Vous êtes sur la page 1sur 301

INFORMATION TO USERS

This manuscript has been reproduced from the microfilm master. UMI films
the text directly from the original or copy submitted. Thus, some thesis and
dissertation copies are in typewriter face, while others may be from any type of
computer printer.
The quality of this reproduction is dependent upon the quality of the
copy submitted. Broken or indistinct print, colored or poor quality illustrations
and photographs, print bleedthrough, substandard margins, and improper
alignment can adversely affect reproduction.
In the unlikely event that the author did not send UMI a complete manuscript
and there are missing pages, these will be noted.

Also, if unauthorized

copyright material had to be removed, a note will indicate the deletion.


Oversize materials (e.g., maps, drawings, charts) are reproduced by
sectioning the original, beginning at the upper left-hand comer and continuing
from left to right in equal sections with small overlaps.

ProQuest Information and Learning


300 North Zeeb Road, Ann Arbor, Ml 48106-1346 USA
800-521-0600

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

ON THE RELATION BETWEEN THORACIC KYPHOSIS, ATHLETIC


TRAINING, HAMSTRING SHORTNESS, AND ANTHROPOMETRY
IN THE DEVELOPING SPINE

by

Paul John Moga

A dissertation submitted in partial fulfillment


of the requirements for the degree of
Doctor o f Philosophy
(Kinesiology)
in The University o f Michigan
2002

Doctoral Committee:
Associate Professor Melissa Gross, Co-chair
Research Scientist James Ashton-Miller, Co-chair
Professor Dee Edington
Associate Professor Bernard Martin

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

UMI Number: 3068923

Copyright 2002 by
Moga, Paul John
All rights reserved.

__ ___

__

UMI

UMI Microform 3068923


Copyright 2003 by ProQuest Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.

ProQuest Information and Learning Company


300 North Zeeb Road
P.O. Box 1346
Ann Arbor, Ml 48106-1346

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Paul John Moga


All Rights Reserved

2002

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

DEDICATION

To He Who Sustains us and our hunger for Knowledge

ii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

ACKNOWLEDGMENTS
I would like thank the members o f my dissertation committee for their invaluable
assistance. One of my co-chairs, Dr. Melissa Gross, Associate Professor of Movement
Science, Division o f Kinesiology, exhibited exceptional tolerance in reviewing my early
drafts. I also owe a debt o f gratitude to my other co-chair, Dr. James Ashton-Miller,
Research Scientist, Department o f Mechanical Engineering and Applied Mechanics,
College of Engineering, for his guidance and many suggestions.
Both Dr. Ashton-Miller and Edward Wojtys, M.D., Division o f Orthopaedic
Surgery, University o f Michigan Medical School, were the original projects co
investigators, which was sponsored in part by a grant from the Orthopaedic Research and
Education Foundation. I thank them both for supporting me as a graduate assistant for
two years and the giving me the opportunity to do the secondary analyses on their data
that make up the bulk o f this dissertation.
Professor Dee Edington, Director o f the Center for Health Behavior Research and
former Director o f the Division o f Kinesiology, had always shown me opportunities during
my enrollment at the University. Dr. Bernard Martin, Associate Professor o f Industrial
and Operational Engineering, College o f Engineering, continuously gave me
encouragement to complete the project.
My thanks to Dr. Donita Bylski-Austrow, University o f Cincinnati, for sharing her

iii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

findings on her porcine spine loading. Thanks also are extended to R.N. Hensinger, M.D.,
Professor o f Orthopaedics, University o f Michigan Medical School, for his Scheuermanns
Kyphosis slides.
I also thank my European contacts who helped with my research: Dr. T.E.
Kennedy, Chief o f International Affairs, and Connie Olsen of the Danish Medical
Association (Copenhagen); Eivind Thorling, Curator of Medical History at the Steno
Museum (Arhus), and Joem Street-Jensen o f the State and University Library (Arhus) for
their help with biographical sketches o f the Danish physicians H.W. Scheuermann, M.D.,
K. V. Wassman, M.D., and K.H. Sorensen, M.D. Thanks also to Tina Craig o f the Royal
College o f Surgeons (London) for the biographical sketch on C. Lambrinudi, M.D.
I would like to acknowledge the kind assistance o f K.P. Singer, Ph.D. (University
o f Western Australia), Julie Lawley (W.B. Saunders), Ametta Queen (Lippincott,
Williams & Wilkins), Sherman Kupfer, M.D. (Editor-in-Chief, Mt. Sinai Journal of
Medicine), Mady Tissenbaum (Managing Editor, JBJS, Inc.), Ann Curtin (BMJ Publishing
Group, London), Caroline Caulton and Nadine Barton (Lancet Publishing Group,
London), Stephen Bishop (JBJS London), J. Kirby Robinson (Cardin Jennings), and
Jeremy J. Kaye, M.D. (International Skeletal Society) in granting permission to use
copyrighted images.
On a personal note, thanks to my draftsman dad for his work on the images. Our folks
Traian, Anna, Gill, and Joyce helped in countless ways during this quest. Thanks also to
their siblings as well as our own (and their respective families) for listening throughout the

iv

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

years. A great big thank-you to my wife Kris, Annie, Joey, and Timmy for their
boundless patience and support. Finally, an acknowledgment to those who came before
us, paving the way and teaching us perseverance, amongst other things: Pavel, Raveica,
Ionita, and Cristina.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

TABLE OF CONTENTS

DEDICATION

ii

ACKNOWLEDGMENTS

iii

LIST OF FIGURES

xii

LIST OF TABLES

xv

LIST OF APPENDICES

xxi

CHAPTER
I.

INTRODUCTION

The Primary Questions

The Classification of Hyperkyphosis

Scheuermanns Juvenile Kyphosis: A Model for Non-Postural,


Acquired Hyperkyphosis and the Effect o f Abnormal Stress on
the Developing Spine

Additional Characteristics of Scheuermanns Disease

10

The Thoracic Spine is Predisposed to the Development o f


Hyperkyphosis

13

The Flexion Moment

13

Thoracic Vertebral Morphology

14

Vertebral Development

16

Purpose and Organization o f the Dissertation

19

Setting the Stage for the Reader:Evolution o f these Studies

22

vi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

O.

m.

ON THE RELATION BETWEEN THE THORACIC


HYPERKYPHOSIS AND SPINE MECHANICAL LOADING:
THE ANIMAL MODELS
24
Introduction

24

Background

25

External Loading in vivo Produces Gross Vertebral Changes


Similar to those Found in Scheuermanns Disease

26

External Loading in vivo Produces Ultrastructural Vertebral


Changes Similar to those Found in Scheuermanns Disease

28

ABNORMAL CARTILAGE AND VERTEBRAL WEDGING

34

The Vertebral Anterior Aspect is More Susceptible to Loading,


Especially in Younger Tissues

34

Loading Affects Normal Chondrocyte Physiology

36

Discussion

38

Conclusions

39

A CROSS-SECTIONAL STUDY ON THE RELATION


BETWEEN THORACIC KYPHOSIS AND REPETITIVE
LOADING IN THE FORM OF ATHLETIC TRAINING
IN 1,822 8-TO-18 YEAR-OLDS

41

Introduction

41

The Null Hypotheses

42

Background

43

Materials and Methods

44

Photographic Data Acquisition:The Test Platform

46

Test Protocol

47

Data Reduction

52
vii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

IV.

V.

Data Management and Statistical Analysis

54

Results

54

Discussion

62

Limitations

64

Conclusions

65

A CROSS-SECTIONAL STUDY OF THORACIC


HYPERKYPHOSIS AND ATHLETIC TRAINING HOURS
FOR SIX SELECTED SPORTS IN 8-TO-I8 YEAR-OLDS

66

Introduction

66

Background

68

Materials and Methods

70

Accuracy/Repeatability o f the Method

71

Optical Method Validation

73

Results

74

Differences o f Age, Height, and Weight between Sports

74

Differences o f Training Time and Thoracic Angle between


Sports and within Sports

77

The Amounts o f Training Associated with Hyperkyphosis

80

Discussion

83

Limitations

87

Conclusions

90

A CROSS-SECTIONAL STUDY OF HAMSTRING


SHORTNESS AND ITS RELATION TO PELVIC TILT
AND LUMBAR LORDOSIS IN A SMALL SAMPLE OF
CHILDREN AND ADULTS

92

viii

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Introduction

92

Background

93

Prevalence and Etiology

94

Hamstring Function

96

Materials and Methods

98

Apparatus and Protocol fo r the Small Sample Study

100

Optical Data Processing

102

Data Analysis

104

Results

104

Discussion

VI.

108

Limitations

109

Conclusions

110

ON THE RELATION BETWEEN HAMSTRING


SHORTNESS AND THORACIC KYPHOSIS IN SMALL
AND LARGE, CROSS-SECTIONAL SAMPLES OF
CHILDREN AND ADULTS

112

Introduction

112

Background

114

Hamstring Shortness and Scheuermanns Disease

116

Prevalence

118

Materials and Methods

119

Test Apparatus and Protocol

120

Data Management and Statistical Analysis

121

be

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

VH.

Results

121

Discussion

126

Limitations

128

Conclusions

128

ON THE RELATION BETWEEN HAMSTRING SHORTNESS


AND ATHLETIC TRAINING IN 8-TO-18 YEAR-OLDS
130
Introduction

130

Background

131

Materials and Methods

133

Data Management and Statistical Analysis

13 3

Results

134

Discussion

142

Limitations

145

Conclusions

146

VIH. ON THE RELATION BETWEEN THORACIC KYPHOSIS,


HAMSTRING SHORTNESS, AND ANTHROPOMETRY IN
SMALL AND LARGE, CROSS-SECTIONAL SAMPLES OF
CHILDREN AND ADULTS
147
Introduction

147

Background

148

Materials and Methods

150

Data Analysis

151

Results

151

Thoracic Kyphosis Angle and Thoracic Spine Length

151

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

IX.

X.

Leg Length and Hamstring Shortness

157

Discussion

164

Limitations

165

Conclusions

166

GENERAL DISCUSSION

168

Thoracic Hyperkyphosis and Physical Activity

168

Vertebral Histology: A Comparison o f Experimental and


Scheuermanns Disease Specimens

169

Thoracic Hyperkyphosis and Hamstring Shortness

170

Anthropometric Characteristics

172

How Much Training is Associated with both Thoracic


Hyperkyphosis and Hamstring Shortness?

172

Preliminary StudiesSkin Distraction and Platform Marker


Design

176

Significance

178

Limitations

179

Suggestions for Future Study

185

CONCLUSION

189

APPENDICES

192

REFERENCES

247

xi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

LIST OF FIGURES
Figure
1.1. Holger Werfel Scheuermann, M.D.

1.2. Radiographic Appearance of ThoracicVertebral Wedging

1.3. Hyperkyphotic Posture

1.4. Cobb Method (after Riseborough & Herndon, 1975)

1.5. Appearance o f Schmorls Nodes

11

1.6

Vertebral Ossification Centers

16

2.1

Cartilage Endplate from Unloaded Control

29

2.2

Cartilage Endplate from Loaded Rat Tail

30

2.3

Normal Human Spine Growth Plate

31

2.4

Growth Plate Micrograph

32

2.5

Growth Plate Micrograph

32

2.6 Porcine spinal growth plate structure on the unstapled side

33

2.7 Porcine spinal growth plate structure on the stapled side

34

3.1.

Test Apparatus

49

3.2.

Grid Pattern Projected onto Calibration Board, Subjects Back

51

3.3.

Scatterplot o f Thoracic Angle vs. Annual Training Time

57

3.4. Mean Thoracic Kyphosis Angle by Age for Male Athletes

59

3.5. Mean Thoracic Kyphosis Angle by Age for Female Athletes

59

3.6. Mean Thoracic Kyphosis Angle by Age for Controls

60

3.7. Annual Training Time versus Age for Male Athletes

61

xii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

5.1. Experimental Apparatus

102

5.2. Spine Curvature Angles

103

6.1. Constantine Lambrinudi, M.D., F.R.C.S. (1890-1943)

117

6.2. Lambrinudis Model of Hamstring Shortness and Thoracic Kyphosis 117


6.3. Thoracic Kyphosis (Lower Line) and Lumbar Lordosis (Upper Line)
Angles versus Reach DistanceLarge Sample, 8-to-l0 year-olds
124
6.4. Lumbar Lordosis Angle (Lower Line) and Thoracic Kyphosis Angle
(Upper Line) versus Reach DistanceSmall Sample
125
7.1. Reach Distance versus Annual Training Time for 14-18 year-old
Female Athletes

138

7.2. Reach Distance versus Trochanterion Height

142

8.1. Density Plot for Thoracic Spine Length/Height

153

8.2. Leg Length vs. Reach Distance for 11 year-olds

157

8.3. Leg Length/Spine Length Ratio vs. Reach Distance for 11 year-olds

158

8.4. Mean Leg Length-to-Spine Length Ratio by Age (All Subjects)

158

8.5. Density Plot o f Leg Length/Spine Length

159

G .l. Straight Leg Raising Test (adapted from Bohannon, et al, 1985)

204

G.2. Measurement o f Popliteal Angle (adapted from Speers, 1993)

207

G.3. Standing Reach Test

209

G.4. Sit and Reach Test (Subject begins in upright position)


(adapted from Hoeger and Hopkins, 1992)

211

G.5. Modified Sit and Reach Test (from Hoeger and Hopkins, 1992)

212

G.6. The ASIS/PSIS and Pelvifemoral Lines

213

G.7. Hip Flexion Angle (adapted from Stokes and Abery, 1980)

215

xiii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

G.8. Method of Loebl

218

G.9. Debrunners Kyphometer and Willners Pantograph

219

H .l. Ferguson Method

224

H.2. Balsa Template

228

H.3. Superoinferior Skin Surface Strain by Gender

230

H.4. Mediolateral Skin Surface Strain by Gender

230

H.5. The Unique Platform Marker

237

xiv

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

LIST OF TABLES
Table
1.1 Ranges o f Thoracic Kyphosis Angles from Various Studies Using
Radiographic and Non-radiographic Methods

3.1 Differences o f Mean Age, Height, Weight, and Thoracic Angle (T)
between Unmatched Controls and Athlete Groups

55

3.2. Subject Number and Gender Composition for Three Separate Subject
Groups: Active Athletes, Inactive Controls, and a Athlete/Control
Group Matched for Age, Height, and Weight
55
3.3. Differences o f Mean Age, Height, Weight, and Thoracic Angle (T)
between Matched Controls and Athletes
56
3.4.

Linear Regression Equation for Active Athletes

3.5.

Stepwise (Backward) Linear Regression Equation for Active


Athletes

57

60

3.6.

Mean Annual Training Times by Age Group for Athletes

61

4 .1.

Subject Size Range Accommodated by the Adjustable Platform

71

4.2.

Differences o f Mean Age, Height, and Weight between


Male and Female Athletes

74

Subject Count for Each Sport by Gender

75

4.3.

4.4. Mean Age, Height, and Weight by Sport (Male and Female
Athletes)

75

4.5. Differences (p-values) o f Mean Age, Height, and Weight


between Sports

76

4.6. Comparison o f Mean Height and Weight by Sport for 12 year-old


Female Athletes and 14 year-old Male Athletes

76

4.7. Mean Body Mass Index (BMI) by Sport for Female Athletes
over Age 14 years

77

xv

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

4.8. Mean Annual Training Time (Time) and Thoracic Kyphosis Angle
(T) by Sport

78

4.9. Mean Thoracic Kyphosis Angle and Annual Training Time for
l4-to-l8 year-old Female Volleyball Players and Swimmers

78

4.10. Mean Annual Training Time-to-Body Mass Index for Male Athletes 79
4.11. Mean Annual Training Time and Thoracic Kyphosis Angle for
Wrestlers grouped as Normokyphotic and Hyperkyphotic

80

4.12. Mean Ages o f each Age Group for Males and Females

81

4.13. Mean Annual Training Times for Athletes grouped by Gender,


Sport, Age Group, and Thoracic Kyphosis Category

81

4.14. The Ratio o f Thoracic Kyphosis Angle per Annual Training Hour
Controlled (Normalized) by Age for Female and Male Athletes

83

4.15. Number o f Thoracic Kyphosis Angle degrees per Annual Training


Hour by Sport and Age Group

83

4.16. Mean Annual Training Time for each Age Group, with Standard
Deviation (s.d.) expressed as a Percentage o f the Mean

89

5.1. Spine Angle, Reach Distance, and Range of Motion for HamstringNormal and Hamstring-Short Subjects

105

5.2. Mean Lumbar Lordosis Angle o f Representative Hamstring-Normal


and Hamstring-Short Subjects (Large Sample Study)
106
5.3. Linear Regression Equation (Small Sample)~Flexion Range
o f Motion

107

5.4. Linear Regression Equation (Small Sample)Reach Distance

107

6.1. Mean Thoracic and Lumbar Angles for Hamstring-Normal and


Hamstring-Short Subjects

122

6.2. Mean Thoracic and Lumbar Angles for Subjects grouped as


Normokyphotic or Hyperkyphotic

123

xvi

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

6.3. Mean Thoracic Kyphosis Angles for Hamstring-Short Wrestlers


grouped as Moderately Short and Severely Short

125

6.4. Mean Age for Hamstring-Short Subjects grouped by Thoracic


Angle Magnitude

126

7.1. Mean Age and Reach Distance for Controls and Athletes, with
Reach Distance Normalized by Age

134

7.2. Mean Age, Annual Training Time, Period, and the Training Variables
Normalized for Age for Athletes grouped as Hamstring-Normal or
Hamstring-Short
135
7.3. Mean Age, Period, and Annual Training Time (Time) for Athletes
grouped by Hamstring Shortness Category

135

7.4. Mean Age, Annual Training Time, Reach Distance by Gender,


with both Time and Reach Distance Normalized by Age

136

7.5. Mean Annual Training Time for Athletes grouped by Gender,


Age, and Hamstring Shortness Category

137

7.6. Mean Annual Training Times for Female and Male Athletes
grouped by Age Group and Hamstring Shortness Category

137

7.7.

139

Linear Regression Equation for All Subjects

7.8. Mean Age and Period for Male Athletes grouped by Hamstring
Shortness Category

139

7.9.

140

Mean Age and Period for Athletes grouped by Age Category

7.10. Mean Period by Gender for 16 Year-Old Athletes

140

7.11. Mean Values o f the Significant Predictor Variables for Reach


Distance in Male Athletes by Age Group

141

8.1. Mean Age, Height, and Weight for Normokyphotic and


Hyperkyphotic Subjects

151

8.2. Mean Anthropometric and Spine Angle Values o f Subjects


grouped according to Thoracic Kyphosis Angle Magnitude

152

xvu

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

8.3. Mean Height for Subjects divided according to Age Group


and Gender

I S3

8.4. Mean Thoracic Angles and Thoracic Spine Lengths for Subjects
grouped according to Thoracic Angle Magnitude from both
Large and Small Study Samples

154

8.5.

155

Linear Regression Equation for Active Athletes (Thoracic Angle)

8.6. Mean Spine Length Normalized for Height for both Females and
Males by Sport and Age Group

156

8.7. Mean Spine Length Normalized for Height for both Normokyphotic
and Hyperkyphotic Females and Males by Age Group
156
8.8. Linear Regression Equation for All Subjects (Reach Distance)

159

8.9. Mean Age, Height, Weight, and Reach Distance by Gender

160

8.10. Mean Age, Height, Weight, and Reach Distance by Hamstring


Shortness Category

160

8.11. Mean Period and Leg Length-to-Spine Length Ratio (GTFST1)


by Hamstring Shortness Category

161

8.12. Mean Age for Males and Females by Hamstring Shortness Category 161
8.13. Mean Leg Length-to-Spine Length Ratio for Subjects grouped by
Hamstring Shortness Category (Males younger than 14 years)

162

8.14. Mean Leg Length-to-Spine Length Ratio by Hamstring Shortness


Category for each Sport and Age Group

163

8.15. Mean Leg Length-to-Spine Length Ratio for each Gender by Age
Group and Hamstring Shortness Category

163

9.1. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category, Hamstring Shortness
Status, and Sport

174

9.2. Annual Training Time Group Means for Male Athletes grouped by
Kyphosis Category and Hamstring Shortness Status and according
to Age, Age Group, and Sport
175
xviii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

9.3. Profile o f Typical Female Subjects who are either Hamstring-Normal


(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or
Hyperkyphotic (HK)
175
9.4. Profile o f Typical Male Subjects who are either Hamstring-Normal
(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or
Hyperkyphotic (HK)

176

9.5. Annual Training Time Means, Standard Deviations, and Variance


for All Subjects and Wrestlers divided according to Age Group

182

G. I .

Mean Flexibility Values for Three Different Methods


(after Hoehler and Tobis, 1982)

202

Range o f Motion Parameters for the Three HamstringLength


Categories by Author and Method (SLR and Hip Flexion Angles;
after Gajdosik, et al., 1994)

203

G.3.

Typical Straight Leg Raise Test Values (in degrees)

205

G.4.

Typical Values - Popliteal Angles

207

G.2.

G.5. Category Definitions: Standing Reach Test (after Gleim, et al.,1990)209


G.6. Typical Ranges - Hip Flexion Angle (after Stokes and Abery, 1980) 215
G.7. Comparison o f the Reliability Coefficients of the Various Methods

216

G.8. General Measuring System Considerations (after Chaffin and


Andersson, 1991)

217

G.9. Advantages and Disadvantages o f Goniometric Systems


(after Chao, 1978)

219

G.10. Advantages and Disadvantages o f Photogrammetric and


Videographic Systems (after Chao, 1978)

220

H. 1. Mean Percent Strain at Various Spine Landmarks

229

H.2. Mean Differences o f Percent Strain between Landmark Points

229

H.3. Skin Distraction (Mean Percent Strain) at L3 for Hamstring


Normal and Hamstring-Short Subjects

231

xix

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

H.4. Mean Ages o f Subjects Grouped as Over 30 years and Under 30


years o f Age

232

H.5. Mean Weight and Height for Females and Males

232

H.6. Tally o f the Number o f Measurement Errors expressed as Percent


o f Total Measurements

240

H.7. Mean Distance between Surface Marker Perpendicular Line and


Endplate Tangent for each Vertebral Body, expressed as
Fractions o f Vertebral Body Height

240

H.8. Mean X-ray-based and Surface Marker-based Angle Values for


the T1-T10, T10-L3, and L3-S1 Spine Segments

242

I.1. Mean Annual Training Times by Age in Years for Female and Male
Athletes grouped by Kyphosis Category and Hamstring
Shortness Status

246

1.2.

Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category and Hamstring
Shortness Status

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

246

LIST OF APPENDICES
Appendix
A. Reported Prevalence o f Scheuermann's Juvenile Kyphosis

193

B. Theoretical Causes o f Scheuermanns Kyphosis

194

C. Conditions Associated with Thoracic Hyperkyphosis

195

D. Vertebral Development

196

E. Subject Questionnaire

198

F. Kyphosis Image Processing Protocol

199

G. Select Hamstring Shortness and Spine Curvature Measurement


Methods

202

H. The Development o f a Platform Marker for use in Determining


Spine Angles

222

I. Mean Annual Training Times for Various Groups

246

xxi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER I
INTRODUCTION
Thoracic hyperkyphosis is a significant spine problem. It is associated with a
distinct cosmetic deformity, a restriction o f normal trunk motion, and a reduction of
physical function (Ryan and Fried, 1997). At least one form, Scheuermanns Disease, has
a reported prevalence o f 0.4% to 8.3% (Sorensen, 1964) and above, depending upon
diagnostic methods used (radiographic or clinicalBradford, 1995) and subject sample
(Appendix A). The more permanent, non-postural type o f hyperkyphosis may also be
associated with adult onset back pain, particularly if the deformity is at the thoracolumbar
area. In rare instances, those with severe hyperkyphosis may have spinal cord
compression and nerve root impingement, or, in extreme cases, may suffer from
ventilatory and circulatory embarrassment (Sorensen, 1964).
Because o f the significance o f the sequellae associated with the deformity, it is
preferable to prevent thoracic hyperkyphosis, rather than be obliged to treat it after the
fact. It is the goal o f the studies described in this dissertation to identify certain
relationships that may be integrated into the design o f training or rehabilitation programs
that are aimed at preventing the development of non-postural, thoracic hyperkyphosis.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The Primary Questions


Since the early part o f the twentieth century, authors have hypothesized various
causes of non-postural hyperkyphosis. The most commonly suggested etiology o f this
spine deformity is repetitive loading, especially if it occurs during the period o f spine
development. Such repetitive loading has been hypothesized to be associated with manual
labor (e.g. Schantz, 1907; Scheuermann, 1920; Wassman, 1949), as well as with certain
athletic activities (e.g. Hafiier and Surrey; 1952; Micheli, 1979; Sward, 1992). Other
authors have suggested that hamstring shortness was causally related to the development
o f thoracic hyperkyphosis (e.g. Lambrinudi, 1934).
While many authors have agreed that some type o f abnormal loading may produce
the pathognomonic, vertebral wedging o f acquired hyperkyphosis, there has been some
disagreement as to the specific pathology. Several mechanisms have been proposed,
including abnormal epiphyseal behavior (Scheuermann, 1920), local circulatory
embarrassment (Mau, 1929), and intervertebral disc herniation (Schmorl, 1930) (Appendix
B). Some authors had even hypothesized a common etiology for both hyperkyphosis and
scoliosis (Deacon, et al., 1985). This is not unreasonable, as asymmetric loading has also
been associated with an increased risk for the development o f scoliosis (Noone, et al.,
1993), which is found in 20 to 40 percent o f those having the hyperkyphosis o f
Scheuermanns Disease (Sorensen, 1964; Bradford, et al., 1975).
This dissertation addresses the possible causes o f thoracic hyperkyphosis by first
reviewing the existing evidence. It will then present the result o f studies designed to
answer three primary questions: First, is there epidemiologic evidence to indicate a
2

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

relation between repetitive loading and thoracic hyperkyphosis? This question is


important, for if there is a demonstrable relation, then intervention programs may be
designed to limit the amount o f spine loading. Second, is there experimental evidence
suggesting a relation between hamstring shortness and hyperkyphosis? This question is
also important, for hamstring shortness may be corrected. Third, is there epidemiologic
evidence demonstrating a relation between anthropometry and hyperkyphosis, as has been
suggested in the case in another spine deformityscoliosis (Skogland and Ashton-Miller,
1981)? This question is important because individuals at risk for the development of
hyperkyphosis may be identified before they submit their spines to repetitive loading.

The Classification of Hyperkyphosis


Historically, there has been a ...general agreement that 20-40 degrees be
considered the normal range o f thoracic kyphosis (Kling and Hensinger, 1982).
Hyperkyphosis has been defined as being present when the angle o f thoracic kyphosis
exceeds this range. This normal range, extended by some to include spine angles of up to
45 [e.g. Winter and Hall, 1978; Bradford (in Moe, 1995)], has been established based on
the results o f a number o f studies in which the kyphosis angles o f subjects were measured
using primarily radiographic methods (e.g. Fon, et al., 1980; Probst-Proctor and Bleck,
1983). The radiographic methods use the Cobb technique (Figure 1.3) to measure lateral
view, spine x-rays.
The results o f several o f these studies are summarized in Table 1.1. This table is
taken after the work o f Singer, et al. (1990), who measured the T3-T11 thoracic kyphosis

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 1.1. Ranges of Thoracic Kyphosis Angle from Various Studies using Radiographic and Non-radiographic Methods
[After Table 1, "Radiographic assessment o f thoracic kyphosis with reference to population, measurement and recorded values on page 22 in Singer KP,
Jones TJ, Breidahl PD, A comparison o f radiographic and computer-assisted measurements o f thoracic and thoracolumbar sagittal curvature.
Skeletal Radiology 19:21-26,1990; copyright holder: International Skeletal Society; n.a. = not available; p = pantograph; x = x-rqy]
Mathod

Author

Sample

Radioaraohic

Bosaker (1958)
Cowan (1965)

121 children
139 males
167femalee
163 males
133fematas
159 mates
157 females
104 "normals''
114 safeties
18 patients
(kyphotic deformity)
75 males
62 females
251 males
419 females

Fonatal. (I960)
Propst-Proctor and Black (1963)
Axelgaard, at al. (1963)
Stagnara, et al. (1962)
Voutsinas and Mac Ewan (1966)

Non-ndiooraohic

Boaakar, at al. (2000)

121 children

Winer (1961)

15scoiiotics
40 controls
16 Scheuermann's
560 males
540 females
56 (intra-observer
reliability sample)

Winer and Johnson (1963)


Nissinen (1995)

Kyphosis Angle
mean(a.d.)(deg.)

Age
(years)
n.a.
60 to 69
60 to 69
70 to 79
70 to 79
2to77
2 to 77
2 to 19
2 to 19
n.a.

43
50
49
56
25.1 (8.2) for 2810-19 y.o.
26 (7.4) for 2210-19 y.o.
27
28
57(10)

20 to 29
20 to 29
5to9
10 to 14
15 to 20

37
37
36.7(6.9)
37.5(8.0)
38.5(8.1)

Range
(deg.)
(2542]

Measurement Criteria

(5-66]
(7-56]
[21-33]
[16-36]
[42-73]

...upper and lower verte


brae defining the curve..."
T5toT12

[7-37]
[7-37]

T4 to "intermediate
vertebral bod/*
T2stoT12
(if T2 not visible, -> T3)

n.a.
T2-3toT11-12

T3toT12(shOMi)

[20-50]
teenagers

25.9 (9.3)[p] 25.9 (10.1 ){x]


39.7 (12.2)(p] 40.9(13.6Xx)
61.8(12.5Xp] 62.8(12.6Xx]
32.6(3.7)
31.0(3.4)
32.5

Upper and lower


vertebrae of curve
both pantograph and x-ray
[2342]
[1946]

pantographs

angle in 286 radiographs. They reported thoracic angle ranges o f 32 to 44 Cobb for
males 10-19 years o f age (n = 10; mean = 33.8 5.2 ) and 18 to 40 for females o f the
same age group (n = 3; mean = 31.0 11.5). The males had a mean thoracic angle o f
33.8 ( 5.2), while the females mean was 31.0 ( 11.5). The results of Singer, et al.
(1990) were similar to those reported by Fon, et al. (1980) for male and female subjects of
the same age group. In Fons study, male subjects (n = 28) had a mean thoracic angle o f
25.1 ( 8.2), with a range o f 8 to 39. Females (n = 22) had a mean angle value o f
26.0 ( 7.4) and a range 11 to 41.
In some instances, non-radiographic methods were used by authors as Willner
(1981) and Nissinen (1995). Both used the surface device known as a pantograph, whose
measurements underestimated those o f radiographic methods from less than 2 (Willner,
1981, Table 1.1) to about 5.5 (Nissinen, 1995). Even with the difference in methods,
over two-thirds of Nissinens sample o f 1060 children had thoracic angles within the
radiographic 20 to 40 range.
Hyperkyphosis may be grouped into two general categories: postural, which is the
result o f poor posture and is more readily correctable, and non-postural. The latter tends
to be fixed and is the result o f the inadequacy o f one or more o f the spines support
mechanisms (Winter and Hall, 1978). These support mechanisms include the vertebral
body, intervertebral disc, as well as the muscular and ligamentous soft tissues.
Non-postural hyperkyphosis may be further subdivided into three subtypes:
congenital, pathologic, and acquired (Appendix C). Congenital hyperkyphosis is caused

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

by abnormal vertebral development in utero. Pathologic hyperkyphosis refers to a


deformity o f the spine that results from various disease conditions, such as poor nutrition,
endocrine disorders, or metabolic problems. Acquired hyperkyphosis is the result o f spine
support mechanism failure from trauma, surgery, or, as has been heretofore anecdotally
suggested, from external loading.

Scheuermanns Juvenile Kyphosis: A Model for Non-Postural, Acquired


Hyperkyphosis and the Effect of Abnormal Stress on the Developing Spine
There are several characteristics that make Scheuermanns Juvenile Kyphosis (or
Scheuermanns Disease) a good clinical model for acquired thoracic hyperkyphosis. In
1920, Holger Werfel Scheuermann, M.D. (1877-1960) (Figure 1.1), published the findings

Figure 1.1 Holger Werfel Scheuermann, M.D.


[Permission granted by the copyright holder: Lippencott, Williams & Wilkins: image is Figure 1, page 6,
from Scheuermann HW (EM Bettman, E d) The Classic Kyphosis Dorsalis Juvenalis. Clinical
Orthopaedics and Related Research, 128:5-7, 1977.]
6

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

from his landmark, radiographic study of patients who demonstrated a unique type o f
thoracic hyperkyphosis. In his paper, Dr. Scheuermann identified unique,
roentgenographic findings that have become the prerequisite characteristics of the disease
process that bears his name: osseous wedging o f the anterior aspects o f the thoracic
vertebrae in otherwise healthy adolescents whose spines were still developing (Figure 1.2).

Figure 1.2. Radiographic Appearance of Thoracic Vertebral Wedging


The thoracic portion o f the vertebral column is along the left side o f the radiograph, with
the vertebral bodies oriented towards the heart shadow (right of center). Wedging is
particularly evident in three vertebral bodies at the curves apex (at the curves concavity)
(image courtesy ofR .N . Hensinger, M.D.)

Sorensen (1964) suggested that the magnitude o f the wedging should be at least 5 by the
Cobb method (described below) and should be present in at least three, adjacent vertebrae

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

before a patient could be diagnosed as having Scheuermanns Disease (Figure 1.3).


Bradford (1977) later modified this requirement, writing that the pathognomonic wedging
should be present in at least one vertebra.

Figure 1.3. Hyperkyphotic Posture


The profile of the subjects back cast onto the wall depicts the pronounced increase in the curvature of the
thoracic spine, as well as a compensatory increase of the lumbar curve.

(image courtesy o f R. N. Heminger, M.D.)

The amount o f vertebral wedging, as well as the overall angle o f the thoracic spine
segment, is generally determined using the Cobb method (Cobb, 1948). The method is
illustrated in Figure 1.4, showing the angle o f interest as the angle between two
intersecting tangents to vertebral endplates at either extreme o f the spine segment.
Scheuermann made additional observations that further characterized thoracic
hyperkyphosis. He wrote that the disease was noted especially in youngsters who were
8

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 1.4. Cobb Method (after Riseborough and Herndon, 1975)


Angle 6, representing the angle of the spine segment, is measured
as the angle between tangents to vertebral endplates.

involved in strenuous, agricultural work, and credits Schanz (1907, 1911) for first having
called attention to the occupational, or apprentice's, deformation (Scheuermann, 1934).
The relation between work and hyperkyphosis was also observed by Wassman (1951),
who noted that Scheuermanns Disease was more prevalent not in urban dwellers, but
rather in the lads from the country (a phrase likely from a lecture delivered on
September 6,1946, at the Dansk Selskab for Gigtforskning).
Since Scheuermanns observations were first published, an anecdotal association
has also been made between thoracic hyperkyphosis and repetitive work in the form o f
sports activities. Authors as Hafner and Surrey (1952), Micheli (1979), Endler, et al.
(1980), Falter, et al. (1981), Wilson, et al. (1982), and Sward (1992) all reported an
association between hyperkyphosis and sports activities, which included gymnastics,
9

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

rowing, and swimmingsports that involve repetitive and extreme flexion o f the torso.
However, experimental evidence to support the observations that repetitive work was a
likely cause o f Scheuermanns Disease was still lacking.

Additional Characteristics of Scheuermanns Disease


Once thought to occur spontaneously, Scheuermanns Disease affects otherwise
healthy young people who are still in their growth years. The process initially manifests
itself in the peripubescent period and is observed clinically by 12 or 13 years o f age (Moe,
et al., 1978; Reid, 1992). The disease has been linked to the eventual development o f low
back pain (Sorensen, 1964; Fisk and Baigent, 1981; Blazek, et al., 1986; Harreby, et al.,
1995) and various intervertebral disc pathologies, including degenerative disc disease and
disc herniation (Moe, et al., 1978; Stoddard and Osborn, 1979). In Sorensens study
(1964), degenerative disc changes were found to occur most frequently at the central
area of the kyphosis, especially from T7 to T10.
Several additional roentgenographic characteristics are frequently noted in
Scheuermanns Disease patients, but they are not required for the diagnosis. These
characteristics include narrowing o f the intervertebral disc spaces (Sorensen, 1964; Moe,
et al., 1978; Bradford & Hensinger, 1985) and vertebral endplate irregularities, which are
present in about 73% o f patients (Alexander, 1977). Other common radiographic findings
include spondylolysis (a stress fracture of the vertebral pars inter-articularis) and
Schmorls nodes. Spondylolysis is present in 35% o f patients with thoracic
Scheuermanns Disease (Greene, et al., 1985) and in 35% to 50% o f those having

10

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

thoracolumbar Scheuermanns (Keim and Hensinger, 1985). Schmorls nodes were first
described by Dr. George Schmorl (1930) as the radiographic representation o f an
extravasation o f the intervertebral discs nucleus pulposus material into the bony
spongiosum o f the vertebral body (Figure 1.5). This herniation, which is said to be

Figure l.S. Appearance of Schmorls Nodes


Note the hollowed-out appearance of the defect in the superior endplate of the vertebral
body midway in the radiograph, (image courtesy o f R. H. Hensinger, M.D.)

secondary to compressive force (e.g. Alexander, 1977; Aufdermaur, 1981), was


hypothesized by Schmorl to cause the vertebral wedging o f Scheuermanns Disease.
While these nodes would likely cause a disruption o f the vertebral endplate and result in
uneven vertebral growth, the reported prevalence in Juvenile Kyphosis varies widely. For
instance, Murray, et al. (1993), found that only 41% o f their 67 Scheuermanns Disease
subjects demonstrated the lesions, whereas Scoles, et al. (1991) identified the nodes in
93% o f their sample o f 1,384 spinal columns.
While most cases o f Scheuermanns Disease involve the thoracic spine alone, with
vertebral wedging commonly at the region o f T7-10 (Sorensen, 1964), other spine regions

11

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

may also demonstrate the typical radiographic findings. Dorsolumbar kyphosis (Wiles,
1949) has been identified at the thoracolumbar junction (Hafiier and Surrey, 1952).
Sorensen (1964) identified 23% o f Scheuermanns Juvenile Kyphosis cases in his subjects
as being at the regions o f T l l-L l or T12-L2. In contrast to the thoracic form, which is
initially pain-free, at least 78% o f those having Scheuermanns Disease at the
thoracolumbar region have marked pain (Sorensen, 1964). Lumbar Scheuermanns has
also been documented (e.g. Lindemann, 1933; Edgren and Vainio, 1957). In these cases,
end-plate deformity and disc space narrowing is seen more than the typical, anterior
vertebral wedging (Sorensen, 1964), and degenerative disc disease is a common sequella
(Paajenen, et al., 1989).
Several gross anatomic findings have been identified in cases o f Scheuermanns
Juvenile Kyphosis. These include contracted, thickened anterior vertebral longitudinal
ligaments (Bradford and Hensinger, 1985) and an atypical insertion o f the annulus fibrosus
o f the intervertebral disc. Anchoring o f annular fibers into sites such as the apophyseal
ring, for example, may produce a vertebral segment that is less resistant to mechanical
stresses (Ippolito, et al., 1985). In addition, thickening and subsequent bowstringing o f
the anterior longitudinal ligament would tend to augment anterior compression o f the
involved vertebral segment. This notion is supported by the work o f Bimbaum, et al.
(2001), who were able to demonstrate a correction of kyphotic deformity by surgically
transecting the anterior longitudinal ligament in cadavers.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

stabilizing mechanisms, which include the vertebral bodies, intervertebral discs, and, less
importantly, the ligamentous, intervertebral joint capsules (less developed in the thoracic
spineWhite, et al., 1977) may lead to a larger flexion moment and subsequent greater
compression load to the mid-thoracic spine (Skogland and Ashton-Miller, 1980), with the
development o f hyperkyphosis as a possible result.

Thoracic Vertebral Morphology


Another factor that predisposes the thoracic spine to the development of
hyperkyphosis is vertebral morphology. There are several morphologic characteristics
unique to the thorax that enhance this region's susceptibility to loading. The vertebral
bodies o f the thorax exhibit a unique anatomic structure that is different from those o f the
cervical and lumbar regions. When viewed from above, the typical thoracic vertebra has a
cardioid appearance with a comparatively narrow apex that is oriented ventrally (Grays
Anatomy, 1974; Deacon, et al., 1987). As a result, both the osseous mass and the
intervertebral articular surface area of the anterior aspects o f the vertebrae are reduced,
factors that give less structural resistance to the compression that occurs in sagittal plane,
spine flexion.
There are other, morphologic characteristics that can predispose the thoracic spine
to the development o f hyperkyphosis. Using the ratio o f vertebral width to vertebral
depth, Panjabi, et al. (1991) identified three distinct regions o f the thoracic spine: upper,
middle, and lower. They observed that the vertebrae in the middle thoracic region, from
T4 to T9/10, had relatively narrow endplates and narrow spinal canals. This is

14

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

approximately the same thoracic region that is affected by the classic, thoracic type o f
Scheuermanns Disease (Sorensen, 1964). It is likely that vertebrae having narrow
endplates would be more susceptible to the effects o f repetitive loading, which include a
loading-related reduction in the local blood supply plays a role in vertebral wedging
suggested by authors as Mau (1927), Ferguson (1949), and Roaf (1960).
When viewed from the lateral aspect, the thoracic vertebrae display yet another
unique, morphologic characteristic. There is an anterior wedging of the individual
thoracic vertebral bodies o f approximately 3.8 (Panjabi, et al., 1991), slightly less than the
5 minimum required for a diagnosis of Scheuermanns Disease. Goh, et al. (1999)
quantified vertebral wedging as an anterior-to-posterior vertebral height ratio. They found
the ratio was highly predictive o f thoracic curvature, which supports the idea that
physiologic wedging contributes to the normal, thoracic kyphotic curve. These factors
may predispose the thoracic spine to the development o f hyperkyphosis and
All o f these morphologic features can enhance the risk o f compressive injury to the
thoracic vertebral ventra (e.g. Kasra and Grynpas, 1997). They can do so not only by
affecting developing bone at the endplates, but by contributing to a non-uniformity o f
compressive strain distribution within thoracic vertebral trabecular bone as well. Bay, et al.
(1997) identified a load-dependence o f the intraosseous, strain distribution pattern o f
trabecular bone. They found that, when vertebrae were subjected to loads o f 60% o f
ultimate bony failure, most compressive strain was located in the anterior aspect o f the
vertebral body. If such a strain occurred in immature bone, it is likely that the structure

15

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

would be at risk for the poor development and enhanced wedge deformity, as discussed
below.
Vertebral Development
The third factor that is important in the pathogenesis o f juvenile hyperkyphosis is
vertebral development. The sequence o f ossification begins at birth, when the vertebral
body centrum and an unfused pair of vertebral arches are ossified (e.g. Gray, 1974;
Appendix D) (Figure 1.6). The process extends gradually from each vertebral centrum,

AT

BIRTH

V E R T E B R A L 8O 0 Y
AND NEURAL ARCH

2Y R S . O F AGE
LAMINAE FUSE POSTERIORLY
( STARTS I N LLM8AR AREA AND
ASCENDS 8U T SACRUM IS LASTJ
CT TO lO YRS )

BY 6 - 7 YRS. OLD
neural

arch

u n i t e s w it h

V E R T E B R A L B O O Y ( EA RLIEST

IN N E C K .L A S TIN SACRUM ;

SECONOARY C E N T E R S O F O S S .F IC A T O N
A PPEA R
AT PU B ER TY AND FU SE A T
25 Y E A R S O F A O *

Figure 1.6. Vertebral Ossification Centers


Because o f the timing o f the appearance o f and closure o f the ring apophysis, which is a
secondary ossification center, this structure is particularly susceptible to loading.
(Permission granted by the copyright holder: W.B. Saunders; image is Figure 1-45, page 46 from
Meschan I, Farrer-Meschan RM. Roentgen Signs in Diagnostic Imaging, 2nd ed., vol. 3 Spine and
Central Nervous System; Saunders, Phila. 1985.)

16

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

with bony tissue replacing chondral (cartilaginous) tissue until, in adolescence, two
cartilaginous plates at both superior and inferior vertebral margins remain. These plates
represent the longitudinal growth physes for endochondral ossification and are zones that
display a particularly active cell turnover during the growth spurt (Taylor, 1975; Meschan
and Farrer-Meschan, 1985; Ogden, et al., 1994).
The growth areas that contribute to the development o f the anterior, load-bearing
rims o f the vertebrae are the ring apophyses. These C-shaped regions are located at
the anterolateral margins of the superior and inferior surfaces o f the vertebrae. They begin
to appear at about age 6 and start to ossify at age 13 years (Bick and Copel, 1951). The
ossification process is generally not complete radiographicaUy until the late teens, with
histologic fusion o f the ring apophysis with the vertebral body occurring by the early to
mid-twenties (e.g. Matsumoto, 1988). Incomplete dorsally and not a contributor to
longitudinal growth (Bick and Copel, 1951), these structures act both to anchor the
intervertebral disc to the vertebral body (Ippolito, et al., 1985; Outland and Sneddon,
1955) and to eventually provide the osseous collars o f the superior and inferior aspects
o f the vertebrae. With such important functions, it is possible to imagine that poor
ossification might lead to vertebral structural deficit and wedge deformities.
The rapid growth spurt during adolescence is likely a key factor in the
susceptibility o f the immature spine to repetitive loading, as suggested by Mau (1929) and
Ferguson (1949). Tanner (1962, 1973) wrote that, in females, the adolescent growth
spurt occurs from ages 9.5 to 14.5 years, with a maximum growth velocity (peak height
velocity) at a mean age o f 12 years. The end o f the growth spurt in females occurs at

17

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

menarche, whose onset is said to correlate with body composition (e.g. Frisch and
Revelle, 1971; Crawford and Osier, 1975; Zacharias and Rand, 1983). In males, the
growth spurt occurs later, from about ages 10.5 to 16 years, and reaches a peak height
velocity at about 14 years o f age.
During the growth spurts, there is an increase o f total body height, which is based
upon growth o f the head, spine, pelvis, and lower extremities. The length o f each o f these
segments increases at different rates (Anderson, et al., 1978). The lower extremities grow
fastest while growth o f the head is slowest, with the spine growth rate between the two
(Lonstein, in Moe, 1978). DiMeglio and Bonnel (1990) measured spinal growth rates for
three age groups: birth to age 5 years, greater than 5 years to age 10 years, and greater
than 10 years to 16 years. They observed that, between the first thoracic vertebra (Tl)
and the first sacral segment (SI), the thoracic region accounts for 63% o f the spines
growth, with longitudinal growth increasing at a rate of 1.2 centimeters per year between
the ages of 10 and 16 years. The lumbar spine elongates at a rate o f 0.6 centimeters per
year over the same time interval, a rate one-half that of the thorax. The comparatively
rapid thoracic growth rate during this time period with the associated rapid turnover of
developing cellular structures may enhance the regions relative susceptibility to the effects
o f increased spine loading. In fact, Willner and Johnson (1983) demonstrated a positive
correlation between growth velocity and the range o f thoracic kyphosis, a trend that was
not demonstrated for lumbar lordosis.

18

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Purpose and Organization of the Dissertation


The purpose o f this dissertation is to demonstrate the relation between thoracic
hyperkyphosis and athletic training (a form o f repetitive loading), hamstring shortness, and
anthropometry. In so doing, it provides support for the traditional models of Kyphosis
Dorsalis JuvenilisJuvenile Thoracic Kyphosis~as set forth by early authors as
Scheuermann (1920) and Lambrinudi (1934). Each chapter of this dissertation will
address a different but related topic, beginning with Chapter n. This chapter briefly
reviews the animal model studies o f others who have used in vivo loading to create
structural changes in mammalian vertebrae. Chapter II also uses existing histologic
evidence to illustrate that loading-related changes in the vertebral epiphyseal growth plate
may well be the cause o f hyperkyphosis. Finally, this chapter discusses some o f the effects
mechanical loading has on cartilage.
Several o f the subsequent chapters present the results o f secondary analyses o f the
data from a study by Edward Wojtys, M.D. and James Ashton-Miller, Ph.D., o f the
University o f Michigan. The post-hoc analysis reviewed in Chapter m extends the
original work o f these co-investigators that examined the first primary question: Is there a
relation between thoracic kyphosis and extrinsic, repetitive loading in the form o f athletic
training? In both studies, the upright posture, thoracic spine angle data were estimated by
photogrammetry, while the amounts o f training were estimated using self-reported data.
In their study, Wojtys, et al. (2000) modeled athletic training by cumulative
training hours, which was the product o f annual training hours and the number o f years o f
sport participation. They identified a significant relation between training and cumulative

19

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

hours. Because o f this association, it was assumed that there would also be a significant
relation between thoracic angle and one or both o f these component variables. Thus, in
this study, the extrinsic loading o f athletic training was modeled by annual training hours
and a comparison o f mean, thoracic kyphosis angles was made between inactive controls
and active athletes. In addition, it was felt that the actual training time in hours would be
clearer to coaches and those who designed training programs.
Chapter IV summarizes the next step in the secondary analysisthe confirmation
o f what was suggested in the previous chapter regarding the relation between thoracic
kyphosis and training. This was performed by comparing thoracic angles and annual
training times within the athlete group. Chapter IV also presents an attempt to quantify
the relation between thoracic kyphosis and athletic training in an effort to determine how
much training might be too much. This was done by calculating both the amounts o f
training per sport and age group for normokyphotics and hyperkyphotics, and the ratio of
the number o f annual training hours to thoracic kyphosis angle.
The next three chapters address the second primary questionIs there
experimental evidence to confirm a relation between thoracic hyperkyphosis and intrinsic
loading in the form o f hamstring shortness? Chapters V and VI report the results o f
studies that use data generated from the same subject sample and methods as the two
previous chapters (the large sample study), as well as data obtained from a second,
smaller subject sample using a different method. Chapter V describes the qualitative
relation between hamstring shortness, which is determined using the Finger-to-Floor
Reach method (Appendix G), pelvic tilt, and lumbar lordosis. Chapter VI examines the
20

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

relationship between hamstring shortness and thoracic kyphosis, presenting evidence that
supports the idea o f hyperkyphosis as an adaptive mechanism. Chapter VII examines the
relation between hamstring shortness and athletic training. In a manner similar to the
number o f training hours associated with thoracic hyperkyphosis, as presented in Chapter
IV, this chapter includes the amounts o f annual training times associated with hamstring
shortness. This information may be helpful in the design o f confirmatory, prospective
studies aimed at supplying quantitative information regarding training times and
anthropometric norms.
Chapter VQI addresses the third primary questionIs there experimental evidence
demonstrating a relation between anthropometry and hyperkyphosis? Data obtained from
both subject samples using the two different methods are used to identify a relation
between these two variables. Chapter IX, the General Discussion, integrates the main
findings o f the studies and how they support the traditional models o f thoracic
hyperkyphosis. In addition, the strengths and weaknesses o f the studies are presented.
Finally, Chapter X presents the conclusions.
The Appendices include miscellaneous information, such as the Subject
Questionnaire, a summary o f the image processing protocol, and summaries o f hamstring
shortness and spine curvature measurement methods. It also includes a technical paper
that describes the development o f a unique platform marker for use in determining spine
anglesa preliminary project essential to the optoelectronic method used to estimate the
spine angles. The first part of this paper describes the quantification o f skin surface
distraction at select landmark points over the midline of the spine during sagittal plane
21

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

flexion from upright to frilly flexed postures. The second part o f this paper describes the
design o f the marker, while the third part describes the validation o f the platform marker.

Setting the Stage for the Reader: Evolution of these Studies


In the late 1980's, Drs. James Ashton-Miller and Edward Wojtys received support
from the University o f Michigans Department of Surgery, the Orthopaedic Research and
Education Fund, and the NIH (Grant 1P30 AG 08808) to study the association between
athletic training and the sagittal curvature o f the immature spine. The original hypotheses
were based to a large extent on clinical observations, and both investigators cite R. N.
Hensinger, M.D., Professor and Orthopaedic Surgeon, University o f Michigan, for his
contributions to the initial idea o f the project (Wojtys, et al., 2000).
In the early days of the project, much effort was dedicated to the development o f a
protocol, to the construction o f the testing apparatus, and to the validation o f the method.
My graduate student predecessorsVivi Francesco, Kelly McGlashen, Youda He, and co
author Laurie Huston, have all been acknowledged by the co-investigators for their
contributions during this period. The efforts o f the co-investigators and their team
continued during the subsequent data collection phasea time when the heavy test
platform and photographic supports were transported to and set up in un-airconditioned,
athletic locker rooms. This equipment was used to collect data on over 2000 young
volunteers during the sweltering heat o f summer sports camps o f 1989, 1990, and 1991.
In 1995,1 had the opportunity to join Drs. Ashton-Miller and Wojtys as a graduate
assistant. By then, huge amounts o f time had already been dedicated to the conceptual

22

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

thinking and planning, the primary hypotheses, and the study design for the original
project. With the bulk o f the data gathered, my tasks included assisting in the remaining
data collection from inactive controls, and in the data processing and analysis. Scott
Booth, a graduate student, was instrumental in the latter part, having written the necessary
specialized, data processing programs (Appendix F).
I was able to play more o f a role in the much smaller hamstring shortness study,
helping to select the equipment, to develop and test a unique spine marker (with technical
advice from Dave Warwick, Mechanical Engineering and Applied Mechanics
Biomechanics Research Lab, University o f Michigan), and to establish a protocol. I was
also able to help recruit and test subjects, and to process and analyze the data.
Many o f the ideas for the secondary analyses stemmed from our weekly group
meetings. I would especially like to credit Dr. Ashton-Miller, the co-chair o f my
dissertation committee, for his many observations and informal suggestions, including his
ideas regarding the development o f our unique spine marker (Appendix H). His query as
to the possibility o f thoracic hyperkyphosis as a compensatory mechanism formed the
basis for the analysis reviewed in Chapter VI. His earlier work on the relation between
scoliosis and anthropometry was the inspiration for the study reviewed in Chapter VIII.

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

CHAPTER H
ON THE RELATION BETWEEN THORACIC HYPERKYPHOSIS
AND SPINE MECHANICAL LOADING: THE ANIMAL MODELS
Introduction
In the early 1920s, H.W. Scheuermann made three important points regarding a
unique type o f thoracic hyperkyphosis that would eventually bear his name. First, he used
roentgenographic imaging to describe the vertebral wedging responsible for the abnormal
increase in the sagittal plane curvature o f the thoracic spine. Second, he observed that the
wedging and the deformity that it caused seemed to be more prevalent in adolescent
agricultural workers. Third, he postulated that the pathognomonic wedging was the result
o f epiphyseal plate abnormalities.
If Scheuermanns ideas are valid, then two things should follow. The increased
prevalence o f the disease among adolescent laborers whose spines are still developing
implies a link between spine deformity and heavy or repetitive loading. If there is a link,
then it should be possible to experimentally produce hyperkyphotic deformity by externally
loading vertebrae. Second, if the epiphyseal plate is involved in the development of
vertebral wedging, then tissue from experimentally wedged vertebrae should have
histologic characteristics that are similar to tissue samples from Scheuermanns Disease
patients. This paper provides evidence to support both o f these notions.

