EFFECT OF MULTIPLE ANGLE HAMSTRING ISOMETRIC… 1

5.0 DISSCUSSION :

The characteristics of the study’s are consistent with the epidemiology of

Anterior Cruciate Ligament (ACL) Reconstruction in terms of Age, Leg Length Discrepancy
(LLD), LE muscle flexibility, playing surface, weight, foot posture, knee jt. laxity, shoe type,
BMI, LE muscle strength, Balance and Temperature (LaBella, Hennrikus and Hewett (2014);
Dashmandi, Saki, Shahheidari & Khoori, 2011; Griffin et al., 2006; Bagherifard et al. 2015;
Murphy, Connolly & Beynnon, 2003; Griffin et al., 2000; Beutler et al., 2009; Price et al., 2017;
Mansfield & Bucinell 2016; Posthumus, Collins, September & Schwellnus, 2011; Hewett et al.,
2005; Parus, Lisinski & Huber, 2015; Smith et al., 2012) except for Height, Q-angle, leg
dominance and playing position. According to Bowers, Spindler, McCarty and Arrigain (2005),
Increased height has been cited as predisposing the knee to exertion injuries, height, weight, and
BMI are significant risk factors for injuries to articular surfaces and menisci as observed during
ACL reconstruction. Excessive Q angle has been identified as a potential risk factor for knee
injuries, but evidence to support this relationship is unclear. A reason for these inconsistent
findings may be in part due to limited understanding of how other anatomical characteristics
influence the magnitude of the Q angle (Nguyen, Boling, Levine and Shultz, 2010). Increase in
QA might contribute to an increase in the contact pressure applied to the patellofemoral joint (Li,
DeFrate, Zayontz, Park and Gill, 2004). The authors reported that soccer players mostly use their
dominant leg (DL) when passing or kicking rather than the non-dominant leg (NDL). Because of
that, the players were at risk of muscle strength imbalances of the knee flexors and extensors and
may have induced strength differences between the two legs (Rouissi et al., 2016). Leg
dominance in certain sports, the dominant leg may be at increased risk of injury because it is
preferentially used for kicking, pushing off, jumping, or landing Foot posture (Murphy, Connolly,
& Beynnon, 2003). Two soccer studies broke down playing position into striker, defender,
midfielder, and goalkeeper. Data from both studies revealed that the strikers and defenders were
more likely to get injured than midfielders and goalkeepers. One reported that defenders were
more likely to injure their ACL when “tackling” an opponent, whereas strikers were more likely
to injure this when being tackled (Serpell, Scarvell, Ball & Smith, 2012). Soccer players are at
greatest risk for ACL injury when defending, especially when tackling the opponent in an attempt
to win possession of the ball. Females are more likely to injure their ACLs when defending and

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are at greater risk for noncontact injuries in their left lower extremity (Brophy, Stepan, Silvers
and Mandelbaum, 2015).

The characteristics of the study’s are consistent with the profile of a soccer player in
terms of Age, Leg Length Discrepancy (LLD), LE muscle flexibility, playing surface, weight,
foot posture, knee jt. laxity, shoe type, BMI, LE muscle strength, Balance and Temperature
(LaBella, Hennrikus and Hewett (2014); Dashmandi, Saki, Shahheidari & Khoori, 2011; Griffin
et al., 2006; Bagherifard et al. 2015; Murphy, Connolly & Beynnon, 2003; Griffin et al., 2000;
Beutler et al., 2009; Price et al., 2017; Mansfield & Bucinell 2016; Posthumus, Collins,
September & Schwellnus, 2011; Hewett et al., 2005; Parus, Lisinski & Huber, 2015; Smith et al.,
2012) except for Height, Q-angle, leg dominance and playing position. In this study, the subjects
were shorter in height compared to the earlier studies. Heron and Cupples (2014) stated that the
mean height of the players was 179.3 cm since Zengin et al. (2016). Stated that South
Asian men had smaller bones and lower trabecular volumetric bone mineral density at the
tibia. Subjects in our study has greater Q-angle values since. Emami et al. (2007). and
Tallay et al. (2004). found a significant association between higher Q-angle and the rate
of knee injuries. In our study’s subjects, majority of them tend to use dominant leg as
kicking leg in which Brophy, Silvers, Gonzales and Mandelbaum (2010) stated males
tend to injure their kicking leg. This research suggests that limb dominance does serve as
an aetiological factor with regard to ACL injuries sustained while playing soccer.
Majority of our subjects are defenders as main playing position, as what Faude et al.
(2004). Found that injury incidence was higher in defenders (9.4 injuries per 1,000 hours
exposure) and strikers (8.4/1000 hours) than goalkeepers (4.8/1000 hours) and
midfielders (4.6/1000 hours).

