The Knee 20 (2013) 532536

Contents lists available at ScienceDirect

The Knee

A diagonal landing task to assess dynamic postural stability in ACL

reconstructed females
Matthew R. Patterson a,c,, Eamonn Delahunt a,b
a
b
c

School of Public Health, Physiotherapy and Population Science, University College Dublin, Health Sciences Centre, Beleld, Dublin 4, Ireland
Institute for Sport and Health, University College Dublin, Dublin, Ireland
Clarity Centre for Sensor Web Technologies, University College Dublin, Ireland

a r t i c l e

i n f o

Article history:
Received 28 January 2013
Received in revised form 9 July 2013
Accepted 12 July 2013
Keywords:
Landing
Time to stabilization
Ground reaction force
Dynamic balance
Postural control

a b s t r a c t
Background: Previous research has used time to stabilization (TTS) from forward landing tasks to assess dynamic
postural stability in ACL reconstructed (ACLR) athletes in order to identify impaired sensorimotor control and
mechanical stability. This may not be an appropriate test due to the fact that research has suggested that
ACL injury has a multi-planar mechanism of injury. The purpose of the present study was to compare TTS
values from a forward land and a diagonal land to determine if diagonal landing TTS values are more sensitive
to dynamic postural stability decits in female ACLR athletes.
Methods: A group of ACL reconstructed female athletes and a group of female control athletes performed three
forward lands and three diagonal lands onto a force-plate and remained still on one foot for 15 s. TTS was calculated
for the anteriorposterior and mediallateral ground reaction forces as well as the resultant vector of both forces.
Results: All three TTS values were signicantly increased in the ACLR group from the control group for the diagonal
landing task. There was no difference in TTS values between the groups for the forward landing task.
Conclusion: TTS values from a diagonal landing are more sensitive at detecting impaired dynamic postural stability
in a group of female ACLR athletes compared to TTS values from a forward land.
Level of evidence: III Casecontrolled study.
2013 Elsevier B.V. All rights reserved.

1. Introduction
Rupture of the anterior cruciate ligament (ACL) is a frequently
incurred injury by athletes who participate in high intensity and high
velocity eld and court sports. Reports in the literature suggest that
female athletes have an elevated risk of ACL injury compared to male
athletes playing similar sports [1,2], with a high percentage of
these injuries being described as non-contact in mechanism [3,4].
The ACL contributes to knee joint sensorimotor control and
mechanical stability [5,6]. Lower limb functional joint stability is
dependent upon the complex interaction of afferent information
emanating from cutaneous, articular, ligamentous and musculotendinous mechanoreceptors, and the resultant central nervous system
output to alpha motor neurons, extrafusal muscle bers and the
-muscle spindle system [7]. Lower limb ligament injury will produce
a number of functional insufciencies including decits in proprioception, postural stability, strength and neuromuscular control [8], all of
which can contribute to compromised functional joint stability.
Following complete ACL rupture, surgical reconstruction of the ACL
is recommended [2,9]. The primary aim of ACL reconstruction is to
Corresponding author at: G26 Science North, University College Dublin, Beleld, Dublin
4, Ireland. Tel.: +353 877900856; fax: +353 17166501.
E-mail address: matt.patterson@ucd.ie (M.R. Patterson).
0968-0160/$ see front matter 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.knee.2013.07.008

restore knee joint mechanical and functional joint stability such that
the athlete can return to full sports participation. However, recent evidence suggests that restoration of knee joint function and return to
full pre-injury sports participation are not achieved by all athletes
[1012]. Of particular concern following ACL reconstruction is the high
reported incidence of re-rupture and subsequent knee joint injury
[1315]. Re-rupture rates of 17% for patients younger than 18 years,
7% for patients aged 18 to 25 years, and 4% for patients older than
25 years have been reported [15].
An increasing body of literature suggests that deciencies in static
and dynamic postural stability increase the risk of lower limb injury
[1618]. It has been recently reported that competitive athletes who
have returned to full sports participation after ACL reconstruction still
exhibit postural stability decits [19,20]. Time to stabilization (TTS) is
a functional measurement of neuromuscular control and dynamic
postural stability. TTS scores assess an athlete's ability to transfer from
a dynamic to a static situation on one leg. Longer TTS values have
been reported in athletes with chronic ankle instability as well as athletes who have undergone ACL reconstruction surgery when compared
to healthy controls [2022]. These studies considered TTS scores from a
forward landing task.
Recently it has been suggested that dynamic postural stability tests
should include landings that challenge stability in the mediallateral
(ML) direction, thus emphasizing an increased requirement for frontal

