Journal of Athletic Training 2019;54(12):000–000

doi: 10.4085/1062-6050-550-17
Ó by the National Athletic Trainers’ Association, Inc
www.natajournals.org

Hop Stabilization Training and Landing Biomechanics in

Athletes With Chronic Ankle Instability: A Randomized
Controlled Trial
Mohammad Karimizadeh Ardakani, PhD*; Erik A. Wikstrom, PhD, ATC, FACSM†;
Hooman Minoonejad, PhD, PT*; Reza Rajabi, PhD*; Ali Sharifnezhad, PhD‡
*Department of Health and Sport Medicine, Faculty of Physical Education and Sport Sciences, University of Tehran,
Iran; †Department of Exercise and Sport Science, University of North Carolina at Chapel Hill; ‡Sport Science
Research Institute, Tehran, Iran
Context: Hopping exercises are recommended as a func- Results: The hop-stabilization program resulted in improved
tional training tool to prevent lower limb injury, but their effects self-reported function (P , .05), larger sagittal-plane hip- and

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on lower extremity biomechanics in those with chronic ankle knee-flexion angles, and greater ankle dorsiflexion (P , .05)
instability (CAI) are unclear. relative to the control group. Reduced frontal-plane joint angles

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Objective: To determine if jump-landing biomechanics at the hip, knee, and ankle as well as decreased ground reaction
change after a hop-stabilization intervention. forces and a longer time to peak ground reaction forces were
Design: Randomized controlled clinical trial. observed in the hopping group compared with the control group
Setting: Research laboratory. after the intervention (P , .05).
Patients: Twenty-eight male collegiate basketball players Conclusions: The 6-week hop-stabilization training pro-
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with CAI were divided into 2 groups: hop-training group (age ¼ gram altered jump-landing biomechanics in male collegiate
22.78 6 3.09 years, mass ¼ 82.59 6 9.51 kg, height ¼ 187.96 6 basketball players with CAI. These results may provide a
7.93 cm) and control group (age ¼ 22.57 6 2.76 years, mass ¼ potential mechanistic explanation for improvements in patient-
78.35 6 7.02 kg, height ¼ 185.69 6 7.28 cm).
reported outcomes and reductions in injury risk after ankle-
Intervention(s): A 6-week supervised hop-stabilization
sprain rehabilitation programs that incorporate hop-stabilization
training program that consisted of 18 training sessions.
exercises.
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Main Outcome Measure(s): Lower extremity kinetics and

kinematics during a jump-landing task and self-reported function Key Words: hopping training, kinetics, kinematics, ankle
were assessed before and after the 6-week training program. injuries
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Key Points
 A 6-week hop-stabilization program resulted in improved jump-landing biomechanics of the ankle, knee, and hip in
patients with chronic ankle instability.
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 A 6-week hop-stabilization program resulted in decreased ground reaction forces during a single-limb jump landing
in patients with chronic ankle instability.

A
nkle sprains are the most common injuries in In addition to recurrent sprains and giving-way episodes,
collegiate athletes and represent a significant CAI is associated with a variety of sensorimotor adapta-
contribution to time lost from sports participation.1 tions, including biomechanical alterations. Individuals with
Approximately 11 000 ankle sprains occur per year in US CAI land in a more plantar flexed5 and inverted position.6,7
collegiate athletes, and ankle-ligament sprains were most Kinematic alterations have been identified proximal to the
frequent in men’s basketball players.1 Unfortunately, ankle ankle joint during dynamic tasks.8,9 Altered kinetics,
sprains are not a 1-time injury, and a common sequela is the including greater ground reaction forces and loading rates,
have also been observed in individuals with CAI during a
development of chronic ankle instability (CAI), a condition
landing task.10 These alterations are hypothesized to
characterized by recurrent sprains or repetitive giving way potentially increase an individual’s risk for recurrent injury
(or both) of the ankle.2 Approximately 40% of people who and ankle-joint degeneration.
sustain a lateral ankle sprain will experience a recurrent A number of therapeutic interventions have been used to
sprain and residual symptoms, such as pain and instability treat CAI-associated impairments. Balance training, a
that last for at least 12 months.3 Further, a link between common intervention, was effective in improving postural
CAI and posttraumatic ankle osteoarthritis has been control11 but only influenced some biomechanical outcomes
established and is thought to be due, at least in part, to in individuals with CAI.12 Hop-stabilization exercises
aberrant biomechanics.4 represent a dynamic and fundamental movement in a

