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Functional electrical stimulation of the ankle dorsiflexor (DF-FES) may have advantages over ankle foot orthoses (AFOs) in managing pediatric cerebral palsy (CP). This study assessed the functional benefit and orthotic effect of DF-FES in children with hemiplegic CP. We conducted an open-label prospective study on children with hemiplegic CP ≥ 6 years who used DF-FES for five months. The functional benefit was assessed by repeated motor function tests and the measurement of ankle biomechanical parameters. Kinematic and spatiotemporal parameters were assessed by gait analysis after one and five months. The orthotic effect was defined by dorsiflexion ≥ 0° with DF-FES at either the mid or terminal swing. Among 26 eligible patients, 15 (median age 8.2 years, range 6-15.6) completed the study. After five months of DF-FES use, the results on the Community Balance and Mobility Scale improved, and the distance in the Six-Minute Walk Test decreased (six-point median difference, 95% CI (1.89, 8.1), -30 m, 95% CI (-83.67, -2.6), respectively, p < 0.05) compared to baseline. No significant changes were seen in biomechanical and kinematic parameters. Twelve patients (80%) who showed an orthotic effect at the final gait analysis experienced more supported walking over time, with a trend toward slower walking. We conclude that the continuous use of DF-FES increases postural control and may cause slower but more controlled gait.
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BACKGROUND: Even though the importance of leg length discrepancy (LLD), with its potential of causing several pathological conditions or gait deviations, is well known, measuring LLD is still challenging with limited reliability and validity. OBJECTIVE: To assess the capability of the dynamic leg length (DLL) measurement in detecting the presence of anatomic LLD. METHODS: A lower limb x-ray was performed on 15 participants with suspected LLD in addition to a gait analysis study using a motion analysis system to measure DLL (the absolute distance from the hip joint centre to the heel, to the ankle joint centre and to the forefoot). Average DLLs were compared between sides for symmetry by the paired t-test at 51 sample points during the gait cycle in conjunction with the differences between the sides based on the maximal stance phase and minimal swing phase DLLs. Differences were correlated with anatomic LLD by Pearson correlation. RESULTS: No significant differences in DLLs between sides throughout the gait cycle were found. Significant differences between sides were found between the maximal stance and minimal swing phase DLLs. CONCLUSIONS: DLL measurement is capable of detecting an anatomic leg length difference based on functional changes in leg length and functional discrepancy.
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Diferencia de Longitud de las Piernas , Pierna , Marcha , Análisis de la Marcha , Humanos , Diferencia de Longitud de las Piernas/diagnóstico , Reproducibilidad de los ResultadosRESUMEN
Dynamic leg length [DLL] is a resultant factor of anatomic leg length and lower limb movement that is measured by the distance from the hip to the heel, ankle, and forefoot during the gait cycle. The aim of this study was to present DLL measurement during normal gait. Forty healthy participants underwent a gait evaluation using a motion analysis system. The average DLLs were compared between sides during the gait cycle using the paired t-test at 51 sample points. Time of maximal and minimal DLLs and the ratio between maximal and minimal DLLs during the gait cycle were calculated. DLLs were found to be consistent, indicated by a within standard deviation of <6.65 mm and by being symmetrical with no significant differences between sides [p > 0.103]. DLL patterns and time of maximal and minimal DLLs were established. The ratio between maximal DLLs during the stance phase and minimal DLLs during the swing phase was also defined and found to be symmetrical. Normative data of DLL measures were set with respect to magnitude and pattern during the gait cycle. These data might serve as a reference for abnormal gait deviation reflected by abnormal DLLs, thus promoting a new perspective in gait analysis.