M.R. Patterson, E. Delahunt / The Knee 20 (2013) 532536

and transverse plane neuromuscular control, as well as the anterior

posterior (AP) direction [23]. Injury mechanisms are more likely
to include a ML component to the landing, which the forward landing
protocol does not challenge. This is in agreement with recent research
which suggests that ACL injury is most likely the result of multiplanar neuromuscular control decits [24,25].
The role of the ACL is primarily to prevent anterior translation of
the tibia in relation to the femur. For this reason, previous research
has likely utilized forward jump landing protocols when assessing
TTS. However, the mechanism of injury in ACL injuries is not always
due to anterior shear in the sagittal plane [26]. Other ACL mechanisms
of injury include an increased knee valgus torque [27,28] as well as abnormal transverse plane knee rotations and torques [29,30]. The ACL
provides restraint to knee movement in all three planes. Thus, testing
TTS with a landing task that requires multi-planar stabilization and
control is potentially more appropriate for identifying movement
patterns which may lead to ACL injuries than using a forward landing
task.
The aim of the present study was to examine TTS values in a group of
female athletes who had returned to full sports participation following
ACL reconstruction as well as in a group of controls. TTS from a diagonal
landing was compared to TTS from a forward landing. The hypothesis of
this study is that TTS values will be longer from a diagonal landing
compared to a forward landing.

533

Table 1
Time from ACLR surgery for each subject in the patient group.
ACLR knee
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
AVG
SD

Time from surgery (years)

1.33
1.00
2.50
1.08
3.67
3.92
1.83
10.67
5.67
3.75
8.33
0.92
1.67
1.08
1.08
9.83
1.17
3.50
3.24

AVG average, SD standard deviation.

An a priori sample size of 17 participants per group was calculated

[ error probability = 0.05, power (1 error probability) = 0.80]
based on the results of Webster and Gribble, who reported an effect
size of 1.0 when investigating TTS decits in a group of female NCAA
athletes following ACL reconstruction [20]. Ethical approval for the
study was approved by the Universities ethics committee. Before each
subject began the study, they were told the risks of participation and
then they read and signed an informed consent form.
Seventeen lower limbs of 14 female athletes constituted the ACLR
group. Of these athletes, 3 participants had previously ruptured both
right ACL and left ACL, thus both lower limbs were tested in these participants. The mean age, height and body mass of the ACLR group
were: 20.76 1.14 years; 1.64 0.04 m; and 64.26 7.96 kg. Of
these involved lower limbs, eight were reconstructed via a hamstring
auto-graft surgical procedure, with the remaining being a bonepatellar
tendonbone auto-graft. The time from surgical stabilization to the
present study for each knee in the ACLR group is presented in Table 1.
At the time of testing all athletes were fully engaged in eld or
court based sports (e.g. Gaelic football, soccer, hockey, basketball) at
club or county level and no athlete was undergoing any form of
formal rehabilitation. Seventeen female athletes without a previous
history of knee joint injury constituted the control group. The mean age,
height and body mass of the control groups were: 22.58 3.44 years;
1.64 0.09 m; and 65.38 7.36 kg. All athletes played eld or court
based sports (e.g. Gaelic football, soccer, hockey, basketball) at club or
county level.
All athletes were required to complete the International Knee
Documentation Committee Subjective Knee Form (IKDC) questionnaire
as well as the Knee Injury and Osteoarthritis Outcome Score (KOOS)
subscales. Both instruments have been validated for use with an ACL
reconstruction population [31,32].