24

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Background
For almost a century, repetitive loading has been implicated as a cause o f acquired,
non-postural, thoracic hyperkyphosis. Scheuermann credited Schanz (1907) as being the
first to use the label apprentice in connection with deformity o f the spine
(Lehrlingekyphose or Lehrlingescoliose, as reported by Sorensen, 1964). In his now
classic publication o f 1920, Scheuermann echoed Schanz sentiment by observing that
most o f the young subjects in his study who had the typical findings o f Kyphosis Dorsalis
Juvenilis (Juvenile Thoracic Kyphosis) were also farm workers. He wrote that the
etiology o f adolescent, thoracic hyperkyphosis was the involvement o f strenuous physical
work during the period o f increasing growth spurt during puberty (Scheuermann, as
translated by EM Bettmann, 1977).
Not only did Scheuermann report the typical radiographic wedging now commonly
identified with this disease, but he also noted that there was radiographic evidence of
changes in epiphyseal plate architecture. In his original paper, he acknowledged the
presence o f irregular epiphyses of the vertebral bodies at the involved spine segments.
These triangular shadows were at the anterior vertebral borders, and were structures
which he would later (1934) describe as annular epiphyses (ring apophyses). He stated
that these structures, plus the columnar layer of cartilage at the zone o f growth, were
affected by the disease. Insufficient growth o f these structures was thought to occur,
which resulted in wedging o f the anterior vertebral bodies.

25

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

External Loading in vivo Produces Gross Vertebral Changes


Similar to those Found in Scheuermann's Disease
For decades, scientists have used animal models in the laboratory setting to
demonstrate loading-related vertebral wedging. One o f the most popular models is the rat
tail, used as early as 1929 by Dr. C. Mau. Like Scheuermann, Mau was interested in the
relation between loading, changes in the epiphyseal plate, and vertebral deformity. He
bent rat tails in vivo by surgically fixing them to the animals torsos for periods o f 80-220
days. This technique applied compressive loading to the concave aspect o f the caudal
vertebrae and distraction to the convex aspect. The animals were sacrificed at various
intervals and microscopic analysis o f the vertebral epiphyses was performed. Cartilage
atrophy and even adjacent bone necrosis was demonstrated in specimens harvested toward
the end o f the loading period. These results implied that compressive loading of
developing epiphyses resulted in tissue changes that could lead to wedge deformities.
Similar methods have been used by contemporary researchers to demonstrate a
relation between loading and vertebral tissue change. Some o f the most prolific work in
this area comes from the University o f Vermont, where Stokes, et al. have been
mechanically modulating vertebral body growth in animal tails by applying asymmetric,
bending loads. In their first study (1996), rat tails were bent in vivo for periods o f up to
nine weeks. Compression or distraction forces o f 25-75% body weight were applied using
a special apparatus. The compressed aspects o f the caudal vertebrae were observed to
grow at the reduced rate o f 68% that o f unloaded controls. In contrast to the compressed
side, the distracted side o f the caudal vertebrae grew at an increased rated, or 114% that

26

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

o f unloaded controls. Aronsson, Stokes, et al. (1999) found the same vertebral growth
differential using calf tails loaded asymmetrically loaded with a 30-50N load for a period
o f 6 months. The longitudinal growth rate o f compressed vertebrae was 68 42% that of
adjacent controls, while the growth rate o f distracted vertebrae was 123 78% that o f
controls. These patterns o f growth modulation supported the Hueter-Volkmann Law,
which is a clinical tenet stating that bone growth is retarded by compression and is
accelerated by tension.
Mente, Stokes, et al. (1997) went on to confirm that vertebral wedging resulted
from asymmetric loading. The rat tail model was again used, with tails loaded in
compression with a force o f 34-58% body weight for 6 weeks. Within a few days o f
loading, tail wedging was noted. Ninety-six percent o f this early wedging was shown to
take place at the intervertebral disc, likely due in part to a hydrostatic water shift within
the disc. By the sixth week after loading, the disc-deformation contribution to wedging
dropped to about 57%, while 43% of wedging was now due to asymmetrical physis
growth o f the vertebrae. The longitudinal growth rate o f the compressed vertebrae was
suppressed, averaging 61.3% 10.2% the growth rate o f unloaded controls. By using
calcein, a fluorochrome that labels ossifying bone, Mente, et al. were able to quantify the
difference in growth between the convex and concave sides o f the bent rat tails, which
averaged 2.7 1.5 tim/day. These findings indicated that unequal growth rates resulted in
vertebral wedge deformities.
Mente, et al. (1999) again used the rat tail model to investigate the reversibility of
loading-related, vertebral wedging. External fixators were used to produce an angular

27

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

deformity o f 30 in rat tails, with a compressive force o f 60% body weight. After 4 weeks,
the fixators were removed, having produced an average vertebral wedge deformity o f 10
4.4. A group o f rats then underwent load reversal, with one week o f distraction loading
and four weeks o f angular deformity and compression on the opposite aspect o f the tail.
The load removal-only group demonstrated a slight but significant improvement o f
wedging (to 7.3 3.9). The load removal-plus-opposite-side-reloading group
demonstrated a pronounced wedge improvement, with a decrease to an average o f 0.1
1.4. These findings provide important implications for the treatment of human spine
curve abnormality, suggesting that removal of load and modification of posture from
compression to distraction might modify the curve.

External Loading in vivo Produces Ultrastructural Vertebral Changes


Similar to those Found in Scheuermann's Disease
The relation between external loading and vertebral wedge deformity has been well
established, at least using animal models. But how does loading affect tissue
ultrastructure? In 1992, Revel, et al. published the findings o f their rat tail model study, in
which rat tails were loaded by bending in daily motion cycles o f two hours over a period
o f two months. While their experiment did not produce gross vertebral wedging,
subsequent histologic analysis o f the vertebral tissue revealed two important findings. The
first o f these were intervertebral disc prolapses into vertebral endplates, findings similar
Schmorls nodes seen in the spines o f Scheuermanns Disease patients.
The second finding was one o f altered cartilage ultrastructure. Revel, et al. (1992)
observed that the immature epiphyses o f the young control rats had a different histologic
28

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

appearance than those o f rats whose tails were subjected to loading. The control rat tails
(Figure 2.1) demonstrated a parallel, columnar arrangement o f deep zone chondrocytes,
the cells that maintain healthy cartilage. These cells are normally oriented perpendicular to
the tidemark delineation between cartilage and subchondral bone (Nordin and Frankel,
1981). In contrast, caudal tissue specimens from experimental group subjects (Figure 2.2)
displayed disrupted and uneven deep zone chondrocyte columns. These findings suggest
that abnormal loading disrupts the physiologic arrangement o f chondrocytes in vertebral
cartilage endplates.

Figure 2.1. Cartilage Endplate from Unloaded Control


Deep layer chondrocytes (number 2 in the center o f the image)
are organized in a linear, columnar fashion.

29

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 2.2. Cartilage Endplate from Loaded Rat Tail


The black arrow in the center o f the image points to chondrocytes that are
no longer arranged in linear columns, but rather are more disorganized.
(Permission fo r use o f these images granted by the copyright holder: Lippincott, Williams & Wilkins;
images are Figures 2 and 5 from: Revel M, Andre-Deshays C, Roudier R, Roudier B, Hamard G, Amor B.
Effects o f repetitive strains on vertebral end plates in young rats. Clinical Orthopaedics and Related
Research 279:303-309, June 1992).

The work of Revel, et al. (1992) does more than suggest a relation between
external loading and changes in vertebral ultrastructure. Revels micrographs are
strikingly similar to those from human spines. Like Revels unloaded rat tail specimen, the
normal, human vertebral epiphysis demonstrates a parallel, columnar arrangement o f
deep layer chondrocytes (Figure 2.3). Revels loaded rat tail specimen demonstrates the
same types o f changes found in the growth plates o f Scheuermanns Disease patients.
Like the rat tail specimens, micrographs of both the post mortem specimen o f Ippolito and
30

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 2.3. Normal Human Spine Growth Plate


Deep layer chondrocytes are linearly arranged, in parallel columns (image center).
(Permission granted by the copyright holder: Mt. Sinai Medical Journal; image from Bick, EM. The
osteohistology o f the normal human vertebra. Its relation to scoliosis and certain lesions incident to
growth and senescence. J Mt. Sinai Hosp, 19:490-527, 1952.)

Ponseti (1981)(Figure 2.4) and the cadeveric specimens o f Scoles, et al. (l991)(Figure
2.5) display disorganized cartilage columns and chondrocytes that are arranged in clumps
or clusters.
Similar loading-related alterations in chondrocyte organization has been observed
by others. Bylski-Austrow, et al. (2000) used a porcine spine model to demonstrate how
surgical intervention might modify spine growth. First, staples were surgically fixed at the
anterior aspects of the mid-thoracic vertebrae o f domestic pigs. These staples spanned the
intervertebral disc and two adjacent growth plates o f at least three contiguous motion

3t

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 2.4. Growth Plate Micrograph


Chondrocytes (horizontal strip, lower part of the image) are not arranged
in a linear fashion and lack parallel column organization.

(Permission granted by the copyright holder: The Journal o f Bone and Joint Surgery, Inc.: image is
Figure 2 page 176from: Ippolito E, Ponseti IV. Juvenile kyphosis, histological and histochemical studies.
JBJS(Am), 63-A(2):175-182, Feb 1981.)

Figure 2.5. Growth Plate Micrograph


The chondrocytes (horizontal strip, middle o f the image) are disorganized and clustered.

(Permission granted by the copyright holder: Lippencott, Williams & Wilkins; image is Figure 4B, page
512 from Scoles PV, Latimer BM, DiGiovanni BF, Vargo E, Bauza S, Jellema LM. Vertebral alterations
in Scheuermann's kyphosis. Spine, 16(5):509-515, 1991.)
32

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

segments (six vertebrae). The staples were left in place for six to nine weeks, after which
the spines were for histologic analysis.
The group made two observations. First, the surgical stapling o f the anterior
aspect of the spine resulted in a 20-25 to 35-40 increase in the thoracic spine curvature.
This finding illustrates the Hueter-Volkman Law, as the fixed anterior aspect could be
thought of as being held in relative compression, while the posterior aspect of the spine
was left free to grow. The second observation was made by comparing growth plate
micrographs from the unstapled aspect of the porcine vertebrae (Figure 2.6) to those o f
the stapled, or loaded sides (Figure 2.7). Chondrocytes from growth plate cartilage o f
the unstapled aspects were linearly arranged in parallel columns, similar in appearance to

Figure 2.6. Porcine spinal growth plate structure on the unstapled side.
Chondrocytes o f the deep layer (lower aspect o f the stripe in the middle o f the image)
are linearly arranged and are in parallel columns.

33

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 2.7. Porcine spinal growth plate structure on the stapled side.
Chondrocytes are poorly organized, losing the parallel column orientation.
(Permission fo r use o f these images granted by the copyright holder: images are from Crawford AH.
Endoscopic Mechanical Spinal Hemiepiphysiodesis Modifies Spine Growth. Abstract presented at the
2000IMAST meeting as cited in Orthopedics forum : Copyright 2000Carden Jennings Publishing Co.,
Ltd., Charlottesville, VA.)

those o f unloaded rat tail (Figure 2.1) and normal human spines (Figure 2.3). In contrast,
chondrocytes from growth plate cartilage o f the stapled aspects, the side under relative
compression loading, were poorly organized, similar in appearance to those from loaded
rat tails (Figure 2.2) and humans having Scheuermanns Disease (Figures 2.4 and 2.5).

ABNORMAL CARTILAGE AND VERTEBRAL WEDGING


The Vertebral Anterior Aspect is More Susceptible to Loading,
Especially in Younger Tissues
Can the abnormal cartilage associated with compressive loading result in the
development o f osseous wedging? Both Ippolito and Ponseti (1981) and Scoles, et al.

34

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

(1991) suggested that an abnormal cartilage matrix leads to disrupted endochondral


ossification. This can especially occur at the anterior end-plate, an area shown by Lundin,
et al. (1998) to be the weakest part under compression, at least in the porcine spine model.
Abnormal cartilage matrix can be the result o f a synthesis mechanism damaged by the
application o f high force, even for short periods (Caterson and Lowther, 1978; Greco, et
al., 1989). Such forces may be repeated microtrauma from activities such as
gymnastics, resulting in the disturbed ossification o f the anterior apophysis (Tertti, et al.,
1990).
Some have hypothesized that pressure-modulated, circulatory embarrassment
affects cartilage function. From their study using chondral tissue taken from wedged
vertebrae, Ogden, et al. (in Weinstein, 1994) theorized that excessive mechanical
compression reduces normal perichondral and intraepiphyseal vertebral circulation. This
results in apophyseal ischaemia and injury, which is manifested by areas of poor cell
division and maturation, as well as focal slowing o f enchondral ossification and growth.
The bony specimens used in their study showed an accentuation o f the sub-apophyseal,
radial indentations o f the calcified vertebral centrum, disruption of the chondro-osseous
transition zone, and irregular mineralization o f both apophyseal ring and cartilage plate. In
contrast, tissue specimens from the unaffected regions o f the physis, particularly the
posterior aspects o f the vertebrae, continued to demonstrate longitudinal growth. The net
result of the asymmetric vertebral body growth rates was vertebral wedging.
Other researchers have reported an age component to tissue susceptibility to
loading, suggesting that young growth plate cartilage is less resistant to stress than adult

35

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

cartilage (Bright, et al., 1974). This notion is supported by the work o f Pazzaglia, et al.
(1997). In their study, forty-eight Sprague-Dawley rats were divided into two groups
young rats and adult rats. The experimental group had their tails bound in a loop for 3060 days. Subsequent, histologic analysis o f the tail vertebrae revealed significant
differences in the appearance o f both growth plates and osseous trabeculae between the
young and adult rats. Unlike the tails o f old rats, the compressed aspects o f the young rat
tails demonstrated fragmented and irregular growth plates, along with shortening and
thickening o f the epiphyseal and metaphyseal trabeculae. In addition, the distracted
aspects of the young rat tails under tension demonstrated transverse fractures o f the
hypertrophic chondrocyte layers. These findings supported the idea that the loading
response of cartilage is age-dependent.

Loading Affects Normal Chondrocyte Physiology


Loading affects chondrocyte physiology through several mechanisms. One such
mechanism is modulation o f the expression o f genes such as aggrecan (Buschmann, et al.,
1996), a large proteoglycan which is a key component o f the cartilage matrix (Maroudas,
et al., 1998; Hughes, et al., 1998), and the synthesis o f gene-expression mediators such as
nitrous oxide (NO), which is a mediator whose expression results in cartilage catabolism.
For example, Loening, et al. (2000) observed significant increases o f nitrite levels in
bovine articular cartilage subjected to uniaxial compression, in addition to collagen fibril
network degradation at 7-12 MPa. In transplanted bovine chondrocytes, DNA synthesis

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

has been shown to be inhibited by as little as a 24 hour application o f a static compression


load o f 0.006-0.4 MPa (Li, et al, 2000).
Another mechanism by which loading affects chondrocyte physiology is through
stretch- and shear-sensitive cation channels. These ion channels regulate intracellular ion
concentrations, macromolecular transport (Quinn, et al., 1997), as well as cell membrane
and electron streaming potential (Frank and Grodzinsky, 1987; Hung, et al., 1998). They
also regulate interstitial fluid flow, fluid pressurization (Armstrong, et al., 1984), ionic
composition, osmotic pressure (Urban, et al., 1993), and cartilage permeability (Stanford,
et al., 1998).
Loading affects the synthesis o f the components of normal cartilage. It can reduce
both proteoglycans and collagen fibril production (Ascani and Montanaro, in Bradford &
Hensinger, 1985). It has been shown to inhibit the chondrocytic synthesis o f
proteoglycans components, such as glycosaminoglycans (GAGs) (Onga, et al., 1998), as
well as sulfates o f keratan and chondroitin, especially in deeper cartilage layers (Lee, et al.,
1997). In fact, loading frequency is also important, with low frequency, dynamic loading
depressing GAG synthesis (Lee, et al., 1998; Sah, et al., 1992). With this in mind, it is
easy to appreciate how repetitive work or athletic training can be associated with thoracic
vertebral wedging and acquired hyperkyphosis.
Glycosaminoglycans synthesis is diminished in part by the loading-related inhibition
o f the mesangial cell production o f cytokine transforming growth factor beta (TGFB)(Studer, et al., 1998). TGF-B acts as a principal growth factor for chondrocytes by
enhancing proteoglycan anabolism and protein synthesis (Klein-Nulend, et al., 1998). In
37

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

addition to enhancing collagen synthesis, TGF-B has also been shown to stimulate both
stem cell differentiation into chondrocytes and dedifferentiated chondrocyte reexpression
o f normal function (Qiao, et al., 1998). A strain-sensitive subtype o f the growth factor,
TGF-fil, has been shown to stimulate periosteal mesenchymal precursors to proliferate
and differentiate in the growth plate (Joyce, et al., 1990) and to regulate expression of
osteopontin messenger ribonucleic acid (mRNA) expression, itself important in bone
mechanotransduction.
Excessive loading is linked to an alteration of both gross cartilage appearance and
cartilage physiology. These abnormal tissues have a relative paucity o f chondrocytes,
which are arranged in a disorganized fashion. Fewer chondrocytes produce less collagen
fibrils and proteoglycans, components that help to determine the tissue's biomechanical
behavior (Nordin and Frankel, 1989). It is likely that abnormal epiphyseal cartilage
ossifies in an abnormal manner, leading to the vertebral wedge deformities seen in
Scheuermanns Disease.

Discussion
At least one question foliowsgiven the predisposition of the thoracic spine to
hyperkyphosis described here, why dont all repetitively loaded, immature spines develop
Scheuermanns Disease? The probable answer is that a combination o f factors is likely
necessary. These factors might include a familial tendency towards the disease (e.g.
Sorensen, 1964). They may include age, gender, the amount o f training, and factors such
as hamstring tightness and anthropometry.

38

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The remainder o f this dissertation will be focused on two general points


identifying the relationships between hyperkyphosis and these variables and quantifying
the relationships among them.

Conclusions
Several different studies have investigated the effect o f asymmetric loading on
vertebral growth and structure. Whether rat, bovine, or porcine models are used, all have
shown that asymmetric growth is the result, with retarded vertebral growth resulting from
compression loading. The histologic samples from these compressed tissues all have a
striking resemblance to specimens from Scheuermanns Disease patients. The similarities
between experimentally loaded tissue and pathologic human tissue support Scheuermanns
observation o f abnormal epiphyseal plate behavior in thoracic hyperkyphosis.
If the gross and histologic findings o f the animal model experiments are
extrapolated to the human thoracic spine and asymmetric, bending, compressive loading is
modeled as the intense, repetitive sagittal plane flexion o f farm work or athletic training, it
is feasible that a hypothetical vicious cycle o f hyperkyphosis can result. The cycle is one
in which increased thoracic flexion augments compressive loading o f the anterior aspects
o f the vertebrae, leading to asymmetric growth and wedging, which allows more flexion,
an increased flexion moment, more loading, then more wedging, and so on. If one takes
into account the reports o f age-related susceptibility o f vertebral tissues to the effects o f
loading, it is easy to see that early pioneers as Schanz and Scheuermann were likely

39

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

correct in their observation that thoracic hyperkyphosis is related to repeated loading,


especially in adolescents whose immature spines are still developing.

40

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER HI
A CROSS-SECTIONAL STUDY ON THE RELATION BETWEEN
THORACIC KYPHOSIS AND REPETITIVE LOADING IN THE FORM
OF ATHLETIC TRAINING IN 1,822 8-TO-18 YEAR-OLDS
Introduction
Is thoracic kyphosis related to repetitive loading, as suggested by H.W.
Scheuermann and others? As described thus far in this dissertation, two lines o f evidence
support this observation. First, the in vivo application o f abnormal amounts o f external
loading onto mammalian vertebrae caused gross spine curve deformity and the typical
vertebral wedging similar to that identified by Scheuermann. Second, the same type o f
experimental loading produced ultrastructural changes that were remarkably similar to
those present in the vertebral tissues o f Scheuermanns Disease patients.
Until recently, evidence that confirms a link between thoracic kyphosis and
repetitive, external loading in the form o f physical activity has been lacking. This chapter
reviews the findings o f a secondary analysis o f data from the cross-sectional study of
Wojtys, et al. (2000), one of the first studies to demonstrate a statistical link between
thoracic kyphosis and athletic training, which includes the repetitive use o f sport-specific
conditioning, and strengthening techniques. The analysis described herein is intended to
support the original study by testing the hypothesis that thoracic kyphosis is associated

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

with the amount o f physical activity in the form o f athletic training, as modeled by the
number o f annual participation hours reported by the subjects.

The Null Hypotheses


If kyphosis were related to athletic training, then those who train a great deal
should have larger thoracic kyphosis angles than those who train only a small amount.
With this in mind, the Primary Null Hypothesis was advanced. It stated that there was no
statistically significant difference in the magnitudes o f the thoracic kyphosis angles
between those skeletally immature, adolescent individuals who undergo repetitive loading
while training for and participating in structured athletics (active athletes) and the
thoracic kyphosis angles o f non-participants (inactive controls).

Primary Null Hypothesis


Ho I

^controls

^athlete group

where 6 = mean Thoracic Kyphosis Angle

It was expected that there would be a difference in the magnitude o f the mean thoracic
kyphosis angle between athletes and controls. If repetitive loading were a factor, then
athletes should have a larger mean kyphosis angle.
Several secondary hypotheses were subsequently tested in a post-hoc fashion.
These were aimed at identifying age, gender, and anthropometric differences between the
Control and Athlete groups. They were also aimed at identifying age, gender, and
age*gender interaction effects on both thoracic kyphosis angle and annual training time.

42

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Secondary Null Hypotheses


H 0 2 : There are no age, gender, or anthropometry differences between controls and athletes
H 0 3 : There are no age- or gender-related differences in thoracic kyphosis angle
H 0 4 : There are no age*gender interaction effects on thoracic kyphosis angle
Hos: There are no age- or gender-related differences in training time
H 0 6 : There are no age*gender interaction effects on training time

It was anticipated that there would be differences o f annual training time by age in
athletes, such that the amount o f training increased with age. It was also anticipated that
there might be gender-related difference in both training and thoracic kyphosis angle.

Background
The notion that hyperkyphosis is related to increased loading is decades old. As
mentioned earlier, Scheuermann (1920) observed that most o f his subjects who
demonstrated the unique radiographic findings o f Juvenile Kyphosis were adolescents
engaged in repetitive agricultural work. Scheuermanns idea o f the work-relatedness was
based primarily on surveys o f the occupations o f the adolescent, hyperkyphotic subjects,
particularly those of males. In two studies, his reported percentages o f those
hyperkyphotic subjects engaged in heavy agricultural work were 46% (1934) and 61%
(1920).
Others also felt that work was somehow associated with thoracic kyphosis,
including Dr. K.V. Wassman (1951), who characterized this same type o f hyperkyphosis
as an occupational disorder. He observed that, in a sample o f 24 cases in which
occupational trauma occurred proximate to development o f hyperkyphosis, 23 were
involved in hard physical labor. He noted that the disease was eight times more prevalent

43

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

in the country than in the city, based on his study that compared the prevalence o f the
disease in urban and rural military conscripts. Of the 750 lads from the country in
Wassmans study, 3.2% exhibited the findings o f Scheuermanns Disease, whereas only
0.4% o f the sample o f 1500 urban conscripts had thoracic hyperkyphosis.
Athletic activities have also been named as a source of repetitive loading
associated with the development o f thoracic hyperkyphosis (e.g. Aggrawal, et al., 1979).
Competitive athletes have been anecdotally observed to have an apparent higher rate o f
hyperkyphosis than youngsters who did not engage in rigorous sport activity (Hensinger,
as cited in Wojtys, et al., 2000). Blazek, et al. (1986) reported an incidence o f
Scheuermanns Kyphosis that was four times greater in 81 top sportsmen than in non
sportsmen o f the same 18-25 year old age group (40.5% versus 9.6%). These
observations, plus those of a link between sport and back complaints in general (Kujala,
1992; Balague, 1988; Micheli, 1979) have likely contributed to the decision to discourage
competitive weightlifting and the use o f maximal weights in prepubescents (Bar-Or,
1989), and for the American Academy of Pediatrics to issue a warning regarding the
possibility of sport-related, epiphyseal damage in preadolescents (AAOP, 1992).

Materials and Methods


As the principal co-investigators o f the original study that was designed to identify
a relation between thoracic kyphosis and athletic training, Drs. James Ashton-Miller and
Edward Wojtys oversaw the development o f the protocol, which is described in their
recent publication (Wojtys, et al., 2000) and in this chapter. The original subject sample

44

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

consisted o f 2270 volunteer 8-to-18 year-olds. The 407 female and 1863 male subjects
had a mean age o f 14.6 ( 2.1) years, mean height of 1.69 ( 0.13) meters (range: 1.23 to
1.96 meters), and a mean weight o f 62.82 ( 18.38) kilograms (range: 20.45 to 133.18
kilograms). Most o f the subjects were from the University of Michigans annual summer
sports clinics, while 182 were tested at local public schools during the academic year. All
enrollees at each testing site were invited to participate, and those who chose to were
required to obtain written parental permission in order to act as subjects in this Human
Use Committee-approved project.
Each subject was required to complete a questionnaire, the test/retest reliability of
which was determined using kappa statistics. The information obtained from these
questionnaires (Appendix E) included sports participation data. From these raw data,
three parameters were used to quantify the amount o f training for each participant:
Annual Training Time (the number o f reported training hours per year), Period (the
number o f years of participation), and the product o f these two variablesCumulative
Training Time. The calculation o f Annual Training Time may be illustrated by the young
athlete who reports training two and a half hours per day for a five day training week
during a season which lasts an average o f 3 months at the high school level. That
students annual training time would be 2.5 hours/day x 5 days/week x 12 weeks/season,
or 150 hours/season. Training time was expressed as hours/year if the subject participated
in only one primary sport, which included football, gymnastics, ice hockey, track,
swimming, volleyball, or wrestling. Active athletes were defined as those who trained for
at least one primary sport on four or more days per week for at least four months per year.
45

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Those individuals having an Annual Training Time o f zero hours were classified as
Inactive Controls.
In addition to the subjective questionnaire information, objective anthropometric
data were collected for each participant. These included measurements as height, weight,
arm and leg lengths, shoulder and abdominal breadths and depths, and the greater
trochanter-to-floor height (GTF). Hamstring shortness was determined using a Finger-toFloor Reach Test (Appendix G). Subjects standing with feet separated at shoulder width
and with knees straight were asked to touch the floor. Those able to touch the floor were
classified as hamstring-normal, while those unable to touch the floor were hamstringshort. Specific spine segment lengths were also measured, including the distances
between the first sacral segment (SI) and each o f several landmarks: the greater
trochanterion (GT), third lumbar vertebra (L3), the tenth thoracic vertebra (TIO), and the
first thoracic vertebra (T l). The four bony landmarks at the spine midline (T l, TIO, L3,
SI) were selected as the locations for surface markers that would be used in the
photographic determination o f sagittal plane spine curvature.

Photographic Data Acquisition: The Test Platform


Each subjects questionnaire information and anthropometric measurements
provided only part o f the data required for the study. The remainder of the information
was derived from photographs taken o f both test apparatus calibration structure and the
back o f each participant. These raw data were then processed to yield the angles of
thoracic and lumbar spine curvature. A special test apparatus provided a stable structure

46

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

in which each participant was fixed in standardized test positions and orientations. As
described in Wojtys, et al. (2000), the platform supported both light emitting diodes
(LEDs) and a rotating pivot point. The fixed LED arrays were used in the calibration
procedure and for subject position reference. The pivot points provided a rotational axis
for either calibration board or subjects. The apparatus permitted fixation of the subjects
pelvis and permitted trunk rotation in flexion at the hips while eliminating body sway from
either knee or ankle motion.

Test Protocol
Bright tape markers large enough to be detected on photographs (S/8 inch by 1
and 1/4 inch) were affixed to the skin surface at the midline o f the bared backs o f each
subject. These markers were placed at palpated landmarks representing the first and tenth
thoracic vertebrae (Tl & TIO), the third lumbar vertebra (L3), and the first sacral segment
(SI). Each subject was instructed to position themself in postures ranging from upright
(vertical) to fully flexed (horizontal), with intermediate positions intended to place the
spine landmarks T l, TIO, and L3 in a horizontal plane. The desired subject orientation
was obtained by instructing each person to stand in one of several test postures. For
Position 1, the subject stood in a relaxed, upright position with head held erect, arms at
the sides, and hands clasped. In Position 2, subjects were instructed to roll the shoulders
forward and cross the arms across the chest. Subjects slouched their shoulders and flexed
head and neck in Position 3, rounded the upper back in Position 4, and tried to touch their
toes in Position S. A fluorescent light and a pair o f red and green filters were built into the

47

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

platform floor. Oriented along the floors long axis, the light provided a means o f
maintaining true sagittal orientation during torso flexion. The fluorescent tube and
colored filters were arranged so that when light escaped through a narrow slit in the
platform floor, the subject would see a white color if he was flexing in the desired sagittal
plane, red if he veered to the right o f that plane, or green if he veered off to the left.
Photographs were then taken o f each subject in each posture, providing the raw
spine angle data. The photographic equipment consisted of one pair o f motor-driven,
35mm single lens reflex cameras and one pair o f projectors. These were positioned
around the platform as depicted in Figure 3.1. Paired as one camera (C) and one projector
(P), each was supported by individual stands at either end o f the apparatus. The first pair,
Cl /PI, was positioned behind the subjects as they stood on the apparatus. This pair was
used to record the sagittal curvature o f each subjects back at the midline from the first
thoracic vertebral surface landmark (T l) to the first sacral segment surface landmark
(SI) for the upright, standing posture and three increments o f partial flexion. The second
camera/projector pair (C2/P2) was positioned at the opposite end and was used to record
the spine curvature (TI to SI) in a standardized, fully-flexed position.
The light projectors served two functions in data collection. First, they illuminated
the otherwise darkened test room. Second, they projected a grid slide image onto
whatever was positioned on the platformeither calibration board or subject. The grid
slide was a photographic slide marked with parallel lines o f known spacing and geometry.
It was sandwiched between the projectors light source and lens, so that light passing

48

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1192 mm

1369 mm

C2

Cl

O
60S nun

j 850

Platform

-+
m i

P2

vii

DEVICE
Camera 1 (Cl)
Projector 1 (PI)

HEIGHT
2460 nun
2140 mm

"*j*------------ ^

1695 mm

ANCLE
37.0
21.4

940 mm

DEVICE
Camera 2 (C2)
Projector 2 (P2)

HEIGHT
2170 mm
2370 mm

PI
ANGLE
36-3
42.9

SUBJECT stands between the stanchions with left side to L and right side to R, looking down the long axis of the platform.
HEIGHT is measured from the floor to the intersection of lens axis and either camera film plane or projector grid-slide plane.
ANGLE is measured from the horizontal to the lens optical axis.

Figure 3.1. Test Apparatus


49

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

through it would cast a grid shadow on the target surface. The grid had a darkened line in
its center which served to accent the midline o f the spine and provide a clean, non-contact
reference for the locations o f the coordinates o f the spine contour landmark points (Figure
3.2).
A calibration procedure was performed at the beginning o f each test day. First, a
calibration structure imprinted with a rectangular pattern o f nine, equally spaced, fixed
dimension points was placed between the stanchion pivots. The calibration board, a flat
reference plane, was positioned vertically when the subjects would be photographed in the
upright and partially flexed subject positions (Positions I through 4). Projector PI and
Camera C l were used to project the grid and record the images while subjects were in the
upright postures. Their optical axes were focused at the center point o f the calibration
board during the calibration procedure. For imaging o f the subjects in the fully flexed
position (Position 5), the calibration board was oriented horizontally. For this posture,
Camera C2 and Projector P2 were used. Both C2 and P2 were also initially focused at the
center point o f the board during calibration.
Once the cameras and projectors were aligned, the system was ready for
calibration. First, the grid slide image was first projected onto the calibration board.
Measurements were made o f the distances between the nine calibration board reference
points, as well as between each point and the central point (origin) o f the nine-point
rectangle. The central point, O, was the target point for the optical focusing process
and was the intersection o f the projected central light ray with the plane. The distances
between the nine calibration points and the four, fixed LEDs arranged as paired arrays on
50

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 3.2. Grid Pattern Projected onto Calibration Board, Subjects Back
(LEDs as white dots located on either side of board or subject; rectangular tape pieces
may be seen along the subjects midline at T l, TIO, L3, and SI
51

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

the stanchion were also measured. These dimensions were entered into a digital file for
eventual use in data processing. Next, calibration photographs were made o f the
calibration board in both vertical and horizontal positions by Camera/Projector pair 1 and
pair 2. The same dimensions that were hand-measured would now be taken from the
photographs using a program custom written for the purpose o f semi-automated data
processing. Thus, the calibration board was used both to provide a scale and to locate
each subject relative to the apparatus. This was accomplished by comparing the
calibration points to the LED locations and then by comparing the subjects spine data to
the LED locations.
With the calibration process was complete, the flat reference board could be
removed and subject photos taken. Each subject would have a complete data set o f five
35mm color slides representing each o f the five test positions: fully upright, three
increments of forward-flexion, and folly flexed. Testing o f each subject required
approximately ten minutes. Two minutes were used for the interview and questionnaire
and two to three minutes were needed for anthropometry. Skin marker application took
approximately two minutes, while subject positioning and photography required the
remaining two to three minutes.

Data Reduction
The analog photographic images for the folly upright posture (Position I) were
then converted to digital bitmap files o f approximately 150 kbytes each using a Nikon
CoolScan slide scanner (Nikon Corporation, Toyko, Japan). The bitmap files were then

52

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

processed using a sequence o f computer programs written to quantify the angles o f


thoracic kyphosis and lumbar lordosis o f each subject (Appendix F). This software
permitted manual selection o f the reference LEDs, calibration board points, and subject
landmark points. It permitted the automatic assignment o f coordinate values to all
selected points and the creation o f calibration files. It automated the identification and
digitization o f the positional information o f at least 120 points along the optically
demarcated spinal midline o f each subject. The program permitted the automatic
reconstruction o f the positions o f missing LEDs, the automatic combination of calibration
and subject data, and development of real world coordinate pair files.
Once subject coordinate data were available, the special program could plot these
pairs and generate a rough outline o f the subjects spine curve topography in the
cephalocaudad midline. The automated procedure fit a fifth-order polynomial curve to
smooth the rough outline. From that, angles o f thoracic kyphosis and lumbar lordosis
could be calculated by measuring the angles between lines tangent to the selected spine
surface landmarks (T l, T10, L3, and SI).
About 12% of the original data were still unusable, even though the software
program facilitated cleaning o f the data by allowing the operator to highlight the spine
midline, to locate and enhance otherwise indiscernible LEDs, and to dampen spurious light
noise. Data loss was mostly due to both the absence o f LEDs on the photographic
image and the truncation o f the image itself, primarily because o f poor camera placement
in the early pilot work. In addition, some of the photographs for Upright Subject Position

53

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1 were lost during the development process because the exposures were located too close
to the beginning o f the film roll.

Data M anagement and Statistical Analysis


Photographic data were digitized and the bitmap files input into a Pentium-based
PC, while questionnaire data were originally entered into spreadsheet files using a Power
Mac. Descriptive statistics were generated using standard desktop statistical packages
(SYSTAT and SAS). In addressing the Primary Null Hypothesis, t-tests were used to
compare the mean o f the variable thoracic kyphosis angle between the Control and Athlete
groups. Linear regression analysis was used to assess predictor variables first for Thoracic
Kyphosis Angle (T) and second for Annual Training Time (Time). Since data followed a
Gaussian distribution, one-way analysis o f variance (ANOVA) was used to comparing the
means o f several variables (Age, Annual Training Time, and Thoracic Kyphosis Angle)
between athletes grouped according to sport.

Results
The primary null hypothesis was tested first. The analysis revealed a significant
difference (p=0.013) between the mean thoracic kyphosis angles o f the inactive controls
and those o f active athletes (Table 3.1), with the mean angle o f the athletes being about
24% larger than that of controls. The 75 controls had, by definition, an Annual Training
Time equal to zero, while the 2195 athletes had a mean training time 260.3 ( 190.9)
hours. However, the gender composition o f the two groups was different, as the athlete
group had a significantly greater number o f males than did the control group (p=0.000;
54

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Table 3.2). The inactive controls were also significantly younger, with a mean age about
16% less than that o f the athlete group. The controls were also about 8% lighter and
21% shorter than athlete subjects, reflecting the direct relation between age and the
anthropometric variables o f height and weight. The differences between subject groups
led to the rejection o f the first o f the Secondary Null Hypotheses, H02 , which was that
there were no significant differences of age, gender, or anthropometry differences between
controls and athletes.

Table 3.1. Differences of Mean Age, Height, Weight, and Thoracic Angle (T)
between Unmatched Control and Athlete Groups
G roup
Controls
Athletes
p-values

W eight (kg.) A ngle T (deg.)


H eight (m.)
A ge (yre.)
12.69 (+/-3.28) 1.57 (+/-0.17) 52.10 (+/-16.88) 30.6 (+/-21.6)
14.66 (+/-2.03) 1.69 (+/-0.13) 63.18 (+/-18.32) 38.0 (+/-15.5)
0.013
0.000
0.000
0.000

Table 3.2. Subject Number and Gender Composition for Three Separate
Subject Groups: Active Athletes, Inactive Controls, and a Athlete/Control
Group Matched for Age, Height, and Weight
G en der
Male
Female
Totals

A thletes
1796
374
2170

%
82.76
17.24
100

C o n trols
56
33
89

%
62.92
37.08
100

36
16
52

%
69.23
30.77
100

Regression modeling (Table 3.4) suggested that the variables age, gender, and
anthropometry were all predictors o f thoracic angle. To control for the mean differences
o f age, height, and weight between the two groups, a sample o f active athletes was
matched to a sample o f inactive subjects according to these three variables. As was the
case hi the larger sample, t-tests again demonstrated a significant difference o f mean

55

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

thoracic kyphosis angle between the Control and Athlete groups (p=0.000, n=52; Table
3.3). Because the athlete groups for both sample sets had a significantly larger mean

Table 3.3. Differences of Mean Age, Height, Weight, and


Thoracic Angle (T) between Matched Controls and Athletes
(n.s. = not significant)
G roup
Controls
Athletes
p-values

Afle (y rs.)
13.77 (+1-2.67)
13.77 (+1-2.67)
n .s.

H eight (m.)
1.66 (+/-0.14)
1.66 (+/-0.14)
n .s.

W eight (kg.)
58.06 (+/-14.55)
58.74 (+/-17.19)
n .s.

T (deg.)
28.93 (+/-21.54)
44.02 (+/-15.02)
0.000

thoracic kyphosis angle than controls, the decision was made to reject the Primary Null
Hypothesis, Hoi, which was that the mean thoracic angle o f controls was equal to that of
athletes.
The significant difference o f the mean Thoracic Kyphosis Angle between Controls
and Athletes when matched by age, gender, height, and weight, implied a direct relation
between this dependent variable and Annual Training Time. This was confirmed by Linear
Regression (Table 3.4).
The analysis confirmed the findings o f the t-tests by showing that Annual Training
Time (Time) was a significant (p=0.004) predictor o f Thoracic Angle (T). A scatterplot
o f these two variables demonstrates the direct relation (Figure 3.3). The use o f LOWESS
(LOcally JFEighted Sbatterplot Smoothing) for smoothing demonstrates the non-linearity
o f the relation as indicated by the low r2. Other significant predictors o f T included Age,
Sex, and the interaction o f Age and Sex. O f all the anthropometric variables, including
height and weight, only Torso Depth at L3 (LDP) and Spine Length (STl) were

56

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

significant predictors. The relation between anthropometry and angle will be discussed in
Chapter V m .

Table 3.4. Linear Regression Equation for Active Athletes


[Stepwise/backward regression; N=1822, with 349 cases deleted due to missing data;
p=0.000 (ANOVA); r2=0.049]
r = 7 9. 629 (K) - 3 . 740 (Aga) - 0 . 6 0 0 (S ax) +1. 721 (Agm*Sax) + 0 . 0 0 6 (Tima)

+ 6 9 . 5 5 2 (S T 1 )+ 0 .0 2 2 (LUTB)- 0 . 0 8 3 (LDP)- 1 1 . 0 0 9 (HTH)


Significant Bradictors
VARIABLE
Age
Sex
Age*Sex
ST1
LDP
Time
where

P (2 TAIL)
0.000
0.003
0.001
0.000
0.000
0.004

T = Thoracic Kyphosis Angle (deg.)


K = Constant
Age = Age (yrs.)
Sex = Gender
Age*Sex = Age and Gender interaction
Time = Annual Training Time (yrs.)
ST1 =
SI to T1 (m.; 1st sacral segment
to 1st thoracic vertebra)
LDP =
Torso depth at the L3 level (m.)
LWTH = Torso width at the L3 level (m.)
HTM =
Height (m.)

-r r .u i' '3:nirg r >rr;^ r.r*

Figure 3.3. Scatterplot of Thoracic Angle vs. Annual Training Time


Data from Athletes. Note the increase of T with Time. Smoothing is logarithmic,
which most closely mirrors the LOWESS line (ZOcally WEighted Scatterplot Smoothing).
57

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

After gender and age were identified as significant predictors of thoracic angle, ttests were used to further test the Secondary Null Hypotheses. First, a significant gender
difference o f mean thoracic angle (p=0.007) was identified, with the mean angle of males
(38.43 14.98) being about 7% larger than that o f females (35.84 17.65). Male
athletes, who made up the majority of the subject sample, were significantly older
(p=0.000) than female athletes [14.86 ( 1.94) years versus 13.83 (2.08) years]. Unlike
their male counterparts, female athletes demonstrated a significant relation between Age
and Thoracic angle, such that older females tended to have larger angles than younger
females (p=0.006). However, when thoracic angle was normalized for age, there was no
significant difference o f T between genders and H03 , stating that there were no age- or
gender-related differences in thoracic kyphosis angle, was accepted.
The interaction between the variables Age and Sex was also a significant predictor
o f thoracic angle. The relation o f these two variables to T is illustrated below. Figure 3.4
shows that in male athletes, mean thoracic angle remained relatively unchanged with
increasing age. Figures 3.5 and 3.6 illustrate that this was not the case with controls or
female athletes, whose mean thoracic angle decreased with age in the l4-to-l8 years o f
age. The 168 female !4-to-l8 year old athletes had a significantly smaller (p=0.000) mean
thoracic angle, T, o f 32.07 ( 17.02), while the 1271 male 14-to-18 year old athletes had
a mean T o f 38.45 ( 15.39). Because o f this difference, the decision was made to reject
Ho4 that there were no interaction effects o f age and gender on thoracic kyphosis angle.

58

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 3.4. Mean Thoracic Kyphosis Angle by Age for Male Athletes
Note that there are no differences in mean thoracic angle between male athletes younger
than 14 years and those 14 years or older.

5=

:
-

...

..

. ..

-c e

-6

--

.i

rri

Figure 3.5. Mean Thoracic Kyphosis Angle by Age for Female Athletes
Thoracic Angle (T) is in degrees, Age is in years. In contrast to Male Athletes,
mean T values decrease with age for the L4-to-l8 year-olds.

59

R e p ro du ced with permission o f the copyright owner. Further reproduction prohibited without permission.

Figure 3.6. Mean Thoracic Kyphosis Angle by Age for Controls


As with Female Athletes, mean T values decrease with age for the l4-to-18 year-olds.

The next o f the secondary null hypotheses examined the relation between age,
gender, and the interaction o f the two (Age*Sex) with Annual Training Time. Again, a
general linear model was used to identify significant predictors o f Training Time, which
included Sex, Age*Sex, and Height (Sex: p=0.000, Age*Sex: p=0.000; Table 3.5).
Female athletes reported a significantly larger (p = 0.000) mean annual training time [320
( 246) hours] than their male counterparts [259 ( 179) hours], a finding that was true

Table 3.5. Stepwise (Backward) Linear Regression Equation for Active Athletes
[p=0.000 (ANOVA), r:=0.047; N=2150, with 45 cases deleted due to missing data]
rim*

= 3 7 2 . 8 5 1 (K) - 2 0 7 . 2 6 5 (Smx) + 9 . 8 7 0 (Ag*Smx)


Significant Pradictors
VARIABLE
Sex
Age*Sex

where

P (2 TAIL)
0.000
0.000

Sex = Gender (Female: 1, Male: 2)


Age*Sex = Age and Gender interaction

60

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

even after normalizing Time by Age. While Training Time increased in age in both
subjects o f both genders, the relation between the two variables was significant in male
athletes, such that older males tended to train more than younger males (p=0.000; Table
3.6 and Figure 3.7). This gender-related difference illustrates the Age*Sex interaction
effect on Time. These findings led to the decision to reject secondary null

Table 3.6. Mean Annual Training Times by Age Group for Athletes
While the Training Times of Females are larger than those of Males in every age group,
there are increases o f mean training times between male age groups.

A ge G roup M ean
Fem ales
8-10 yrs.
11-13 yrs.
14-18 yrs.
M ales
8-10 yrs.
11-13 yrs.
14-18 yrs.

Time (h is.)

M ean Age (yrs.) s.d.

s.d.

296
317
321

213
246
246

9.7
12.4
15.1

0.5
0.7
1.0

30
121
167

131
211
267

140
195
173

9.5
12.3
15.7

0.7
0.6
1.1

72
285
1401

2
i

I__L

'

Figure 3.7. Annual Training Time versus Age for Male Athletes
Note the direct increase o f annual training time with age (p = 0.000; r2 = 0.049).

61

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

hypotheses H os and H 06, which stated that there were no age- or gender-related differences
in training time and there were no age*gender interaction effects on training time.
Discussion
Prior to this analysis, only one study, Wojtys, et al. (2000), demonstrated a direct
relation between thoracic kyphosis and repetitive loading in the form of athletic training.
In that study, training was calculated as Cumulative Training Timethe product o f selfreported Annual Training Time (in hours) and self-reported Period, the number o f years o f
sport participation. In this chapter, athletic training was represented by Annual Training
Time (in hours) alone. That variable was chosen as it was thought to be a simpler
representation of the amount o f training, and was a variable more easily conceptualized
when making training recommendations to coaches. Regression analysis supported this
decision, as annual training time was more often a significant predictor o f thoracic angle
than period.
The findings described in this chapter support those o f Wojtys, et al. (2000).
However, they are different in that many years o f sports participation are not required to
be associated with larger thoracic kyphosis angles. Rather, the training undertaken in only
a year has been shown to have a direct relation. Perhaps, future analysis to estimate the
interaction o f period could be achieved by looking at the relation between thoracic angle
and athletic training hours with subjects grouped into the number o f years o f sport
participation.
The large data set o f Wojtys, Ashton-Miller, et al. (2000) was the source for this
secondary analysis. These authors reported a mean thoracic angle o f 38.5 ( 13.6). For
62

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

these values, the range o f thoracic kyphosis angles within one standard deviation was
about 25 to 52. Subtracting the 7, systematic overestimation o f radiographic angles
reported from the validation portion of the Wojtys, et al. (2000) study gives a
roentgenographic equivalent range o f 18 to 45. This agrees well with the 15 to 45
normal kyphosis range suggested as normal by Winter and Hall (1978) and closely
approximates the 20 to 45 range suggested by Bradford (in Moes text, 1995) and by
Nissenen (1995).
Eleven percent o f our inactive control subjects and seventeen percent o f our active
athletes had thoracic kyphosis angles beyond one standard deviation from the mean (52,
as determined using the photogrammetric/surface method). These values approximate
prevalences reported for Juvenile Kyphosis by Blazek, et al. (1986) [9.6% in inactive
controls (ages 18-25 years)] and by Nitzsche and Hildenbrand (1990) for active males
(15.3%). About 4% o f subjects had kyphosis angles greater than two standard deviations
from the mean (greater than 65). This figure agrees well with what has been reported by
Ascani, et al. (1977) and is within the range o f the prevalence reported by Sorensen
(1964) and Tertti (1990) for subjects o f similar ages (Appendix A).
The subjects o f our study were not subjected to radiographic analysis. Therefore,
we could not presume that our hyperkyphotic subjects had Scheuermanns Disease.
Nonetheless, the prevalence of hyperkyphosis in our subject sample compared favorably
with the prevalence o f Scheuermanns Disease as reported by others. O f our sample o f
307 female athletes, 16% had thoracic kyphosis angles greater than 52, while 17% o f a

63

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

sample o f 1581 male athletes had angles greater than 52. In our non-athlete control
sample, 11% had thoracic kyphosis angles greater than 52.

Limitations
The methods used to obtain the spine angle and training time data were those
described by Wojtys, et al. (2000). The limitations o f those methods are described in that
publication and in greater detail in Chapter IX. One of the most notable limitations is the
use o f surface, photogrammetric methods for spine angle estimations. Our method was
shown to systematically overestimate radiographic angles by about 7. However, after
accounting for this error, our subject sample thoracic angle mean and standard deviation
support the normal range for thoracic kyphosis angle described by Bradford (1981) and
others.
The use o f childrens self-reporting has its own limitations (e.g. Anderssen, et al.,
1995). Our test/retest validation of our survey instrument demonstrated repeatability o f
the subjects responses, although with this method we had no way o f knowing the
accuracy o f their participation time estimates. In addition, the convenience sample o f
volunteers was not a random sample. Because summer sports camps were the sources o f
many o f the subjects, socio-economic limitations excluded those who could not afford to
participate. Thus, the results o f these analyses could not be generalized to the entire
population.

64

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Conclusions
The results o f this secondary analysis o f data from a cross-sectional study implied a
direct relationship between thoracic kyphosis and annual athletic training hours. While the
cross-sectional design o f the study prohibited the establishment o f cause and effect, the
results showed that, in an 8-to-l8 year old, public school student, volunteer sample, the
mean thoracic kyphosis angle o f active athletes was significantly larger than that of
inactive controls. This finding remained true when controlling for age, gender, and
anthropometric differences (height and weight) between subject groups. Regression
analysis confirmed that Annual Training Time was a significant, direct predictor of
Thoracic Angle in athletes, indicating that those who trained more tended to have larger
thoracic angles.
These results lend support to the anecdotal clinical observations that the
development o f thoracic hyperkyphosis is related to work in adolescent individuals whose
immature spines are likely more susceptible to loading. The implication is o f these
findings is important, for modification o f activity could result in the prevention and
possibly the improvement o f hyperkyphotic deformity. In the next chapter, the relation
between thoracic angle and training time is further investigated within active athletes, and
an effort is made to quantify the actual amounts of training time associated with thoracic
kyphosis by sport.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER IV
A CROSS-SECTIONAL STUDY OF THORACIC HYPERKYPHOSIS
AND ATHLETIC TRAINING HOURS FOR SIX SELECTED SPORTS
IN 8-TO-I8 YEAR OLDS

Introduction
The preceding chapters have presented evidence to support the notion that
repetitive loading is associated with thoracic hyperkyphosis in adolescents whose
immature spines are still developing. This evidence includes animal model experiments
that have produced both gross and microscopic changes typical o f those seen in
Scheuermanns Disease, a type o f acquired thoracic hyperkyphosis. The evidence also
includes the results of a secondary analysis of the data from a cross-sectional study by
Wojtys, et al. (2000) that demonstrate a direct relation between thoracic hyperkyphosis
and repetitive loading in the form o f athletic training. In that study, active athletes had
larger thoracic kyphosis angles than inactive controls. In addition, those active athletes
who logged more training hours tended to have larger kyphosis angles.
In this chapter, we will continue to look at the association between thoracic
kyphosis and athletic training. We will do so by analyzing the data from the Wojtys, et al.
(2000) study with active athletes grouped according to their primary sports activity.
Because o f the uniqueness o f sports activities, we anticipate that there will be differences
in the amounts o f reported training between sports. I f there is an association between
66

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

thoracic kyphosis and the amount o f repetitive, physical activity, then participants of
sports requiring more training should have larger kyphosis angles. Within sports, those
who train more should similarly have larger angles. Expressed as the Primary Null
Hypotheses:

Primary Null Hypotheses


Ho i: There are no thoracic kyphosis angle or training time differences

between sports
H 0 2 : There are no differences of mean annual training time
between normokyphotic and hyperkyphotic athletes within sports

In Chapter HI, regression analysis showed that in addition to annual training hours,
both age and gender were significant predictors o f thoracic kyphosis angle (Table 3.5).
Thus, additional comparisons were made between sports in order to identify differences o f
age, gender, and anthropometry by addressing the Secondary Null Hypothesis:

Secondary Null Hypothesis


H 03:

There are no age, gender, or anthropometric differences between


participants of different sports

It was expected that there would be differences o f age and gender between sports,
as well as differences o f height and weight.
The remainder o f this analysis was aimed at estimating how much training is too
much? This was done in two ways. First, the amount o f training associated with
thoracic hyperkyphosis was quantified by first calculating the number o f annual training
hours by sport for each o f three age groups for both normokyphotic and hyperkyphotic
subjects. Next, the sports in which the relationship between kyphosis and training was the
67

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

strongest were identified. This was done by determining the mean thoracic angle per
annual training hour by sport.