The result of the study indicated a positive or direct relationship between agility and
soccer player's height. However the result of the study is inconsistent with the findings of Navali

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and Jafarabadi (2015) study showed a weak correlation between patellar tendon length and
patient height. This finding is in contrast to the usual measurements in human
anthropometry in which taller individuals have normally longer tendons and ligaments. A
weak positive correlation between patient height and patellar tendon length was found in
our study. None of the previous studies showed a strong correlation between patient
height and patellar tendon length. Despite these associations of anthropometric measures
with knee pathology, there are no published studies investigating how a patient’s height,
weight, or obesity impact injuries with ACL injury (Bowers, Spindler, McCarty and
Arrigain, 2005).

The result of the study indicated a positive or direct relationship between agility and
soccer player's Q-angle. However the result of the study is inconsistent with the findings of
Nguyen, Boling, Levine and Shultz (2010). Excessive Q angle has been identified as a potential
risk factor for knee injuries, but evidence to support this relationship is unclear. A reason for
these inconsistent findings may be in part due to limited understanding of how other anatomical
characteristics influence the magnitude of the Q angle.

The result of the study indicated a positive or direct relationship between agility and
soccer player's leg dominance. However the result of the study is inconsistent with the findings of
Negrete, Schick and Cooper (2007) The results of this study indicate that there is no significant
relationship between lower-limb dominance and the likelihood of sustaining a noncontact ACL
tear. However, the strong trend toward females tearing their left ACLs more often than their right
ACLs warrants further investigation to determine what neuromuscular asymmetries may exist
between the right and left lower limbs. There also was no significant gender effect on the
relationship between limb dominance and side of injury (P=.65). Limited numbers precluded an
analysis of specific limb-dominant sports activities as potential risk factors. The results of this
pilot study suggest limb dominance is not a significant etiologic factor for noncontact ACL tears
(Matava, Freehill, Grutzner and Shannon, 2002).

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The result of the study indicated a positive or direct relationship between agility and
soccer player's playing position. However the result of the study is inconsistent with the findings
of Harris et al. (2013) No significant relationship (P > 0.05) was demonstrated for position
and injury quarter or position and time left in the quarter when the injury occurred. No
significant relationship (P > 0.05) was demonstrated between the quarter of the injury and
the time left in the quarter when the injury occurred.

This study hypothesized that Multiple Angle Hamstring Isometric Exercises

(MAHIE) has significant effect on agility. This hypothesis has accepted the result of the
study is consistent with the study of Pousson et al., 1990 and Grosset et al., 2009; Kubo
et al. (2000) These findings suggest that isometric training is the most effective
mechanism for enhancing MTS, though future research is necessary to permit
comparisons to other training modes known to influence stiffness e.g. eccentric.
However the result of study is inconsistent with the findings of Blackburn & Norcross,
(2014) Isometric training may be an important addition to ACL injury prevention
programs. Isometric training increases hamstring MTS (Musculotendinous stiffness).
The result of the study can be explained by Specific Adaptation to Imposed Demand
(SAID) principle. Furthermore, advice on exercises from professional experts in
physiotherapy, ACL-reconstruction rehabilitation and knee-joint biomechanics, have
been implemented. No isolated development or feasibility work of the present exercise
program has been developed. Implementation in accordance with “best practice” has been
undertaken (Bregenhof et al., 2018) and this study hypothesize that Multiple Angle
Hamstring Isometric Exercises (MAHIE) has no significant effect on agility. This
hypothesis was rejected. The result of the study is consistent with the study of Shaw,
Williams and Chipchase (2005) quadriceps exercise performance was associated with a
significantly lower incidence of abnormal knee laxity. In the study of van Ark et al.
(2016). This is the first study to show a decrease in patellar tendon pain without a
modification of training and competition load and the first study to investigate isometric
exercises in a clinical setting. Both isometric andisotonic exerciseprograms are easy-to-