Journal of Athletic Training 0

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Figure. CONSORT flow chart of participant enrollment, allocation, follow up, and analysis.
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variety of sports.13 Training programs that emphasize hop 3.1.9.2; Kiel, Germany) and previous research,18 we
stabilization enhance function and postural control in estimated that 12 participants per group were needed to
individuals with CAI.14,15 In addition, plyometric-training detect statistical significance at an a level of .05, 95%
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programs that included a variety of hopping exercises power, and an effect size of 0.79. All participants were
improved lower extremity biomechanics in healthy control enrolled, trained, and tested at a single site after reading and
participants.16 Despite this evidence, it remains unclear signing the informed consent form that was approved by the
how a hop-stabilization intervention would affect lower University of Tehran Institutional Review Board, which
extremity jump-landing biomechanics in individuals with also approved the study.
CAI.
Therefore, the purpose of our study was to determine the Participants
effects of a 6-week hop-stabilization training program on A total of 43 male collegiate basketball players expressed
lower extremity jump-landing biomechanics (ie, kinematics interest in participating. However, 13 failed to meet the
and kinetics) in male collegiate basketball players with CAI-specific inclusion criteria, as shown in the CONSORT
CAI. Based on the literature, we hypothesized that the hop- diagram (Figure). Thus, 30 university male basketball
stabilization program would improve lower extremity players with CAI were enrolled, but 2 withdrew. The
jump-landing biomechanics relative to a control condition. remaining 28 participants (14 per group) completed the
investigation and were randomized to either the experi-
METHODS mental group (age ¼ 22.78 6 3.09 years, mass ¼ 82.59 6
Study Design
9.51 kg, height ¼ 187.96 6 7.93 cm, missed days of desired
physical activity due to ankle injury ¼ 10.5 6 6.08) or
This investigation was part of a larger single-blinded control group (age ¼ 22.57 6 2.76 years, mass ¼ 78.35 6
randomized controlled trial.17 Participants were randomly 7.02 kg, height ¼ 185.69 6 7.28 cm, missed days of desired
assigned to either an experimental group (hopping pro- physical activity due to ankle injury ¼ 10.21 6 5.60). Only
gram) or a control group. Using G*Power software (version men were enrolled in this investigation because of a lack of

0 Volume 54  Number 12  December 2019

women’s teams at this competition level in Iran and cultural internal rotation, hip extension adduction, and internal
constraints. All participants were required to be between 18 rotation.
and 30 years of age, playing basketball at the university Cortex software was used to ensure marker identifica-
level, and actively practicing during the off-season at least tion throughout the trial, and a custom MATLAB program
3 times per week for 2 hours per session. Chronic ankle (The MathWorks, Natick, MA) was used to complete data
instability-specific criteria were consistent with the recom- processing. The kinematic angles of interest were the hip,
mendations of the International Ankle Consortium.2 knee, and ankle joints in all 3 planes. These variables were
Specifically, participants were required to have (1) at least extracted at initial contact and peak vertical ground
1 acute ankle-inversion sprain that resulted in swelling, reaction force. Initial contact was identified as the point
pain, and dysfunction that occurred at least 12 months prior when the vertical ground reaction force exceeded 10 N.
to the study (experimental group: 16.35 6 3.70 months, Peak ground reaction force and time to peak force in the
control group: 17.21 6 3.68 months); (2) at least 2 episodes vertical, anterior, posterior, medial, and lateral directions
of the ankle ‘‘giving way’’ within the past 6 months were extracted and normalized to body weight (N). The
(experimental group: 6.14 6 4.32, control group: 6.5 6 loading rate, calculated as normalized peak vertical
3.77); (3) answered 4 or more questions with yes on the ground reaction force divided by the time to reach peak
Ankle Instability Instrument; (5) a disability score of 90% force, was calculated based on the following equation:
on the Foot and Ankle Ability Measure (FAAM); and (6) a loading rate ¼ ({Peak Force [N]/Body Weight [N]}/Time
disability score 80% on the FAAM-Sport (FAAM-S). to Peak Force [millisecond]). Three trial averages for all
Additionally, CAI participants were required to score outcomes were used for further analysis. After baseline
,75% in 3 or more categories on the Foot and Ankle testing, participants were randomized to either the
Outcome Score, score ,24 on the Cumberland Ankle experimental or control group using a computer-generated
Instability Tool, and have clinically negative anterior table of random numbers and immediately started their
drawer and talar tilt tests. Ligamentous assessments were assigned intervention. The posttest assessment was

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performed by a physical therapist with more than 10 years’ completed within 48 hours of the final training session.

