A Comparative Study: Knee Proprioception in Football Players

This report investigates the differences in knee proprioception between injured and non-injured football players. It begins by defining proprioception and its importance in movement control and sports performance, particularly in football, where knee injuries are common. The report details the mechanisms of proprioception, including the role of mechanoreceptors and central processing, and discusses various methods for testing proprioception, such as JPR, AMEDA, and TTDPM. It highlights the vulnerability of the knee joint to injury and the factors affecting proprioception, such as pain, trauma, and fatigue. The research explores both static and dynamic proprioception, and the impact of anterior cruciate ligament (ACL) injuries on proprioception. It emphasizes the need for proprioceptive training in rehabilitation programs to prevent knee injuries. The report also reviews a previous study by Paul and Nagarajan (2015) and Relph et al (2014), highlighting their findings on the impact of knee injuries on proprioception in football players. The study aims to understand the difference in proprioception between non-injured and injured knees in football players using a comparative cross sectional study.

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THE DIFFERENCE IN KNEE PROPRIOCEPTION ON INJURED AND NON-INJURED
FOOTBALL PLAYERS
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Proprioception and knee injury 2
Difference in knee proprioception between injured and non-injured football players
Summary
In 1906, Sir Charles Sherrington referred to proprioception as the awareness of position
of the joints and body movements (Han et al, 2016). Proprioceptive function of the knee
ligaments has been a subject of much research; especially the anterior cruciate ligament. They
play an important role in the stability of the knee. They are also important for efficient transfer of
muscle force effectively over a stable joint. Considered one of the most played sports in the
world is football. Footballers are daily exposed to potential injuries with knee injuries being the
most commonly sustained injuries. The research covers the difference in knee proprioception
between the groups: injured and non-injured footballers (Cronström, Creaby, Nae, and Ageberg,
2016, p. 315). This research is important as the knee is a complex joint and it is very vulnerable
to injury. A comparative study design was used to collect data. It included one hundred and six
male professional footballers. This study is important because professional football players are at
a constant exposure to risk of knee injury every time they step into the field. The appropriate
training is required of them to minimize risk.

Proprioception and knee injury 3
Introduction
The body, to control movements, integrates proprioceptive information from the
mechanoreceptors. In competitive sports like football, price body movement is important to
ensure success (Zech and Wellmann, 2017). The capability to analyze signals from
mechanoreceptors in order to determine the position of body segments in space is proprioception
(Han et al, 2016). It is the individual’s ability to recognize the location of body parts, whether
consciously or subconsciously. It is considered crucial for normal motor control. The spine, brain
stem and higher cortical centres are where the proprioceptive information is processed. The
cerebellum and the cerebral nuclei also process proprioceptive information (Bosco and Poppele,
2001; Amaral, 2013; Lisberger and Thach, 2013; Pearson and Gordon, 2013).Performance in
football is enhanced by central processing in proprioception. One is required to pay attention
when learning complex skills in football, such as when dribbling the ball with the foot. As one
learns movement skills, as the proprioceptive information is been processed the player is learning
new skills in movement. A beginner athlete uses the closed loop system to master new skills. An
elite soccer player spends more time on tasks such as pinpointing the location of his teammates
and players of the opposing team than on his moves. This is due to the player using little
cognitive ability to process the proprioceptive information of movement as found out by Han et
al. To date, the mechanisms underlying proprioceptive control are unclear. Han et al found out
that the processing of sense of effort was done centrally. The findings of Han et al differ from the
current knowledge of movement-related proprioception. Under the current literature, central and
peripheral mechanisms are needed. However, Han et al. found out peripheral sensory
information provided little or no assistance to movement-related proprioception.

Proprioception and knee injury 4
Several methods for testing proprioception are utilized. The three main testing methods
are; JPR, AMEDA and TTDPM. These methods have different concepts, different testing
conditions and different aspects of proprioceptive modalities (Han et al, 2016). Medical and
sports science researcher have spend tremendous amount of time conducting research on knee
proprioception. AMEDA approach is the most to difference in knee proprioception. This is due
to that fact that it examines proprioception functions under normal conditions. Researchers are
able to do a comparison when other factors come into play apart from the normal conditions. The
AMEDA approach has proven to be effective in assessing proprioception during performance of
exercises and sports. E.g. football
Football as a sport involves a lot of physical activity with varied intensity at any given
moments. The sport exposes the footballer to high risks of injury due to the heavy physical
contacts among players. The knee is a very complex joint. It manages the high loads between
patella, femur, tibia and fibula. The knee is surrounded by muscles, the quadriceps and hamstring
groups. The co-contraction of the surrounding muscles helps stabilize extension and flexion of
the knee (relph, 2015). The sense of location of knee joints is transmitted to the central nervous
system by the joint capsules and ligaments found in the knee. They play a role in protecting the
knee from injury through reflexes (Barrack et al., 1994). It is very vulnerable to injury during
moments of play in football. Several factors do affect the proprioception of the knee: when a
player is in pain, proprioception can be affected. This results to the gamma-muscle spindle
system sensitivity and reflex abilities to change (Johansson et al., 2003); trauma and fatigue,
injury risk increases after exhausting physical activity among footballers. In the long run altered
proprioception may be linked to increased risk to injury.

