🧱Core Strength & Stability⤵️ reposted with permission from Matthew Ibrahim's Instagram - ⠀

Ever since the original Hodges TrA research, the "core" has been a core of much of rehab and fitness programs. I've even had world record power lifters been told they need to strengthen their core. Dalton Urrutia, @physicaltherapyresearch on instagram put together a great series on the Myths of Core Stability. Please share with everyone who is so core focused and promoting weakness and Thought Viruses! #stopthoughtviruses.

It's 5+some bonus slides for this Top 5 Fridays!

🔬📚 (0/6) MYTH OF CORE STABILITY SERIES: 💡 Core stability (CS) is widely accepted in training for the prevention and treatment of injury and various musculoskeletal conditions, especially low back pain. . 💡 CS came about is the late 1990s and was based on studies demonstrating changes in onset timing of the trunk muscles in back injury and chronic lower back pain (CLBP) patients (Hodges and Richardson, 1996 & 1998) 💡 Trunk control research has contributed to the understanding of neuromuscular reorganization in back pain and injury. . 💡 CS studies have confirmed that motor control of the trunk muscles of patients who suffer from back injury and pain are altered. 💡 However, these findings combined with general beliefs about the importance of abdominal muscles for a strong back, and influences from Pilates, have promoted several assumptions prevalent in CS training. 💡 Lederman (2010), re-examines core stability/spinal stabilization approaches and their efficacy within the wider knowledge of motor control, prevention of injury and rehabilitation. ✅✅ This week’s Myth of Core Stability Series will reviews several assumptions prevalent in ‘Core Stability’ training: 1️⃣Assumptions about stability and the role of TrA and other core muscle 2️⃣The timing issue 3️⃣The strength issue 4️⃣The single/core muscle activation problem 5️⃣CS and training in relation to motor learning and training issues 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain ↗️↗️ Don’t miss anything! - Make sure and turn post notifications on 💭💭 Post your thoughts, comments, and questions below 📚📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp. 84e98.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 23, 2018 at 10:42pm PST

🔬📚 (1/6) MYTH OF CORE STABILITY SERIES: 💡 Myths of Core Stability Series: 1. Assumptions about stability and the role of Transverse Abdominis (TrA) and other core muscles. 💡 The TrA receives most of the CS focus and is widely believed to be the main anterior component of trunk stabilization. . 💡 However, many different muscles of the trunk contribute to stability and their action may change according to varying tasks. 💭💭 How essential is TrA for spinal stabilization? . 💭 This can be assessed in situations where the muscle is damaged or put under abnormal mechanical stress, for example in: Pregnancy Post-partum Obesity 💭 The abdomen distension can disrupt the normal mechanics and control of the trunk muscles, including TrA. . 💭 According to the CS model this should result in an increased incidence of back pain. . 💭 However, epidemiological studies demonstrate Pregnancy, Post-partum, and obesity are only weakly associated with lower back pain (LeboeufYde, 2000; Fast et al 1990) . 💥💥 What about abdominal muscles damaged by surgery? Would such damage affect spinal stability or contribute to back pain? . 💥 In breast reconstruction after mastectomy, one side of the rectus abdominis is used for reconstruction of the breast. . 💥 Leaving only one side of rectus abdominis and weakness of the abdominal muscles. 💥 Such alteration in trunk biomechanics would also be expected to result in profound motor control changes, yet there is no relationship to back pain or impairment to functional/movement activities, measured up to several years after the operation (Mizgala et al., 1994; Simon et al., 2004). . 💥 No study to date has demonstrated that LBP is due to spinal instability. Despite a decade of research in this area it remains a theoretical model. . ↗️↗️
Make sure and turn post notifications! Keep posted for: 2️⃣The timing issue 3️⃣The strength issue 4️⃣The single/core muscle activation problem 5️⃣CS and training in relation to motor learning and training issues 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp. 84e98.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 25, 2018 at 5:38am PST