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experience. For those with bilateral ankle sprains, the ankle An independent assessor who was blinded to group
with the lowest self-reported questionnaire scores was assignment completed the baseline and posttest assess-
selected. Exclusion criteria were neurologic or vision ments on all participants. All testing took place in the
problems, any surgery to the musculoskeletal structures, biomechanics laboratory of the Sport Science Research
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or chronic musculoskeletal, severe acute lower extremity, Institute of Iran.
or head injury.2
Intervention
Procedures
Three supervised sessions occurred per week for 6
Upon enrollment, participants completed the baseline weeks (Table 1),17 and training volume increased during
jump-landing protocol. Reflective markers were placed the program. Both M.K.A. and H.M. supervised all
in

using the modified Helen Hayes marker set, which training sessions. Hopping exercises consisted of hopping
consisted of the left and right anterior-superior iliac spine, side to side, hopping forward and backward, hopping
midthigh, lateral knee, midshank, lateral malleolus, calca- forward,14 hopping in a figure 8,19 hopping in a zigzag
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neus, foot between the second and third metatarsal heads, pattern, and hopping in a 4-square shape.13 Briefly, the
and sacrum. Before completing the baseline assessment, figure-8 hop involved hopping in a pattern that was 2 m in
participants were allowed to practice the jump-landing task. length. Side-to-side hopping required participants to hop
They were asked to stand on a 40-cm box adjacent to a 40- back and forth laterally over a distance of 30 cm.
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3 60-cm force platform (Advanced Medical Technologies Forward-and-backward hoping required the participant to
Inc, Watertown, MA). Participants were then instructed to hop back and forth sagittally over a 30-cm distance.
stand on the test limb and drop forward onto the force plate, Forward hops required the participant to hop forward
where they were required to maintain the single-limb 91.44 cm, stabilize, and hop the same distance again. The
landing for 3 seconds. No constraints were placed on trunk zigzag pattern required participants to hop diagonally in a
or upper extremity placement or movement during the task. zigzag pattern (45-cm wide) outlined on the floor with
Three successful trials were recorded, and jump-landing tape. They were instructed to hop diagonally over the 15-
attempts were separated by 60 seconds of rest.5,10 A cm-wide line, alternating sides. The 4-square hop
successful trial was defined as the participant contacting the required participants to hop within each of the four 40-
force plate cleanly without any loss of balance or any 3 40-cm squares drawn on the floor. With the right limb,
corrections after initial contact (eg, double hop, shifting, or they hopped in a clockwise direction, and with the left
sliding the stance limb). Kinetic data, collected at 2000 Hz, limb, they hopped in a counterclockwise direction. All
were synchronized with 6 infrared cameras (model Eagle; exercises were performed shod throughout the training
Motion Analysis Corporation, Santa Rosa, CA) that program. Further descriptions of the exercises and the
collected kinematic data at 200 Hz via Cortex software training specifications per week are provided in Table 1.
(version 5.5.0.1579; Motion Analysis Corporation). Both Before each session, a standardized warmup consisting of
kinetic and kinematic data were filtered using a low-pass, 5 minutes of free running and 5 minutes of dynamic
zero lag, fourth-order Butterworth filter with a 12-Hz cutoff stretching was completed.13,14
frequency. A global axis system was used based on a right- The total volume of landings started at 80 per session
hand convention: positive kinematic values represented during the first week and increased by 20 for weeks 2
dorsiflexion, inversion, foot adduction, knee flexion, varus, through 5. During the final week, the training volume was

