Effect of Q-angle,lateral distal tibial angle and hip muscle torques on ankle injury

Abstract

BACKGROUND:

The ankle sprain is the most common ankle injury. Although the factors that increase the risk of ankle injury are included in the literature, the definitive evidence is controversial.

OBJECTIVE:

The aim of our study was to examine whether Q-angle, lateral distal tibial angle (LDTA), and hip muscle torque are associated with ankle sprain.

METHODS:

Thirty-six individuals who underwent an axial X-ray examination of the lower extremity following ankle sprain were included. The Q-angle and LDTA were measured on the axial knee X-rays on both sides. The isometric muscle strength was measured with a digital handheld dynamometer for the quadriceps femoris muscle, the gluteus medius muscle and the gluteus maximus muscle. Muscle torques were calculated by multiplying isometric muscle strength values with the distance to the joint center.

RESULTS:

Discrimination analysis shows that the gluteus maximus (0.90), gluteus medius (0.49), quadriceps femoris muscle torques (0.34), and lateral distal tibial angle (0.43) were the factors that most contributed to ankle sprain. No significant relationship was found between the Q-angle and ankle sprain (p = 0.603). A strong relationship was found between LDTA, quadriceps femoris, gluteus medius and gluteus maximus muscle torques and ankle sprain (p = 0.014, p < 0.001, p = 0.011, p = 0.002, respectively).

CONCLUSIONS:

In conclusion, the torques of the proximal muscle may be more related than the Q-angle to lateral ankle sprain injury. Individuals with high LDTA should also be carefully examined for the risk of ankle sprain.

Keywords

Ankle injury muscle strength torque knee lower extremity

1 Introduction

The ankle sprain is the most common ankle injury, comprising nearly 80% of all injuries affecting this area and 77% of sprains involving the lateral ligaments [1]. Although the reported risk factors for ankle sprain include asymmetric tension in the flexor muscles of the ankle, increased body mass index (BMI), increased body weight, and younger age, definitive data are lacking [2]. The alignment of the pelvis, knee, and ankle has attracted significant research interest as a potential risk factor for lower extremity injury. The quadriceps angle (Q-angle) has been reported to be an indicator for the biomechanical functions of the lower extremity, reflecting the effect of the quadriceps mechanisms on the knee, as well as providing information on patellar movements within the trochlear sulcus and on the functions of the thigh muscles [3]. The Q-angle is measured as the narrow angle between the line that connects the anterior superior iliac spine (ASIS) to the mid-patella and the line that connects the tibial tubercle to the center of the patella [3, 4]. The Q-angle is responsible for transmitting pressure from the pelvis to the legs. Although there is no consensus on the net value of the angle, there are studies that suggest it is around 10 degrees for men and 15 degrees for women [5]. However, there are also studies that indicate that the angle will not vary by gender, and the mean standardized Q-angle value for all adults is 15°; the standard deviation is 2.71°. It has also been stated that the Q-angle would be affected by height, not gender, and the angle is larger in taller people [6]. This angle may be a risk factor for ankle injuries if it deviates from its normal position in addition to impairments in patellofemoral function. It causes an imbalance in load distribution in the lower extremity joints, causing injuries such as sprains and strains [5]. Therefore, the prevalence of ankle sprains seems to be directly related to the Q-angle. Several studies suggested that the Q-angle may represent an independent risk factor associated with an increased risk of ankle sprain [6, 7]. It has been proposed that individuals with knee valgus and a Q value exceeding 15 degrees have an increased risk of lower extremity injury. Also, a positive correlation between the ankle sprain and the Q-angle has been reported among recreational basketball players [3]. On the other hand, no direct correlations were found between these two parameters in a study involving 45 professional athletes [8].

Another measurement that can be utilized to evaluate the alignment disorders of the lower extremity is the lateral distal tibial angle (LDTA). LDTA is the angle between the distal tibial joint orientation line and the anatomical and mechanical axis of the tibia, and its mean value is 89 degrees. An angle of less than 86 degrees and more than 92 degrees indicates the presence of valgus and varus positions, respectively [9]. To the best of our knowledge, no previous studies have examined the association between LDTA and ankle sprain. It is plausible to assume that the excessive value of LDTA may increase the predisposition to lateral ankle ligament injury. Therefore, this study was based on the hypothesis that LDTA and Q-angle may affect the occurrence of ankle sprain.

