THE RELATIONSHIP BETWEEN LOWER LEG LEAN TISSUE, FUNCTIONAL
INDEX SCORES AND TRICEPS SURAE ENDURANCE IN ATHLETES

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Caitlin Kamide

Research Advisor, Dr. Edwin Zuchelkowski
California, Pennsylvania
2013

ii

iii

ACKNOWLEDGEMENTS

I would like to take the opportunity to thank the
individuals that had a tremendous role in the completion of
this thesis.

Firstly, I would like to thank my thesis

chairperson Dr. Edwin Zuchelkowski for being so involved
with every aspect of this study.

Dr. Zuchelkowski went

above and beyond his role as chairperson.

He was easily

accessible, whether through scheduling last minute meetings
or conversing through email.

Furthermore, he offered great

insight and suggestions for the overall research design of
this study.

Dr. Zuchelkowski’s contributions and guiding

role in this study were a huge part of its success.
I would also like to thank my thesis committee members
Dr. Shelly Fetchen DiCesaro and Robert Sepesy for their
time and commitment to this study.

Dr. DiCesaro was

instrumental in the statistical analysis portion of this
study, whether it was guiding me through SPSS or analyzing
its production of tables.

In addition, her Athletic

Training background was highly valuable to the success of
this study.

Robert Sepesy was extremely flexible, allowing

me to attend team lift sessions to recruit volunteer
student-athletes as well as providing and guiding in the

iv
use of the instruments used in this study.

He was also

readily available to answer any questions or concerns I
had.
Although Dr. Thomas F. West was not directly part of
my thesis committee, I called upon him often for help.

Dr.

West committed time and supplies to the construction of the
parallel uprights seen in Figure 1.

In addition, he was

helpful in suggesting the Dance Studio as a place to
conduct my data collection as well as providing many of the
instruments needed to complete my research.

Furthermore,

he aided in the statistical analysis of my data.

He was

extremely involved and helpful throughout this entire
process.
Finally, I would like to thank my family, friends and
God for their love and support throughout this research
study.

The encouragement to push forward through every

obstacle was extremely inspirational and kept me on the
path to complete this study.

Most of all, I would like to

thank my Mom for her motivating words and believing in me
when I became discouraged.

v

TABLE OF CONTENTS

Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES

. . . . . . . . . . . . . . v

. . . . . . . . . . . . . . . viii

LIST OF FIGURES . . . . . . . . . . . . . . . ix
INTRODUCTION
METHODS

. . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . 4

Research Design
Subjects

. . . . . . . . . . . . . . 4

. . . . . . . . . . . . . . . . . 5

Preliminary Research. . . . . . . . . . . . . 6
Instruments . . . . . . . . . . . . . . . . 7
Procedures

. . . . . . . . . . . . . . . . 7

Hypotheses

. . . . . . . . . . . . . . . . 14

Data Analysis
RESULTS

. . . . . . . . . . . . . . . 14

. . . . . . . . . . . . . . . . . . 15

Demographic Information
Hypothesis Testing

. . . . . . . . . . . 16

. . . . . . . . . . . . . 17

Additional Findings . . . . . . . . . . . . . 20
DISCUSSION . . . . . . . . . . . . . . . . . 24
Discussion of Results . . . . . . . . . . . . 24

vi
Conclusions . . . . . . . . . . . . . . . . 29
Recommendations. . . . . . . . . . . . . . . 30
REFERENCES . . . . . . . . . . . . . . . . . 33
APPENDICES . . . . . . . . . . . . . . . . . 34
APPENDIX A: Review of Literature

. . . . . . . . 35

Introduction . . . . . . . . . . . . . . . . 36
Etiology of Anterior Tibial Pain . . . . . . . . 37
Leg Soft Tissue Composition . . . . . . . . . . 41
Body Mass Index Determination . . . . . . . . . 43
Disability Indexes

. . . . . . . . . . . . . 46

Triceps Surae Strength Testing . . . . . . . 47
Summary . . . . . . . . . . . . . . . . . . 49
APPENDIX B: The Problem . . . . . . . . . . . . 51
Statement of the Problem . . . . . . . . . . . 52
Definition of Terms . . . . . . . . . . . . . 52
Basic Assumptions . . . . . . . . . . . . . . 53
Limitations of the Study . . . . . . . . . . . 54
Delimitations of the Study . . . . . . . . . . 54
Significance of the Study

. . . . . . . . . . 55

APPENDIX C: Additional Methods . . . . . . . . . 56
Informed Consent Form (C1) . . . . . . . . . . 57
IRB: California University of Pennsylvania (C2) . . 62
Preliminary Questionnaire (C3)

. . . . . . . . 64

Lower Limb Functional Index Sheet (C4)

. . . . . 66

vii
Individual Data Collection Sheet (C5) . . . . . . 69
REFERENCES . . . . . . . . . . . . . . . . . 71
ABSTRACT