Background
Certain types o f exercise have been shown to enhance the mechanical competence
o f the skeleton in prepubertal and peripubertal athletes (Daly, et al., 1999) by mechanisms
that include an increase o f bone mineral density (Bass, et al., 1998). In fact, the growth of
the intervertebral disc and vertebrae have been shown to be dependent upon activity
(Taylor, 1975).
In contrast, excessive sports activity has long been thought to have a negative
effect on the spine (e.g. Hafiier and Surrey; 1952). Based on what has been discussed in
Chapters I and n , it is not surprising that the repetitive microtrauma (Dalton, 1992), the
rapid or forceful movements (Sward, et al., 1990-A), or the increased compressive
loads on the vertebral end plates (Wilson and Lindseth, 1982) from sports such as
gymnastics, wrestling, volleyball (Stiletto, et al., 1996) could adversely affect normal spine
development.
Athletic training has been identified with several types o f back problems. Harreby,
et al. (2001), studying 1,389 eighth and ninth grade students, identified a positive
correlation between competitive sports and recurrent or continuous back pain. Tanchev,
et al. (2 0 0 0 ) identified an incidence o f one type o f spine deformity, scoliosis, that, in active
individuals, was over ten times the incidence in inactive controls (12% versus 1%). The
Tanchev group observed that repeated, asymmetric stress on the spine was a typical

68

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

element of the active groups training program. Another type o f spine abnormality,
spondylolysis, was observed by Hellstrom, et al. (1990) to occur in male athletes at a rate
two to three times that o f non-athletes. Hellstroms group also observed that radiographic
spine lesions such as anterior Schmorls nodes and reduced disc height were displayed by
57% o f a sample o f 30 wrestlers and by 43% o f a sample o f 52 gymnasts, roughly 3 to 4
times that of the 13% prevalence in a group of 30 non-athlete controls.
Other spine problems have also been found to be more prevalent in wrestlers and
gymnasts. When compared to soccer and tennis players, wrestlers reported 69% more
back pain, while gymnasts reported 85% more (Sward, et al., 1990-C). In a study by
Goldstein, et al. (1991), 63% o f elite gymnasts were found to exhibit spine lesions, which
were found to be associated with both age and training. Such sport-related spine lesions
include osteochondrotic lesions (Lohrer, 1998), apophyseal excavation (Sward, et al.,
1993), and intervertebral disc abnormalities (Tertti, et al., 1990), all o f which are similar to
what have been observed in Scheuermanns Disease.
As mentioned in Chapter m , several authors have related the thoracic
hyperkyphosis o f Scheuermanns Disease to sports activities (e.g. Hafiier and Surrey;
1952; Micheli, 1979; Sward, 1992). Blazek, et al. (1986) observed that 40% o f top
sportsmen participating in sports that included gymnastics and volleyball displayed
radiographic findings o f Juvenile Kyphosis~fbur times the prevalence in non-athletes.
Tertti et al. (1990) noted that 43% o f gymnasts with abnormal discs also had
Scheuermanns Disease. Sward (1992) noted that the thoracolumbar form o f
Scheuermanns was much more common in athletes than non-athletes. Falter and Hellerer
69

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

(Table 4.1). Grids were optically projected onto both a calibration board and onto all
subjects (Chapter in, Figure 3.2). For each participant, four, predetermined landmark

Table 4.1. Subject Size Range Accommodated by the Adjustable Platform


Minimum
Maximum

S tanding H t (m.) T ro ch an ter Ht. (m.) W eight (kg.)


22.7
0.64
1.23
1.07
113.6
2.13

points and a number o f additional points were selected and digitized along the length o f
the highlighted, spine midline. This information was then combined with calibration data
and processed using computer programs to eventually yield subject thoracic angle data.
The thoracic angles were compared between subjects divided according to sport. Sport,
age, and training data were obtained using self-reporting questionnaires, while
anthropometric measurements were taken at the time o f testing.

Accuracy/Repeatability of the Method


Several steps were used to establish the accuracy and repeatability of the data
processing methods. The first step was to determine the accuracy o f the photogrammetric
method. A metal cylinder o f known diameter (300 mm.) was used as a subject and
positioned on the test platform. Inserted between the vertical stanchions, the cylinder was
photographed using the standard calibration and upright position protocols. Repeated
measurements using both precision calipers and photogrammetry were made to determine
the angle o f curvature o f the cylinder. Comparison o f the results demonstrated that the
optical method was accurate to 1 mm. across the camera field o f view, which was
deemed adequate for application to the subjects.
71

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The next phase o f accuracy testing involved the comparison o f the results of
manual digitization with those o f computer-based data processing. In the early, pilot
stages o f this study, the spine angles were determined using manual digitization. The
projected images o f approximately 247 subjects were calculated from data points that had
been hand-digitized. Subject slides were projected onto a SAC digitization platform
having a resolution o f 1 : 2 0 0 0 and at least

100

points were digitized along the spine

midline from T 1 to SI. However, this method was both time- and labor-intensive, and it
was determined that a computer-based data handling system would facilitate the process.
As described earlier, the use o f the digital system began with the analog-to-digital
conversion of the photographic images. After testing various combinations o f cropped
and uncropped preparations o f the calibration and subject slides, it was determined that
uncropped calibration slides and cropped subject image slides provided the combination of
new-method angle values most consistent with those obtained using hand-digitization.
This combination had the highest correlation coefficient (r = 0.87), with t-test showing no
significant differences between angles measured using manual and digital methods.
Once an automated protocol was selected, the repeatability o f the spine angle
results was tested. Repeated measurements were made o f 10 subject slides to determine
the error due to operator digitization and software angle calculations. Each o f the ten
slides were digitized using computerized techniques. The spine angles for the ten slides
were calculated on three separate occasions, with a test-retest error o f approximately 3.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Optical Method Validation


The optical method was validated using ten patients having documented thoracic
hyperkyphosis o f greater than 40. All were Scheuermann's Disease patients from the
University o f Michigan Pediatric Orthopaedic Clinic. In addition, all had radiographic
evaluations done within a six month period, with spine angle values determined using the
Cobb method. These same patients were then tested in an upright position according to
our photogrammetric protocol.
With the patient/subjects acting as their own controls, a comparison was made of
the angles generated using both radiographic and photogrammetric methods. The mean
differences between angle values generated from standard radiograph and those from the
non-invasive optical (photographic) method were, for thoracic angles, 5.5 ( 2.4), while
the mean difference in lumbar angles was 7.7 ( 3.3). The photographic method
generally underestimated the x-ray angles. Linear regression showed a relationship
between photographic and radiographic techniques that had a r2 = 0.985 for the thoracic
region and r2 = 0.853 for the lumbar region. The high correlation and low mean
differences demonstrated that the photographic method used in this study accurately
reflected the gold standard" o f x-ray-based thoracic angles.
Next, statistical comparisons were made o f the Landmark Point and Inflection
Point photographic methods used to determine the thoracic and lumbar spine angles at the
midline. The Inflection Point method calculated spine curve angles as the angle between
tangents to the points o f spine curve inflection, rather than at select landmarks. There
were no significant differences between like angles generated by either method, in fact,
73

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

there was a high correlation between the two (r2 = 0.85). When the mean angles
generated by each method and expressed in degrees were compared, the thoracic angle
mean difference was 1.88, while that o f lumbar angles was 2.47. Despite their close
similarity, the landmark tangent method angles were selected for analysis because their
variances were about one-half o f those angles generated from spine inflection point
tangents.
Results

Differences o f Age, Height, and Weight between Sports


In the study described in Chapter m , statistically significant interrelations were
identified not only between thoracic kyphosis angle and training time, but between age,
gender, and anthropometry as well. In this chapter, similar relationships were noted. For
example, male athletes tended to be older, taller, and heavier than female athletes (Table
4.2).

Table 4.2. Differences of Mean Age, Height,


and Weight between Male and Female Athletes
GROUP
Fem ales
Males
p-values

n
286
1529

Age (yrs.)
m ean s.d .
2.0
13.6
14.9
1.7
0.000

Heightt(m .)
m ean s.d.
0.1
1.6
1.7
0.1
0.000

W eight (kg.)
m ean s.d.
52.0
11.3
66.3
18.1
0.000

In order to test the secondary null hypotheses and to control for gender-related
differences o f age, anthropometry, and training time, subjects were grouped according to

74

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

their primary sports. First, the number o f males and females were tallied for each sport to
identify any gender composition differences. As noted in Table 4.3, the distribution of
subjects according to sport was gender-related in most instances. Several sports were
found to be comprised exclusively o f either male or female subjects, while others were
dominated by one gender. Female-dominated sports included volleyball and gymnastics,
whereas male-specific sports were wrestling, football, and ice hockey.

Table 4.3. Subject Count for Each Sport by Gender


G ender Volleyball Wrestling Swimming Track Football G ym nastics Hockey TOTALS
4
35
327
217
15
0
53
3
Females
1
12
391
188
1718
951
175
Males
0

The analysis was continued with sports grouped according to gender


predominance. Mean Age, Height, and Weight were then determined for each sport
(Table 4.4). Between-sport comparisons o f the three variables (Table 4.5) were made

Table 4.4. Mean Age, Height and Weight by Sport (Male and Female Athletes)
As expected, Height and Weight increase along with increasing Age

SPORT Age (yrs.)


Fem ales
volleyball
14.5
n = 51
swimming
13.3
n = 217
gymnastics
13.0

s.cf. H eight (m.) s.d. W eight (kg.) s.d.


1.7

0.07

54.7

7.91

2.0

1.6

0.09

51.3

9.32

2.4

1.5

0.11

44.7

9.92

13.4

2.1

1.6

0.1

55.1

153

15.0

1.5

1.7

0.1

62.9

16.0

16.1

1.1

1.8

0.1

83.7

14.6

13.9

2.2

1.7

0.1

57.9

13.5

3
n
c

1.5

Males
hockey
n = 187
wrestling
n = 942
football
n = 389
swimming
n-175

75

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 4.5. Differences (p-values) of Mean Age, Height, and Weight between Sports
Older subjects were also taller and heavier, (n.s. = not significant)

B etw een th e S p o rts of:


F em ales
Volleyball, Swimming
Volleyball, Gymnastics
Track, Swimming
Track, Gymnastics
M ales
Wrestling, Swimming
Wrestling, Football
Wrestling, Hockey
Swimming, Track
Swimming, Football
Swimming, Hockey
Track, Hockey
Football, Hockey

A ge (yrs.)

H eight (m.) W eight (kg.)

0.000
0.001
0.003
0.007

0.045
0.000
0.024
0.000

0.017
0.000
0.000
0.000

0.000
0.000
0.000
0.000
0.000
0.017
0.000
0.000

n.s.
0.000
0.000
0.004
0.000
0.000
0.000
0.000

0.000
0.000
0.000
0.000
0.000
n.s.
0.000
0.000

using ANOVA and t-tests. As anticipated, older subjects tended to be taller and heavier.
The statistical significance o f these differences led to the decision to reject H03 , which
stated that there were no age, gender, or anthropometry differences between sports.
In some instances, the between-sport differences o f mean height and weight
persisted, even when controlling for gender and age (Table 4.6). Data from female

Table 4.6. Comparison of Mean Height and Weight by Sport


for 12 year-old Female Athletes and 14 year-old Male Athletes
Even with age controlled, there are intersport differences o f anthropometry

I
I

G roup

S p o rt

age 12 yrs.

Swimming
Gymnastics

31

p-value Il
M ales
Football
age 14 yrs.
Hockey
p-value
Wrestling
Swimming
p-value

Height.<m.)
m ean s.d.

W eight (kg.) |
m ean a.d.

1.58
1.52

0.06
0.10

46.29
41.59
0.050

523
7.75

1.76
1.68
0.001
146 1.67
24 1.73

0.08
0.09

76.78
57.52
0.000

14.09
10.07

28
29

0.08
0.07

76

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

athletes age

12

years and male athletes age 14 years were used to illustrate a significant

difference in mean height between certain sports. This finding was interpreted as implying
that certain sports may be associated with specific somatotypese.g. the husky football
player and the lithe gymnast. It is reflected by the comparison of Body Mass Index (BMI-kg./m2) between sports. This variable combines both height and weight values to give an
approximation o f body habitus. As noted in Table 4.7, gymnasts have a smaller, mean
BMI than volleyball players or swimmers.

Table 4.7. Mean Body Mass Index (BMI) by Sport


for Female Athletes over Age 14 years
(ANOVA; p = 0.041; r = 0.921; n = 103)

S p o rt
Volleyball
Swimming
Gymnastics

n
25
69
9

BMI
34.1
33.9
32.2

s.d.
3.2
3.3
2.1

Differences o f Training Time and Thoracic Angle between Sports and within Sports
Both training time and thoracic angle were calculated for each sport grouped by
gender predominance (Table 4.8). As expected, training time differed significantly
between sports for both genders. For females, the level o f significance was p = 0.000
(ANOVA; r2 = 0.483). For males, comparison o f mean training hours between sports also
showed significance, such as between wrestlers and swimmers (t-test; p = 0 .0 0 0 ) and
between football and ice hockey players (p = 0 .0 0 0 ).
In general, greater amounts o f training time was associated with larger thoracic
angles. This remained true even after controlling for age, as for a sample o f 14-to-l8 year
old female athletes (n = 134; Table 4.9). In these subjects, annual training time was found
77

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 4.8. Mean Annual Training Time (Time) and


Thoracic Kyphosis Angle (T) by Sport
Generally, those reporting more hours had larger kyphosis angles.

T (deg.)

s.d.

27

15

41

16

42

15

3
II

1 SPORT Tim e (hrs.ll a.d.


F em ales
156
72
volleyball
n = 51
348
swimming
230
n = 217
464
gymnastics
396
M ales
hockey
n = 187
wrestling
n = 942
football
n = 389
swimming
n = 175

198

166

37

13

230

136

39

13

284

163

41

17

417

295

38

14

to be significantly different between the sports o f volleyball, swimming, and gymnastics


(ANOVA, p = 0.033, n = 134, r2 = 0.694). For the same group, there were no differences
o f age, height, and weight between volleyball players and swimmers, yet both training time
and thoracic angle were significantly different (p = 0.000). These findings led to the
rejection o f Hoi, which stated that there are no differences o f time or angle between
sports.
Table 4.9. Mean Thoracic Kyphosis Angle and Annual Training Time for
14-to-18 year-old Female Volleyball Players and Swimmers
The swimmers, with a larger reported training time, have a larger mean thoracic angle.

S p o rt
Volleyball
Swimming
Gymnastics

n
32
91
11

T raining Time (hrs.)


m ean
s.d.
73
175
360
212
607
450

T horacic A ngie (deg.)


m ean
s.d.
11
26
40
15
41
9

78

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

For males, swimmers had the largest reported training time but did not have the
largest thoracic angle. Since age and anthropometry were shown to differ between sports,
and anthropometric variables have been identified as significant predictors of thoracic
angle (Chapter EQ), then perhaps male swimmers exhibited a unique, anthropometric
feature. The ratio of Annual Training Time-to-Body Mass Index was developed and
determined for male sports (Table 4.10). The value for swimmers was nearly twice that o f
wrestlers, football players, and ice hockey players (p = 0.000). A similar relation was not
seen in female swimmers.

Table 4.10. Mean Annual Training Time-to-Body Mass Index for Male Athletes
Swimmers have a mean ratio value nearly twice that of wrestlers, football players, and hockey players.

S p o rt
Wrestling
Swimming
Football
Ice Hockey

m ean
6.30
12.34
6.21
6.27

n
932
173
389
182

s.d .
3.65
8.49
3.72
5.68

Thus far, between-sport evidence for an association between training and thoracic
angle has been found. But did the association hold true within sports? To answer that
question, the next of the primary null hypotheses was tested. Mean annual training hours
were calculated for athletes having kyphosis angles between 25 and 52 photogrammetric
method (normokyphotic) and those having angles over 52 (hyperkyphotic) (see Chapter
III). Our subject sample o f 754 wrestlers exemplified the general trend, such that, with no
difference of age, height, or weight between kyphosis groups, training time was
significantly larger in the hyperkyphotic subjects (Table 4.11). This finding led to the

79

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

rejection o f H0 2 , which stated that there were no differences o f mean annual training time
between normokyphotic and hyperkyphotic athletes.

Table 4.11. Mean Annual Training Time and Thoracic Kyphosis Angle for
Wrestlers grouped as Normokyphotic and Hyperkyphotic.
The hyperkyphotic wrestlers, having a significantly larger thoracic angle than normokyphotics,
also have a significantly larger mean annual training time.

G roup
Normokyphotic
Hyperkyphotic
p-value

n
624
133

T raining Time (hrs.)


m ean
s.d .
230
138
263
144
0.016

T h o racic A ngle (deg.)


m ean
a.d.
7.2
38.6
6
59.6
0.000

The Amounts o f Training Associated with Hyperkyphosis


Just how much training was associated with hyperkyphosis? The next part o f this
study had two goals. One was to quantify how many annual training hours were
associated with hyperkyphosis. The other was to identify the sports whose participants
had the greatest thoracic angle magnitudes associated with the least amount o f training.
In order to provide more specific training time information, the active athlete
subjects, already divided according to gender and sport, were further separated into three
age groups. These groups were believed to be a reflection o f the age distribution o f
students at each public school level: 8-to-10 year olds in elementary school, I l-to-13 year
olds in middle school, and 14-to-18 year olds in high school. It was thought likely that the
training programs at each o f these school levels would be unique to these age groups. The
mean ages for each o f the three groups by gender are listed in Table 4.12.
The age grouping also roughly corresponded to three developmental periods: pre
puberty, peri-puberty, and post-puberty. With this grouping scheme, the maximum
80

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 4.12. Mean Ages of each Age Group for Males and Females
Age
G roup
8 to 10
11 to 13
14 to 18

n
41
137
224

FEMALES
m ean yrs.
9.51
12.29
15.37

xd.
0.67
0.75
1.15

n
92
301
1429

xd.

m ean yrs.
9.37
12.31
15.65

0.72
0.79
1.08

growth spurt mean age of females, at about age 12 years (Lonstein, 1978), would fall in
the middle school category, while that o f males (at approximately age 14) would lie within
the high school grades. With subjects thus divided, the mean annual training times were
determined for each sport for both normokyphotic and hyperkyphotic subjects (Table
4.13).
Table 4.13. Mean Annual Training Times for Athletes grouped by
Gender, Sport, Age Group, and Thoracic Kyphosis Category
(Age Group: 1 = 8-l0yrs., 2 = 11-13 yrs., 3 = 14-18 yrs.; s.d. = standard deviation)
In general, hyperkyphotics reported training more than normokyphotics.
Sport
Females
sw im m in g

g ym n a stics

vo lleyb a ll

Noimoky ihotic
mean hrs. xd.

Age
Group

1
2
3
1
2
3
2
3

25
86
104
5
17
11
18
35

319
340
364
228
352
518
125
160

235
217
227
124
324
397
78
80

2
3
1
2
3
1
2
3
1
2
3

5
376
17
71
88
14
57
100
6
137
796

225
292
186
169
216
276
398
481
127
164
242

173
161
159
182
148
285
260
299
57
102
136

Hyperkyphotic
mean hrs. x d .
483
404
360
220
816
576
90

145
221
163

262
480
248
322
232
781
508
144
191
275

151

204
42

Males
fo o tb all
ic e h o c k e y

sw im m in g

w restlin g

254
281
121
500
305
.

80
150

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

In an attempt to further quantify the amounts o f training associated with


hyperkyphosis, the quotient Thoracic Kyphosis Angle/Annual Training Time was
developed. The thoracic angle values of the active athletes were divided by their training
times and then controlled (normalized) for age. Figure 4.1 shows the density plot for
the new quotient. The implications o f this skewed distribution are addressed in the
Discussion.

'rcracic

i*

vcr-csio ~r>Q>=. T'airufxj 7.it.?

hr

Figure 4.1. Density Plot of Thoracic Angle/Time


Skewed to the right; Angle/Time: median = 0.160 deg./hr.; mean = 0.224 deg./hr.

Table 4.14 shows the mean Angle/Time quotients with subjects grouped by gender
and sport, while Table 4 .IS shows the quotients for subjects further divided according to
age group. For males, ice hockey players had the largest ratio values, followed by
wrestling. There were significant differences o f the ratio means between wrestling and
swimming (p = 0.001) and between ice hockey and football (p = 0.000). For females,
gymnasts had the largest ratio values, followed by volleyball players, although betweensport differences were not significant.
82

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 4.14. The Ratio of Thoracic Kyphosis Angle per Annual Training Hour
Controlled (Normalized) by Age for Female and Male Athletes
Those with the largest ratio are also the youngest for both females or males.
(s.d. = standard deviation)

S p o rt
Fem ale
Volleyball
Swimming
Gymnastics
MaLe
Ice Hockey
Swimming
Wrestling
Football

Ratio
(deg./hr./yr.)

s.d.

51
217
33

0.016
0.015
0.023

0.017
0.025
0.057

187
175
954
389

0.027
0.012
0.016
0.012

0.026
0.016
0.017
0.010

Table 4.15. Number of Thoracic Kyphosis Angle degrees


per Annual Training Hour by Sport and Age Group
(s.d. ~ standard deviation; largest values fo r each category in bold print)
After dividing the subjects by age group, female gymnasts and male wrestlers still
have the largest ratio values, with the exception of the older, female volleyball players.

S port
sw im m in g
g y m n a stic s
vo lleyb a ll

8 to 10 yr. o ld s
s.d .
0.019
0.027

0.014
0.014

|
n

23
5

11 to 13 yr. o ld s
s.d . I n

14 to 1t1yr. o lds |
deg/hr/yr s.d.
n

0.019
0.037
0.026

0.037
0.087
0.024

77
12
15

0.011
0.007
0.012

0.011
0.005
0.009

91
11
32

0.017
0.031
0.015
0.028

0.007
0.027
0.020
0.028

5
70
43
128

0.012
0.020
0.008
0.014

0.010
0.020
0.007
0.013

338
87
92
727

Malee
fo o tb a ll
h ockey
sw im m in g
w restlin g

0.045
0.037
0.031

0.042
0.030
0.140

15
10
5

Discussion
The results o f this secondary analysis complement what has already been discussed
in Chapter HI. The significant difference of mean thoracic kyphosis angle that was
identified between inactive controls and active athletes implied a direct relation between

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

thoracic angle and physical activity (in this case, athletic training and participation). That
conclusion was drawn because the active subjects had the larger mean thoracic angle.
In this chapter, similar findings were made using active athletes alone as the subject
sample. Simply put, those who trained more tended to have larger kyphosis angles. This
observation was well illustrated both between sports (e.g. female swimmers and gymnasts,
Table 4.7) and within sports (e.g., wrestlers, Table 4.11). These findings corroborate
those o f Wojtys, et al. (2000), one o f the few studies to show a statistically significant
relation between thoracic kyphosis and physical activity. They also support the ideas of
earlier authors who associated thoracic curvature with some type of work (e.g. Schanz,
1907; Scheuermann, 1920; Wassman, 1951; Hafiier and Surrey, 1952).
Athletes o f both genders displayed a similar pattemthose who reported more
practice hours also had larger mean kyphosis angles. For instance, even though they were
the youngest, female gymnasts reported the most annual training hours and had the largest
mean thoracic kyphosis angles, followed next by swimmers and then by volleyball players.
Older male athletes logged more training hours and had larger mean kyphosis angles than
did younger athletes. Hockey players, those with the least reported hours were the
youngest and had the smallest mean thoracic kyphosis angle (Table 4.8). Wrestlers,
followed finally by football players, were older, logged more hours, and had larger mean
thoracic angles.
Male swimmers were an exception to this observation. This group had the largest
reported, mean annual training time (Table 4.8). I f thoracic angle is directly related to
training, then male swimmers should have had the largest, mean thoracic angle. It is likely
84

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

that this discrepancy was due to an interaction o f other variables, including age and
anthropometry, as the swimmers had a mean weight that was lighter than that of both
football players and wrestlers. To further investigate this exception, the variable Body
Mass Index, based on the anthropometric variables Height and Weight, was used as a
representation o f relative subject size. It was combined with training time to form a ratio
whose value for swimmers was about twice that o f the wrestlers, football players, and
hockey players. The comparison indicated that the male swimmers had the smallest body
size relative to the amount o f time spent in training. While it is speculation, and causeand-effect conclusions cannot be made, perhaps this anthropometric feature protected"
their spines from hyperkyphosis.
Our BMI comparisons between sports in females agrees favorably with the
findings o f Peltenberg, et al. (1984). The group compared indices o f maturation, body
composition, and growth of 1,064 female gymnasts, swimmers, and controls ages 8-to-14
years. They found that gymnasts were smaller than girls in the other groups, a difference
that was even more pronounced" after 10 years o f age. It is possible that findings such as
these indicate the likelihood that successful performance in each sport favors certain
anthropometric characteristics, that training for the sport enhances these characteristics,
and that self-selection for physical activity (e.g. Janz, et al., 1992) may be based, in part,
on sport-specific characteristics. The relation between anthropometry and thoracic angle
will be explored further in Chapter Vm .
Division o f the athlete subjects into two kyphosis categories formed the basis for
the next portion o f this study: the identification o f specific training times. As expected,
85

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

the mean training times o f the hyperkyphotic subjects were generally larger than those o f
the normokyphotic subjects (Table 4.13). These findings further help to confirm the
observations made in Chapter III about thoracic angle and training.
Next, the variable Thoracic Kyphosis Angle/Annual Training Time was developed
in an attempt to identify the sports in which the relation between thoracic angle and
training was stronger. As indicated in Table 4.14, for females, the largest quotient value
was seen in gymnasts, followed by volleyball players and swimmers. For males, ice
hockey players had the largest thoracic kyphosis angle per annual training time values,
followed by wrestlers and then by swimmers and football players. If our study design
permitted cause-and-effect conclusions, these results imply that for females, training for
gymnastics and for older adolescents, volleyball, may be more strongly associated with
thoracic hyperkyphosis. A similar relation may be noted for males training for ice hockey
and wrestling. Such notions are not unreasonable, given the repeated extremes of flexion
postures associated with these sports and the relation between hyperkyphosis and
repetitive loading.
Whereas the mean and median o f our variable Thoracic Angle were fairly close
(mean o f 37.9 degrees and median o f 38.4 degrees), the formed quotient Angle/Time
quotient had a heavy-tailed distribution. As such, Angle/Time values were not normally
distributed, but rather skewed slightly to the right (Figure 4.1). In that distribution, the
mean, median, and mode are no longer the same, as in the case o f normal distributions
(e.g. Mendenhall and Reinmuth, 1982). Rather, the mode is at the highest point on the
graph (point o f greatest frequency), the median (the middle value when data are ordered
86

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

by magnitude) is the next closest parameter from the mode, and the mean (arithmetic
average) now lies farthest from the mode, along the skewed tail. Thus, the standard
deviation distributions are no longer symmetrical (normally distributed), negatively
affecting statistical inference.
Others have identified the same sports as being associated with spine pathology.
An increased prevalence o f back problems has been observed in gymnastics, wrestling
(e.g. Goldstein, et al., 1991; Sward, et al., 1990-C) and volleyball (e.g. Stiletto, et al.,
1996; Blazek, et al., 1986). Our findings regarding also agree with those o f others
regarding hockey, a sport whose repetitive, maximum spine ranges o f motion have been
anecdotally reputed to be bad for posture (Watson, 1983) and have been associated with
back pain (Kujala, et al., 1997). Field hockey, a sport that also requires repeated, flexed
spine postures, has been also associated with "physiologic strain and excess spinal
loading (Reilly and Seaton, 1990).

Limitations
Many o f the limitations o f the photogrammelric method employed for the original
data collection have been addressed in Wojtys, et al. (2000) and in Chapter IX. There are
at least two primary limitations. The first is a concern over the use o f surface methods as
an indicator o f radiographic angles. Our value o f r2 = 0.985 for the relationship between
photographic and radiographic techniques agreed well with a similar between-method,
correlation coefficient o f 0.91 reported by Troup, et al. (1968).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Wojtys, et al. (2000) reported a systematic, overestimation of radiographic angles


by their photogrammetric method, which was used to collect data for these studies. They
also reported a mean thoracic angle o f 38.5 ( 13.6) for 1744 subjects. One standard
deviation on either side o f the mean gives a range o f approximately 25 to 52, which, after
subtracting the overestimation o f 7, translates to a radiographic approximation o f 18 to
45. Despite the use o f surface, photogrammetric techniques, our 1 standard deviation
range is quite close to the normal kyphosis ranges that have been established from xraysthe 15 to 45 range suggested by Winter and Hall (1978) or the 20 to 45 range
recommended by Bradford (in Moe, 1995) and Nissenen (1995). Thus, the definition of
hyperkyphosis that is used in this dissertation (greater than 52 by the photogrammetric
method) is in keeping with the work o f others. It also agrees with the range at which
point clinical treatment is initiated (e.g. Bradford, in Moe, 1995; Hensinger, personal
communication 2 0 0 2 ).
Another primary limitation is a concern over the validity o f the self-reporting of
annual, athletic training hours. Our study used retrospective, self-reporting to quantify
training times. Although self-report has been called ...the method of choice by
epidemiologists and health educators... (Baranowski, 1988), the method has limitations.
Two major sources o f errors or constraints on accuracy include ...the definition o f the
desired variables, and human cognitive processes (Baranowski, 1988). Cognitive process
weaknesses include memory decay, deficits o f rare-event and planned activity, and lack of
motivation in form completion.

88

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Significant memory decay in children has been identified over as little o f seven
days. Wallace, et al. (1985) found that children could remember only 46% o f the mode
o f activity, while Baranowski, et al. (1984) could remember only 55 to 65% o f their
activities. Wallaces group found that their subjects (n = 11) underestimated their
activities, reporting only about 75% o f the observed amount o f activity.
At least two factors, age and time span o f the recall, have been related to validity
(or does the instrument measure what we think its supposed to be measuring
Baranowski, 1988). Sallis, et al. (1996) have indicated that pre-adolescents will have
trouble with recalling physical activity, and that younger children are more sensitive to the
period recall. Age-related, reporting accuracy is reflected in Table 4.16, which lists the
mean reported, annual training time and standard deviation by age group. With standard
deviation expressed as a percentage o f the mean, the value for the older age groups is less
than that of the young children.

Table 4.16. Mean Annual Training Time for each Age Group, with
Standard Deviation (s.d.) expressed as a Percentage of the Mean
8 to 10
11 to 13
14 to 18

n
110
420
1621

m ean i a.d.
169.31
177.68
237.55
215.35
272.16
181.13

p ercen t
104.95
90.66
66.55

Test-retest validation o f the survey questionnaire originally used by Wojtys, et al.


(2 0 0 0 ) indicated good repeatability o f the athletes responsessimilar to what had been
observed by Beunen, et al. (1992) and Thompson, et al. (1997) in working with their own
groups. The association between thoracic kyphosis angle to training time identified in this

89

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

analysis was made for subjects o f all age groups for both genders, not just the older
individuals who perhaps report more accurately. In our case, the addition o f the possibly
underestimated 25% to our reported annual training hours did not strengthen the already
weak r2 o f 0.005, nor did it change the p - 0.003 between thoracic angle and training time.
This studys design was not the prospective, experimental design necessary to
imply causality. Because of this, only associations between the variables could be
demonstrated. However, if athletic training were a causative factor in the development o f
hyperkyphosis, then modification o f the amount o f training might help to prevent spine
curve abnormalities. If such a relationship were valid, then training time information
provided here could be incorporated into training program designs for just that purpose.
In Chapters II, HI, and IV, a relation between thoracic hyperkyphosis and
repetitive loading was been identified. The next section o f this dissertation will be aimed
at investigating the association between thoracic kyphosis and another variable, hamstring
shortness, long thought to be a cause o f at least one type o f hyperkyphosis
Scheuermanns Disease (Lambrinudi, 1934). In order to identify such a relationship, the
link between hamstring shortness and pelvic tilt will first be addressed.

Conclusions
Three points were made based upon the results o f this study. While the design o f
the study prohibited the establishment o f cause and effect, the results showed that, in an 8 to-18 year old, public school student, volunteer sample, those who trained more tended to

90

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

have larger thoracic angles. Not only was this true between inactive controls and active
athletes (Chapter III), but it was true between sports and within sports.
The second and third points was an approximation o f amounts o f time associated
with hyperkyphosis. This was done by calculating the number o f annual training hours and
the Thoracic Kyphosis Angle per Annual Training Time ratio for each sport by age group
and by kyphosis status. In virtually every age group, normokyphotic athletes had smaller
mean training times than did hyperkyphotic athletes. Female gymnasts, followed by
volleyball players, had the largest number o f degrees per hour o f training values. For male
athletes, those having the largest Kyphosis Angle per Training Time were ice hockey
players, followed by wrestlers.
Our findings are important pieces o f information that may be o f assistance in the
design of athletic training programs. Although the values listed are specific to our subject
sample, coaches and support staff might be able use them as rough guidelines, making sure
to keep the number o f annual training hours under the values listed for hyperkyphotics.
Particular care should be taken in designing programs for those sports in which the
Thoracic Angle/Training Time ratios are the largest, with the understanding that training
times are safer when selected closer to normokyphotic mean values. Prudent monitoring
o f annual training time may help in the prevention o f acquired and load-related spine
deformities in adolescents, as well as the prevention their sequellae, which include reduced
function and back pain.

91

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER V
A CROSS-SECTIONAL STUDY OF HAMSTRING SHORTNESS AND ITS
RELATION TO PELVIC TILT AND LUMBAR LORDOSIS IN A SMALL
SAMPLE OF CHILDREN AND ADULTS
Introduction
What other factors are associated with thoracic kyphosis? In Chapter II, we had
seen that vertebral abnormality similar to what is found in the hyperkyphosis of
Scheuermanns Disease can be induced experimentally by external loading. In Chapters
III and IV, we had seen that thoracic hyperkyphosis in adolescents is related to repetitive
loading in the form o f athletic training, such that hyperkyphotic individuals tend to be
those who train more, thereby submitting their immature spines to repetitive loading. Is
hamstring shortness also related to thoracic hyperkyphosis, as suggested by Lambrinudi
(1934)?
To understand the relation between the hamstring shortness and the thoracic spine,
one must first understand how it relates to the pelvic tilt and lumbar lordosis. This chapter
describes the results o f a study intended to define that relationship. It does so by
addressing several questions concerning popularly held notions. First, is hamstring
tightness, more accurately defined as hamstring shortness, associated with a posterior
pelvic tilt, as is commonly described in the literature? If it is, then hamstring-short
subjects should have a greater pelvifemoral angle than hamstring-normal subjects.

92

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Second, is posterior pelvic tilting associated with flattening o f the lumbar spine, as is also
commonly described? If it is, then the lumbar lovdosis angles of hamstring-short subjects
should be smaller than those of hamstring-normals. Third, is it possible that hamstring
shortness limits the sagittal plane, flexion range o f motion o f the torso? If so, then there
should be significant differences of individual, segmental spine ranges o f motion between
hamstring-normal and hamstring-short individuals. These questions may be expressed as
Null Hypotheses:

Null Hypotheses
Hoi: There is no difference of pelvic tilt, as defined by the pelvifemoral angle,
between hamstring-normal and hamstring-short subjects.
H 0 2 : There is no difference of the lumbar lordosis angle between hamstring-normal
and hamstring-short subjects.
H 0 3 : There is no difference of sagittal plane, trunk range of motion between
hamstring-normal and hamstring-short subjects.

where

Trunk Range of Motion is the sum of spine segment ranges of


motion, each of which are defined as the difference between initial
(upright position) and final (fully flexed position) angle values, or:

AOthoracicflexion "b AQlumbarflexion "b AQlumbosacralflexion "b AQpelvifemoral

It was expected that, in hamstring-short individuals, there would be a posterior


pelvic tilt, a relative flattening o f the lumbar lordotic curve, and a reduction o f sagittal
plane, flexion range o f motion o f the torso.

Background
Like thoracic kyphosis, hamstring tightness is an important problem. Defined here
as hamstring shortness, an actual reduction in the normal length o f the musculo-tendinous
93

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

unit (GajdosDc, 1991; Hoffinger, et al., 1993), it has been linked to several types o f spine
pathology. These include Scheuermanns Juvenile Kyphosis (e.g. Lambrinudi, 1934), back
pain (Fisk, 1979; Stephen, 1983), paravertebral muscle spasm, lumbar degenerative disc
disease, disc herniation, spondylolysis, spondylolithesis (Hoppenfeld, 1976; Takata and
Takahashi, 1994), and nerve root compression (Stokes and Abery, 1980). Hamstring
shortness has also been associated with sciatica (Takata and Takahashi, 1994), as well as
sacroiliac strain and dysfunction (Kendall and Boynton, 19S2; Cibulka, et al., 1986).

Prevalence and Etiology


The reported prevalence o f hamstring shortness varies widely, depending on
author and hamstring testing method used (Appendix G). For example, Kuntzleman, et al.
(1993) found 16% o f a subject pool o f 710 public school-age youngsters were hamstringshort. In their study, tightness was ascertained by a seated flexion test, which determines
hamstring status by checking the subjects ability to slide along a wall from a standing to a
seated position, while keeping their pelves flush against it. Hellsing (1988) used the
Straight Leg Raising Test to evaluate the hamstring status o f approximately 600 subjects
o f military age and found that 57% had less than the normal minimum value o f 80 passive
range o f motion. The Popliteal Angle method was used by Brodersen, et al. (1993), in
their study o f 769 subjects. They showed that 75% o f males and 35% females over the
age o f 10 had short hamstrings, which produced a knee extension deficit o f 40 or more,
while more than 10% o f males o f the same age group had deficits o f 60 or more.

94

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Many theories exist as to the etiology o f muscle shortness. One is unloading,


which has been shown to cause skeletal muscle atrophy (Lieber, 1992). Lack o f exercise
and muscle inactivity can result in reductions o f both resting muscle length and muscle
extensibility (Starring, et al., 1988; Jozwiak, et al., 1997). These observations lend
support to the notion expressed by Fisk and Baigent (1984), who suggested that the
relative inactivity of classroom sitting caused the hamstrings of public school age
youngsters to reset to a shorter length.
A difference o f tissue growth rates in developing children may also be a cause o f
hamstring muscle shortness. This may be from a growth rate differential between bone
and the musculotendinous unit, which elongates at a slower rate (Burkett, 1970; Ekstrand
and Gillquist, 1983; Jozwiak, et al., 1997). While it is conjecture, the type of passive
tension that results may affect nerve tissue as well as muscle. Perhaps, the mechanically
irritated nerves could reflexly mediate end-organ, muscle shortening, similar to what has
been observed to occur from the nerve root irritation found in sciatica or herniated lumbar
discs (Sprangfbrt, 1971; Takata and Takahashi, 1994).
Shortened muscle tissue exhibits several histologic characteristics. These
characteristics include a loss o f serial sarcomeres (Williams, 1990), which is likely a major
cause of the reduced amount o f muscle protein that is observed (Booth and Criswell,
1997). In addition, there is a decrease o f both sarcomere length (Jakubiec-Puka and
Carraro, 1991) and the lengths o f parallel elastic components (Tardieu, et al., 1982). The
sarcomere membrane systems, including sarcoplasmic reticulum, transverse tubules, and
triads, are disordered (Takekura, et al., 1996). Finally, there is a thickening o f both
95

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

perimysium and endomysium, a greater proportion o f collagen (Williams, et al., 1988), and
a rearrangement o f collagen fibers to a more acute orientation relative to the muscle fiber
axes (Williams and Goldspink, 1984).
Regardless o f the etiology, muscle shortness exhibits several functional
characteristics. These include a reduced cross-sectional area (Booth and Criswell, 1997),
less contractile force, and, subsequently, less torque (Rassier, et al., 1999; Jonhagen, et al.,
1994). Tight hamstrings are stiffer (Williams and Goldspink, 1984), and have a lower
stretch tolerance (Magnusson, et al., 1997). These factors likely contribute to an increase
o f the passive tension and a left shift o f the length-tension curve (Brown, et al., 1999).

Hamstring Function
The hamstring muscles perform several roles. First, these biarticular muscles are
important in trunk kinematics and gait. They serve as both knee flexors and hip extensors,
depending upon the load bearing status o f the limb. Hamstring shortness interferes with
this normal function by causing changes such as diminished hip range o f motion (e.g.
Halbertsma and Goeken, 1994). Not only are these factors associated with joint
dysfunction (Ekstrand and Gilquist, 1982; Starring, 1988), but they are also associated
with lower extremity muscle injuries, which include hamstring strain (Worrell et al., 1991;
Sullivan et al., 1992; Jonhagen et al., 1994).
The hamstrings also perform another important rolethat o f primary postural
muscles. In the upright posture, this muscle group influences the position o f the pelvis
(Carlsoo, 1961; Cibulka, et al., 1986), such that hamstring contraction acts to extend the

96

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

hip and posteriorly tilt the pelvis. Pathologic shortening o f the hamstrings interferes with
this role by restricting the pelvis in this tilted position (DeLuca, et al., 1998).
Pelvic tilt, in turn, has been shown to affect the spine. First, it affects sacral
position, largely because the complex and tight articulations between the two structures
(Gerlach and Lierse, 1992) permit only a small amount o f movement at the sacroiliac
joints (Miller, et al., 1987). The sacrum is tightly articulated with the lumbar spine and its
position is an important determinant o f lumbar lordosis (Amonoo-Kuofi, 1992). Thus,
pelvic tilt influences the lumbar spine (Beal, 1982; Grieve, 1982; Legaye, et al., 1998).
The relation is such that lumbar curve flattening results from posterior pelvic tilting,
especially in sagittal plane flexion (Day, et al., 1984; Yasukouchi and Isayama, 199S;
Levine and Whittle, 1996; Delisle, et al., 1997; Korovessis, et al., 1998). It is through the
sacropelvic mechanism that lumbar curve flattening has been identified in cases o f
hamstring shortness (McCarthy and Betz, 2000).
Hamstring shortness has been shown to affect not only torso posture, but sagittal
plane torso flexion as well (Winter, et al., 1997). Full torso flexion requires normal ranges
o f motion o f hip, pelvis, and spine (Anderson and Hall, 1995). If any o f these component
ranges are restricted by hamstring shortness (Stokes and Abery, 1980; Gleim et al., 1990;
Gajdosik et al., 1992), then two things can result. First, forward reach distance is
reduced, especially when standing with the knees extended (Daniels and Worthingham,
1980). Second, there is an increase in spine musculo-ligamentous stress (Fisk and
Baigent, 1981; Fisk et a l, 1984), which predisposes the soft tissues o f the back to injury
(Stokes and Abery, 1980; Gajdosik et al., 1992).
97

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Materials and Methods


This study is a secondary analysis o f the data from two earlier studies. Each used
a different optical method for spine angle data collection and each had a separate subject
sample. The method from the first study has been described in detail in Wojtys, et al.
(2000), Chapter III, and Chapter IV. Both photogrammetric and questionnaire data
(Appendix E) were obtained for this study (referred to here as the large sample study).
The photogrammetric techniques were based on still photography and projected grids for
the determination of thoracic kyphosis and lumbar lordosis angles. The original volunteer
sample in this study consisted o f nearly 2300, 8-to-18 year old students from summer
sports camps and public schools. Each was required to obtain parental permission prior to
their participation in this Human Use Committee approved study.
The second study (the small sample study) utilized an optoelectronic technique
to generate spine angle data. This sample was much smaller and consisted o f thirty-one
volunteers. The fifteen males and sixteen females had a mean age o f 23.5 ( 13.8) years
(range: 10 to 70 years). This mean age was 8.9 years older than the mean o f subjects in
the large sample (e.g. Chapter m ). The 31, small study subjects had a mean height of
1.66 (0.15) meters (range: 1.3 to 1.9 meters) and a mean weight o f 60.76 ( 19.18)
kilograms (range: 25.9 to 60.8 kg.). Each o f these subjects responded to the same
questionnaire (Appendix E) that was used in the large sample study. While each
responded to questions regarding back pain and lifting, sport participation background
was not obtained as most were not athletes from sport camps.

98

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

As in the large sample portion, anthropometric measurements were taken on


each subject. These measurements included height, weight, and several spine dimensions
taken as distances between landmark pairs. As described in Chapter III, these dimensions
included the distances between the first sacral segment (SI) and three other landmarks:
the first thoracic vertebra (Tl), the tenth thoracic vertebra (T10), and the third lumbar
vertebra (L3). Torso widths and depths at the SI and L3 levels were also obtained.
For subjects in the small study, several additional measurements were taken.
These included the lateral epicondyle-to-floor (elbow) height, acromion-to-lateral
epicondyle length, lateral epicondyle-to-fingertip (forearm) lengths, suprasternale height,
trochanterion-to-lateral condyle length, and lateral condyle-to-lateral malleolus length.
The greater trochanterion (GT) to SI distance was also measured, and a Greater
Trochanterion-to-Floor Height (GTF) was determined after the method o f Chandler et al.
(in Chaffin and Andersson, 1990).
In both studies, hamstring shortness was ascertained by the Finger-to-Floor
Forward Reach Test (Appendix G). Those subjects able to touch the floor with fingertips
after bending forward from an upright position with knees extended were classified as
hamstring-normal. Those subjects unable to touch were categorized as hamstring-tight
(hamstring-short), and their finger-to-floor distance was measured. O f the 31 subjects in
the small sample study, fourteen subjects were hamstring-normal and seventeen subjects
were classified as hamstring-tight. While the subject pool was largely a convenience
sample, an effort was made to match hamstring normal and hamstring short groups by age
and gender.
99

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Apparatus and Protocolfor the Small Samplen Study


Unlike the 35mm., still photography methods employed in the large sample study,
an optoelectronic system was used to obtain the torso angle data. A stereo-optoelectronic
camera and video processor system (MacReflex from Qualisys, Glastonbury, CT) was
used in conjunction with a desk-top computer (Macintosh) to monitor in real time twodimensional spine motion from an upright to fully flexed position and to generate the raw
data for both postures. The system tracked marker positions and trajectories at a sampling
rate o f 120 Hz.
The optoelectronic equipment utilized infrared light emitting diodes. The
stereoscopic camera sensed the infra-red light originally emitted from diode arrays that
were arranged peripheral to each o f its two lenses. The infrared light was reflected from
passive target material (reflective tape) that was applied at several skin surface landmark
points on the right side o f each subject. These landmark points included both anterior and
posterior-superior iliac spines o f the pelvis (ASIS & PSIS), the greater trochanter
(trochanterion) o f the femur, the lateral femoral condyle, and the lateral epicondyle o f the
elbow.
Positional data were also obtained from several spine markers. The retroreflective
tape was also affixed to specially designed platform markers that were capable o f
withstanding skin surface strains without loss o f perpendicularity to the skins surface
(Appendix H). The markers were placed on the surface of the skin at the spines midline
over the first and tenth thoracic vertebrae (T1 and T10), the third lumbar vertebra (L3),
and the first sacral segment (SI). These markers were fashioned o f expandable wire loops
100

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

that were attached to the chemically cleansed skin surface by means o f adhesive electrode
patches. The wire loops had pieces soldered to them which were perpendicular to the
surface o f the skin (Appendix H, Figure H.7). Reflective tape patches were attached to
both ends o f vertical stanchionsone placed proximal and one placed distal to the skin.
The infrared light source o f the camera system optically activated the tape markers, whose
reflection was sensed by the camera.
Once the markers were in place, subjects were then tested according to the
following protocol. The subjects stood in front o f the camera, which was oriented at a
right angle to the each persons antero-posterior plane. The camera was positioned to
include in its field o f view the entire right side of each subject, as well as a reference post
upon which reflective tape was placed at a height o f SO cm. (Figure 5.1). The subjects,
standing upright with feet set shoulder-width apart, toed a line that was positioned on
the floor. Each participant was then asked to bend forward at the waist with knees held
straight and attempt to touch the floor. Once they reached the end o f their flexion range
o f motion, they would return to the upright position-all within a ten second time span.
The protocol was repeated for each subject, with image acquisition taking place during
both flexion attempts.
Each subject was positioned in a manner that would optimize video recording.
Participants, dressed in gym trunks taped at the hip, were asked to clasp their hands in
front o f their waists while flexing forward. This modification o f the method described by
Polley and Hunder (1978) permitted visualization o f the trochanteria, ASIS, PSIS, and SI
landmarks at all times and in both upright and flexed postures.
101

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CAMERA

COMPUTER

VIDEO PROCESSOR?
MONITOR
SUBJECT

REFERENCE POST

Figure 5.1. Experimental Apparatus


Subjects stand in front o f the apparatus, next to the reference post, and flex in the sagittal plane from
the upright to fully flexed positions in an attempt to touch the floor (a Finger-to-Floor Reach Test).
Reach Distance determines hamstring shortness. Markers are placed on each subject to permit
optoelectronic determination of the various torso angles.

Optical Data Processing


As in the previous two studies, the raw data were optical in origin and were
processed using a automated, computer-based system. In this study, the MacReflex and
commercially available, WingZ software packages were used to calculate the various
torso angles. The raw video signals that were reflected from the platform marker
102

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

stanchions and landmark tape pieces were first reduced to centroid coordinates (X,Y)
using the MacReflex system. The spine marker and pelvifemoral landmark points were
then paired, as illustrated in Figure S.2. The centroid positional data from the reflected
point pairs provided the basis for the automated creation o f paired lines, whose
intersections were measured by the WingZ* software as the spine segment angle o f
interest (expressed in degrees). The segments used in this study included the Thoracic
(T1-T10), Thoracolumbar (T10-L3), Lumbosacral (L3-SI), and Pelvifemoral angles (PF).

TITIO
T10L3
L3SI

PELVIFEMORAL

Figure 5.2. Spine Curvature Angles


These include T1-T10, T10-L3, L3-S1, and the Pelvifemoral Anglethe angle between the long
axis of the femur and a line between the Anterior Superior and Posterior Superior Iliac Spines

The Pelvifemoral angle defined the pelvis position relative to the femoral shank,
and quantified pelvic tilt. It was the angle between two lines: one that was defined by a
pair o f points on the Anterior-Superior and the Posterior-Superior Iliac Spine
(ASIS/PSIS), and one formed by a pair o f points on the greater trochanterion to lateral
femoral condyle o f the thigh (after the Hip Flexion Angle method o f Stokes and Abery,
1980).
103

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Three values were reported for each spine segment. Angles were determined with
subjects in the upright posture, the initial position and in the flexed posture, or final
position. The differences between initial and final position values were then calculated,
and reported as the range.

Data Analysis
Data were analyzed in the same manner as in the previous studies. Commercially
available, PC-based statistical software packages (Systat, SAS) were used. With the
level o f significance (a) set at 0.05, t-tests and one-way Analysis o f Variance (ANOVA)
were used to determine significant mean differences and relationships. Stepwise, linear
regression was used to identify significant predictor variables.

Results
Subjects from the small sample, optoelectronic study were grouped as hamstringnormal and hamstring-short. T-tests revealed that there were no significant differences of
mean age, gender, height, weight, and the anthropometric variables. T-tests were also
used to compare mean angle values between the two hamstring groups (Table 5.1). There
were significant differences o f the Pelvifemoral angle (PF) in both the upright and flexed
postures. This finding led to the decision to reject the first null hypothesis, Hot, which
stated that there was no difference in pelvifemoral angle between hamstring shortness
groups.
The second null hypothesis, that there was no between-group difference o f lumbar
lordosis angle, was then tested. The flexed posture, mean lumbosacral angle (L3-S1) o f
104

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table S.l. Spine Angle, Reach Distance, and Range of Motion


for Hamstring-Normal and Hamstring-Short Subjects
(Hamstring-normal: n = 15, Hamstring-short: n = 16; n.s. = not significant)

S pine
S egm ent
T1T10
1
II

T10L3
II
II

L3S1
II
ll

PF
ll
II

FB
ROM
ROMHTM

Angle
Initial
Final
Range
Initial
Final
Range
Initial
Final
Range
Initial
Final
Range
*

Ham string-Norm al
m ean (deg.)
s.d.
39.80
8.91
13.87
13.99
25.93
12.61
-10.73
8.78
16.07
15.79
32.40
11.06
25.60
9.66
[-10.53]
8.62
36.13
8.63
73.60
6.71
7.79
7.33
66.27
11.52
0.00
0.00
160.73
21.46
96.26
14.55

Hamstring -Short
m ean (deg.)
s.d.
41.50
13.21
26.00
12.77
15.50
7.09
-9.94
8.67
8.63
25.31
35.25
10.52
27.37
7.70
M .19]
8.12
31.56
9.76
79.25
7.61
24.12
17.42
55.13
17.23
127.38
54.07
137.44
18.37
83.67
11.11

p-value
n.s.
0.018
0.01
n.s.
0.058
n.s.
n.s.
0.044
n.s.
0.036
0.002
0.043
0.000
0.003
0.012

the hamstring-short subjects was significantly smaller than that o f hamstring-normals, by


about 60% (Table S.l). The smaller lumbar lordosis angle in the flexed position led to the
decision to reject H0 2 , which states that there is no difference of lordosis angle between
groups.
A similar finding was noted in the upright posture data from the large sample study
(Chapters m , IV). Both the method (photogrammetric) and subject sample were
different in that study. However, hamstring-short subjects also had smaller, mean lumbar
lordosis angles than hamstring-normal subjects, as exemplified by a select groups of
athletes from the large sample study (Table 5.2).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 5.2. Mean Lumbar Lordosis Angle of Representative


Hamstring-Normal and Hamstring-Short Subjects (Large Sample Study)
Hamstring-short subjects have a significantly smaller, mean lordosis angle.

Group
11 y.o. athletes
14-to-18y.o. hockey players

H amstring-Normal
s.d.
m ean (deg.)
14
48
11
40

n
26
60

H am string-S hort
n
m ean (deg.) s.d.
15
39
12
27
34
13

P
0.045
0.047

The third null hypothesis was addressed by comparing the mean torso flexion
ranges o f motion between the two hamstring shortness groups. As mentioned previously,
the flexion range o f motion (ROM) was defined as the sum o f the component spine
segment ranges, or ROM = T 1 - T 1 0 r a n g e

+ T 1 0 - L 3 RAn g e + L 3 - S 1 r a n g e

+ P F range- There

was a significant difference (p=0.003) o f the mean torso flexion range o f motion between
hamstring-normal and hamstring-short subjects, with hamstring-normal subjects having a
mean sagittal flexion range o f 160.73 ( 21.46) and hamstring-short subjects having a
smaller mean flexion range o f 137.44 ( 18.37) (Table 5.1). The between-group
difference persisted even after normalizing for height (ROMHTM). These findings led to
the rejection of H03, which stated that there was no difference o f sagittal plane, trunk
range o f motion between hamstring-normal and hamstring-short subjects.
Linear regression was used next to assess the relative contributions of the various
component spine segment angle ranges to the flexion range o f motion (Table 5.3). The
predictive model was developed with an effort to keep tolerance as high as possible, while
striving to obtain the lowest possible analysis o f variance significance. Despite this, the
small subject sample restricted the number o f variables that could used in the regression
models. One model was based upon a variable for each ten subjects, the other was based

106

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

on the square root o f the sample size. The best models are shown below (Tables 5.3 and
5.4). Although males were older and significantly taller and heavier, Age, Sex, Age*Sex,
and the anthropometric variables were not predictors o f either reach distance or range o f
motion. Body Mass Index was, in addition to Pelvifemoral Angle in the upright position,
a significant predictor o f Reach Distance (Table 5.4).

Table 5.3. Linear Regression Equation (Small Sample)Flexion Range of Motion


[General Linear Model, Stepwise Regression; N=31, p=0.000 (ANOVA); r=0.738]
ROM = 1 2 9 . 0 4 6 (K) + 1 . 3 5 7 (TTZ) - 1 . 1 0 3 (TTF) - 0 . 8 3 3 (PFF)

Significant Prmdictors
VARIABLE
TTI
TTF
PFF
where

ROM
K
TTI
TTF
PFF

P (2 TAIL)
0.000
0.000
0.000

- Flexion Range of Motion (deg.)


