dominant extremity is more susceptible to injury than the dominant extremity during landing strategies in female athletes [23, 24], the evaluation was conducted solely on the non − dominant extremity to streamline the process. The mean score of three jump landing attempts was calculated to obtain an overall assessment of the landing technique.

Statistical Analysis

The study evaluated the relationship between SSJL and DF-ROM of elite and amateur female soccer players. Data were analysed by a researcher blinded to participant characteristics and not involved in the data collection process. The Kolmogorov-Smirnov test was used to check the assumption of normality. The relationship between variables was assessed using Pearson's product-moment correlation analysis. The correlation coefficient is interpreted based on the following references [25]: insignificant (< 0.10), small (0.10 − 0.29), moderate (0.30 − 0.49), strong (0.50 − 0.69), very strong (0.70 − 0.89), or excellent (> 0.90).

In addition to correlation analysis, regression analyses were also performed in the study. While potential outliers in the study data were analysed using Cook's distance, heteroskedasticity was assessed using the Breusch-Pagan test [26]. While outliers were identified in the study data (Fig. 1), heteroscedasticity was also observed (p < 0.05). Therefore, the Akaike Information Criterion (AIC) test was performed to determine the most appropriate method for the regression analysis in the study. A lower AIC value indicates a more appropriate regression analysis method [27]. Linear regression analysis was compared with quantile regression (QR) analysis to determine whether DF-ROM is a predictor of SSJL. Details regarding the comparison results are presented in Table 1.

Table 1

Comparison results of linear and quantile regression analyses based on Akaike's Information Criterion.
𝜏	Amateur Female Soccer Players				Elite Female Soccer Players
	LR		QR		LR		QR
	df	AIC	df	AIC	df	AIC	df	AIC
0.10	3	200.95*	2	215.62	3	162.65*	2	165.78
0.25	3	200.95*	2	219.73	3	162.65	2	160.03*
0.50	3	200.95*	2	202.75	3	162.65	2	161.57*
0.75	3	200.95	2	194.17*	3	162.65*	2	171.44
0.90	3	200.95	2	196.71*	3	162.65*	2	196.15
Legend. df: Freedom of degrees; AIC: Akaike’s Information Criterion; *: It is represents a more appropriate method to analyse data; 𝜏: Percentile of data (i.e., 0.90 represents the 10% that contains the highest landing scores in the dataset.); LR: Lineer regression; QR: Quantile regression.

The study data included outliers and revealed heteroscedasticity. Additionally, the AIC results showed conflicting outcomes for different percentiles. Therefore, both linear regression and QR analyses were performed in the study. While evaluating the relationship between two variables in a data set, QR analysis is based on the median values instead of the mean values [28]. In the study, QR analysis was calculated using the following equation:

$$\text{Y} = {\beta }₀\left(\text{q}\right) + {\beta }₁\left(\text{q}\right) \text{*} \text{X}₁ + {\beta }₂\left(\text{q}\right) \text{*} \text{X}₂ + ... + {\beta }\text{ᵣ}\left(\text{q}\right) \text{*} \text{X}\text{ᵣ} + {\epsilon }$$

Y represents the dependent variable in this equation, while β defines the estimation coefficients. The expression x represents the independent variable, and q represents the percentiles. Finally, the symbol ε represents the error term in the equation. QR analysis was performed based on previous studies, and five percentiles (10%, 25%, 50%, 75%, 90%) were selected [29]. While the Q10 and Q25 percentiles included female soccer players with lower SSJL landing quality scores, the Q75 and Q90 percentiles included female soccer players with higher SSJL landing quality scores.

R (ver. 4.2.2., Core Team, Vienna, Austuria) software was used for the statistical analysis and data visualization of this study. These operations were performed using the {quantreg}, {olsrr}, {ggplot2}, {gridExtra}, {patchwork}, {gtsummary}, and {performance} packages. Statistical significance was set at p < 0.05 for all analyses. The R codes of the study are presented in Appendix 3.

One hundred two female soccer players were included in the study, and all of them participated in the test session. No injuries or incidents occurred during the testing session following the study protocol.