. . . . . . . . . . . . . . . . . 73

viii

LIST OF TABLES
Table

Title

Page

1

Demographics of Subjects According to
Sport . . . . . . . . . . . . . . . 16

2

Pearson Product Correlation of Subjects’
Mean Muscular Endurance Score, Lean
Tissue Girth and LLFI Score . . . . . . . 18

3

Pearson Product Correlation of Subjects’
Muscular Endurance Score, Lean Tissue
Girth and LLFI Score in their Dominant Leg . 18

4

Pearson Product Correlation of Subjects’
Muscular Endurance Score, Lean Tissue
Girth and LLFI Score in their Non-Dominant
Leg . . . . . . . . . . . . . . . . 18

5

Independent-Samples t Test Comparing the
Mean Muscular Endurance Score and Mean Lean
Tissue Girth in Subjects with History of
Anterior Shin Pain and Subjects without
History of Anterior Shin Pain . . . . . . 21

ix

LIST OF FIGURES
Figure

Title

Page

1

Muscular Endurance Screening

2

Scatter plot of Subjects’ Average Skinfold
Measurement and Body Fat Percentage . . . 23

. . . . . . 13

1

INTRODUCTION

Anterior shin pain is a common pathology among elite
and novice athletes.

Anterior shin pain is a broad term

similar to “low back pain.” This term is used to describe
the result of many etiological factors.

Often clinicians

look to a single underlying cause to attribute to its
onset.

However, a multitude of risk factors can play a

role in its development.1 The purpose of this study was to
identify the role, if any, lean calf girth and lower leg
endurance have in the occurrence of anterior shin pain.
Minimal research has been conducted to include lean
calf girth measurements within its data collection.
Furthermore, little research has been done to examine the
ratio distribution of muscle mass between the plantar
flexors of the lower leg and its effect on the development
of anterior shin pain.

There is still plenty of research

to be done and the benefits of determining any correlation
will aid in reducing the risk of anterior shin pain
development through the modification of training
techniques.

2
Among the few studies that have been conducted in this
area, researchers Burne et al2 and Schinkel-Ivy et al3 found
similar results, indicating decreased lean muscle mass as a
possible contributory factory to the lower leg’s incapacity
to adapt to loading forces and withstand injury.
Interestingly, both studies found females to suffer higher
rates of injury than their male counterparts.

The study

conducted by Burne et al revealed that 25% of female cadets
could not complete the Australian Defense Force Academy
training requirements due to early onset exertional medial
tibial pain.
component.

However, 95% of male cadets passed the running
Schinkel-Ivy et al concluded that females in

the study presented with lower lean tissue mass than their
male counterparts resulting in greater acceleration
response of the tibia following impact, predisposing them
to greater risk of musculoskeletal disorders.
This study used the Lower Limb Functional Index4 to
analyze the effect of anterior shin pain among varsity
athletes at California University of PA and used questions
that assessed their ability to perform their respective
sport.

A study conducted by Wikstrom et al5 used the Foot

and Ankle Disability Index questionnaire to determine the
diagnostic utility of a self-assessed disability
questionnaire.

Its results demonstrated perceptual

3
disability had the greatest diagnostic accuracy in
comparison to mechanical and sensorimotor indicators.
Anterior shin pain accounts for 10.7% of injuries in men
and 16.8% of injuries in women and as a result decreases
the athletes’ participation in practice and competition.6
The focus of this study was to determine any
relationship between lean calf girth and anterior shin
pain.

The results of this study will aid in narrowing down

the possible risk factors associated with anterior shin
pain.

Any association between variables may result in

further investigation to reduce or increase lean mass
composition in the lower leg among athletes to decrease the
implications of anterior shin pain on performance.

4

METHODS

The primary purpose of this study was to determine any
relationship between lean calf girth, lower leg muscular
endurance measurements and Lower Limb Functional Index
scores.

The methods section includes the following

subsections:

(1) Research Design, (2) Subjects, (3)

Instruments, (4) Procedures, (5) Hypotheses, and (6) Data
Analysis.

Research Design

This research was a correlational design.

The

variables were lean calf girth, lower leg muscular
endurance scores and Lower Limb Functional Index scores
(LLFI).

A measurement of lean calf girth was correlated to

lower leg muscular endurance scores to objectively
determine if lean calf girth size corresponded to muscular
endurance scores.

Lean calf girth was then correlated to

Lower Limb Functional Index scores to determine if
excessive or limited amounts of lean calf girth correlated
to self-reported injury.

Lower leg muscular endurance

5
scores were then correlated to Lower Limb Functional Index
scores to determine any relationship existing between
endurance testing and self-reported injury.

The group used

for testing was volunteers from varsity sports involving
repetitive lower extremity impact that completed at least
one competitive season from California University of
Pennsylvania, or another collegiate program, without
current lower extremity injuries.

A Preliminary

Questionnaire was used to eliminate athletes from inclusion
in the study currently suffering from lower leg injury.
The study examined the relationship between lean calf girth
measurements, lower leg muscular endurance scores and LLFI
scores, which could potentially identify lean calf girth as
a diagnostic tool for possible injury and permanently alter
training techniques.