🔬📚 (2/6) MYTH OF CORE STABILITY SERIES: 💡 Myths of Core Stability Series: 2. The Timing Issue . 💡 Research shows with rapid arm/leg movement, the TrA in CLBP patients had delayed onset timing 💡 Consequently it was assumed TrA is dominant in controlling spinal stability (Hodges et al., 2003). . 💡 Therefore any weakness or decreased control of TrA means trouble for the back. . 💡 This is a faulty assumption: 1. TrA is one of many trunk muscles anticipating movement. Recent suggestions state earlier activity of TrA may compensate for its long elastic anterior fasciae (Macdonald et al., 2006). . 2. Delayed onset timing may be an advantageous protection strategy rather than a dysfunctional activation pattern. . . 3. During the fast movement of the outstretched arm the subject performed a reflexive pain evasion action that involved delayed activation of TrA, an action unrelated to stabilization (Moseley et al., 2004) . 4. Onset time differences between asymptomatic and CLBP were 1/50 sec. (Radebold et al., 2000). 💭 This is well beyond the patient’s conscious control and the clinical capabilities of the therapist to test or alter. . . 5. Strength training for TrA is believed to normalize timing dysfunction. . 💭 This is unlikely to reset timing due to transfer and specificity training principles. 💭 It is like aspiring to play the piano faster by exercising with finger weights. 💭 To control onset timing switch movements between synergists at a fast rate, and hope that the system will reset itself (Lederman, 2005). . . 6. To overcome the timing problem, continuously contracting TrA is taught . 💭 This is an abnormal pattern of control to overcome a natural protective strategy (SEE PHOTO) 💭 7. No study to date demonstrates core stability exercise resets onset timing in CLBP patients ✅✅ Make sure and turn post notifications! Keep posted for: 3️⃣The strength issue 4️⃣The single/core muscle activation problem 5️⃣CS and training in relation to motor learning and training issues 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp. 84e98.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 27, 2018 at 1:44am PST

🔬📚 (3/6) MYTH OF CORE STABILITY SERIES: 💡 Myths of Core Stability Series: 3. The Strength Issue . 💡 There is confusion about trunk strength’s relation to back pain and injury prevention. . 💡 Trunk muscle control including force losses can be consequential of back pain/injury. . 💡 However, several assumptions are often made: 1. Loss of core muscle strength could lead to back injury. 2. Increasing core strength can alleviate back pain. 💭 To what force level do the trunk muscles need to co-contract in order to stabilize the spine?…Not very much [SWIPE LEFT] 💭 During standing trunk muscles, deep spinal erectors, psoas and quadratus lumborum are nearly silent! . 💭 Maximal voluntary contraction (MVC) during walking: Rectus abdominis: 2% External oblique: 5% . 💭 During standing ‘‘active’’ stabilization is achieved by less than 1% MVC of trunk flexors and extensors. 💭 During bending and lifting a weight of about 15 kg co-contraction increases by only 1.5% MVC. 💭 Why are strength exercises prescribed with such low required levels of co-contraction for functional movement? 💭 For most, conscious co-contraction is: . * More than is required for stabilization . . * Could increase compression of the lumbar spine * Reduce economy of movement . 💥 Is there a relationship between weak abdominals (e.g. TrA) and back pain? . 💥 There is no evidence reduced trunk muscle strength or endurance will predispose individuals to LBP . 💥 There are inconclusive finding regarding loss of trunk muscle strength and atrophy in response to CLBP 💥 CS exercises do not provide the overtraining challenge expected for strength or endurance gains 💥 70% MVC is needed to promote strength gains in abdominal muscle . 💥 Improvement in back pain seems to be due to: Changes in lumbar muscles neural activation Psychological changes (motivation or pain tolerance) ✅✅
Make sure and turn post notifications! Keep posted for: 4️⃣The single/core muscle activation problem 5️⃣CS and training in relation to motor learning and training issues 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Th