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Análisis de la Marcha , Marcha/fisiología , Pierna/anatomía & histología , Adulto , Fenómenos Biomecánicos , Femenino , Humanos , MasculinoRESUMEN
Understanding the effects of leg length discrepancy (LLD) on the biomechanics of gait and determining as to what extent of LLD alters gait is essential. A total of 91 biomechanical data were assessed from 14 lower limbs of healthy individuals walking under random conditions: shod only and with a 5, 10, 15, 20, 30 and 40 mm sole lift. Lower limb kinematics and dynamic leg length (DLL) were measured by a motion capture system. Hotelling's T-Square test was used to evaluate the differences in DLLs throughout the gait cycle in conjunction with differences between the sides based on the maximal stance phase and minimal swing phase DLLs. Kinematics were compared using the one-way blocked analysis of variance and Post-hoc analysis by the paired t-test. Significant dynamic shortening of the longer limb, mainly during the swing phase, and significant change in maximal stance and minimal swing phase DLL relationship started at a 10 mm lift condition (pâ¯<â¯0.05). Thirteen kinematic variables produced a significant angular main effect (pâ¯<â¯0.05), with a more flexed position of the longer limb and extended shorter limb beginning at a 5 mm lift. An increase in hip abduction and external foot rotation during the swing phase was also found. This study demonstrates that simulated LLD, as low as 5 mm, causes biomechanical changes in the lower limbs during gait revealed in both kinematics and dynamic leg length, suggesting that LLD, as small as 5-10â¯mm, should not be ignored.
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Marcha/fisiología , Diferencia de Longitud de las Piernas/fisiopatología , Extremidad Inferior/fisiología , Adulto , Análisis de Varianza , Femenino , Humanos , Masculino , Rango del Movimiento Articular/fisiología , Zapatos , Caminata/fisiología , Adulto JovenRESUMEN
BACKGROUND: Functional electrical stimulation (FES) is a well-known intervention used during walking to improve walking abilities and correct gait deviations by facilitating the proper muscle group at the appropriate timing in the gait cycle. Our aim was to study the types of surface FES currently used in a cerebral palsy (CP) population and examine the evidence of its ability to improve gait deviations, functional ability and therapeutic effects. METHODS: A computerized database search was conducted from inception until 6/2016. Included were all clinical trials performing gait analysis of children with CP applying surface FES to any lower leg muscles evaluating the efficiency of the stimulation and any carry-over effect. RESULTS: Fifteen studies met the inclusion criteria. The most common FES stimulated the dorsi flexors muscles with a positive orthotic effect, improved dorsi flexion during the swing phase and enhanced the foot contact pattern. A smaller positive effect was found for knee extensors stimulation facilitating knee extension during the stance phase and for hip abductors stimulation improving frontal plane knee alignment. No evidence was found to support the use of plantar flexors stimulation in correcting gait deviations. There is scarce evidence of any retention effect. CONCLUSION: We encourage the clinician to evaluate the use of FES on a case to case basis. Controlled investigations with larger numbers of participants are warranted to determine the orthotic and therapeutic efficacy of FES.
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Parálisis Cerebral/rehabilitación , Terapia por Estimulación Eléctrica/métodos , Adolescente , Niño , Femenino , Ortesis del Pié , Humanos , MasculinoRESUMEN
Leg length discrepancy (LLD) is associated with many musculoskeletal disorders. Its clinical significance is unclear mainly due to limited functional measurement capacity. An integrated approach measuring true LLD, gait deviations and functional leg length during the gait cycle, based on location of joint centre and anatomical landmarks using a three-dimensional motion analysis system was performed on two patients. In one case, strong agreement was found between all measurements thus, leading to the same treatment intervention. However, in another case, true LLD was not correlated with functional LLD or gait deviations, which led to contradictory results. Functional LLD was found to be correlated with gait deviations in both cases. Our results indicate the effectiveness of integrating into the diagnostic regimen, a dynamic method of measuring LLD, together with the functional outcome of gait deviations as a basis for decision-making regarding the presence and clinical significance of LLD in musculoskeletal disorders.
