Hamill et al.

Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012, 4:45

http://www.smarttjournal.com/content/4/1/45

REVIEW Open Access

Coordinative variability and overuse injury

Joseph Hamill*, Christopher Palmer and Richard E A Van Emmerik

Abstract
Overuse injuries are generally defined as a repetitive micro-trauma to tissue. Many researchers have associated
particular biomechanical parameters as an indicator of such injuries. However, while these parameters have been
reported in single studies, in many instances, it has been difficult to verify these parameters as causative to the
injury. We have investigated overuse injuries, such as patella-femoral pain syndrome, using a dynamical systems
approach. Using such methods, the importance of the structure of coordinative variability (i.e. the variability of the
interaction between segments or joints) becomes apparent. We view coordinative variability as functionally
important to the movement and different from end-point or goal variability. Using concepts derived from the work
of Bernstein, we conducted studies using a continuous relative phase and/or modified vector coding approaches to
investigate the coordinative variability of overuse injuries. Consistently, we have found that the higher variability
state of a coordinative structure is the healthy state while the lower variability state is the unhealthy or pathological
state. It is clear that very high coordinative variability could also result in injury and that there must be a window of
‘higher variability’ in which non-injured athletes function. While this finding that coordinative variability is functional
has been shown in several studies, it is still not clear if reduced variability contributes to or results from the injury.
Studies are currently underway to determine the potential reasons for the reduced variability in injured athletes.
Nevertheless, our laboratory believes that this understanding of how joints interact can be important in
understanding overuse injuries.
Keywords: Variability, Coordination, Dynamical systems, Overuse injury

Introduction There have been many noted risk factors related to

The incidence of overuse injuries in running has not overuse injuries in running. Several risk factors often cited
changed over the last 30 years [1]. The knee, leg and are: 1) repeated loading; 2) foot/ground contact force; 3)
foot are the most frequently injured by runners with running footwear [2]; 4) running surfaces; 5) anatomical
knee injuries reported by approximately 45% of runners. predisposition; 6) training errors; and 7) previous injury
Running injuries are generally divided into two broad [2]. While there is a multiplicity of variables thought to be
categories: 1) traumatic injuries; and 2) cumulative risk factors for overuse injuries, it is without question that
micro-trauma injuries. Traumatic, or acute, injuries can some of the factors are biomechanically-related. A signifi-
be thought to result from a single, large magnitude force cant problem in studying overuse injuries is that there are
that is usually applied over a very short period of time. multiple interactions among the risk factors making it dif-
For example, an Achilles tendon rupture is defined as ficult to determine the etiology of the injury. A related
a traumatic injury. Cumulative micro-trauma injuries, problem in determining the cause of an overuse injury is
often called overuse or chronic injuries, result from a the general lack of prospective studies, which makes it dif-
number of repeated low magnitude impacts applied over ficult to draw causal inferences from retrospective data.
a considerable time period. Most running injuries fall Additionally, the use of the typical dependent measures
into the category of overuse injuries. Examples include and standard kinematic and kinetic analyses cannot lead
patellofemoral pain, Achilles tendinitis, and iliotibial to a definitive cause of injury.
band syndrome. Over the last 30–35 years, biomechanists have primarily
used kinematic and kinetic analyses to probe the etiology
* Correspondence: jhamill@kin.umass.edu
of overuse injuries. Of particular interest has been the cal-
Department of Kinesiology, Biomechanics Laboratory, University of culation of rearfoot angle (i.e. the motion of the calcaneus
Massachusetts Amherst, 30 Eastman Lane, Amherst 01003, MA, USA

