THE DROP-JUMP VIDEO SCREENING TEST:
RETENTION OF IMPROVEMENT IN NEUROMUSCULAR
CONTROL IN FEMALE VOLLEYBALL PLAYERS
SUE D. BARBER-WESTIN, STEPHANIE T. SMITH, THOMAS CAMPBELL,
Cincinnati Sportsmedicine Research and Education Foundation, Cincinnati, Ohio
ABSTRACT
Barber-Westin, SD, Smith, ST, Campbell, T, and Noyes, FR.
The drop-jump video screening test: retention of improvement
in neuromuscular control in female volleyball players. J Strength
Cond Res 24(11): 30553062, 2010A valgus lower limb
alignment is commonly documented during noncontact anterior
cruciate ligament injuries. We previously developed a video-
graphic drop-jump test to measure overall lower limb alignment
in the coronal plane as a screening tool to detect such
an abnormal (valgus) position on landing. A neuromuscular
retraining program developed for female athletes was shown to
be effective in improving lower limb alignment on this test
immediately after completion of training. What remained
unknown was whether these improvements would be retained
for longer periods of time. Therefore, this study was undertaken
to determine if these improvements in overall lower limb
alignment would be retained up to 1 year after the training.
Sixteen competitive, experienced female high-school volleyball
players underwent the video drop-jump test and then
completed the neuromuscular retraining program. The program
consisted of a dynamic warm-up, jump training, speed and
agility drills, strength training, and static stretching and was
performed 3 times a week for 6 weeks. The athletes repeated
the drop-jump test immediately upon completion of training
and then 3- and 12-months later. Significant improvements
were found in the mean normalized knee separation distance
between the pre and posttrained values for all test sessions
(p , 0.01). Immediately after training, 11 athletes (69%)
displayed significant improvements in the mean normalized
knee separation distance that were retained 12 months later.
Five athletes failed to improve. The video drop-jump test,
although not a risk indicator for a knee ligament injury, provides
Address correspondence to Sue D. Barber-Westin, sbwestin@csmref.org.
24(11)/30553062
Journal of Strength and Conditioning Research
2010 National Strength and Conditioning Association
Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
AND FRANK R. NOYES
a cost-effective general assessment of lower limb position and
depicts athletes who have poor control on landing and
acceleration into a vertical jump.
KEY WORDS limb alignment, valgus screening, female athletes
INTRODUCTION
I
t is well known that adolescent and adult female
athletes have a 4- to 8-fold higher incidence of
sustaining a serious noncontact knee ligament injury
compared to male athletes participating in the same
sport (1,10,11). The factors responsible for the disparity
between women and men in anterior cruciate ligament
(ACL) injury rates are controversial and remain scientifically
undefined. Theories have included inherent differences in
anatomic and hormonal variables (10,16), but published
studies are inconclusive and their findings are contradictory.
Many authors have speculated that altered neuromuscular
control and strength of the lower extremity are responsible
for this problem (7,15,17,18,2729). Differences between
female and male athletes in movement patterns; muscle
strength, activation, and recruitment patterns; and knee joint
stiffness have been demonstrated under controlled, pre-
planned, and reactive conditions in the laboratory (3).
Studies have shown that a valgus lower limb alignment
commonly occurs during noncontact ACL injuries, fre-
quently either when an athlete lands from a jump or attempts
to accelerate into a jump (6,8,9). Previous investigations have
examined differences between men and women in knee
flexion angles (17) and ground reaction forces on the lower
extremity upon landing (15,21,23,24,26). One investigation
reported that a valgus torque combined with an anterior tibial
force in a cadaver model resulted in a statistically significant
larger strain in the ACL than an anterior force alone (p ,
0.0001) (5). The authors concluded that ACL injury pre-
vention programs for female athletes must control combina-
tions of loads such as those incurred during a combined
valgus-anterior loading situation.
We previously described a simple videographic drop-jump
test that measures the distance between the hips, knees, and
ankles in the coronal plane, which was developed to be used
as a general indicator of an athletes ability to control lower
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 Retention Improvement Neuromuscular Control Drop-Jump Test