width apart. They were then instructed to place their hands on their
hips and to look straight ahead. After an audio cue from the tester
each subject stepped forward, leading with the test leg, and dropped
from the step, landing on the force plate on the test leg only. Subjects
were instructed to stabilize as quickly as possible upon landing and to
hold a still position for 15 s [21].
For the execution of the diagonal landing task, subjects stood
bare-foot in single-leg stance at the posterior lateral aspect of a
force plate on the non-test leg. They were then required to perform a diagonal jump to land onto the middle of another force plate, land on the
test leg and remain still for 15 s (Fig. 1). Subjects were instructed to
stabilize as quickly as possible upon landing. Each subject performed
three trials of the diagonal hop. A trial was considered successful if
the tester deemed the landing to have occurred in the middle of
the force plate and the subjects' hands remained on their hips for
the duration of the trial. The distance across the ground of each
jump was roughly 110 cm. This distance was chosen because it
resulted in resultant ground reaction forces that were similar to
that seen in the forward landing protocol. The angle of progression
of the athlete during the maneuver was roughly 55 to the anterior
direction from the medial direction from an above view. Unsuccessful trials were discarded and additional trials were undertaken if
necessary. Prior to the test trials all subjects were allowed three
practice trials for familiarization with the testing procedures, during
which verbal feedback was provided by the investigators. The ACL
reconstructed leg was used as the test leg in the ACLR group. This
resulted in nine left and eight right ACLR knees being tested. An
equal number of left and right legs were tested in the control
subjects.
A drop land was used for the forward landing task because that is
what has been used in previous TTS research [21]. Preliminary testing
indicated that a diagonal drop land from a box was awkward for the
athletes; even after up to twenty practice trials the athletes felt they
could not repeat the maneuver consistently. The use of a diagonal hop
to land resulted in athletes being able to learn the task after as few as
three practice trials, which is similar to the learning curve for the forward
landing protocol.

2.2. Jumping protocol

2.3. Data processing

Each subject performed three forward landing trials and three

diagonal landing trials. Forward landing trials started with each subject standing on top of a 35-cm box with the feet positioned shoulder

AP and ML ground reaction forces were sampled at 2000 Hz from

an AMTI force plate (Watertown, Massachusetts). Previously published
methods of calculating TTS were used in this study [20,22,33]. Data

2. Methods
2.1. Participants

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M.R. Patterson, E. Delahunt / The Knee 20 (2013) 532536

Statistics, 24 Version 18.0, IBM Corporation, NY, USA). An independent

samples, two-tailed t-test was used to compare the APTTS, MLTTS and
RVTTS values between the ACLR group and the control group. The
level of signicance was set at p b 0.05. A Levene's test was used to
assess if the two groups had equal variance on each score. Minitab 15
statistical analysis software (Coventry, United Kingdom) was used for
statistical analysis. Associated effect sizes (eta squared) were calculated
using the formula as described in Pallant [34]: t2/t2 + (N1 + N2 2)
and quantied according to Cohen [35] as 0.01 = small effect size,
0.06 = medium effect size and, 0.14 = large effect size.
3. Results
Levene's test for equality of variance revealed that the assumption of equal variance was
not violated for all IKDC and KOOS subscale scores. ACLR participants differed signicantly
from the control group participants on the IKDC (P = 0.00), as well as on the KOOSpain
(P = 0.02), KOOSsymptoms (P = 0.00), KOOSsport (P = 0.00), and KOOSKQoL (P = 0.00).
The associated effect sizes were large (Table 2). There was no statistically signicant
difference between the ACLR participants and the control participants on the KOOSADL
(P = 0.16).
An independent-samples t-test was conducted to compare the APTTS, MLTTS and
RVTTS scores between the ACLR group and the control group for both the forward landing
task as well as the diagonal landing task. Levene's scores were all over 0.05, indicating that
variance was equal between groups on all TTS scores. Mean scores, standard deviations,
t values, signicance values and eta squared values are presented in Table 3.

4. Discussion

Fig. 1. An above view of the jumping protocol for the diagonal hop. Right leg testing was
performed from a jump off the left leg over a distance of roughly 110 cm. Left leg testing
was performed from a jump off the right leg over the same distance. Jumps were
performed at an angle of roughly 55 from the medial direction.

processing was done in MATLAB 2008a (Natick, Massachusetts).

The data was down-sampled to 180 Hz as done previously [22]
and a Butterworth 12 Hz low pass lter was applied to the data.
The data was then modeled via a 3rd order unbounded polynomial
from the peak GRF after landing for 15 s. Range of variation was
determined using a previously published normalized method [33]. TTS
was calculated from the time of landing until the tted curve crossed
the range of variation value. This was determined for each jump from
each subject in the AP and ML directions; resulting in AP time to stabilization (APTTS) and ML time to stabilization (MLTTS). The resultant
vector time to stabilization (RVTTS) was also calculated by squaring
APTTS and MLTTS, then adding them together and then taking the
square root [20].