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 28, 2018 at 1:17am PST

📚🔬 (4/6) MYTH OF CORE STABILITY SERIES: 💡 Myths of Core Stability Series: 4. The single/core muscle activation problem . 💡 One principle of CS is to isolate TrA from the rest of the abdominal muscles 💡 It is doubtful a ‘‘core’’ group of trunk muscles can be recruited independently (McGill et al., 2003; Kavcic et al., 2004). . 💡 To specifically activate the core muscles during functional movement natural patterns of trunk muscle activation would have to be overridden. 💡 This would be impractical and next to impossible (Georgopoulos, 2000). . 💡 If you bring your hand to your mouth the nervous system ‘‘thinks’’ hand to mouth rather than flex the biceps, then the pectorals, etc. . 💡 Research has demonstrated, when tapping the tendons of rectus abdominis, external oblique, and internal oblique the evoked stretch reflex responses spread extensively to ipsilateral and contralateral muscles (Beith and Harrison, 2004). . 💡 This suggests sensory feedback and reflex control of the abdominal muscles is functionally related and would be difficult to separate by conscious effort. 💭💭 This simple principle in motor control poses two problems to CS training: 1. It’s doubtful following injury one group of muscles would be affected. In CLBP a complex and wide reorganization of motor control is seen in response to damage or pain. 2. There is no support from research that TrA can be singularly activated (Cholewicki et al., 2002a,b). So why focus on TrA or any other specific muscle or muscle group? . 💭💭 We can summaries that: 1️⃣ The control of the trunk (and body) is whole. No evidence exists suggesting any core muscles work independently during normal functional movement. 
2️⃣ There is no evidence individuals can effectively learn to specifically activate one muscle group independently ✅✅↗️
Make sure and turn post notifications! Keep posted for: 5️⃣CS and training in relation to motor learning and training issues 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp. 84e98.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 28, 2018 at 9:51pm PST

🔬📚 (5/6) MYTH OF CORE STABILITY SERIES: 💡 CS training clashes with three important principles: 1️⃣Transfer & Specificity When we train for an activity we become skilled at performing it. . 📉 Contracting anterior abdominal muscles lying supine is not guaranteed to transfer to control and physical adaptation during standing, running, bending, etc. 📉 Such control would have to be practiced during these activities [SWIPE LEFT] 📉 Anyone who is giving CS exercise to improve sports performance should re-familiarize themselves with this basic principle. . 2️⃣Internal/External Focus When learning movement it can be helpful to focus on: Their technique (internal focus) - Novice Learners The movement goal (external focus) - Skilled Learners 📈 but skilled learning ability reduces when focus is on internal processes (McNevin et al., 2000, 2003). . 📈 Tensing trunk muscles is shown to degrade postural control (Reeves et al., 2006). . 📈 What about movement rehabilitation for CLBP patients? . 📈 Complex internal focusing is the essence of CS training, but would be difficult to apply when learning simple tasks; I.e. hip hinging . 3️⃣Economy of Movement CS advice involves continuously tighten abdominal and back muscles. . 📊 This could reduce the efficiency of movement during daily and sports activities. . 📊 Our bodies are designed for optimal expenditure of energy during movement. 📊 Co-contraction is known to be an ‘‘energy waster’’ in initial motor learning situations. . 💥💥 We can conclude for the evidence: CS exercises conflict with motor learning and training principles. CS exercises are dissimilar to normal physiological movement and is ineffective when learning motor skills. 
Internal-focus approach is likely to degrade motor learning and skilled performance. 
Additional tensing of trunk muscles during daily activities or sports is likely more energetically inefficient. . ✅✅↗️
Make sure and turn post notifications! Keep posted for: 6️⃣CS in prevention of injury and therapeutic value, specifically Low Back Pain 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp. 84e98.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Dec 30, 2018 at 10:24pm PST

🔬📚 (6/6) MYTH OF CORE STABILITY SERIES: 💡 The CS approach is used for improving sports performance, preventing injury and treating lower back pain (Kibler et al., 2006). . 💡 However, some clinical studies don't support this: 💭💭 Helewa et al., (1999), included 402 asymptomatic subjects; . 💭 Were given back education or back education and abdominal strengthening exercise. 💭 No significant differences were found between the two groups over 1 year for LBP and LBP episodes. 💭 This study was carried out on asymptomatic subjects who were identified as having weak abdominal muscles. . 💭 Four hundred individuals with weak abdominal muscles and no back pain! . 💭 Nadler et al. (2002), examined the influence of a core-strengthening program on LBP in 257 collegiate athletes. 💭 No significant advantage was found of core strengthening to reduce LBP occurrence. . 📈📈 CS a treatment for recurrent LBP and CLBP . 📈 Initially, studies of CS exercise for the treatment of recurrent LBP look promising and significant improvements can be demonstrated when compared to other forms of therapy. 1,2,3,4,5,6,7 A: [SWIPE LEFT] 📈 Systematic reviews found stabilization exercise to be better than general practitioner care, but not from any other form of physical therapy. 8,9,10 . 📈 However, none of these studies actually showed relationships between improvement in LBP and spinal stabilization or core control. . 📈 Many of these studies did not have a control group. 📈 Meaning CS may not be any better than a placebo/sham treatment. . 📈 An interesting trend emerges when CS exercise are compared to general exercise [SWIPE LEFT]. 📈 Both exercise approaches are demonstrated to be equally effective . 📈 Suggesting improvements are due to positive effects of physical exercise vs. spinal stability. 📈 Which includes CS exercise. But patients should be informed the spine is inherently stable and CS is only as effective as any other exercise. . 💥💥 CONCLUSION: CS exercise may be better than general medical care . 💥 CS exercise is no better than other manual or physical therapy or general exercise . 📚📚 SOURCE: Lederman 2010. The Myth of Core Stability. Jrn Body & Mvmt Thera. 14, pp.