Subjects

The subjects used for this study were volunteer male
and female varsity athletes involved in football,
volleyball, and men and women’s soccer at California
University of Pennsylvania.

All subjects completed at

least one season of their competitive sport.

All subjects

took the Preliminary Questionnaire to determine inclusion

6
within the study.

Individuals currently suffering from any

lower leg injury at the time the survey was distributed
were eliminated from the study due to the potential
inflammation of the lower leg during the healing process.
Each subject was required to participate in calf girth
measurements, lower leg skin fold measurements, lower leg
muscular endurance screening, height, weight, Bioelectrical
Impedance Analysis and Lower Limb Functional Index
screening. The study was approved by the Institutional
Review Board (Appendix C2) at California University of PA.
Each participant’s identity remained confidential and was
not included in the study.

Preliminary Research

A pilot survey was conducted with this research
project.

The Lower Limb Functional Index was given to the

surveyors to be modified to assess the severity of previous
anterior shin pain among individuals participating within
the study.

Subjects involved in completing the pilot

survey passed the BOC exam, obtained Athletic Training
Licensure, were currently practicing as Athletic Trainers,
and therefore had the qualifications to recognize the signs
and symptoms of anterior shin pain.

This ensured the

7
subjects were qualified to assess the validity of the
modified Lower Limb Functional Index to diagnose anterior
shin pain pathology and make further modifications as
needed.

The researchers conducting the study agreed upon

the final product of the Lower Limb Functional Index.

Instruments

The instruments used in this study included a Sammons
Preston Rolyan flexible tape measure, Lange skinfold
caliper, hand-held dynamometer Model 01163, OMRON hand-held
bioelectrical impedance analysis device Model HBF-306CN
(HBF-306-Z5), weight scale Model 884 7021099, National
Football Scouting height measurement tool, flexible height
measurement tool, metronome, goniometer, surgical tubing
and two parallel uprights.

Procedures

Lower Limb Functional Index Scores
Subjects answered the questions on the survey
separately for both legs.

Subjects could answer yes, no or

maybe if the questions pertained to symptoms they had
experienced in the past.

Each answer was correlated to a

8
number value, yes=1 point, no=0 points, and maybe=1/2
point.

The total points for each leg were multiplied by

four and then divided by the total number of possible
points to determine the percentage.4

Height and Weight Measurement
Height was measured using a National Football Scouting
height measurement tool or a standard flexible height
measurement tool based on availability.
required to remove their shoes.

The subjects were

The subject stood upright,

both feet flat on the floor and heels touching.

The heels,

midbody and upper body parts remained touching the wall.
The subject’s head remained in neutral position relative to
the chin while looking straight ahead.
was used to take weight measurements.

An electronic scale
Subjects were

instructed to void the bladder within the hour prior to
testing and asked to remove excessive outerwear if they
were comfortable doing so. Subjects’ weight measurements
were taken before noon in order to make accurate
comparisons among measurements.7

9
Bioelectrical Impedance Analysis
Subjects were required to take their height and weight
measurements in order to enter the correct demographic data
into the BIA to determine body fat percentage.

Subjects

held the handheld dynamometer with both arms extended away
from their bodies until the reading was done.

America’s

College of Sports Medicine suggests the hydration status of
the subjects be controlled for prior to testing.

Subjects

should not consume alcohol forty-eight hours prior to
testing and products containing diuretic properties in the
previous twenty-four hours before the test.

The subjects

should not exercise up to twelve hours before testing and
avoid eating or drinking anything within four hours prior
to the test.

Finally, the bladder should be completely

voided within thirty minutes of the test.7 It would be
extremely unrealistic to ask subjects to meet these
standards prior to testing.

Instead, subjects were asked

to avoid eating anything within one hour of testing and
void the bladder within thirty minutes of testing.

Testing

was completed in the morning prior to subjects working out.

Calf Girth Measurements
The subject stood with both feet 20 cm apart.

A

flexible tape measure was placed horizontally around the

10
maximum circumference of the calf between the knee and
ankle.

The tape measure was placed on the skin’s surface

without compressing the subcutaneous adipose tissue.
Duplicate measurements were taken once the skin returned to
normal texture.

A third measurement was taken if the

previous measurements were not within five millimeters of
one another.

The measurements were averaged for the

individual’s calf girth measurement.7

Skinfold Measurements
The skinfold measurement was taken on the side
undergoing testing while the subject remained standing
upright.

The skinfold measurement was taken at the maximal

circumference of the calf on the midline of its medial
border.

The researcher used the index finger and thumb to

pinch the skin and underlying adipose tissue away from the
deeper layers of muscle.

This pinch was maintained for one

to two seconds before reading the caliper.

The caliper was

placed perpendicularly on the skin, 1 cm away from the
thumb and index finger and halfway between the crest and
base of a vertical fold.

Once the skin returned to its

normal texture and thickness this measurement was repeated
to ensure validity of the measurement.

A third measurement

was taken if duplicate measures were not within two

11
millimeters of one another.

The measurements were averaged

for the individual’s calf skinfold measurement.7

Muscular Endurance Screening
Subjects stood barefoot between two parallel uprights
fitted perpendicularly with surgical tubing.