2.4. Data analysis

Independent-samples t-tests were used to test for differences in
the ACLR and control group IKDC and KOOS subscale scores (PASW

The main nding of this study was that TTS values from a diagonal
landing were able to distinguish ACLR athletes from healthy control athletes, whereas TTS values from a forward landing were not able to distinguish between groups. The ACLR group in this study had functional
decits, as indicated from the KOOS questionnaire. These ndings
suggest that TTS values from a diagonal landing are more sensitive
at detecting dynamic postural stability decits in an ACLR population
compared to TTS values from a forward landing.
Previous research using TTS to assess dynamic postural stability has
utilized forward landing protocols [20,21,33]. These studies have shown
that forward landing TTS times are signicantly different between ACLR
athletes and controls [20,21] as well as athletes with chronic ankle
instability and controls [33]. A study of female NCAA division I athletes
reported RVTTS values of 2.01 (SD = 0.15) s and 1.90 (SD = 0.07) s for
an ACLR group and a control group respectively during single leg forward landings [20]. In the present study RVTTS values using a diagonal
landing protocol were longer for the ACLR group, at 2.14 (SD = 0.34) s,
but shorter for the control group, at 1.87 (SD = 0.33) s.
The TTS value standard deviations presented in Table 3 are similar to
values reported in previous TTS research [2022]. As Table 3 also shows,
the differences between the ACLR and control groups were small, only
around 510% for the diagonal land TTS values. The fact that TTS values
from the diagonal land were signicantly different between groups,
whereas TTS values from the forward land were not signicantly
different suggest that TTS from a diagonal land may be more sensitive
in detecting abnormal, ACLR landing patterns.
Research on ACL injury mechanisms suggests that the use of forward
landing protocols may not challenge athletes enough to allow researchers to obtain an accurate dynamic postural stabilization value.
Frontal plane loads at the knee have previously been identied as a

Table 2
IKDC and KOOS subscale results.

Control
ACLR
Effect size

IKDC

KOOSpain

KOOSsymptoms

KOOSADL

KOOSsport

KOOSQOL

99.07 3.74
84.31 11.82
0.43 (large)

99.81 0.75
92.94 10.59
0.18 (large)

98.13 2.66
87.18 9.57
0.39 (large)

99.81 0.75
98.35 4.06
0.06 (small)

99.38 2.50
85.00 16.00
0.29 (large)

99.25 2.05
74.76 14.86
0.56 (large)

IKDC and KOOS questionnaire scores for the ACLR group and the control group. Values are presented as mean SD.
Signicantly different from control participants.

M.R. Patterson, E. Delahunt / The Knee 20 (2013) 532536

Table 3
TTS values for the forward landing task and the diagonal landing task.

Forward land

Diagonal land

TTS

ACLR

AP
ML
RV
AP
ML
RV

1.30
.67
.90
1.52
1.40
2.14

Control
.16
.28
.43
.15
.10
.34

1.24
.76
.94
1.42
1.31
1.87

.11
.20
.25
.13
.12
.33

Sig

1.463
1.145
0.336
2.016
2.506
2.356

.153
.261
.739
.052
.018
.025

Eta squared
(effect size)

0.119 (moderate)
0.173 (large)
0.157 (large)

TTS scores for the forward landing task and the diagonal landing task. Mean values are
presented in seconds with SD. Effect size calculations were not performed on TTS
scores which did not have a signicant difference between the groups. TTS time to
stabilization, AP anterior/posterior, ML medial/lateral and RV resultant vector.
Signicantly different from control participants.