limb axial alignment on landing (Figure 1) (22). The test
uses a single camera and is relatively easy to perform by
researchers, coaches, trainers, or therapists in any facility. We
do not propose that this test can be used as a risk indicator for
knee ligament injury but as a screening tool to detect athletes
who demonstrate an abnormal (valgus) lower limb position
on landing from a drop jump.
The video drop-jump test was previously conducted on
325 female and 130 male high-school athletes (22). Sixty-two
of the female athletes underwent 6 weeks of neuromuscular
retraining in a supervised program (SportsmetricsTM) that
had been reported to significantly reduce the risk of
a noncontact knee ligament injury in high-school female
athletes (2,12,15). The athletes underwent the drop-jump test
again within 1 week of completion of training. Statistically
significant increases were found after training in the absolute
and normalized knee and ankle separation distances for all
phases of the jump-land sequence (p , 0.001), reducing the
number of athletes who demonstrated an abnormal lower
limb position from 77 to 34%.
Although the neuromuscular retraining program studied in
our investigation was effective in improving the overall lower
limb alignment on the drop-jump test in two-thirds of the
female athletes, it is unknown whether the improvements are
retained over a longer period of time. Therefore, the purpose
of this investigation was to determine if female athletes
retained improvements in overall lower limb alignment on the
video drop-jump test up to 1 year after completion of the
neuromuscular training program. To our knowledge, this is
the first study to investigate this question. We hypothesized
that those athletes who im-
proved their overall lower limb
alignment on the video drop-
jump test immediately after 6
weeks of neuromuscular re-
training would show similar
results in this test up to 1 year
later.

METHODS
Experimental Approach to the
Problem
This study was undertaken to
determine if immediate im-
provements in overall lower
limb alignment in adolescent
female athletes on a video drop-
jump test after a 6-week
previously published neuro-
muscular retraining program
(2,15) would be retained up to
1 year later. A video drop-jump
test with proven reliability that
measures the distance between
the hips, knees, and ankles in
the coronal plane and provides
an indicator of an athletes
ability to control lower limb
axial alignment on landing was
used to address the study
hypothesis. The athletes who
participated in this study were
experienced, competitive
female volleyball players who
played high-school and
Figure 1. The 3 phases of the drop-jump video screening test are shown on the printout that is given to the athletes. club-level leagues year round.
The absolute centimeters of distance between the hips, knees, and ankles are shown on the left of the stick figures, All subjects underwent the
whereas the normalized knee and ankle separation distances are shown on the right. During the landing phase, this
subject demonstrated a 22% normalized knee separation distance. The overall valgus lower limb alignment is clearly video drop-jump test 1 week
demonstrated in the photographs. before the neuromuscular train-
ing program was initiated. The
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subjects then participated in the supervised training program of the arms and the body as the subjects prepared to perform
3 sessions per week for 6 weeks. The sessions lasted between the maximum vertical jump.
90 and 120 minutes and consisted of a dynamic warm-up, The absolute centimeters of separation distance between
jump training, strength training, speed and agility drills speci- the right and left hips, knees, and ankles was measured as
fic for volleyball, and flexibility. The athletes then underwent previously described (22). The distance between the knees
the drop-jump video test within 7 days of completion of and ankles was then normalized according to the hip
training and then 3 and 12 months after training. separation distance. We compared the distribution of subjects
who had #60% normalized knee separation distance,
Subjects
6180%, and .80% during preland, land, and take-off. We
All testing and training procedures were fully explained, and