Constant
= T1-T10 Initial (deg.)
= T1-T10 Final (deg.)
= Pelvifemoral Final (deg.)

Table 5.4. Linear Regression Equation (Small Sample)Reach Distance


[General Linear Model, Stepwise Regression; N=30, p=0.008 (ANOVA); r=0.304]
FB = - 2 2 6 . 4 1 9 ( K ) + 5 . 3 7 3 ( P F I ) - 1 . 9 2 7 (BHI)
Signiticaat Prmdictors
VARIABLE
PFI
BMI
where

P (2 T AI L)
0.005
0.011

FB = Reach Distance (mm.)


EC = Constant
PFI = Pelvifemoral Angle Initial
BMI = Body Mass Index (kg./m.2)

(deg.)

107

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Discussion
What has been observed in the literature regarding the relation between hamstring
shortness, pelvic tilt, and the lumbar spine was supported by our results. First, all three o f
our pelvifemoral angles from the small study were significantly different between the
hamstring shortness groups, which were matched for age and gender (Table S.l). These
angles were the initial (upright posture), the fin a l (flexed posture), and the range (the
difference between upright and final values). The mean upright, pelvifemoral angle o f the
hamstring-tight group was approximately 7% greater than that o f the normal group. The
mean pelvifemoral angle in full flexion was almost three times greater in the hamstringtight group. Finally, the mean pelvifemoral angle range was about 17% larger in the
hamstring-normal group. The larger mean initial and final angles in hamstring-short
subjects were interpreted as representing a posterior pelvic tilt in hamstring-short subjects.
The significantly lower pelvifemoral range that was about 10 less in hamstring-short
subjects was thought to indicate a restriction o f sagittal plane flexion.
Our pelvic tilt findings agree with those o f others, including Fisk and Baigent
(1981), and Yasukouchi and Isayama (1995). In fact, our mean standing pelvic angle
values (Table 5.1) were within the angle range reported by Gajdosik, et al. (1994), who
used a similar method. Their 30 subjects had a similar mean age o f 23 (4.1) years, a
mean height o f 178.6 ( 7.2) cm, and a mean weight o f 77.5 ( 10.7) kg.. Their upright
pelvic tilt angle ranges were 75.5 to 90.8 for hamstring-short subjects and 71.5 to 90.5
for hamstring-normal subjects. In addition, our flexion ranges o f motion values were also

108

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

close to those of Gajdosflcs hamstring-short (59.0 11.7 ) and hamstring-normal (68.7


9.2) subjects, varying by less than 5.
Analysis o f the data from both large and small sample studies revealed that
hamstring-short subjects had smaller angles of lumbar lordosis than hamstring-normal
subjects, which agreed with the findings o f McCarthy and Betz (2000). The significantly
smaller lordosis angles were interpreted as a relative flattening o f the lumbar spine,
which, along with a posterior pelvic tilting, has been identified by others, including Day, et
al., 1984; Levine and Whittle, 1996; Delisle, et al., 1997; and Korovessis, et al., 1998).
The pelvifemoral range was not the only spine segment whose mean sagittal
flexion range was different between hamstring groups. The mean thoracic range was
about 10 less in the hamstring-short group, and the mean lumbosacral range was about 5
less. Because the overall flexion range o f motion was defined as the sum o f component
spine segment ranges, it was not surprising that hamstring-short subjects had a
significantly smaller (p = 0.003) mean flexion range that was about 24 less than
hamstring-normals. These findings agreed with other authors who had found a difference
o f flexion range o f motion in hamstring shortness, especially in the lumbar region
(Gajdosik, et al., 1994; Winter, et al., 1997).

Limitations
Many o f the limitations of the small sample study were similar to those reported
for the large sample study. The original design o f a cross-sectional study prohibited the
drawing o f cause-and-effect conclusions, which would require a randomized, clinical trial.

109

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Our small sample size prohibited the development of multi-variable predictive regression
models. In addition, the sample was a convenience sample, rather than a truly random
one. The subjects were o f a particular socio-economic and ethnic pool, which would pre
empt extrapolation of the results to the general population.
Like the large sample study, the use of surface, optical methods to estimate
radiographic angles is a concern. In our validation study (Appendix H), surface marker
placement error was greatest at SI, and was likely due in part to the overlying soft tissue
thickness at the lumbosacral region (e.g. Bryant, et al., 1989; Refshauge, et al., 1994). It
is likely that placement error accounted for the significant underestimation o f the L3-S1
angle seen in this method, similar to what has been reported by others (e.g. Chemukha, et
al., 1998; Leroux, et al., 2000). Despite this systematic error, relative flattening o f the
lumbar spine angle was seen in two different subject samples using two different optical
methods.
Conclusions
Several important findings were made in this study. The first was that, for the
subjects of our study, hamstring shortness was 25-33% less prevalent in females, which
suggested that females were more flexible than males. Hamstring shortness was also over
50% less prevalent in athletes, which indicated that a baseline amount o f physical activity
is important for flexibility.
The next several findings pertained to the relation between tightness and the spine.
Our hamstring-short subjects demonstrated posterior pelvic tilting. They had smaller
angles o f lumbar lordosis, as determined by non-invasive, optical methods o f metrology,
110

permission of the copyright owner. Further reproduction prohibited without permission.

indicating flattening o f the lumbar spine. Finally, hamstring-short subjects had smaller
sagittal flexion ranges o f motion, largely due to smaller thoracic, lumbosacral, and
pelvifemoral ranges. These findings agreed with popularly held notions regarding
hamstring shortness and the spine.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER VI
ON THE RELATION BETWEEN HAMSTRING SHORTNESS
AND THORACIC KYPHOSIS IN SMALL AND LARGE,
CROSS-SECTIONAL SAMPLES OF CHILDREN AND ADULTS
Introduction
Is there a link between thoracic kyphosis and hamstring shortness, as suggested by
early authors as Lambrinudi? This chapter presents the results o f a study in the form of a
post-hoc analysis intended to define the relation between these two variables. The analysis
was done using data originally collected for the study o f Wojtys, et al. (2000), a study that
was designed to identify the relation between thoracic kyphosis and athletic training. The
corroboration o f a relation between thoracic kyphosis and hamstring shortness is
important for at least two reasons. First, if a direct relationship does exist, then it could be
possible to prevent the development o f hyperkyphosis, an increase o f the thoracic kyphosis
angle beyond the normal range, by preventing hamstring shortness and maintaining
flexibility. Second, it may likewise be possible to treat existing hyperkyphosis by
correcting hamstring shortness.
In the last chapter, three observations were made regarding hamstring shortness
and the spine. The first was that hamstring shortness was associated with a posterior
tilting o f the pelvis. The second was that hamstring shortness was also associated with a
relative flattening of the lumbar lordotic curve. The third was that sagittal plane flexion o f
the torso was restricted in hamstring shortness. All three o f these observations agree with
112

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

the findings o f others (e.g. Fisk and Baigent, 1981; Day, et al., 1984; Gajdosik, et al.,
1994; Winter, et al., 1997; McCarthy and Betz, 2000).
In order to define the relation between hamstring shortness and the thoracic curve,
an apparent contradiction must be resolved. The first part o f this contradiction is that
spine curves have been said to balance one another (e.g. Stagnara, et al., 1982). If that
were true, then the flattening o f the lumbar curve associated with hamstring shortness
should be accompanied by a flattening o f the thoracic curve. Thus, the mean thoracic
kyphosis angle o f hamstring-short subjects should be smaller than that o f hamstringnormal subjects. The second part o f the contradiction is based on the anecdotal
association o f hamstring shortness with the acquired hyperkyphosis o f Scheuermanns
Disease. Here, hamstring shortness has been implicated as a cause of hyperkyphosis
(Lambrinudi, 1934). In this instance, the mean thoracic angle o f hamstring-short subjects
should be larger than that of hamstring-normal subjects.
One theory may explain this apparent contradiction. It may be possible that both
observations are true, and that some hamstring-short subjects might exhibit thoracic curve
flattening while others might exhibit hyperkyphosis. If, as suggested by Ashton-Miller
(personal communication, 1995), an increase in the normal thoracic kyphosis angle is an
adaptive mechanism to enhance the otherwise restricted sagittal plane flexion o f hamstring
shortness, it is likely that this adaptation occurs over time. If so, then older hamstringshort subjects, those who have been hamstring-short longer, could tend towards
hyperkyphosis and display a direct relation between tightness and thoracic angle. In
contrast, younger subjects, those whose spines have not yet had time to adapt to
113

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

hamstring shortness, would simply have a flatter thoracic spine, one that balances the
relative flattening o f the lumbar curve seen in tight hamstring mediated, posterior pelvic
tilting. These subjects would display an inverse relation between hamstring shortness and
thoracic angle.
If this theory regarding a temporal component to the relation between
hyperkyphosis and hamstring shortness were true, then several things should follow. First,
there should be a significant, mean difference o f thoracic kyphosis angle between
hamstring-normal subjects and hamstring-short subjects. Second, if the relation between
tightness and kyphosis angle is direct, there should be differences o f mean kyphosis angle
between moderately tight and severely tight subjects. Lastly, if hyperkyphosis is an
adaptive mechanism, then at least some o f the severely tight subjects should be
significantly older than moderately tight subjects. Expressed as null hypotheses:

Null Hypotheses
H oi: There is no difference of the angles o f thoracic kyphosis or lumbar
lordosis between hamstring-normal and hamstring-short subjects.
H 0 2 : There is no difference of thoracic kyphosis angle between those who are
moderately hamstring-short and those who are severely hamstring-short.
H 0 3 : There is no difference o f age between those who are moderately hamstring
tight and those who are severely hamstring-short.

Background
Both the thoracic and lumbar regions o f the spine have been said to balance one
another, particularly in the upright posture (Stagnara, et al., 1982; Willner and Johnson,
1983; Bridger, et al., 1989). Voutsinas and MacEwen (1986), in their study o f 670

114

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

normal spine radiographs, identified a significant, positive correlation between thoracic


kyphosis and lumbar lordosis (p < 0.001). Using a similar method, Korovessis, et al.
(1998) found a strong correlation o f sacral inclination with both lordosis (p < 0.001) and
kyphosis (p < 0.002). From the upright posture, lateral radiographs o f 100 subjects,
Stagnara, et al. (1982) identified a parallel relation between the sagittal plane angulation of
both maximum lordosis and maximum kyphosis and called the compensatory relation
a corollary.
One theoretical function o f the compensatory change (Hellsing, et al., 1987) of
spine curve balancing is a centering o f the head over the pelvis and a minimization o f the
muscle effort needed to maintain vertebral stability and an upright posture (Kendall and
Boynton, 1952; Salter, 1970; Riseborough and Herndon, 1975). While supportive
evidence for this notion is sparse, it follows that tight hamstring-mediated, posterior pelvic
tilting and subsequent lumbar curve flattening should also be accompanied by relative
flattening o f the thoracic spine, at least initially.
There is also little experimental evidence supporting the possibility o f thoracic
hyperkyphosis as an adaptation to enhance reach distance. In 1981, Fisk and Baigent
reported the results o f their pilot, radiographic study o f 20 Scheuermann's Disease
patients. All of their subjects had hamstring shortness, which was defined as passive
hamstring stretch values of 30 or less. These subjects were observed to have a loss of
sagittal plane flexion, both round the hip joints and at the lower dorsal (thoracic) spine,
as well as a flattened appearance o f the thoracolumbar junction in forward flexion. If one
considers these findings and adds to them the fairly high prevalence o f hamstring shortness
115

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

in Scheuermanns Disease, which ranges from about half (50%Butler, 1955; 67%-MacGowan, 1944) to virtually all (Apley, 1977; Salter, 1970; Sorensen, 1964), it is not
difficult to imagine that hyperkyphosis could be an adaptive mechanism.
Other studies have also confirmed an association between spine flexion range o f
motion and hamstring shortness. In their photogrammetric method study (n = 30),
Gajdosik, et al. (1994) identified a decrease in both pelvic and lumbar ranges in short
hamstring subjects. They also found that the mean flexed position, thoracic kyphosis
angle of hamstring-short subjects was larger than the mean kyphosis angle of hamstringnormal subjects [39.7 ( 9.0) versus 34.4 ( 7.8)].
Two important relationships have been demonstrated in the literature. First,
hamstring-short subjects have reduced sagittal plane flexion ranges o f pelvic and lumbar
spine motion. Second, groups o f hamstring-short subjects have larger kyphosis angles
than hamstring-normal subjects. If hamstring shortness causes increased stress and
strain on the thoracic spine (Lambrinudi, 1934, as quoted by Fisk and Baigent, 1981), if
spine wedging can occur from compression (Chapters I and II), and if motion restriction at
one spine level leads to increased motion at another (Nordin and Frankel, 1989), the
subsequent development o f thoracic hyperkyphosis as an adaptive response to loading and
to the otherwise reduced reach distance o f hamstring shortness seems plausible.

Hamstring Shortness and Scheuermann *s Disease


One o f the earliest and perhaps most concise models regarding thoracic kyphosis
and hamstring shortness was proposed by C. Lambrinudi, M.D. (Figures 6.1 and 6.2).

116

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

MajkCma

Figure 6.1. Constantine Lambrinudi, M.D., F.R.C.S. (1890-1943)


(Permission granted by the copyright holder: Lancet Publishing Group; image is by Hugh Cecil,
from Camb BA. Obituary: Constantine Lambrinudi. Lancet, 1:601-602, May 8, 1943)

D iagram

A. N'ormit position lor tcc-touching


Koto l l o : contour of th e Kcl*
is regular
Anterior suy er.'.r spir.c ot the ilium on th e m
lio r.iu n u l plane as th e to;, of th e great trochanter.
Spring in the
ham string muscles not vtretched.
. . .
U. Norm al l u r k !lcx! lieyoml com fortable lim it.
S o to tli.it UM
contour of th e back IS unchanged.
A nterior superior spine below
th e level of the icreat trochanter.
H am string spring stretch ed .
C. S h ort hamstrings.
Note tlia t th e an terio r superior spine is
above th e level cl th e great trochanter. Contour of th e back is
normal.
D. S h ort IvimHtnngs.
Dack flexed bcvorut n o r a u l lim its. ^Iiowtnf
t)*,c uicrc.iyr*l rcn v c x ily wt i h r towr*r t!ursl And lu ttib ir rcRtons.

Figure 6.2. Lambrinudis Model of Hamstring Shortness and Thoracic Kyphosis


(Permission granted by the copyright holder: BMJ Publishing Group; image is Diagram I,
page 803 from Lambrinudi C. Adolescent and senile kyphosis. Br M edJ, ll(2):800-804, 1934.)

117

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

In 1934, Dr. Lambrinudi published his paper outlining a possible causal relation between
these two variables, and illustrated his ideas with a stick figure drawing (Figure 6.2). In
this drawing, Lambrinudis two normal figures (A and B) are depicted as being able to
reach the floor in sagittal plane flexion. Not only did these subjects have a smooth
curvature of the spine, but they had normal pelvic motion as well. The short hamstrings
subjects (Figures C and D) did not exhibit these characteristics. They were not able to
reach the floor in sagittal flexion and their pelvic motion was restricted. Figure D also
depicts an increased kyphosis o f the thoracolumbar spineperhaps an adaptation to
enhance the otherwise restricted forward reach distance.

Prevalence
The prevalence o f hamstring shortness in the large study subject sample was
comparable to that reported by others. The overall prevalence o f 14.3% was quite close
to the 16% figure reported by Kuntzleman, et al. (1993). Like Kuntzlemans sample, most
o f our subjects were not screened radiographically for Scheuermanns Disease. O f a
sample of five documented Scheuermanns Disease patients whose data were used in
method validation, 66% had hamstring tightness, a figure that agrees with the 67%
prevalence reported by MacGowan (1944).
The prevalence o f hamstring shortness for each gender only approximated what
had been previously reported. In their study o f Scheuermanns patients, Fisk and Baigent
(1981) found that 24% o f male and 15% o f female hyperkyphotic subjects were
hamstring-short. In our study, 15.4% o f male hyperkyphotic subjects and 13.7% of

118

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

female hyperkyphotic subjects had hamstring shortness. In our study, the prevalence of
hamstring tightness in hyperkyphotics was greater than that o f normokyphotics (about 5%
in females and about 1% in males).
Dividing our subjects according to sport participation confirmed that there was a
gender difference o f hamstring shortness prevalence. O f our inactive controls, 29% o f
females and 41% of males were hamstring-short. Of our active athletes, 9.6% o f females
and 14.6% o f males were hamstring-short. If hamstring shortness reflects flexibility, then
these figures indicate that our female subjects were more flexible than males. In addition,
the fact that hamstring shortness was more than twice as prevalent in inactive controls
than it was in our active athletes subjects implied some benefit in flexibility from training.
The relation between hamstring shortness and athletic training will be explored in Chapter
VII.

Materials and Methods


The data analyzed in this study were obtained using the materials and methods
originally used for two cross-sectional studies. The first study, the large sample study,
was done by Wojtys, et al. (2000) and had an original subject sample o f 2270, public
school age volunteers with a mean age o f 14.6 years ( 2.1 years). It was designed to
define the relation between thoracic kyphosis angle (photogrammetrically determined) and
athletic training (Chapters HI and IV). The second study, the small sample
study, had a subject sample o f 31 volunteers with a mean age o f 24.5 years ( 13.8 years).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

It was designed to define the relation between spine angle (optoelectronically determined)
and hamstring shortness (Chapter V). Questionnaire information was obtained from all
subjects (Appendix E) and anthropometric measurements were taken on these same
subjects. In both studies, hamstring shortness was ascertained by using the Finger-toFloor Forward Reach Test. Each subject was asked to bend forward in the sagittal plane
from an upright position, with knees extended, in an attempt to touch the floor. Those
who were unable to touch the floor with their fingertips were classified as hamstring-short,
and the distances from their fingertips to the floor were measured. Those able to touch
the floor with their fingertips were classified as hamstring-normal.

Test Apparatus and Protocol


For the large sample study, each subject stood on a specially designed platform
(Chapter HI, Figure 3.1). The device painlessly restrained each volunteer at the hips and
also provided a means of photographic calibration. Thirty-five millimeter photography
was used to collect the raw data, which were processed to yield thoracic and lumbar spine
angles o f curvature in various subject postures ranging from upright (vertical) to folly
flexed (horizontal).
For the small sample study, each subject stood upright before an optoelectronic
imaging system that utilized infrared light emitted from LEDs. The light reflected from
specially designed platform markers, which were affixed to the skin o f the back, was
detected by a camera and digitally stored. These raw data were processed to yield the
spine angles for both upright and frilly flexed postures, as well as the angle o f pelvic tilt.

120

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Data Management and Statistical Analysis


The data were analyzed in much the same way as was described previously.
Photographic data were input into a Pentium-based PC, while questionnaire data were
originally entered managed using a Power Mac. Descriptive statistics were generated
using standard desktop statistical packages (SYSTAT and SAS). T-tests were used to
compare the mean thoracic kyphosis angles between hamstring shortness categories.
Graphs were prepared for Thoracic and Lumbar Angles versus Reach Distance for
both large and small sample subjects. Smoothing o f these graphs was done first by using
LOWESS (ZOcally Weighted Scatterplot Smoothing). The method perhaps gave the most
accurate, local data point smoothing, but the smoothing line was irregular in some places.
As compared with linear or logarithmic smoothing, quadratic smoothing most closely
mirrored LOWESS smoothing, and did not give an irregular appearance.

Results
First, the relation o f thoracic kyphosis angle to hamstring shortness was examined.
Subjects were grouped as being hamstring-normal, or those able to touch the floor in
sagittal plane flexion, and hamstring-short, or those unable to touch the floor. T-tests
revealed no statistically significant differences of age, height, or weight between these two
groups. However, hamstring-normals tended to have larger thoracic kyphosis and lumbar
lordosis angles than hamstring-short subjects (Table 6.1). Because o f this trend and the
finding of significance in subgroups such as the 15 year old, male ice hockey players, the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

decision was made to reject Hoi, which stated that there were no differences o f thoracic or
lumbar angles between hamstring shortness groups.

Table 6.1. Mean Thoracic and Lumbar Angles for Hamstring-Normal and
Hamstring-Short Subjects
G roup
Large Sam ple
Ice Hockey

Angle

Thoracic
Lumbar
14-18 y/o hockey Thoracic
Thoracic
15 y/o hockey
Lumbar
Sm all Sam ple
under 18 years Thoracic
Lumbar

Hamatring-Normal
n
m ean (deg.) s.d.

Hamatrinta-Short
m ean (deg.) s.d.
n

38
46
40
43
49

13
14
11
8
13

124
124
60
18
18

35
41
34
30
37

12
15
13
11
16

61
61
27
12
12

0.063
0.065
0.047
0.003
0.053

44
11

9
11

8
8

37
9

16
11

8
8

n.s.
n.s.

The smaller thoracic angles of hamstring-short subjects were interpreted as


representing a flattening o f the thoracic spine, which may be viewed as balancing the
relatively flatter lumbar spine (and posterior pelvic tilting) that were demonstrated in
hamstring-short subjects (Chapter V). This idea was supported by comparing the
correlation of thoracic and lumbar angles for hamstring-normal and hamstring-short
subjects. A moderately strong correlation coefficient o f 0.597 between these two spine
angles was noted in 1,357 hamstring-normals from the large study. If the spine did tend to
straighten with the degree o f hamstring shortness, then one would expect the relation to
become stronger in hamstring-short subjects. Our data indicated just that, as 280
hamstring-short subjects had a Pearson correlation coefficient o f 0.730 between thoracic
and lumbar angles.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Two additional lines o f evidence helped to support the notion o f thoracic and
lumbar curve balancing. One was that normokyphotic subjects, those having thoracic
angles within a range o f 25 to 52 by the photogrammetric method (Chapters i n and IV),
had a significantly smaller (t-test, p = 0.000), mean lordosis angle than hyperkyphotic
subjects (those with thoracic angles greater than 52) (Table 6.2). The other line of
Table 6.2. Mean Thoracic and Lumbar Angles for Subjects
grouped as Normokyphotic or Hyperkyphotic
G roup

Normokyphotic
Hyperkyphotic

n
1094
294

p-value

T horacic Angle
m ean (deg.)
s.d.
38.9
7.4
60.6
7.3
0.000

Lum bar A ngle


m ean (deg.)
a.d.
42.7
15.0
58.9
17.3
0.000

evidence is illustrated in Figures 6.3 and 6.4graphs of both thoracic and lumbar angles
versus reach distance. In Figure 6.3, as reach distance increased (subjects become
tighter), both thoracic and lumbar spine angles initially decreased in a roughly parallel
manner. This finding was interpreted as a relative straightening of the spine. However, at
reach distances o f about 95 to 155 mm., the parallel change in the spine angles ceased.
With increasing hamstring shortness, the thoracic angle was now seen to increase. As
similar pattern was also displayed by small study subjects. Like Figure 6.3, Figure 6.4
illustrates a parallel decrease o f both thoracic and lumbar angles for reach distances o f less
than about 130 mm. At about 165 mm. or so, the thoracic angle again began to increase
directly with reach distance.
Hamstring-short subjects were then divided according to the approximate reach
distance ranges in which the slope o f the thoracic angle quadratic smoothing lines changed

123

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 6.3. Thoracic Kyphosis Angle (Lower Line) and Lum bar Lordosis Angle
(Upper Line) versus Reach DistanceLarge Sample, 8-to-10 year-olds
The two spine angles tend to decrease in a parallel fashion for less tight subjects (reach distances less
than about ISO mm.) indicating a spine curve balance. Beyond about ISO mm., thoracic angle
tends to increase, which supports the idea of a compensatory mechanism (p = 0.000; n = 65;
for thoracic curve: r2 = 0.014; for lumbar curve: r = 0.068).

in Figures 6.3 and 6.4. Those with a reach distance of 95 mm. to 159 mm. were classified
as moderately tight and those with a reach distance of 160 mm. and above were classified
as severely tight. Comparison o f the mean thoracic angles and ages between these two
groups showed important differences. Data from hamstring-short wrestlers were used to
illustrate these differences. Not only did severely tight subjects have a significantly larger
mean thoracic angle than moderately tight subjects, but they were also older (Table 6.3).
These findings led to the decision to reject H02 and H03 , which stated that there were no
differences o f thoracic kyphosis or age between moderately hamstring-short and severely
hamstring short subjects.
124

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

ntikijcrt

>mm

Figure 6.4. Lumbar Lordosis Angle (Lower Line) and Thoracic Kyphosis Angle
(Upper Line) versus Reach DistanceSmall Sample
Both lines decrease with increasing reach distance to about a reach distance of 160 mm.,
illustrating spine curve balancing. Similar to what is illustrated for the Large Sample (Figure 6.3),
as the degree of hamstring shortness increases beyond 160 mm., the thoracic angle increases, again
illustrating a possible compensatory relation. The graph is slightly different in appearance, due to
the difference in optical methods (Chapters III, IV, and V) [n = 16; for thoracic curve: p = 0.048;
r = 0.269; for lumbar curve: p = n.s.; r = 0.004).

Table 6.3. Mean Thoracic Kyphosis Angles for Hamstring-Short Wrestlers


grouped as Moderately Short and Severely Short
Variable
Thoracic Angle
Age

R each D s ta n c e 95-159 mm.


n
m ean I
s.d.
29
40 deg. I
16 deg.
67
14.4 yrs.
1.5 yrs.

Reach D istance *>160 mm.


n
m ean
a.d.
22
48 deg.
12 deg.
15.1 yrs. 1.2 yrs.
22

P
0.045
0.046

In order to lend support to the rejection o f H03 , the mean ages o f hamstring-normal
and hamstring-short subjects were compared between kyphosis categories (Table 6.4).
Hyperkyphotic, hamstring-short subjects were found to be older, with no significant
differences o f height and weight between the two kyphosis groups. For large sample,
hamstring-short subjects, this difference was statistically significant. In contrast, large
125

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

sample, hamstring-normal, hyperkyphotics had about the same mean age as


normokyphotics. Small sample study, hamstring-short, hyperkyphotic subjects also had
smaller reach distances than normokyphotics, but this difference was not significant.

Table 6.4. Mean Age for Hamstring-Short Subjects


grouped by Thoracic Angle Magnitude
(HSS = Hamstring-short; HSN = Hamstring Normal; s.d. = standard deviation)
Videographic methods were used for the Small sample study, photogrammetric methods were
used for the Large sample study. Note that the hyperkyphotic, hamstring-short subjects are older.

G roup
HSS

HSN

Study
Small
Large
Large

N orm okyphotic
m ean
s.d.
20.8 yrs.
11.5yrs.
14.1 yrs.
Z 1 yrs.
14.8 yrs.
1.9 yrs.

n
12
167
856

H yperkyphotic
m ean
s.d.
37.8 yrs.
24.8 yrs.
14.9 yrs.
1.7 yrs.
14.9 yrs.
1.8 yrs.

n
4
47
248

P
n.s.
0.009
n.s.

Discussion
Three findings supported the idea o f other authors (e.g. Stagnara, et al., 1982) that
spine curves tended to balance one another. In Chapter V, hamstring-short subjects were
shown to have both posterior pelvic tilting and relatively smaller lumbar lordosis angle (a
flattening of the lumbar spine). In this chapter, hamstring-short subjects were also
shown to have significantly smaller thoracic kyphosis angles. This finding agreed with
Lambrinudis observation (1934) that both lower thoracic and lumbar regions were less
convex in hamstring short individuals. Lambrinudis theory was also supported by a
second finding, illustrated by graphs o f spine angle versus reach distance for hamstringshort subjects. Both thoracic and lumbar curve values tended to decrease in a roughly
parallel fashion with increasing reach distance (tightness), at least for distances less than
about 100 mm.

126

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The third finding that supported spine curve balancing was the high correlation
between thoracic and lumbar spine angles in hamstring-short subjects. Strong correlations
between these angles have been reported by groups as Voutsinas and MacEwen (1986)
and Korovessis, et al. (1998). In fact, the correlation coefficient o f 0.730 in our
hamstring-short subjects was comparable to the findings o f Hetlsing, et al. (1987), who
reported correlation coefficients o f up to 0.690.
Two lines o f evidence helped to give credence to the idea that an increased
kyphosis angle might be a compensatory change, as suggested in the Introduction. If this
notion was valid, then some hamstring-short subjects would not demonstrate spine curve
balancing, a parallel decrease o f angle values with increasing reach distance, but rather an
increase in the thoracic kyphosis angle. Graphs o f spine angle versus reach distance for
both large and small sample subjects (Figures 6.3 and 6.4) showed an initial, parallel
relation o f reach distance to both thoracic and lumbar angles. However, beyond reach
distances o f about 110 mm. to about 160 mm., thoracic angle increased with reach
distance (increased with the severity of hamstring shortness). This relation between
thoracic kyphosis angle and reach distance would give a sagittal plane, range o f motion
advantage to those hamstring-short subjects having larger angles.
The second line o f evidence that supported a theory o f compensatory, thoracic
curve adaptation was a difference o f age between subject groups. In both large and small
sample studies, using spine angle data acquired using two different, optical methods, the
hamstring-short, hyperkyphotic group tended to be older than the hamstring-short,
normokyphotic group.
127

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Limitations
The limitations of the optical methods used to collect the spine angle data as well
as the use of convenience subject samples are discussed in detail elsewhere (e.g. Chapters
III, IV, and IX). For this analysis, perhaps the most important limitation is one o f study
design. In contrast to a randomized, clinical trial, the cross-sectional design does not
permit cause-and-effect conclusions. Because o f this, while the results might imply certain
things, any conclusions regarding spine curve balancing the development o f thoracic
hyperkyphosis as active, adaptive processes are purely speculative.

Conclusions
This secondary analysis produced several important findings. First, there was a
significant difference of thoracic and lumbar angles between hamstring-normal and
hamstring-short subjects, with the latter having smaller mean angle values. The smaller
mean thoracic and lumbar angle values indicated flattening of the spine. Second,
subjects with severe hamstring shortness, or those having reach distances beyond about
160 mm., tended to have larger thoracic angles than those able to reach closer to the
ground. In addition, these severely tight subjects also tended to be older. While causeand-effect conclusions cannot be drawn, these results imply that, at least initially, the spine
curve tends to straighten in hamstring shortness, with the thoracic curve balancing the
relatively flattened lumbar curve seen in hamstring-short subjects, the posterior pelvic
tilting associated with hamstring shortness. Since severely tight subjects have not only
larger kyphosis angles, but are older, the implication is that hyperkyphosis may be an

128

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

adaptive response to hamstring shortness, one that develops over time as a compensatory
change to offset the otherwise restricted, sagittal plane flexion of hamstring shortness.

129

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER VU
ON THE RELATIONSHIP BETWEEN HAMSTRING SHORTNESS AND
ATHLETIC TRAINING IN 8-TO-I8 YEAR-OLDS

Introduction
Is there a relation between hamstring shortness and physical activity? As
mentioned in Chapter V, the prevalence o f hamstring shortness in active athletes was
found to be less than one-half that o f inactive controls, those subjects who reported zero
annual training hours. The marked difference in the prevalence o f hamstring shortness
between inactive and active subjects suggests that hamstring muscle tightness may be
related to the level of physical activity.
If hamstring muscle tightness were related to physical activity, then at least two
relationships should hold true. First, there should be significant differences in the Fingerto-Floor Reach Distances (our indicator o f hamstring shortness) between active and
inactive individuals. Similarly, among active individuals, there should be significant
differences o f physical activity training times between subjects grouped as hamstringnormal or hamstring-tight. In this secondary analysis o f the data from a cross-sectional
study by Wojtys, et al. (2000), two variables were used to model physical activitythe
number o f Annual Training Hours (Time) and the number o f years o f sports participation
(Period), Written as null hypotheses:

130

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Primary Null Hypotheses


Hoi: There is no difference of Reach Distance between Inactive Controls and Active Athletes.
H 0 2 : There is no difference o f Annual Training Time between Active Athletes
grouped as Hamstring-normal and Hamstring-tight.

This study was also aimed at answering an additional question. Was there a
difference o f reach distance between males and females, as is suggested by the gender
difference in hamstring shortness prevalence cited in Chapter V? Two secondary null
hypotheses were posed to answer this question:
Secondary Null Hypotheses
H 0 3 : There is no difference of Reach Distance between males and females.
H 0 4 : There is no difference of the amounts of training normalizedfor age between male
and female athletes.

It was expected that hamstring shortness was indeed related to physical activity,
such that those who trained more would have smaller reach distances. It was also
expected that females and older individuals, those who had participated in sports for
longer periods o f time, would be less tight.

Background
Why should hamstring shortness be avoided? In Chapters V and VI, hamstring
shortness was described as being associated with several problems, which included
hyperkyphosis (e.g. Lambrinudi, 1934), low back pain (Stephen, 1983), a reduction in
torso motion (Gajdosik, et al., 1994), and lower extremity injuries (Burkett, 1971;
Jonhagen, et al., 1994; Krivickas and Feinberg, 1996), especially muscle strains (Garrett,
et al., 1984). In addition, muscle inactivity has been cited as a general cause o f muscle

131

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

shortness (e.g. Jozwiak, et al., 1997). To reduce the incidence o f these problems,
clinicians and coaches have relied on stretching programs to enhance muscle flexibility and
to reduce muscle tightness (Starring, et al., 1988; Sullivan, et al., 1992; Bandy and Irion,
1994).
The use of stretching to enhance muscle flexibility is important for several reasons.
Hamstring stretching has been shown to lengthen the hamstring muscles (Gajdosik, 1991),
to enhance both joint range o f motion (Magnusson, 1998) and torso flexion in the sagittal
plane (Li, et al., 1996), and to improve hamstring torque, especially at the end range-ofmotion (Wiemann and Hahn, 1997). These types of functional improvements likely
accounted for the reduced incidence o f lower extremity injuries seen in military trainees,
who had more flexible hamstrings (Hartig and Henderson, 1999).
Muscle stretching has also been shown to have several, positive tissue
ultrastructural effects. These include prevention of serial sarcomere loss (Williams, 1990)
and improvement o f serial elastic component compliance (Almeida-Silveira, et al., 1994).
Increases in the volume density o f non-contractile tissue, muscle fiber cross-sectional area,
and total number of fibers have also been demonstrated, at least in avian muscle (Alway, et
al., 1989). Passive stretching has been shown to increase the levels o f muscle regulatory
factors (Zador, et al., 1999) and glucose transport in muscle (Ihlemann, et al., 1999). It is
likely that hamstrings use in athletic training acts to stretch the muscle tissues and thus
provide these positive effects.

132

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Materials and Methods


This study was primarily a post-hoc analysis using data that had been collected
earlier with the materials and methods as described by Wojtys, et al. (2000).
Photogrammetric methods were used to determine spine angles on a large sample o f
volunteers (original n = 2270). Each o f the 8 -to-l 8 year old, public school male and
female subjects provided self-reported training time information. Anthropometric
measurements were obtained from each participant, and the hamstring shortness o f all
subjects was ascertained using the Finger-to-Floor Forward Reach Test. In this test, each
subject was asked to bend forward in the sagittal plane from an upright position, with
knees extended, in an attempt to touch the floor. Those who were unable to touch the
floor with their fingertips were categorized as hamstring-tight and the fingertip-to-floor
distance measured. Those able to touch the floor with their fingertips were classified as
hamstring-normal. An additional grouping was made for some comparisons, such that
those able to touch the floor with palms flattened were categorized as hamstring loose.

Data Management and Statistical Analysis


The data were analyzed in much the same way as was described in Chapter III.
Descriptive statistics were generated using a standard desktop statistical package
(SYSTAT). Since data followed a Gaussian distribution, both ANOVA and t-tests were
used to compare hamstring shortness between various subject groups, such as the inactive
Controls (Annual Training Time equal to zero) and the active Athletes (Annual Training

133

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Time greater than zero). Linear regression analysis was used to assess predictor variables
for Finger-to-Floor Reach Distance (FB).

Results
Subjects were first divided into two groups according to physical activity-inactive
controls and active athletes. A comparison of their finger-to-floor reach distances showed
that inactive controls had a mean reach distance over twice that o f active athletes (Table
7.1). Because they were also significantly younger, reach distance was normalized for
age. These normalized means were still significantly different (p = 0.001), a finding that
led to the decision to reject the first null hypothesis, Hoi, which stated that there is no
difference o f Reach Distance between controls and athletes.

Table 7.1. Mean Age and Reach Distance for Controls and Athletes,
with Reach Distance Normalized by Age
C ontrols
m ean
s.d.
Variable
3.15 yrs.
Age
12.46 yrs.
69 mm.
44 mm.
Reach Distance
Normalized Reach 3.72 mm./yr. 6.17 mm./yr.

n
88
83
82

m ean
14.68 yrs.
20 mm.
1.42 mm./yr.

A thletes
s.d.
2.01 yrs.
55 mm.
3.86 mm./yr.

n
2128
1757
1717

P
0.000
0.003
0.001

To test the second primary null hypothesis, active athletes were grouped according
to hamstring shortness categorythose able to touch the floor in sagittal plane flexion
were Hamstring-normal and those unable to do so were Hamstring-short. Next, the
means of the training variables Annual Training Time and Period were calculated for each
hamstring group. Because o f the significant difference in Age between groups, both o f the
training variables were again normalized for age (Table 7.2). All o f the training variable

134

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

means were larger for the hamstring-normal group, which led to the decision to reject H0 2 ,
which stated that there was no difference in training time between hamstring-normal and
hamstring-short athletes.

Table 7.2. Mean Age, Annual Training Time, Period, and the Training Variables
Normalized for Age for Athletes grouped as Hamstring-Normal or Hamstring-Short
(* = values for 14-18 year old wrestlers; s.d. = standard deviation)

Variable
Age
Per
Normalized Period*
Time
Normalized Time

Hamstring-Normal
m ean
s.d.
1.99 yrs.
14.80 yrs.
4.78 yrs.
2.65 yrs.
0.266
0.161
288 hrs.
206 hrs.
14 hrJyr.
20 hr./yr.

n
1440
1446
520
1470
1440

H am string-Short
m ean
s.d.
14.13 yrs.
2.19 yrs.
4.44 yrs.
2.65 yrs.
0.216
0.152
251 hrs.
173 hrs.
18 hrVyr.
12 hrJyr.

n
294
304
72
305
294

P
0.000
0.043
0.011
0.001
0.017

The relation o f age to hamstring shortness groups was better illustrated when
subjects were divided into three hamstring categories. The hamstring-loose category,
those who were able to touch the floor with flattened palms, were found to be significantly
older and to log significantly more training. Mean age and training times were less in the
hamstring-normals and hamstring-shorts, respectively (Table 7.3). These findings
indicated that hamstring shortness decreased with increased amounts o f training, such that
hamstring-loose subjects logged the most training.

Table 7.3. Mean Age, Period, and Annual Training Time (Time) for Athletes
grouped by Hamstring Shortness Category
( * = between hamstring-normals and hamstring-short groups)

Variable
Age (yrs.)
Period (yrs.)
Time (hrs./yr.)
n

Hamstring-Loose
mean
s.d.
15.17
1.68
2.6
5.0
337
228
352

Hamstrinjg-Normal
mean
s.d.
2.01
14.68
4.7
2.7
272
195
1118

Hamstring-Short
mean
s.d.
2.19
14.13
2.7
4.4
173
251
305

135

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

P
0.000
0.010
0.001*

The secondary null hypotheses were tested with subjects grouped by gender and by
comparing the means o f several variables between these groups (Table 7.4). Although
females were significantly younger, they logged significantly more training hours and had
smaller mean reach distances. These differences remained even after normalizing for age.
These findings led to the rejection o f both H03 and H04 , which stated that there were no
differences o f reach distance or normalized training time between genders.

Table 7.4. Mean Age, Annual Training Time, Reach Distance by Gender,
with both Time and Reach Distance Normalized by Age
Fem ales
Variable
m ean
Age
14 yrs.
Time
284 hrs.
Reach Distance
13 mm.
Normalized Time 20.83 hrs./yr.
Normalized Reach
1 mm./yr.

s.d.
2 yrs.
240 hrs.
40 mm.
17.76 hrs./yr.
3 mm./yr.

Males
n
402
407
304
402
300

mean
15 yrs.
245 hrs.
23 mm.
16 hrs./yr.
2 mm./yr.

s.d.

2 yrs.
181 hrs.

1822
1862
1540
1822
1502

58 mm.
12 hrs./yr.
4 mm./yr.

P
0.000
0.002
0.000
0.000
0.003

To illustrate the relation between training and hamstring shortness, mean annual
training time was determined for both hamstring-normal and hamstring-short subjects.
Training times were tabulated both by age in years (Table 7.5) and with subjects divided
according to three age groups (Table 7.6), as described in Chapter IV. For most ages,
hamstring-short subjects had smaller, mean training times than hamstring-normals.
However, 18 year old males and 14-18 year old females males were an exception to this.
Figure 7.1 is a graph Reach Distance versus Training Time for the older group o f female
athletes. An negative relation between the two variables is maintained until about 400

136

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

hours, after which the relation becomes positive and those with greater amounts o f
training also have larger reach distances (are more tight). While it is purely speculation,
perhaps too much training is also related to hamstring shortness.

Table 7.5. Mean Annual Training Times for Athletes grouped by


Gender, Age and Hamstring Shortness Category
Gender
Female

Male

Hamstring-Normal Hamstrlng-S hort


mean
hrsJyr. s.d. mean hrsiyr. s.d.
Age (yrs.)
,
208
88
9
8
220
66
414
10
147
358
3
11
406
208
172
364
251
12
214
411
303
332
13
241
174
413
451*
14
184
465*
270
320
15
122
328
326
512
16
584
371
17
137
207
174
219
9
117
215
186
240
10
189
147
227
218
11
184
243
198
232
12
145
218
232
251
13
251
191
14
251
196
149
185
270
272
15
167
177
270
288
16
305
201
17
316
178
143
288
410*
308
18

Table 7.6. Mean Annual Training Times for Female and Male Athletes
by Age Group and Hamstring Shortness Category
Gender
Female

Male

Hamstring-Short
Hamstring-Normal
Age Group mean hrsJyr. Stf. mean hrsJyr. s.d.
340
207
66
8
8 to 10 yrs.
297
191
262
386
11 to 13 yrs.
200
414
270
429*
14 to 18 yrs.
117
180
182
208
8 to 10 yrs.
156
232
211
243
11 to 13 yrs.
176
184
274
279
14 to 18 yrs.

137

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

ZCO

4 CO

00.0

O'00

Annual Trainng Tirr,e rrc.

Figure 7.1. Reach Distance versus Annual Training Time


for 14-to-18 year-old Female Athletes
Note the indirect relation between reach distance and training time up until about 400
annual training hours [for subjects with Time > 400 (n = 43); p = 0.050; r = 0.860].

Regression analysis confirmed that training activity was a significant predictor o f


Finger-to-Floor Reach Distance. In addition to the training variables Annual Training
Time and Period, other variables, including Age, Sex, Age*Sex, as well as various
anthropometric, were incorporated into the model. Stepwise, linear regression (Table 7.7)
showed that Period, the number of years o f participation in a sport, rather than annual
training time was a significant predictor of Reach Distance (p = 0.017). Like the negative
relation between annual training time and reach distance, those who had larger Period
values had smaller reach distances. In male athletes, ages 14-18 years, Period was
significantly different (ANOVA, p = 0.041, r2 = 0.028; n = 1159) between subjects when

138

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

grouped as being hamstring-loose (able to touch palms to the floor), hamstring-normal, or


hamstring-short (Table 7.8). This finding held true with no significant differences o f
height or weight between groups.

Table 7.7. Linear Regression Equation for All Subjects


[General Linear Model, Stepwise Regression; N=1758, with
513 cases deleted due to missing data; p=0.000 (ANOVA); 1^=0.038]
FB = - 5 4 . 6 8 3 (K) - 2 . 1 9 3 ( A g a ) + 1 2 . 8 1 4 ( S a x ) + 6 8 . 0 7 0 (GTF)
- 1 . 1 5 3 (P ar) - 0 . 4 5 1 (WTKG)+ 4 3 . 1 1 4 (ETH) - 0 . 1 7 8 (SETH)+ 0 . 3 2 1 (LDP)
S i g n i f i c a n t Prmdictora
VARIABLE
Age
Sex
GTF
Per
WTKG
SWTH
LDP

P (2 TAIL)
0.024
0.001
0.049
0.017
0.041
0.001
0.000

where
FB = Finger-to-Floor Reach Distance (ram.)
K = Constant
Age = Age (yrs.)
Sex =* Gender (Female: 1, Male: 2)
GTF = Greater Trochanterion-to-Floor Distance (m.)
Per = Period (number of years in primary sport)
WTKG = Weight (kg.)
SWTH = Torso width at the SI level (m.)
LDP Torso depth at the L3 level (m.)
HTM Height (m.) ( n . s . , p - 0 . 1 1 8 )

Table 7.8. Mean Age and Period for Male Athletes


grouped by Hamstring Shortness Category
Note that hamstring-short subjects tend to be younger, and they have
participated in a primary sport for less time.

C ategory
Hamstring-Loose
Hamstring-Normal
Hamstring-Short

n
226
757
178

Age (years)
m ean
s.d.
15.98
0.92
15.64
1.09
15.44
1.11

P eriod (years)
m ean
s.d.
2.54
4.88
2.76
4.79
4.57
2.79

139

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Another significant predictor of reach distance, Age, was also significantly


different between the three hamstring shortness categories (ANOVA, p = 0.000; Table
7.8). Period was significantly different between age group categories, increasing with age

Table 7.9 . Mean Age and Period for Athletes grouped by Age Category
As noted previously, older subjects report a larger Period (p = 0.000; r = 0.058; n = 2142)

r
8-to-10
11-to-13
14-to-18

f 1

n
109
418
1615

Age (years)
m ean
s.d.
9.53
0.62
0.76
12.33
15.61
1.08

P eriod (years)
s.d.
m ean
3.24
1.87
4.45
2.38
4.75
2.73

(Table 7.9). In addition, there were gender differences related to Period, in that, for each
year o f age, females reported training for longer periods o f time than males, a difference
that is significant in 16 year-olds (p = 0.007; Table 7.10).
Table 7.10. Mean Period by Gender for 16 Year-Old Athletes
G ender
F em a les
M a les

m ean (yrs.)
6.1
4.8

s.d .
3.0
2.6

To control for the difference o f age and gender differences and to illustrate the
difference in Period between hamstring categories, data from male subjects, ages 8-to-10,
were selected for analysis. In this group, there was no difference in mean age between the
hamstring-normal and hamstring-short subjects. Nor were there differences in height,
weight, or the torso anthropometry variables. However, mean Period was still
significantly smaller (t-test, p = 0.049) in the hamstring-short group [2.81 years ( 2.27
years); n = 13] than it was for hamstring-normals [4.47 years ( 2.04 years); n = 17].

140

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

In keeping with our goal o f identifying the relationship between our dependent
variables and independent variables such as age, sex, and somatotype, several
anthropometric variables were included in the regression modeling. Four of these
variables were found to be significant predictors o f reach distance. Older subjects were
found to have larger mean values o f the anthropometric variables (Table 7.11), which was
interpreted as reflecting age-related growth. Three o f the four variables were interrelated,
with both Torso Width at SI (SWTH) and Torso Depth at L3 (LDP) having strong
Pearson correlations with Weight (r equal to 0.839 and 0.788, respectively). This direct
relation suggested that the torso variables were more indicators of weight, rather than o f
reach distance.
The fourth, significant, anthropometric predictor variable was Trochanterion
Height (GTF). As depicted in Figure 7.2, the relation between this variable and reach

Table 7.11. Mean Values of the Significant Predictor Variables for


Reach Distance in Male Athletes by Age Group
[FB = Reach Distance (mm.); GTF = Trochanter-to-Floor Length (m.);
SWTH = Torso Width at SI (m.); LDP = Torso Depth at L3 (m.);
TIME = Annual Training Hours; PER = Number o f years in Primary Sport]

Variablo
Age
FB
GTF
SW TH
LDP
TIME
PER

8-to-10 year-olds
(n=53)
m ean
s.d.
9.67
0.52
45.97
60.39
0.737
0.050
0.022
0.346
0.018
0.166
130.58
140.31
3.64
1.89

11-to-13 y ear-o ld s
(n=275)
m ean
s.d .
0.77
12.36
27.08
56.75
0.060
0.829
0.034
0.382
0.171
0.023
211.3
195.28
4.37
2.28

14-to-18 year-olda
(n-1369)
m ean
s.d.
15.65
1.06
54.44
17.98
0.913
0.059
0.444
0.039
0.193
0.029
267.31
172.99
4.72
2.72

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

distance was direct, such that subjects with leg length values o f about 0 . 8 m. tended to be
have larger reach distances. This link between hamstring shortness and anthropometry
will be explored in more detail in Chapter VIIL

'i

-1 a

-I

C'l'

r i r 'c n / i n t o r w n

m ,

Figure 7.2. Reach Distance versus Trochanterion Height


Note that reach distance tends to increase with leg length, although not in
linear fashion (from the regression equation: n = 1758; r2 = 0.038; p = 0.049).

Discussion
Up to now, data linking hamstring shortness with specific amounts o f physical
activity have been lacking. We have identified a negative relation between the two
variables, such that those who train more have less hamstring shortness and are able to
reach closer to the ground. If one could assume that physical activity in the form of
athletic training acts to provide a form o f cyclic, hamstring stretching, then these findings
agree with what has been suggested in the literature, namely that hamstring muscle
stretching increases the muscle length and therefore, increases joint range o f motion (e.g.
Starring, et al., 1988; Bandy and Irion, 1994; Magnusson, et al. 1998).

142

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

There are several theories as to why stretching increases muscle length. These
include change o f muscle stretch tolerance (Halbertsma and Goeken, 1994) and a
reduction o f series elastic stiflhess (McNair and Stanley, 1996). Ultrastructurally, muscle
tissue subjected to stretch has been reported to exhibit increased protein synthesis
(Goldspink, 1977), fiber phenotype adaptation, and IGF-I gene expression increase (Yang,
et al., 1997).
For most subjects, increased training was related to decreased reach distance
(decreased hamstring shortness). However, in older, female, hamstring-short subjects, the
opposite was found to occur. Those who trained more than 440 hours per year tended to
have larger reach distance, signifying tighter hamstrings. For the same small group (n =
26), the same finding was true o f Period, a significant predictor o f reach distance. Those
who reported participation for more than about 4.5 years tended to have larger reach
distances. These findings suggested that, in some individuals, too much training may be
deleterious to muscle flexibility. It is possible that high amounts o f training could have
been responsible for the relative hamstring shortness observed in the study o f Wang, et al.
(1993). In their study o f 40 subjects having a mean age o f 25.6 ( 5.5) years, long
distance runners were found to have tighter hamstrings than inactive controls, the
converse o f what might have been expected.
Since training was shown to be a predictor o f hamstring shortness as defined by
reach distance, it was not surprising that both Age and Sex were identified as predictor
variables, as females and older individuals log more training hours (Chapter IV). For
example, our 14-to-l8 year old males had a reach distance o f less than half that o f the 8 143

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

to-10 year olds, and logged about twice the number o f training hours (Table 7.8). If one
were able to assume a cause-and-effect relation between the two variables, this was equal
to about a 4 mm. per-year-of-age reduction o f finger-to-floor distance between the two
groups.
Our identification o f a relation between gender and hamstring shortness also agrees
with what has been suggested in the literature. First, females had significantly smaller
reach distances than males, even when normalizing for height, controlling for training, and
with no significant age difference between select subject groups. Second, the prevalence
o f hamstring looseness was greater in females, with over twice the percentage o f
hamstring-loose subjects as compared to males (35.2% versus 16.2%). Third, the
prevalence o f hamstring shortness was much less in female athletes, such that, o f the
hamstring-short subjects, only 11% were female, while 89% were male. The increased
normalized reach distances and difference o f prevalences implies a gender-difiference o f
hamstring muscle flexibility, similar to that reported by Wang, et al. (1993) and Kuo, et al.
(1997).
There was also a relationship between age, reach distance, and the amount o f
training. Hamstring-loose, female and male athlete subjects were about 7% older, had
about a 14% larger training period, and had about 35% more annual training time than
hamstring-short subjects. In an attempt to quantify these differences, a rough estimate o f
reach distance per amount of training was made by dividing the mean difference o f reach
distance between hamstring shortness groups by the mean difference o f both annual
training time and training period between hamstring shortness groups. If a cause-and144

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

effect conclusion were possible, the resulting quotients would imply that reach distance
decreased by about 0.21 mm. per annual training hour and by about 2.77 mm. per year of
training. Such an implication would lend credence to the findings of others who have
suggested that muscle inactivity from the lack o f exercise is a cause o f hamstring shortness
(Fisk and Baigent, 1984; Starring, et al., 1988; Jozwiak, et al., 1997).
In addition to Age, several anthropometric parameters, including Greater
Trochanterion-to-Floor Leg Length (GTF), were predictors o f Reach Distance (Table
7.7). Not surprisingly, the GTF increased with age, as did the other anthropometric
predictors (Table 7.8). It is likely that a unique ratio incorporating this anthropometric
variable exists that would lend support to an explanation o f hamstring shortness in terms
o f a differential growth rates between long bone and soft tissue. The relation between
anthropometry and hamstring shortness will be discussed at length in the next chapter.

Limitations
Some o f the limitations of this study have been discussed in Chapters III, IV, V,
and IX. First, the subjects from both large and small studies were convenience samples
from relatively narrow ethnic and socio-economic pools. As such, one cannot assume
randomness, nor can one extrapolate the results to the general population. Second, some
have reported concern regarding the accuracy o f childrens self-reporting as a data source
(e.g. Anderssen, et al., 1995). However, the test-retest validity of the questionnaire
instrument (Chapter HI) and the consistency o f the athletic training time/hamstring
shortness relationship for our three age groups and for each gender lessens this concern.

145

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Another limitation o f this secondary analysis is the cross-sectional nature o f the


original study design. Unfortunately, the design does not permit the cause-and-effect
conclusions that might be inferred from a randomized, clinical study. If these conclusions
could be drawn, then the training hour information listed in Tables 7.5 and 7.6 might be o f
help to those involved in designing training programs. Although the values are unique to
the 8 -to -l 8 year olds o f our study, the amounts o f annual training reported here could
serve as rough guidelines for the identification o f the amounts of training that might be
appropriate for the prevention o f hamstring shortness. This information will be even more
informative when combined with the annual training time tables based on kyphosis
category, which were presented in Chapter IV.