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Marcha/fisiología , Diferencia de Longitud de las Piernas/diagnóstico , Movimiento/fisiología , Caminata/fisiología , Adolescente , Puntos Anatómicos de Referencia/fisiopatología , Articulación del Tobillo/fisiopatología , Fenómenos Biomecánicos , Femenino , Articulación de la Cadera/fisiopatología , Humanos , Diferencia de Longitud de las Piernas/etiología , Diferencia de Longitud de las Piernas/fisiopatología , Masculino , Adulto JovenRESUMEN
Controversy still exists as to the clinical significance of leg length discrepancy (LLD) in spite of the fact that further evidence has been emerging regarding the relationship between several clinical conditions and LLD. The objectives of our study were to review the available research with regard to LLD as a cause of clinically significant gait deviations, to determine if there is a relationship between the magnitude of LLD and the presence of gait deviations and to identify the most common gait deviations associated with LLD. In line with the PRISMA guidelines, a literature search was carried out throughout the Medline, CINAHL and EMBASE databases. Twelve articles met the predetermined inclusion criteria and were included in the review. Quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) scale was completed for all included studies. Two main methodologies were found in 4 studies evaluating gait asymmetry in patients or healthy participants with anatomic LLD and 8 studies evaluating gait deviations while simulating LLD by employing artificial lifts of 1-5cm on healthy subjects. A significant relationship was found between anatomic LLD and gait deviation. Evidence suggests that gait deviations may occur with discrepancies of >1cm, with greater impact seen as the discrepancy increases. Compensatory strategies were found to occur in both the shorter and longer limb, throughout the lower limb. As the discrepancy increases, more compensatory strategies occur. Sagittal plane deviations seem to be the most effective deviations, although, frontal plane compensations also occur in the pelvis, hip and foot.
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Marcha/fisiología , Diferencia de Longitud de las Piernas/fisiopatología , Adaptación Fisiológica , HumanosRESUMEN
BACKGROUND: Functional electrical stimulation (FES) is commonly used to ameliorate gait deficits in patients with multiple sclerosis (PwMS). This review critically evaluates the literature describing the orthotic and therapeutic effects of FES on gait in PwMS. METHODS: The PubMed, CINAHL, and ProQuest databases were searched. Included were studies that evaluated therapeutic and/or orthotic effects of FES in PwMS with at least one outcome measure related to gait. Methodology was assessed using the Downs and Black checklist. RESULTS: Twelve relevant studies were reviewed. Their methodological quality ranged from 14 to 21 of 28. Eleven studies reported the effects of peroneal stimulation. Most found a significant orthotic effect (measured during stimulation), mainly on walking speed. Only three assessed the therapeutic effect (carry-over), which was not significant. CONCLUSIONS: The evidence presented in this review suggests that FES has a positive orthotic effect on walking in PwMS. Yet, more robust trials are needed to substantiate this finding. Therapeutic efficacy of FES was not demonstrated, and almost all studies tested a single channel peroneal stimulator. Future studies involving FES technological innovations with advanced clinical approaches might contribute to a carry-over effect from FES and increase the percentage of PwMS who benefit from this technology.
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Terapia por Estimulación Eléctrica , Trastornos Neurológicos de la Marcha/terapia , Marcha , Esclerosis Múltiple/fisiopatología , Fenómenos Biomecánicos , Trastornos Neurológicos de la Marcha/etiología , Humanos , Esclerosis Múltiple/complicaciones , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
BACKGROUND: Neuromuscular impairments may compromise gait function in patients with cerebral palsy (CP). As such, ambulatory children with CP often use ankle foot orthosis (AFO) to facilitate and optimize their ability to walk.The aim of this study was to evaluate whether the different gait indices, the Gillette Gait Index (GGI), the Gait Deviation Index (GDI), and the Gait Profile Score (GPS), reflect the improved gait that was previously shown using AFO. METHODS: A retrospective analysis of 53 studies on children with spastic diplegic CP. All had undergone a comprehensive gait study and were analyzed while walking, both barefoot and with their braces, in the same session.Kinematic and temporal spatial data were determined and summarized by 3 methods: GPS, GDI, and GGI. RESULTS: Significant differences were found between the barefoot condition and the AFO conditions for temporal and kinematic parameters: changes in GGI, GDI, and GPS were not statistically significant, with an improvement of 9.33% in GGI (P=0.448) and no change in GDI and GPS. CONCLUSIONS: The use of AFO in diplegic CP children caused a statistically significant improvement in temporal and kinematic parameters. Interestingly, it was found that this improvement was not reflected by GGI, GDI, or GPS.These findings might suggest that gait indices, as outcome measures, may sometimes not reflect all the effects of specific interventions. LEVEL OF EVIDENCE: Level III-retrospective study.