The subject’s

foot was placed in their neutral position and then measured
using a goniometer (the angle between the lateral midline
of the fibula and lateral fifth metatarsal).

Subjects

stood on one foot and raised their heel to their end range
of plantar flexion so that the height of the surgical
tubing could be adjusted to make contact with the dorsal
side of the foot during testing.

The subject’s weight-

bearing plantar flexion was documented.

Heel raises were

performed to a metronome at a ratio of one heel raise every
two seconds by raising the heel to make contact with the
surgical tubing and lowering the heel to the ground.
Repetitions were counted each time the dorsal side of the
foot made contact with the surgical tubing.

The knee

remained straight in the leg undergoing testing and the
same side upper extremity remained relaxed.

The subject’s

forward lean was controlled with the use of a handheld
dynamometer in the upper extremity opposite to the leg
being tested.

Maximal forward lean was equivalent to 2% of

12
the subject’s body weight.
of an acceptable calf raise.

Subjects were shown an example
They were also given the

opportunity to practice calf raises to the metronome if
they chose to.

Subjects were given the opportunity to use

the dynamometer to get a feeling of the amount of pressure
they were allowed to apply during the test.

Two

investigators determined termination of the test by
monitoring if the subject exhibited a forward lean greater
than 2% of their body weight, the subject’s knee flexed,
became too fatigued to continue or did not make contact
with the surgical tubing for three consecutive repetitions.8

13

Figure 1. Muscular Endurance Screening

14

Hypotheses

The following hypotheses were based on previous
research and a review of the literature.
1.

There will be a relationship between calf girth
and functional index scores.

2.

There will be a positive relationship between
calf girth and muscular endurance scores.

3.

There will be a relationship between functional
index scores and muscular endurance scores.

Data Analysis

The data was analyzed through the use of Pearson
Product Correlations.

The three variables correlated

included lean calf girth, muscular endurance scores and
Lower Limb Functional Index Scores.

The Additional

Findings subsection used Independent-Samples t Tests and a
Scatter plot.

15

RESULTS

The purpose of this study was to determine any
relationship between lean calf girth and lower leg
endurance on anterior shin pain. Subjects’ Lower Limb
Functional Index scores, muscular endurance scores and lean
calf girth measurements were analyzed through Pearson
Product Correlations and an Independent-Samples t Test.
The mean LLFI score, muscular endurance score and lean calf
girth measurement of subjects’ right and left legs were
analyzed using Pearson correlations.

Two additional

Pearson correlations were analyzed using the same three
variables, but isolated for subjects’ dominant and nondominant legs.

Finally, a t Test was performed between the

group of individuals that scored a 0% on the LLFI and the
group of individuals that scored greater than 0% on the
LLFI to determine any correlation between the muscular
endurance scores and lean calf girth measurements between
the two independent samples.

The following section

contains the data collected in this study and is divided
into three subsections: Demographic Information, Hypotheses
Testing, and Additional Findings.

16
Demographic Information

Data collection was taken for nineteen subjects;
however, five were excluded from statistical analysis.
Four were excluded due to the fact one leg had been injured
within the past 6 months.

Therefore we could not compare

lean tissue girth, muscular endurance score or LLFI score
between their dominant and non-dominant leg and chose to
discard them altogether. The final subject never identified
dominance and therefore a similar issue came about.

The

subjects used in this study (N=14) were volunteer studentathletes from California University of Pennsylvania.

The

subjects included athletes from volleyball, football and
Men and Women’s soccer.
and four males.
years.

The subjects included ten females

The subjects’ ages ranged from 18-22

At the time of data collection athletes were in

their off-season.
Table 1. Demographics of Subjects According to Sport
Sport
Volleyball
Football
Women’s
Soccer
Men’s Soccer

Number of Subjects

Age (# of subjects)

5
2
5

19(4), 20
21, 22
18, 19(2), 20, 21

2

19, 20

17
Hypothesis Testing

The following hypotheses were tested in this study.
All hypotheses were tested with a level of significance set
at α ≤ 0.05.

Pearson Product Correlations were calculated

for the effect of lean calf girth on anterior shin pain.

Hypothesis 1: There will be a relationship between
calf girth and functional index scores.

Conclusion: A Pearson correlation was calculated for
the relationship between participants’ average LLFI score
and average lean calf girth.

A moderate correlation that

was not significant was found (r(12)=-0.517,p>.05). A
Pearson correlation was calculated examining the
relationship between participants’ lean calf girth and LLFI
score in their dominant leg.

A moderate correlation that

was not significant was found (r(12)=-0.527, p>.05). A
Pearson correlation was calculated examining the
relationship between participants’ lean calf girth and LLFI
score in their non-dominant leg.

A moderate correlation

that was not significant was found (r(12)=-0.494, p>.05).

