PM R 7 (2015) 229-235

www.pmrjournal.org

Original ResearcheCME

Single Leg Squat Test and Its Relationship to Dynamic Knee Valgus
and Injury Risk Screening
Viviane Ugalde, MD, Chuck Brockman, PT, Zach Bailowitz,
Christine D. Pollard, PhD, PT

Abstract

Background: Lower extremity injuries are common in athletes. Valid tests to assess for risk of injury that are easily performed
during a preparticipation sports physical examination are lacking. Two-dimensional (2D) analysis of the drop-jump test can
identify athletes at risk, but it is too expensive and cumbersome to use in this setting.
Objective: To identify if those who perform a positive(abnormal postures) single leg squat (SLS) test also exhibit greater
dynamic valgus on the 2D drop-jump test. Our secondary purpose was to assess whether group differences in gender, age, or
body mass index are evident between those who exhibit a positive SLS test result versus a negative SLS test result. Also, we
wanted to determine any gender differences with the 2D drop-jump test.
Design: A cross-sectional study.
Setting: Private practice, preparticipation sports physical examinations.
Participants: A total of 142 middle school and high school athletes.
Methods: Participants performed a SLS test and a drop-jump test during their preparticipation sports physical examination.
Individuals were partitioned into groups based on the outcome of their SLS test (positive SLS group versus negative SLS group).
Independent sample t-tests were used to evaluate SLS group differences in the drop-jump test, age, and body mass index, and the
c2 test was used to evaluate SLS group differences in gender (P ! .05).
Main Outcome Measurements: The SLS test and drop-jump test.
Results: Seventy-three of the 142 athletes (51%) had a positive SLS test result, whereas 69 athletes (49%) had a negative SLS test
result. Individuals in the positive SLS group had a significantly lower knee-hip ratio), indicative of greater dynamic knee valgus,
than did those in the negative SLS group (P .02). Individual characteristics between SLS groups including gender, age, and body
mass index were similar.
Conclusion: The SLS test is a reasonable tool to use in preparticipation sports physical examinations to assess for dynamic knee
valgus and the potential risk of lower extremity injury.

Introduction 100,000 athletic exposures [4]. Interest in sport injury

Lower extremity injury in sports is common in high
school athletes, ranging from 29%-89% of all injuries
sustained in 1 year [1]. The incidence of lower extremity
injury in high school athletes was 1.33 per 1000 athletic
exposures, which represents 807,222 nationally per year
[2]. Some lower extremity injuries, such as anterior
cruciate knee ligament (ACL) injuries, result in signifi-
cant time loss from sport and an increased risk of
osteoarthritis later in life [3]. Girls soccer has the
highest incidence of ACL injury in the 14-18-years-old
age group, at 14.08 per 100,000 athletic exposures, with
football the second highest incidence, at 13.8 per
prevention has been expanding in the past 10-15 years,
particularly in light of injury prevention programs that
have been shown to reduce injury rates of the ACL and
other lower extremity injuries [5-10]. Implementation
of these injury prevention programs can be challenging
and are not readily available. An alternative to gener-
alized injury prevention training for all athletes would
be to prescreen athletes and stratify individual risk of
injury. This type of prescreening may allow targeted
prevention techniques for individual athletes [11].
Clinical biomechanical tests proposed to identify
at-risk athletes for lower extremity injuries include
the single leg squat (SLS) test [12,13], drop-jump test