believed that 60% represented a distinctly abnormal lower
written informed parental consent was obtained for each
limb valgus alignment position, which was visually evident
subject. The study was approved by the Internal Review
from the captured photographs (Figure 1).
Board for use of human subjects at the hospital where the
The reliability of the drop-jump test was reported
testing was conducted. Sixteen competitive female volleyball
previously (22). For testretest trials, the interclass correlation
players from 2 area high schools (mean age 14.6 6 0.7 years,
coefficients (ICCs) for the hip separation distance demon-
range, 1316 years; mean height 1.69 6 0.03 m, range, 1.63
strated high reliability (preland, 0.96; land, 0.94; take-off,
1.78 m; mean weight 58 6 6 kg, range, 4977 kg) voluntarily
0.94). For within-test trials, the ICCs for the hip, knee, and
participated in this study. All subjects had no history of knee
ankle separation distance were all $0.90, demonstrating
injury or pathology and had no symptoms of pain, patella
excellent reliability of the videographic test and software
instability, or visible joint effusion. All subjects had partici-
capturing procedures.
pated in competitive volleyball for a minimum of 2 years
before this study was initiated. The neuromuscular training
was conducted at the 2 high schools upon the conclusion of
Neuromuscular Retraining Program. The Sportsmetrics (Cin-
the summer club-level season and just before the start of the
cinnati Sportsmedicine Research and Education Foundation,
fall high-school season. All subjects participated in their high-
Cincinnati, OH, USA) program consisted of a dynamic
school volleyball season directly upon completion of training
warm-up, jump training, speed and agility drills, strength
and then played club-level volleyball for the remainder of
training, and static stretching (2). All training sessions were
the study period. None of the athletes underwent any other
supervised by certified instructors; there were 3 sessions per
formal strength or neuromuscular training programs in the
week (on nonconsecutive days) for 6 weeks. Each session
1-year duration of this study.
lasted approximately 90120 minutes. During the jump
Procedures training and speed and agility drills, subjects were encour-
Video Drop-Jump Test. The video drop-jump test was aged to maintain a neutral alignment by reinforcing the knees
previously described in detail (22). A standard video and ankles to be placed hip distance apart with exaggerated
camcorder was positioned approximately 366 cm in front knee and hip flexion on landing from a jump, decelerating
of a box that was 30 cm in height and 38 cm in width. and cutting. Trainers gave constant feedback on jump-land
Reflective markers were placed at the greater trochanter, the mechanics and decelerating, cutting, and pivoting technique.
lateral malleolus, and the center of the patellaes on both the Terms such as quiet landing, toes and knees forward,
right and left legs. The subjects performed a drop-jump by knees and feet directly under hips, and bend at the knees
first jumping off the box, landing, and immediately perform- were repeatedly used to aid in the re-education process. The
ing a maximum vertical jump. No specific instructions were jumps included a wall jump, tuck jump, squat jump, barrier
provided regarding how to land or jump; the subjects were jumps side-to-side and forward-back, 180 jump, bounding,
only instructed to land straight in front of the box to be in the scissors jump, single-leg hop, jump into bounding, and broad
correct angle for the camera to
record properly. This sequence
was repeated 3 times.
The following images were TABLE 1. Comparisons of mean normalized knee separation distance values between
captured: (a) preland, the frame test sessions.
in which the subjects toes just
Time period comparison Mean 6 SD Mean difference p Value
touched the ground after the
jump off of the box; (b) land, Pretrain vs. immediate posttrain 50 6 16 217 ,0.01
the frame in which the subjects 67 6 17
were at the deepest point; and Pretrain vs. 3-month posttrain 66 6 17 216 ,0.01
Pretrain vs. 12-month posttrain 74 6 17 224 ,0.001
(c) take-off, the frame that
demonstrated the initial for-
ward and upward movements