A post shared by Dalton Urrutia (@physicaltherapyresearch) on Jan 1, 2019 at 10:05pm PST

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In my Evaluate, Stabilize, Reset system, I try to find patterns that are common among symptoms regardless of condition. You may find that if sidegliding in standing relieves complaints, but does not last between sessions; this is despite patient compliance and proper end range loading. 

“That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.”

“That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.” Is a great line from one of my favorite YouTube short film clips: It’s Not About the Nail. But the phrase also applies to my own worries about our constant attempt to so easily blame a weak core as the source of back pain. Some researchers and clinicians have been working to debunk this commonly held misbelief for some time, see Eyal Lederman’s The Myth of Core Stability or Peter O’Sullivan’s Core Stability: separating facts from fiction as a couple examples. One would think that we could move past this illusive search for the weak core impairment that needs fixed to eliminate back pain.

That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.

I get an email feed from Pain Week as one of many sources to stay current with pain research and current topics around pain. The most recent headline was: AVOIDING RUNNER'S CHRONIC BACK PAIN: IT'S ALL IN THE CORE. Needless to say, it perked my interest so I read the story. I’m guessing the opening few lines sounded very convincing to many, especially when they referred to the high-level technology (force place, motion detection, and computer simulation) used in the research. The results have to be good if they used high-level technology, right?

Then you get to the results:  “When your deep core is weak, your body is able to compensate in a way that allows you to essentially run the same way. But that increases the load on your spine in a way that may lead to low back pain.” I have to do is a few planks and my pain will go away, right?

That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.

I dug a bit deeper into results by following the links to another news story. It came from Newswise, so the information should be wise, right? The title of this press release: “Study Uncovers Potential Key to Preventing Back Pain in Runners” and it provide the findings summary in the second paragraph. “The study, published in the Journal of Biomechanics, suggests that runners with weak deep core muscles are at higher risk of developing low back pain. And, unfortunately, most people’s deep core muscles aren’t nearly as strong as they should be.”

That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.

Trying to figure out how the authors came to this conclusion, I decided not to take the news media’s slant on the research and went straight to the paper, found here. So how was the study done? They used data from 3 people that had consented to a previously published study. They took that data and made computer simulations of running and then ran various computer simulations of what would happen if you weakened some of the core muscles. Their findings showed that taking away some of the muscles lead to increased axial load onto the spine. Their findings suggest that all deep core muscles contribute to maintaining stability of the spine. I can agree with all of these. I struggle with how these findings suggest that just getting your core strong enough is all that needs to be done to prevent back pain.

That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.

One limitation listed in the study that never made it to the news media reports listed by the authors was that because it was a computer simulation running kinematics were forced to stay the same after the muscle weakness was simulated into the model and thus it is unknown if people may alter kinematics to compensate for muscle weakness. Oh, and one more limitation provided by the authors: “It is unknown if this phenomenon is entirely realistic clinically.”

Once again, we see the public being feed a story that isn’t accurate about back pain and the dreaded core weakness as the cause by twisting up research to make inaccurate claims.

That’s the thing that scares me the most, is that I don’t know if it’s ever going to stop.

via Dr. Kory Zimney, DPT

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INTRODUCTION

Over the past four years there has been a resurgence in interest about a small little lateral ligament of the knee known as the anterolateral ligament (ALL). I’m not even sure I remember learning much about it during school, but with the number of ACL reconstructions associated with chronic rotational instability rising, researchers and surgeons have been diverting focus to understand what impact an ALL-deficient knee has on ACL recovery and regaining rotational stability. 