Journal of Athletic Training 0

Table 1. Hop Training Program
Volume
(Foot Contacts
Week per Session, No.) Hopping Exercise Session Information Set 3 Repetitions
1 80 Hopping side to side on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
Hopping forward and backward on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
Hopping forward on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
Hopping in a figure-8 shape on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
2 100 Hopping side to side on 1 leg All: Hands free 2 3 10
Hopping forward and backward on 1 leg All: Hands free 2 3 10
Hopping forward on 1 leg All: Hands free 2 3 10
Hopping in a figure-8 shape on 1 leg All: Hands free 2 3 10
Hopping in a zigzag shape on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
3 120 Hopping side to side with 1 leg All: Arms across the chest 2 3 10

t
Hopping forward and backward on 1 leg All: Arms across the chest 2 3 10
Hopping forward on 1 leg All: Arms across the chest 2 3 10

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Hopping in figure-8 shape on 1 leg All: Arms across the chest 2 3 10
Hopping in zigzag shape on 1 leg All: Hands free 2 3 10
Hopping in 4-square shape on both legs 1: Hands free 2 3 10
2: Arms across the chest
3: Hands behind head
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4 140 Hopping side to side on 1 leg All: Hands behind head 3 3 10
Hopping forward and backward on 1 leg All: Hands behind head 3 3 10
Hopping forward on 1 leg All: Hands behind head 2 3 10
Hopping in figure-8 shape on 1 leg All: Hands behind head 2 3 10
Hopping in zigzag shape on 1 leg All: Arms across the chest 2 3 10
Hopping in 4-square shape on 1 leg All: Hands free 2 3 10
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5 160 Hopping side to side on 1 leg All: Hands behind head 3 3 10

Hopping forward and backward on 1 leg All: Hands behind head 3 3 10
Hopping forward on 1 leg All: Hands behind head 3 3 10
Hopping in figure-8 shape on 1 leg All: Hands behind head 3 3 10
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Hopping in zigzag shape on 1 leg All: Hands behind head 2 3 10

Hopping in 4-square shape on 1 leg All: Arms across the chest 2 3 10
6 150 Hopping side to side on 1 leg All: Hands behind head 3 3 10
Hopping forward and backward on 1 leg All: Hands behind head 3 3 10
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Hopping forward on 1 leg All: Hands behind head 3 3 10

Hopping in figure-8 shape on 1 leg All: Hands behind head 2 3 10
Hopping in zigzag shape on 1 leg All: Hands behind head 2 3 10
Hopping in 4-square shape on 1 leg All: Hands behind head 2 3 10

reduced slightly (from 160 to 150) to minimize the chance limb landing. In all subsequent weeks, an exercise was
of fatigue on posttest assessments. During the first 3 weeks, completed with a single-limb landing.21 The support
participants were instructed to focus on stabilizing and surface for the exercises changed during each session of a
landing with proper form.20 Proper form was determined by training week. Throughout the program, the exercises of the
M.K.A. and H.M. and was defined as the participant (1) first, second, and third sessions of the week were performed
keeping his knees over his toes, (2) landing with flexed on a firm surface, an artificial turf surface, and an unstable
knees, (3) avoiding an erect posture while landing, and (4) surface, respectively.14,16 Participants rested for 30 seconds
landing with his feet shoulder-width apart. During the final between sets and for 1 minute between exercises. All
3 weeks, all exercises were performed at a speed of 2 Hz, exercises were performed in front of a mirror so that
using a metronome, in an effort to better replicate sport (ie, immediate visual feedback was available to all partici-
land, stabilize, and immediately repeat). Program difficulty pants.20 Immediate oral feedback was also provided
was also enhanced during the study by increasing the throughout the training program as needed (ie, when errors
number of exercises, constraining hand position, and were noted). Oral feedback focused on decreasing knee
transitioning from double-limb to single-limb landings valgus, landing softly, avoiding an erect posture while
(Table 1). More specifically, during the first week an landing, and maintaining the proper alignment and position
exercise was introduced, it was performed with a double- of the feet.20