The weakness of the proximal muscles may be another potential risk factor for injury [10]. This latter was particularly evident in studies in which researchers showed that hip abductor weakness may lead to poor balance and neuromuscular adaptations in the ankle, thereby contributing to increased inversion moments, increased activation, and earlier activation of the ankle evertors. However, a prospective study has suggested that the hip abductor, flexor or adductor strength has no role in predicting the future risk of ankle sprain [11]. The potential effects of hip muscle strength on ankle sprain are controversial. The primary objective of our study was to examine whether the Q-angle, LDTA, and hip muscle torque were associated with ankle sprain. The secondary objective was to determine the parameter that had the most significant impact on ankle injury risk.

2 Materials and methods

2.1 Participants

A total of 40 people (27 men, 13 women) who were diagnosed with ankle sprain by a specialist doctor and who had axial X-ray examination of the lower extremities were included in the study. Exclusion criteria were previous foot, knee and/or pelvis surgery, being under 18 years of age, over 65 years of age, and presence of congenital / developmental lower extremity pathologies and other anomalies.

Thirty-six individuals (25 male, 11 female) who applied with the complaint of ankle sprain in the last 6 months were included in the study (Fig. 1). All participants signed and provided a written informed consent form. The study protocol was approved by the local ethics committee (Date: 12 March 2019, No. 05/07).

Fig. 1

Patient flowchart.

2.2 Measurements

2.2.1 Q-Angle and LDTA

The radiological imaging included the ASIS, femur, patella, the long axis of the patella, and ankle. The Q-angle and lateral distal tibial angle (LDTA) measurements were performed using manual goniometry on the axial knee X-rays on both sides. Special care was taken to obtain the radiological imaging in the antero-posterior position of the knee with the patient standing and quadriceps femoris muscle being relaxed, in order to have a good view of the knee ankle and Q-angle. When assessing the clinical Q-angle, plain radiographs, magnetic resonance imagery and computed tomography images may be considered such a gold standard [12].

For Q-angle measurements, the pivot of the goniometer was placed on the patella midpoint. One arm of the goniometer followed the long line of the femur from the spina iliaca anterior superior, and the other arm was passed through the tuberositas tibia (Fig. 2).

Fig. 2

Q-angle and LDTA measurements.

LDTA was determined on the antero-posterior X-ray of the lower extremity by drawing a line on the anatomical axis of the tibia and another line for the distal tibial orientation, and LDTA was taken as the measure of the angle lateral to these two lines (Fig. 2).

The Q-angle and LDTA were measured by an orthopedic surgeon who had 15 years of experience. He is an expert in the field of musculoskeletal disorders. The test-retest reliability of X-ray measurements was evaluated based on a previous study that suggested that, reporting an intraobserver variability of 0.91, the test-retest reliability of measurements taken by a single evaluator would be high, reflecting a perfect fit [13].

2.2.2 Isometric muscle strength and muscle torque

In order to obtain standard and reliable measurements, detailed information was provided to each participant before the test, and a demonstration was carried out. Isometric muscle strength was measured with a digital handheld dynamometer (Lafayette Instrument Company, USA), with the patient stabilized using external belts that precluded any movement of the muscle of concern. For quadriceps femoris muscle measurements, the patient was asked to sit at the edge of the bed, and the knee was positioned at 90 degrees flexion. For the gluteus medius muscle test, the patient was asked to lie down on the opposite side. For gluteus maximus muscle measurements, the patient was asked to lie in a prone position, with the hip in extension and knee at 90 degrees flexion [14]. The patients were asked to exert maximum voluntary contraction, and the average value of three repetitions was recorded [15].

The distance between the reference point representing the center of joint and the dynamometer was measured using a measuring tape. Muscle strength value was multiplied by the distance in order to calculate muscle torque for each muscle. The reference point for the gluteus medius and gluteus maximus muscles was the greater trochanter, while it was the lateral condyle of the patella for the quadriceps femoris.

2.3 Statistical analysis

The sample size of the study was calculated based on the data in the study by Koca et al. [16]. Accordingly, it was decided to include at least 40 participants in the study, with an effect size of d = 0.80. A pre-analysis was performed on all available data, and the normal distribution was examined with the Shapiro-Wilk test. The variables with normal distribution were expressed as mean±standard deviation (mean±SD), those without normal distribution were expressed with median (min-max) values, and categorical variables were expressed in percentages.

Based on the test for normal distribution, comparisons between the groups were performed using the Mann Whitney U test for variables without normal distribution, and the independent two samples t test for variables with normal distribution. The correlation between variables was tested with biserial correlation analyses. A p value of < 0.05 was considered to denote statistical significance. Correlations coefficient values were stratified as follows: negligible (0.00–0.10), weak (0.10–0.39), moderate (0.40–0.60), strong (0.70–0.89), very strong (0.90–1.00) correlations [17].