© 2012 Hamill et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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relative to the tibia in the frontal plane). “Excessive” rear- different spatio-temporal scales (e.g., motor units, mus-
foot motion is often cited as a cause of overuse injury [3,4] cles, joints/segments) into functional units. According to
although there is no clinical definition as to what is “ex- Turvey [14], coordination involves bringing the multiple
cessive.” From a kinetic standpoint, ground reaction forces degrees of freedom at each level into proper relations.
have often been used to relate external forces to the eti- These proper relations are formed because of redun-
ology of impact injuries [5,6]. The parameters that are dancy in the motor system. Many years ago, Bernstein
often used in this type of analysis are the peak impact described this redundancy in the available degrees of
force and the loading rate. The peak impact force has not freedom and he strongly advocated that action systems
proven successful in differentiating loads on the body in with multiple degrees of freedom enable different solu-
individuals with differing injuries [7,8]. On the other tions to a particular task [15,16]. Functional systems that
hand, loading rate (i.e. the slope of the force-time curve are stable and adaptable use all their degrees of freedom
from 20%-80% of the peak impact force) has shown some effectively in order to optimize task performance [17].
promise in differentiating healthy and injured groups There are components to analyzing a task, according to
[9,10]. Joint moments and forces, calculated from an the Bernstein perspective, which are key [18]. First is
inverse dynamics procedure, have also been used in that relationships between parts is critical and not an in-
injury research. For example, the knee adduction mo- vestigation of the parts themselves. This position derives
ment has been related to the incidence of patellofemoral from the fact that the many individual parts can be orga-
pain (e.g. [11]). nized in a large number of ways to sub serve the same
For the most part, however, the traditional kinematic coordination pattern. The second key point is that vari-
and kinetic analyses have provided definitive results in ability is of paramount importance, as it provides metric
that they have distinguished between runners with and related to the variety of ways in which the coordinative
without injuries and between healthy and injury-prone pattern is maintained.
individuals. The explicit cause of injury has not been
forthcoming in these studies, and may not be empirically Types of variability
accessible given the interacting injury mechanisms The traditional view of variability is based on the con-
involved. Thus, the results of these studies have not lead cept of ‘end-point’ variability. From this perspective, the
to a clearer understanding of the injury mechanisms and variability of the product of a movement (e.g. stride
have not brought about a rehabilitative process for re- length, stride time, etc.) should be less in a healthy indi-
covery or prevention from these injuries. For example, vidual and greater in a less healthy individual [19]. That
there are numerous studies on iliotibial band syndrome is, expert performers would have less variability than
all of which present different distinguishing factors be- novices and healthy individuals would have less variabil-
tween those with and without iliotibial band syndrome ity than those with movement disorders. It is now clear,
[12,13]. Because there are many contributing factors to however, that stability in the performance of goal-
injury, the level of analysis “above” these interacting in- directed performance (low variability at the ‘working-
jury mechanisms may be fruitful for characterizing in- point’) is only achievable only through variability at the
jury etiology. This macroscopic analysis of the combined level of coordinative relations underlying that perform-
contributions of interacting injury mechanisms to the ance [15,20-22].
state of a system (the states being injured, uninjured, The view put forth in this paper shares this perspective
progressing towards injury, or recovering from injury) that coordinative variability would in fact have the op-
underlies the Dynamic Systems approach, as it inher- posite interpretation of ‘end point’ variability, and that
ently recognizes that there may be many injury these two concepts of variability must be integrated in
“mechanisms” interacting to cause such a state. Thus, it any functional movement analysis. To illustrate the dif-
appears necessary to explore other than the traditional ference, we will present a paper by Arutyunyan et al.
techniques to fully understand the mechanisms and eti- [21] who conducted a pistol shooting test with experts
ology of injury to answer the questions that have posed and novices. They found that expert pistol shooters had
previously. In this paper, we present evidence that seg- less ‘end-point’ variability (i.e. the ability to hold the bar-
mental coordinative phase relations and coordinative rel of the pistol steady) than the novices. On the other
variability can be helpful in determining overuse injuries hand, they reported that the coordinative variability be-
and characterize the macroscopic level of analysis useful tween the shoulder, elbow and wrist of the expert shoo-
for determining injury etiology. ters was greater than the novices. This study shows that
the two types of variability are different, have different
The dynamical systems approach interpretations, and are related when goal-directed
Smooth goal directed movements require the integration movements are examined. In gait dynamics, the goal-
and coordination of the individual degrees of freedom at directed ‘end point’ is not a discrete spatial location, but
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the maintenance of segmental relations (co-ordination) loss of complexity has to do with the reduction in the
over many cycles that define the locomotor pattern many interacting degrees of freedom that underlie a
itself. macroscopic state of affairs (coordinative pattern rela-
In most research in biomechanics and motor control, tionships) in the system of interest. Over time, reduc-
variability is traditionally equated with noise, considered tions in effective degrees of freedom, interacting
detrimental to system performance and is typically elimi- components and synergies involved in the control of the
nated from data as a source of error. Equipment noise, biological system may become associated with a loss of
electrical interference and movement artifacts are exam- variability. When these reductions in degrees of freedom
ples of sources contributing to this measurement noise. and variability reach a critical threshold, injury or dis-
A second source of biological variation is dynamical ease emerge.
variability and arises from within the system to be stud- An important emphasis in recent research in biomech-
ied. In this case no clear separation can be obtained be- anics is link between variability and overuse injuries
tween the ‘original’ signal and variability. This form of [27], [28,29]. Even in repetitive activities such as running
variability emerges from underlying nonlinearities and is the motions of the body’s segments will vary somewhat,
important for pattern formation, sensation, and percep- and these variations may be functional and healthy. Sev-
tion in biology [23]. eral studies have now demonstrated an association be-
Thus, variability observed in human performance can tween reduced coordination variability and orthopedic
be fundamentally of two different forms, namely noise disorders or overuse injuries e.g. [30]. The relationship
due to measurement error and coordinative variability between absolute and relative coordination and coord-
or variation due to inherent dynamics of the system inative variability and how this relates to overuse injuries
[24]. It has been suggested that coordinative variability is is presented in Figure 2. We propose that absolute co-
simply ‘noise’ in the system. According to Kantz and ordination with its low variability causes forces to be dis-
Schreiber [24], we can define a system as: tributed across small surface areas, possibly resulting in
overuse injuries. In contrast, the variations present dur-
xnþ1 ¼ Fðxn Þ ing relative coordination allow joint or tissue forces to
Measurement noise is additive to the system: be distributed, thereby minimizing the change for over-
use injuries.
xnþ1 ¼ Fðxn Þ þ ηn