Proprioception and knee injury 5
The proprioceptive function of the knee has been a subject of research for over three
decades. In measuring knee proprioception, researchers look at two aspects static proprioception
and dynamic proprioception. Static proprioception the researcher observes the locations of
segments and compares it to the location of other segments (Jeroschand phymka, 1996a, jerosch
and phymka, 1996b). The joint sense technique is used. Dynamic proprioception focuses on the
movement of segments. The researchers use threshold to detect passive motion techniques to
collect the information. Using the matching knee angle methods, researchers can measure the
position sense of the knee joint (smith et al., 2012). During the study, the subject vision is
blocked using a blindfold. Since there has not been a standardized direction of movement, both
extension and flexion are used when conducting the research. The leg is moved to a range of
target angles. The subject is requested to move his/her leg to the target angle and hold it
(Grygorowicz et al., 2017). This can be referred to as passive active reproduction. The subject is
asked to repeat the same process several times. The angles are recorded and the data is taken. Up
to date there has not been a standardized measurement technique for normal proprioception
levels.
Anterior cruciate injuries are raising major concerns for football players (Hagglund and
Walden, 2016). The injury rate to the knee was 0.35/1000 hours; the injuries occur much more
during game play than during training sessions (Hagglung and Walden, 2016). The anterior
cruciate ligament plays a vital role in knee stability. Proprioception measurement enables
clinicians to recognize the minimal joint movements (skinner et al, 1984). Injuries to footballers
are frequent. This has brought the necessity to come up with prevention measures. Limp
dominance, sex and participation in football may affect anterior cruciate ligament tears. Players
with a higher numbers in terms of weight, BMI and age had increased risk to ACL injury

Proprioception and knee injury 6
(Needle, Lepley, and Grooms, 2017, p. 1279). Sex as a factor, the female footballers are
associated with more cases of ACL injury rates (Hagglund and Walden, 2016).Regular physical
activity is beneficial to proprioception. The gamma motor neuron route is made more efficient
through regular and consistent exercises (Ribeiroand Oliveita, 2010).
As the knee is highly susceptible to injury, most rehabilitation regimes for knee injury
have been developed around proprioceptive training. Training programs assist prevent knee
anterior cruciate ligament injuries in soccer players. Proprioceptive training reduces the risk of
injury in young football players (Hammes, Aus der Fünten, Bizzini, and Meyer, 2016).
Proprioceptive training should be included in training programs for football players. This paper
focuses on evaluating the difference between knee proprioception in injured and non-injured
football players.
A previous paper by Paul, J and Nagarajan, M. Using a cross sectional comparative
study, sample analysis to evaluate the proprioception error of the knee between two groups: one
with uninjured knee and the other with injured knee joints. Their findings provide insight on the
effect on a knee injury to knee proprioception. The study concluded there is a difference of
proprioception between knees injured and injured footballers. Relph et al (2014) also conducted
a meta-analysis from various past papers on the same topic. There is a huge gap of
proprioception of athletes with ACL injuries as per the results of the study. They have poor
proprioception compared to athletes without ACL injuries. The huge gap in proprioception is
highly noticed when using the joint position sense (Relph, 2015)
Problem Statement
the most played sport in the world is football. The number is approximately 265 million
players around the world. This is according to the data provided by FIFA (2006). Everyone has

Proprioception and knee injury 7
even once in their lifetime played it, from professional footballers to just playing in the backyard
with friends. Football involves high intensive physical activity. The players are under constant
exposure to potential injury. Each year in the United States alone, approximately 250,000 people
sustain injury to their anterior cruciate ligament each year (Hewett et al., 2007). Hewett et al.
(2007) argued that low proprioception ability is one of the reasons which contribute to these
injuries. To get static and dynamic stability the knee joint depends on other structures
(Ravichandran and Janakiraman, 2017). There has been the need to understand knee
proprioception and the difference in knee proprioception during an injury (Olivier et al., 2016, p.
79). Sports science and medical researchers have done extensive research on the subject (Weiss,
and Whatman, 2015, p. 1325). A cross sectional comparative study will be used to compare the
difference in proprioception of an injured knee and the non-injured knee. Does knee
proprioceptive differ between non-injured knee and an injured knee?
Critical Review of Previous Paper
This study was done by Paul, J. And Nagarajan, M. (2015) to determine the
proprioception differences in knee in injuries of male professional football players. A control
group of uninjured football players was used Int J physiother 2015; 2(1), 361-363. The study
was a cross sectional comparison. The knee injury was to be categorized under first and second
degree. It was studied within a period of five months. The age group of the footballers was
between twenty and thirty five years. Samples from One hundred and six subjects were selected
and analyzed Ninety four uninjured, one hundred and eighteen injured. The subjects were from
the football association in Malaysia. Knee injured footballers were selected twenty weeks prior
to the investigation (Jones, Griffiths, and Mellalieu, 2017, p. 943). Any subject with lower limb