A discrimination analysis was carried out to identify the variable with the greatest impact on the likelihood of ankle sprain. Prior to the discrimination analysis, a number of hypotheses were tested. By calculating Mahalanobis Distance Coefficients, the multi-dimensional extreme points were determined and examined, showing that no multi-dimensional extreme points were present in the dataset. The homogeneity of the covariance matrices was evaluated with Box-M statistics. The F value with regard to Box-M statistics was not significant [F (15.19728.947) = 28.983 p > .05], indicating the homogeneity of the covariance matrices of the groups. Also, this can be utilized as proof for meeting the normal distribution assumptions. Additionally, the correlations between independent variables were assessed to examine the multiple linear correlation problem. No correlations ≥0.80 were found between independent variables, indicating the absence of a multiple linear correlation problem. The sprain status (i.e., presence/absence of sprain) was identified as a two-category dependent variable. The effect of the following independent variables on the dependent variable was explored: Gluteus maximus torque, gluteus medius torque, quadriceps femoris torque, Q-angle, and LDTA. However, since analyses showed a very poor association of the Q-angle (–0.096) with the standardized canonical discrimination function, it was removed from the model due to the absence of a significant effect in discriminating an ankle with and without sprain (F (1.70) = 0.273, p > 0.05). The analysis was repeated with other variables.

Initially, the eigenvalue indicating the relative discriminative power of the discrimination function and the canonical correlation coefficient explaining the relationship between groups formed by dependent variables and the discrimination function were determined in the analyses. Since the categorical dependent variable of the study had two levels, only one discriminative function and eigenvalue were produced. The eigenvalue was determined to be 0.231, while the canonical correlation coefficient was estimated to be 0.433. Based on this result, the function may be thought to be moderately powerful in discriminating the groups. Since Wilk’s lambda statistic was statistically significant [χ2 (4) = 14.116; p < 0.01], the resultant function may have high discriminative power, and groups can be discriminated using a discrimination function. The total accurate classification ratio of the discrimination function was 66.7%. All analyses were performed using the SPSS v.22 statistical software pack (SPSS Inc., Chicago, IL, USA).

3 Results

Thirty-six individuals were included in the study (25 males and 11 females). The mean±SD of age, height, weight, and body mass index were 36.11±13,41 years (male 31.24±11.89, female 47.18±9.63), 171.36±8.64 cm (male 176.12±4.38, female 160.55±5.57), 78.83±9.69 kg (male 77.36±5,.0, female 82.18±14.99), and 26.98±4.69 kg/cm² (male 24.95±1.9, female 31.60±5.81), respectively.

There was a relationship between the gluteus maximus, gluteus medius and quadriceps muscles strength and ankle sprain (p < 0.001, p = 0.001, and p < 0.001, respectively). The quadriceps femoris muscle, gluteus medius muscle and gluteus maximus muscle strengths were significantly lower on the involved side compared to the noninvolved side (p < 0.001, p = 0.011, and p = 0.002, respectively) (Table 1).

Table 1
The comparison of muscular strength, torque, Q-angle, and LDTA between with and without sprained side

n Mean±SD t df/U^* p

Quadriceps femoris muscle strength (N)

Non-sprain side 36 13,47±3,084 5,055 70 < 0.001

Sprain side 36 9,97±2,782

Quadriceps femoris muscle torque (Nm)

Non-sprain side 36 2,12±0,87 5,543 70 < 0.001

Sprain side 36 2,87±1,08

Gluteus medius muscle strength (N)

Non-sprain side 36 11,86±2,997 3,580 70 0.001

Sprain side 36 9,39±2,861

Gluteus medius muscle torque (Nm)

Non-sprain side 36 2,24±0,87 2,609 70 0.011

Sprain side 36 2,83±1,00

Gluteus maximus muscle strength (N)

Non-sprain side 36 15,28±2,982 5,272 70 < 0.001

Sprain side 36 11,56±3,009

Gluteus maximus muscle torque (Nm)

Non-sprain side 36 3,06±1,11 3,276 70 0.002

Sprain side 36 4,04±1,26

Q-angle (°)

Non-sprain side 36 12,11±1,64 – 576^* 0.417

Sprain side 36 12,57±3,12

LDTA (°)