1934-1482/$ - see front matter 2015 by the American Academy of Physical Medicine and Rehabilitation
http://dx.doi.org/10.1016/j.pmrj.2014.08.361
230 SLS Test and Dynamic Knee Valgus and Injury Risk Screening
[13-17], landing error scoring system [18], star excursion
balance test [19], and the functional movement screen
(FMS) [20,21]. The drop-jump test and the landing error
scoring system use two-dimensional (2D) or three-
dimensional (3D) video analysis, and the star excursion
balance test and FMS require multiple tasks, which
make them impractical for implementation at large
group preparticipation examinations or in physician of-
fices. The SLS test is a simple test that can easily be
used in these settings. The SLS test identifies core
strength [22] and generally relates to landing, running,
and cutting tasks [13,23-25]. Strensrud et al [13] re-
ported a good correlation between subjective assess-
ment of an SLS test and 2D frontal plane video analysis
with elite handball players; however, this has not been
examined in middle school and high school athletes
[13]. The primary purpose of this study was to examine
the relationship between performance on a simple yet
defined SLS test and a 2D drop-jump test in middle
school and high school athletes. In particular, our aim
was to identify if those who have a positive SLS test
result (which suggests poor lower extremity mechanics)
also exhibit greater dynamic valgus on the 2D drop-
jump test. Our secondary purpose was to assess
whether group differences in gender, age, or body mass
index (BMI) are evident between those who exhibit a
positive SLS test result versus those with a negative SLS
test result. Finally, we aimed to determine if there was
a gender difference in dynamic valgus by using the 2D
drop-jump test in this population of athletes who
attended preparticipation physical examinations.
Methods
Participants
Participants consisted of 142 athletes (92 girls and 50
boys; mean (standard deviation) age, 13.8 # 1.8 years)
who were recruited at preparticipation sports physical
examinations from 4 physical examination sessions over
a 2-year period (Table 1). Athletes with previous lower
extremity injuries were excluded from participating in
the study. The participants were composed of middle
school and high school athletes who were participating
in cross country, track, soccer, football, wrestling,
volleyball, Nordic and alpine ski racing, lacrosse, and
basketball. All the athletes signed assent forms and
their parents signed consent forms before participation.
Table 1
Participant characteristics
Group Mean
No. Girls No. Boys Age, y
Positive SLS group 48 25 13.6
Negative SLS group 44 25 13.8
BMI body mass index; SLS single leg squat.
The St Charles Medical Center Institutional Review
Board approved the study.
Procedures
The participants were evaluated while performing an
SLS test and a 2D drop-jump test. Evaluators were
licensed physical therapists, orthotists, or certified
athletic trainers who had undergone training in the
testing methods. Each of these tests was performed on
the same day (ie, the day of their preparticipation
sports physical examination). Data were obtained in a
blinded fashion for the SLS test and the 2D drop-jump
test results, in that participants completed the SLS
test at the SLS testing session and the 2D drop-jump test
at the 2D drop-jump test station, which was located in a
different room.
SLS Test
This test was conducted similarly to the SLS test
described by Sciascia and Kibler [12]. The barefooted
athletes were asked to place their hands on their hips
and stand on one limb and flex the opposing limb to 90$ .
They then were instructed to perform an SLS to 30$ of
knee flexion and then return to a fully extended knee
position (Figure 1). Visual inspection was used to esti-
mate whether the participants squatted to 30$ . If not,
then the rater would give verbal cues to either increase
or decrease the amount of knee flexion in subsequent
squats. The participants performed the SLS test 3 times
in a row on each leg. The investigator noted any
abnormal responses, which consisted of arms flailing,
the Trendelenburg sign, or collapse of the supporting
knee into valgus, which indicated an abnormal response
[12]. We defined a positive SLS test result as more than
two-thirds of abnormal responses on either leg of the 6
total trials (3 SLS trials on each leg). Each participant
was given either a positive or a negative score on the SLS
test. A positive SLS test result may be suggestive of poor
lower extremity mechanics, reduced core strength, or
hip abductor weakness.
2D Drop-Jump Test
This test was conducted as described by Noyes et al
[16]. A Sony DCR-HC52 Mini DV Handycam Camcorder
(Sony Electronics Inc, San Diego, CA) was connected to a
Dell Latitude E6400 laptop (Dell Inc, Round Rock, TX)
equipped with Dartfish ProSuite 4.5.2.0 video software
(Dartfish Software, Alpharetta, GA). The camcorder then
was placed on a DYNEX Digital Series 60 Universal Tripod
(Dynex Products, Richfield, MN). The tripod, which stood
Group Mean at 102.24 cm in height, was placed 365.76 cm in front of
BMI, kg/m2 a box of 32.0 cm in height and 34.0 cm in width.
20.3 The participants were barefoot during the drop-jump
20.8 test. Orange Styrofoam (Dow Chemical Co, Midland, MI)
spheres were placed by a physical therapist onto each
 V. Ugalde et al. / PM R 7 (2015) 229-235 231