A strong negative correlation was found between SSJL and DF-ROM of amateur female soccer players (r = − 0.63, p = 0.00). However, there was no statistically significant difference between SSJL and DF-ROM in elite female soccer players (r = 0.22, p = 0.13). Details for the correlation analyses are presented in Fig. 4.

While linear regression analyses reported that DF-ROM of amateur female soccer players could be a predictor for SSJL (β = − 0.16, p < 0001), these results were not observed in elite female athletes (β = 0.04, p = 0.20). QR analyses reported that DF-ROM levels of elite female soccer players in different percentiles were not a predictor of SSJL. Similarly, it was revealed that the DF-ROM level of amateur female soccer players in the Q10 percentile did not affect SSJL (β = − 0.06, p = 0.08). However, it was revealed that DF-ROM could be a more critical predictor as SSJL increased. The strongest negative relationship was detected between the DF-ROM level and SSJL of amateur female soccer players in the Q90 percentile with the highest SSJL scores (β = − 0.20, p < 0.001). Details of the regression analyses are presented in Table 2.

Table 2

Linear and quantile regression analysis results based on the relationship between ankle joint range of motion and soccer-specific jump landing score.
Analyses/Group	AFSP			EFSP
Analyses/Group	β	95% CI	p-value	β	95% CI	p-value
LR	-0.16	-0.21 to -0.11	< 0.001 *	0.04	-0.02, to 0.11	0.2
QR10	-0.06	-0.13 to 0.01	0.08	0.00	-0.08 to 0.08	> 0.9
QR25	-0.09	-0.17 to 0.00	0.03 *	0.07	-0.03 to 0.16	0.2
QR50	-0.18	-0.27 to -0.09	< 0.001 *	0.00	-0.08 to 0.08	> 0.9
QR75	-0.17	-0.21 to -0.12	< 0.001 *	0.00	-0.12 to 0.12	> 0.9
QR90	-0.20	-0.26 to -0.14	< 0.001 *	0.09	-0.12 to 0.30	0.4
Legend. AFSP: Amateur female soccer players; EFSP: Elite female soccer players; LR: Linear regression; QR: Quantile regression; 95% CI: Upper and lower limit of %95 confidence interval.

This study assessed the correlation between non-dominant ankle DF-ROM and landing quality during the SSJL task in female elite and amateur soccer players. Also, it aimed to model the results using a quantile regression approach. While the results of the correlational analysis indicated a strong negative correlation between landing quality and ankle DF-ROM level in amateur female soccer players (r = − 0.63, 95%CI = − 0.36 to − 0.90, p = 0.00), the analysis results for elite female soccer players were not statistically significant (r = 0.22, 95%CI = − 0.05 to 0.49, p = 0.13). Quantile regression analysis results for amateur female soccer players showed that ankle DF-ROM level affected landing quality more in the group with high landing quality scores (i.e., Q75 and Q90) compared to the group with low landing quality scores (i.e., Q10 and Q25). While these results pointed out that the DF-ROM level would not affect the landing quality during SSJL in elite female soccer players, they revealed that the DF-ROM level was more significant for amateur female soccer players with a high landing quality score.

Our findings were consistent with previous study on male soccer players using a similar protocol [9]. However, the correlation level was higher in amateur female soccer players than their male counterparts. Considering that biomechanical indicators and injury rates differ between genders [10], the study results obtained for amateur female soccer players supported the hypothesis of the literature. On the other hand, the lack of a significant correlation between the DF-ROM level of elite female soccer players and the quality of landing during SSJL can be attributed to various factors. Elite athletes have a lower injury rate than amateur athletes [30], exhibit better attention and decision-making processes [31], and achieve higher sports performance outcomes [11]. This may explain the statistically non-significant results for elite soccer players.