risk factor for ACL injury [36] with athletes at risk of injury commonly
exhibiting dynamic knee valgus collapse during cutting or one-legged
landing maneuvers [25]. Cutting and one-legged landing during game
play do not always occur in the forward direction, thus dynamic postural stability testing should include a mediallateral component to
the landing task. An in depth review of ACL injury literature found
that the vast majority of studies supported the idea of a multi-planar injury mechanism [24], thus highlighting the need for multi-directional
dynamic postural stability testing. Forward landing protocols challenge
mostly sagittal plane stabilization. Utilizing a jump protocol that challenges frontal plane stabilization as well is more likely to identify dynamic
postural stability decits in athletes following lower limb injury [23].
Dynamic postural stability from a jump-landing that challenges multiplanar stabilization has not previously been tested on an ACLR patient
population. The results of the present study show that dynamic postural
stability assessed, via TTS from a diagonal jump clearly identies postural
stability deciencies in female athletes who have had ACL reconstruction
surgery. TTS values from forward landings on the same population were
not able to differentiate between the ACLR group and the control group.
Dynamic postural stability testing is commonly utilized to determine
future risk of lower limb injury [16,17]. In a prospective study on a female athletic ACLR group, it was found that athletes that re-injured
their ACL exhibited an increase in total frontal plane knee joint excursion, greater asymmetry in internal knee extensor moment at initial
contact, and a decit in single leg postural stability of the injured limb
[37]. Recently it has been suggested that traditional measures of static
postural stability assessment including single leg stance on forceplates may not be sensitive enough to detect decits associated
with lower limb athletic injuries [38]. Furthermore, inconsistencies
in sampling rates, test trial time intervals and dependent variables
during static postural stability testing make comparisons across studies
arduous [38]. Consequently it has been suggested that high velocity
dynamic functional tasks replicating game specic demands are more
appropriate for the assessment of dynamic postural stability in athletes
who have sustained lower limb injuries.
The present study has shown that ACLR female eld sport athletes
have altered dynamic postural stability compared to healthy controls.
It is not clear from this study whether the altered dynamic postural stability was present prior to the original ACL injury or was a consequence
of the injury and surgical intervention. Ligaments contribute to joint
stability by both mechanical and sensory characteristics. It has been
suggested that injury can result in altered afferent feedback from the
ligament, which increases an athlete's risk of re-injury [39]. It is possible
that the ACLR group in this study had lower dynamic postural stability
scores for these reasons. Conversely, the poor dynamic postural stability
may have been present pre-injury and may have predisposed the
athletes to ACL injury. Recent prospective work has found that certain kinematic patterns upon landing put athletes at a greater risk
for ACL injury [40]. Perhaps, poor dynamic postural stability can be
used to predict athletes who may be at risk for a lower limb injury
due to poor movement patterns. No research has looked at the TTS

535

method of dynamic postural stability analysis prospectively to see if it

can be used to predict ACL injuries.
Clinically, the results of this study suggest that rehabilitation
protocols post-ACLR should incorporate functional multi-planar dynamic stabilization drills, whereby the athlete is challenged to transition from a dynamic to static posture as fast as possible. Furthermore,
research should look into the use of diagonal jump landing protocols
during injury screening in female athletes as such jump landing protocols challenge athletes in ways that are more replicable of actual ACL
injury mechanisms in the eld.
4.1. Limitations
A limitation to this study was that we did not control for graft type.
Two graft types (hamstring and patellar autographs) were used in the
ACL-R group. Recent research has shown that there is no signicant
difference in knee adduction moments between hamstring or patellar
autographs in male subjects [41]. Also, a literature review has suggested
that graft type may not be a crucial factor in the outcome after ACL-R
surgery [42], however there may still be a minimal effect related to
graft type. Another potential limitation of this study is that three subjects
were used twice in the ACLR group because they had injured both their
right and left knees. Movement patterns may be similar between the
knees because they belong to the same subject. However, for all three
subjects, the knees were injured at different times and they had surgery
at different times, thus the surgical intervention and subsequent
rehabilitation could not have been exactly the same for both knees.
A nal limitation of this study is that data was collected while the subjects
were barefoot. Future work in this area should consider shoed landings
since athletes wear shoes in game play.
5. Conclusion
The results of the present study indicate that TTS values from a diagonal landing are more sensitive in detecting impaired dynamic postural
stability than TTS values from a forward landing task in female ACLR
athletes. More work is required to conrm this in an athletic male population. Also, prospective research should consider if dynamic postural
stability testing using diagonal landing maneuvers can be used to
predict future injuries.
6. Conict of interest statement
There are no known conicts of interest associated with this
publication and there has been no signicant nancial support for
this work that could have inuenced its outcome.
Acknowledgments
The authors would like to thank Lauren Sweeney, Mark Chawke,
Katie Murphy, Anna Prendiville and Judy Kelleher for their help with
subject recruitment and data collection. Matthew Patterson is supported
by Science Foundation Ireland under grant 07/CE/I1147.
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