18
Table 2. Pearson Product Correlation of Subjects’ Mean
Muscular Endurance Score, Lean Tissue Girth and LLFI Score
Group
Muscular
Endurance
Score
Lean
Tissue
LLFI
Score

Muscular
Endurance Score
(Correlation)
1
0.187
-0.098

Lean Tissue,
mm
(Correlation)
0.187
1
-0.517

LLFI Score,
percentage
(Correlation)
-0.098
-0.517
1

Table 3. Pearson Product Correlation of Subjects’ Muscular
Endurance Score, Lean Tissue Girth and LLFI Score in their
Dominant Leg
Group

Muscular
Endurance Score
(Correlation)

Muscular
Endurance
Score
Lean
Tissue
LLFI
Score

1

0.237

-0.070

0.237

1

-0.527

-0.070

Lean Tissue,
mm
(Correlation)

-0.527

LLFI Score,
percentage
(Correlation)

1

Table 4. Pearson Product Correlation of Subjects’ Muscular
Endurance Score, Lean Tissue Girth and LLFI Score in their
Non-Dominant Leg
Group

Muscular
Endurance Score
(Correlation)

Lean Tissue,
mm
(Correlation)

Muscular
Endurance
Score
Lean
Tissue
LLFI
Score

1

0.120

0.120

1

-0.071

-0.494

LLFI Score,
percentage
(Correlation)
-0.071
-0.494
1

19
Hypothesis 2: There will be a positive relationship
between calf girth and muscular endurance scores.

Conclusion: A Pearson correlation coefficient was
calculated for the relationship between participants’
average muscular endurance score and average lean calf
girth.

Table 2 illustrates a weak correlation that was not

significant was found (r(12)=0.187,p>.05).

A Pearson

correlation was calculated examining the relationship
between participants’ muscular endurance score and lean
calf girth in their dominant leg.

Table 3 illustrates a

weak correlation that was not significant was found
(r(12)=0.237,p>.05).

A Pearson correlation was calculated

examining the relationship between participants’ muscular
endurance score and lean calf girth in their non-dominant
leg.

Table 4 shows a weak correlation that was not

significant was found (r(12)=0.120,p>.05).

Hypothesis 3: There will be a relationship between
functional index scores and muscular endurance scores.

Conclusion: A Pearson correlation was calculated for
the relationship between participants’ average muscular
endurance score and average LLFI score.

Table 2

20
illustrates a weak correlation that was not significant was
found (r(12)=-0.098,p>.05). A Pearson correlation was
calculated examining the relationship between participants’
muscular endurance score and LLFI score in their dominant
leg.

Table 3 reveals a weak correlation that was not

significant was found (r(12)=-0.070,p>.05). A Pearson
correlation was calculated examining the relationship
between participants’ muscular endurance score and LLFI
score in their non-dominant leg.

Table 4 illustrates a

weak correlation that was not significant was found
(r(12)=-0.071,p>.05).

Additional Findings

A supplementary test was performed to determine if
muscular endurance scores and lean tissue girth varied
among subjects that reported a history of anterior shin
pain and subjects that reported no history of anterior shin
pain.

Subjects scoring a zero on the Lower Limb Functional

Index confirmed no history of anterior shin pain.

Any

subjects scoring above zero on the Lower Limb Functional
Index were identified as having a past history of anterior
shin pain.

21
An independent-samples t test comparing the mean
scores of the subjects with a history of anterior shin pain
and the subjects without a history of anterior shin pain
found a significant difference between the means of the two
groups when comparing lean calf girth (t(16.716) = 3.972, p
= .001).

The mean lean girth of the subjects with a

history of anterior shin pain was significantly lower (m =
334.7, sd = 14.42) than the mean girth of the subjects
without a history of anterior shin pain (m = 337.6, sd =
37.73).
Table 5. Independent-Samples t Test Comparing the Mean
Muscular Endurance Score and Mean Lean Tissue Girth in
Subjects with History of Anterior Shin Pain and Subjects
without History of Anterior Shin Pain
Group
History of
Shin Pain
No History
of Shin Pain

Muscular Endurance
Score
Mean(SD)
27.7(10.67)

Lean Tissue, mm
Mean(SD)

33.1(18.81)

337.6(37.73)

334.7(14.42)

An independent-samples t test was calculated comparing
the mean scores of the subjects with a history of anterior
shin pain and the subjects without a history of anterior
shin pain.

Table 5 illustrates no significant difference

was found between the means of the two groups when
comparing mean muscular endurance scores (t(20.582)= .939,
p > .05).

The mean muscular endurance score of the

22
subjects with a history of anterior shin pain (m = 27.7, sd
= 10.67) was not significantly different from the mean
score of the subjects without a history of anterior shin
pain (m = 33.1, sd = 18.81).
Bioelectrical Impedance Analysis was used to calculate
Body Fat percentage among subjects in order to determine
any relationship between their prospective skinfold
measurements.

The purpose of collecting Body Fat

percentage was to determine standardization and accuracy of
the skinfold measurements collected.

Subjects with larger

Body Fat percentages were hypothesized to have larger
skinfold measurements, resulting in less lean calf tissue.
Greater or lesser amounts of lean calf tissue were
hypothesized to have an effect on the development of
anterior shin pain.