Conclusions
While our study design did not allow cause-and-effect conclusions, the statistically
significant, indirect relation between reach distance and the amount of athletic training
implied that hamstring shortness is improved with physical activity. Females and older,
more trained subjects in this study were able to reach closer to the floor than males and
younger, less trained subjects. These observations were made in spite o f the direct
relation o f hamstring shortness to several anthropometric variablesvariables which
themselves increase linearly with age. The relation o f hamstring shortness to training is
clinically important, as exercise programs can be designed to assure hamstring-safe
amounts o f training.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER VIII
ON THE RELATION BETWEEN THORACIC KYPHOSIS, HAMSTRING
SHORTNESS, AND ANTHROPOMETRY IN SMALL AND LARGE,
CROSS-SECTIONAL SAMPLES OF CHILDREN AND ADULTS

Introduction
Do individuals with thoracic hyperkyphosis or hamstring shortness exhibit unique
anthropometric characteristics? In two previous chapters, linear regression analysis used
in post-hoc analyses identified at least two significant, anthropometric predictors o f the
dependent variables Thoracic Kyphosis Angle (Chapter III) and Finger-to-Floor Reach
Distance (Chapter VII). These predictors included Spine Length from the First Sacral
Segment to the First Thoracic Vertebra (ST1, Table 3.4), which was a predictor o f
Thoracic Angle (p = 0.000), and the Greater Trochanterion-to-Floor Height, which was a
predictor o f Reach Distance (p = 0.049), our determinant of hamstring shortness.
It was theorized that these predictor variables could be the basis for the
development o f two unique, anthropometric indicators. This chapter describes the results
o f a study aimed at defining the relation between thoracic kyphosis, hamstring shortness,
and anthropometry. The study was done as a post-hoc analysis using data originally
collected to answer other questions (Wojtys, et al., 2000). This chapter also describes the
development o f anthropometric indicators, which are intended for use as screening tools

147

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

to help identify those individuals at risk for either the development o f acquired
hyperkyphosis or for lower extremity injuries stemming from hamstring muscle tightness.

Background
For several years, stature has been associated with spine curve abnormalities. For
example, taller males have been said to be more prone to the development o f the thoracic
hyperkyphosis o f Scheuermanns Disease (Fisk, et al., 1984). Girls with another type of
spine deformity, idiopathic scoliosis, have also been found to be significantly taller than
those having normal spines (Willner, 1975; Nordwall and Willner, 1977, Normelli, et al.,
1985).
Some authors have related anthropometric factors in females to the menarche and
growth spurt. Females who tended to be taller than average were observed to be so
two years before the pubertal growth spurt and to display an early pubertal maturation
(Hagglund, et al., 1992). Skogland and Miller (1981) suggested that the pubertal growth
spurt o f the spine started earlier and lasted longer in scoliotic subjects, and indicated that
scoliotic children are likely to have longer thoracic spines. In their radiographic study of
274 children ages 6.5 to 18.5 years old, they found that scoliotics had significantly taller
T 6 vertebrae. Skogland, et al. (1985) went on to report that the incidences o f both
scoliosis and Scheuermanns Disease in tall stature females were much higher...than
normal. In their sample o f 62,9-18 year old girls, 21% had scoliosis, 29% had thoracic
hyper-kyphosis, and 18% had findings o f Scheuermanns Disease.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Fewer studies have looked at the relation between anthropometry and hamstring
shortness. Two ideas from these sparse studies formed the basis for the development o f
our unique, indicator variable. The first was the notion that unequal growth rates o f long
bone and the musculoskeletal unit cause passive muscle tension and, as a result, muscle
tightness (Burkett, 1970; Ekstrand and Gillquist, 1983; Jozwiak, et al., 1997). The second
idea involved an observation o f a disparate growth rate between the leg and the spine.
The leg has been shown to lengthen at a constant rate until the growth spurt peaks in both
males and females, after which the lengthening rate declines (Terver, et al., 1980). The
trunk peak growth rate lags behind that o f the legs, which allows for a continued increase
in stature after the legs have stopped elongating (Anderson, et al., 1978). Upadhyay, et al.
(1991) used a similar measure, the leg-to-spine ratio, in their study o f scoliotic girls, ages
8-to-21 years. They found that those subjects whose angles were severe enough to
require fusion had a significantly larger leg-to-spine ratio than normals.
By combining what has been reported in the literature with the findings reported in
the preceding chapters regarding anthropometric predictors, two indicators were
developed. The first indicator, the Spine Length-to-Height ratio, was intended to be a
predictor o f thoracic kyphosis angle. The second indicator, the Leg Length-to-Spine
Length ratio, was theorized to be a predictor o f reach distance, and thus, an indicator o f
hamstring shortness. To test the applicability o f these variables as indicators, the
following Primary Null Hypotheses were advanced:

Primary Null Hypotheses


Ho i : There is no difference o f Spine Length-to-Height between
normokyphotic and hyperkyphotic subjects.
149

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

H 0 2 : There is no difference of Leg Length-to-Spine Length between


hamstring-normal and hamstring-short subjects.

It was anticipated that those with larger thoracic angles would have longer
thoracic spines relative to overall height, and that hamstring-short subjects would have
longer leg lengths relative to their spine length.
Secondary hypotheses were advanced to look at the differences o f age and body
habitus between groups. These were:

Secondary Null Hypotheses


H0 3 : There is no difference of age, height, or weight between
normokyphotic and hyperkyphotic subjects.
H 0 4 : There is no difference o f age, height, or weight between
hamstring-normal and hamstring-short subjects.

Materials and Methods


The data analyzed here were obtained using the materials and methods described in
previous chapters. They were from two studies originally designed to answer other
questions. The 'large sample study was so named because o f the original sample size o f
approximately 2300 volunteer subjects. A photogrammetric method was used to
determine angles of thoracic kyphosis and lumbar lordosis (Chapters m and IV). Each o f
the 8-18 year old, public school students filled out questionnaires, which provided
information on training. Anthropometric measurements were also taken on each subject,
and all were evaluated for hamstring shortness using a Finger-to-Floor Reach Test.
The small sample study was so named because o f a sample size o f thirty-one
volunteer subjects. An optoelectronic method was used to determine angles o f thoracic
150

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

kyphosis, lumbar lordosis, and pelvic tilt (Chapters V and VI). Again, anthropometric
measurements were taken on all subjects, and each subject was evaluated for hamstring
shortness. Spine length was measured from palpated landmark to palpated landmark,
along the surface o f the skin with subjects in the upright position.

Data Analysis
The same statistical methods used in the previous studies were employed here.
ANOVA and t-tests were used to compare means between various groups, while linear
regression was used to identify predictors o f our dependent variables thoracic angle and
reach distance.
Results

Thoracic Kyphosis Angle and Thoracic Spine Length


Initially, mean age along with the means o f several anthropometric variables were
compared between subjects grouped according to angle o f thoracic kyphosis
normokyphotics, or those with angles between 25 and 52 degrees (photogrammetric
method; n = 1755) and hyperkyphoticsthose with thoracic kyphosis angles over 52 (n =
73) (Table 8.1). The secondary null hypothesis H03 stated that there were no significant

Table 8.1. Mean Age, Height, and Weight for Normokyphotic


and Hyperkyphotic Subjects
G roup
Normokyphotic
Hyperkyphotic

n
m ean y i* .
1224
14.64
327
14.89

s.d.
1.92
1.86

m ean m.
1.69
1.71

s.d.
0.12
0.11

m ean kg.
63.10
64.33

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

s.d.
18.24
16.38

differences o f age, height, or weight between these two groups. Between-group


comparisons confirmed this and the hypothesis was accepted.
The next step in identifying a relation between anthropometry and thoracic
kyphosis was the comparison o f the anthropometric variables Overall Spine Length (from
T l to SI) and Thoracic Spine Length (from T1 to T10) between normokyphotic and
hyperkyphotic subjects (Table 8.2). With no significant difference o f age, height, or

Table 8.2. Mean Anthropometric and Spine Angle Values


of Subjects grouped according to Thoracic Kyphosis Angle Magnitude
Those with larger kyphosis angles tended to have longer, overall spine lengths as well as
longer thoracic spines.

Variable
T1 to S1 Length (mm.)
T1 to T10 Length (mm.)

N orm okyphotic
m ean
s.d.
446
44
250
30

H yperkyphotic
m ean
s.d .
461
42
260
30

p-value
0.004
0.002

weight between groups, both spine lengths were larger in hyperkyphotic subjects. The
difference of thoracic spine length was more significant (p = 0.002) than that of the entire
spine (p = 0.004). Of the two, the thoracic region was the spine region more typically
associated with the classic forms of hyperkyphoses such as Scheuermanns Disease. For
those reasons, the analysis was continued using the TI-T10 length as the basis for a new
predictor variable.
In Chapter m , regression analysis identified Height as a significant predictor o f
thoracic angle (Table 3.4). Because Height was significantly different between genders (p
= 0.000; Table 8.3) and between age groups (p = 0.000; r2 = 0.627; Table 8.3), it was
decided that the TI-T10 Length should be normalized for Height to help control age- and

152

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

gender-related differences o f stature. The density plot for normalized thoracic spine
length is displayed below (Figure 8.1). Note the relative closeness of the mean and
median values, indicating a normal distribution.

Table 8.3. Mean Height for Subjects divided according to Age Group and Gender
Mean height (m.) increased with age, and was greater in males (who were also older).

G roup
8-to-10 year olds
11-to-13year olds
14-to-18 year olds
Fem ales
Males

n
132
432
1641
403
1846

mean m.

s.d.

1.42
1.58
1.74
1.61
1.70

0.08

0.10
0.09

0.11
0.13

7: L
(]r\

7rcraC'-C iC'f'e L.

Figure 8.1. Density Plot for Thoracic Spine Length/Height


Normally distributed [the mean (0.145) is equal to the median (0.145)]

To test the first null hypothesis, the new spine length variable was compared
between normokyphotic and hyperkyphotic subjects from both the large sample study
(Chapters HI and IV) and the small sample study (Chapters V and VI). Table 8.4 shows
that the hyperkyphotic subjects o f both samples have significantly larger normalized,
thoracic spine lengths than the normokyphotic subjects, despite the differences o f optical

153

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

method used in the studies. There were no significant differences o f age, height, or weight
between the kyphosis categories o f either sample. Because o f these differences, the
decision was made to reject Hoi, which stated that there was no difference in Spine
Length-to-Height between kyphosis groups.
Linear regression was used next to confirm whether the normalized, spine length
variable was a significant predictor o f thoracic angle. In Chapter m , regression analysis
showed that the variable Spine Length alone (S T llength from SI to LI) was a
significant predictor of thoracic angle, as were both Age and Sex (Table 3.4). The new
regression model (Table 8.S) did indeed show that normalized Thoracic Spine Length was
a significant predictor (p = 0.000), along with Sex, LDP (an indicator of weight), and

Table 8.4. Mean Thoracic Angles and Thoracic Spine Lengths for Subjects grouped
according to Thoracic Angle Magnitude from both Large and Small Study Samples
s.d. = standard deviation. Normalized Length is the T1-T10 Length normalized for Height
Note that those with greater kyphosis angles from both subject samples have longer mean
thoracic spine lengths.

Sam ple
Large

Small

Variable
Thoracic Angie (deg.)
Normalized Length mm.)
n
Thoracic Angle (deg.)
T-spine Length (mm.)
Normalized Length (mm.)
1
n

Normok)^photic
m ean
s.d.
12
38
146
13
1726
37
9
218
35
14
131
26
-

H yperkyphotic
a.d.
m ean
72
6
14
151
73
57
6
17
250
146
6
5
.

p-value
0.000
0.004
0.000
0.010
0.002
*

Annual Training Time (as discussed in Chapters III and IV). The new model resulted in a
reduction in the number o f predictor variables, as Age and the Age*Sex interaction were
no longer significant. There was an increase in r-squared value (albeit small, from 0.049
to 0.051), although this did little to enhance the already weak linearity o f the equation.
154

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 8.S. Linear Regression Equation for Active Athletes (Thoracic Angle)
[General Linear Model, Stepwise/Backward Regression; N=1828, with
367 cases deleted due to missing data; p=0.000 (ANOVA); r^O.051]
T = 1 5 . 2 2 1 (K) - 0 . 3 0 8 ( A g a )+ 4 . 0 5 5 (Sm x)- 0 . 0 5 7 (LDP)
+ 0. 0 0 6 (Tixam) + 1 9 8 .1 7 0 (TBTH)
Significant Predictors
VARIABLE
Sex
LDP
Time
THTM
where

P ( 2 TAIL)

0.000

0.000
0.002

0.000

T = Thoracic Kyphosis Angle (deg.)


K = Constant
Age = Age (y rs.)
Sex = Gender (Female: 1, Male: 2)
LDP =
Torso depth at the L3 level (m.)
Time = Annual Training Time (yrs.)
THTM = Spine Length normalized for Height

In an effort to provide approximate guidelines to help identify those who might be


predisposed to the development o f hyperkyphosis on the basis o f spine anthropometry,
Tables 8.6 and 8.7 were compiled. Both tables list the mean normalized thoracic length
values for subjects grouped according to thoracic angle magnitude. In Table 8.6, these
means are listed by gender and sport, with subjects divided into three age groups. In
Table 8.7, the means are displayed by gender and age group. Where there are missing
values in Table 8.6, thoracic spine length means may be approximated from those listed
for the appropriate gender and corresponding age group in Table 8.7. While these spine
length means are specific to our subject group, potential participants whose normalized
spine length values are greater than those listed for normokyphotic subjects should take
care not to overtrain and should perhaps consider participating in sporting activities that
do not have large thoracic kyphosis angle/annual training hour values (Chapter IV, Table
4.12).

155

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 8.6. Mean Spine Length Normalized for Height for


both Females and Males by Sport and Age Group
s.d standard deviation; * = n< 5. Note that in most cases,
hyperkyphotics have larger values than normokyphotics

S p o rt
FEMALE
Swimming
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
G ym nastics
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Volleyball
11 to 13 yrs.
MALE
Hockey
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Swimming
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
W restling
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.

Norm okyphotic
m ean
s.d.

H yperkyphotic
m ean
s.d .

0.148
0.147
0.149

0.013
0.012
0.013

0.156
0.148
0.155

0.024
0.009
0.017

0.148
0.143
0.147

0.016
0.010
0.011

0.156
0.134*
0.148

.
0.002

0.146

0.017

0.130*

0.004

0.144
0.138
0.142

0.009
0.017
0.013

0.140*
0.135
0.147

0.009
0.010

0.136
0.141
0.147

0.015
0.021
0.012

0.141
0.150
0.148

0.010
0.021
0.010

0.141
0.143
0.147

0.012
0.012
0.013

0.149
0.145
0.149

0.019
0.012

Table 8.7. Mean Spine Length Normalized for Height for both
Normokyphotic and Hyperkyphotic Females and Males by Age Group
s.d. = standard deviation; normo- = normokyphotic; hyper- = hyperkyphotic. In most cases,
hyperkyphotics have larger mean values than normokyphotics.

m ean

8 to 10 yrs.
normohyper11 to 13 yrs.
normohyper14 to 18 yrs.
normohyper-

F em ales
s.d .

m ean

M ales
s.d .

0.148
0.156

0.013
0.02

21
4

0.142
0.142

0.011
0.008

21
5

0.146
0.145

0.012
0.01

60
24

0.141
0.143

0.015
0.017

176
29

0.148
0.155

0.015
0.016

89
21

0.147
0.149

0.013
0.012

793
222

156

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Leg Length and Hamstring Shortness


To help identify the relation between hamstring shortness and anthropometry, a
variable was developed as a potential screening aid to ascertain the potential for
hamstring-shortness status. This variable was created taking into account two important
points. The first point was the result o f earlier regression analysis. In Chapter VII, the
Greater Trochanterion-to-Floor Length, or Leg Length, was identified as a significant
predictor variable o f Reach Distance (Table 7.7). Figure 8.2 illustrates the positive
relationship.

*rcrr. m

Figure 8.2. Leg Length vs. Reach Distance for II year-olds


Longer Leg Lengths are associated with larger Reach Distances (n = 75, p = 0.001; r = 0.805).

The second point were the observations o f Terver, et al. (1980) and Anderson, et
al. (1978), who identified a difference in the relative growth rates o f the torso and
extremities. Because the peak growth rate o f the trunk was shown to lag behind that of
the leg, the variable Leg Length-to-Spine Length ratio (GTF/ST1 or GS), which
combined leg length and spine length, was set up with Leg Length in the numerator and

157

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Spine Length (not a significant predictor o f Reach Distance) in the denominator. Like
GTF and Reach Distance, the relation between GS and Reach Distance was direct (e.g.
Figure 8.3). Figure 8.4 shows the variable values plotted by age for all subjects, while
Figure 8.5 is the density plot o f the Leg Length/Spine Length variable. Note the close
proximity o f the mean and median, which indicates minimal skewness.

--s-ratf

Figure 8.3. Leg Length/Spine Length Ratio vs. Reach Distance for 11 year-olds
Tighter subjects tend to have larger ratio values (n = 75; p = 0.014; r = 0.677).

Figure 8.4. Mean Leg Length-to-Spine Length Ratio by Age (All Subjects)
Note that the values peak in the peripubertal period, from ages 10 to 14.
158

R e p ro du ced with permission o f the copyright owner. Further reproduction prohibited without permission.

Figure 8.5. Density Plot of Leg Length/Spine Length


A near-normal distribution, with mean (2.001) approximately equal to the median (2.000).

Regression analysis confirmed that the new variable was a significant predictor
(Table 8 .8 ). In addition to the GS ratio, Sex, Age*Sex, and the training time variable,

Table 8.8. Linear Regression Equation for All Subjects (Reach Distance)
[General Linear Model, Stepwise Regression; N=1760, with
511 cases deleted due to missing data; p=0.000 (ANOVA); r2=0.030]
FB = - 1 0 3 . 0 0 2 (K )+ 4 1 . 5 6 2 (Smx)+ 2 6 . 1 1 9 (HTH) - 2 . 2 0 5 (Agm*Sx)
- 0 . 9 9 0 (PER)+ 2 7 . 5 6 2 (GTFST1)+ 0 . 0 9 8 (T 10-L 3)

Significant Prmdictora
VARIABLE
Sex
Age*Sex
GTFST1
Per
where

P (2 TAIL)
0.000
0.000
0.002
0.032

FB = Finger-to-Floor Reach Distance (mm.)


K = Constant
Sex = Gender
GTFST1 = Greater Trochanterion-to-Floor Distance (m.)
divided by Spine Length from SI to T1 (m.)
Per = Period (number of years in primary sport)

159

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Period, were also predictors. Comparisons o f mean reach distance by gender (Table 8.9)
revealed that males had a larger reach distance, signifying that their hamstrings were
shorter. Males were also older, heavier, and taller. The low r2 (0.030) o f the equation
was interpreted as indicating the weak linearity o f the model.

Table 8.9. Mean Age, Height, Weight, and Reach Distance by Gender
G ender
Female
Male
p -v a lu e

Weighl
R sach D istance
Age
H eight
n
m ean yre. s .d . m ean m. s .d . m ean kg. s .d . m ean mm.
s .d .
2.23
51.88
12.76
58.32
402
13.72
1.61
11. s s
0.11
1.7
65.18
22.92
1822
18.73
40.41
14.78
Z 03
0.13
0 .0 0 0

0 .0 0 0

0 .0 0 0

0 .0 0 0

To test the secondary null hypothesis H0 4 , means of the same variables were
compared between hamstring shortness categories. Table 8.10 shows that age, height, and
weight were also significantly different between categories, with hamstring-short subjects
being younger, shorter, and lighter. This finding led to the rejection of H 0 4 , which stated
that there was no difference o f age, height, or weight between hamstring groups.

Table 8.10. Mean Age, Height, Weight, and Reach Distance by


Hamstring Shortness Category
Reach D istance
H eight
W eight
Age
n m ean yrs. s.d. mean m. s.d . mean kg. s.d . mean mm. s.d.
2.08
0.00
18.89
0.13 i 64.23
0.00
14.74
1.69
Hamstring-Normal 1484
2.29
18.52
76.92
118.34
0.14
59.95
1.67
Hamstring-Short 319
14.01
0.000
0.000
0.006
p-value
-

The younger, hamstring-short subjects had participated in their primary sports for fewer
years than the older, hamstring-normal subjects (Table 8.11). They also had larger mean
Leg Length-to-Spine Length ratios.

160

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The effect o f the last predictor variable, Age* Sex interaction, is illustrated in Table
8

.12. Both males and females demonstrated a difference o f age between hamstring

shortness categories, such that hamstring-short subjects were younger than hamstringnormals. However, this difference was significant (p = 0.000) only in males.

Table 8.11. Mean Period and Leg Length-to-Spine Length Ratio (GTFST1)
by Hamstring Shortness Category

Hamstring-Normal
Hamstring-Short
p-va/ue

n
1510
330

Period
m ean y rs.
s.d .
4.65
2.73
4.09
2.79
0.001

GTFST1
m ean
s.d .
1.98
0.15
2.03
0.17
0.000

Table 8.12. Mean Age for Males and Females by Hamstring Shortness Category

Hamstring-Normal
Hamstring-Short
p-va/ue

n
1198
259

M ales
m ean y rs.
s.d .
1.84
15.03
14.21
2.18
0.000

n
182
23

F em ales
m ean y rs.
s.d .
13.23
2.13
13.09
1.62
n.s.

To test the second, primary null hypothesis H02 , mean Leg Length-to-Spine Length
ratio was compared between subjects grouped into hamstring shortness categories.
Hamstring-normal subjects, those able to touch the floor in sagittal plane flexion, had a
significantly smaller mean GS ratio than hamstring-short subjects, those who were unable
to touch the floor (p = 0.000; Table 8.11).
The hamstring-normals were also significantly older, heavier, and taller than
hamstring-short subjects. Since there was a direct relation between age and
anthropometry, it was necessary to control for this variable. Division o f subjects by age

161

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

(e.g., less than 15 years-old) or by gender and age (e.g. males younger than 13 years-old)
controlled for between-hamstring group differences o f the age, height, weight, GTF, ST1,
and BMI. After controlling for these variables, there were still significant differences o f
the GS ratio between hamstring-shortness groups (Table 8.13). These findings led to the

Table 8.13. Mean Leg Length-to-Spine Length Ratio for Subjects grouped
by Hamstring Shortness Category (Males younger than 14 years)
(s.d. = standard deviation)

Group
All < 15 years
Males < 13 yrs.
Males 14 yrs.

H am string-N orm al
m ean
s.d.
n
2.024
0.148
560
0.148
2.031
140
0.154
145
2.015

H am string-S hort
m ean
n
s.d.
0.169
177
2.078
0.17
67
2.092
0.168
2.105
43

p-value
0.000
0.013
0.003

decision to reject H0 2 , which stated that there was no Leg Length-to-Spine Length
difference between hamstring groups.
Mean Leg Length-to-Spine Length values were then determined for subjects
divided by hamstring-shortness status, sport, and age group, as well as by gender and age
group (Tables 8.14 and 8.15). As predicted, hamstring-short subjects had larger mean
Leg Length/Spine Length ratios. Again, while these values are specific to our subject
sample, they provide rough estimates that may be used by those involved in designing
training programs and in screening potential participants.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 8.14. Mean Leg Length-to-Spine Length Ratio by Hamstring


Shortness Category for each Sport and Age Group
(s.d. = standard deviation) Values omitted due to small sample sizes

S p o rt
FEMALE
Swim m ing
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.

H am stringI Normal
m ean
s.d .

8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
MALE
F ootball
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Hockey
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Swim m ing
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
W restling
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.

H am string S ho rt
m ean
s.d .

0.014

2.030
2.007
1.968

0.178
0.154
0.121

2.180

2.014
2.117
2.011

0.175
0.110
0.088

.
.

2.193
1.996

0.202
0.148

2.210
2.084
2.001

0.166
0.137
0.163

2.154
2.060

0.168
0.129

2.018
2.025
1.965

0.157
0.122
0.174

2.048
2.083
2.008

0.033
0.226
0.138

2.010
2.037
1.952

0.107
0.136

2.052
1.992

0.100
0.166

Table 8.15. Mean Leg Length-to-Spine Length Ratio for each Gender
by Age Group and Hamstring Shortness Category
(s.d. = standard deviation)

A ge G roup C ategory
Normal
8 to 10 yrs.
Short
11 to 13 yrs. Normal
Short
14 to 18 yrs. Normal
Short

F em ales
m ean s.d.
2.027 0.174
2.180 0.014
2.028 0.153
2.027 0.16
1.968 0.123
1.953 0.13

n
25
2
77
18
88
16

m ean
2.050
2.053
2.044
2.083
1.971
2.008

M ales
s.d.
0.173
0.165
0.128
0.164
0.147
0.17

163

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

n
32
18
177
60
970
177

Discussion
Up until now, there was relative little in the literature addressing a link between
anthropometry and thoracic kyphosis. One o f the few studies addressing the
anthropometric components o f spine curve abnormalities was by Skogland and AshtonMiller (1981). They had noted that scoliotics tended to have longer spines than nonscoliotic subjects. In our subjects, those having larger thoracic angles also tended to have
longer total spine lengths as well as significantly longer Tl-to-TIO spine segment lengths
(p = 0.000; Table 8.2). This same significant difference was true even after normalization
by height and with no statistically significant differences o f age, height, weight, or body
mass index between normokyphotic and hyperkyphotic individuals (Table 8.4).
Likewise, there has been little work done looking at the relation between
anthropometry and hamstring shortness. Our hamstring-short subjects had larger Leg
Length-to-Spine Length ratios than hamstring-normals. As discussed in Chapter VII, the
hamstring-short subjects tended to be younger and trained less. However, several groups
displayed significant differences o f this unique variable between hamstring categories, with
no significant, between-category differences o f age or training.
Figure 8.1 shows the mean Leg-Length/Spine Length ratio values for our samples
male subjects by year o f age. Note that these values were highest during the peripubertal period from ages 10 to 14 years and tapered off after the growth spurt. This
indicated that younger subjects had larger leg lengths relative to their spine lengths than
older subjects, whose spine lengths tended to be larger relative to their leg lengths. While
the study design prohibits cause-and-effect conclusions, one implication is that, in younger
164

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

individuals, the rate of elongation of the lower extremities is greater than that o f the spine.
These findings are consistent with the observations o f both Tervers and Andersons
groups.
In contrast to our quotient described in Chapter IV, the distributions o f the two
quotients whose development was described here were not skewed, but rather normally
distributed. The means and medians o f the new quotients (Figures 8.1 and 8.5) were
closer than that o f at least one o f their two respective component variables (e.g. Height,
with a mean o f 1.686 m. and a median of 1.702 m., or Leg Length, with a mean of 0.884
m. and a median o f0.890 m.). The normal distribution implies the potential for
generalization to a population.

Limitations
The limitations o f optical methods that were used to generate the thoracic angle
data, of the self-reporting questionnaire used to generate training time data, and of the
subject selection employed in the original studies have been discussed elsewhere (e.g.
Chapters HI, V, and IX). This secondary analysis of cross-sectional data from a
convenience sample cannot be used to establish cause-and-efiect conclusions. Even if it
did, our sample from a specific socio-economic group would prohibit extrapolation o f the
results to the general population.
In light o f the inherent limitations, several tables were constructed to illustrate
certain trends. Table 8.6 and 8.7 were meant to show differences in thoracic spine length
between several groups o f subjects divided as normokyphotic and hyperkyphotic. Tables

165

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

8.14 and 8.15 were meant to show differences o f the Leg Length-to-Spine Length variable
between subjects divided as hamstring-normal and hamstring-short. While the values
contained in these tables are specific to our subject sample, were cause-and-effect
established, the values listed in these tables might be used as rough guidelines by clinicians
and coaches in screening sports participants. Those who might be at risk for the
development of hyperkyphosis or hamstring shortness-related injury could be identified,
and special care could be used in designing their training programs and monitoring their
progress.
While it is difficult to say, it is possible that our between-landmark, surface
measurement o f spine length may have underestimated the actual length. This may have
due to error in marker placement or to the thickness o f the soft tissues over the lumbar
region (e.g. Willner, 1981; Bryant, et al., 1989). If so, then a systematic error would
overestimate the size o f the Leg Length/Spine Length, perhaps resulting in an
overestimation o f group differences.

Conclusions
Two findings were noted in this study. The first was that those 8-to-18 year old
hyperkyphotic subjects, those with thoracic angles greater than 52 (photogrammetric
method) tended to have significantly longer thoracic spines normalized by height than
normokyphotics (those with kyphosis angles between 25 and 52) . The second was that
hamstring-short subjects tended to have longer leg lengths normalized by spine length than
hamstring-normal subjects. While cause-and-efiect conclusions could not be made

166

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

because o f study design, these results imply that those with proportionally longer thoracic
spines are predisposed to the development o f acquired hyperkyphosis, and those with
proportionally longer legs may by prone to hamstring shortness, which, in turn, may be
directly related to the development o f thoracic hyperkyphosis.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER IX
GENERAL DISCUSSION
In his classic paper o f 1920, Dr. Holger W. Scheuermann theorized that farm
work, a form o f repetitive physical activity, and cartilage abnormalities were likely causes
o f the hyperkyphosis that would eventually be named after him. Later, Constantine
Lambrinudi (1934) suggested that hamstring shortness was a possible cause o f the nonpostural, acquired thoracic hyperkyphosis described by Scheuermann. The purpose o f this
dissertation was to determine the relation between thoracic hyperkyphosis and physical
activity (repetitive loading in the form o f athletic training), hamstring shortness, and
anthropometry. Although our subjects were not diagnosed as having Scheuermanns
Disease, or Juvenile Thoracic Kyphosis, our findings support the notions o f these two
authors.

Thoracic Hyperkyphosis and Physical Activity


As early as 1907, Schantz hypothesized that an abnormal increase in the sagittal
plane curvature o f the thoracic spine was the result o f excessive physical work. In
addition to agricultural work (Scheuermann), the types o f physical work that have been
associated with the development o f thoracic hyperkyphosis include sporting activities (e.g.
Hafner and Surrey, 1952). However, these earlier studies were either based on anecdotal
observations (Scheuermann, 1920), individual histories (Greene, Hensinger, and Hunter,
168

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1985), or were prevalence studies (Sorensen, 1964; Wassman, 1951). In contrast to the
work of others, the work o f Wojtys, et al. (2000) and the present study found a
statistically significant, direct relation between the angle o f thoracic kyphosis and the
hours of athletic training. The relation was such that individuals who reported more
athletic training hours tended to have larger thoracic spine angles (Chapter m ). While the
cross-sectional, study design prohibited the identification o f causal relationships, these
results suggested that repetitive, physical work may indeed be linked to the development
o f hyperkyphosis in the susceptible spines o f adolescents. This finding is important
because it might be possible to reduce the risk o f thoracic hyperkyphosis by modifying the
amount o f annual athletic training.

Vertebral Histology: A Comparison of Experimental


and Scheuermanns Disease Specimens
Several researchers have produced vertebral, wedge deformities in vivo. The
various animal models used include the rat tail (Mau, 1929; Stokes, et al., 1996), calf tail
(Aronsson, et al., 1999), and porcine spine (Bylski-Austrow, et al., 2000). Only a few o f
the groups had done histologic examination o f the grossly deformed tissue (e.g. Revel, et
a l, 1992), and none had compared these findings to the tissue specimens from the
vertebral wedging noted in Scheuermanns Disease. Our comparison of existing
micrographs from animal models (Revel, et al., 1992; and Crawford, et al., 2000) to some
from Scheuermanns patients (Ippolito and Ponseti, 1981; Scoles, et al., 1991) revealed
that both shared at least one common finding. This finding was one o f disruption and
disorganization o f the chondrocyte columns o f the vertebral endplates. This finding
169

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

confirms Scheuermanns observation o f abnormal cartilage in his radiographic study o f the


wedged vertebrae found in some hyperkyphotics (1920).

Thoracic Hyperkyphosis and Hamstring Shortness


Dr. Constantine Lambrinudis 1934 paper presented his theories on the connection
between thoracic hyperkyphosis and hamstring shortness (tightness in his paper).
Noting that the hamstrings o f Scheuermanns patients were usually tight and theorizing
a causal relation between the two variables, he summarized his findings in his model. He
depicted a hamstring-short subject making an unsuccessful attempt to touch the ground, in
contrast to his hamstring-normal subject. The caption described the subject as having a
back flexed beyond normal limits, showing the increased convexity o f the lower dorsal
and lumbar regions.
Lambrinudi also commented on pelvic position. He noted that the anterior
superior iliac spine o f the subject with hamstring tightness was above the level o f the
greater trochanter, again in contrast to the hamstring-normal subject. Finally, he
hypothesized that short hamstrings lose the spring action that normal length hamstrings
exhibit. This resulted in spine hyperflexion during forward flexion, which subsequently
loaded the anterior parts o f the bodies o f the vertebrae, thereby producing vertebral
wedging.
Many o f our findings supported Lambrinudis model (Chapter V). First, posterior
pelvic tilting was found in our hamstring-short subjects, a finding reported previously by
others (e.g. Carlsoo, 1961; Cibulka, et al., 1986; DeLuca, et al., 1998). As observed by

170

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

others (e.g. Halbertsma and Goeken, 1994), a restriction o f sagittal plane flexion range o f
motion was also noted in our subjects, both for the pelvic and total ranges. In addition,
the lumbar lordosis angles were smaller, a finding interpreted as being a relative
flattening o f the lumbar spine. Similar observations have also been reported elsewhere
(e.g. Beal, 1982; Day, et al., 1984; McCarthy and Betz, 2000).
Smaller, mean thoracic kyphosis angles were also identified in our hamstring-short
subjects. Interpreted as a relative flattening o f the thoracic spine, this finding corroborated
the notion o f others that spine curves tend to balance one another (e.g. Stagnara, et al.,
1982; Willner and Johnson, 1983; Voutsinas and MacEwen, 1986; Bridger, et al., 1989;
Korovessis, et al., 1998). This spine balance was noted particularly in younger
hamstring-short subjects with reach distances less than about 95 mm. Subjects with more
severely hamstring shortness, having reach distances above about 160 mm., tended to be
hyperkyphotic and older. While cause-and-effect results cannot be assumed, due to
research design, one implication o f these findings is that perhaps a larger thoracic kyphosis
angle may be an adaptive response to enhance the otherwise restricted reach distance
found in hamstring-short subjects. This idea agrees with the general concept o f Farcy and
Schwab (1997), who concluded that restricted motion in one area tends to lead to
increased motion in another.
Data from our hyperkyphotic subjects did not support Lambrinudis idea that
hamstring shortness is the sole etiology o f hyperkyphosis. The main reason is that not all
hyperkyphotics were hamstring-short. Seventeen percent o f our 889 hyperkyphotics were
hamstring-short, although diagnoses o f Scheuermanns Disease could not be inferred for
171

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

these subjects. Of our small sample o f documented Scheuermanns Disease volunteers


used in the preliminary stages o f our investigations, only 66% were hamstring-short, which
agrees with the findings o f MacGowan (1944). Thus, Kling and Hensingers (1982)
opinion that tight hamstrings were likely secondary to the kyphosis, rather than the
cause o f it, appears to be more accurate.

Anthropometric Characteristics
One unique finding o f our studies is similar to what has been observed by Skogland
and Miller (1981) in their study o f scoliotic subjects. Our hyperkyphotic subjects tended
to have proportionally longer thoracic spines (Chapter V O ). It is possible that this
characteristic predisposes the anterior aspects o f thoracic vertebrae to an increased flexion
moment (Chapter I), which, with repeated loading, may result in wedge deformity.
The hamstring-short subjects o f our studies also displayed unique, anthropometric
characteristics. They tended to have proportionally longer legs, relative to their height or
spine lengths (Chapter V O ). Likely the result o f the growth rate differential between legs
and torso, it is possible that the lengthening bone actually puts a passive stretch on the
hamstring muscles, thereby causing relative tightness.

How Much Training is Associated with both


Thoracic Hyperkyphosis and Hamstring Shortness?
In these studies, an effort was made to identify sports that were associated with the
larger thoracic kyphosis angles. For females, participants in gymnastics had the largest,
mean Thoracic Kyphosis Angle per Annual Training Hour values, normalized by Age.

172

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

This was followed by volleyball, with a mean angle/hour value 30% less than that of
gymnasts. For males, participants in ice hockey had the largest mean angle/hour value,
followed by wrestlers, whose mean was 41% less. Participants o f these same sports were
also identified as having increased thoracic kyphosis angles by several other groups,
including Kujala, et al. (1997), Stiletto, et al. (1996), Goldstein, et al. (1991), and Reilly
and Seaton (1990).
Just how much training is associated with larger thoracic kyphosis angles, or with
hamstring shortness? Because the immature spine is likely particularly vulnerable to
excessive loading (e.g. Mau, 1929; Ferguson, 1949), partially because the immature
cartilage and bone are undergoing relatively rapid development, it was deemed important
to attempt to quantify the amounts of training seen in hyperkyphotic subjects and in
hamstring-short individuals. Unfortunately, cause-and-efiect cannot be presumed in our
studies. Thus, our training times tabulated here, which arc specific to our subject sample,
should not be used clinically for a basis for the establishment o f training programs, but
rather to give academic insight as to the relative times between groups of subjects.
Mean annual training times were tabulated for athlete subjects grouped in several
ways. First, subjects were divided according to gender. Next, they were divided into four
groups: normokyphotic (those with thoracic kyphosis angles between 25 and 52
photogrammetric method), hyperkyphotic (those with kyphosis angles greater than 52),
hamstring-normal, and hamstring-short. Following that, the subjects were divided

according ageeither by age in years or into one o f three age groups. The mean training
hour data for subjects divided by gender and age are displayed in Appendix I (Tables 1.1
173

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

and 1.2). Annual training time means for subjects also divided according to primary sport
are displayed below (Table 9.1).

Table 9.1. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category, Hamstring Shortness Status, and Sport
Age Group: 1 = 8-10 years, 2 = 11-13 years, 3 = 14-18 years; s.d. = standard deviation
Sport
Female
Swimming

Gymnastics
Volieyball
Male
Football

Ice Hockey
Swimming
Wrestling

Age
Nomnlkyphotic
Group m ean
s.d.

Hamstri ng-Short Hamstring-Normal


s.d.
mean
s.d.
mean

1
2
3
1
2
3
2
3

319
340
364
228
352
518
125
160

235
217
227
124
3 24

66
309
457*

39 7

78
60

2
3
1
2
3
1
2
3
1
2
3

225
292
186
169
216
276
398
481
127
164
242

173
161
159
182
148
285
260
299
57
102
136

8
193
220

148
285
170
212*
203
219
322
440
152
154
240

368
372
389
226
445
607

218
212
226
107
416
450

6
170
102
152
143
175
214
249
57
90

122

243
290
203
166*
224
318
475
514
54*
183
261 I

Hyparity photic
mean
s.d.
483
404
360
220
816
576
90

145
221
163
204
.

42

209
163
195
188
176
229
305
326

105
148

262
480
248
322
232
781
508
144
191
275

151
254
281
121
500
305
.

80
150

Despite the method used for grouping subjects, a pattern emerged, which is
illustrated using the group means for males (Table 9.2). Normokyphotic subjects tended
to log the smallest number of annual training hours. These were followed by hamstringshort subjects and hamstring-normal subjects. As indicated previously, hyperkyphotic
subjects logged the greatest amounts o f training hours. In some cases, this pattern was
not followed. These tended to be instances in which the mean training times were
calculated from smaller subject samples.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 9.2. Annual Training Time Group Means for Male Athletes grouped
by Kyphosis Category and Hamstring Shortness Status and according to Age,
Age Group, and Sport
Times are in hours; s.d. = standard deviation
G rouped by;

Age (in Years)


Age Group
Sport and Age Group

Normokyphotic Ham string-Short Hamstring-Normal Hyperkyphotic


mean
mean
mean
s.d.
s.tL
mean
s.dl
s .d
34
41
56
72
262
248
260
215
47
12
222
243
36
278
226
28
89
133
192
106
344
252
231
266

Profiles o f typical female and male individuals are displayed below (Tables 9.3 and
9.4). These tables were prepared by determining the mean variable values for each o f the
categories o f kyphosis and hamstring shortness. As indicated previously, the hamstringshort subject is younger, is longer-legged, and trains less than the hamstring-normal
subject. The hyperkyphotic male is older, has a longer thoracic spine, and trains more
than the normokyphotic male.

Table 9.3. Profile of Typical Female Subjects who are either Hamstring-Normal
(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or Hyperkyphotic (HK)

Age
hit
Wt
BMI
GTF
ST1
GTFST1
T1-T10
THTM
Time
Per
Reach
T
I

HSN
13.6
1.6
50.86
31.50
0.849
0.425
2.007
0.235
0.147
335.5
4.66
0.0
38.2

HSS
13.1
1.62
51.32
31.6
0.860
0.432
1.999
0.242
0.149
332.8
4.94
99.7
40.8

NK
13.4
1.61
51.44
31.8
0.851
0.421
2.032
0.237
0.147
323.1
4.8
9.6
39.2

HK
13.3
1.62
50.90
31.3
0.846
0.430
1.972
0.242
0.150
395.4
5.24
15.6
61.7

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 9.4. Profile of Typical Male Subjects who are either Hamstring-Normal
(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or Hyperkyphotic (HK)

Age
Ht
Wt
BMI
GTF
ST1
GTFST1
T1-T10
THTM
Time
Per
Reach
T

HSN
15.0
1.71
67.0
38.7
0.90
0.46
1.984
0.252
0.147
267.3
4.6
0.0
39.8

HSS
14.4
1.69
62.7
36.6
0.90
0.44
2.030
0.245
0.145
253.4
4.5
119.8
40.1

NK
14.8
1.70
65.1
37.8
0.89
0.45
1.998
0.248
0.146
254.8
4.4
21.0
38.9

HK
15.2
1.73
67.0
38.4
0.91
0.46
1.980
0.256
0.148
281.3
4.9
21.2
60.3

Preliminary StudiesSkin Distraction and Platform Marker Design


Two preliminary studies (Appendix H) were necessary in order to develop the
skin-surface marker that was required for the Chapter IV hamstring shortness study. The
first was designed to quantify the ranges of skin distraction over the midline o f the back.
This information formed the basis of the surface marker design specifications. The results
were that the mean skin distraction in the superoinferior direction was greater than the
mean distraction in the mediolateral direction for the skin over the T l, L3, SI, and PSIS
landmarks. The greater mean mediolateral distraction at the T10 level was likely the result

o f traction on the skin caused by the dependence o f osseous and soft tissue [upper
extremities, scapulae, and breast tissue (Fouquet, et al., 1991)] in forward flexion. The
superoinferior skin distraction, expressed in terms o f strain, increased consistently from
cephalad to caudad along the spine, with the greatest mean distraction over the PSIS and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

SI (53.9% and 49.7% strain, respectively). In contrast, mean mediolateral strains


diminished from T10 to PSIS.
There were two additional findings from this small study that were important. The
first was that the greatest between-landmark strain difference in the superoinferior
direction occurred between the T10 and L3 landmarks. This difference likely reflected the
greater flexion range o f motion o f the thoracolumbar spine as compared to the thoracic
spine, which is relatively fixed due to the ribs. There was also no statistically significant
difference in superoinferior distraction at this level between hamstring-short and control
subjects. This finding was parallel to that o f Chapter VI, in which there was no significant
difference in the flexion range o f motion o f the T10-L3 segment between the two
hamstring groups. Again, these findings corroborate observations of Lambrinudi (1934)
and Gajdosik (1994), who noted increases in the thoracic and thoracolumbar ranges o f
motion in hamstring-tight individuals, possibly as a compensatory mechanism (Fisk and
Baigent, 1981). In keeping with what was noted earlier in our studies, hamstring-short
subjects did display a reduction of the mediolateral distraction of the skin over the L3, SI,
and PSIS landmarksa finding which likely reflected their reduced lumbar spine flexion
range o f motion.
The second preliminary study was conducted to validate the unique, skin-surface
marker. The marker displayed three basic characteristics: Good tolerance to skin-surface
distraction, which reached strains o f over 50%, maintenance of an orientation normal to
the skin-surface with changes o f subject posture, and accurate placement over spine
landmarks cephalad to the lumbosacral level. The surface marker also demonstrated
177

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

strong correlations between angles generated from marker-based lines and lines drawn
based on radiographic landmarks, at least for the thoracic spine and thoracolumbar spines.
Placement o f the surface marker over landmarks at mid-lumbar and below resulted in
angles that were poorly correlated with those generated from x-rays, an observation made
by other authors (e.g. Refshauge, et al., 1994). This was thought to be due primarily to
the thickening o f the soft-tissues superficial to the vertebral column at the lumbar and
lumbosacral regions.
Significance
Why is it important to investigate the relation between spine curvature and loading
or between spine curvature and hamstring shortness? Many types of back pathologies are
common to both thoracic hyperkyphosis and hamstring shortness. Both hyperkyphosis
and hamstring shortness have been associated with changes o f normal kinematics and
spine load bearing, factors which have been shown to result in injury. Because o f the
epidemiologic and financial significance o f back injury, it would be beneficial to prevent
both hyperkyphosis and hamstring shortness.
How can the information discussed in this dissertation be o f benefit? The
limitations o f our study design do not enable us to show a causal relation. Only a
prospective, randomized clinical trial could corroborate what has been suggested in this
dissertation. Were that the case, we could give in to the temptation to state that our
training time table values (Table 9.1) could be used as approximate guidelines in the
design o f training programs, so that annual training hour minima for the prevention o f
hamstring shortness and training hour maxima for the prevention o f hyperkyphosis may be
178

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

estimated. Astute coaching staff could use the training time information to help determine
how much training is appropriate to the sport, age group, and gender of their athletes. We
could likewise be tempted say that the anthropometric predictor variable values presented
in Chapter V m could be used in pre-participation screening exams as a predictor of who
might be at risk for the development of thoracic hyperkyphosis or hamstring shortness
related injury. Early identification would thus facilitate enable timely clinical intervention.
Besides adolescents, who else might benefit from the information provided by
these studies? Rehabilitation practitioners, physiatrists, manual medicine practitioners,
orthopaedists, athletic trainers, physical therapists, and others involved in the diagnosis
and treatment o f low-back pathology, as well as those associated with worksite wellness
and the burgeoning health and fitness industry, could benefit by the application of these
testing methods to permit early identification of those at risk. The health care professional
can assist in the training program design process, advising young athletes as to the amount
of training that is appropriate for healthy spine development. They can help to develop
preventative programs that might include stretching and strengthening protocols aimed at
normalizing posture and improving torso and pelvic mechanics. They could also include
the routine monitoring o f the patients progress. Our optical methods are well suited for
this, as they are relatively simple to use, inexpensive, and are non-invasive.

Limitations
Several limitations, or threats to internal validity, were inherent to these studies. In
general, limitations may be divided into several types or families (Wiersma, 1994).

179

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

These families include history, maturation, testing, instrumentation, statistical regression,


differential selection o f subjects, experimental mortality, and the selection-maturation
interaction.
Instrumentation limitations were likely the most important. One such limitation
was one shared by both o f the optical methods used to collect spine angle datathe use of
skin surface markers to estimate the skeletal position. Authors as Stokes (1977) or
Thurston and Harris (1983) have shown that the error between skin mounted targets and
true skeletal motion ranges horn 8 to 10%. Troup, et al. (1968) related that movement of
the skin was a particular source o f errors, especially in the lumbar region. Even though,
they obtained correlation coefficients o f 0.91 between surface marker and x-ray spine
angles for erect and fully flexed postures for 14 observations, with no significant
differences between the methods by Students t-test at the p< 0.001 level.
As with most non-radiographic methods, our optical method results did not agree
exactly with the gold standard o f x-ray-based measurements. For the large sample
study, our photogrammetric method overestimated radiographic, spine angle values by
about 7 (Wojtys, et al., 2000). For the small sample study, our optoelectronic method
results underestimated T1-T10, radiographic values by about 5 (in agreement with
Leroux, et al., 2000)(Appendix H, Table H.8). Despite these systematic errors and the
different methods, this multimethod approach helped to mitigate the instrumentation threat
to validity, as our findings regarding thoracic angle and hamstring shortness or
anthropometry were similar in both subject samples.

180

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Surface markers at the lumbar area are less reliable for other reasons, which
include soft tissue thickness (Bryant, et al., 1989; Willner, 1981). The thickness o f the
superficial tissues, especially at the lumbosacral area, can affect marker position relative to
the bony reference point. This is reflected by our finding o f a surface marker positioning
error at SI that was twice that o f the positioning error at T1 (Appendix H, Table H.7).
Because o f the potential for inaccuracy in measuring the lower spine (L3-S1) angles,
special care must be taken when placing surface markers at this region.
Testing limitations also posed a potential threat to internal validity. Our testing
protocols and apparatus were standardized, and there were no post-treatment evaluations.
However, testing was carried out at several different locations over the span of six years
by different testing crews. To minimize interoperator differences in technique, we tried to
have a veteran team member take our measurements (or at least, instruct as to
methodology).
Because there was no post-treatment evaluation, limitations such as maturation or
subject loss were not as important. Likewise, the selection-maturation interaction was
likely not as important as differential selection (discussed below). History, on the other
hand, may have been important. Over the course o f the data collection, it was likely that
testing may have been administered at different seasons and at different times o f the day.
Postural reactions to cold weather and diurnal adaptations may have affected thoracic
kyphosis values (e.g. Adams, et al., 1990; Broberg, 1993; Keller and Nathan, 1999).
Even though most sports and age groups demonstrated statistical differences in
training times and thoracic angles, large variance in the thoracic kyphosis angles was
181

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

responsible for lack o f statistical significance for all sports and age groups. While the
testing methods used in the study agreed well with radiographic standards and between
themselves, there was still variance in the kyphosis angle means. For example, the
thoracic angle variance for the female subjects (n = 407, mean o f 36, 18) was 316,
while for male subjects (n = 1862; mean of 38, 15) was 228. Nissenen (1995)
identified large variance as physiologic.
Another inherent limitation was the question of the reliability of childrens selfreporting, since questionnaires were the sole source for training information. There were
large variances of annual training times reported by our subjects (Table 9.5). In part,
these large values likely reflect the different training regimens o f the various sports, as the
variance o f training times reported by wrestlers, for instance, is considerably less than
those of the subject sample as a whole.

Table 9.5. Annual Training Time Means, Standard Deviations, and Variance
for All Subjects and Wrestlers divided according to Age Group
1

j
1

1
n

8 to 10
11 to 13
14 to 18

133
438
1654

A ll S u b j e c t s
m ean

h rs.