Figure 1. Single leg squat test. The athletes were asked to place their hands on their hips and stand on one limb and flex the opposing limb to 90$ .
They then were instructed to perform a single leg squat to 30$ of knee flexion and then return to a fully extended knee position. They performed
the single leg squat 3 times in a row on each leg. The investigator noted any abnormal responses, which consisted of arms flailing, the Trende-
lenburg sign, or collapse of the supporting knee into valgus, which indicated an abnormal response.

subjects left and right greater trochanter, and the
center of the left and right patellas. A solid black
backdrop was used behind the jump box to accentuate
contrast and visibility of the orange spheres. The par-
ticipants were instructed to step up onto the box and
directly face the camera. Each athlete was then cued by
the physical therapist who was monitoring the video
camera to jump down from the box onto the floor by
using both feet and then precede to jump straight up in
the air as high as he or she could by using both feet.
Each participant was given these instructions for a total
of 3 trials.
High-speed video analysis by using Dartfish ProSuite
4.5.2.0 video software was used to assess the distance
between the hips and the knees in the frontal plane
during the drop-jump test. All Dartfish analyses were
conducted by a single investigator (V.U.) blinded to the
SLS test results. Hip distance was measured from hip
markers with the participant in the quiet stance. Knee
distance (from mid marker right knee to mid marker
left knee) was measured at maximum knee flexion
landing from the box (Figure 2). The distance between
the knees was normalized by the hip separation dis-
tance (knee-hip ratio), and this value was used as an
indicator of lower limb alignment in the frontal plane
(ie, dynamic knee valgus). The knee-hip ratio was
calculated by taking the knee distance at maximum knee
flexion and by dividing it by the hip distance at a quiet
stance. The knee-hip ratio then was used as an indicator
of lower limb alignment in the frontal plane (ie, dynamic
knee valgus). A lower knee-hip ratio is suggestive of
greater knee valgus or frontal plane collapse.
Statistics
The participants were partitioned into groups
based on the outcome of their SLS tests. Therefore, we
had a positive SLS group and a negative SLS group.
Independent sample t-tests were used to evaluate SLS
group differences in the knee-hip ratio (ie, dynamic
knee valgus), age, and BMI. A c2 test was used to eval-
uate SLS group differences in gender. In addition, in-
dependent sample t-tests were used to evaluate gender
differences in the knee-hip ratio measured during the
2D drop-jump test. All data were analyzed by using SPSS
(version 21.0; SPSS Inc, Chicago, IL), with an a priori a
level of .05.
To assess interrater reliability of the more subjec-
tive SLS test, we used a subset of 78 participants (51
girls and 27 boys). Interrater reliability was assessed by
using a second and third rater for these participants.
These 3 raters consisted of 2 physical therapists (PT1
(C.D.P.) and PT2) and a certified athletic trainer (ATC).
All 3 raters observed the same athlete at the same time
but were blinded to the others results. Interrater
reliability was determined for 3 trials for the 3 ob-
servers. The Spearman correlation was used to assess
interrater reliability. Spearman correlation coefficients
were calculated by using an a of .05 for all rater
pairings (PT1-PT2, PT1-ATC, PT2-ATC). The range in
values is from e1.0 (which indicates perfect inverse
correlation) to 1.0 (which indicates perfect
correlation).
Results
Seventy-three of the 142 athletes (51%) had a positive
SLS test result, whereas 69 athletes (49%) had a negative
SLS test result. Individuals in the positive SLS group
(ratio, 0.47) had a significantly lower knee-hip ratio
(ratio, 0.47), which was indicative of greater dynamic
knee valgus, than did those in the negative SLS group
(ratio, 0.55) (P .02). Regarding the outcome of the
interrater reliability test on the subset of SLS test re-
sults data, all 3 raters were highly correlated. PT1 and
PT2 were the most correlated (0.72), whereas ATC was
232 SLS Test and Dynamic Knee Valgus and Injury Risk Screening
Figure 2. The two-dimensional drop-jump test normalized knee separation distance was measured as the knee separation distance at peak knee
flexion during landing (A) divided by the hip separation distance measured during quiet stance (B).
correlated with PT1 and PT2 at 0.45. Individual char-
acteristics between the SLS groups, including gender,
age, and BMI were similar. The positive SLS group con-
sisted of 25 boys and 48 girls, whereas the negative
SLS group consisted of 25 boys and 44 girls, and there
was no difference in gender between the SLS groups
(P .80). There also was no statistical difference
among ages of the athletes in each group (average