where ηn is the measurement noise. We have means Approaches to determining coordinative variability
such as filtering to eliminate this measurement noise be- In injury research, we often refer to the concept of coup-
cause it is of sufficiently high frequency [25]. On the ling. Coupling in this context refers to the interaction
other hand, coordinative variability is a part of the between segments or joints and implies that the motion
higher order dynamic of the signal: of one segment (or joint) can influence the motion of
xnþ1 ¼ Fðxn þ βn Þ another segment (or joint). For example, in the lower ex-
tremity, the motion of sub-talar joint eversion must be
where βn is the coordinative variability. Coordinative accompanied by internal tibial rotation and external
variability cannot be removed from the signal. The mul- femoral rotation. Also, sub-talar joint inversion must be
tiple degrees of freedom involved in the coordination accompanied by external tibial rotation and internal
and control of human movement are a potential source femoral rotation. The motions of these segments are said
of this dynamical variability, which is suggested to arise to be coupled and deviations from these motions are re-
from the many combinations of interacting parts from ferred to as “asynchronous” and were thought to have
which patterned movement emerges. implications for injury.
There is a growing body of literature in the biological The three primary methods [31] that evaluate the co-
and physical sciences stressing the beneficial and adap- ordination and coordination variability of coupling beha-
tive aspects of variability in system function. From this viors are: 1) discrete relative phase (evaluates the timing
perspective, increased variability is no longer rigidly of key events in each of the angle profiles); 2) vector
associated with decreased skill levels, injury and health. coding (a spatial measure based on an angle-angle plot);
Instead, the path to frailty or injury is identified in this and 3) continuous relative phase (a spatio-temporal
emerging perspective by a loss of variability in funda- measure based on the phase planes generated from the
mental variables reflecting biological function [26]. This angular position and angular velocity of the segments).
loss of complexity hypothesis can also be applied to Each of these techniques has been used to assess coord-
neurological disease or orthopedic injuries (Figure 1). ination in injury research studies. There is no one right
The proposed relation between loss of variability and technique to assess coordination variability because the
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Figure 1 Loss of complexity hypothesis based on the work of Lipsitz and colleagues (2002) applied to injury or pathology. Top and
middle panels: over time reductions in effective degrees of freedom, interacting components and synergies become associated with a loss of
variability in the system. When these reductions in degrees of freedom and variability reach a critical threshold, injury or disease may emerge
(bottom panel).