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EFFECT OF MULTIPLE ANGLE HAMSTRING ISOMETRIC… 5

use exercises that can reduce pain from patellar tendinopathy for athletes in-season. In the
study of Anwer and Alghadir (2014) The results of the study demonstrated that isometric
quadriceps exercises brought significant gains in strength of the quadriceps muscle in the
experimental group after the 5-week training program. Moreover, increased muscle
strength does not lead to lower knee joint compressive forces during walking (Aaboe et
al., 2012). It can be concluded from the study that proprioceptive exercises in addition
with other treatment can relief knee osteoarthritis pain intensity and physical difficulties
than isometric quadriceps exercise( Ojoawo, Olaogun and Hassan, 2016).

The result of the study can also be explained by the differences between EG and
CG’s characteristics at baseline. Both the EG and CG had low agility; based on the law
of initial values (Frontera &deLisa, 2010), both the EG and CG will improve.

6.0 CONCLUSION

A significant association was noted between a soccer player’s height, Q-angle, leg
dominance playing position and Agility. Soccer players who are shorter in height, tend to be
more agile. Multiple Angle Hamstring Isometric Exercises (MAHIE) can improve the agility of
soccer players better than usual training beginning 5th week.

7.0 RECOMMENDATIONS
Soccer players and soccer coaches should consider including a 6-week multiple angle
hamstring isometric execise program to usual training to improve agility of the players.

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EFFECT OF MULTIPLE ANGLE HAMSTRING ISOMETRIC… 6

1.0 ABSTRACT

Agility is the true indicator of an athlete’s soccer playing skills. This study
used a quantitative multiple time series true-experimental research design. The
subjects had been selected purposively and randomly assigned to a 6-week multiple
angle-hamstring isometric exercise (experimental group, EG) or usual training
(control group, CG). Soccer – Specific Agility Tests were used to measure agility
performance such as T-test (TT), 4x5m (S4x5) and 9-3-6-3-9m with 180° (S180).
Pearson and Spearmen rho- correlational statistics were used to determine the
relationship between ACL Injury prognosticators and agility while Mann-Whitney
was used to test the main hypothesis. Chi-square revealed a statistically insignificant
improvement between person’s agility and leg dominance. Pearson correlation
revealed a high positive significant correlation between agility and height (r=0.81;
p=0.001), Q-angle (r=1.000; p=0.013) and playing position (r=.670; p=0.042). Mann-
Whitney revealed a statistically significant improvement in Agility of EG starting
from week 2 (p=0.55) until week 6 (p=0.35). EG showed better improvement in
Agility.

KEYWORDS: ACL reconstruction, Multiple Angle Hamstring Isometric Exercises, Agility