The ligament was first published in 1879, when French Surgeon Paul Segond described the ALL in-relation to an avulsion fracture known as a Segond Fracture (Pomajzl et al., 2015). For a long time there remained a paucity in the literature about the exact anatomy, histology and biomechanical function of the ALL. In 2015, Pomajzl et al conducted a systematic review on all articles prior to 2014 about the ALL. Only 13 papers met the inclusion criteria, but what these articles confirmed, is that there were several studies clearly defining the ALL as a distinct ligament and not a fibrous branch of the LCL or ITB. It was around this time that the ALL made its way back onto the map of the knee. The remainder of this blog is a refresher about the anatomy and biomechanical function of the ALL and what we currently know to be true about it’s role in rotational stability of the knee. 

ANATOMY

The anterolateral ligament (ALL) of the knee is a distinct ligament, separate to the lateral collateral ligament, that has fibres which span obliquely over the LCL connecting the lateral femoral condyle to Gerdy’s tubercle on the tibia (Bonanzinga et al., 2017). Vincent et al (2012, p.147) describe the anatomy in greater detail stating that:

• The ALL begins near or on the poplitus tendon insertion on the lateral femoral condyle.
• It inserts into the lateral meniscus and the tibial plateau 5mm distal to the articular surface and posterior to Gerdy’s tubercle. 
• The average width is 8.3mm ± 1.5 mm.
• The average length is 34.1 ± 3.4mm.

Image courtesy of Google Images

The ALL is not an anatomical anomaly, which begs the question as to why we seemed to have forgotten about it? Vincent et al (2012) found the ALL present in 100% of the test sample. These authors dissected 30 knees to find the ALL and after understanding its anatomical connections further, proposed that the ALL plays an important role in stability of the lateral meniscus “even in the absence of ACL pathology, including limiting anteroposterior translation during flexion and preventing meniscal extrusion” (Vincent et al, 2012., p.156). These statistics are consistent with other papers published in more recent years (Farhan, et al., 2017). 

Image source: (Vincent et al., 2012, p. 149)

Bonanzinga et al (2017a) published two papers after dissecting 10 fresh-frozen knees to establish the role that the anterolateral ligament (ALL) of the knee plays in rotational stability compared to the anterior cruciate ligament (ACL). What these authors found is that the ALL plays a key role in stabilization of tibial internal rotation but less anterior translation at the knee. They used three common clinical tests, the anterior draw, Lachman’s and pivot shift test to detect different degrees of stability in an ACL-impaired versus ACL & ALL - impaired knee. From these test conditions the authors were able to conclude that ‘the ALL plays a significant role in controlling static internal rotation and acceleration during pivot shift test… but, ALL resection does not produce any significant change in terms of anterior displacement’  (Bonanzinga et al., 2017a, p.1055). What this means is that the ALL plays a significant role as a biomechanical restraint to knee internal rotation. Holger Drews et al (2017) further specified that the ALL has the highest impact on rotational stability between 60-120 degrees of knee flexion. 

Song et al (2017) looked more closely at the correlation between instability on the pivot shift test and the prevalence of ALL injury on MRI. These authors found that when using the pivot shift test to assess an ACL-deficient knee, there is a strong correlation between more severe gradings on the pivot shift test and the presence of GR II and III injuries of the ALL. Interestingly, they also found that lateral compartment contusion was more commonly found in patients with a concomitant ALL injury.

CLINICAL RELEVANCE

As there has been some confusion about the anatomy and function of the ALL in recent years, many specialists are urging clinicians to consider the role of the ALL in anterolateral rotational stability of the knee, but also cautioning them to consider that many other structures contribute to this stability as well. These structures include the ITB, lateral meniscus, ACL and lateral capsule. It may be more helpful to be assessing these combines structures as an “anterolateral complex” of the knee than individual structures and to remember that ligamentous injury, meniscal lesions and bony morphology can all contribute to instability (Musahl, et al., 2017). Interestingly, while some authors have proposed that the ALL plays an important role to stability of the lateral meniscus (Vincent, et al., 2012), a lateral meniscal injury is associated with delayed ACL surgery rather than increases rotational instability (Hardy, et al., 2017). 