positive SLS group age 13.6; average negative SLS
group 13.8 years; P .53). Finally, there was no
statistical difference in BMI between the groups
(average positive SLS group BMI 20.3 kg/m2; average
negative SLS group BMI 20.8 kg/m2; P .47). When
comparing the knee-hip ratios of the boys and girls
during the 2D drop-jump test, we found that the female
athletes exhibited significantly lower knee-hip ratios
compared with the male athletes (female group average
knee-hip ratio 0.45; male group average knee-hip ratio
0.63; P .003).
Discussion
Evaluating dynamic knee valgus is important in
assessing the risk for lower extremity injury because it
has been associated with an increased risk of ACL injury
[15]. Our findings indicate that the SLS test provides
similar information regarding dynamic knee postures to
the 2D drop-jump test. The SLS test is a simple screening
tool that can be used in the physicians office or during
large-scale preparticipation physical examinations to
screen for athletes with poor knee control. The results
of this study that examined middle and high school
athletes are similar to those reported by Strensrud
et al [13] who found a strong relationship between
dynamic knee valgus during the SLS test and 2D drop-
jump landings in elite handball players. The primary
differences between the current study and that of
Strensrud et al [13] were participant characteristics
and difficulty of the testing protocol. The study by
Strensrud et al [13] was limited to female handball
players with a mean age was 22 years. However, our
investigation included younger (mean age, 13 years)
male and female athletes who were participating in a
variety of sports. Furthermore, the SLS test technique
used in their study required 90$ of knee flexion with
a plumb bob. In contrast, our SLS test was simpler
and could easily be used in a physicians office or
during sports physical examinations with no additional
equipment.
In young adults, the SLS test results showed good
interrater and intrarater reliability that correlated well
with 3D analysis of peak knee flexion, knee mediolateral
displacement, and hip adduction [26]. The SLS test re-
sults compared with 2D and 3D video analysis was valid
and reliable in young, healthy adults for mediolateral
knee motion and hip function [26-29]. Thus, as seen in
our study of younger recreational athletes and in other
studies of young adult recreational and elite athletes,
the SLS test can reliably predict dynamic knee valgus.
With the SLS test results, we found no significant dif-
ference in dynamic knee valgus between boys and
girls. Dwyer et al [30] had similar findings at the knee
in a group of collegiate athletes. In addition, no gender
differences in peak knee valgus or frontal plane
 V. Ugalde et al. / PM R 7 (2015) 229-235
movement was found with the SLS test results in a group
of young adults [23]. In contrast, a study of collegiate
age athletes demonstrated significant gender differ-
ences in knee varus and valgus, and in ground reaction
forces during the SLS test when using a 3D kinematic
analysis [25]. The sensitivity of 3D analysis with mea-
surement of joint angles likely explains this difference.
In another study, of 46 collegiate athletes, gender dif-
ferences with the SLS test results were identified with
female athletes exhibiting greater knee valgus [24].
Gender differences or lack thereof in the above studies
may reflect differences in methodology, subject char-
acteristics (age or level of athlete), or variations in the
definition of an abnormal SLS test result.
Our study found no gender differences when using
the SLS test to examine lower extremity movement
patterns. In contrast, when we examined the influence
of gender on the 2D drop-jump test alone in this popu-
lation, we found that the girls exhibited decreased
knee-hip ratios, which is suggestive of increased dy-
namic knee valgus. These findings are consistent with 2D
studies with similar methodology [16,31] and in
numerous 3D motion analysis studies that reported that
girls exhibit greater knee valgus angles compared with
their male counterparts during drop-landing tasks in
high school athletes [32-34], in >12 year olds [35], and
in collegiate age athletes [36-38]. Only one study that
used a 2D analysis found no gender difference in drop-
jump landings [39]. The predominance of data sup-
ports that gender differences exist in knee movement
patterns during landing. In our study, there was a clear
link between movement patterns exhibited during the
SLS and the drop-jump tests movement patterns; how-
ever, differences in findings regarding gender indicate
that, although related, the SLS and drop-jump tests
measure different variables and offer different biome-
chanical challenges. One primary advantage of the SLS
test over the drop-jump test is the ability to assess in-
dividual limbs.
During the data collection and reduction, it was