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Parálisis Cerebral/fisiopatología , Ortesis del Pié , Trastornos Neurológicos de la Marcha/fisiopatología , Trastornos Neurológicos de la Marcha/rehabilitación , Índice de Severidad de la Enfermedad , Tobillo/fisiopatología , Fenómenos Biomecánicos , Tirantes , Parálisis Cerebral/complicaciones , Niño , Femenino , Marcha/fisiología , Trastornos Neurológicos de la Marcha/etiología , Humanos , Masculino , Estudios Retrospectivos , Caminata/fisiologíaRESUMEN
We retrospectively assessed the effect of ankle-foot orthosis (AFO) on the foot progression angle (FPA) of 97 children with spastic cerebral palsy (CP) who had undergone comprehensive computer-based gait analysis both barefoot and with their orthosis, during the same session. The physical examination results and the gait study temporal and kinematic parameters comprise the study data. We focused on the peak FPA reached during stance and swing phases and at mid-stance and mid-swing, and also measured the transverse rotations of the pelvis, the femur and the tibia. AFOs improved gait, as reflected by improved temporal parameters, but they also increased internal rotation of the feet in diplegic CP children by 4.29 degrees for mid-stance, and by 3.72 degrees for mid-swing. The correlation between components of the rotational profile and FPA was significant for the diplegic group. AFOs did not produce any noteworthy differences between walking barefoot and walking with the brace in the hemiplegic group in what concerns FPA. Children with diplegic CP who use AFOs walk with increased internal FPAs in their orthoses. These findings might be explained by anatomical attributes as well as dynamic features during gait.
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Parálisis Cerebral/terapia , Ortesis del Pié , Pie/fisiopatología , Marcha/fisiología , Adolescente , Fenómenos Biomecánicos , Parálisis Cerebral/fisiopatología , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
A normal motion and segmental interrelationship has been determined as a significant factor in normal function. Yet, the relationship between distal segments and pelvic alignment needs further investigation. The aim of this study was to investigate the interrelationship between distal and proximal lower extremity segments while standing and during induced feet hyperpronation. Changes in alignment of the pelvis and lower extremities were measured at a gait laboratory using the VICON 612 computerized motion analysis system. Thirty-five healthy volunteer subjects were recruited. Four randomized repeated-measure standing modes were used: standing directly on the floor and then on three wedges angled at 10°, 15° and 20° to induce bilateral hyperpronation for 20 seconds. A significant (p<0.05) bi-variate relationship was found between the anterior pelvic tilt and thigh internal rotation, in all four standing positions (.41≤r≤.46, in all p<0.014). A combined effect of rotational alignment between segments and the cumulative effect of foot hyperpronation on pelvic tilt revealed that only the shank significantly affected pelvic alignment, acting as a mediator between a foot and a thigh with the thigh having a crude significant effect on the pelvis. When internal rotation of the shank occurs, calcaneal eversion couples with thigh internal rotation and anterior pelvic tilt. It can be concluded that in response to induced hyperpronation, the shank is a pivotal segment in postural adjustment.