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Table 2. Effect of Hop-Stabilization Training on Self-Reported Function Questionnaire
Group, Mean 6 SD
Experimental (n ¼ 14) Control (n ¼ 14)
Effect Size
Questionnaire Pretest Posttest Pretest Posttest (95% Confidence Interval)c
Foot and Ankle Ability Measurement, %a 84.5 6 4.3 92.4 6 10.1b 81.7 6 6.2 81.6 6 6.4 1.95 (1.03, 2.86)
Sporta 73.6 6 10.7 89.2 6 14.2b 67.6 6 9.3 70.7 6 13.1 1.35 (0.51, 2.18)
Cumberland Ankle Instability Tool, scorea 19.7 6 3.7 24.0 6 4.6b 19.3 6 3.2 20.0 6 3.8 1.07 (0.26, 1.87)
Foot and Ankle Outcome Score, %
Symptoma 67.8 6 12.8 82.6 6 17.3b 67.3 6 10.9 68.1 6 10.6 1.40 (0.56, 2.24)
Paina 73.6 6 10.2 89.0 6 17.1b 71.0 6 13.8 78.3 6 14.4 0.98 (0.18, 1.78)
Activities of Daily Living 80.1 6 3.7 84.5 6 5.4b 78.3 6 5.4 79.3 6 3.9 0.52 (0.24, 1.29)
Sporta 70.7 6 6.4 95.2 6 3.6b 72.5 6 6.7 71.8 6 6.7 3.47 (2.27, 4.66)
Quality of Lifea 71.4 6 10.8 89.2 6 20.4b 71.8 6 10.3 70.7 6 9.3 1.19 (0.37, 2.00)
a
Significant interaction (P , .05).
b
Difference between the pretest-to-posttest change of the experimental group relative to the control group (P , .05).
c
Hedges’ g pretest-to-posttest between-groups effect size.

Statistical Analysis extremity jump-landing biomechanics (ie, kinematics and

Demographic characteristics as well as baseline kine- kinetics) in men’s collegiate basketball players with CAI.
matic and kinetic variables were compared between groups Six weeks of hop-stabilization training altered lower
using independent-samples t tests. Three separate group 3 extremity jump-landing biomechanics and improved self-
reported function. These results support our a priori

t
time repeated-measures multivariate analyses of variance
hypothesis.

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were conducted to determine the effect of the hopping
intervention on the kinematics at initial contact and at peak Like other interventions, the current 6-week hopping
vertical ground reaction force and the kinetics. We program improved self-reported function in those with CAI.
For example, improvements were noted after 4-week
calculated post hoc t tests to analyze changes between
interventions that included hop-stabilization exercis-
groups. Data were analyzed using SPSS (version 19.0; IBM
es.14,15,19 Additionally, the magnitude of the improvements
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Corp, Armonk, NY), and an a priori a level of .05 was set to
we found were consistent with, if not larger than, those
determine statistical significance. The Hedges’ g pretest to
reported previously. The magnitudes of improvement on
posttest between-groups effect sizes were also calculated
the FAAM and FAAM-S were also larger than previously
and interpreted as small (,0.4), moderate (0.41–0.7), or
established22 minimal clinically important difference scores
large effects (.0.71). (8% and 9%, respectively) for these questionnaires in
in

patients with CAI. For example, earlier researchers19 noted

RESULTS an average Foot and Ankle Disability Index Sport change
Demographic characteristics did not differ between groups score of 11%, whereas our mean change score for the
(P . .05). At baseline, none of the dependent variable FAAM-S was 15%. It is possible that the greater volume of
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differed between groups (P . .05). The hopping intervention hop stabilizations performed in the current investigation or
resulted in improvements in all self-reported questionnaires the longer duration of the intervention (6 versus 4 weeks) or
relative to the control condition (P , .05). Large effect sizes both were responsible for the larger improvements, but
future investigation is needed to confirm this hypothesis.
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and 95% confidence intervals (CIs) were noted for all