Non-sprain side 36 88,88±1,60 – 425,5^* 0.011

Sprain side 36 89,80±1,39

	n	Mean±SD	t	df/U^*	p
Quadriceps femoris muscle strength (N)
Non-sprain side	36	13,47±3,084	5,055	70	< 0.001
Sprain side	36	9,97±2,782
Quadriceps femoris muscle torque (Nm)
Non-sprain side	36	2,12±0,87	5,543	70	< 0.001
Sprain side	36	2,87±1,08
Gluteus medius muscle strength (N)
Non-sprain side	36	11,86±2,997	3,580	70	0.001
Sprain side	36	9,39±2,861
Gluteus medius muscle torque (Nm)
Non-sprain side	36	2,24±0,87	2,609	70	0.011
Sprain side	36	2,83±1,00
Gluteus maximus muscle strength (N)
Non-sprain side	36	15,28±2,982	5,272	70	< 0.001
Sprain side	36	11,56±3,009
Gluteus maximus muscle torque (Nm)
Non-sprain side	36	3,06±1,11	3,276	70	0.002
Sprain side	36	4,04±1,26
Q-angle (°)
Non-sprain side	36	12,11±1,64	–	576^*	0.417
Sprain side	36	12,57±3,12
LDTA (°)
Non-sprain side	36	88,88±1,60	–	425,5^*	0.011
Sprain side	36	89,80±1,39

N = Newton; Nm = Newtonmeter; SD = Standard deviation. LDTA: Lateral distal tibial angle.

There were no significant correlations between Q-angle and occurrence of ankle sprain (p = 0.603), on the other hand, there was a positive and weak correlation between LDTA and ankle sprain (p = 0.014, r = 0.288) (Table 2). A moderate and negative correlation was found between Q-angle and quadriceps femoris muscle torque values (p < 0.001, r = –0.497). A moderate and negative correlation was found between Q-angle and gluteus medius muscle torque values (p < 0.001, r = –0.575). A strong and negative correlation was found between Q-angle and gluteus maximus muscle torque values (p < 0.001, r = –0.702). On the other hand, LDTA was found to be weak and negatively correlated with the quadriceps muscle torque only (p = 0.001, r = –0.389). There was a weak negative correlation between gluteus maximus, gluteus medius muscle strength and ankle sprain (r = –0.365, p = 0.002, and r = –0.298 p = .011, respectively). There was a moderate negative correlation between quadriceps muscle strength and ankle sprain (r = –0.552, p < 0.001) (Table 2).

Table 2

The correlation of ankle sprain with Q-angle, LDTA and muscle torque

	Q-angle (°)		LDTA (°)		Ankle sprain
n = 72	Rho	p	rho	p	rho	p
Quadriceps femoris muscle torque (Nm)	–,497^**	< 0.001	–,389^**	,001	–,552^**	< 0.001
Gluteus medius muscle torque (Nm)	–,575^**	< 0.001	–,200	,092	–,298^*	,011
Gluteus maximus muscle torque (Nm)	–,702^**	< 0.001	–,296^*	,012	–,365^**	,002
Q-angle (°)	1	–	,369^**	,001	,062	,603
LDTA (°)	,369^**	,001	1	–	,288^*	,014

rho = The biserial correlation coefficient; p = level of significance. ^*. Correlation is significant at the 0.05 level (2-tailed). ^**. Correlation is significant at the 0.01 level (2-tailed).

An examination of standardized coefficients for discrimination function indicated that the independent variables making the greatest contribution were, in decreasing order, “Gluteus maximus muscle torque” (0.906), “Gluteus medius muscle torque” (0.494), “LDTA” (0.436) and “Quadriceps femoris muscle torque” (0.341) (Table 2).

Table 3

The coefficient of discrimination analyses for standardized canonical discrimination function

Discrimination analysis	Function
	1
Gluteus maximus muscle torque	0,906
Gluteus medius muscle torque	–0,494
LDTA (°)	–0,436
Quadriceps femoris muscle torque	0,341

LDTA: Lateral distal tibial angle.

4 Discussion

This study examined the associations among Q-angle, LDTA, isometric muscle strength, and proximal muscle torque on ankle injuries. No significant associations between the Q-angle and ankle sprain were observed. However, there were significant correlations between the ankle sprain and LDTA and hip muscle torques.

Literature data on the association between the Q-angle and ankle sprain is controversial. It has been reported that despite low sensitivity and consistency, Q-angle measurements may represent a useful tool that can be used in the diagnosis and treatment of low extremity alignment disorder and associated conditions [18]. In a study involving 300 patients, the Q-angle was approximately 2 degrees greater in those with a history of ankle sprain [5]. In another report, significant associations were found between the Q-angle and ankle sprain among a group of female basketball players in the US [19]. In contrast with these studies, we failed to observe any significant relationship between the Q-angle and ankle sprain. In line with our observations, Pefanis et al. did not observe any significant associations between the Q-angle and ankle sprain in a group of athletes [8]. The effect of navicular drop, anterior pelvic tilt, femoral anteversion, tibiofemoral angle, and BMI may have attenuated the direct impact on ankle injuries [20, 21].