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4.0 RESULTS

There were twenty male soccer players during the study, but only ten consented to
participate. Ten out of twenty were excluded from the study (eight had no previous ACL injury,
two had an ACL injury occurred in less than 7 months). All subjects were able to complete the
study.
The comparison between experimental group and control group characteristics at baseline
is shown in Table 1. There were 5 subjects for both experimental group and control group.
Majority of both experimental group and control group has leg length discrepancy and played on
a natural turf.
The mean age of Experimental Group (EG) was 21.40±1.14, (R) hip extension ROM of
18.60±2.19, (L) hip extension ROM of 19.00±2.27, (R) hip flexion ROM of 119.00±2.23, (L) hip
flexion ROM of 114.00±4.18, (R) hip abduction ROM of 37.00±4.22, (L) hip abduction ROM of
39.00±2.24, (R) hip adduction ROM of 17.00±4.47, (L) hip adduction ROM of 18.00±2.74, (R)
hip external rotation ROM of 43.00±2.74, (L) hip external rotation ROM of 39.00±2.24, (R) hip
internal rotation of 40.00±3.54, (L) hip external rotation ROM of 37.00±2.74, (R) knee flexion
ROM of 131.00±4.18, (L) knee flexion ROM of 131.00±4.18, (R) ankle dorsiflexion ROM of
14.00±5.48, (L) ankle dorsiflexion ROM of 16.00±4.18, (R) ankle plantarflexion ROM of
47.00±4.47, (L) ankle plantarflexion ROM of 48.00±2.74, (R) ankle eversion of 12.00±2.74, (L)
ankle eversion ROM of 12.00±2.74, (R) ankle inversion ROM of 31.00±4.18, (L) ankle inversion
ROM of 28.00±2.74, (R) true leg length of 91.62±3.75 and (L) true leg length of 90.38±2.18 ;
while the age of Control Group (CG) was 21.80±2.18, (R) hip extension ROM of 16.60±2.30, (L)
hip extension ROM of 16.60±2.30, (R) hip flexion ROM of 117.00±2.30, (L) hip flexion ROM of
114.00±4.18, (R) hip abduction ROM of 35.00±5.00, (L) hip abduction ROM of 37.00±2.74, (R)
hip adduction ROM of 17.00±4.47, (L) hip adduction ROM of 17.00±2.74, (R) hip external
rotation ROM of 40.00±5.00, (L) hip external rotation ROM of 44.00±2.24, (R) hip internal
rotation ROM of 43.00±2.74, (L) hip internal rotation ROM of 41.00±4.18, (R) knee flexion
ROM of 130.00±3.54, (L) knee flexion ROM of 130.00±5.00, (R) ankle dorsiflexion ROM of
15.00±3.54, (L) ankle dorsiflexion ROM of 14.00±4.18m (R) ankle plantarflexion ROM of
47.00±4.47, (L) ankle plantarflexion ROM of 47.00±2.74, (R) ankle eversion ROM of
13.00±2.74, (L) ankle eversion ROM of 12.00±2.74, (R) ankle inversion ROM of 31.00±4.18, (L)

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ankle inversion ROM of 30.00±5.00, (R) true leg length of 89.56±2.16 , and (L) true leg length of
88.50±3.01.

The Levene’s Homogeneity revealed a p-value of p>0.05 indicating that both

Experimental Group (EG) and Control Group (CG) are characteristically homogenous at baseline
except for playing surface (p=0.011).

Table 1. Comparison between Experimental Group (EG) and Control Group’s (CG) Characteristics
at baseline.
EG CG
VARIABLES p-value
(n=5) (n=5)
Age (Mean±SD, yrs) 21.40±1.14 21.80±2.17 0.105
Height 212.4±2.81 212.4±3.04 0.390
BMI 23.01±1.00 22.57±1.80 0.845
ROM (Mean±SD, degrees)
(R) hip extension 18.60±2.19 16.60±2.30 0.012
(L) hip extension 19.00±2.24 16.60±2.30 0.020
(R) hip flexion 119.00±2.24 117.00±2.74 0.025
(L) hip flexion 114.00±4.18 114.00±4.18 0.045
(R) hip abduction 39.00±2.24 35.00±5.00 0.044
(L) hip abduction 39.00±2.24 37.00±2.74 0.022
(R) hip adduction 17.00±4.47 17.00±4.47 0.034
(L) hip adduction 18.00±2.74 17.00±2.74 0.010
(R) hip external rotation 43.00±2.74 40.00±5.00 0.014
(L) hip external rotation 39.00±2.24 44.00±2.24 0.031
(R) hip internal rotation 40.00±3.54 43.00±2.74 0.048
(L) hip internal rotation 37.00±2.74 41.00±4.18 0.044
(R) knee flexion 131.00±4.18 130.00±3.54 0.046
(L) knee flexion 131.00±4.18 130.00±5.00 0.028
(R) ankle dorsiflexion 14.00±5.48 15.00±3.54 0.037
(L) ankle dorsiflexion 16.00±4.18 14.00±4.18 0.041
(R) ankle plantarflexion 47.00±4.47 47.00±4.47 0.030