questionnaires and scales except for the Activities of Daily Plyometric and hop-stabilization training have been
Living subscale of the Foot and Ankle Outcome Score. shown to positively influence the biomechanical profile
Means, standard deviations, and effect sizes for the self- (ie, reduce the magnitude of known lower extremity
reported questionnaires can be seen in Table 2. biomechanical injury risk factors) in healthy control
Compared with the control condition, the hop-stabiliza- participants16 and anterior cruciate ligament (ACL)-injured
tion intervention also resulted in changes in ankle, knee, individuals.23 More specifically, the evidence hop-stabili-
and hip kinematics (P , .05; Table 3) and kinetics (P , zation training reduced ground reaction forces, increased
.05; Table 4). All but 2 kinematic variables demonstrated hip- and knee-flexion angles, and reduced knee valgus and
large effect sizes with 95% CIs that did not cross zero. In varus torque. Interventions that focus on or include hop-
general, more sagittal-plane flexion at all joints and less stabilization exercises in CAI patients18,24 have also
frontal-plane deviation at all joints were observed after the demonstrated biomechanical changes: increases in sagit-
hopping intervention. All but 1 of the kinetic variables tal-plane kinematics (eg, hip- and knee- flexion angles,
demonstrated a large effect size and 95% CIs that did not ankle dorsiflexion) occurred concurrently with reductions
cross zero. The observed changes highlighted a reduction in in frontal (eg, ankle inversion)- and transverse- plane (eg,
peak force and loading rate with a corresponding increase hip internal rotation) motion.25 Increased dorsiflexion at
in the time to peak force. initial foot contact decreased peak passive inversion
moments as well as peak inversion joint angles,26 further
highlighting how increasing sagittal-plane–flexion angles
DISCUSSION
corresponds with reductions in frontal-plane motion.
The purpose of our study was to determine the effects of Our observed kinematic changes in this investigation are
a 6-week hop-stabilization training program on lower consistent with findings in the literature. For example,

Journal of Athletic Training 0

Table 3. Effect of Hop-Stabilization Training on Kinematic Variable of Ankle, Hip, Knee (8)
Group, Mean 6 SD
Experimental (n ¼ 14) Control (n ¼ 14)
Effect Size
Joint Kinematic Variable Pretest Posttest Pretest Posttest (95% Confidence Interval)c
Ankle Dorsiflexion-plantarflexion
ICa 41.89 6 7.71 33.35 6 7.43b 42.14 6 6.95 41.67 6 6.14 1.89 (2.77, 0.99)
Peak VGRFa 14.34 6 6.44 9.11 6 7.42b 14.40 6 5.07 14.42 6 5.17 1.26 (2.07, 0.44)
Inversion-eversion
ICa 2.90 6 0.90 2.05 6 0.97b 2.93 6 0.70 2.86 6 0.95 0.97 (1.75, 0.18)
Peak VGRFa 1.88 6 0.90 0.90 6 0.90b 1.92 6 0.70 1.87 6 0.66 3.62 (4.82, 2.41)
Abduction-adduction
ICa 3.13 6 0.87 2.34 6 0.80b 3.05 6 0.95 3.07 6 0.96 0.66 (1.42, 0.10)
Peak VGRFa 1.45 6 0.87 0.76 6 0.87b 1.58 6 0.95 1.63 6 0.99 5.81 (7.50, 4.11)
Knee Flexion-extension
ICa 6.24 6 3.18 13.10 6 3.19b 5.55 6 2.84 5.65 6 2.64 1.53 (0.68, 2.37)
Peak VGRFa 20.68 6 5.77 28.01 6 4.09b 20.40 6 5.95 20.64 6 6.02 1.64 (0.78, 2.49)
Varus-valgus
ICa 2.93 6 1.29 2.07 6 1.39b 3.30 6 1.54 3.30 6 1.56 0.88 (1.65, 0.10)
Peak VGRFa 4.19 6 3.19 3.00 6 1.89b 4.81 6 2.72 4.74 6 2.42 0.69 (1.45, 0.07)
Internal- external rotation
ICa 2.94 6 1.09 1.60 6 1.24b 3.38 6 1.89 3.49 6 1.71 1.19 (1.99, 0.38)
Peak V GRFa 6.79 6 2.42 4.25 6 2.36b 7.61 6 2.82 7.36 6 3.02 1.47 (2.30, 0.63)
Hip Flexion-extension

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ICa 20.39 6 5.28 28.75 6 5.03b 20.45 6 5.40 20.75 6 5.41 1.85 (0.96,2.74)
Peak VGRFa 27.00 6 8.44 35.23 6 6.62b 26.46 6 8.18 26.70 6 8.03 1.40 (0.57, 2.22)