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 Retention Improvement Neuromuscular Control Drop-Jump Test

Figure 2. The 12-month posttrain test of the subject shown in Figure 1. This 15-year-old volleyball player improved her normalized knee separation distance value
on landing to 78%, which is clearly depicted on the captured photograph.

jumps. The progression of this portion of the training 3 posttraining tests. Linear regression was also used to
program has been previously described in detail (2,15). determine if an association existed between the athletes
Strength training placed an emphasis on hamstring, hip height and weight and the normalized knee separation
flexion/abduction and core strength to aid in proper lower distance at the pretrain test and the 12-month posttrain test
extremity alignment and muscle recruitment patterns. Two time periods. Paired t-tests were used to determine if
different strength training methods were used based on significant differences occurred between the pretrain and
equipment availability at each school. Eight athletes per- 12-month posttrain test sessions for height and weight. All
formed strength training on the
court with the use of resistance
bands and body weight exer-
cises. The other 8 athletes per-
formed strength training in
a weight room and incorporated
machines, free weights, a cable
system, and body weight exer-
cises. Static flexibility exercises
were performed at the end of
each training session.

Statistical Analyses
Repeated-measures analysis
of variance using the Tukey
Kramer Multiple Comparisons
test was selected to determine if
significant differences existed in
the mean normalized knee sep-
aration distance values between
testing sessions. A linear re-
gression model was used to
determine if an association
was present between the num-
Figure 3. The distribution of the normalized knee separation distances during the landing phase for all testing
ber of training sessions com- sessions is shown. The stick figures are representative of the knee separation distance but not of the ankle
pleted and the normalized knee separation distance.
separation distance value at the
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data were normally distributed (KolmogorovSmirnov test). separation distance values at the pretrain test and 12-month
Alpha was set to p # 0.05. posttrain test sessions.
Power and sample size calculations were done to evaluate The number of subjects that improved their normalized
the effect of training on the normalized knee separation knee separation distance according to the study criteria at the
distances. With 16 subjects in this study, it was found that this 3 posttrain test sessions compared to their pretrain test value
investigation had sufficient power (.90%) to detect signif- is shown in Figure 4. The pre and posttrained normalized
icant differences in normalized knee separation distances (at knee separation distance values for the subjects who showed
least 15 6 1%) at a level of 0.05. improvements are shown in Figure 5. In Figure 6, 3 subjects
We classified the normalized knee separation distance as are shown who had smaller normalized knee separation
improved and retained if (a) the posttrained value was $20% distance values at the immediate posttrained test compared
more than the pretrained value and (b) the posttrained to the pretrained test, but then improved at the 3- and
normalized knee separation dis-
tance was $60%. For athletes
who demonstrated $60% nor-
malized knee separation dis-
tance on their pretrain test,
the posttrain test must have
been $20% more than the
initial test to be considered
improved.

RESULTS
Significant improvements were
found in the mean normalized
knee separation distance be-
tween the pretrain and post-
trained values for all test sessions
(Table 1, Figure 2). The distri-
bution of the subjects in the
normalized knee separation dis-
tance categories demonstrated
that although 75% had ,60% Figure 4. The number of athletes that improved their normalized knee separation distance at the 3 posttrain test
sessions compared to their pretrain test value is shown.
knee separation distance before
training, 31% had this value at
the immediate posttrain and
3-month posttraining times pe-
riods, and only 19% had this
value 12 months after training
(Figure 3). There was no signif-
icant effect of the number of
training sessions attended and
the normalized knee separation
distances during each posttrain-
ing test period. Seven subjects
completed 1012 training
sessions, 8 completed 1315
sessions, and 1 completed 17
training sessions. There was no
significant difference in the mean
height or weight of the subjects
between the pretrain test and
12-month posttrain test sessions.
There was no association be- Figure 5. Subjects who demonstrated improvements in normalized knee separation distance values compared to
tween the subjects height or the pretrain values.
weight and the normalized knee

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 Retention Improvement Neuromuscular Control Drop-Jump Test

No subject sustained an in-

jury during this study that
resulted in loss of practice or
playing time or that required
formal medical attention.