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BACKGROUND: Crouch gait is a major sagittal plane deviation in children diagnosed with cerebral palsy (CP). It is defined as a combination of excessive ankle dorsiflexion and knee and hip flexion throughout the stance phase. To the best of our knowledge, functional electrical stimulation (FES) has not been used to decrease the severity of crouch gait in CP subjects and assist in achieving lower limb extension. PURPOSE: To evaluate the short- and long-term effects of FES to the quadriceps muscles in preventing crouch gait and achieving ankle plantar flexion, knee and hip extension at the stance phase. METHODS: An 18-year-old boy diagnosed with CP diplegia [Gross Motor Function Classification System (GMFCS) level II] was evaluated. The NESS L300(®) Plus neuroprosthesis system provided electrical stimulation of the quadriceps muscle. A three-dimensional gait analysis was performed using an eight-camera system measuring gait kinematics and spatiotemporal parameters while the subject walked shod only, with ground reaction ankle foot orthotics (GRAFOs) and using an FES device. RESULTS: Walking with the FES device showed an increase in the patient's knee extension at midstance and increased knee maximal extension at the stance phase. In addition, the patient was able to ascend and descend stairs with a "step-through" pattern immediately after adjusting the FES device. CONCLUSIONS: This report suggests that FES to the quadriceps muscles may affect knee extension at stance and decrease crouch gait, depending on the adequate passive range of motion of the hip, knee extension, and plantar flexion. Further studies are needed in order to validate these results.
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PURPOSE: To evaluate functional electrical stimulation (FES) neuroprothesis as a method to improve gait in hemiplegic patients, using three different gait scoring methods as measures. METHODS: Five hemiplegic patients (four with cerebral palsy at GMFCS I, one with diffuse pontine glioma) with a mean age of 16.5 years were given a FES neuroprosthesis (NESS(®) L300™) that was applied and calibrated individually. After an adaptation period during which the participants increased their daily use of the neuroprosthesis, gait was assessed with the stimulation off and with the FES on. Kinematic, kinetic, and temporal spatial data were determined using motion analysis and summarized by three scoring methods: Gait Profile Score (GPS), Gait Deviation Index (GDI), and Gillette Gait Index (GGI). Indices were calculated using the Gaitabase program available online. Patients were followed for a minimum of 1 year. RESULTS: When comparing gait with and without stimulation, all scoring methods showed improvement. GPS and GDI of the affected leg were significantly improved: 12.23-10.23° (p = 0.017) and 72.36-78.08 (p = 0.002), respectively. By applying the movement analysis profile, the decomposed GPS score, we found that only the ankle dorsiflexion and the foot progression angle were significantly changed. GGI of the affected leg showed improvement, but without statistical significance: 168.88-131.64 (p = 0.221). Total GPS of legs and the GPS, GDI, and GGI of the nonaffected leg showed improvement without statistical significance. At the 1-year follow-up, all patients expressed high satisfaction and continued to use the device. CONCLUSIONS: Dorsiflexion functional electrical stimulation improves gait in hemiplegic patients, as reflected by GPS, GDI, and GGI.
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The purposes of the present study were to (1) determine the internal plantar mechanical stresses in diabetic and healthy subjects during everyday activities, and (2) identify stress parameters potentially capable of distinguishing between diabetic and healthy subjects. A self-designed, portable, real-time and subject-specific foot load monitor which employs the Hertz contact theory was utilized to determine the internal dynamic plantar tissue stresses in 10 diabetic patients and 6 healthy subjects during free walking and outdoors stair climbing. Internal stress parameters and average stress-doses were evaluated, and the results obtained from the two groups were compared. Internal plantar stresses and averaged stress-doses during free walking and outdoors stairs climbing in the diabetic group were 2.5-5.5-fold higher than in the healthy group (p<0.001; stair climbing comparisons incorporated data from five diabetic patients). The interfacial pressures measured during free walking were slightly higher ( approximately 1.5-fold) in the diabetic group (p<0.05), but there was no significant difference between the two groups during stairs climbing. We conclude that during walking and stair climbing, internal plantar tissue stresses are considerably higher than foot-shoe interface pressures, and in diabetic patients, internal stresses substantially exceed the levels in healthy. The proposed method can be used for rating performances or design of footwear for protecting sub-dermal plantar tissues in patients who are at risk for developing foot ulcers. It may also be helpful in providing biofeedback to neuropathic diabetic patients.