Although the LDTA parameter has not been extensively investigated in previous studies, it has been found to be an important factor affecting injury. Mechanical axis measurements in the tibia and subtalar joint supination were found to be significant predictors of the varus stresses on the knee joint [22]. Since LDTA is the lateral angle formed by the distal tibia joint orientation line and the anatomic and mechanical axis of the tibia, we predicted that there would be an association between subtalar joint supination and LDTA. Increasing LDTA would push the ankle in the direction of varus deformity, leading to increased supination in the subtalar joint, which in turn would result in an increased predisposition to lateral ankle sprain by the creation of adduction, inversion, and plantar flexion moment in the ankle. In our study, ankle sprain had a strong and positive correlation with LDTA. To the best of our knowledge, no previous studies have examined the effect of LDTA on ankle injury. It has been observed that those with ankle sprain have increased LDTA.We also observed a significant relationship between quadriceps muscle torque and ankle sprain. The stronger quadriceps muscle may cause a reduced Q-angle. In this line of thinking, physical activities requiring intense quadriceps training may be related with reduced Q-angle. Stresses placed upon the ankle will affect the alignment in the lower extremity and will predispose the individual to an ankle sprain, particularly in the lateral side. On the other hand, in the presence of adequate muscle strength, these stressors can be compensated, at least theoretically. Here, we observed a significant link between muscle torque and ankle sprain. We also found that increasing muscle strength was associated with prevention while decreasing levels of muscle strength were associated with an increased predilection to ankle sprain. It may be proposed that exercise programs for subjects with a history of the ankle sprain, or for those who want to avoid such injury, should also include muscle strength training, mainly focusing on the quadriceps femoris, gluteus maximus, and gluteus medius muscles. Our discriminatory analysis also confirmed the effect of pelvic muscle strength on this injury, with gluteus maximus having the most marked impact, followed by the gluteus medius.

The presence of weak hip muscles has been shown to contribute to poor balance and compensatory neuromuscular adaptations, namely increased inversion moments, increased activation, and earlier activation of ankle evertors. Thus, it has been proposed that weak abductor muscles of the hip may be associated with an elevated risk of ankle sprain [11]. Another significant association was observed between muscle torques and strength in the gluteus medius and gluteus maximus muscles in our study. Among the parameters with an impact on ankle sprain risk, gluteus maximus torque was found to have the most profound effect. Previously, it was shown that individuals with a history of ankle sprain had lower hip abductor strength than those without such history. Fatigue in hip abductors leads to reduced medial-lateral posture stability that may contribute to ankle sprain risk via altered plantar pressure underneath the lateral column of the foot [22, 23].

The limitations of our study relate to the activity level, occupation, ethnic origin, and factors that have an impact on muscle strength as well as on tendon and joint stability. The use of advanced statistical analysis, such as discriminatory analysis, that could evaluate the effect of all research parameters simultaneously allowed us to identify the contributory factors more accurately. We believe that this approach may have reduced the effect of limitations inherent to the multifactorial etiology of the ankle injury. In addition, according to published guidelines for the evaluation of ankle sprain, X-ray for evaluation and therefore exposure to radiation is an important limitation in our study, since X-ray is not a standard method routinely used in evaluation [24]. Another limitation is that BMI was not included in the correlation analysis because the injured and uninjured side belongs to same individuals. Since the injured and uninjured legs have particular values in terms of other biomechanical parameters, correlation analysis could be made with these values.

5 Conclusion

In light of these findings, it appears that the inclusion of quadriceps femoris, gluteus medius, and gluteus maximus-strengthening exercises in training protocols may represent an essential tool for the prevention of ankle injury. Since a strong and positive correlation was observed between LDTA and ankle sprain, protective measures against ankle strain could be emphasized in subjects with higher levels of LDTA.

Further studies may shed more light on biomechanical and structural effects on ankle injury by examining other potential parameters. It may be helpful to pay attention to individuals with high LDTA to prevent ankle sprains. The torques of the quadriceps femoris, gluteus medius and gluteus maximus muscles may be more related to lateral ankle sprain injury than the Q-angle.

Footnotes

Acknowledgments

The authors thank all participants who participated in the study.

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

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