Proprioception and knee injury 8
trauma was not included in the study. At least a subject with an experience of one year was
included.
They used photographic analysis method to determine the error of proprioception. They
determined proprioception from three ranges: inner, middle and outer range for both knees. The
area to be examined was exposed. The subject was instructed to lie in a comfortable position.
The therapist made three markings; at lateral epicondyle, tibial malleoli above grater trochanter
of the femur; by placing adhesive markers. The digital camera was placed perpendicular to the
knee joint, one and half metres away.
The knee joint was moved 3 to 4 times, it would be stopped at the target angle and the
position of the joint photographed (McCunn, aus der Fünten, Fullagar, McKeown, and Meyer,
2016, p. 763). The subject would then memorize the position. Later the subject would be
blindfolded and then asked to flex the joint to the position he had memorized. The joint was also
photographed. Image tool software was used examine the data from the photographs. The
proprioception different was calculate and recorded (Silfies, Ebaugh, Pontillo, and Butowicz,
2015). The data was analyzed to find out the proprioception difference between knee injured and
non injured professional football players. The results of the study shows that knee injuries have a
great influence on proprioception. The data concluded that the knee injured group had a larger
gap of proprioception than that of the knee uninjured group. Mechanoreceptors are lost during
knee injuries. Thus, knee proprioception decreases (Relph, 2015).
Paul J. and Nagarajan M.s’ study provides a great insight as to the effect of knee injury
on proprioception in football players (Kyritsis, Bahr, Landreau, Miladi, and Witvrouw, 2016, p.
946). Their ideas and other studies have proved proprioception error and knee injuries are
associated.

Proprioception and knee injury 9
Non-injured elite players have high levels of proprioceptive ability (Han et al, 2013) this
is due to development of muscle spindles and central processing as a result of many hours of
training. The results of meta-analysis (Relph, 2014) have shown that athletes with knee injuries
experience reduced sense in location of the knee joint in both extension and flexion when
compared to healthy athletes. Even though an elite footballer has high levels proprioception there
is still chances of knee injury. Injury to the knee can be brought about by many factors. The
players with knee injuries recorded a knee proprioception error score of 7.2 and 8.1 degrees,
players with healthy knees produced 3.5 and 1.9 degrees error score (Steffen, Nilstad,
Krosshaug, Pasanen, Killingmo, and Bahr, 2017, p. 253). The control group had a 3.1 and 2.8
degrees error score (Relph, 2015). Following the ACL damage, mechanoreceptors in the knee
joint are destroyed
Footballers are mandated to train well to avoid knee injuries. As proprioception is
considered important for movement and balance during play and the importance of
understanding proprioception is receiving much attention in the recent past (Valle et al., 2015).
Therapies of improving proprioception have been developed by therapists such as
Augmentation of somato sensory information (Relph and Herrington, 2016, p. 1029). The use
taping or braces and soft tissue techniques are valuable. Exercise can be used to develop
proprioception. The most recognized proprioceptors are the muscle spindles. They are simulated
during physical activities. This is as a result of the activation of alpha-gamma (Ghai, Driller, and
Ghai, 2017, p. 65). There are specific exercises designed to improve proprioception. Training
programs have also been developed to improve proprioception ability and reduce risk of injury
(Yeung, Cleves, Griffiths, and Nokes, 2016). This study has proven helpful to physiotherapists
and players when choosing an appropriate training program. Players attain motor skills during

Proprioception and knee injury 10
these exercises. Training increases joint stability. It involves partly the central nervous system
building a constructing a model used in feed forward control. It leaves little room for error by
players. The player is also able remain stable while utilizing the slightest effort (Kadiallah et al.,
2012). It is important to maintain emphasis on exercise therapy.
Paul J. And Nagarajan M concludes that the proprioception difference of the knee joint
was more among injured footballer than uninjured footballers (Relph, 2015). This study has been
able to provide a base for research on training programs to enhance proprioceptive ability of
football players (Goossens, Witvrouw, VandenBossche, and De Clercq, 2015, p. 436). When
treating knee injury, clinicians put on emphasis in improving proprioception.
Conclusion
The study of proprioception difference in knees of uninjured and injured football players
has received application in variety of training programs. The training programs are important to
increase the proprioception levels of the players and reduce risk of injury. It has also been
applied in rehabilitation programs. Clinical practitioners are confident that knee injury to the
ACL does reduce static proprioceptive ability. Rehabilitation programs are focusing on
improving static proprioceptive ability. Swanik et al., (1997) states that rehabilitation must
include balanced training. However, it is unclear how these exercises improve proprioception
abilities.

Proprioception and knee injury 11
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