A Scatter plot comparing subjects

average skinfold measurement to Body Fat percentage
revealed an R2 value of 0.375.

There was not a strong

correlation between subjects’ calculated skinfold
measurement and Body Fat percentage.

23

Subjects Average Skinfold
Measurement vs. Body Fat
Percentage
30
y = 0.8719x + 2.971
R² = 0.37501

Body Fat (%)

25
20

Series1

15

Linear(Series1)
10
5
12

14

16

18

20

22

24

26

Subjects Average Skinfold (mm)

Figure 2. Scatter plot of Subjects’ Average Skinfold
Measurement and Body Fat Percentage

24

DISCUSSION

The purpose of this research study was to determine
any relationship between lean calf girth and lower leg
endurance on anterior shin pain.

The following section is

divided into three subsections: Discussion of Results,
Conclusions, and Recommendations.

Discussion of Results

Anterior shin pain is a broad injury caused by many
etiological risk factors.1 Researchers have not yet been
able to isolate one risk factor that has more prevalence on
the development of anterior shin pain in comparison to
others.

Limited research has examined lean calf girth as a

possible contributory factor.

The focus of this study was

to determine the role, if any, lean calf girth and muscular
endurance plays in the development and severity of anterior
shin pain.
Burne et al2 conducted research to determine the role
of lean calf girth among other variables on the sudden
development of Exertional Medial Tibial Pain (EMTP) through
a prospective study in Australian Defense Force cadets over

25
the course of a twelve month training period.

The results

of this study revealed decreased lean muscle mass as a
possible contributory factory to the lower leg’s incapacity
to adapt to loading forces and withstand injury.

This

incapacity contributed to 25% of female cadets not being
able to complete training requirements and only 95% of male
cadets completing the fitness test.
It was hypothesized that there would be a relationship
between calf girth and functional index scores.
Statistical analysis of three Pearson Product Correlations
revealed no significant relationship. The subjects’ average
LLFI score was not related to the average lean girth
measurement. Subjects’ lean tissue girth was not related to
LLFI score in the dominant leg. Subjects’ lean girth
measurement was not related to LLFI score in their nondominant leg.
It was hypothesized that there would be a positive
correlation between calf girth and muscular endurance
scores.

Statistical analysis of three Pearson Product

Correlations revealed no significant relationship.
Subjects’ average muscular endurance score was not related
to their corresponding average lean tissue girth.
Subjects’ muscular endurance score was not related to lean
calf girth in the dominant leg. Subjects’ muscular

26
endurance score was not related to subjects’ lean calf
girth in their non-dominant leg.
It was hypothesized that there would be a relationship
between functional index scores and muscular endurance
scores.

Statistical analysis of three Pearson Product

Correlations revealed no significant relationship.
Subjects’ average muscular endurance score was not related
to average LLFI score. Subjects’ muscular endurance score
was not related to LLFI score in the dominant leg.
Subjects’ muscular endurance score was not related to LLFI
score in their non-dominant leg.
In addition there was an Independent Samples t Test
performed comparing the mean muscular endurance scores of
the subjects with a history of anterior shin pain and the
subjects without a history of anterior shin pain.

No

significant difference was found between the means of the
two groups when comparing muscular endurance scores.
An Independent Samples t Test comparing mean girth
measurement of subjects with a history of anterior shin
pain and without a history of anterior shin pain was found
significant.

Subjects with a history of anterior shin pain

had a significantly lower mean girth than the subjects
without a history of anterior shin.

The results of this

27
statistical analysis were similar to those reported by
Burne et al2 and Shinkel-Ivy et al3.
The results of the statistical analysis of the three
Pearson Product Correlations and Independent Samples t Test
comparing mean muscular endurance scores of subjects with a
history of anterior shin pain and subjects without a
history of anterior shin pain were not similar to those
reported by Burne et al and Schinkel-Ivy et al. There are
possible explanations for the results of this study
differing from the literature.
This study used the Lower Limb Functional Index as a
tool to determine subjects’ past experience with anterior
shin pain.4 Subjects were not currently suffering from
anterior shin pain at the time of data collection.

It is

possible subjects’ past experience with anterior shin pain
was so long ago that the lean calf girth calculated at the
time of the study was not the same value as when they were
suffering from anterior shin pain.

For example, subjects

may have increased or decreased their lean calf girth due
to varying training regimens over time.

One of the

preliminary requirements of the study disqualified any
subject that suffered from any lower extremity injury
within six months of data collection to prevent residual
swelling from interfering with the accuracy of the data.

28
It is possible that the number of subjects had a
negative effect on the statistical significance.

Due to

time constraints, subjects’ class schedules and the rigid
testing parameters, it was difficult to recruit a large
sample size.

Perhaps with a greater subject pool results

may have differed.

Furthermore, there were an unequal

number of males and females that participated in this study
(f=10, m=4).

Given a greater number of male participants,

it may have proven beneficial for gender comparison of
muscular endurance score, lean calf girth and LLFI score
due to past research by Burne et al and Shinkel-Ivy et al.
Both studies revealed a greater number of females suffering
from injury than their male counterparts.
Subjects included within this study were not required
to have suffered from anterior shin pain in the past.