choice of the technique to use should be based on the joint or segment angles or two other related physio-
question asked in the study. logical parameters. For example, many researchers have
investigated the relative timing of knee flexion/extension
Discrete relative phase and subtalar inversion/eversion during the support
Discrete relative phase (DRP) illustrates a temporal phase of a running stride [32,33]. The key event in this
phase relationship in a specific coupling. A discrete rela- analysis would relate to the functionally important in-
tive phase angle is determined at a discrete event during stance when the knee joint reaches maximum flexion.
a movement cycle using the time-series profiles of two At this point in time, the subtalar joint should have

a) b) c) d) °

0 0 0 0
°
Figure 2 a) Absolute coordination with Low coordinative variability; forces during locomotion are distributed over a smaller surface
area and contribute to overuse injury. b) Relative coordination with an optimal coordinative variability pattern, distributing forces across
biological tissues in a manner that does not contribute to overuse injury with appropriate training cycles. Potential paths to injury via High
coordinative variability include: c) maintenance of phase relations around similar values with increased variability beyond the norm; d) similar
coordinative variability, but an offset from the normative phase relations generally observed (fixed point drift). While relations between a) and b)
have been demonstrated in differentially injured participants, the generation of normative values and the potential etiology of injury involving
both low and high coordinative variability require prospective studies within groups of interest.
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reached maximum eversion. The initial point in the ana-

lysis is determined by another key event such as foot
touchdown establishing time zero from which the other
events are determined. The DRP angle (φ) is then calcu-
lated as follows:

t1  t2
φ¼  360
T

where t1 is the time to maximum knee flexion, t2 is the

time to maximum subtalar eversion and T is the support
period. The DRP angle can range from 0o to 360o where
φ = 0o or 360o implies that the timing of the events are Figure 4 Calculation of phase angles between rearfoot and
perfectly in-phase (i.e. occur at exactly the same instant forefoot inversion using a modified vector coding technique.
in time). DRP angles between 0o and 360o indicate that The phase angle is calculated relative to the right horizontal for each
the timing of the events are out-of-phase (i.e. one event pair of contiguous points and then plotted across the time interval.
lags behind the other event). To calculate the mean and
standard deviation of the DRP angle over a number of while at 135o and 315o indicate equal movement but in
trials (or footfalls in this example) circular statistics opposite directions.
must be used. Another example of DRP is presented in In this approach, couplings are determined that are
Figure 3 in which breathing inspiration/expiration is relevant to the movement in question. The angles in
coupled with stride frequency [34]. the analysis are derived from standard 3-D kinematic
procedures and are time-scaled to 100% of the cycle.
Modified vector coding This computation is done over many cycles (i.e.
The modified vector coding approach is an adaptation of strides of gait) for each subject in each condition. Be-
a method suggested by Sparrow et al. [35]. In this ap- cause the coordination angle is classified as circular
proach, a measure of coordination and thus coordination variable, circular statistics must be performed to calcu-
variability is assessed using angle-angle plots (see late the mean and standard deviation of multiple
Figure 4). The orientation of a vector between two adja- cycles [36].
cent points on the angle-angle plot relative to the right
horizontal is referred to as the coordination angle (φ). Continuous relative phase
The resulting angles range from 0o to 360o where values Continuous Relative Phase (CRP) is another measure of
of 0o, 90o, 180o and 270o indicate movement of one of coordination from which we can develop a coordination
the joints or segments. When the more distal segment is variability profile. The CRP for a single stride or cycle is
fixed and the proximal segment or joint is rotating the obtained by calculating the four-quadrant arctangent
coordination angle is 0o or 180o while 90o and 270o indi- phase angle from a parametric phase plot (position vs.
cate the opposite actions. The two segments or joint will velocity) of the segments or joint of interest. For each of
move in the same direction with values of 45o and 225o the time-series angles of one segment or joint, the