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Diabetes Mellitus/fisiopatología , Pie/fisiopatología , Adulto , Anciano , Fenómenos Biomecánicos , Femenino , Úlcera del Pie/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/instrumentación , Estrés Mecánico , Caminata/fisiologíaRESUMEN
The present paper examines gender differences and changes in prevalence of ankylosed sacroiliac joint (SIJ) with age. SIJs of 287 patients (159 males and 128 females), aged 22-93 years, were examined for fusion, using 3-D CT images. Presence, side and location of the fusion along the joint borders were recorded. Fusion of the SIJ was found to be gender and age dependent; present in 27.7% of all males in contrast to only 3.0% in females (p<0.001). The phenomenon increased with age in the male population from 5.8% in the 20-39 age cohorts to 46.7% in the 80+ cohort. As mobilization and/or manipulation of a dysfunctional SIJ are common procedures used by manual therapists, the effect that aging has on SIJ mobility requires therapists to alter or change their method with advancing age.
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Anquilosis/epidemiología , Articulación Sacroiliaca , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Anquilosis/diagnóstico por imagen , Anquilosis/rehabilitación , Femenino , Humanos , Israel/epidemiología , Masculino , Persona de Mediana Edad , Manipulaciones Musculoesqueléticas , Distribución por Sexo , Tomografía Computarizada por Rayos XRESUMEN
Hyperpronation may cause malalignment of the lower extremity, frequently leading to structural and functional deficits both in standing and walking. Our aim was to study the effect of induced foot hyperpronation on pelvic and lower limb alignment while standing. Thirty-five healthy subjects were requested to remain in a natural standing position for 20s in four different modes: feet flat on the floor, and on wedges angled at 10 degrees, 15 degrees and 20 degrees, designed to induce hyperpronation. Sequencing was random, repeated three times and captured by eight computerized cameras using the VICON three-dimensional motion analysis system. We found that standing on the wedges at various angles, induced hyperpronation, with 41% to 90% of the changes attributable to the intervention. In addition, a statistically significant increase (paired t-test) in internal shank rotation (p<0.0001), internal hip rotation (p<0.0001) and anterior pelvic tilt (p<0.0001) was identified. A strong correlation was found between segmental alignment in every two consecutive modes at all levels (r=0.612-0.985; p<0.0001). These findings suggest that alignment of the lower extremity up to the pelvic girdle, can be altered, due to forces acting on the foot. Interaction between the foot and pelvis occurs in a kinematic chain reaction manner. Although this study was limited to healthy subjects, clinicians should be aware that when addressing pelvis and lower back dysfunction, foot alignment should be examined as a contributing factor.
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Pie/fisiología , Pelvis/fisiología , Postura/fisiología , Adulto , Femenino , Humanos , Masculino , Pronación/fisiología , Rotación , Caminata/fisiologíaRESUMEN
OBJECTIVE: Little is known about the interactions of sports-related demands and human body, in particular on musculoskeletal features, during growth. Focusing on the relationship between soccer and lower limb alignment, we examined the hypothesis that varus knee deviation is more prevalent among high-performance pediatric and adolescent soccer players. DESIGN: Cross-sectional study with focused sampling. SETTING: First league sports clubs. PARTICIPANTS: 106 male child/adolescent soccer players aged 10 to 21 years and 68 age-matched tennis players. INTERVENTIONS: All athletes completed a demographic questionnaire and underwent physical examinations, which included height, weight, generalized laxity, knee, ankle, foot and spine axis, hip range of motion, tibial torsion, Q angle, foot navicular height, and progression angle. MAIN OUTCOME MEASUREMENT: Varus/valgus axis was determined by the intercondylar intermalleolar distance while standing. Soccer and tennis players were compared on knee axis and other outcome variables by analysis of covariance, adjusting for age and by t-tests within age groups. RESULTS: A significantly higher prevalence of knee varus was found among the soccer players compared to that among the tennis players. The difference in intracondylar distance was statistically significant after the age of 13 years (P < 0.001). In addition, compared to tennis players, soccer players had higher foot arches, decreased hip external rotation and increased external tibial torsion. CONCLUSIONS: Varus knee axis deviation was more common among children and adolescent soccer players than among tennis players. The prevalence was more pronounced among players aged 13 years or older. Further research is needed to explore the rationale of this phenomenon.