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Abduction-adduction
ICa 10.52 6 4.24 8.39 6 2.94b 11.80 6 4.85 11.94 6 5.02 1.07 (1.85, 0.27)
Peak VGRFa 11.12 6 4.02 9.17 6 3.82b 13.46 6 4.77 13.36 6 4.68 1.01 (1.79, 0.22)
Internal-external rotation
ICa 11.31 6 1.43 9.24 6 1.70b 10.68 6 1.23 10.66 6 1.19 1.30 (2.11, 0.48)
eF
Peak VGRFa 12.26 6 1.60 10.68 6 1.97b 12.03 6 1.51 12.03 6 1.34 1.05 (1.84, 0.25)
Abbreviations: IC, initial contact; VGRF, vertical ground reaction force.
a
Significant interaction (P , .05).
b
Difference between the pretest-to-posttest change of the experimental group relative to the control group (P , .05).
c
Hedges’ g pretest-to-posttest between-groups effect size. Positive kinematic values represented dorsiflexion, inversion, foot adduction,
knee flexion, varus, internal rotation, hip extension adduction, and internal rotation.
in

reductions in ankle inversion, plantar flexion, and knee kinematics. However, future research is needed to deter-
valgus were noted. Concurrently, increases in hip and knee mine both the midterm and long-term positive and possible
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flexion were observed. Given that these changes are negative effects of altering jump-landing kinematics in
associated with reductions in lower extremity joint injury those with CAI. It is also important to note that a link
risk factors and improvements in self-reported function, we between a history of a lateral ankle sprain and an increased
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speculate that they represent improvements in jump-landing risk for ACL injury has been established.27 The kinematic

Table 4. Effect of Hop-Stabilization Training on Peak Ground Reaction Forces (Peak [%Body Weight]), Time to Peak Ground Reaction
Force (TTP [ms]), and Vertical Loading Rates ([N/BW]/s) Between Groups
Group, Mean 6 SD
Experimental (n ¼ 14) Control (n ¼ 14)
Effect Size
Direction Kinetic Variable Pretest Posttest Pretest Posttest (95% Confidence Interval)c
Medial Peaka 0.16 6 0.02 0.13 6 0.02b 0.16 6 0.03 0.16 6 0.03 0.85 (1.62, 0.07)
TTPa 52.75 6 1.29 56.57 6 2.13b 52.85 6 1.54 52.50 6 1.68 1.49 (0.64, 2.32)
Lateral Peaka 0.27 6 0.06 0.21 6 0.05b 0.27 6 0.07 0.27 6 0.07 1.12 (1.91, 0.32)
TTPa 46.69 6 2.32 52.12 6 4.59b 46.75 6 2.55 46.96 6 3.27 1.29 (0.47, 2.09)
Posterior Peaka 0.77 6 0.09 0.68 6 0.09b 0.76 6 0.09 0.76 6 0.099 1.07 (1.86, 0.27)
TTPa 53.99 6 4.62 59.17 6 5.78b 54.53 6 4.91 54.84 6 4.86 0.99 (0.20, 1.77)
Anterior Peaka 0.06 6 0.04 0.04 6 0.03b 0.10 6 0.11 0.11 6 0.11 1.26 (2.07, 0.45)
TTP 51.17 6 3.28 54.90 6 4.17b 51.78 6 3.11 51.86 6 3.47 0.98 (0.29, 1.76)
Vertical Peaka 3.81 6 0.54 3.33 6 0.68b 3.89 6 0.57 3.85 6 0.62 0.79 (1.55, 0.01)
TTPa 58.18 6 1.64 64.06 6 3.28b 58.66 6 1.96 59.09 6 3.52 1.14 (0.34, 1.93)
Vertical loading rate 0.12 6 0.23 0.05 6 0.008b 0.06 6 0.009 0.06 6 0.01 0.29 (1.03, 0.45)
a
Significant interaction (P , .05).
b
Difference between the pretest-to-posttest change of the experimental group relative to the control group (P , .05).
c
Hedges’ g pretest-to-posttest between-groups effect size.