Ek-1 Breath 1 E
EIkk-1 Breath 2 Ek+1

HS1 HS2 HS3 HS1 HS2 HS3

t1
t2
t3

T1 T2 T3

Time

Figure 3 An example of a Discrete Relative Phase setup during running with two time-series: a) breathing inspiration-expiration (black
solid line); and b) heel contact (gray solid line).
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normalized angle is plotted against the normalized vel- An ensemble profile can be calculated by averaging on
ocity. The normalization procedure is a critical step [37]. a point-by-point basis across multiple cycles. CRP vari-
Generally, each of the time-series profiles are time nor- ability (i.e. coordination variability) may be calculated as
malized such that a cycle ranges from 0–100%. At this the standard deviation on a point-by-point basis over the
point, a phase angle between adjacent points on the complete cycle (see Figure 5c), or over a portion of the
position-velocity phase plane is calculated for each in- movement pattern of functional interest to the research
stant in time across the cycle (see Figure 5a). The CRP questions (e.g. mid-stance phase only).
angle is found by subtracting the phase angle of one seg-
ment or joint from the other at each point in time over The functional role of coordinative variability
the entire cycle (see Figure 5b): Several studies in motor control and biomechanics have
illustrated that coordinative variability has a functional
CRP ðt Þ ¼ φ1 ðt Þ  φ2 ðt Þ role. It has been shown that variability is important for
coordinative changes in bimanual coordination and in
where φ1 (t) and φ2 (t) are the normalized phase angles gait [38-41]. The hypothesis put forward by Lipsitz [26],
for segment/joint 1 and segment/joint 2 respectively. referred to as the ‘loss of complexity hypothesis’, sug-
CRP angles can range from 0o to 360o but there is a re- gested that a lack of variability may be a characteristic of
dundancy in certain angles and the scale is usually pre- dysfunction in a performance, frailty or disease (see
sented as 0o to 180o. The assumption made here is Figure 1).
that CRP(t) = 0o indicates that the respective segments We emphasized the functional role of coordinative
are moving in-phase while a CRP(t) = 180o indic- variability and related it to overuse injury using a dy-
ates the segments/joints are anti-phase. Any angle be- namical systems perspective [27]. In this study, we
tween these extremes indicates a relative amount of assessed coordinative variability in individuals with and
in- or anti-phase. without knee pain. It was reported that greater

A position-velocity phase plot, right thigh position-velocity phase plot, right leg

1 1

0.5 0.5
position

position

0 0
-1 -0.5 0 0.5 1 -1 -0.5 0 0.5 1

-0.5 -0.5

-1 -1
velocity velocity

B
right thigh phase angle right leg phase angle
phase angle (deg)
phase angle (deg)

180 180
135 135
90 90
45 45
0 0
1 100 1 100
percent stride cycle percent stride cycle

-
C
Right thigh-leg CRP
Relative Phase (deg)