This

particular study included subjects without a history of
anterior shin pain because of limited volunteers and time
constraints.

After statistical analysis of an Independent

Samples t Test comparing the mean girth of subjects with a
history of anterior shin pain and subjects without a
history of anterior shin pain revealed significance, it may
have been beneficial to strictly include subjects with a
history of anterior shin pain.

I hypothesize subjects

without a history of anterior shin pain will have lean

29
girth measurements that remain stable over time due to lack
of history. Perhaps the three Pearson Product Correlations
would have shown statistical significance if only subjects
that experienced anterior shin pain participated in data
collection.

Based on the results of this study, I believe

it is worthwhile to investigate further whether lean girth
plays a role in anterior shin pain on subjects with a
previous history.

Conclusions

The relationship between subjects’ lean calf girth,
muscular endurance scores and Lower Limb Functional Index
scores were not proven statistically significant.

However,

additional findings revealed subjects with a history of
anterior shin pain had a lower mean girth than subjects
without a history of anterior shin pain.
to current literature findings.2,

3

This is similar

The additional findings

included within this study are important to propel further
research and insight into the role of lean calf girth on
anterior shin pain.

30
Recommendations

Athletic trainers, strength and conditioning professionals
and coaches must work closely together to aid in the
rehabilitation process of injured and healthy athletes.

It

is important to realize the possible implications of lesser
or greater amounts of lean calf girth in the development of
anterior shin pain.

The sports professionals must

collaborate to develop training regimens to ensure athletes
are not over or under-worked.

The rehabilitative

exercises, lifting sessions and repetitive drills at
practice may require modification to prevent or aid in
Triceps Surae lean mass gains.
Further research to determine the role, if any that
lean calf girth plays in the development of anterior shin
pain is suggested.

1)

A greater population of subjects would create a larger
sample population to examine for statistical
significance.

In addition to data collected from

volleyball, football and men and women’s soccer at
California University of PA, it would be beneficial to
include as many varsity teams that are willing to
participate.

31
2)

An equal number of male and female subjects from
athletic teams would create a more equal distribution.
For instance, including ten subjects from men’s soccer
would require ten subjects from women’s soccer.

For

sports teams that do not have a male or female
counterpart (ie. football and volleyball) the number
of subjects from each team should remain equal to
confirm an equal number of males and females included
within the study.
3)

It is recommended that strictly subjects with a
history of anterior shin pain are included in data
collection.

I hypothesize subjects without a history

of anterior shin pain should not have altered lean
calf girth measurements due to lack of previous
injury.

Therefore, subjects with a history of

anterior shin pain should be exclusively used in this
study to determine any relationship between lean calf
girth and previous anterior shin pain.
4)

It is recommended that BIA is not included in further
research of the relationship between lean calf girth
and history of anterior shin pain.

Simply collecting

height and weight measurements to calculate Body Mass
Index would be appropriate to standardize skinfold
measurements to determine accuracy of lean calf girth

32
measurements.

33
REFERENCES

1.

Craig, DI. Medial tibial stress syndrome: current
etiological theories part 1-background. Athl Ther
Today. 2008;13(1):17-20.

2.

Burne SG, Khan KM, Boudville PB, et al. Risk factors
associated with exertional tibial pain: a twelve
months prospective clinical study. Br J Sports Med.
2004;38(4);441-5.

3.

Schinkel-Ivy A, Burkhart T, Andrews D. Leg tissue mass
composition affects tibial acceleration response
following impact. J Appl Biomech. 2012;28(1):29-40.

4.

Gabel C, Melloh M, Burkett B, Michener L. Lower limb
functional index: development and clinimetric
properties. Phys Ther. 2012;92(1):98-110.

5.

Wikstrom E, Tillman M, Chmielewski T, Cauraugh J,
Naugle K, Borsa P. Discriminating between copers and
people with chronic ankle instability. J Athl Train.
2012;47(2):136-142.

6.

Clement DB, Taunton JE, Smart GW et al. A survey of
overuse running injuries. Phys Sportsmed. 1981;9:4758.

7.

Kaminsky, LA. Body Composition: ACSM’s Health-Related
Physical Fitness Assessment Manual. 3rd ed. Baltimore,
MD: Lippincott Williams & Wilkins, a Wolters Kluwer
business;2010.

8.

Ross M, Fontenot E. Test-retest reliability of the
standing heel-rise test. / Fiabilite du test du talon
leve en position debout, effectue a deux reprises. J
Sport Rehabil. 2000;9(2):117-123.

34

APPENDICES

35

APPENDIX A
Review of Literature

36

INTRODUCTION

The purpose of this Review of Literature is to
enlighten the reader about conflicting data regarding the
etiology of anterior shin pain. Clement et al found that
Medial Tibial Stress Syndrome accounted for 10.7% of
injuries in men and 16.8% of injuries in women suggesting
it is a common pathology. Clement draws attention to the
fact that relatively little is known about its causes
suggesting the need for further investigation.1 It is widely
accepted that musculoskeletal and neuromuscular adaptations
result from exercise.