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(L) ankle plantarflexion 48.00±2.74 47.00±2.74 0.049

(R) ankle eversion 12.00±2.74 13.00±2.74 0.038
(L) ankle eversion 12.00±2.74 12.00±2.74 0.012
(R) ankle inversion 31.00±4.18 31.00±4.18 0.018
(L) ankle inversion 28.00±2.74 30.00±5.00 0.019
Muscle Strength
(R) hip extension Normal Normal 0.079
(L) hip extension Normal Normal 0.982
(R) hip flexion Normal Normal 0.586
(L) hip flexion Normal Normal 0.774
(R) hip abduction Normal Normal 0.958
(L) hip abduction Normal Normal 0.472
(R) hip adduction Normal Normal 0.945
(L) hip adduction Normal Normal 0.946
(R) hip external rotation Normal Normal 0.853
(L) hip external rotation Normal Normal 0.635
(R) hip internal rotation Normal Normal 0.712
(L) hip internal rotation Normal Normal 0.753
(R) knee flexion Normal Normal 0.854
(L) knee flexion Normal Normal 0.745
(R) knee extension Normal Normal 0.923
(L) knee extension Normal Normal 0.756
(R) ankle dorsiflexion Normal Normal 0.945
(L) ankle dorsiflexion Normal Normal 0.754
(R) ankle plantarflexion Normal Normal 0.986
(L) ankle plantarflexion Normal Normal 0.654
(R) ankle eversion Normal Normal 0.986
(L) ankle eversion Normal Normal 0.235
(R) ankle inversion Normal Normal 0.654
(L) ankle inversion Normal Normal 0.754
Playing Surface 0.011
Natural turf 5 5
Artificial turf
Grass

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Lower Extremity Alignment

Leg Length Discrepancy 0.046
Right 91.62±3.75 89.56±2.16
Left 90.38±2.18 88.50±3.01
Navicular Drop Test
Left 12.38±2.18 15.90±2.00
Right 14.09±3.90 14.99±1.45
Q-Angle
Right 2.14±0.13 4.90±0.89
Left 5.37±0.48 5.71±0.12
Knee Joint Laxity 0.589
Lachman Test (no. of positive)
Right 3 3
Left 2 2
Anterior Drawer Test (no. of
positive)
Right 3 3
Left 2 2
Foot Posture Index
(R) Foot Posture Index 0.984
Normal 3 3
Supinated 0 0
Highly supinated 0 0
Pronated 2 2
Highly pronated 0 0
(L) Foot Posture Index
Normal 3 3
Supinated 0 0
Highly Supinated 0 0
Pronated 2 2
Highly Pronated 0 0
Playing Position 0.321
Defender 3 3
Midfielder 2 2

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Attacker 1 1
Shoe Type 0.432
Round Studded Cleats
Turf Shoes 5 5
Bladed Studded Cleats
Soft Ground
Temperature Neutral Neutral 0.290
Balance (Mean ± SD, SEBT
average reach distance in
cm)
(R) Anterior 89.23±1.42 88.37±1.42 0.294
(R) Anterolateral 92.86±4.29 89.31±4.29 0.834
(R) Anteromedial 72.09±3.09 93.10±3.09 0.918
(R) Lateral 90.85±4.89 80.97±4.89 0.472
(R) Medial 78.09±2.48 94.27±2.48 0.381
(R) Posterior 94.08±4.92 86.47±4.92 0.961
(R) Posterolateral 87.97±5.14 78.73±5.14 0.123
(R) Posteromedial 78.57±5.38 83.84±5.38 0.412
(L) Anterior 83.84±5.20 78.57±5.20 0.512
(L) Anterolateral 78.73±5.14 87.97±5.14 0.532
(L) Anteromedial 86.47±5.15 94.08±5.15 0.641
(L) Lateral 94.27±2.79 78.09±2.79 0.512
(L) Medial 80.97±3.35 90.85±3.35 0.564
(L) Posterior 93.10±5.14 72.09±5.14 0.632
(L) Posterolateral 89.31±5.80 92.86±5.80 0.245
(L) Posteromedial 88.37±3.52 89.23±3.52 0.523
Leg Dominance (no. of right) 5 5 .058
*SD = Standard Deviation, EG = Experimental Group, CG = Control Group, Yrs = Years, ROM = Range
of Motion, (R) = Right, (L) = Left