140
228
267

\W

s.d .

v a ria n c e

174
216
183

30201

128

46695

133

164

33603

791

241

m ean

h rs.

re s tle rs

s.d .

v a ria n c e

46
97
136

2080
9328
48539

While some recommend cautious use o f adolescents reports of some types of


physical activity (Anderssen, et al., 1995), others have been comfortable using written
questionnaires. For example, Thompson, et al. (1997) confirmed a close agreement o f
childrens self-report by comparing reported bicycle speed with actual measurements.
Beunen, et al. (1992) relied on questionnaire data that was verified by control interview.
182

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Instead o f using interviews, we had validated our instrument by having subjects repeat
their written responses in a test/retest fashion.
There were several other factors that could bias the outcome o f these studies. One
such factor is obesity. Generally associated with a protruding abdomen, obesity has been
associated with an increase in the lordotic angle (e.g. Ridola, et al., 1994). It is likely that
the mechanism is one o f mechanical traction by the abdominal musculature and
interconnected soft tissues on the anterior aspect o f the lumbar spine. Since there is an
association between the lumbar lordosis angle and the thoracic kyphosis angle (Chapter
VT), it is possible that obesity is also related to thoracic hyperkyphosis. While not an
exclusionary characteristic in data selection, there were no morbidly obese subjects in our
pool. Furthermore, in most cases in our analyses, there were no significant differences o f
height or weight were noted.
The differential selection o f subjects was another threat to internal validity. Two
other interrelated factors that may bias the results are socioeconomic status and nutrition.
Malnutrition has been associated with thoracic hyperkyphosis (Kemp, et al., 1948), as has
vitamin deficiency (Simon, 1942; Ellender and Gazelakis, 1996; Appendix C). Most o f the
participants o f the summer sports camp were volunteers from the area's public schools.
The socioeconomic make-up was largely upper middle class, with most students reared in
an environment o f good nutrition and health care. Thus, in our sample, the likelihood o f
hyperkyphosis from nutritional causes was minimized.
Because o f the socioeconomic stratum represented by our convenience sample,
certain ethnic or racial groups may not have been represented. Such groups may have a
183

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

predisposition to thoracic hyperkyphosis. In certain regions, genetic syndromes or disease


states that are associated with spine curvature abnormalities may be endemic or have a
unusually high prevalence. These include the Nevo syndrome, an autosomal recessive,
genetic disorder seen in Arab populations that is associated with hyperkyphosis (al-Gazali,
et al., 1997), the spondylo-epimetaphyseal dysplasia seen in South African Germans
(Kozlowski and Beighton, 1984), or the calcification o f longitudinal, spine ligaments that
is very common in Japan (Orth, 1975). The largely Caucasian volunteers of our sample
were screened for significant health history, trauma, or spine disorder to help minimize
confounding data. However, our samples ethnic and racial make-up may not be
not be representative o f the worlds population.
Self-selection was also a limiting factor in the studies. First, subjects volunteered
to participate, thus creating a convenience rather that random sample. In addition, there
was self-selection for sport participation. Self-selection has been suggested to introduce
some bias, as noted by Morris, et al. (1997). This is not surprising, as several physical
parameters, as genetic and biological endowment, must be factored along with social and
geophysical conditions into the model o f the sport participation choice process
(Woodman, 1977; Carter, 1970). In this dissertation, much o f the analysis was done by
sport to control for sport-specific anthropometric differences.
O f course, the retrospective, cross-sectional nature of the study was another
important limitation. In the absence o f a randomized and controlled clinical trial o f the
effect o f training dose or o f the prospective monitoring o f hamstring shortness, it was not
possible to conclude that there was a direct cause-and-effect relationship between training
184

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

and thoracic kyphosis or between hamstring shortness and thoracic kyphosis. Future
studies should prospective, controlled protocols, in which training regimens could be
designed, standardized, documented, and applied, and in which outcomes could be closely
observed. The results would have been more predictive, and interventions such as passive
hamstring stretching might or spine manipulation could have been made to enhance the
scope of the studies.
Finally, our the original method used to determine hamstring shortness did not
quantify the reach distance o f hamstring loose subjects. The use o f a raised platform
would have permitted this measurement. As a result, between-group significance would
have been enhanced and much more predictive information would have been obtained by
quantifying the reach distances o f those subjects, rather than assigning a qualitative value
to the variable.
Suggestions for Future Study
To offset our inherent design weaknesses of the study design, a prospective,
controlled study is needed in which quantifiable loading can be applied and outcomes can
be measured directly. A primate model whose results could be generalized to humans
should be used. In this study, repetitive tasks such as repetitive flexing, rowing,
pulling/dragging, or lifting could be used to load the spine. Indwelling intradiscal or
intravertebral load cells may be used to directly measure spine loading. Indirect
measurement may be done by using EMG to quantify paravertebral muscle contraction
force. Either x-ray or optical methods may be used to quantify spine angle, with the
anticipation that large amounts o f loading will cause greater hyperkyphosis, and small
185

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

amounts will cause less. This type o f evaluation would confirm a causal relation between
the thoracic kyphosis angle and repetitive loading and support our observations.
The primate model may also be used to examine the relation between thoracic
kyphosis and hamstring shortness. Hamstring muscle length may be adjusted surgically to
test whether shortening causes an increase in thoracic spine angle or whether lengthening
causes a decrease. Human, clinical interventional studies may also be conducted to test
whether conservative treatment o f hamstring shortness results in spine angle reduction.
Longitudinal follow-up o f the large sample studys current subjects could be done
next. Evaluation of progress o f the thoracic angle relative to the amounts o f training
would be an important next step. Hyperkyphotics who train more than the amounts listed
for normokyphotics can have their training hours reduced, with the anticipation that their
kyphosis angles might reduce [using the animal model, Mente, et al. (1999) found that
curve deformities may be reversible].
Longitudinal studies may also be used to quantify the effectiveness of
hyperkyphosis treatment programs. For example, in non-surgical cases o f Scheuermanns
Juvenile Kyphosis, those having thoracic kyphosis angles ranging from about S0 to 65
(Sorensen, 1964; Bradford and Hensinger, 1985), spine-extension exercises are used with
or without bracing. Our training time guidelines may similarly be evaluated. The
prevalence of both hyperkyphosis and hamstring shortness could be compared between
those who adhere to our general recommendations and those who do not.
Predictive models may be developed from the dynamic evaluation o f the changes
in spine angles. It is likely that both the spine and pelvis motion o f the hamstring-normal
186

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

and hamstring-short groups move differently as subjects bend from the upright to frilly
flexed postures. The use o f time-course data from this type o f study could define the
influence o f hamstring shortness on spine angle rates-of-change.
Additional studies may help to verify the histologic etiology o f hyperkyphosis and
hamstring shortness. One study could involve the use o f hamstring muscle biopsies
obtained from both hamstring-normal and hamstring-short individuals. These samples
would be used to examine sarcomere ultrastructure and fibrous connective tissue content
and would be compared to confirm the ultrastructural characteristics o f short hamstring
muscles. Another study could use Magnetic Resonance Imaging (MRI) to confirm
whether the anterior longitudinal spine ligament is one of the possible causes o f
hyperkyphosis. It has been anecdotally noted that thickening and bowstringing o f this
ligament is a gross anatomical finding o f Scheuermanns Disease (Bradford, 1985). If
spine ligament thickening is present in most cases o f documented Scheuermanns Juvenile
Kyphosis, the non-roentgenographic, MRI method may be used to predict who might be
at risk for the development o f hyperkyphosis.
The current testing protocols may be improved in several ways. Statistical
significance would be enhanced if it were possible to reduce the variance o f the outcome
variable, thoracic kyphosis angle. Perhaps this may be achieved by using additional
methods o f thoracic angle measurement (as goniometry), or by dividing the subjects into
more limited age and anthropometry groups. Significance may also be enhanced by
subdividing hyperkyphotic subjects into two thoracic curve categorieseither postural or
permanent, because it is likely that the relation between spine curve and hamstring
187

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

shortness is different between the two groups. Additional methods o f evaluation using
tests as the Prone Extension Test (Appendix G) may help to differentiate whether subjects
have a permanent or temporary (postural) hyperkyphosisone that disappears with
extension and changes with sagittal plane flexion.
The hamstring shortness protocols used in these studies may be improved by using
certain technical improvements. These include the use o f an elevated platform to more
accurately quantify the finger-to-floor reach distance. The reach distance o f hamstringloose subjects, those able to touch the floor with fingertips or even palms, would be more
accurately determined if these subjects stood on a surface that extended above the floor.
This would enhance the data base and permit more inferences to be drawn from the
hamstring shortness/spine angle relation.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

CHAPTER X
CONCLUSION
Comparison between micrographs o f immature vertebral endplates from animals
whose vertebrae were deformed in vivo by the application o f asymmetric, compressive
loading and micrographs o f Scheuermanns Disease patients demonstrate similar patterns
o f chondrocyte column disruption (Chapter II). This observation implies a causal link
between asymmetric, compressive spine loading and vertebral deformity in skeletallyimmature humans.
When the relation between thoracic kyphosis and spine loading (modeled by the
amount o f time 8-to-18 year-old students spent in athletic training) was examined in a
cross-sectional study (Chapters HI and IV), the following conclusions were reached:

The mean thoracic kyphosis angle o f active athletes was significantly


larger than that o f inactive controls.
Hyperkyphotic athletes had accumulated more annual training hours
than did normokyphotic athletes
Female gymnasts, follow ed by volleyball players, had the largest
thoracic angle per hour o f annual training time.
Male ice hockey players, follow ed by wrestlers, had the largest
thoracic angle per hour o f annual training time.

Reproduced with permission of the copyright owner. Further reproduction prohibited w ithout permission.

Next, the relation between thoracic kyphosis and hamstring shortness was
examined (Chapters V, VI, and VII) and the following conclusions were drawn:

--Hamstring shortness was 25-33% less prevalent in fem ales.


Hamstring shortness was more than 50% less prevalent in athletes.
The hamstring-short subjects demonstrated greater posterior pelvic
tilt and smaller lumbar lordosis than hamstring-normal subjects.
The hamstring-short subjects had smaller sagittal flexion ranges o f motion,
largely due to smaller thoracic, lumbosacral, and pelvifemoral ranges.
The hamstring-short subjects had significantly smaller thoracic kyphosis
angles, especially younger subjects with reach distances less than about 95 mm.
Inflexible subjects, those having reach distances beyond about 160 mm.,
tended to have larger thoracic angles than moderately flexible subjects.
Subjects with marked hamstring shortness also tended to be significantly older.

The cross-sectional study design precludes cause-and-efFect conclusions being


drawn. But the lower prevalence o f hamstring shortness in athletes implies that certain
amounts of activity are important for flexibility. The relation between hamstring
shortness, posterior pelvic tilt, and a flattening o f the lumbar and thoracic spines helps to
explain the associated reduction in the sagittal plane flexion range o f motion. The
observation that hyperkyphosis is seen in subjects with markedly shorter hamstrings who
are also significantly older suggests a possible functional association.

190

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Finally, the relation between thoracic kyphosis and anthropometry was examined
(Chapter VHI) and the following conclusions drawn:

Hyperkyphotic subjects (those with thoracic angles greater than 5 T by


our photogrammetric method) tended to have significantly longer thoracic
spines normalized by height than normokyphotics (those with kyphosis angles
between 25 and 52).
-Hamstring-short subjects tended to have longer leg lengths normalized by
spine length than hamstring normal subjects.

In sum, these results are consistent with the hypothesis that thoracic hyperkyphosis
is the result o f repetitive loading of the spine. Likewise, the observations relating to
hamstring shortness, pelvic tilt, lumbar lordosis, and thoracic kyphosis corroborate the
findings o f Lambrinudi (1934).

191

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

APPENDICES

192

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix A. Reported Prevalence of Scheuermanns Juvenile Kyphosis

Afsani and Kuhn (1991)

20-30% (frequency)

Ascani, etal. (1977)

3.1% (6-14 year olds)

Blazek, et al. (1986)

9.6% in inactive controls (ages 18-25years)


40.5% in sportsmen (ages 18-25years)

Commandre, etal. (1988)

30% o f the general population

Endler, et al. (1980)

68% (oarsmen)

Fisk and Baigent (1984)

30.3% (females)
56.3% (males)

Griegel-Mom's, et al. (1992)

38%

Harreby, et al. (1995)

12%

Hazebroek-Kampschreur, et al. (1992)

0.3% in 11 year olds

Heithoff, et ai. (1994)

9%

Nissinen (1995)

0.4% (of a sample o f 1060 school children ages 11-14 years)

Nitzsche and Hildenbrand (1990)

12% (females)
15.3% (males)

Scoles, etal. (1991)

7.4% (in a sample o f 1384 thoracolumbar spinal


columns from persons o f ages 16-89)

Sorensen (1964)

o f a sample o f 311 subjects ages 3-20:


0.4% (radiographic criteria)
8.3% (clinical criteria)

Tertti, etal. (1990)

8.6% (of a sample o f 35 gymnasts ages 8-19 years)

Wood, et al. (1995)

38%

193

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix B. Theoretical Causes of Scheuermanns Kyphosis


von Luschka (1858)
Pollosson (1885)

prolapse o f disc associated with hyperkyphosis

Scheuermann (1920):

abnormal epiphyseal plate behavior (avascular


necrosis o f cartilage, particularly the ring apophysis),
causing bone growth inhibition, hyperkyphosis

Mau (1929)

aseptic necrosis due to epiphyseal vessel injury,


especially from vertebral overloading during second
rapid-growth period, causing osteochondrosis

Schmorl (1930)

intervertebral disc nucleus puiposus herniation


through the growth plate into bony spongiosum,
causing disturbed enchondral growth

Hellstadius (1947)

paradiscal defect as impingement o f superoanterior


vertebral body with disc compressed into cancellous
bone

Ferguson (1949)

persistence o f intersegmental artery vascular


grooves in the vertebral body, causing kyphosis,
when combined with rapid growth and
asymmetrical growth tension

Butler (1955)

nuclear herniation peripherally and submarginally


beneath apophyseal ring, causing ring separation
corpus

from
R oaf(1960)

spongiosa blood squeezed from endplate region,


causing shock absorption reduced, endplate
fracture, nuclear herniation

Rogge and N iem an (1976)

paradiscal defect, synostosis

Winter and Hall (1978)

disruption o f vertebral support mechanisms: disc,


anterior vertebral body, posterior longitudinal
ligament, causing kyphosis

Stephen (1983)

vertebral body microfractures, causing wedging

Bradford and Hensinger (1985)

weakness o f cartilaginous plates at sites o f vertebral


vessel penetration, causing less resistance to
nucleus puiposus pressure

194

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix C. Conditions Associated with Thoracic Hyperkyphosis


(sources: Sorensen, 1964; Winter and Hall, 1978; Kling and Hensinger, 1985)
P O S T U R A L (non-fixed; absent muscle contracture or radiographic findings)

NON-POSTURAL (fixed)
I. CO N G EN ITAL (absence o f vertebral bodies; anterior failure o f segmentation)
U. PATH O LO G IC
A. Paralytic
B. Myelomeningocele
C. Inflammatory (e.g. tuberculosis spondylitis)
D. Post-irradiation and destructive lesions
E. Metabolic (e.g. rickets, osteogenesis imperfecta, idiopathic juvenile osteoporosis)
F. Developmental [e.g. bone dyplasias: achondroplasia, pseudoachondroplasia;
diastrophic and metatrophic dwarfism; spondyloepiphyseal dysplasia congenita and tarda
M uhlbach, et al. (1970); Gardemin and Herbst (1966)]

G. Neurofibromatosis (mesenchymal disease)


H. Endocrine [e.g. hypo- and hyperparathyroidism; Turners Syndrome (M uller and
Gschwend, 1969), producing an osteoporosis and alterations in bone growth (Ascani and
M ontanaro, 1985)]
/. Storage Diseases (e.g. Gauchers, mucopolysaccharidoses causing
osteochondrodystrophy: M orquios, Hurlers)

J. Nutritional [e.g. fluoride (Bradford and Hensinger, 1985), malnutrition (Kemp, et al.,
1948), rickets, or vitamin deficiency, especially that o f vitamin A (Simon, 1942), vitamin
C (Ellender and Gazelakis, 1996]
III. A C Q U IRED
A. Scheuermann's (vertebral wedging, end-plate irregularity, disc narrowing)
B. Post-traumatic (e.g. serial compression fractures, fracture/dislocations)
C. Post-surgical (e.g. Post-laminectomy)

195

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Appendix D. Vertebral Development


(source: Grays Anatomy, 1974)
/. General Developmental Stages o f the Vertebral Column
A. Primitive Streak
B. Mesoderm
C. Membranous Skeleton-characterized by tissue aggregates or sheets
migrating from the central region
O. Cartilaginous Skeletoncharacterized by chondrous intercellular substance
E. Bony Skeletoncharacterized by the appearance of ossification centers

II. Specific Embryology


A. Notochord
1. Acts as a central embryo axis for the development of vertebrae
2. A rod of cells in median line between the neural tube and
the primitive gut, from midbrain to end of the tail
B. Paraxial mesoderm parallel to neural tube give rise to these primordia:
1. Sclerotome, whose cells migrate to the notochord and form a
sclerotogenous layer on either side.
2. Myotome
3. Dermotome

III. Membranous Vertebral Column


A. Segmental primordial portions:
1. Cranial portion is loosely arranged, separated into cranial and caudal
halves, so that the loose portions o f two adjacent somites in close
juxtaposition become the vertebral body centrum.
2. Caudal portion is densely arranges caudally, migrating craniolaterally,
until reaching the center level of the original somite, spreading back
to the midline to envelope the notochord. Dense portion becomes
the intervertebral disc.
3. Dorsal migration o f the sclerotome around neural tube forms (from
loosely arranged cells) the arch and costal processes; those from the
densely arranged cells form the ligamentous structures.

IV. Cartilaginous Vertebral Column


A. In the 4th week, two cartilaginous centers, on either side o f notochord,
eventually surround it (forming the future vertebral body).
1. A second pair o f foci in the lateral vertebral bow, grow separately into
the vertebral arch, with separate centers for each costal process.
B. By the 8th week, the arch has fused with the body
196

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix D (cond)
C. By month 4, the posterior aspect has fused, with processes growing from these
arch components.
1. Mesodermal tissue bar or hypochordal brace remains in C 1 to form arch
and dens o f C2.
2. Vestigial notochord evolves into nucleus puiposus.

V. Bony Vertebral Column


A. Ossification
1. Each vertebra with 3 primary centers:
a. 1 for the body; beginning to ossify at week 8 in the lower thorax,
proceeding cephalad and caudal ly. Dorsolateral portions of the
body are ossified by extensions from centers at the arches.
b. 2 for the arch, beginning to ossifying at weeks 7, 8 in the cervical
spine. Ossification from these centers progress caudally at
transverse process roots, then dorsally to spinous process, ventrally
to pedicles, and laterally to transverse and articular processes.
2. At birth, the vertebrae are of three ossified pieces: I body and 2 arch
halves
3. First year: there is dorsal arch union (from lumbar region cephalad)
4. Third year: the bodies of the upper cervical spine vertebrae unite with
their arches
5. Sixth year: the arch/body union has been completed to the caudal
lumbar spine
6. Before puberty: there is an increase o f primary center ossification
7. Sixteenth year: S secondary centers have become active to complete
the ossification of vertebral body endplates (the ring apophyses) and
tips of the spinous and transverse processes
8. Twenty-fifth year: ossification of secondary centers is complete
B. Exceptions: C l, C2, C7, and L-vertebrae
1. The latter have two additional centers for mammillary processes, while
the former two have unique arches and processes

197

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix E. Subject Questionnaire


SUBJECT

SPORT CAMP:

Bl&THDATE:.

R/L HAND:_

SEX:

HEIGHT

WEIGHT:.

CT-FLOOR

SHOULDER WIDTH: _

GT-S1:

SHOULDER DEPTH:.

S l-T l:.

U WIDTH:.

Sl-TIO:.

U DEPTH:.

S1-L3:

SUDE *

TEST DATE:_

NAME:

ASM LEHCTH:
TESTED BY US LAST SUMMER? V / H

FORWARD BEHO/F1HCERTI? TO FLOOR:

How such claa do you apand practicing th is sport?


la aaaaon
days par vaafc:
Boors par day:
laufcfa of aaaaon?
Ara you a

r o f a school caaa?
a club eaaa?
ochor?

ooc of aaaaon

Y/ H
Y/ H

How Long have you participated in th is apart?


Whac klnda o f additional phyaieai conditioning do you partlcipaca in?
In aaaaon
out of aaaaon
weight training (houro/voakH
upper body:
lowar body:
running (hours/waefc)?
aviating (hours/wood)?
oebar?
Whac ochar aports do you partlcipaca in?
Hava you had any Injuries? Ara they sporca ralaead?
Do you hava any back pain now? I f ao, where and during what a cd v itia a ?
C( )
C/T ( )
T( )
T/L ( )
L ( )
Do you havo a job whara you li f e heavy things (aoro chan 20 Lba)?

198

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix F. Kyphosis Image Processing Protocol


The KPROC (Kyphosis Batch Processor) program automatically locates LEDs and the midline of the spine on a
scanned image (.BMP file). In addition, it locates LEDs on calibration images (projections o f the grid onto a board).
The KPOST (Kyphosis Post-Processor) program takes the feature set extracted from the image file by KPROC and
generates an output file that is compatible with UV2XY. The user will be required to fine-tune the midline o f the
spine (adding or removing segments or pixels; interpolation between existing points) as well as select the locations
o f the 4 LEDs and the landmarks.
The KBATCH program can be used to automate the processing o f large groups o f image files. It will run KPROC
or KPOST sequentially on each file in the group.
The KCAL (Kyphosis Calibration) program takes the features extracted from the calibration image by KPROC and
generates output files which will be used by VERAI and KPOST (see below). The user will be required to indicate
the locations o f the 4 LEDs and the 9 points on the calibration board (A-l).
The UV2XY program is used to convert digitized images from the (u.v) coordinate system o f the digitizer to the (x,y)
coordinate system o f the "world". UV2XY expects that the images for a days subjects differ from the related
calibration file only in terms of a shift in the (u.v) plane o f the digitizer (i.e. imperfect alignment o f the individual
slides as they are digitized). We will need to verify that we do not have the additional problem o f varying scale
between different subject images due to image cropping considerations. If Photoshop is giving a consistent number
o f pixels per inch in the scanned (..bmp) files regardless o f how the image is cropped during the scanning process,
then differently cropped images will differ only by a (u.v) shift.

UV2XY reads the position o f the d2 (top-left) LED from the digitized subject image file and from the CALFILE flic
generated by VERAI from the digitized calibration image file. It uses the difference in the LED's position in these
files to shift the coordinate system for the subject image. It ignores the position of the remaining 3 LEDs, under the
assumption that all o f the subject files corresponding to a particular calibration file will be digitized at the same
magnification and rotationa plausible assumption.
This means that if we merely make our scanning/digitizing system (i.e. KPROC and KPOST) generate an output file
whose format is identical to the flies generated by the old digitizer, we cannot get meaningful data from images that
lack a d2 (top-left) LED. On the other hand, if we keep track of the location o f all 4 LEDs in the calibration image
(by having KCAL write an extra file) and use this information in the KPOST program, we can accomplish the
following objectives:

Verification o f consistent image scaling or correction for inconsistent scaling (by measuring the distance
between two o f the LEDs on the calibration image and on the subject image)
Correction for rotation of the image by measuring the angle between the u (or v) axis and a line connecting
two o f the LEDs (may not be important).
Reconstruction o f the position o f the d2 (top-left) LED if it is missing from the subject image. If we have
two other LEDs in the subject image, and all four LEDs in the calibration image, we can correct for both
shifting and scaling factors and figure out where the d2 LED would have been in the subject image.

Steps for Processing Calibration and Batches of Kyphosis Image Files


( For other groups o f subject data, the 61 / s would be replaced with different numbers)
1.

Move a calibration file (e.g. 6II0CLI V.BMP) and its associated subject files (e.g. 6llxxxVl.BM P) to a directory
for batch processing:
(in a DOS window, starting from the directory containing the image files)
MD 611BATCR
MOVE 6 1 10C L lV .b m p 611BATCH
MOVE 6 1 1 ? ? ? V 1 .b m p 611BATCH
CD 611BATCH
DIR * .BMP / - P > BATCH.DIR

199

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Notes:
a. May use copy command to avoid losing original data that may otherwise occur with program testing.
b. Can evoke f:\salvage to undelete any files.
c. May also copy fi\* batch and f:\programs to f:\tmp
d. At this point, must copy programsW* to the batchfile, in order for KBATCH command to work.

2.

Run KBATCH to run KPROC on each o f the files listed in BATCH.DIR:


(in Matlab)
CD F : \ ------\611BATCH

(fill in the full path of the 611BA TCH directory)

KBATCH
when prompted for the batch directory file, enter BATCH. DIR
when prompted for the desired action, choose KPROC (image processing and feature extraction)

Notes:
a. May cd fA*batch
b. May run KPRO <filename> for a step-wise display o f the various outputs o f the program, thus being able to
visualize the data file without horizontal lines, vertical lines, and spurious pixels, as well as seeing it in its final form
(and being able to print).
c. Could use a pause during this sequence, enabling the printing o f each step.
KPROC

3.

Input: *.bmp
O utput: *.mat, with same names, containing features extracted from the images.

Run KCAL on the calibration file:


(in Matlab)
KCAL

when prompted for the calibration file, enter it (e.g. 6110C L1V )

Notes:
a. Old calfiles have been saved by typing copy calfile veal*.*'.
b. In KCAL, you use the mouse to select the LEDs and the 9 reference positions A-l.
KCAL

4.

Input: *.mat (from calibration files through KBATCH/KPROC)


O utput: will create two files:
6llOCLlV.ver
for VERAI
61I0CLI V.kps
for KPOST

Run KBATCH to run KPOST on all o f the subject files:


(in Matlab)
KBATCH

when prompted for the batch directory file, enter BATCH .D IR


when prompted for the desired action, choose KPOST (image post-processing and feature selection)

Notes:
a. Enter calibration filename
b. May KPOST <filename>
c. Could use Manual Mode for selecting LEDs which the program has missed
d. Could use an Escape command, to abort and restart (or backup).
e. In KPOST, you use the mouse to do the following:
add or remove segments or pixels from the spine midline
-interpolate points missing from the spine midline
-select landmarks
-select LEDs

200

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

KPOST

Input: *.kps from calibration files and, from subject files, *.mai (created by KPROC)
Output: *uv, with same names as *.mat's (for UV2XY).

5. Run VERAI on the file generated by KCAL. (Note: VERAI also needs a file called CALPTS.)
(in a DOS window)
VERAI < 6 1 1 0 C L 1 V .v e r

Soles: From earlier manual processing:


a. Delete any preexisting calpts and calfile, as must start processing each days subjects using that day's
calibration data.
b. Copy *.v (or *.h) for the day to "calpts
c. Previous operations (verai, etc.) on calv*.* (or calh*.*) have been performed by typing 'verai <calv*.*.

VERAI

6.

Input: CALPTS and data digitized from days calibration slide


Output: CALFILE that is used by UV2XY.

Run UV2XY on the files generated by KPOST. It also needs CALFILE.


(in a DOS window)
UV2XY < 6 1 1 ? ? ? V l.u v > 6 1 1 ? ? ? V l .x y

Notes:
a. It is likely that KBATCH can be made to also run VERAI and UV2XY (and any other DOS programs needed
finish the processing) so that we wont need to write additional batch files for this purpose.
b. Old version called by *uv2xy *.0lp > *.lp

UV2XY
Input: CALFILE and data digitized from subject slides (*.uv from KPOST)
Output: A series of files ending in .xy which will be used for the remaining programs.
7. Run POLY.EXE (a quadratic polynomial smoothing program for UV2XY output)
(in old manual version:)
POLY < * .lp > $*.lp

POLY

8.

Input: Vxy from UV2XY


Output: $*.xy

Run ANGLE.EXE (calculates kyphosis and lordosis angles, formatting them as:)

btl = thoracic angle from landmarks (LM)


bt2 = lumbar angle from landmarks
btl = thoracic angle from inflection points (IP)
bt2 = lumbar angle from inflection points
Notes:
a. These are now sequenced automatically in the *.m program series
b. In old version, called by angle < $*.10>#*.Ip
ANGLE Input: $*.*

Output: #*.*

201

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix G. Select Hamstring Tightness and Spine Curvature


Measurement Methods
Hamstring Tightness Methods
Introduction
The hamstring muscle group influences movement, balance, posture (Cibulka, et al., 1986), and
the mechanics of other related structures, primarily knees, hip, pelvis, and spine. Assessment of
hamstring flexibility is a necessary part of identifying those who otherwise might be predisposed to
tightness-related tissue injury.
Several tests have been used to assess hamstring muscle tightness, both clinically and in the
laboratory setting. These include Straight-Leg Raising, Knee Extension (both Active and Passive), Sitand-Reach, Standing-Reach, and Hip Flexion Angle methods. One of the primary purposes of these tests
is to determine hamstring flexibility, defined as the state of muscle length, allowing (or restricting)
freedom of joint movement (Kreighbaum and Barthels, 1990). Each measurement method has its pros
and cons, largely depending upon the type of information required, resources (including time, personnel,
and instrumentation), and subject population. This chapter will review the methodology o f some of the
more popular hamstring tightness measurement techniques.

Straight-leg Raising Test (SLR)


Sullivan, et al., (1992) related that this test was used by most authors to determine hamstring
flexibility. The test has been reported to be clinically valid (Gajdosik, et al., 1994)one that generally
reflects hamstring muscle length (Bridger, et al., 1989). Halbertsma and Goeken (1994) suggested that
the SLR test is good for evaluating hamstring treatment and strengthening protocols, in this application,
the test serves to estimate hamstring extensibilitythe ability o f a muscle to allow elongation or
maximum angle of passive limb motion, <{>. The angle phi (ijt) is between the long axis o f the leg and a
line from the anterior superior iliac spine (ASIS) through the center of hip rotation to the ischium. It is
determined by subtracting angle cp, the amount o f posterior pelvic tilt with leg raising, from angle a , the
angle between the elevated leg and the horizontal. Hoehler and Tobis (1982) suggested that progress from
manipulative medicine therapy for low back pain might be followed using this test. During a SLR test,
they noted a difference in both the onset of hamstring tautness and the absolute limits of passive and
active methods for subjects with and without low back pain (LBPXTable G. 1).

Table G .l. Mean Flexibility Values for Three Different Methods


(after Hoehler and Tobis, 1982) (In degrees, with s.d. in parentheses)
Flexibility Test
Hams tightness
Passive SLR
Active SLR

test

LBP

No LBP

56 (10)
65 (15)
63(21)

61(6)
77(7)
79(7)

According to the methods critics, the confounding problem is pelvic rotation. Such motion
should be controlled, as, according to Bohannon, et al. (1985), it may contaminate the results of the test
by exaggerating hip motion by as much as 11 (Pitkin and Pheasant, 1936) when compared to methods as
the over the Popliteal Angle Test. The most common means to secure the pelvis is to use straps, a method
evaluated by Gajdosik, et al. (1993). First, with subjects supine, pelves and opposite thighs were
stabilized, and SLR performed. Next, again with subjects supine, their low backs were actively flattened
and opposite thighs slightly flexed, being on pillows, which induced a 10 pelvic tilt. Although others
have suggested that short hip flexors (ascertained by the Thomas test) would limit posterior pelvis

202

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

rotation, hamstring tightness using the Straight Leg Raise Test with both approaches to pelvis control
yielded essentially the same results. Other pelvis motion control methods include having the subject
actively extend the knee during the leg lift. This, according to Bohannon (1982), would essentially
eliminate pelvis, sacroiliac joint and low back motion, as subjects dont force their legs past the point of
initial mild resistance.
In addition to controlling the pelvis, Gajdosik, et al. (1985). suggest monitoring the position of
both foot and ankle during the test. When the SLR test is used to assess hamstring muscle tightness
(referred to as a passive muscle stretch test by Halbertsma and Goeken, 1994), the ankle should be
relaxed in plantarflexion. For the purpose o f diagnosing sciatica and nerve root irritation, the ankle
should be held in dorsiflexion. This augments tension on the nerve roots and is Lasegues test for
neurogenic pathology ( Halbertsma and Goeken, 1994). In the SLR test, dorsiflexion of the foot limited
the SLR range by about 7, presumably from soft tissue tension across leg. O f course, as with most of
the tests for hamstring tightness, the SLR should be used judiciously with subjects having a history of
neurologic completes or disorders of the thigh, pelvis, lumbar spine, hip, and sacroiliac joints (Bohannon,
et al., 1985).
There is some disagreement whether a pre-test warm-up, or prestretch, should by used prior to
applying the SLR test. Some, as Halbertsma and Goeken (1994), feel that there should be no pre
stretching, and that the initial test should be used. In theory, this disallows a training effect and prevents
lengthening of the connective tissue elastic components. Others, as Gajdosik, et al. (1994), believing that
the stretched tissue permits a more realistic evaluation, and allow several warm-ups, using the 6th stretch
and the test and the 7th as a retest.
The accuracy of the method differs amongst authors. Gleim, et al. (1991) advised that the use of
goniometry to determine the SLR angle carries a +/-100 error. Others, as deVries and Housch (1994),
have suggested a coefficient of more than 0.90 when using more advanced goniometers as the Leighton
flexometer. Kendall and Kendall (1949) suggested that there could be apparent hamstring tightness
when, in actuality, the hip flexors were short, especially on the side of the thigh that is pushed to table. In
these instances, the lumbar spine is hyperextended and the pelvis tilted anteriorly, so that when the
measured side appeared artificially tightin actuality, it was lengthened or stretched. Similar
findings can result from lower erector spinae tightness and hip flexor tightness, where the apparent
range of hip flexion is augmented by tilting the pelvis more posteriorly after maximum hip flexion is
achieved (at 80XTable G.2).

Table G.2. Range of Motion Parameters for the Three Hamstring Length Categories by Author
and Method (SLR and Hip Flexion Angles; after Gajdosik, et al., 1994)

short
medium
long

SLRtdeq.)
Gajdosik, et al.
Stokes and Abery

Hip Flexion(deq.)
Gajdosik, et al.

(1994)

(1980)

(1994)

<65
65-85
>85

<40
40-70
>70

59.0
68.7
76.7

To correct for these technical problems, the supported thigh could be allowed
to flex enough to permit flattening of the lumbar spine on the table's surface.

203

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

TECHNIQUE G .l. Passive Straight-Lee Raising


(a test o f lower extremity flexibility and hip flexion Kuntzleman, et al., 1993)
A. Subject supine, leg straight, knee extended (occasionally, braced in this position)
B. Pelvis is strapped to the table across the ASlSs (Gajdosik, et al., 1994), to limit pelvic tilt.
Contralateral ASIS palpated to monitor tilt (Hoehler and Tobis, 1982).
C. Opposite leg strapped to table at mid-thigh, to limit contribution of pelvic tilt
D. Leg lifted at calcaneus (foot in a relaxed position)
E. Operator monitors onset o f any of the following:
1. Onset of leg tightness/resistance,
2. Knee flexion (flexing of knee relaxes the hamstrings- Fisk, 1979),
3. Pelvic tilt/rotation (Beal, 1982; Ekstrand, 1982; Hoehler and Tobis,
1982; Troup, et al., 1968),
4. Onset of discomfort (Troup, et al., 1968).
5. Onset of lifting o f contralateral thigh (Troup, et al., 1968)
F. At one o f these end-points, the angle o f the long axis o f the straightened leg is measured
relative to the horizontal. A pendulum goniometer may be used, strapped S cm. above patella,
with a second examiner to read score (Ekstrand, 1982).
G. Test/retest coefficient of correlation similar between sides (0.78 and 0.79Troup, et al., 1968)

Figure G .l. Straight Leg Raising Test (adapted from Bohannon, et al., 1985)

204

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table G J . Typical Straight Leg Raise Test Values (in degrees)

Gajdosik, et al.
(1994)

SLR <65
SLR = to or 65 to 85
SLR >85

Short:
Medium:
Long:

Gleim, et al.
(1990)

tight = < 6 0
normal = 6 0 -9 0
loose = >90

Halbertsma and Goeken,


(1994)

normal = 80 or more, without pain


insufficient elasticity of hamstrings < 80 (with
non-specific or no pain)
insufficient elasticity with significant, specific pain:
neurogenic cause, not hams

Hoehler and Tobis


(1982)

61 +/- 6 (no LBP)

56 +/- 10 (LBP)

Jonhagen, et al.
(1994)

74.1 (uninjured R)

67.2 (injured R)

Kendall and Kendall,


(1949)

Normal approx. 80

(<45 severely tightened)

Wang, et al.
(1993)

81+ /-4(N R ,d) 6 9 + /-8 (R ,d )


84 +/-S (nd)
73 +/-8 (nd)

86 +1-1 (NR, d) 74 +/-5 (R, d)


86 +1-5 (nd)
82 +1-1 (nd)

KEY:

M = Male
F = Female
LBP = Low Back Pain

d = dominant
R = Runners

nd = non-dominant
NR = Non-Runners

205

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Knee Extension Tests


In contrast to the erector group and the gluteals, the hamstring muscle group show an increase in
electromyographic (EMG) activation at an earlier point during a straight knee lift than when the knee is
flexed (Nemeth, 1984). This, plus the difficulty in controlling pelvic tilt that occurs as early as 45 of the
SLR, has led some to the conclusion that the SLR/horizontal angle does not give a valid indication of
hamstring muscle length (Bohannon, 1982). A refinement o f the SLR was developed that inherently
controlled pelvis motion inherently is known as the Active Knee Extension Test (AKE). This was
reported to be more objective and reliable than the SLR test for measuring hamstring tightness (Gajdosik
and Lusin, 1983), because, with the knee bent, the pelvis would not begin to rotate until hip flexion
approached 90.
In a manner similar to the SLR, the pelvis and opposite thigh o f the supine subject are secured to
the table with straps. The thigh to be tested is maintained in flexion at an angle of 90, which isolates
movement to the knee and excludes pelvis and low back movement. With foot in relaxed plantar flexion,
the gastrocnemius is not tight and does not limit knee extension. The subject then actively extends the
knee to a point o f initial mild resistance, defined by some as the point where a mild tremor or myoclonus
occurs. At this point, the subject backs off and the final measurement of the long axis of the teg relative
to the vertical is taken (Gajdosik, et al., 1993).
Occasionally, the subject has difficulty in identifying the point of tremor. Because of this, plus
the significant limitation the active test might have for patients having neuromuscular disorders, a passive
test is available, the Passive Knee Extension Test (PKE). Also known as the Popliteal Angle Test, the
technique is operator mediated, ideally at a pelvic tilt angle of 0 (Delp, et al., 1996). Like the Active test,
it measures hams tightness by angle o f knee flexion (in contrast to the SLR, which uses the angle of hip
flexion - Gajdosik and Lusin, 1983). As shown by Delp, et al.(1996), the method is used extensively to
measure the hip flexion contractures in diseases as cerebral palsy. In comparing the two tests, Gajdosik
noted that the active angle values were less than those obtained from passive tests. The group thought
that the AKE measured the unstretched, initial length of the hamstrings, whereas PKE measured the
maximum, stretched length, with the value possibly equal to extensibility. Fredriksen, et al. (1997)
described the technique as simple and reliable.

206

with permission of the copyright owner. Further reproduction prohibited without permission.

TECHNIQUE G.2. Knee Extension (Passive)


A. Subject supine, thigh at 90 to horizontal (table surface)
B. Flexed knee is extended until resistance of hamstrings group to further
extension is noted.
C. Angle of leg relative to thigh at that point is measured, the vertical being 0.

Table G.4. Typical Values - Popliteal Angles


Normal
Tight
Severely Tight

< 30
> 30 (Bandy and Irion, 1994)
> 40 (Delp, et al., 1996)

Figure G.2. Measurement of Popliteal Angle


(adapted from Speers, 1993)

207

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Standing Reach (Finger-to-Floor)


Tight hamstrings, wrote Somhegyi and Ratko (1993), restrict the trunk in the forward-reach test,
with increased lumbar anteflexion as compensation. Despite the fact that the method has some who
disapprove of its use (citing poor reproducibility), Harris (1969) reviewed that the Adapted Kraus-Weber,
a standing flexion screening test to measure low back and hamstring flexibility, was found to be more
reliable than the Sit-and-Reach. Although some groups have reported correlations ranging from 0.90 to
0.9S, Scott and French (19S9) felt that the Standing-Reach test had artificially higher scores due to the
effect of gravity on the flexed torso and the ability of the subject to shift the hip backwards.
Originally the Kraus-Weber Toe-Touch Test, it was graded pass/fail, based upon the ability of the
subject to touch the floor while flexing in the sagittal plane. Authors as Harris (1969) and Scott and
French (1959) commented that quantification of the forward-reach distance could be achieved by having
subjects stand on a box or bench onto which was affixed a tape measure. Subjects would stand with legs
together and ankles touching, with the instructions to relax the shoulders and touch chin to chest, prior to
bending forward at the waist. Matthews and Fox (1976) suggested that the arms and head should hang
loosely, while the subject concentrated on relaxing the muscles. In the Standing/Bobbing variation
(similar to a Seated Bobbing Test or Seated Toe-Touch, which emphasis on upper back flexibility
Matthews and Fox, 1976), the subject, with arms and trunk relaxing forward, would bob up and down
four times with knees straight, holding the position on the fourth attempt. Critics stated that this
technique might increase reach distance but would reduce objectivity and reliability. As a variant,
Merritt, et al. (1986) had subjects do only one episode of flexion, which was held for 15 seconds. They
suggested that reproducibility was a factor only if the test is used for trunk flexibility and not hamstring
tightness.
Harris, (1969) found minimal to no correlation between toe-touch and body build, habitus,
anthropometry, and weight in the Standing Flexion Test (with the possible exception of extreme trunk
length and arm-length-to-leg-length ratios). Bridger, et al. (1989) and Nemeth, (1984), felt that height
and weight ratios didnt correlate with variables as spine kyphotic or lordotic curves.
Drawbacks to the method include false positives from sacroiliac joint dysfunction that produces
pelvic innominate asymmetry and an ipsilateral hamstring tightness (Cibulka, et al., 1986). However,
confirmation of suspected sacroiliac joint problems may be made using a Prone Leg-Length Test (a prone
Knee-Flexion Test).

208

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

TECHNIQUE G.3. Standing-Reach


A. Subject standing with feet shoulder width apart. Flex head/neck to
encourage full trunk flexion (Gajdosik, et al., 1994).
B. Flexes trunk to touch floor (knees extended), until firm
resistance/slight discomfort in posterior thighs
C. Distance from fingertips to floor measured
D. Greater test-retest reliability than seated reach tests (Harris, 1969)
E. A variation of this test is the Finger-to-heel, with the position and
subject motion as above, except that subject attempts to reach behind
heels, if possible. That distance (fingertips to heels, or beyond) is
measured (Kirby, et al., 1981).

Table G.5. Category Definitions: Standing Reach Test (after Gleim, et al., 1990)
Normal
Loose
T ight

touches floor with fingertips


palms flat on floor
unable to touch floor (distance measured)

Figure G.3. Standing Reach Test


NOTE: While using the Standing reach test, note the appearance o f the spinal profile in the lateral view o f those
with juvenile kyphosis and tight hamstrings. In those with a compensatory increase in lumbar lordosis: flattened low
thoracic and lumbar curvatures (Fisk, 1981; Kendall and Boynton, 19S2) and relatively increased upper thoracic
curve.

209

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Sit-and-reach: Traditional and Modified


In her 1969 review, Harris stated that the Sit-and-Reach Test (SAR) was developed by Wells and
Dillon (19S2) to eliminate fear o f the standing test, primarily by younger school-age children. It is the
most common test used in fitness batteries to assess flexibility (Hoeger and Hopkins, 1992) and is
particularly applicable to hamstring flexibility (Jackson and Baker, 1986; Jackson and Langford, 1989).
One draw back is that subjects have to be proportional, as the method does not account for limb length
or trunk/extremity proportion differences (Kuntzleman, et al., 1993). Those with long legs and/or short
arms have a structural disadvantage that gives higher scores to those having this converse anthropometry
(Hoeger and Hopkins, 1992; Kuntzleman, et al., 1993). To correct for this, a modification o f the
traditional method was derived. The method used an adjustable scale fixed on the apparatus which could
be positioned according to the individual, thereby negating the bias o f disproportionate arm and leg
length. The test did, however, require a slight increase in time of administration. Other adaptations
include the use of a table at shoulder height upon which the hands are moved to the limits of reach
(reliability: 0.98 for young adults, 0.83 for middle-age and older adults - Shepard and Berridge, 1990) and
the maintenance of a head-up position for better scores (Smith and Miller, 198S). As the traditional
method includes dorsiflexed toes, said to stretch the tibia! band o f the sciatic nerve, the modified version
positioned subjects with toes pointed. Even with these changes, a greater percentage of females and older
children were found to pass the test (Kuntzleman, et al., 1993).
The Kuntzleman group preceded the modified version with a screening exam that was similar to
an upright SLR. Subjects, seated on the floor against a wall, were instructed to flatten their low backs and
buttocks against it, while keeping heads and shoulders against it. If they were unable to keep either legs
straight or butts flush with the wall, they were considered inadequately flexible and the test was finished.
If they passed this rudimentary hamstring flexibility screening test, then they proceeded on to Part II - the
Modified SAR.

210

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

TECHNIQUE G.4. Sit-and-Reach

I. Traditional
A. Subject seated on floor, legs extended and spread approximately 1012 apart
1. Scale (standard yardstick) placed in midline on box between
legs at fixed distance (may be performed with or without box)
2. With box, starting point requires placement o f feet against box,
relative to 12 inch point (zero point)
B. Subject flexes trunk, reaching forward, holding final position for 2
seconds, and touches scale with fingertips
C. Reading taken along scale, which is zeroed at heel line
1. Criterion score as 12 inches, +/- distance reached (Hoeger and
Hopkins, 1992)

Fixed
Measurement Scale

Figure G.4. Sit and Reach Test (Subject begins in upright position)
(adapted from Hoeger and Hopkins, 1992)

211

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

II. Modified
A. Subject positioned with head, back, and hips against wall, with feet
12-18 apart, against box (30.S cm high), upon which is sliding
measurement scale with 0-70 cm range. The box elevates the scale
between the subjects legs.
B. Initial reach: upper body against wall, hands in front with palms
touching, then hand over hand reach over scale, with scapulae abducting
C. Scale moved to zero at fingertips (finger-to-box distance)
establishes zero based upon proportional differences in limb lengths
D. Subject flexes trunk, with final reading as forward-bending reach and
final finger position along scale marked
1. Difference between two values gives reach
E. Negates bias of disproportionate arm and leg length (Hoeger and
Hopkins, 1992).

Sliding
Measurement Scale

Figure G.5. Modified Sit and Reach Test (from Hoeger and Hopkins, 1992)

212

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Hip Flexion
Perhaps this test could be classified as a variation o f the Standing-Flexion method, as it involves
trunk flexion in the sagittal plane, utilizing its gravity-related benefits. Rather than measuring the
distance from the fingertips to the floor, the angle of hip flexion is determined. The definition of hip
flexion angle varies among authors, as it is measured by several approaches. In the broad sense, it is the
pelvifemoral anglethe angle between the long axis o f the femur and the pelvis. The femur is readily
labeled by skin markers positioned at proximal (trochanterion) and distal (lateral femoral condyle)
anatomic landmarks. The demarcation o f the pelvis is less standardized. Clayson, et al., in their
radiographic study of 1962, used the method of Mundale and associates (1956) and compared the femoral
line to the longitudinal axis of the pelvis. This is delineated by a perpendicular from the innominate
transverse axis (a line between the ASIS and the posterior-superior iliac spine, PSIS) running through the
acetabulum (Figure G.6). The ASIS and PSIS line has since been used by itself to represent the pelvis to
track pelvic position and tilt (Bohannon, et al., 1985; Gajdosik, et al., 1994).

ASIS/PSIS LINE

P E L V I F E M O R A L L IN E

Figure G.6. The ASIS/PSIS and Pelvifemoral Lines


Troup, et al. (1968) made a study in an attempt to identify the relationship between lumbar,
pelvis (inclination angle), sacral motion and pure hip movements. The group affixed surface markers
to the femur and platform markers perpendicular to the skin surface over the spine at the midline. To
justify the use of surface markers to reflect bonny vertebral angles, the authors cited Flint (1963), who
statistically correlated surface perpendicular markers with underlying radiographs. They performed their
own marker position corroboration tests, obtaining correlation coefficients o f 0.91 between surface marker
results and roentgenograms for erect and fully flexed postures. Thurston and Harris (1983) related an 8%
error when using skin mounted targets to represent vertebral movement.
Troups team measured trunk flexion with their method, subtracting hip flexion from hip/lumbar
spine flexion to give lumbar flexion. The latter was the angle between a tangent to the spine at T 11/12
and the femoral long axis. This approach was similar to that of Lindahl (1966), with the exception of
accounting for thoracic and sacroiliac motion, which, when not addressed, led to an overestimate of
lumbar sagittal mobility. They found a positive correlation between the lumbar flexion method and the
straight-ieg method in female subjects.
Rather than use the ASIS/PSIS line, Stokes and Abery (1980) chose a platform-type
perpendicular pointer placed over the sacrum to indicate pelvis movement. Markers were then placed on
the femur and lower leg. Measurements were then taken of the angle between the pelvis marker and
femoral shank and the angle between femur and leg in both standing and seated postures. Subtraction of
the knee flexion angle from the hip angle gave the desired result. The method had an overall
213

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

reproducibility o f+/- 2, and revealed that, in an unselected group of 35 adults, 10% had loose hamstrings
and 10% had tight hams, as defined by standards noted below (Table G.6).
Gajdosik, et al. (1994) used an SLR test to screen and select subjects with tight hamstrings for
inclusion in a hip flexion angle experiment. Using a ASIS/PSIS line to track pelvis motion, surface
markers were placed along the femoral shank, while platform perpendiculars were positioned at T 12/Ll
and C7/T1. Thoracic, lumbar and pelvis angles were then defined according to surface landmarks and
marker positions (method similar to Figure G.7). The lumbar angle was defined relative to pelvis and the
sacrum not considered, largely because of the small 1 to 2 motion found at the sacroiliac joint. Their
results included the identification of a significant difference in the toe-touching range of motion between
the short and medium hamstring groups and the short and long hams groups. They also noted a
significant difference in thoracic angle and all flexion range of motion measurements between short and
long hamstrings groups.

214

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

TECHNIQUE G.S. Hip Flexion Angle


A. Marker placed perpendicular to skin surface at the sacrum (SI or S2) to
monitor pelvis motion
B. Thigh markers at Greater Trochanter and Lateral Femoral Condyle to denote
thigh long axis
C. Subject (standing) flexes trunk (with knee extended)
D. Angle between sacral perpendicular and thigh long axis measured (recording
subjects videographically or with still photography - Gajdosik, et al., 1994).
E. Marking the lateral malleolus, Stokes and Abery (1980) measured the knee
flexion angle and subtracted it from the hip flexion angle for a more reproducible
measurement (flexing of knee while bending forward to touch toes permits greater
hip flexion). Reproducibility approx. +/- 2. Repeated measures improved performance,
such that second performance was measured.

Table G.6. Typical Ranges - Hip Flexion Angle (after Stokes and Abery, 1980)
Loose =
Normal
Tight =

>70
= 40-70
<40'

Figure G.7. Hip Flexion Angle (adapted from Stokes and Abery, 1980)

215

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Conclusions
It is difficult to declare which method for measuring hamstring muscle tightness is the best and
which is inadequate. All have been shown to have high coefficients of reliability (Table A3.4.7). Perhaps
the best test depends upon its application and subject group. For example, youngsters who might be afraid
of standing on a box and bending forward as in a Finger-to-Floor Test might be better suited for a
Modified Sit and Reach Test. Investigators looking for a simpler method might select a Straight Leg
Raising Test over those which require the extensive use of skin markers and photographic methods. In
contrast, flexion-contractured subjects may require the application of the Passive Popliteal Angle Test,
rather than an active test as the Sitting or Standing Reach.
Table G.7. Comparison of the Reliability Coefficients of the Various Methods
Author

Test

Coefficient

AKE

0.99

(Gajdosik and Lusin, 1983) intratester reliability coefficient

PKE

0.98

(Worrell, et al., 1991)

Sit-and-Reach (SAR)

0.98

(Wells and Dillon, 1952)

Modified SAR

0.94

(Hoeger and Hopkins, 1992)

Standing-Reach

0.97

(Fleishman, 1964)

Hip Flexion

0.93-0.98

(Gajdosik, et al., 1994)-long and short


hams groups

Kuntzleman, et al. (1993), referred to two tests as gold-standard teststhe Leighton Flexometer
and SLR/Goniometer (AAOS, 1966). The group stated that the former is most helpful to determine hip
and lower back flexibility. It is performed during the Kraus-Weber Standing-FIexion Test, using a
Leighton pendulum goniometer applied with straps to the chest under the axillae, while the subject rests
his hands on his head. Following that, the arms are lifted above the head and the instrument is zeroed.
Finally, the subject bends forward and maintains a maximum flexion position for three seconds, at which
point, both fingertip distance and Flexometer readings are taken (Broer and Galles, 1958).
Including operator involvement and goniometric measurement, the passive tests, as PKE and
SLR, require extensive hands-on involvement, as well as a treatment table. The AKE and Sit-andReach Test require a table and floor space, respectively, as well as subject effort. In and o f itself, the
Standing-Reach Test needs no operator contact and only minimal eflort, as gravity assists the subject.
The Hip Flexion Angle version o f this test needs hands-on contact only for marker application, but
requires perhaps the most equipment and processing. However, this last method yields the most
information about trunk, pelvis, and pelvifemoral motion.
It is probable that those who combine tests as Gleim, et al. (1990), who used both SLR and
Standing-FIexion in a screening battery, or Gajdosik, et al. (1994), utilizing both SLR and Hip Flexion
Angle, may get optimal results. Combining Standing-Reach and Hip Flexion Angle might yield a means
for quantifying the former in terms o f the latter. If appropriate markers are applied, additional data about
pelvisacral movement can be taken, increasing the base o f information.

216

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Appendix G (cond.)
Spine Curvature Methods
Introduction
As is the case with hamstring tightness, there are several approaches to quantifying spinal
curvature and range of motion. Like many measurement methods, the one selected depends upon the
application and available resources. The more popular techniques, some which have been used
interchangeably with hamstring assessment, will be summarized in this chapter.

General Considerations
Chaffin and Andersson (1991) reviewed several methods for acquiring joint range of motion
information, compiling several 'universal considerations for selecting an appropriate technique. In
developing their list, they had compared several methods, including goniometers, flexometers, and spatial
imaging. The general points essential in the selection of the measurement approach are reviewed below
(Table G.8). One important consideration not listed below is the system resolution.

Table G.8. General Measuring System Considerations (after Chaffin and Andersson, 1991)
1.
2.
3.
4.

5.

6.

Accuracy - report true joint angle deviation (lost if instrument


shifts or not properly positioned over joint center)
Specificity - well-correlated and unbiased measurement of a definable
motor function.
Repeatability - (also lost if measuring device shifts, improves if
it is well-attached).
Ease of use - (minimal prep and data recording times).
a.
Safe
b.
Practical, with easy set-up and use, insensitive to outside influence
Measurement flexibility
a.
Measurements comparable to specific population-based limits
of function (distinguishing between normal and abnormal)
b.
Should not alter function being measured
Cost

Radiographic
Perhaps the gold standard for measuring spinal curvature has been by the use of
roentgenographic methods, primarily those of Cobb (1948) or Ferguson (1949). The former measures the
angle between two tangents to the vertebral endpiates at either end o f the spine segment of interest,
whereas the method o f Ferguson measures the angle between lines drawn at the centroids of three
vertebral bodies: two at the curves extremes and one at the curves apex.

Non-radiographic Methods: Flexion Tests and Goniometry


Because o f several drawbacks, including cost and, most importantly, exposure to radiation,
several non-radiographic methods have been developed to measure spine flexibility and determine the
range o f motion. These include the most commonly-used tests: the Finger-to-Floor, Schdber, and the
single goniometer method of Loebl (1967) (Ohlen, et al., 1989; Dopf, et at., 1994).
The Finger-to-Floor method is essentially the same as that for assessing hamstring muscle
tightness. Both D opf et al. (1994) and Gleim, et al. (1991) felt that the test exhibited poor reproducibility
and was not the best method to determine trunk flexibility, due largely to spurious flexion at the hip. They
did, however, feel that it had better application as a test for hamstring tightness.
217

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The Schdber test compares the distance between two points on the skin surface over the low back
in two postures: standing and flexed in the sagittal plane. The initial point is at the SI landmark, defined
as being in the midline at the level of the sacroiliac dimples. Points are marked on the skin 10 cm
cephalad and 5 cm caudad to S I. The interpoint distance is then measured and IS subtracted for the final
value. Macrae and Wright (1969) described a variation of this test, which included the vertical
measurement to a surface landmark point over C7. Subjects perform a seated flexion test, with the
distances between points measured in the same manner as in the Schdber test, but with the additional
measurement of the distance from the most caudad point to the cervical spine point.
Finally, Loebls pendulum goniometer (inclinometer) is a single goniometric method (Figure
G.8). The technique traditionally uses the T12 spinous process as the landmark, with the subject first in
an erect, then flexed seated position.

Figure G.8. Method of Loebl

Luttgens, et al. (1992) suggested that one of the limitations o f the goniometric methods lies in the
instruments positioning. Accuracy suffers if the instrument is not placed properly over the joint axis o f
rotation, or if bony landmarks are poorly defined (as in the case o f excessive soft tissue). They suggested
that pendulum goniometers, including the Leighton (Leighton, 1955) or Elgon (Adrian, 1968)
instruments, might improve upon this weakness. Gleim, et al. (1991) felt that there was generally a +/10 error with goniometric measurements. Agreeing with Dopf, et al. (1994), they preferred
the modified Schdber test for trunk flexion determination, claiming that Loebl test required more time,
training, and calculations than either of the former two methods. Troup, et al. (1968), commented that
use of Loebls method could better overcome the pelvis movement that contaminates and overestimate true
torso motion. However, even these methods were subject to such error because they, too, encompassed
sacroiliac rotation. More contemporary groups, as Gajdosik, et al. (1994), include sacroiliac motion as
part o f the lumbar spine range, because the motion is so slight and otherwise difficult to control for.
Ohlen, et al. (1989) compared the techniques of Loebls inclinometer to Debrunners
kyphometer. Although more expensive than a goniometer, the measurement time proved to be less
(readings in I minute, as compared to 5 minutes using Loebls inclinometer) and exhibited good
repeatability (Dopf et al., 1994). In addition, determining sagittal mobility was reported to be easier than
with a pantograph (Willner, 1983) and gave good correlations with the Myrin goniometer (Figure G.9).