120

90

60

30

0
1 100
percent stride cycle
Figure 5 Calculation of a continuous relative phase angle: a) a phase plane constructed from a normalized position-velocity graph is
developed for each segment or joint: b) phase angles are then calculated from each phase plane; c) a continuous relative phase angle
is calculated by subtracting the two phase angles at each instant in time.
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coordinative variability (i.e. looser coupling between recovery from injury within a cross-sectional population,
selected segments and/or joint) is the norm for a healthy and; that despite being pain free, the ‘recovered’ runners
individual. On the other hand, lower coordinative vari- still had lower coordinative variability than those never
ability (i.e. tighter coupling) is the norm for individuals injured. This reduced variability in the pain free runners
with knee pain (see Figure 6). This concept has been the with previous injury compared to those never injured is
focus of our research on overuse injuries since then. thought to increase the stress on a smaller cross-section
The mechanism that we proposed suggested that there of soft tissues, contributing to the cyclic injury occur-
were numerous combinations of intra-segment coordin- rence in low back pain and other chronic injuries. These
ation that could be accomplished by a healthy individual types of findings suggest that longitudinal research using
thus giving that individual the potential for higher co- coordinative variability may be a fruitful next step to
ordinative variability (relative coordination patterns, understanding the etiology of injury, and can help deter-
Figure 3). However, in an injured individual, the number mine the progress of recovery from or progression to-
of combinations is reduced and thus the coordinative wards and injured state.
variability is significantly reduced. We have suggested
that there is a threshold of coordinative variability below Functional coordinative patterns
which an individual would be injured, and that coordina- Although Heiderscheit et al. [44] showed that the coup-
tive variability may be used clinically to track the pro- ling angles were not substantially different between the
gression towards recovery [42,43]. PFP and healthy control subjects, this study revealed
Seay et al. [43] demonstrated that coordinative vari- reduced joint coordination variability at heel strike in
ability measures are able to discriminate between run- the PFP group. The variability of coordination can then
ners with low back pain, those recovered from low back be computed over many stride cycles using all of the co-
pain, and those who never experienced low back pain. In ordination calculation techniques. It has been reported
this study, coordinative variability of trunk-pelvis trans- that the greater the coordination variability, the healthier
verse plane relations were greatest in those never the state of the system while lower variability has been
injured, smallest in those with back pain, and in between related to a pathological or an injured system [27]. How-
these values for those who had ‘recovered’ from injury. ever, too much variability in a system may also be indi-
This finding has two important implications: that coord- cative of an injured individual (see Figure 7). That is,
inative variability is able to differentiate these stages of there is some window of variability in which a healthy
individual functions. In the low variability state (i.e. the
state in which an injured individual operates), it has
been suggested that a reduced number of movements
between the coupled joints or segments are available
that may result in overuse of particular tissues causing
an exacerbation to the injury. In addition, by reducing
the number of available movement patterns, a less flex-
ible system results that may not respond appropriately
to an external perturbation. These findings have been
substantiated in several studies on a variety of overuse
injuries (e.g. [44]). In a study on tibial stress fractures in
female runners compared to healthy, matched controls
[45], the coordination variability in the injured limb was
significantly less than in the non-injured limb while
there was no difference in the level of variability in the
limbs of the control subjects.

Conclusions
Biomechanists have long used kinematic and kinetic
analyses to investigate the etiology of running injuries.
These analyses have provided definitive results in distin-
Figure 6 Continuous relative phase (coordinative) variability guishing between runners with and without injuries and
during a stride in healthy and patellofemoral pain participants. between healthy and injury-prone individuals. However,
The coordinative variability is greater in the patellofemoral pain these studies have not lead to a clearer understanding of
participants relative to the healthy participants. Figure adapted from
the injury mechanism and have really not provided a re-
Hamill et al. [27].
habilitative measure that captures recovery from injury
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methods, or progression towards an injured state be-

fore injury occurs.
injured
Authors' contribution
Each author contributed equally to the writing of this paper. All authors
too high read and approved the final manuscript.
coordinative
Competing of interest
variability The authors declare that they have no competing interests.

Received: 5 November 2012 Accepted: 15 November 2012

Published: 27 November 2012
increasing coordinative
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doi:10.1186/1758-2555-4-45
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