The correlation between Anterior Cruciate Ligament (ACL) injury prognosticating

factors and agility is shown in Table 2.1. Chi-square correlation revealed a statistically significant
low positive correlation between agility and leg dominance (p=0.021). Pearson correlation
revealed a statistically significant high positive correlation between agility and height (r=0.81,

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p=0.001), Q-angle (r=1.000, p=0.013), playing position (r=.670, p=0.042). All other factors
showed statistically insignificant correlation.

Table 2.1 Correlation between Anterior Cruciate Ligament Injury Prognosticating Factors and
Agility
R value P value
Height (mean±SD, cm) 0.81 0.001
Q angle 1.000 0.013
Normal
Increased
Decreased .058
Leg Dominance (no. of right) 0.021
Players’ Position .670 0.042
Midfielder
Attaker
Defender
*SD = Standard Deviation, EG = Experimental Group, CG = Control Group, Yrs = Years, ROM = Range of Motion, (R) = Right, (L)
= Left

The correlation between Anterior Cruciate Ligament (ACL) injury prognosticating

factors and agility is shown in Table 2.2. Chi-square correlation revealed a statistically significant
low negative correlation between agility and leg dominance (p=0.021). Pearson correlation
revealed a statistically significant high positive correlation between agility and height (r=0.81,
p=0.001), Q-angle (r=1.000, p=0.013), playing position (r=.670, p=0.042). All other factors
showed statistically insignificant correlation.

Table 2.2 Correlation between Anterior Cruciate Ligament Injury Prognosticating Factors and
Agility
R value P value
Height (mean±SD, cm) -0.81 0.001
Q angle -1.000 0.013
Normal
Increased
Decreased -.058
Leg Dominance (no. of right) 0.021
Players’ Position -.670 0.042
Midfielder
Attaker
Defender
*SD = Standard Deviation, EG = Experimental Group, CG = Control Group, Yrs = Years, ROM = Range of Motion, (R) = Right, (L)
= Left

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EFFECT OF MULTIPLE ANGLE HAMSTRING ISOMETRIC… 13

The Effects of Multiple-Angle Hamstring Isometric Exercises on Agility is shown

in Table 3. The Mann-Whitney revealed between group comparisons revealed a
statistically significant higher improvement in agility of the EG subjects from week 2
(p=0.55) until week 6 (p=0.35). It was also revealed that there was statistically significant
effect in EG (p=0.021).

Table 3: Effect of Multiple Angle Hamstring Isometric Exercises on Agility

Agility
(mean+SD, ft/sec)
Week EG CG P value
(n=5) (n=5)
0 13.02±3.50 12.90±2.82 0.78
2 12.65±3.21 13.89±2.75 0.55
4 10.20±2.65 12.85±2.65 0.42
6 9.80±2.45 12.88±2.44 0.35
Mean 1.12±.60 .89±.54 0.01
Difference
P value 0.021 0.021
*significant if p<0.05; EG= Experimental Group; CG= Control Group; SD= Standard Deviation; ft=Feet;
sec=seconds, Higher agility score indicate lower agility.
*significant if p <0.05; T-TEST MDC=1.10(Raya et al., 2013); 4 x 5 m sprint test MCID=0.40 (Gabbett,
and Domrow, 2007)

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