observed that many of the athletes with poor knee
control on landing had difficulty lowering their heels to
the floor. This phenomenon may be due to a tight
Achilles tendon but was not examined in this investi-
gation. Bell et al [40] investigated flexibility patterns in
persons with excessive medial knee displacement. They
found reduced flexibility in the Achilles tendon corre-
lated with poor frontal plane knee control. Hip strength,
indirectly measured by the SLS test, also has been
shown to be a component of frontal plane knee motion
control [23,28]. Future studies of frontal plane knee
motion should include an evaluation of hip and ankle
strength and flexibility. The SLS test has shown value in
other assessments as well, which were not evaluated in
the current study. The SLS test identifies core strength
[22] and relates to landing, running, and cutting tasks
[13,23-25,41].
233
Future Direction
Risk assessment may be useful, either alone, as with
the SLS test, or the subjective drop-jump test, or in
combination, such as in the FMS to identify athletes at
risk for injury. The FMS is not practical in a physicians
office or during large-volume preparticipation sports
physical examinations. The SLS test as described in this
study or an observed drop-jump test could easily be
performed in the physicians office. To fully understand
the utility of the SLS test, it needs to be studied with a
large cohort over time and matched with injury data to
determine its predictive value. In addition, for the SLS
test to be applied as a clinical test, uniformity in per-
formance of the test is needed. Variations in the degree
of knee flexion for the squat have been described from
30$ -60$ to maximal squat without losing balance
[12,13,23-25,30].
Limitations
The 3D motion capture is the criterion standard
technique to measure knee valgus angles. Although it is
the criterion standard, the majority of clinicians do not
have access to this technology, and 2D analysis has its
limitations. For example, McLean et al [42] found
transverse plane excursions measured in 2D accounted
for a significant portion of the variance in the 3D knee
valgus angle. Even though 2D has its limitations, it is
considerably more affordable and has been shown to
be a reliable indicator of frontal plane projection
angles that correlate with 3D knee valgus angles [43].
An additional study limitation is related to clothing.
Ideally, the participants would have worn a tight fitting
short but, due to the nature and fast pace of the
preparticipation sports physical examinations, we
captured data with the participants wearing the shorts
in which they arrived. A final limitation was that
different SLS test raters were used during year-1 and
year-2 testing.
Conclusion
Although injury rates for middle school athletes are
unknown, lower extremity injuries in high school ath-
letes are more than 800,000/y nationally [2]. Identifying
athletes at risk for these injuries and implementing
methods to prevent injury are important to keeping
children active and preventing disabling sequelae, for
example, posttraumatic knee arthritis. Our findings
revealed that the simple SLS test can be used in the
clinical setting both in providers offices or during large
preparticipation sports physical examinations to add a
component of biomechanical screening for potential
injury risk reduction. It is a simple step to implement
clinically in a movement toward more widespread risk
injury assessment. For athletes who do not have the
234 SLS Test and Dynamic Knee Valgus and Injury Risk Screening
opportunity to participate in large-scale ACL prevention
programs, individual instruction may be helpful in
reducing individual risk.
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This journal-based CME activity is designated for 1.0 AMA PRA Category
1 Credit! and can be completed online at www.me.aapmr.org.
This activity is FREE to AAPM&R members and available to non-
members for a nominal fee. For assistance with claiming CME for
this activity, please contact (847) 737-6000.

Disclosure

V.U. Orthopedic and Neurosurgical Center of the Cascades, PM&R Division, The
Center Foundation, Bend, OR. Address correspondence to: V.U.; e-mail:
vugalde@thecenteroregon.com
Disclosures outside this publication: board membership, volunteer, The Center
Foundation (no money)
C.B. Therapeutic Associates Physical Therapy, Bend, OR
Disclosure: nothing to disclose
Z.B. University of Arizona College of Medicine, Tucson, AZ
Disclosure: nothing to disclose
C.D.P. Exercise and Sports Science, Oregon State University-Cascades, Bend, OR
Disclosure: nothing to disclose
Submitted for publication January 28, 2014; accepted August 4, 2014.

CME Question
In middle and high school athletes, with which of the following is a positive single leg squat test (SLS) shown a positive correlation?
a. female gender
b. younger age
c. body mass index
d. knee/hip ratio
Answer online at me.aapmr.org