218

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure G.9. Debrunners Kyphometer (left) and Willners Pantograph (right)


Commonly used in clinical settings to compare the effects of treatment programs on movement
patterns, goniometry has limitations. To be practical, attachment of the device to body segments must be
relatively easy, often restricting their use to the measurement of simple planar motions. Complex, multiaxial motions require complex systems. Attempts at improving the devices led to the production of
instruments as the Flexometer (the inclinometer of Leighton), or the automated Elgon. The Flexometer
demonstrated a standard deviation in repeated measures of less than 3 and correlation of 0.91 with X-ray
when measuring lumbar mobility (Adams, et al., 1986.). However, as with the manual goniometer, use of
the instrument is still limited by its shifting during muscle contraction and positional changes and by well
as errors in attachment (Table G.10).
Table G.9. Advantages and Disadvantages of Goniometric Systems (after Chao, 1978)
A dvantages:
1.
2.
3.
4.

Easy to use, inexpensive


Direct measurements of positions easily understandable
Avoid requirement of direct visualization of segment
position during complex motion
Reasonable repeatability

D isadvanCages:
1.
2.
3.
4.

Positioning difficult, with alignment errors


Signal cross-talk with several transducers at one joint
Soft-tissue motion errors of device relative to skeleton
Abnormal geometries and motion confound transducer/joint
center alignment
5. Joint-angle data to be transformed into inertial reference
axis system for analysis
6. Joint-angle displacement data numerically differentiated
to provide velocity and acceleration data, "which can
be in error because of noise in the displacement signals"
7. Attachment of instrument can alter normal motion patterns

219

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Dopf, et al. (1994) critiqued most of the standard methods and experimentally compared a
commercialiy-produce computerized electrogoniometer with both Schdber and the more complex double
inclinometer methods. For the latter, the angle of interest is the difference of angle readings from two
goniometers placed at different locations along the spine. In addition to quantifying flexion, the authors
suggested that both the inclinometer and electrogoniometer could be used for measuring extension, lateral
flexion, as well as rotation. The good correlation between goniometry, especially, double inclinometer
techniques, and radiographs have led clinical groups as the American Academy of Orthopedic Surgeons
and American Medical Association to recommend their use in spine function evaluation.

Photogrammetry, Videography, and Spatial Imaging


In contrast to the measurement of joint angles and ranges of motion using contact
instrumentation, spatial imaging can be used to locate reference points from photographs or electronic
video systems . Other than the application of surface markers (reflective, non-reflective, or LEDs) over
various landmarks, this method is relatively non-contact and permits a wider range o f subject motion. In
the case of electronic systems, the markers positions are sensed by video spot locators, or cameras with
dual-axis photosensitive diodes. The cameras interface directly with the computer, permitting more
accurate data transduction and simpler digitization than older techniques requiring film or tape as the data
collection medium. Despite the time-consuming calibration, initial cost, and computer time inherent in
electronic spatial imaging systems, their use saves film processing and video data coding time (Table
G .l 1).
Table G.IO. Advantages and Disadvantages of Photogrammetric
and Videographic Systems (after Chao, 1978)
Adva n c a g e s:
1.
2.

3.

4.
5.

P hocogram m etric/V ideographic

Produce motion estimates in absolute reference frame.


Joint centers accurately located by projecting inter
section of long axes of segments when several (3+)
reference markers placed on segment, rather than
over-estimated joint center.
Body reference markers smaller and lower in mass than
either exoskeleton/goniometric or accelerator type
system, with less motion interference.
Multiple camera systems allow 3-D motion determination,
activities may be diverse
Resulting data produce stick diagrams, providing visual

feedback on spatial positions over time.


Disadvantages;

Photogram m etric

1.

Film data manually coded, requiring time and prone to error.

2.

Use of multiple cameras requires care to maintain alignment


and frame synchrony, requiring extra time.
With still cameras, reference points cluster if sampling
rate too low, with difficulty in assessing synchronization
of reference points.
Reference points may be obscured from camera by other body
segments.
Additional calculations required to estimate relative
motions may produce cumulative errors.

3.

4.
5.

Disadvantages:
1.
2.
3.
4.

Videographic

( t e l e v i s i o n and o p to e le c tr o n ic )

Necessary high resolution and fast sampling system of multiple


cameras and electronic equipment is expensive.
Lighting must be controlled, restricting background point-sources.
Large amounts of data that must be stored are quickly acquired,
requiring direct transfer at high sampling rates.
Requires "advanced expertise" in computers and electronics to
maintain and adapt system.

220

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Applications o f these techniques include the comparison of the angles between lines extended
from skin-mounted platform markers placed along the spine in the standing position (Flint, 1963; Troup,
et al., 1968). When ascertaining spine motion or curvature, these markers are frequently positioned at the
ends o f each thoracic and lumbar regions. Such locations include T l, T 11/12, the commonest site o f the
thoracolumbar mortice joint or upper functional limit of the lumbar region (Davis, 19SS), LI, and S2.
Dopf, et al. (1994), in reviewing the use of photogrammetric methods, felt that there was marker
placement variability. In contrast, Drerup and Hierholzer (198S) cited a coefficient of reliability o f 0.87
using the moire fringe technique, at least in the thoracic region.

Surface Tangents Methods


Several authors have determined range of motion angles by measuring the intersections of
tangents drawn at various points along the spinal contour. Israel (19S9) mirrored the spines profile by
using a Keuffel and Esser Flexicurve, a flexible lead strip encased in a plastic sheath. After molding
the strip to the spines surface, the for may be transcribed to paper and marked with tangents to the curve
at various landmarks points along the spine. Dopf, et al. (1994) suggested that a source of variability lies
with the application of the device and transcription of the curve. Willner (1983), rather than using a
draftsmans curve, used a pantograph (a protractor with elongated arms) to look at spine curvatures. Once
the spine shape information was obtained, three tangent lines were used from C7 to LS, placed at points
of inflexion (sic), rather than at landmarks. He gave correlation coefficients of 0.8 and 0.7 between his
method and radiographic data, with differences of 2 to 7 between the methods, which underestimated the
thoracic curve and overestimated the lumbar.

Summary
Examination methods to quantify trunk motion include the popular Schdber, Debrunner, and
double inclinometer techniques, as well as more sophisticated optoelectronic methods. O f the first three,
the double inclinometer appears to have the most applicability in the clinical environment, where a
reliable estimate in required in a fairly rapid and cost-effective manner. The automated methods,
although requiring additional training and greater financial investment, can provide both static and
dynamic data in a non-contact, non-roentgenographic manner. Data processing for these techniques may
be automated considerably because of their direct computer interface. The lack of operator intervention in
taking the actual measurements obviates one important source o f error, thus enhancing the methods
attractiveness. Perhaps the best technique is a combination o f methods, using a simple screening
approach and reserving more expensive applications for more exacting measurement.

221

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix H
THE DEVELOPMENT OF A PLATFORM MARKER
FOR USE IN DETERMINING SPINE ANGLES

Introduction
What is necessary to determine spine angles in a non-radiographic, non-contact
fashion? Two different methods o f optic metrology have been used in the studies
described in the preceding chapters. Both methods required the use o f surface markers
that were affixed to the skin over the midline o f subjects spine. The photogrammetric
method o f Wojtys, et al. (2000) utilized flat, adhesive markers placed on the skins
surface. These markers were appropriate for this method, because the cameras
photographic axis was perpendicular to the plane of the subjects backs, positioning that
was somewhat dependent upon the test platform (Chapter m ). In contrast, the
optoelectronic method described in Chapter V required that the cameras photographic
axis to be parallel to the plane o f our subjects back. This arrangement necessitated the
use o f three-dimensional, spine surface markers.
Pilot studies revealed that commercially available platform markers had two basic
design problems. First, the markers base had a tendency to dislodge when the skin was
distracted during torso movement. In addition, the protrusion of vertebral spinous
processes during torso flexion changed the orientation o f the markers vertical arm relative
to the skins surface. This positional change caused a loss o f marker perpendicularity
relative to the underlying vertebral bodies, which resulted in inaccurate spine angle
measurements.
222

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

This chapter, arranged in three parts, describes the development o f a special


platform marker that was designed to adapt to skin surface stretching while maintaining a
perpendicular orientation to the skin surface. The first part describes a small study that
quantifies the amount o f skin distraction that occurs at select landmarks during sagittal
plane motion from the upright to fully flexed positions. The second part o f the study
details the marker design and the third part describes the marker validation.

Background
There are primarily two approaches used to determine spine segment angles:
contact and non-contact. The contact approach requires the application o f goniometric
measuring devices directly to the skin over palpated landmarks. Some o f the more
popular contact methods and goniometric devices are reviewed in Appendix G.
The non-contact approach may be subdivided into two basic categories:
radiographic and non-radiographic. The radiographic (or roentgenographic) approach
utilizes x-ray exposure o f the subject to identify certain vertebral landmarks. The angles
between the these landmarks are then generally determined by using either the Cobb or,
less commonly, the Ferguson method. Both methods measure the angle between two lines
that demarcate the spine segment o f interest. In the Cobb technique (1948) (Figure 1.3,
page 6), the most cephalad vertebra of the spine segment of interest is demarcated by a
line tangent to its superior endplate. The most caudad vertebra o f the same spine segment
is similarly marked, only by a tangent to its inferior endplate. The angle between the two
tangents at their intersection represents the spine segment angle.

223

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Fergusons method (1949) also determines a spine segment angle by measuring the
angle between two intersecting lines. In this case, centroids o f three vertebral bodies are
used as landmark points, rather than two vertebral endplates. The vertebral bodies that
are selected are at either end (cephalad and caudad) and at the apex o f the spine segment
o f interest (Figure H .l). Centroids are then determined for these vertebrae, and two lines
are drawn, one from the cephalad vertebra to the apical vertebra and one from the caudad
vertebra to the apical vertebra. As in the Cobb method, the angle between the intersection
o f two lines represents the spine segment angle.

Figure H .l. Ferguson Method


Spine angle calculated as the angle between vertebral centroid-based lines

The non-radiographic, non-contact techniques used to measure spine segment


angles include photogrammetric methods that mitigate the need for x-ray exposure. Like
contact goniometric methods, non-radiographic techniques generally require manual
demarcation o f spine segment landmarks. Rather than relying on roentgenologic
224

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

landmarks, surface-mounted markers are placed adjacent to manually palpated structures


which mark the endpoints o f each spine segment.
Once the spine landmarks are identified and the spine segment defined, techniques
similar to those o f Cobb and Ferguson may be used to determine the spine angle.

modification o f the Ferguson method was used in our photogrammetric method (Chapter
III) to measure the angles o f intersection between lines tangent to the skins surface that
originated at surface landmarks at either end o f the spine segment o f interest. A
modification o f the Cobb technique was utilized in our optoelectronic method (Chapter V)
to measure the angles o f intersection between lines that originated from perpendiculars to
the skin surface at either end o f the spine segment o f interest. In both instances, the angle
between two intersecting lines gave the spine segment angle.
Do skin surface markers accurately reflect the position of bony landmarks? The
use of these types o f markers for kinematic studies has been a concern because o f the
potential for inaccuracy in representing both skeletal position and motion. Authors as
Thurston and Harris (1983) or Stokes (1977) have shown that the error between skin
mounted targets and true skeletal motion ranges from 8 to 10%. Troup, et al. (1968)
obtained correlation coefficients o f 0.91 between surface marker and x-ray spine angles
for erect and fully flexed postures for 14 observations, with no significant differences
between the methods by Students t-test at the p< 0.001 level. Using platform markers
perpendicular to the spine at the midline, they nonetheless made the observations that
displacements o f the skin in the long axis o f the spine ... proved to be considerable, and

225

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

that movement o f the skin was a particular source o f errors, especially in the lumbar
region.
Surface markers at the lumbar area are less reliable for other reasons, which
include soft tissue thickness (Willner, 1981; Bryant, et al., 1989). Special care must be
taken when placing surface markers at this region, as the thickness of the superficial
tissues can affect marker position relative to the bony reference point. O f course, such a
feature is less important if radiographic methods are used to identify spine landmarks.

Part One:
The Distraction of the Skin at Select Landmark Points over the Spine Midline
during Sagittal Plane Flexion from Upright to Fully Flexed Postures
The accuracy o f spine angle measurements that are based on skin surface markers
depends on the markers ability to withstand skin distraction. Quantification o f such
movement is therefore essential to surface marker design. Because such information is
lacking in the literature, a small, experimental study was performed to answer two
questions: first, how much does the skin distract over the midline o f the spine at select
landmarks and second, are there significant differences in the amount o f distraction
between landmarks? The answers to these questions provided information that would be
incorporated into the design of a unique surface marker for use in our optoelectronic study
(Chapter V). In that study, optoelectronic methods would be used to determine the spine
angles for hamstring normal (those able to touch the ground in sagittal plane flexion) and
hamstring tight (those unable to touch the ground in sagittal plane flexion) subjects

226

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

positioned in both upright and fully flexed postures. In keeping with the hamstring
category comparison, one primary null hypotheses was advanced:

Primary Null Hypothesis


1).

H o t: There is difference in the amount of skin distraction

between hamstring normal and hamstring tight subjects.

It was expected that hamstring tight subjects would have less skin distraction than
hamstring normals, reflecting a reduced flexion range o f motion.
The secondary null hypothesis was similar to those o f previous chapters:

Secondary Null Hypotheses


1). H 0 2 : There are no age or gender differences of skin distraction.

Methods
Twenty-one volunteers (nine male and twelve female) served as the subject
population for this Human Use Committee-approved study. Our subjects had no gross
kyphoscolioses, had a mean age o f 26.9 ( 10.5) years, a mean height o f 1.73 ( 0.09)
meters, and a mean weight o f 67.68 ( 9.71) kilograms. Approximately one-half exhibited
hamstring tightness (shortness) and were unable to touch the floor with their fingertips in
full sagittal plane flexion (Finger-to-Floor Reach Test, Appendix G).
Skin distraction was measured at five landmark points on the bared backs o f each
subject. These points were the first and the tenth thoracic vertebrae (T l, T10), the third
lumbar vertebra (L3), the first sacral segment (SI), and the posterior-superior iliac spine
(PSIS). The skin over these landmark points was then marked using non-toxic, watersoluble ink. A pattern o f four dots, one at each comer o f a balsa wood template (Figure
227

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

H.2), was placed at each landmark point. The template consisted o f two, rectangular
pieces of wood fastened together at right angles.
Distraction o f the skin over the each landmark site was then determined. Initial
measurements were taken between superoinferior and mediolateral pairs of template

Figure H.2. Balsa Template


Horizontal Base: 1 1/8 x 3/4 x 1/4; Vertical Stanchion: 1 3/4 x 1/2 x 1/4

points at all five landmarks with the subjects in the upright posture. Each participant was
then asked to fully flex in the sagittal plane (bend forward) and the measurements between
the same pairs o f template points were repeated. The differences between the initial and
final measurements at all landmark points for each subject were then calculated and
expressed as percent strain, with mean strains calculated for both hamstring normal and
hamstring tight groups. Repetition o f the measurements produced an error which, with
the exception of two outliers, ranged from an underestimation o f 1.5 mm. to an
overestimation o f the initial value by 1.5 mm., with a mean underestimation o f 0.07 mm.
This measurement error, similar to that found by van Weeren and Bameveld (1986), was
propagated as a maximum strain error o f approximately 1.7%.

228

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Results: Skin Distraction


Mean superoinferior and mediolaterai percent strains for each spine landmark were
calculated (Table H. 1). With the exception o f the skin over the T10 landmark, distraction
in the superoinferior direction was greater than that in the mediolaterai direction. In the
superoinferior direction, percent strain ranged from -3.7% at T1 to 53.9% at the PSIS
landmark. The negative value at the T1 landmark was probably the result o f the cervical
spine extension that occurred during flexion as the subjects lifted their heads to look up.

Table H .l. Mean Percent Strain at Various Spine Landmarks


(s.d. = standard deviation) Note how the mean length % strain increases from T1 to SI

Superoinferior
Landmark m ean (mm.) s.d.
T1
-3.7
13.1
T10
10.7
10.2
7.1
L3
41.7
S1
49.7
9.7
PSIS
53.9
11.8

M ediolaterai
m ean (mm.)
s.d.
0.0
6.1
10.2
20.5
6.1
6.5
6.3
1.6
4.9
0.1

The mean percent strain differences between adjacent landmarks were then
calculated (Table H.2). The greatest change in superoinferior strain occurred between the
T10 and L3 levels, more than twice that of the T1-T10 difference. The greatest difference
in mediolaterai strain was between T1 and T10, almost twice that o f T10-L3. These
findings were exhibited by both gender groups (Figures H.3 and H.4).

Table H.2. Mean Differences of Percent Strain between Landmark Points


T1 to T10
T10toL3
L3 to S1
S1 to PSIS

Superoinferior
14.4
31
8
4.2

Mediolaterai
20.5
-14.4
-4.5
-1.5

229

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

601
11 MALES
a

fe m a le s

-20 J

-------------------------------------------------------------------------------------------------------T10
L3
si
psis

Landmarks

Figures H.3. Superoinferior Skin Surface Strain by Gender

9
a

MALES
FEMALES

-10 J --------------------------------------------------------------------------------------------------------------------------

XI

T10

L3

SI

PSIS

Landmarks

Figure H.4. Mediolaterai Skin Surface Strain by Gender


230

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

T-tests were then used to compare the means of the skin distraction percent strains
at the various landmarks between hamstring normal and hamstring tight subjects. There
were no significant differences o f percent strains between the two groups at the a=0.05
significance level. However, after dividing the subjects according to gender, t-tests
revealed a significant difference o f superoinferior percent strain at the L3 landmark
between hamstring groups for males (p=0.049) and a difference that approached
significance (p=0.080) o f the mediolaterai percent strain at the L3 landmark between
hamstring groups for females (Table H.3). Interestingly, this landmark had a moderately
strong, inverse correlation (r = -0.720) between mediolaterai percent strain and reach
distance in hamstring tight subjects. These findings led to the acceptance of the first null
hypothesis.

Table H.3. Skin Distraction (Mean Percent Strain) at L3 for


Hamstring Normal and Hamstring Tight Subjects
(s.d. = standard deviation)

H am string Normal Ham string Tight


s.d.
m ean
s.d.
m ean

Females
mediolaterai
n
Males
superoinferior
n

p-value

7.62
7

5.42

2.49
5

2.51

0.080

46.33
3

4.61

35.12
3

5.18

0.049

The data were then examined for significant differences of skin distraction by age
and between genders. Subjects were divided into two ages groupunder 30 years old and
over 30 years old (Table H.4). Contrary to what was expected, there were no significant
differences o f percent strains between age groups. Neither were there significant
231

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

differences o f percent strains between genders, even though males were significantly taller
and heavier than females (Table H.5). These findings led to the acceptance o f the second
null hypothesis.

Table H.4. Mean Ages of Subjects Grouped as


Over 30 years and Under 30 years of Age
(s.d. = standard deviation)

< 30 yrs.
> 30 yrs.

s.d.
2.82
19.92

m ean yrs.
23.72
46.00

n
18
3

Table H.S. Mean Weight and Height for Females and Males
(s.d. = standard deviation) Males were significantly larger than females.

females
males
p-value

W eight (kg.)
m ean
s.d.
4.70
61.51
75.91
8.50
0.000

H eight (m.)
m ean
s.d.
1.67
0.06
1.81
0.06
0.000

n
12
9

Discussion: Skin Distraction


How did skin distraction in the two directions compare? At every spine landmark
level, with the exception o f T10, mean skin distraction in the superoinferior direction was
greater than mean distraction in the mediolaterai direction. The superoinferior strains
increased consistently from cephalad to caudad along the spine, with the greatest mean
distraction over the PSIS and SI (53.9% and 49.7% strain, respectively). In contrast,
mean mediolaterai strains diminished from T10 to PSIS. A larger mean mediolaterai
distraction at the T10 level was probably the result o f traction on the skin by the
dependence o f osseous and soft tissue (upper extremities, scapulae, and breast tissue) in

232

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

forward flexion. Tissue dependence was likely also the explanation o f the large difference
in mediolaterai strain between T1 and T10.
How did the differences o f percent strain from landmark to landmark compare?
There was a pronounced difference in mean superoinferior strain between the TIO and L3
landmarks. This likely reflected the greater flexion range o f motion that the lumbar spine
has as compared to the thoracic spine, which is relatively fixed due to the ribs. The greater
flexion range o f motion may also be the explanation o f the moderately strong inverse
correlation between reach distance and mediolaterai distraction at L3 in hamstring tight
subjects.
Conclusions: Skin Distraction
At least two important points were made in this small study. The first point was
the quantification o f the superoinferior and mediolaterai skin distraction at several
landmarks along the human spine, something that is lacking in the literature. The
superoinferior percent strain increased and mediolaterai percent strain decreased from
thoracic to sacral regions, reflecting the relative increase in spine segment motion from
thoracic to lumbar region.
The second point is that hamstring normal subjects able to touch the floor in a
Finger-to-Floor Reach Test had significantly larger superoinferior and mediolaterai skin
distraction than hamstring tight individuals, those unable to touch the floor in sagittal
plane flexion. While it is not possible to prove it in this study, this finding suggests that
hamstring tightness affects lumbar motion during flexion.

233

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Part Two:
The Design of the Unique Platform Marker
Introduction
What kind o f design specifications are required of the new platform marker? The
ideal platform marker for skin surface must adapt to skin motion and maintain a
perpendicular orientation to the skins surface independent o f the subjects degree o f
flexion. This orientation was required in order to use the Cobb method to measure the
angles between lines denoting spine segment endpoints.
From an earlier pilot study, it was apparent that markers modeled after what was
commercially available, a flat base with a vertical arm, would not accurately reflect the
position of the vertebrae in dynamic situations. As stated above, the vertical arm would
have to maintain a perpendicular orientation to the skins surface. The frame that
supported the vertical arm would require both the strength and flexibility to withstand the
skin surface motion that accompanied postural change. These surface motions included
skin distraction o f up to about 54% strain in the superoinferior direction and up to about
21% in the mediolaterai direction. They also included changes in surface topography from
projecting spinous processes and prominent paravertebral musculature.

Materials and Method


The surface markers developed here would be used in the acquisition o f spine
segment angle data by an optoelectronic system. That system (MacReflex*) was equipped
with infrared light emitting diodes (IREDs) and infrared sensors. The sensors, arranged as

234

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

two camera lenses in stereo, would detect light that originated from the IREDs and was
reflected at the target by means o f an optical material, in this case, reflective tape. The
diodes were arranged in arrays surrounding each o f the sensor lenses. Once detected, the
geometric area o f the reflected light signals would be reduced to centroid points and
translated to two-dimensional, point coordinate data using the MacReflex software.
Surface platform markers were designed to act as the carriers o f the
retroreflective, adhesive tape. The markers vertical arms would serve as a frame upon
which two pieces o f the retroreflective tape could be affixed. These pieces of tape, one
placed proximal and one distal to the skin surface, would serve as the basis for spine angle
determination. When optically illuminated and recorded, the two points marked by the
separate tape pieces would be used to establish lines perpendicular to the skins surface.
With one surface marker positioned at either end o f the spine segment o f interest, the
intersection angle o f the two projected lines could then be determined using a method
similar to the Cobb technique (Chapter 1).
The materials selected for the fabrication o f the marker needed to be both rigid and
flexible. Rigidity was required so that the optical marker portion would not loose its
orientation normal to the subjects skin surfaces. Flexibility was necessary in order to
provide clearances for the skin distraction, protruding vertebral processes, and contracting
paravertebral muscles that would accompany changes in subject posture. Nineteen gauge,
beryllium bronze wire was found to be both flexible and rigid, which provided a tolerance
to the experimentally determined skin strains without permanent deformation. A
prototypical design o f a pair o f soldered, A shaped arches having four pivoting balsa
235

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

feet did not meet the distraction criteria and was difficult to affix to the skin. In the final,
improved design, the number o f mounting feet was reduced from four to two, thereby
limiting skin contact area and simplifying application. The construction material o f the
feet was changed from balsa to 0.006 brass shimstock, which also provided the required
rigidity and flexibility. Each shimstock mounting foot was formed as an arch and was
oriented perpendicular to the long axis of the marker. This design o f the shimstock bases
permitted accommodation o f the protruding anatomical structures as well as for the
mediolaterai distraction o f the skin.
The skin surface platform markers were then constructed. The beryllium bronze
wire was shaped as a distensible loop, thereby forming a frame whose rigidity in the
longitudinal orientation was adjusted simply by enlarging the loop size (Figure H.5). A
wire stanchion, constructed o f the same material, was then soldered at the apex o f the
frame loop, perpendicular to it. One piece of retroreflective tape was positioned at either
end o f the stanchion, which would be oriented as a vertical to the skin surface. The two
pieces of tape provided the optical point sources which provided the raw data.
The shimstock feet were then affixed to either end o f the wire loop. The thin,
contoured feet were soldered to sections o f 19 gauge hypodermic needle, which acted as
ferrules. Assembled in this fashion, the shimstock feet would pivot on the bearings. When
the marker was affixed to the skin surface using double-side electrode adhesive tape in a
pre-loaded fashion (pre-bent in compression), the loop could expand and contract
according to the amount o f skin distraction, without disrupting the perpendicular

236

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

orientation o f the markers stanchion relative to the skin surface and to the underlying
vertebra.

Figure H.5. The Unique Platform Marker

Part Three:
Validation of the Unique Platform Marker
Introduction
The third part o f this chapter focuses on the validation o f the marker by answering
three questions: Do the marker perpendiculars remain normal to the skin surface during
distraction? Can the markers be positioned accurately over the spine landmarks whose
position they are to represent? Are the vertebral segment angles generated by these
surface markers equal to those obtained radiographically?

237

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Orientation of the Perpendicular Arm during Distraction


Methods and Results
The first portion o f the validation study was designed to verify the trueness o f the
markers perpendicular stanchions over the superoinferior distraction range o f about 50%
strain. Each of the markers were placed on distractible material mounted over a flat
surface. To provide a hard-copy print for accurate goniometric readings o f
perpendicularity, the marker/material pair was x-rayed, first with the distractible material
relaxed and then with it stretched to about 50% strain, which was equivalent to the
maximum superoinferior skin distraction value determined earlier in this chapter.
A goniometer was then used to measure the x-ray images. The angles between the
vertical stanchions and the horizontal mounting base were determined for all five markers.
Three o f the five marker stanchions remained absolutely perpendicular to the experimental
surface despite the linear distraction o f the mounting material, while the remaining two
were off o f true normal by less than 2.

Surface Marker Placement: The Positions of the Surface Markers


Relative to Underlying Vertebrae
Methods and Results
The second portion o f the validation study was aimed at verifying the position o f
the platform marker stanchion relative to the intended radiographic landmark. Two males
and three females acted as subjects for this portion o f the study, following Human Use
Committee approval. Three subjects were already diagnosed has having Scheuermanns
Disease and required follow-up x-ray evaluation, while two were non-kyphotic volunteers.
238

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The unique platform markers were then applied. To minimize multiple-operator


discrepancy, one person was responsible for identifying the landmark sites and for
applying the platform markers. Each o f four vertebral bodies (T l, TIO, L3, and SI) was
identified by palpation. Over each site, the skin surface was cleansed of body oils and skin
detritis using prepackaged alcohol wipes. The surface markers were affixed to the bared
skin with double-sided electrode adhesive.
Standard scoliosis radiographs were then taken o f each subject. The scoliosis
series consisted of anteroposterior and lateral x-rays taken o f the subject standing upright
with arms outstretched at shoulder height. The x-ray film material was positioned in front
o f a special postural screen in which was imbedded a plumbed, vertical reference line.
Although both views were developed, only the lateral view was used to determine the
spine marker placement error. The error was determined by comparing the position o f a
line extended from each surface markers vertical stanchion to the position of a line drawn
along the corresponding vertebral bodys endplate.
The endplates o f the four vertebrae were demarcated for each o f the five subjects
in the following fashion. First, the four comers of each vertebral body were marked.
Endplate positions were then demarcated by connecting either the superior or inferior
pairs of comer marks with a line, depending upon which aspect of the selected spine
segment that vertebra was intended to represent. The positions o f these endplate lines
were then compared to the positions o f the surface marker stanchion lines, with the
distance between them measured.

239

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The distance between stanchion lines and endplate lines was expressed in terms of
vertebral body height, rather than in millimeters. This was done for two reasons: first, to
control for any age, gender, and stature-related differences in vertebral height and second,
to control for the different vertebral proportions characteristic o f each spine region.
Table H.6 shows that the majority of placement errors were small, ranging from no error
(0) to a difference o f one vertebral body height between surface stanchion line and the
intended, landmark vertebra endplate line (I)- Table H.7 shows the marker placement
error for each landmark vertebra, expressed as an average o f the distances in terms of
fractions o f vertebral body height.

Table H.6. Tally of the Number of Measurement Errors expressed as


Percent of Total Measurements
Difference equals the Difference between Surface Marker Perpendicular Line and the
Vertebral Body Endplate Line expressed in Fractions of Vertebral Body Height
D iffe re n c e

% o f m e a a u rm e n ts

35

0 .5

35

20

1 .5

2 .5

5
100

Table H.7. Mean Distance between Surface Marker Perpendicular Line and
Endplate Tangent for each Landmark Vertebra, expressed as
Fractions of Vertebral Body Height
1
m ean

T1
T10
L3
S1

0 .7
0 .3
0 .2
1 .4

s.d.
0.45
0.27
0.27
1.29

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Discussion
Surface Marker Placement
The vast majority (90%) o f the surface markers were positioned within one
vertebral body height of their intended radiographic targets (35% directly at their targets,
35% within half a vertebral body away, and 20% one vertebral body away). Placement
errors greater than two vertebral body heights away from their mark all occurred at the SI
level. This difference was likely the result of two factors: the thickness of the soft tissue
at that level o f the sacrum and the inclination of the sacral base away from the skin surface
at that point. Surprisingly, the most reliable marker placement was at the level o f L3, with
an average surface marker perpendicular-to-endplate distance o f 0.2 vertebral body
heights (Table H.7). The mean distance values then increased from T10, followed by T l,
and then, SI. The placement error at T l was due not so much to palpatory difficulty (as
this is perhaps the easiest surface landmark to palpate), but in identifying radiographic
endplate landmarks at that level. On x-ray, the first thoracic vertebrae are frequently
washed-out, or obscured, due to the thickness and relative opacity o f the soft and
osseous tissues o f the shoulder girdle.

Comparison of the Spine Segment Angles based on Surface Markers and X-rays
Methods
In the third portion of the Validation Study, we compared the spine segment
angles generated using skin surface markers to those obtained from radiographs. Lateral
radiographs from our five volunteers were again used. The three females and two males

241

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

had a mean age o f 19.3 ( 8.5) years, a mean height o f 1.68 ( 0.07) meters, and a mean
weight o f 57.59 ( 5.25) kilograms. This time, the positions o f the surface marker
stanchion lines were not compared to the positions o f the vertebral body endplate lines.
Rather, the four markers used in Section 2 (T l, T10, L3, and S I) were paired into groups
denoting three spine segments: T1-T10, T10-L3, and L3-S1.
Because the surface markers were radio-opaque, each subjects lateral view x-ray
could provide both surface marker-based and vertebral marker-based spine segment angle
data. Thus, the angle between the vertical stanchion lines from the surface markers over
T l and T10 would be the surface marker method data for the T1-T10 spine segment. The
angle between the superior endplate o f the Tl vertebral body and the inferior endplate o f
the T10 vertebral body would be the radiographic method data for the same segment.
These angles were determined using the Cobb technique, described in Chapters I.

Results: Comparison of the Two Angle Techniques


Mean angle values for each spine segment were then calculated and the means for
each method were then compared. With a set at 0.050, Students unpaired t-tests
demonstrated no significant differences between the two spine segment angle calculation
methods for the T1-T10 and T10-L3 segments (Table H.8).

Table H.8. Mean X-ray-based and Surface Marker-based Angle Values


for the T1-T10, T10-L3, and L3-S1 Spine Segments
(s.d. = standard deviation; n.s. = not significant)
X -ray
m ean d ag.

T1T10
T10L3
L3S1

49
11
53

M ark e r

s.d.
10
7
8

m ean deg.

s .d

44

15
42

7
14

p -v a lu e
n .s .
n .s .
0 .0 0 2

242

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

There was, however, a significant difference between x-ray and platform marker
angles for the L3-S1 spine segment (p=0.002). Like Leroux, et al. (2000), who studied
the difference o f thoracic angles generated by radiographic and stereovideographic
methods in 124 subjects, our results showed that there was a greater between-method
difference o f angle values for the lumbar region that for the thoracic region. While our
surface method underestimated the radiographic method angle, as did the surface tangent
method o f Chemukha, et al. (1998), it did so more dramatically, in that our x-ray based
angle mean was about two and one-half times that o f the surface marker method mean.
With the highest marker placement error at SI, it is likely that the more pronounced
lumbosacral angle o f L5-SI was not incorporated in surface measurements. As stated
earlier, it is likely that soft tissue thickness is a factor, similar to what was reported by
Bryant, et al. (1989) or Refshauge, et al. (1994), who compared surface contour to
radiographic measurements o f the upper spine.
Our findings contradict the observations o f Portek, et al. (1983), who wrote that
surface markers used in the lumbar region tend to overestimate angles. They are also do
not agree with the findings o f Vanneuville, et al. (1994), who had reported that the
overestimation o f spine angles by surface markers was greatest at the L3-S1 segment and
decreased towards the thoracolumbar region, the approximate area where surface markerbased angles began to underestimate radiographic angles.

243

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

anthropometrically-based correction factors for skin thickness and sacral orientation can
be developed from a larger sample.

245

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Appendix I: Mean Annual Training Time for Various Groups

Table 1.1. Mean Annual Training Times by Age in Years for Female and Male
Athletes grouped by Kyphosis Category and Hamstring Shortness Status
Age in years; times are in hours; s.d. = standard deviation; * = small n
N o rm o k y p h o tlc
A ge

m ean

a.d.

H a m s trin g S h o rt
m ean

s.d.

H y p e rk y p h o tic

H a m s trin g -N o rm a l i
m ean

m ean

& d.

s.d.

Female
9

219

94

10

343

253

66

11

360

117
274
229
205
202
222
417

358

12

342

13

282

14

280

15

289

16

401

17

494

208
332
(4 5 1 )*
(4 6 5 )*
326

8
3
172
214
174
270
122

208

58

220

414

483
(6 7 2 )*

364

220
147
251

411

303

405

(4 1 3 )*

241
184
328
371

347

406

(3 2 0 )*
512
584

388

367
445
(3 8 1 )*

145
576
248
282
165
169
168
209

Male
9

155

10

(1 9 3 )*

11

197

12

191

13

233

14

226

15

260

16

274

17

313

18

314

145
191
175
183
197
165
168
167
188
179

174
186
189
198
232
( 2 5 1 )*
270
270
305
( 4 1 0 )*

137
117
147
184
145
191
149
167
201
288

219
240
227
232
251
(2 5 1 )*
272
288
316
(3 0 8 )*

207
215
218
243
218
196
185
177
178
143

300
240
260
323
275
288
273
282
290
244

255
110
353
398
221
264
140
167
173
103

Table 1.2. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category and Hamstring Shortness Status
Age Group: I = 8-10 years, 2 = 11-13 years, 3 = 14-18 years; s.d. = standard deviation; * = small n
A ge
G ro u p

N o rm o lg / p h o t i c
m ean

H a m s trl n g - S h o r t

s.d.

m ean

219
228
245

297

s.d.

H a m s trin g -N o rm a l
m ean

s.d.

Female
1

302

314

330

66

(4 2 9 )*

8
191
200

340
386
414

H yp e rk y rp h o tic
! m ean

s.d.

207
262
270

417

180
232
184

264

153

287

295

281

174

412
372

177
256
162

Male
1

183

214

269

179
189
173

182
211
274

117
156
176

208
243
279

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

REFERENCES

247

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Adams GR. Role o f insulin-like growth factor-I in the regulation o f skeletal muscle
adaptation to increased loading. Exerc Sport Sci Rev, 26:31-60, 1998.
Adams MA, Dolan P, Hutton WC, Porter RW. Diurnal changes in spinal mechanics and
their clinical significance. J Bone Joint Surg 72(2):266-70, Mar 1990.
Adams MA, Dolan P, Marx C, Hutton WC. An electronic inclinometer technique for
measuring lumbar curvature. Clin Biomech, l(l):130-4, 1986.
Adrian MJ. An introduction to electrogoniometry. In Kinesiology Review, Amer Assoc
Health Phys Ed Rec, Washington, DC, 1968.
Afsani E, Kuhn JP. Common causes o f low back pain in children. Radiographics, 11:269291, 1991.
Aggrawal ND, Ravinder K, Kumar S, Mathur DN. A study of changes in the spine in
weight lifters and other athletes. Brit J Sports Med, 13:58-61, 1979.
Alexander CJ. Scheuermanns disease, a traumatic spondylodystrophy? Skel Rad, 1:20921, 1977.
al-Gazali LI, Bakalinova D, Varady E, Scorer J, Nork M. Further delineation o f the Nevo
syndrome. J Med Genet, 34(5):366-70, May 1997.
Almeida-Silveira MI, Perot C, Pousson M, Goubel F. Effects o f stretch-shortening cycle
training on mechanical properties and fibre type transition in the rat soleus muscle.
Pflugers Arch, 427(3-4):289-94, Jun 1994.
Alway SE, Winchester PK, Davis ME, Gonyea WJ. Regionalized adaptations and muscle
fiber proliferation in stretch-induced enlargement. J Appl Physiol, 66(2):771-81, Feb 1989.
American Academy o f Orthopedic Surgeons. Athletic training and sports medicine.
AAOS, Park Ridge, IL, 1991.
American Academy o f Pediatrics, Committee on Sports Medicine: Fitness, Activity, and
Sports Participation in the PreSchool Child. Pediatrics 90(6): 1002-1004,1992.
American Medical Association. Guide to the evaluation of permanent impairment, 3rd ed.
Chicago, 1990.
Amonoo-Kuofi HS. Changes in the lumbosacral angle, sacral inclination and the curvature
o f the lumbar spine during aging. Acta Anat, 145(4):373-7,1992.
Anderson JE. Grants atlas o f anatomy, 8th ed. Williams & Wilkins, Baltimore, 1983.
248

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Anderson M, Green WT, Messner MB. Growth and predictions o f growth in the lower
extremities. ClinOrthop Rel Res 136:7-21, Oct 1978.
Anderson MK, Hall SJ. Sports injury management. Williams & Wilkins, Baltimore, 1995.
Anderssen N, Jacobs DR Jr, Aas H, Jakobsen R. Do adolescents and parents report each
others physical activity accurately? Scand J Med Sci Sports, 5(5):302-7, Oct. 1995.
Aoshiba H, Kusaka Y, Nakajima S, Uemura O, Seo Y, Murakami M, Hirasawa Y. Matrix
strain and water redistribution within the intervertebral disc under non-axial bending
stress. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Apley AG. System o f orthopaedics and fractures, 5th ed. Butterworths, London, p. 212.
1977.
Armstrong CG, Lai WM, Mow VC. An analysis o f the unconfined compression o f
articular cartilage. J Biomech Eng 106(2): 165-173, May 1984.
Ascani E, Montanaro A. Scheuermanns disease. In: The Pediatric Spine (Bradford DS
and Hensinger RN, ed.) Thieme, New York. 307-324. 1985.
Ascani E, Salsano V, Giglio G. The incidence and early detection o f spinal deformities. A
study based on the screening o f 16,104 schoolchildren. Ital J Orthop Traumatol. 3:111117, 1977.
Ashton-Miller JA, McGlashen KM, Schultz AB. Trunk positioning accuracy in children 718 years old. J Orthop Res, 10:217-225, 1992.
Aufdermauer M. Juvenile kyphosis (Scheuermanns disease): radiography, histology, and
pathogenesis. ClinOrthop (154):166-74, Jan-Feb 1981.
Axelgaard J, Nordwall A, Brown JC. Correction o f curvatures by transcutaneous electrical
muscle stimulation. Spine, 8:463, 1983.
Balague F, Dutoit G, Waldburger M: Low back pain in schoolchildren. An
epidemiological study. Scand Journal Rehab Med 20: 175-179, 1988.
Bandy WD, Irion JM. The effect o f time on static stretch on the flexibility o f the hamstring
muscles. Phys Ther, 74(9):845-852, Sept, 1994.
Baranowski T. Validity and reliability o f self report measures o f physical activity: An
Information-Processing Perspective. Res Quar Exer Sport 59(4):314-327,1988.

249

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Baranowski T, Dworkin RJ, Cieslik CJ, Hooks P, Clearman DR, Ray L, Dunn JK, Nader
PR. Reliability and validity o f self report o f aerobic activity: Family Health Project. Res
Quar Exer Sport 55(4):309-317, 1984.
Bar-Or O, Lombardo JA, Rowland TW: Prepubertal exercise: how much, when? Patient
Care, October 30, 1989.
Bass S, Pearce G, Bradney M, Hendrich E, Delmas PD, Harding A, Seeman E. Exercise
before puberty may confer residual benefits in bone density in adulthood: studies in active
prepubertal and retired female gymnasts. J Bone Miner Res. l3(3):500-7, Mar 1998.
Bass S, Pearce G, Young N, Seeman E. Bone mass during growth: the effects o f exercise.
Exercise and mineral accrual. Acta Univ Carolinae-Med 40(l-4):3-6, 1994.
Bay BK, Yerby SA, McLain RF. Spatial distribution o f strain within vertebral trabecular
bone. Proc Orthop Res Soc, p. 797, Feb 1997.
Beal MC. The sacro-iliac problem: review o f anatomy, mechanics, and diagnosis. J Amer
Osteopathic Assoc, 8l(10):73-85, 1982.
Beard DJ, Kyberd PJ, OConnor JJ, Fergusson CM, Dodd CA. Reflex hamstring
contraction latency in anterior cruciate ligament deficiency. J Orthop Res, 12(2):219-28,
Mar 1994.
Beunen GP, Malina RM, Renson R, Simons J, Ostyn M, Lefevre J. Physical activity and
growth, maturation and performance: a longitudinal study. Med Sci Sports Exerc,
24(5):576-585, May 1992.
Bick EM. The osteohistology o f the normal human vertebra. Its relation to scoliosis and
certain lesions incident to growth and senescence. J Mt. Sinai Hosp, 19:490-527, 1952.
Bick EM, Copel JW. The ring apophysis o f the human vertebra. J Bone Joint Surg,
33A(3):783-787, July, 1951.
Bielby RC, Fermor B, Emerton ME, Murray DW, Urban JPG. Mechanical strain alters
proteoglycan synthesis by culture annulus fibrosus cells. Proc Orthop Res Soc, New
Orleans, LA. March, 1998.
Bimbaum K, Siebert CH, Hinkelman J, Prescher A, Niethard FU. Correction o f kyphotic
deformity before and after transection o f the anterior longitudinal Ugament-a cadaver
study. Arch Orthop Trauma Surg, 121(3):142-7, 2001.
Blazek O, Streda A, Cermak V, Skallova O. The incidence of morbus scheuermann in
sportsmen. J Sports Med, 26:55-9, 1986.
250

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Blix M. Die lange and die spannung des muskels. Skand Arch Physiol. 5:149-205, 1894.
Bohannon R, Gajdosik R, LeVeau BF. Contribution o f pelvic and lower limb motion to
increases in the angle o f passive straight leg raising. Phys Ther, 65(4):474-6,1985.
Bohannon RW, Gajdosik RL, LeVeau BF. Relationship o f pelvic and thigh motions
during unilateral and bilateral hip flexion. Phys Ther, 65(10): 1501-4, Oct 1985.
Bohannon RW. Cinematographic analysis o f the passive straight-leg raising test for
hamstring muscle length. Phys Ther, 62:1269-1274, 1982.
Booth FW, Criswell DS. Molecular events underlying skeletal muscle atrophy and the
development of effective countermeasures. Int J Sports Med, 18 Suppl 4:S265-9, Oct
1997.
Booth FW, Gollnick PD. Effects o f disuse on the structure and function o f skeletal
muscle. Med Sci Sports Exerc 15(5):415-20, 1983.
Bosekar EH. The determination o f the normal thoracic kyphosis: a roentgenographic
study of the spines of 121 normal children. Presented at Gillete Childrens Hospital, St.
Paul, MN, 1958.
Bosekar EH, Moe JH, Winter RB, Koop SE. Determination o f normal thoracic
kyphosis: a roentgenographic study o f 121 normal children. J Ped Orthop 20(6):796-8,
Nov-Dee 2000.
Bradford DS. Juvenile kyphosis. ClinOrthop, 128:45-55, 1977.
Bradford, DS. Juvenile kyphosis. In Moes Textbook o f Scoliosis and Other Spinal
Deformities, 3rd. ed. Saunders, Phila., 1995.
Bradford DS, Hensinger RM, eds. The pediatric spine. Thieme, New York, 1985.
Bradford DS, Moe JH, Montalvo FJ, Winter RB. Scheuermanns kyphosis and roundback
deformity, results o f milwaukee brace treatment in twenty-two patients. J Bone Joint Surg
57A:439, 1975.
Bradford DS, Moe JH, Winter RB. Kyphosis and postural roundback deformity in
children and adolescents. Minn Med 56:114-120, 1973.
Bridger RS, Wilkinson D, VanHouweninge T. Hip joint mobility and spinal angles in
standing and in different sitting postures. HumFac, 31(2):229-241,1989.
251

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Bright RW, Burstein AH, Elmore SM. Epiphyseal plate cartilage: a biochemical and
histological analysis o f failure modes. J Bone Joint Surg, 56A:688-705, 1974.
Broberg KB. Slow deformation o f intervertebral discs. J Biomech 26(4-5):501-12, AprMay 1993.
Brodersen A, Pedersen B, Reimers J. Incidence o f short hamstrings and leg muscles at
ages 3-17 years. Ugeskr Laeger, 155(46):3764-6, Nov 1993.
Broer MR, Galles NRG. Importance o f relationship between various body measurements
in performance o f the toe-touch test. Res Quar 29:253-263, 1958.
Brown CH: New dimensions in physical activity and fitness for girls and women.
American Corrective Therapy Journal 25(3): 68-70, 1971.
Brown M, Fisher JS, Salsich G. Stillness and muscle function with age and reduced
muscle use. J Orthop Res, 17(3):409-14, May 1999.
Bryant JT, Reid JG, Smith BL, Stevensen JM. Method for determining vertebral body
positions in the sagittal plane using skin markers. Spine, 14(3):258-65, Mar. 1989.
Buchman J. Osteochondritis o f the vertebral body. J Bone Joint Surg, 9:55, 1927.
Budzinski MA, Han SM, Mazurchuk RV, Swiencicki JF, Ziv I. Disc hydration measured
by magnetic imaging in relation to its compressive stiffness in the dehydrated rat. Proc
Orthop Res Soc, p. 387, Feb 1997.
Burkett LN. Cause and prevention o f hamstring pulls. Athletic J 51:77, 1971
Buschmann MD, Hunziker EB, Kim YJ, Grodzinsky AJ. Altered aggrecan synthesis
correlates with cell and nucleus structure in statically compressed cartilage. J Cell Sci,
109(Pt2):499-508, Feb 1996.
Butler RW. The nature and significance of vertebral osteochondritis. Proc Roy Soc Med,
48:895-902, 1955.
Bylski-Austrow DI, Wall EJ, Kolata R, Ballard E, Crawford A. Endoscopic mechanical
spinal hemiepiphsiodesis modifies spine growth. Proc Orthop Res Soc, 46th Meeting:p.
265, Orlando, FL, March 12-15,2000.
Caine D, Howe W, Ross W, Bergman G. Does repetitive physical loading inhibit radial
growth in female gymnasts? Clin J Sport Med. 7(4):302-8, Oct 1997.

252

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Carlsdd S. The static muscle load in different work positions: an electromyographic study.
Ergonomics, 4:193-211, 1961.
Carter JEL. The somatotypes o f athletes-a review. Hum Biol 42:535-569, 1970.
Caterson B, Lowther DA. Changes in the metabolism of the proteoglycans from sheep
articular cartilage in response to mechanical stress. Biochim Bio phys Acta, 540:412-422,
1978.
Chaffin DB, Andersson GBJ. Occupational biomechanics, 2nd ed. Wiley & Sons, New
York, 1991
Chandler RF, Clauser CE, McConville JP, Reynolds HM, Young JW. Investigation of
inertial properties o f the human body. AMRL-TR-74-137, Aerospace Medical Research
Laboratories, OH, 1975.
Chao EY. Experimental methods for biomechanical measurements o f joint kinematics.
CRC Handbook for Engineering in Medicine and Biology, vol. 1 (Feinberg, BN &
Fleming, DG, eds.). CRC Press, Cleveland; pp. 385-411, 1978.
Chen CT, Burton-Wurster N, Lust G. Loading rate and duration affect degeneration of
articular cartilage: a water content study. Proc Orthop Res Soc, New Orleans, LA. March,
1998.
Chemukha KV, Daffiier RH, Reigel DH. Lumbar lordosis measurement. A new method
versus cobb technique. Spine, 23(l):74-80, 1998.
Chiu EJ, Newitt DC, Hu SS, Lotz JC, Majumdar S. MRI measurement of water diffiision
in the human intervertebral disc with compression. Proc Orthop Res Soc, p. 123-21, Feb
1997.
Cibulka MT, Rose SJ, Delitto A, Sinacore DR. Hamstring muscle strain treated by
mobilizing the sacroiliac joint. Phys Ther, 66(8):1220-3, 1986.
Clayson SJ, Newman IM, Debovec DF, Anger RW, Skowlund HV, Kottke FJ.
Evaluation o f mobility o f hip and lumbar vertebrae o f normal young women. Arch Phys
Med, 43:1-8, Jan 1962.
Cobb JR. Outline for the study o f scoliosis. AAOS Instructional Course Lecture, 5:261275, 1948.
Colliou OK, Chin JR, Liebenberg EC, Lotz JC. Matrix disorganization, apoptosis, and
gene expression in the intervertebral disc are modulated by compressive loading: a mouse
model for disc degneeration (sic). Proc Orthop Res Soc, New Orleans, LA. March, 1998.
253

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Commandre FA, Gagniere G, Zakarian M, Alaoui M, Fourre JM, Bouzayen A. The child,
the spine, and sport. J Sport Med Phys Fitness, 28(1):11-9,1988.
Cowan NR. The frontal cardiac silhouette in older people. Br Heart J 27:231, 1965.
Crawford AH. Endoscopic Mechanical Spinal Hemiepiphysiodesis. Proc Int Meeting
Advance Spine Tech. Calgary, 2000.
Crawford JD, Osier DC. Body composition at menarche: The Frisch-Revelle hypothesis
revisited. Pediatrics, 56(3):449-58. Sep 1975.
Crocker PR, Eldund RC, Kowalski KC. Childrens physical activity and physical self
perceptions. J Sports Sci, 18(6):383-394, Jun 2000.
Dalton SE. Overuse injuries in adolescent athletes. Sports Med. 13(l):58-70, 1992.
Daly RM, Rich PA, Klein R, Bass S. Effects of high-impact exercise on ultrasonic and
biochemical indices o f skeletal status: A prospective study in young male gymnasts. J
Bone Miner Res. 14(7): 1222-30, Jul 1999.
Daniels L, Worthingham C. Muscle testing, 4th ed. Saunders, Phila., 1980.
Davis PR. Observations on the movements o f the human lower thoracic and lumbar
vertebrae. J Anat 89(3):370-376, 1955.
Day JW, Smidt GL, Lehmann T. Effect o f pelvic tilt on standing posture. Phys Ther
64(4):50-6, Apr 1984.
Deacon P, Berkin CR, Dickson RA. Combined idiopathic kyphosis and scoliosis. An
analysis o f the lateral spinal curvatures associated with Scheuermanns disease. J Bone
Joint Surg, 67-B(2):189-192, 1985.
Deacon P, Archer LA, Dickson RA. The anatomy of spinal deformity: a biomechanical
analysis. Orthopedics, 10(6):897-903, Jun 1987.
Delisle A, Gagnon M, Sicard C. Effect o f pelvic tilt on lumbar spine geometry. IEEE
Trans Rehab Eng 5(4):360-6, Dec 1997.
Delp SL, Arnold AS, Speers RA, Moore CA. Hamstrings and psoas lengths during normal
and crouch gait: implications for muscle-tendon surgery. J Orthop Res 14(1):144-151, Jan
1996.

254

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

DeLuca PA, Ounpuu S, Davis RB, Walsh JH. Effect o f hamstring and psoas lengthening
on pelvic tilt in patients with spastic diplegic cerebral palsy. J Ped Orthop 18(6) :712-8,
Nov-Dee 1998.
deVries HA, Housch TJ. Physiology o f exercise. Brown & Benchmark, Madison, 1994.
DiMeglio A, Bonnel F. La Rachis en Croissance. Springer-Verlag, Paris 1990.
Dommisse GF. The blood supply o f the spinal cord: A critical vascular zone in spinal
surgery. J Bone Joint Surg (Br) 56:225, 1974 .
Dopf CA, Mandel SS, Geiger DF, Mayer PJ. Analysis o f spine motion variability using a
computerized goniometer compared to physical examination. Spine, l9(5):586-595. 1994.
Drerup B, Hierholzer E. Movement o f the human pelvis and displacement o f related
anatomical landmarks on the body surface. J Biomech 20(10):971-7, 1987.
Drerup B, Hierholzer E. Objective determination o f anatomical landmarks on the body
surface: measurement o f vertebra prominens from surface curvature. J Biomech
l8(6):467-474. 1985.
Duncan NA, Ashford FA, Lotz JC. Fluid pressure in the annulus fibrosus subjected to
axial compression at varied strain rates: experiment and poroelastic finite element
predictions. Proc Orthop Res Soc, p.388, 1997.
During J, Goudfrooij H, Keessen W, Beeker ThW, Crowe A. Toward standards for
posture. Postural characteristics o f the lower back system in normal and pathologic
conditions. Spine, 10(l):83-87, 1985.
Edgren, W., Vainio, S. Osteochondritis Juvenilis Lumbalis. Acta Chir. Scand. (Suppl.),
227:1-47, 1957.
Ekstrand J, Gillquist J. Soccer injuries and their mechanisms. Med Sci Sports Exer,
15:267-270, 1983.
Ekstrand J, Wiktorsson M, Oberg B, Gillquist J. Lower extremity goniometric
measurements: a study to determine their reliability. Arch Phys Med Rehabil, 63(4):171-5,
Apr 1982.
Ellender G, Gazelakis T. Growth and bone remodelling in a scorbutic rat model. Aust
Dent J, 41(2):97-106, Apr 1996.
Endler M, Haber P, Hofner W. [Spinal deformities and their mechanopathology in
oarsmen (authors transl.)]. Zeit Orthop Ihre Grenz 118(1):91-100,1980.
255

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Engin AE, Chen S-M. On the biomechanics o f human hip complex in vivo-I. kinematics
for determination o f the maximal voluntary hip complex sinus. J Biomech, 21(10):785795,1988.
Falter EW, Aigner R, Hellerer O, Frey KW. [Spinal lesions following modified exercises in
adolescent high performance gymnasts]. Fortsch Med 99(5):l45-8, Feb 1981.
Falter EW, Hellerer O. High performance gymnasts during the period o f growth. Morpho
Med. 2(l):39-44, Feb 1982.
Farcy JP, Schwab FJ. Management o f flatback and related kyphotic decompensation
syndromes. Spine 22(20):2452-7, Oct 15 1997.
Ferguson AB. Roentgen diagnosis o f extremities and spine. Ann Roentg 17:364-5,
Hoeber, NY, 1939.
Fermor B, Gundle R, Evans M, Emerton M, Pocock A, Murray D. Primary human
osteoblast proliferation and PGE2 release in response to mechanical strain in vitro. Proc
Orthop Res Soc, New Orleans, LA. March, 1998.
Fiirgaard B, Agertoft A. [Scheuermanns disease]. Ugesk for Laeg l52(39):2843-6, Sept
24 1990.
Fisk JW, Baigent ML. Hamstring tightness and Scheuermanns disease - a pilot study. Am
J Phys Med. 60(3):122-5. Jun, 1981.
Fisk JW, Baigent ML, Hill PD. Scheuermanns disease: clinical and radiological survey o f
17 and 18 years olds. Am J Phys Med Rehabil, 63(l):l8-30, Feb 1984.
Fisk JW. The passive hamstring stretch test: clinical evaluation. N Z Med J; 89(632):209-ll.
Mar, 1979.
Fleishman EA. The structure and measurement o f physical fitness. Prentice-Hall,
Englewood Cliffs, NJ. 1964.
Flint MM. Lumbar posture: a study o f roentgenographic measurements and the influence
o f flexibility and strength. Res Quar, 34:15-20, 1963.
Fon GT, Pitt MJ, Thies AC Jr. Thoracic kyphosis: range in normal subjects. Am J Radiol
134:979-983, May 1980.