DISCUSSION
A valgus lower limb alignment
is frequently seen during non-
contact ACL injuries, which
commonly occurs either when
an athlete lands from a jump or
attempts to accelerate into a
jump. We developed a video-
graphic drop-jump test to mea-
sure the distance between the
hips, knees, and ankles in the
Figure 6. Subjects who had smaller normalized knee separation distance values at the immediate posttrained test coronal plane to be used as
compared to the pretrained test but who then improved at the 3- and 12-month posttrained tests.
a screening tool to detect an
abnormal (valgus) lower limb
position on landing. This study
found, in a small group of
adolescent female high-school
volleyball players, significant
improvements in the mean
normalized knee separation dis-
tances between the pre and
posttrained values for all test
sessions (p , 0.01). Immedi-
ately after training, 11 athletes
(69%) displayed significant im-
provements in their lower limb
alignment that were retained
12 months later. Before train-
ing, 75% of the subjects had
,60% knee separation dis-
tance, indicating poor overall
lower limb control on this task.
One year later, only 19% were
Figure 7. Subjects that failed to demonstrate improvement or retention of initial improvements of their normalized in this category. The 5 athletes
knee separation distance values.
that failed to improve or retain
their initial improvements in
normalized knee separation
12-month posttrained tests. Five subjects (31%) failed to distances were encouraged to continue neuromuscular and
demonstrate improvement or retention of initial improve- strength training if possible within the allowance of their
ments (Figure 7). volleyball training and season participation.
Eight subjects showed a continued improvement in their The drop-jump video test was designed to be cost effective
normalized knee separation distance over the 3 posttraining and easy to perform by researchers, coaches, trainers, or
test sessions. The average percent improvement from the therapists in any facility. This test only provides a general
pretrain test value was 21% at the immediate posttrain test indicator of an athletes lower limb axial alignment in the
session, 34.5% at the 3-month posttrain session, and 57% at coronal plane in a straightforward drop-jump and vertical
the 12-month posttrain session. There was no noteworthy take-off task. Other investigators have reported similar testing
difference in these 8 subjects in height or weight; only 2 protocols to measure this alignment (14,20). We agree with
subjects had increases in height (2.5 cm each) and only 2 other others that this type of drop-jump test cannot be used as
subjects gained weight (2.272.72 kg). a risk indicator for noncontact knee ligament injuries (25).
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We recognize that this video test performed during 1
maneuver only depicts hip, knee, and ankle positions in
a single plane, and that noncontact ACL injuries frequently
occur in side-to-side, cutting, or multiple complex motions.
More sophisticated and expensive multicamera systems
are required to measure these types of motions in multiple
planes. However, our test provides a general assessment of
lower limb position and depicts those athletes who have poor
control on landing and acceleration into a vertical jump. It
is reliable, practical, and feasible for individuals who do
not have funds or access to multiple cameras, force plates,
and research personnel required to perform extensive data
collection and reduction with more complex systems.
In a prior investigation (22), 77% of 325 untrained female
athletes had #60% normalized knee separation distance on
landing during the drop-jump test. Upon completion of the
neuromuscular training program, this percentage decreased
to 34%. The current study supports these data and
demonstrates that, overall, 69% of the female athletes
improved and retained the improvements 12 months after
the completion of training. It is important to note that
variability existed in the normalized knee separation
distances among the athletes during the 3 posttrain test
sessions for unknown reasons. Normal growth and matura-
tion may account for the continued improvements noted in
some athletes between the early posttrain and 12-month
posttrain test sessions. However, other studies have found
either no influence on maturation in female athletes on knee
flexor and extensor peak torques (4) or a negative influence
on neuromuscular control and lower extremity strength (13).
The goals of the neuromuscular training program were to
teach athletes to control upper body, trunk, and lower body
position; lower the center of gravity by increasing hip and
knee flexion on landing; and develop muscular strength and
techniques to land with decreased ground reaction forces.
Additionally, athletes were taught to preposition the body
and lower extremity before landing to land in the position of
greatest knee joint stability and stiffness, with the goal of
obtaining a more neutrally aligned ankle and knee separation
distance. The data from our prior and current study show that
this program is effective in approximately 70% of adolescent
female athletes in improving the potentially harmful position of
valgus lower limb alignment. This program was also previously
shown to be effective in inducing changes in neuromuscular
indices including decreased peak landing forces of 22%,
decreased peak adduction and abduction moments of 50%,
and increased hamstrings to quadriceps muscle peak torque
ratios of 26% (nondominant side) and 13% (dominant side)
(15). In addition, this program significantly reduced the
incidence of noncontact knee ligament injuries in female high-
school athletes (2,12,15).
This study focused solely on female athletes because of
the gender disparity in noncontact ACL injury rates. Other
investigations have reported significant differences between
genders upon landing in overall lower limb alignment, knee
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flexion angles, knee extension moments, knee valgus mo-
ments, and ground reaction forces (7,13,15,17,19). It is
important to note that the increased incidence of knee
ligament injuries in female athletes is likely multifactorial, and
it is currently unknown as to which factors are dominant and
which play a negligible role (3). Factors inherent in women
have been suggested, including a narrow intercondylar notch,
smaller-sized ACL, pelvichipkneefoot alignment, gener-
alized knee laxity, foot pronation, and hormonal variations
(10). Extrinsic factors related to athletic conditioning, skill,
training, and equipment have also been discussed. Continued
research is required to answer the question of which factors
are most responsible for this injury disparity between male
and female athletes.
PRACTICAL APPLICATIONS
Adolescent female volleyball players can improve their
overall lower limb alignment on a drop-jump test after 6
weeks of neuromuscular retraining designed to reduce the risk
of a noncontact ACL injury. Approximately 70% of the
athletes may retain their improvements in this test up to 1 year
after training. The improvement in lower limb alignment is
important because it reduces the potentially harmful position
of valgus lower limb alignment that is commonly seen during
noncontact ACL injuries. The drop-jump test is useful to
coaches and trainers as a general indicator of an athletes
ability to control lower limb alignment on landing because it
uses standard equipment and a single camera and is relatively
easy to perform in any facility. Athletes who do not improve
on this test are encouraged to continue neuromuscular
training. Further research is required to determine if this
improvement is related to the reduction in ACL injury rates in
trained female athletes and if a poor knee separation distance
on landing from a drop-jump test is a risk indicator for a
noncontact ACL injury.
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