The goal of ACL reconstruction surgery is to abolish rotational and anterior translatory instability, detected on tests like the pivot shift and Lachman’s tests. Not all patients are able to abolish this instability following reconstruction, with 25-38% of patients continuing to have rotational instability (Hardy, et al, 2017, p1118). 

Theoretically, if the ALL plays an important role in knee stability, then surgical reconstruction of the ALL in combination with an ACLR would be logical in the ACL+ALL deficient knee. This would require changes to the current surgical technique involving a tendon graft from semitendinosis to reconstruct the ALL. Although this additional reconstruction is not standard practice, research is emerging to suggest that both reconstructions result in reduced rotational instability on the pivot shift test when a concomitant ALL injury is present (Bonanzingo et al., 2017b; Hardy et al., 2017). It appears that the patients who benefit most from this procedure sustained their injury under an explosive rotational mechanism, have a Segond fracture (makes sense) and exhibit >10mm of anterior translation during the anterior draw test (Hardy, et al., 2017, p.1118). 

Not all articles recommend surgical reconstruction (Stentz-Olesen., et al, 2017) but when reading such papers further it appears that the knees that were investigated were cadavers. Personally, I think it is difficult to know how much research from a non-living knee can be applied to or correlated with clinical instability in a live subject. Just something to keep in mind. 

Definitely a shorter blog this week from us, but hopefully an important reminder that coming back to anatomy can help us further understand the finer detail of injury management and improve our changes of successful rehabilitation. 

Sian - via Rayner and Smale

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

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REFERENCES:

Bonanzinga, T., Signorelli, C., Grassi, A., Lopomo, N., Bragonzoni, L., Zaffagnini, S., & Marcacci, M. (2017a). Kinematics of ACL and anterolateral ligament. Part I: Combined lesion. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1055-1061.

Bonanzinga, T., Signorelli, C., Grassi, A., Lopomo, N., Jain, M., Mosca, M., ... & Zaffagnini, S. (2017b). Kinematics of ACL and anterolateral ligament. Part II: anterolateral and anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1062-1067.

Cavaignac, E., Wytrykowski, K., Reina, N., Pailhé, R., Murgier, J., Faruch, M., & Chiron, P. (2016). Ultrasonographic identification of the anterolateral ligament of the knee. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(1), 120-126.

Claes, S., Vereecke, E., Maes, M., Victor, J., Verdonk, P., & Bellemans, J. (2013). Anatomy of the anterolateral ligament of the knee. Journal of anatomy, 223(4), 321-328.

Drews, B. H., Kessler, O., Franz, W., Dürselen, L., & Freutel, M. (2017). Function and strain of the anterolateral ligament part I: biomechanical analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 1-8.

Farhan, P. S., Sudhakaran, R., & Thilak, J. (2017). Solving the Mystery of the Antero Lateral Ligament. Journal of clinical and diagnostic research: JCDR, 11(3), AC01.

Hardy, A., Casabianca, L., Hardy, E., Grimaud, O., & Meyer, A. (2017). Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1117-1124.

Heckmann, N., Sivasundaram, L., Villacis, D., Kleiner, M., Yi, A., White, E., & Hatch, G. F. R. (2016). Radiographic landmarks for identifying the anterolateral ligament of the knee. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(5), 844-848.

Herbst, E., Albers, M., Burnham, J. M., Shaikh, H. S., Naendrup, J. H., Fu, F. H., & Musahl, V. (2017). The anterolateral complex of the knee: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1009-1014.

Lording, T., Stinton, S. K., Neyret, P., & Branch, T. P. (2017). Diagnostic findings caused by cutting of the iliotibial tract and anterolateral ligament in an ACL intact knee using a standardized and automated clinical knee examination. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1161-1169.

Musahl, V., Getgood, A., Neyret, P., Claes, S., Burnham, J. M., Batailler, C., ... & Karlsson, J. (2017). Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL Injury: a roundtable discussion. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 997-1008.

Neri, T., Palpacuer, F., Testa, R., Bergandi, F., Boyer, B., Farizon, F., & Philippot, R. (2017). The anterolateral ligament: Anatomic implications for its reconstruction. The Knee, 24(5), 1083-1089.

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