0 Volume 54  Number 12  December 2019

changes in our study (eg, increased knee and hip flexion patients know what the movement goal is, it can be difficult
and decreased knee valgus and ground reaction forces) are for them to identify important movement errors from
associated with a decreased risk of ACL injury, so hop- inherent feedback alone (eg, somatosensory input). Second,
stabilization training may also have the potential to external feedback has been shown to positively influence
decrease the risk of ACL injury in those with a history of movement patterns.30 Thus, incorporating external and
ankle sprains. However, prospective studies of injury rates inherent feedback may allow the patient to better
are needed to test this hypothesis. triangulate when a movement error was made (ie, felt,
Kinetically, those with CAI have been reported to have a saw, and told) and subsequently enhance the ability to learn
higher magnitude of and quicker time to peak ground better movement patterns. Thus, clinicians should (1)
reaction force.10 Our results, illustrating a reduction in develop purposeful progressions of their chosen exercises
ground reaction forces and a slower time to peak force after to enhance adaptability and (2) provide external feedback
the hop-stabilization exercises, is consistent with previous to contextualize the errors. Most importantly, training
research in CAI patients28 and those with ACL injury.23 volume must be high enough to ensure that the observed
This finding is not surprising given the known relationship changes are learned (ie, permanent) and not just a transient
between a reduction in ground reaction force magnitude practice effect.
and concurrent increases in hip and knee flexion during
landing23 and the fact that hip and knee flexion increased in Limitations
our participants. As peak impact forces occur ,30 to 50
milliseconds after initial contact, reductions in ground This study, like others, is not without limitations. For
reaction force are likely the result of increased preparatory example, only male university basketball players were
muscle activity. From the larger randomized controlled included, which may limit the generalizability of the results
trial, we were able to illustrate that the hop-stabilization to different playing levels, different sports, and female
program also resulted in earlier onset times and greater athletes. Currently, no data suggest that CAI-associated

t
preparatory muscle activity in the peroneus longus, lateral impairments or responses to rehabilitation differ among

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hamstrings, tibialis anterior, and gluteus medius.17 Thus, these factors, but we have no data to indicate that they are
the cumulative results of our larger randomized controlled equivocal. Our study design did not allow us to conclude
trial confirm the effectiveness of hop-stabilization training that the hopping exercises were better or worse than other
(ie, improved self-reported function) while highlighting intervention programs as comparative effectiveness was not
plausible neurobiomechanical mechanisms underlying this established. Finally, we quantified only the immediate
eF
effectiveness, at least in part. effects of the intervention on a task (jump landing) that was
Although evaluating effectiveness and providing insights similar to the training exercises (hopping). Thus, the
into the underlying mechanisms are important, the motor- retention of the program remains unknown, and it is
learning principles used in the current and previous unclear if the hop-stabilization program would cause
intervention programs that resulted in observed changes improvements in a broader range of tasks and assessments
such as cutting or jumping. Finally, the ability of the
in

are the most pertinent to clinical practice. Those with CAI

have a more constrained sensorimotor system due to hopping training to limit recurrent injury is also unknown.
numerous sensory and motor impairments. These impair-
ments decrease the adaptability for coordinating move- CONCLUSIONS
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ments during changing task and environmental demands, A 6-week hop-stabilization program changed jump-
resulting in a continuum of disability.29 Research11,14,15,17 landing biomechanics (kinematics and kinetics) in male
has consistently shown that coordination training improved university basketball players. This program also resulted in
a variety of outcomes in those with CAI.
O

improvements in multiple patient-reported outcomes.

Maximizing the benefits of such interventions requires Landing from a jump is a frequent demand in basketball
that the patient understand the movement goal (ie, how a and a common mechanism for ankle sprains in basketball
task should be completed) and the purposeful manipulation players. The current hop-stabilization program is an
of task and environmental demands as he or she progresses effective and reasonably sport-specific program that may
through the rehabilitation program. For example, to reduce the lower extremity injury risk in this population.
progress in a hop-training program, the task demands
should be increased from simple to more complex (ie,
ACKNOWLEDGMENTS
double to single limb) and the environmental cues
progressed from predictable to more unpredictable (ie, The authors thank the athletes who participated and the
stable surface to unstable surface). Both task and research assistants who were instrumental in the collection of
environmental demands should be progressed in the context the data.
of sport-specific demands as the patient demonstrates
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Address correspondence to Hooman Minoonejad, PhD, PT, Department of Health and Sport Medicine, Faculty of Physical Education
and Sport Sciences, University of Tehran, Kargar Street, Tehran, Iran. Address e-mail to h.minoonejad@ut.ac.ir.

0 Volume 54  Number 12  December 2019