256

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Fouquet B, GoupiUe P, Rouif M, Rouif V, Mateu J, Valat JP. Breast hypertrophy and
dorsolumbar spine. Prognostic influences o f lumbar lordosis: preliminary results. Rev
Rhum Mai Osteoartic 58(6):453-7, Jun 1991.
Frank EH, Grodzinsky AJ. Cartilage electromechanicsII. A continuum model o f cartilage
electrokinetics and correlation with experiment. J Biomech 20(6):629-39, 1987.
Fredriksen H, Dagfinrud H, Jacobsen V, Maeblum S. Passive knee extension test to
measure hamstring muscle tightness. Scan J Med Sci in Sports 7(5):279-282, Oct 1997.
Frei HP, Oxland TR, Slomczykowski MA, Nolte LP. Vertebral body deformations
contrasted under compression and shear loading. Proc Orthop Res Soc, New Orleans, LA.
March, 1998.
Frisch RE, Revelle R. The height and weight of girls and boys at the time o f initiation o f
the adolescent growth spurt in height and weight and the relationship to menarche. Hum
Biol, 43(1): 140-59, Feb 1971.
Gajdosik R, Lusin G. Hamstring muscle tightness: reliability o f an active-knee-extension
test. Phys Ther, 63(7): 1085-90, Jul 1983.
Gajdosik R, Simpson R, Smith R, DonTigny RL. Pelvic tilt: intratester reliability of
measuring the standing position and range o f motion. Phys Ther, 65(2): 169-74, 1985.
Gajdosik RL, Albert CR, Mitman JJ. Influence o f hamstring length on the standing
position and flexion range o f motion o f the pelvic angle, lumbar angle, and thoracic angle.
J Orthop Sports Phys Ther, 20(4):216-19, Oct 1994.
Gajdosik RL, Hatcher CK, Whitsell S. Influence o f short hamstring muscles on the pelvis
and lumbar spine in standing and during the toe-touch test. Clin Biomech, 7(l):38-42,
Feb 1992.
Gajdosik RL, Leveau BF, Bohannon RW. Effects of ankle dorsiflexion on active and
passive unilateral straight leg raising. Phys Ther, 65:1479-1482, 1985.
Gajdosik RL, Rieck MA, Sullivan DK, Wightman SE. Comparison o f four clinical tests
for assessing hamstring muscle length. J Orthop Sports Phys Ther, 18(5):614-18, Nov
1993.
Gajdosik RL. Passive compliance and length o f clinically short hamstring muscles of
healthy men. Clin Biomech, 6(4):239-244, Nov 1991.

257

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Gamrin L, Berg HE, Essen P, Tesch PA, Hultman E, Garlick PJ, McNurlan MA,
Wemerman J. The effect o f unloading on protein synthesis in human skeletal muscle.
Acta Physiol Scand, 163(4):369-77, Aug 1998.
Gardemin H, Herbst W. Wirbeldeformierung bie der adoleszentenkyphose und
osteoporose. Arch Orthop Unfallchir, 59:134,1966.
Garrett WE, Califf JC, Bassett FH. Histochemical correlates o f hamstring injuries. Am J
Sports Med, 12(2):98-103, 1984.
Gerlach UJ, Lierse W. Functional construction of the sacroiliac ligamentous apparatus.
ActaAnat, 144:97-102, 1992.
Giori NJ, Beupre GS, Carter DR. Cellular shape and pressure may mediate mechanical
control o f tissue composition in tendons. J Orthop Res 11(4):581-591, Jul 1993.
Gleim GW, Stachenfeld NS, Nicholas JA. The influence of flexibility on the economy of
walking and jogging. J Orthop Res, 8(6):814-23, 1990.
Goh S, Price RI, Leedman PJ, Singer KP. The relative influence o f vertebral body and
intervertebral disc shape on thoracic kyphosis. Clin Biomech, 14(7):439-48, Aug 1999.
Goldberg B, Boiardo R. Profiling children for sports participation. Clin Sports Med,
3(1):153-169, 1984.
Goldspink G, Scutt A, Loughna PT, Well DJ, Jaenicke T, Gerlach GF. Gene expression in
skeletal muscle in response to stretch and force generation. Am J Physiol 262(3 Pt
2):R356-63, Mar 1992.
Goldstein ID, Berger PE, Windier GE, Jackson DW. Spine injuries in gymnasts and
swimmers. An epidemiologic investigation. Am J Sports Med, 19(5):463-8, Sep-Oct
1991.
Gordon AM, Huxley AF, Julian FJ. The variation in isometric tension with sarcomere
length in vertebrate muscle fibers. J Physiol, 184:170-192, 1966.
Gray H. Anatomy o f the human body (29th Amer Ed.), CM Goss, ed. Lea & Febinger,
Phila. 1974.
Greco F, dePalma L, Specchia N, Mannarini M. Growth plate cartilage metabolic response
to mechanical stress. JP ed Orthop, 9(5):520-4, Sep/Oct 1989.
Greene TL, Hensinger RN, & Hunter LY. Back pain and vertebral changes simulating
Scheuermanns disease. J Ped Orthop, 5(l):l-7, Jan/Feb 1985.
258

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Griegel-Morris P, Larson K Mueller-Klaus K, Oatis CA. Incidence o f common postural


abnormalities in the cervical, shoulder, and thoracic regions and their association with pain
in two age groups o f healthy subjects. Phys Ther, 72(6):425-31, June, 1992.
Grieve EFM. Mechanical dysfunction o f the sacro-iliac joint. Int Rehabil Med, 5(l):46-52,
1983.
Guilak F, Ratcliffe A, Mow VC. Chondrocyte deformation and local tissue strain in
articular cartilage: a confocal microscopy study. J Orthop Res, 13(3):410-42l, May 1995.
Hafiier RHV, Surrey C. Localised osteochondritis (scheuermanns disease). J Bone Joint
Surg, 34B:38-40,1952.
Hagglund G, Karlberg J, Willner S. Growth in girls with adolescent idiopathic scoliosis.
Spine, 17(1):108-11, Jan 1992.
Halbertsma Jan PIC, Goeken Ludwig NH. Stretching exercises: effect on passive
extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil,
75:976-981, Sep 1994.
Hall AC. Hydrostatic pressure directly affects the activity of articular chondrocyte
membrane transporters. Proc Orthop Res Soc. p. 177-30, 1997.
Hall AC, Horwitz ER, Wilkins RJ. The cellular physiology o f articular cartilage. Exp
Physio 81(3):535-45, May 1996.
Hall AC, Starks I, Shoults CL, Rashidbigi S. Pathways for K+ transport across the bovine
articular chondrocyte membrane and their sensitivity to cell volume. Am J Physiol, 270(5
Pt 1):C1300-1310, May 1996.
Harreby M, Neergaard K, Hesselsoe G, Kjer J. Are radiologic changes in the thoracic and
lumbar spine o f adolescents risk factors for low back pain in adults? Spine, 20(2l):22982303,1995.
Harreby MS, Nygaard B, Jessen TT, Larsen E, Storr-Paulsen A, Lindahl A, Fisker I,
Laegaard E. Risk factors for low back pain among 1,389 pupils in the 8th and 9th grade.
An epidemiologic study. Ugeskr Laeger. 163(3):282-286, Jan 15,2001.
Harris ML. Flexibility. Phys Ther, 49(6):591-601, Jun 1969.
Hartig DE, Henderson JM. Increasing hamstring flexibility decreases lower extremity overuse
injuries in military bask: trainees. Am J Sports Med, 27(2):173-6, Mar-Apr, 1999.
259

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Hawkins D, Hull ML. A method for determining lower extremity muscle-tendon lengths during
flexion/extension movements. J Biomech 23(5):487-94,1990.
Hayes AJ, Benjamin M, Ralphs JR. Roles o f cytoskeletal organisation and cell-cell
communication in early development o f the annulus fibrosus. Proc Orthop Res Soc, p.351,
1997.
Hazebroek-Kampschreur AAJM, Hofinan A, van Linge B. Prevalence o f trunk
abnormalities in eleven-year-old schoolchildren in rotterdam, the netherlands. J Ped
Orthop, 12:480-4, 1992.
HeithofFKB, Gundry CR, Burton CV, Winter RB. Juvenile discogenic disease. Spine,
l9(3):335-40, Feb 1 1994.
Hellsing AL. Tightness of hamstring- and psoas major muscles. A prospective study of back
pain in young men during their military service. Ups J Med Sci; 93(3):267-76,1988.
Hellsing E, Reigo T, Me William J, Spangfort E. Cervical and lumbar lordosis and
thoracic kyphosis in 8 , 11, and 15-year-old children. Eur J Orthop, 9:129-38, 1987.
Hellstadius A. A contribution to the question o f the origin o f anterior paradiscal defects
and so-called persisting apophyses in the vertebral bodies. Acta Orthop Scand, 18:377386, 1947.
Hellstrom M, Jacobsson B, Sward L, Peterson L. Radiologic abnormalities o f the thoraco
lumbar spine in athletes. Acta Rad. 31(2):127-132, 1990.
Hennessy L, Watson AWS. Flexibility and posture assessment in relation to hamstring
injury. Br J Sp Med, 27(4):243-6, 1993.
Hensinger RN. Spondylolysis and spondylolisthesis in children. Instructional Course
Lectures. 32:132-51, 1983.
Hill DK. Tension due to interaction between the sliding filaments o f resting striated
muscle, the effect of stimulation. J Physiol [Lond], 199:637,1968.
Hoeger WW, Hopkins DR. A comparison o f the sit and reach and the modified sit and
reach in the measurement o f flexibility in women. Res Quar Exer Sport, 63(2): 191-5,
1992.
Hoehler FK, Tobis JS. Low back pain and its treatment by spinal manipulation: measures
o f flexibility and asymmetry. Rheum & Rehab, 21:21-6,1982.

260

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Hoffinger S, Rab GT, Abou-Ghaida H. Hamstrings in cerebral palsy crouch gait. J Pediatr
Orthop, 13(6):722-6, Nov-Dee, 1993.
Hoppenfeld S. Physical examination o f the spine and extremities. Appleton-CenturyCrofts, New York. 1976.
Hoy MG, Zajac FE, Gordon ME. A musculoskeletal model o f the human lower extremity:
the effect o f muscle, tendon, and moment arm on the moment-angle relationship o f
musculotendon actuators at the hip, knee, and ankle. J Biomech, 23(2):157-169, 1990.
Hughes CE, Little CB, Buttner FB, Caterson B, Bartnik E. Differential expression o f
aggrecanase and matrix metalloproteinase activity in chondrocytes isolated from bovine or
porcine articular cartilage. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Hung CT, Gu WY, Mow VC. Quantification o f transient swelling behavior in cultured
chondrocytes to osmotic loading. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Hutton WC, Elmer WA, Toribatake Y, Tomita K, Whitesides TE. Do high compressive
forces affect the functioning o f the intervertebral disc cells: an in vivo study. Proc Orthop
Res Soc, New Orleans, LA. March, 1998.
Huxley AF. Muscle structure and theories o f contraction. Prog Biophys Biophys Chem.
7:255-318, 1957.
Iatridis JC, Mente PL, Stokes IAF, Aronsson DD, Alini M. Compression induced
intervertebral disc degeneration in a rat tail model. Proc Orthop Res Soc, New Orleans,
LA. March, 1998.
Ihlemann J, Ploug T, Hellsten Y, Galbo H. Effect o f tension on contraction-induced
glucose transport in rat skeletal muscle. Am J Physiol, 277(2 Pt 1):E208-14, Aug 1999.
Inagaki M, Nishi Y, Nishizawa K, Matsuyama M, Sato C. Site-specific phosphorylation
induces disassembly of vimentin filaments in vitro. Nature, 328(6131):649-652, Aug 13-19
1987.
Ippolito E, Bellocci M, Montanaro A, Ascani E, Ponseti IV. Juvenile kyphosis: an
ultrastructural study. J Ped Orthop, 5(3):315-322, 1985.
Ippolito E, Ponseti IV. Juvenile kyphosis, histological and histochemical studies.
JBJS(Am), 63-A(2):175-182, Feb 1981.
Ishihara H, McNally DS, Urban JP, Hall AC. Effects of hydrostatic pressure on matrix
synthesis in different regions o f the intervertebral disk. J Appl Physiol 80(3):839-46, Mar
1996.
261

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Israel M. A quantitative method o f estimating flexion and extension of the spine; a


preliminary report. Milit Med, 124(3):181-186, Mar 1959.
Jackson AW, Baker AA. The relationship o f the sit and reach test to criterion measures o f
hamstring and back flexibility in young females. Res Quar Exer Sport, 57:183-186, 1986.
Jackson A, Langford NJ. The criterion-related validity of the sit-and-reach test: replication
and extension o f previous findings. Res Quar Exer Sport, 60:384-387,1989.
Jackson W, Wiltse LL, Cirincione RJ. Spondylolysis in the female gymnast. Clin Orthop
RelRes, 117:68-73, 1976.
Jakubiec-Puka A, Carraro U. Remodelling o f the contractile apparatus o f striated muscle
stimulated electrically in a shortened position. J Anat, 178:83-100, Oct 1991.
Janz KF, Phillips D A Mahoney LT. Self-selected physical activity profiles in children and
adolescents. Phys Educator 49:81-87, 1992.
Janz KF, Dawson JD, Mahoney LT. Tracking physical fitness and physical activity from
childhood to adolescence: the muscatine study. Med Sci Sports Exerc, 32(7): 1250-7, Jul
2000.
Jonhagen S, Nemeth G, & Ericksson E. Hamstring injuries in sprinters - the role of
concentric and eccentric hamstring muscle strength and flexibility. Am J Sports Med,
22(2):262-6, 1994.
Joyce ME, Roberts AB, Spom MB, Bolander ME. Transforming growth factor-beta and
the initiation o f chondrogenesis and osteogenesis in the rat femur. J Cell Biol 119(6):2195207, Jun 1990.
Jozwiak M, Pietrzak S, Tobjasz F. The epidemiology and clinical manifestations of
hamstring muscle and plantar foot flexor shortening. Devel Med Child Neurol 39(7):48l3, Jul 1997.
Kaigle A Ekstrom L, Holm S, Rostedt M, Hansson T. In vivo dynamic stiffness of the
porcine lumbar spine exposed to cyclic loading: influence o f load and degeneration. J
Spinal Disorders ll(l):65-70, Feb 1998.
Kalund S, Sinkjaer T, Arendt-Nielson L, Simonsen O. Altered timing of hamstring muscle
action in anterior cruciate ligament deficient patients. Am J Sports Med, l8(3):245-8,
May-Jun 1990.

262

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Kanaley JA, Weltman JY, Veldhuis JD, Rogol AD, Hartman ML, Weltman A. Human
growth hormone response to repeated bouts o f aerobic exercise. J Appl Physiol
83(5):1756-176l, Nov 1997.
Kasra M, Grynpas MD. Effect o f cortical shell geometry on the vertebral body
compressive failure load. Proc Orthop Res Soc, p .66-ll, 1997.
Keegan JJ. Alterations o f the lumbar curve related to posture and seating. J Bone Joint
Surg (Am). 35:589-603. 1953.
Keim HA, Hensinger RN. Spinal deformities. Clin Symp, 41(4):3-32, 1985.
Keller TS, Nathan M. Height change caused by creep in intervertebral discs: a sagittal
plane model. J Spinal Disord 12(4):313-24, Aug 1999.
Kemp FH, Wilson DC, Emrys-Roberts E. Social and nutritional factors in adolescent
osteochondritis o f the spine. Br J Soc Med, 2:66, 1948.
Kempson GE, et al The effects o f proteolytic enzymes on the mechanical properties of
adult human articular cartilage. Biochim Biophys Acta, 428:741,1976.
Kendall HO, Kendall FP. Muscles: testing and function. Williams & Wilkins, Baltimore,
1949.
Kendall HO, Kendall FP, Boynton DA. Posture and pain. Williams & Wilkins, Baltimore,
1952.
Kirby RL, Simms FC, Symington VJ, & Gamer JB. Flexibility and musculoskeletal
symptomatology in female gymnasts and age-matched controls. Am J Sports Med,
9(3):160-4,1981.
Klafs CE, Amheim DD. Modem principles o f athletic training. Mosby, St. Louis, 1981.
Klein G. Zur mechanik des ileosacralgelenkes. A Geburtshilfe und Gynakologie. 21:74108, 1891.
Klein KK. Progression of pelvic tilt in adolescent boys from elementary through high
school. Arch Phys Med Rehabil, 54(2):57-9, Feb, 1973.
Klein-Nulend J, Ostendorf RH, Van Kampen GPJ, Sterck JGH, Semeins CM, Burger EH.
Intermittent loading stimulates the release o f transforming growth factor-B and
prostaglandins E2 and 12 by cultured bovine articular cartilage. Proc Orthop Res Soc,
New Orleans, LA. March, 1998.
263

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Kling TF & Hensinger RN. Adolescent round back deformity. Orthop Survey, 5(5):340-8,
1982.
Korovessis PG, Stamatakis MV, Baikousis AG. Reciprocal angulation o f vertebral bodies
in the sagittal plane in an asymptomatic greek population. Spine, 23(6):700-5,1998.
Kozlowski K, Beighton P. Radiographic features o f spondylo-epimetaphyseai dysplasia
with joint laxity and progressive kyphoscoliosis. Review o f 19 cases. ROFO Fortschr Geb
Rontgenstr Nuklearmed, 141(3):337-41, Sep 1984.
Kreighbaum E, Barthels KM. Biomechanics, 3rd ed. Macmillan, New York, 1990.
Krivickas LS, Feinberg JH. Lower extremity injuries in college athletes: relation between
ligamentous laxity and lower extremity muscle tightness. Arch Phys Med Rehab 77(11):
1139-43, Nov 1996.
Kroeber MW, Duncan NA, Heilmann MR, Lotz JC. Radial tensile properties of the
annulus fibrosus vary though its height. Proc Orthop Res Soc, New Orleans, LA. March,
1998.
Kujala UM, Salminen JJ, Taimela S, Oksanen A, Jaakkola L: Subject characteristics and
low back pain in young athletes and non-athletes. Med Sci Sports Exercise 24:627-632,
1992.
Kujala UM, Taimela S, Oksanen A, Salminen JJ. Lumbar mobility and low back pain
during adolescence. A longitudinal three-year follow-up study in athletes and controls.
Am J Sports Med, 25(3):363-8, May 1997.
Kuntzleman CT, Drake DA, Loubert P, Schork MA, Lu CC, Reiflf GG, Naughton JS,
Edington D, & Spain C. Evaluation o f the flexibility test norms in the pcpfs physical
fitness awards program. Presidents Council on Physical Fitness and Sports, 1993.
Kuo L, Chung W, Bates E, Stephen J. The hamstring index. J Ped Orthop. 17(l):78-88,
1997.
Kusaka Y, Nakajima S, Uemura O, Aoshiba H, Hase H, Seo Y, Murakami M, Hirasawa
Y. The effect o f annulus fibrosus perforation on the intradiscal matrix strain of the axially
loaded intervertebral disc. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Lambrinudi C. Adolescent and senile kyphosis. Br Med J, 11(2):800-804,1934.
Lanyon LE. Using functional loading to influence bone mass and architecture: objectives,
mechanisms, and relationship with estrogen o f the mechanically adaptive process in bone.
Bone, 18(1 Suppl):37S-43S, Jan 1996.
264

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Lee DA, Frean SP, Lees P, Bader DL. Dynamic compressive strain influences nitric oxide
production by articular chondrocytes. Proc Orthop Res Soc, New Orleans, LA. March,
1998.
Lee DA, Noguchi T, Knight MM, ODonnell LB, Bader DL. Differential metabolic
response o f superficial and deep zone chondrocytes to compressive strain. Proc Orthop
Res Soc, p.203-34,1997.
Legaye J, Duval-Beaupere G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic
parameter for three-dimensional regualtion o f spinal sagittal curves. Eur Spine J, 7(2):99103, 1998.
Leighton JR. An instrument and technic for the measurement o f range of joint motion.
Arch Phys Med Rehabil, 36:571-578, 1955.
Leroux MA, Zabjek K, Simard G, Badeux J, Coillard C, Rivard CH. A noninvasive
anthropometric technique for measuring kyphosis and lordosis: an application for
idiopathic scoliosis. Spine, 25(13):1689-1694, Jul 2000.
Levine D, Whittle MW. The effects o f pelvic movement on lumbar lordosis in the standing
position. J Orthop Sports Phys Ther, 24(3): 130-5, Sep 1996.
Li KW, Falcovitz YH, Nagrampa JP, Chen AC, Lottman LM, Shyy JY, Sah RL.
Mechanical compression modulates proliferation o f transplanted chondrocytes. J Orthop
Res. l8(3):374-82, May 2000.
Li Y, McClure PW, Pratt N. The effect o f hamstring muscle stretching on standing
posture and on lumbar and hip motions during forward bending. Phys Ther 76(8):836-49,
Aug 1996.
Lieber RL. Hypothesis: Biarticular muscles transfer moments between joints. Dev Med
Child Neurol, 32:456-8, 1990.
Lieber RL. Skeletal muscle structure and function. Williams & Wilkins, Baltimore. 1992.
Lindahl O. Determination o f the sagittal mobility o f the lumbar spine. Acta Orthop Scand
37:241-254, 1966.
Lindemann, K. Ztschr. f. Orthop. Chir., 58:54, 1933.
Loebl WY. Measurements o f spinal posture and range o f spinal movements. Ann Phys
Med, 9:103-110, 1967.

265

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Loening AM, James IE, Levenston ME, Badger AM, Frank EH, Kurz B, Nuttall ME,
Hung HH, Blake SM, Grodzinsky AJ, Lark MW. Injurious mechanical compression o f
bovine articular cartilage induces chondrocyte apoptosis. Arch Biochem Biophys.
381(2):205-12, Sep 15 2000.
Lohrer H. An increased risk o f spinal injury in high performance gymnasts during pubertal
growth? Wien Med Wochenschr. 148(10):235-8, 1998.
Lonstein JE. Embryology and Spinal Growth. In Textbook o f Scoliosis and Other Spinal
Deformities, ed. Moe. Saunders, Phila. 1978.
Loughna PT, Izumo S, Goldspink G, Nadal-Ginard B. Disuse and passive stretch cause
rapid alterations in expression o f developmental and adult contractile protein genes in
skeletal muscle. Development 109(l):217-23, May 1990.
Lundin O, Ekstrom L, Hellstrom M, Holm S, Sward L. Injuries in the adolescent porcine
spine exposed to mechanical compression. Spine, 23(23):2574-9, Dec 1 1998.
Luttgens K, Deutsch H, Hamilton N. Kinesiology, 8th ed. Brown & Benchmark,
Dubuque. 1992.
MacGowan TJBA. Adolescent kyphosis. Lancet, 1:211-214, Feb 1944.
Macrae IF, Wright V. Measurement o f back movement. Ann Rheum Dis, 28(6):584-9,
Nov 1969.
Mafiulli N, King JB, Helms P. Training in elite young athletes (the training o f young
athletes (TOYA) study): injuries, flexibility, and isometric strength. Br J Sp Med,
28(2):123-136,1994.
Magnusson SP, Aagard P, Simonsen E, Bojsen-Moller F. A biomechanical evaluation o f
cyclic and static stretch in human skeletal muscle. Int J Sports Med, 19(5):310-6, Jul
1998.
Magnusson SP, Simonsen EB, Aagaard P, Boesen J, Johannsen F, Kjaer M. Determinants
o f musculoskeletal flexibility: viscoelastic properties, cross-sectional area, EMG, and
stretch tolerance. Scand J Med Sci Sports, 7(4): 195-202, Aug 1997.
Malina RM. Exercise as an influence upon growth. Clin Ped 8(1): 16-26, Jan 1969.
Marras WS, Granata KP. Changes in trunk dynamics and spine loading during repeated
trunk exertions. Spine 22(21):2564-70, Nov 1 1997.

266

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Marras WS, Granata KP. Spine loading during trunk lateral bending motions. J Biomech
30(7):697-703,1997.
Maroudas A, Bayliss M, Schneiderman R. Quantitative studies o f aggrecan turnover in
human cartilage based on structural data and aspartic acid racemization. Proc Orthop Res
Soc, New Orleans, LA. March, 1998.
Matthews DK, Fox EL. The physiological basis o f physical education and athletics, 2nd
ed. Saunders, Phila. 1976.
Matsumoto M. Radiological and histological studies on the growth o f lumbar vertebra.
Nippon Seikeigeka Gakkai Zasshi 62(4):331-43, Apr 1988.
Mau C. Die kyphosis dorsalis adoles. Zeitschr Orthop Chir, 46:145, 1925.
Mau C. Adoleszenten kyphoskoliose verhaudld. Deutsch Orthop Ges Kong. 21:200, 1927.
Mau C. Die kyphosis dorsalis adoles. Zeitschr Orthop Chir, 51:106, 1929.
McCarthy JJ, Betz RR. The relationship between tight hamstrings and lumbar
hypolordosis in children with cerebral palsy. Spine, 25(2):211-3, Jan 15 2000.
McKeagDB: The role o f exercise in children and adolescents. Clinics in Sports Medicine
10(1): 117-130, 1991.
McMahon TA. Muscles, reflexes, and locomotion. Princeton Univ Press, New Jersey,
1984.
McNair PJ, Stanley SN. Effect o f passive stretching and jogging on the series elastic
muscle stiffness and range o f motion o f the ankle joint. Br J Sports Med, 30(4):313-7, Dec
1996.
Mellin G. Measurement o f thoracolumbar posture and mobility with a myrin inclinometer.
Spine, ll(7):759-62. 1986.
Mendenhall W, Reinmuth JE. Statistics for Management and Economics (4th ed.).
Duxbury Press, Boston 1982.
Mente PL, Stokes LA, Spence H, Aronsson D. Progression o f vertebral wedging in an
asymmetrically loaded rat tail model. Spine 22(12):1292-96, June 15, 1997.
Mente PL, Aronsson DD, Stokes 1AF, Iatridis JC. Mechanical modulation of growth for
the correction o f vertebral wedge deformities. J Orthop Res. 17(4):518-24, Jul 1999.
267

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Merritt JL, McLean TJ, Erickson HP, Oflford KP. Measurement o f trunk flexibility in
normal subjects: reproducibility o f three clinical methods. Mayo Clin Proc, 61:192-7,
1986.
Meschan I, Farrer-Meschan RM. Roentgen Signs in Diagnostic Imaging, 2nd ed., vol. 3
Spine and Central Nervous System; Saunders, Phila. 1985.
Micheli LJ. Back injuries in gymnastics. Clinics in Sports Medicine 4: 85-93, 1985.
Micheli LJ. Low-back pain in the adolescent: differential diagnosis. Am J Sports Med
7:362:364. 1979.
Micheli LJ. Back injuries in dancers. Clin Sports Med, 2(3):473-484, 1983.
Michelle AA. Osteochondrosis deformans juvenilis dorsi, NY J Med, 61:98, 1961.
Miller JAA, Schultz AB, Andersson GBJ. Load-displacement behavior o f sacroiliac
joints. J Orthop Res 5(1):92-101, 1987.
Moe JH, Winter RB, Bradford DS, Lonstein JE. Scoliosis and other spinal deformities.
Saunders, Phila., 1978.
Montgomery S, Erwin W. Scheuermanns kyhosis long-term results of milwaukee brace
treatment. Spine 6:5, 1981.
Morris FL, Naughton GA, Gibbs JL, Carlson JS, Wark JD. Prospective ten-month
exercise intervention in premenarchal girls: positive effects on bone and lean mass. J Bone
Min Res 12(9):1453-62, 1997.
Mow VC, Holmes MH, Lai WM. Fluid transport and mechanical properties o f articular
cartilage: a review. J Biomech, 17:377,1984.
Mow VC, Lai WM. Recent developments in synovial joint biomechanics. SIAM Rev,
22:275, 1980.
Muhlbach von R, Hahnel H, Cohn H. Zur bedeutung biochemischer parameter bei der
beurteilung der scheuermannschen krankeit. Medizin und Sport, 10:331, 1970.
Muller G, Gschwend N. Endokrine storungen und morbus scheuermann. Arch Orthop
UnfaUchir, 65:357,1969.
Mundale MO, Hislop HJ, Rabideau RJ, Kottke FJ. Evaluation o f extension o f hip. Arch
Phys Med, 37:75-80, Feb 1956.
268

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of
scheuermann kyphosis. J Bone Joint Surg (Am) 75:(A):236-48. 1993.
Murray RC, Henson FMD, Zhu CF, Goodship A, Athanasiou KA. The effects o f
strenuous training on equine carpal articular cartilage mechanical behavior and
morphology. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Nachemson A. Lumbar intradiscal pressure. Acta Orthop Scand (Suppl) 43, I960.
Nemeth G, Ohlsen In vivo moment arm lengths for hip extensor muscles at different
angles o f hip flexion. J Biomech, 18:129-40, 1985.
Nissinen M. Spinal posture during pubertal growth. Acta Ped 84:308-312, 1995.
Nitzsche E, Hildenbrand M. Die epidemiologie des rundruckens bei schulkindem. Z
Orthop Ihre Grenzgeb 128(5):477-81, Sep-Oct 1990.
Noone G, Mazumdar J, Ghista DN, Tansley GD. Asymmetrical loads and lateral bending
o f the human spine. Med Biol Eng Comput 31.S131-S136 1993.
Nordin N, Frankel VH. Basic biomechanics o f the musculoskeletal system. Lea & Febiger,
Phila. 1989.
Nordwall A, Willner S. A study o f skeletal age and height in girls with idiopathic scoliosis.
Clin Orthop 110:6-10, 1977.
Normelli H, Sevastik J, Ljung G, Aaro S, Jonsson-Soderstrom AM. Anthropometric data
relating to normal and scoliotic Scandinavian girls. Spine l0(2):123-6, Mar 1985.
OConnell A, Gardner EB. Understanding the scientific bases o f human movement.
Williams & Wilkins, Baltimore, 1972.
Ogawara M, Inagaki N, Tsujimura K, Takai Y, Sekimata M, Ha MH, Imajoh-Ohmi S,
Hirai S, Ohno S, Sugiura H, et al. Differential targeting o f protein kinase C and CaM
kinase II signalings to vimentin. J Cell Biol l31(4):1055-66, Nov 1995.
Ogden JA, Ganey TM, Sasse J, Neame PJ, Hilbelink DR. Development and maturation o f
the axial skeleton. In The Pediatric Spine, ed. SL Weinstein. Raven Press, New York,
1994.
Ogilvie JW', Sherman J. Spondylolysis in scheuermanns disease. Spine, 12(3):251-3,
1987.

269

Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.

Ohlen G, Spangfort E, Tingvall C. Measurement o f spinal sagittal configuration and


mobility with debrunners kyphometer. Spine, 14(6):580-583. 1989.
Onga T, Saura R, Shimomura T, Mizuno K, Hirata S, Ishikawa H. Effects o f
prostaglandins on nitric oxide synthesis o f articular chondrocytes. Proc Orthop Res Soc,
New Orleans, LA. March, 1998.
Orth JO. Calcification and ossification o f the posterior and longitudinal ligament o f the
cervical spine (authors transl). ROFO Fortschr Geb Rontgenstr Nuklearmed, 122(5):4425, May 1975.
Oshima H, Ishihara H, Urban JP, Tsuji H. The use o f coccygeal discs to study
intervertebral disc metabolism. J Orthop Res 11(3):332-8, May 1993.
Outland T, Snedden HE. Juvenile Dorsal Kyphosis. Clin Orthop, 5:155-163, 1955.
Owan I, Burr DB, Turner CH, Qiu J, Duncan RL. Osteoblasts do not respond to
physiological levels o f mechanical strain, but are responsive to fluid effects. Proc Orthop
Res Soc, p. 176-30, 1997.
Paajenen H, Erkintalo M, Kuusela T, Dahlstrom S, Kormano M. Magnetic resonance
study disc degeneration in young low-back pain patients. Spine, 14:982-985, 1989.
Pal GP, Routal RV. A study o f weight transmission through the cervical and upper
thoracic regions o f the vertebral column in man. J Anat 148:245-61, Oct 1986.
Panjabi MM, Takata K, Goel V, Federico K, Oxland T, Duranceau J, Krag M. Thoracic
human vertebrae: quantitative three-dimensional anatomy. Spine 16(8):888-90l, 1991.
Parkkinen JJ, Lammi MJ, Helminen HJ, Tammi M. Local stimulation o f proteoglycan
synthesis in articular cartilage explants by dynamic compression in vitro. J Orthop Res,
10(5):610-20, Sep 1992.
Pazzaglia UE, Andrini L, Di Nucci A. The effects o f mechanical forces on bones and
joints: Experimental study on the rat tail. J Bone Joint Surg [Br], 79-B(6): 1024-30, Nov
1997.
Peltenberg AL, Erich WB, Bemick MJ, Zonderland ML, Huisveld IA. Biological
maturation, body composition, and growth o f female gymnasts and control groups o f
schoolgirls and girl swimmers, aged 8 to 14 years: a cross-sectional survey o f 1064 girls.
Int J Sports Med 5(l):36-42, Feb 1984.
Perey O. Fracture o f the vertebral end-plate in the lumbar spinean experimental
biomechanical investigation. Acta Orthop Scan, Suppl No. XXV, 1957.
270

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Rawlinson SC, Pitsillides AA, Lanyon LE. Involvement o f different ion channels in
osteoblasts and osteocytes early responses to mechanical strain. Bone 19(6):609-14, Dec
1996.
Refshauge K M, Goodsell M, Lee M. The relationship between surface contour and
vertebral body measurements o f upper spine curvature. Spine 19(19):2180-5, Oct 1 1994.
Reid DC. Sports injury assessment and rehabilitation. Churchill Livingstone, New York,
1992.
Reilly T, Seaton A. Physiological strain unique to field hockey. J Sports Med Phys
Fitness. 30(2): 142-6, Jun 1990.
Revel M, Andre-Deshays C, Roudier R, Roudier B, Hamard G, Amor B. Effects of
repetitive strains on vertebral end plates in young rats. Clin Orthop, 279:303-9, Jun 1992.
Ridola C, Palma A, Ridola G, Sanfilippo A, Almasio PL, Zummo G. Changes in the
lumbosacral segment o f the spine due to overweight in adults. Preliminary remarks. Ital J
Anat Embryol, 99(3):133-43, Jul-Sep 1994.
Riseborough EJ, Hemdon JH. Scoliosis and other deformities o f the axial skeleton. Little,
Brown, Boston. 1975.
Roaf R. Vertebral growth and its mechanical control. J Bone Joint Surg (BR);
42B(l):40-59, Feb 1960.
RoafR. Spinal deformities. Lippincott, Phila, 1977.
Rogge CWL, Nieman A. Isolated and atypical manifestations o f Scheuermanns disease.
Arch Chir Neer 28(3): 149-60, 1976.
Ryan SD, Fried LP. The impact o f kyphosis on daily functioning. J Am Ger Soc
45(12): 1479-1486, Dec 1997.
Sah RLY, Kim YJ, Doong JY, Grodzinsky AJ, Plaas AH, Sandy JD. Biosynthetic
response o f cartilage explants to dynamic compression. J Orthop Res 7(5):6l9-636, 1989.
1992
Sallis JF, Strikmiller PK, Harsha DW, Feldman HA, Ehlinger S, Stone EJ, Williston J,
Woods S. Validation o f interviewer- and self-administered physical activity checklists for
fifth grade students. Med Sci Sports Exer 28(7):840-851, 1996.
Salminen JJ. The adolescent back. Acta Ped Scand (Supp) 315:1-122, 1984.1993

272

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Salter RB. Textbook o f disorders and injuries o f the musculoskeletal system. Williams &
Wilkins, Baltimore, pp. 279-281.1970.
Saris WHM: The assessment and evaluation o f daily physical activity in children. A
review. Acta Paediatric Scand Supplement 318:37-48, 1985.
Schanz A. Eine typische erkrankung der wirbelsaule. Berlin klin Wochenschr. 44(3l):986992, Aug 5 1907.
Schanz A. Schule und skoliose. Jahrbuch fur Kinderheilkunde, 73:1, 1911.
Scheuermann HW. Kyfosis dorsalis juvenilis. Ugeskr Laeger, 82:385-393, 1920.
Scheuermann HW. Kyphosis dorsalis juvenilis. Ztschr Orthop Chir 41:305-317, 1921.
Scheuermann HW. Roentgenologic studies o f the origin and development o f juvenile
kyphosis, together with some investigations concerning the vertebral epiphyses in man and
in animals. Acta Orthop Scand 5:161-220, 1934.
Scheuermann HW. The ClassicKyphosis Dorsalis Juvenilis (EM Bettmann, ed.). Clin
Orthop Rel Res, 128:5-7, Oct 1977.
Schmorl G. Die pathogenese der juvenilien kyphose. Fortschr Geb Roentgenstr
Nuklearmed, 41: 359-383, 1930.
Schultz AB, Ashton-Miller JA. Biomechanics o f the human spine, in Basic orthopaedic
biomechanics, Mow, VC & Hayes, WC (ed.). Raven, New York. 1991.
Scoles PV, Latimer BM, Digiovanni BF, Bauza S, Jellema LM. Vertebral alterations in
Scheuermanns kyphosis. Spine, 16(5):509-15, May 1991.
Scott MG, French E. Measurement and evaluation in physical education. WC Brown,
Dubuque, IA. 1959.
Scott PA. Morphological characteristics of elite male field hockey players. J Sports Med
Phys Fitness, 31(1):57-61, Mar 1991.
Shea KG, Bachus KN, Schlegel JD, Nelson R, Dunn HK. The contribution o f the rib cage
to thoracic spine stability. Proc Orthop Res Soc, p.365, 1997.
Shepard RJ, Berridge M. On the generality o f the sit and reach test: An analysis of
flexibility data for an aging population. Res Quar Exer Sport, 61:326-30, 1990.

273

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Shirazi-Adl A, Ahmed AM, Shrivastava SC. Mechanical response o f a lumbar motion


segment in axial torque and combined with compression. Spine, 11:914-927,1986.
Simon RS. The diagnosis and tyreatment o f kyphosis dorsalis juvenilis (scheuermanns
kyphosis) in the early stage. J Bone Joint Surg, 24:681, July, 1942.
Singer KP, Jones TJ, Breidahl PD. A comparison o f radiographic and computer-assisted
measurements o f thoracic and thoracolumbar sagittal curvature. Skel Radiol 19:21-6,
1990.
Skogland LB, Miller JAA. Growth-related hormones in idiopathic scoliosis. An endocrine
basis for accelerated growth. Acta Orthop Scan, 51:779-789, 1980.
Skogland LB, Miller JAA. The length and proportions of the thoracolumbar spine in
children with idiopathic scoliosis. Acta Orthop Scand 52:177-185, 1981.
Skogland LB, Miller JAA. On the importance o f growth in idiopathic scoliosis: A
biochemical, radiological and biomechanical study. Ph.D. Dissertation, University o f Oslo,
Norway, 1982.
Skogland LB, Steen H, Trygstad O. Spinal deformities in tall girls. Acta Orthop Scand
56:155-157, 1985.
Slocum L, Terry RJ. Influence o f the sacrotuberous and sacrospinous ligaments in limiting
movements o f die sacroiliac joint. JAMA, 87:307-309.1926.
Smith JE, Miller CV. The effect o f head position on sit and reach performance. Res Quar
Exer Sport, 56:84-5, 1985.
Somhegyi A, Ratko I. Hamstring tightness and scheuermanns disease (commentary). Am
J Phys Med Rehabil. 72(1):44. Feb, 1993.
Sorensen KH. Scheuermanns juvenile kyphosis. Munksgaard, Copenhagen, 1964.
Speers R. Length o f biarticular muscles in normal and crouch gait. Masters Thesis,
Northwestern Univ, Chicago, IL, 1993.
Sprangfort E. Lasegues sign in patients with lumbar disc herniation. Acta Orthop Scand
42:459-50, 1971.
Stanford CA, Zaharias RS, Martin JA, Brand RA. Bone-related proteins upregulate in
response to strain. Proc Orthop Res Soc, New Orleans, LA. March, 1998.

274

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Stagnara P, De Mauroy JC, Dran G, Gonon GP, Costanzo G, Dimnet J, Pasquet.


Reciprocal angulation o f vertebral bodies in a sagittal plane: approach to references for the
evaluation o f kyphosis and lordosis. Spine, 7(4):335-342, 1982.
Starring DT, Gossman, MR, Nicholson, GG Jr., Lemons, J. Comparison o f cyclic and
sustained passive stretching using a mechanical device to increase resting length o f
hamstring muscles. Physical Therapy, 68(3): 314-20, Mar 1988.
Stephen JPH. Back pain in childhood and adolescence. Austral Fam Phys, 12(5):335-340,
May 1983.
Stevens SS, Beaupre GS, Carter DR. Joint loading regulates the development o f articular
cartilage thickness. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Stevens SS, Beaupre GS, Carter DR. A mechanobiologic model for bone growth and
articular cartilage development. Proc Orthop Res Soc, p.522, 1997.
Stiletto R, Ziering L, Gotzen H. Sporting activity after fractures o f the thoracic and
lumbar spine. Proc AOSSM. Lake Buena Vista FL, June 16-20, 1996.
Stoddard A, Osborn JF. Scheuermanns disease or spinal osteochondrosis: its frequency
and relationship with spondylosis. J Bone Joint Surg, 61B(l):56-8, Feb 1979.
Stokes IA, Spence H, Aronsson DD, Kilmer N. Mechanical modulation o f vertebral body
growth. Implications for scoliosis progression. Spine, 21(10): 1162-7, May 15 1996.
Stokes IAF. Symmetry o f vertebral loading in scoliosis. Spine, 21:1162-67, 1996.
Stokes IAF, Abery JM. Influence o f the hamstring muscles on lumbar spine curvature in
sitting. Spine, 5:525-8; 1980.
Studer RK, Stefanovic-Racic M, Georgescu HI, Evans CH. Inhibition o f TGF-B
production by nitric oxide and its role in the suppression of chondrocyte proteoglycan
synthesis. Proc Orthop Res Soc, New Orleans, LA. March, 1998.
Sullivan MK, Dejulia JJ, Worrell TW. Effect o f pelvic position and stretching method on
hamstring muscle flexibility. Med Sci Sports Exer, 24(12):1383-1389, 1992.
Sutherland DH, Schottstaedt ER, Larsen LJ, Ashley RK, Callander JM, James PM.
Clinical and electromyographic study o f seven spastic children with internal rotation gait. J
Bone Joint Surg, 51A:1070-1082, 1969.
Sward L. The thoracolumbar spine in young elite athletes, current concepts on the effects
o f physical training. Sports Med 13(5):357-64, May 1992.
275

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Sward L, Eriksson B, Peterson L. Anthropometric characteristics, passive hip flexion, and


spinal mobility in relation to back pain in athletes. Spine, 15(5):376-82, May 1990 (A).
Sward L, Hellstrom M, Jacobsson B, Karlsson L. Vertebral ring apophysis injury in
athletes. Am J Sports Med. 21(6):841-5, 1993.
Sward L, Hellstrom M, Jacobsson B, Nyman R, Peterson L. Acute injury o f the vertebral
ring apophysis and intervertebral disc in adolescent gymnasts. Spine, 15(2):144-148,1990
(B).
Sward L, Hellstrom M, Jacobsson B, Peterson L. Back pain and radiologic changes in the
thoraco-lumbar spine of athletes. Spine, 15(2): 124-129, 1990 (C).
Takata K, Takahashi K. Hamstring tightness and sciatica in young patients with disc
herniation. J Bone Joint Surg, 76-B(2):220-4, Mar 1994.
Takekura H, Kasuga N, Kitada K, Yoshioka T. Morphological changes in the triads and
sarcoplasmic reticulum of rat slow and fast muscle fibres following denervation and
immobilization. J Muscle Res Cell Motil, 17(4):391-400, Aug 1996.
Tanner JM. Growth and Adolescence (2nd ed.). Blackwell, Oxford, 1962.
Tanner JM. Physical growth and development. In Textbook o f Paediatrics, Forfar JO and
Ameil GC (eds.). Churchill Livingstone, Edinburgh, 1973.
Tardieu C, Tabary JC, Tabary C, Tardieu G. Adaptation of connective tissue length to
immobilization in the lengthened and shortened positions in cat soleus muscle. J Physiol
(Paris), 78(2):214-20, Aug 1982.
Taylor JR. Growth of human intervertebral discs and vertebral bodies. J Anat 120(1):4968, Sep 1975.
Tertti M, Paajanen H, Kujala UM, Alanen A, Salmi TT, Kormano M. Disc degeneration in
young gymnasts. Am J Sports Med, 18(2):206-208, 1990.
Terver S, Kleinman R, Bleck EE. Growth landmarks and the evolution o f scoliosis: a
review of pertinent studies on their usefulness. Develop Med Child Neurol 22:675-684,
1980.
Thompson DC, Rebolledo V, Thompson RS, Kaufman A, Rivara FP. Bike speed
measurements in a recreational population: validity o f self reported speed. Inj Prevention
3(l):43-5, Mar, 1997.

276

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Thurston AJ, Harris JD. Normal kinematics o f the lumbar spine and pelvis. Spine,
8(2): 199-205,1983.
Toppenberg RA, Bullock MI. The interrelation o f spinal curves and muscle lengths in the
adolescent female. Aus J Physiother, 32:6-12, 1986.
Toribatake Y, Hutton WC, Elmer WA, Whitesides TE, Tomita K. An in vivo study o f the
effect o f applied compressive force on intervertebral disc metabolism. Proc Orthop Res
Soc, p. 145-25, 1997.
Trost SG, Pate RR, Dowda M, Saunders R, Ward DS, Felton G. Gender differences in
physical activity and determinants of physical activity in rural fifth grade children. J Sch
Health 66(4): 145-50, Apr 1996.
Troup JDG, Hood CA, Chapman AE. Measurement of the sagittal mobility o f the lumbar
spine and hips. Ann Phys Med, 9:308-21, 1968.
Uemura O, Kusaka Y, Mikami Y, Hase H, Morimoto T, Hirasawa Y. Water retention in
the loaded human intervertebral disc and its correlation with deformation o f end-plate.
Proc Orthop Res Soc, p.122-21, 1997.
Upadhyay SS, Hsu LC, Ho EK, Leong JC, Lee MK. Disproportionate body growth in
girls with adolescent idiopathic scoliosis. A longitudinal study. Spine, 16(8 SuppI.):S3437, Aug. 1991.
Urban JP, McMullin JF. Swelling pressure o f the intervertebral disc: influence o f
proteoglycan and collagen contents. Biorheology 22(2):145-57,1985.
Vanneuville G, Kyndt T, Massaux M, Harmand Y, Garcier JM, Monnet JP, Guillot M,
Cluzel P, Escande G, Poumarat G. Preliminary opto-electronic study on vertebral
movement. Surg Rad Anat 16(4):385-391, 1994.
van Weeren PR, Bameveld A. A technique to quantify skin displacement in the walking
horse. J Biomech, 19(l0):879-883, 1986.
Vedantam R, Lenke LG, Keeney JA, Bridwell KH. Comparison o f standing sagittal spinal
alignment in asymptomatic adolescents and adults. Spine 23(2):211-5, Jan 1998.
Visser JJ, Hoogkamer JE, Bobbert MF, Huijing PA. Length and moment arm o f human
leg muscles as a function o f knee and hip-joint angles. Eur J Appl Physiol, 61(5-6):453-60,
1990.
von Luschka. Die Halbgelenke des menschlichen Korpers. Berlin, 1858.
277

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Voutsinas SA, MacEwen GD. Sagittal profiles o f the spine. Clin Orthop Rel Res,
210:235-242, 1986.
Walker ML, Rothstein JM, Finucane SD, Lamb RL. Relationships between lumbar
lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther, 67(4):5l2-6, 1987.
Wallace JP, McKenzie TL, Nader PR. Observed vs. recalled exercise behavior: A
validation o f a seven day exercise recall for boys 11 to 13 years old. Res Quar Exer Sport
56(2):161-165, 1985.
Wang SS, Whitney SL, Burdett RG, Janosky JE. Lower extremity muscular flexibility in
long distance runners. J Orthop Sports Phys Ther, l7(2):102-7, Feb 1993.
Warfel JH. The extremities, 4th ed. Lea & Febiger, Phila. 1974.
Wassman K. Kyphosis juvenilis scheuermann--an occupational disorder. Acta Orthop
Scand, 21:65-74, 1951.
Waters RL, Perry J, McDaniels JM, House K. The relative strength o f the hamstrings
during hip extension. J Bone Joint Surg, 56-A(8): 1592-1597, Dec 1974.
Watson AWS. Posture and participation in sport. J Sports Med. 23(3):231-9. Sept 1983.
Wells KF, Dillon EK. The sit and reach - a test of back and leg flexibility. Res Quart,
38:28-33, 1967.
White AA, Panjabi MM, Thomas CL. The clinical biomechanics o f kyphotic deformities.
Clin Orthop Rel Res, 128:8, 1977.
Wiemann K, Hahn K. Influences o f strength, stretching, and circulatory exercises on
flexibility parameters o f the human hamstrings. Int J Sports Med, 18(5):340-6, Jul 1997.
Wiersma W. Research Methods in Education, 6th ed. Simon & Shuster, 1994.
Wiles, P. Essentials o f Orthopaedics. Churchill, London, 1949.
Williams PE. Use o f intermittent stretch in the prevention o f serial sarcomere loss in
immobilised muscle. Ann Rheum Dis, 49(5):316-7, May 1990.
Williams PE, Goldspink G. Connective tissue changes in immobilised muscle. J Anat,
138(Pt 2):343-50, Mar 1984.

278

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Williams PE, Catanese T, Lucey EG, Goldspink G. The importance o f stretch and
contractile activity in the prevention o f connective tissue accumulation in muscle. J Anat,
158:109-14, Jun 1988.
Willner S. A study of height, weight and menarche in girls with idiopathic structural
scoliosis. Acta Orthop Scand, 46(l):71-83, Apr 1975.
Willner S, Johnson B: Thoracic kyphosis and lumbar lordosis during the growth period in
children. Acta Paediatr Scand 72:873-878, 1983.
Willner S. Spinal pantograph - a noninvasive technique for describing kyphosis and
lordosis in the thoracolumbar spine. Acta Orthop Scand 52:525-9, 1981.
Willner S. Spinal pantograph- a noninvasive anthropometric device for describing postures
and asymmetries o f the trunk. J Ped Orthop, 3:245-9, 1983.
Wilson FD, Lindseth RE. The adolescent swimmers back. Am J Sports Med,
10(3): 174-176, 1982.
Winter DA. The biomechanics and motor control of human gait. Univ. Waterloo Press,
1987.
Winter RB, Carr P, Mattson HL. A study o f functional spinal motion in women after
instrumentation and fusion for deformity or trauma. Spine, 22(15): 1760-4, Aug I 1997.
Winter RB, Hall JE. Kyphosis in childhood and adolescence. Spine, 3(4):285-308, Dec
1978.
Wojtys EM, Ashton-Miller JA, Huston LJ, Moga PJ. The association between athletic
training time and the sagittal curvature o f the immature spine. Am J Sports Med,
28(4):490-8, Jul-Aug 2000.
Wood KB, Garvey TA, Gundry C, Heithoff KB. Magnetic resonance imaging o f the
thoracic spine, evaluation o f asymptomatic individual. J Bone Joint Surg Am 77(11):16318, Nov 1995.
Woodman WF. An adapted model o f the sport participation choice process. Res Quar
48(2):452-60, May 1977.
Worrell T, Perrin D, Gansneder B, Gieck J. Comparison o f isokinetic strength and
flexibility measures between injured and noninjured athletes. J Orthop Sports Phys Ther,
13:118-125, 1991.

279

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Yasukouchi A, Isayama T. The relationships between lumbar curves, pelvic tilt and joint
mobilities in different sitting postures in young adult males. App Human Sci 14 (1):15-21,
Jan, 1995.
Yang H, Alnaqeeb M, Simpson H, Goldspink G. Changes in muscle fiber type, muscle
mass and IGF-I gene expression in rabbit skeletal muscle subjected to stretch. J Anat,
190(Pt 4):6l3-22, May 1997.
Zacharias L, Rand WM. Adolescent growth in height and its relation to menarche in
contemporary American girls. Ann Hum Biol, 10(3):209-22, May-Jun 1983.
Zador E, Dux L, Wuytack F. Prolonged passive stretch o f rat soleus muscle provokes an
increase in the mRNA levels o f the muscle regulatory factors distributed along the entire
length o f the fibers. J Muscle Res Cell Motil, 20(4):395-402, May 1999.
Zhu Y, Sandell LJ. Differential collagen expression during intervertebral disc
development. Proc Orthop Res Soc, New Orleans, LA. March, 1998.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.