On the other hand, several physiological factors contribute to the statistically significant correlation between DF-ROM and the landing quality of female amateur soccer players. Due to limited ankle DF-ROM, athletes may be unable to absorb the ground reaction forces during landing in all jumping activities [32, 33]. Additionally, limitations in range of motion may increase sagittal and medial displacements of the knee, predisposing athletes to ACL injury [17]. If the knee joint cannot compensate for the ankle DF-ROM deficiency, the body may adopt the hip strategy as a compensatory kinematic chain movement strategy [34]. If the lower extremity is unable to absorb the forces generated during landing, the trunk will compensate for these deviations, resulting in changes in whole-body movement patterns [35]. Limited ankle DF-ROM can impact multiple joints and their corresponding movements, resulting in compromised movement patterns that may elevate the risk of injury [32]. The mechanism behind the impact of limited ankle DF-ROM on the landing quality of amateur female soccer players can be explained by this hypothesis. Additionally, the absence of a correlation between dorsiflexion ROM and dorsiflexion displacement may result in variations in landing technique among female amateur soccer players. These differences in landing styles may have affected landing biomechanics, particularly dorsiflexion displacement, independently of passive dorsiflexion ROM [36]. Researchers reported that limb dominance can significantly affect the coordination of skilled movement patterns, and biomechanical symmetry between the dominant and non-dominant limbs is crucial for competent performance [37]. Researchers also observed that the non-dominant limb is more vulnerable to injury due to inadequate stability [38, 39]. A study analysing asymmetries in leg dominance during the landing test showed that lower extremity biomechanics, specifically knee and hip joint range of motion, were significantly lower in the non-dominant leg [39]. These findings may explain why female amateur soccer players have poorer movement patterns for their non-dominant limbs.

LIMITATIONS

There are some limitations in the study. The first limitation concerns performing the SSJL task on the non-dominant extremity. Tests on the dominant extremity may yield varying results for female amateur soccer players. Another limitation is the age range of female soccer players. Female soccer players aged 18–25 were included in this study. Since female soccer players in younger age groups are more susceptible to injuries, the outcomes may vary between amateur and elite female soccer players in younger age groups. Therefore, future studies involving the dominant limb in younger age groups are needed. Moreover, studying the effects of various joints during SSJL could be a research topic that would yield more robust empirical evidence. As a result of, there is no relationship between landing quality and DF-ROM levels of elite female soccer players during the SSJL mission. However, the landing quality of female amateur soccer players during the SSJL mission varies depending on the DF-ROM level. Limited ankle DF-ROM affects the landing quality score of all amateur female soccer players. However, the effect of DF-ROM on landing quality scores increases in amateur female soccer players who already have high landing quality scores.

ACL = Anterior Cruciate Ligament

AIC = Akaike Information Criterion

LESS = Landing Error Scoring System

DF-ROM = Dorsiflexion Range of Motion

SSJL = Soccer-Specific Jump-Landing

QR = quantile regression

Competing Interest

None of the authors has a confict of interest.

Funding

The authors did not receive any funding during their research.

Ethics approval and informed consent

This study was approved by the Vasile Alecsandri University Ethics Committee (decision no: 42/2, 14.12.2023) and was conducted by the Declaration of Helsinki.

CRediT authorship contribution statement:

Conceptualization: N.F.R, M.A, Z.M; Data curation: N.F.R, M.A; Formal analysis: Z.M, B.A, S.K; Funding acquisition - ; Investigation: M.A, N.F.R, Z.M; Methodology: H.S.U, A.B.A, S.K; Project administration: N.F.R, M.A, A.B.A; Resources: Z.M, N.F.R, M.A; Software: H.S.U, S.K; Supervision: H.S.U, A.B.A, S.K; Validation: H.S.U, A.B.A; Visualization: N.F.R, M.A, Z.M, H.S.U, A.B.A, S.K; Writing - original draft: N.F.R, M.A, Z.M; and Writing - review & editing: H.S.U, A.B.A, S.K;

Data availability

The study data was presented through OSF (https://osf.io/mtney/).

Code availability

Analysis codes of the study are provided through OSF (https://osf.io/mtney/) and in the appendices.

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No competing interests reported.

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Modeling of Ankle Joint Range of Motion and Landing Quality Scores in Female Soccer Players with Quantile Regression Approach

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Abstract

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INTRODUCTION

MATERIALS AND METHODS

Study design

Participants

Experimental Procedure

Measurements

Soccer-specific jump landing test (SSJL)

Statistical Analysis

RESULTS

DISCUSSION

LIMITATIONS

Abbreviations

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References

Additional Declarations

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Version 1