The aim of this review is to

determine the role, if any, lean calf girth has on the
prevalence of anterior shin pain. This will be accomplished
in the following sections: Etiology of Anterior Tibial
Pain, Leg Soft Tissue Composition, Body Mass Index
Determination, the use of Disability Indexes and Triceps
Surae Strength Testing.

The literature review will end

with a summary of the research performed to date.

37

Etiology of Anterior Tibial Pain

Previous research has revealed multiple etiological
factors that contribute to the development of Medial Tibial
Stress Syndrome (MTSS) and ‘shin splints’, which encompass
the broad diagnosis of anterior shin pain.

The most recent

evidence reveals a multitude of biomechanical factors that
lead to the development of anterior shin pain, contributing
to the vagueness of this injury.2 A study conducted by
Johnell et al3 discredited the theory that anterior shin
pain had a single underlying cause through the assessment
of tissue biopsy from patients suffering from medial tibial
pain post-exercise.
A study conducted by Moen et al4 aimed to examine
multiple theorized risk factors for medial tibial stress
syndrome and through their identification increase their
diagnostic value.

Among the most popular theorized

etiologies to date, the study focused on hip internal and
external ranges of motion, knee flexion and extension,
dorsal and plantar ankle flexion, hallux flexion and
extension, subtalar eversion and inversion, maximal calf
girth, lean calf girth, standing foot angle and navicular
drop test. The multivariate regression analysis performed

38
within this study confirmed significant association between
decreased hip internal rotation, increased plantar flexion
and a positive navicular drop test and the presence of
MTSS.

Moen et al theorized decreased internal hip range of

motion negatively influenced running economy in such a
manner that the tibia became abnormally loaded.

Overall,

greater plantar flexion range of motion found in MTSS
subjects is theorized to predispose forefoot landing as
opposed to initial heel strike during normal running
mechanics leading to overcompensation by unequipped
structures of the lower leg. Abnormal navicular drop
measurements in MTSS subjects can be attributed to genetic
structural differences and has proven to have a negative
effect on functional movement.
A twelve-month prospective clinical study conducted by
Burne et al investigated anthropometric and intrinsic
biomechanical risk factors to exertional medial tibial pain
(EMPT) within the Australian Military Defense Force
Academy. Lean calf girth measurements were recorded and
analyzed among the seven intrinsic variables investigated
in this study.

Following twelve-months of military

training, twenty-three of one-hundred fifty-six military
cadets met the diagnostic standards defined in this study
for exertional medial tibial pain.

Although both male and

39
female cadets were examined in the study, results varied
between the sexes.

A possible contributory factor for

statistical significance correlating lean calf girth and
the presence of EMTP found solely for male cadets is the
greater prevalence of males than females in the academy.
Furthermore, twenty-five percent of the female cadets did
not compete in the running component of the physical
fitness testing because of diagnosed exertional medial
tibial pain.5
Interestingly, male cadets suffering from EMTP had a
right lean calf girth that was 4.2% less than NON-EMTP male
cadets.

Although not statistically significant, it should

be noted that male cadets suffering from EMTP tended to
have a lesser lean calf girth in their left leg in
comparison to NON-EMTP male cadets.

Burne et al attributes

decreased lean muscle mass as a possible contributory
factor to the lower leg’s incapacity to adapt to loading
forces and withstand injury.5
Schinkel-Ivy et al conducted a study that is closely
related to the research question of this project.

The aim

of this article was to determine the effect of body
composition and leg tissue masses on the acceleration
response of the tibia succeeding impact.6 Few studies have

40
attempted to examine the effect of localized anthropometric
measurements on overall function.
The peak acceleration, time to peak acceleration and
acceleration slope measurements were found to be
statistically significant when normalized for measurements
of leg tissue mass. Peak acceleration and acceleration
slope values decreased with increased leg lean mass and
bone mineral content. Schinkel-Ivy et al suggest that
greater lean and bone mass provide protection to tibial
shock.

Furthermore, the females in this study presented

with lower lean mass and bone mass than their male
counterparts resulting in greater peak acceleration and
acceleration slope values.

The data suggests that

localized tissue make-up is a factor in injury
susceptibility and that individuals with less lean mass and
bone mass run a greater risk of musculoskeletal disorders.6
Researchers have shown various relationships
associated with the development of anterior shin pain.
Little investigation has been done to isolate the role of
excessive or sparse amounts of lean calf girth in the
progression of musculoskeletal damage.

This particular

study will determine any relationship between lean calf
girth and anterior shin pain.

41

Leg Soft Tissue Composition

The literature review includes the examination of the
lean mass and fat mass of the lower leg in order to
determine if an optimal ratio exists to absorb impact
forces adequately.

The purpose of the present study is to

determine if abnormal amounts of muscle tissue predispose
subjects to anterior shin pain.

Several anthropometric

measurements can be taken and further manipulated in order
to determine a crude lean mass value of the lower leg and
multiple researchers have done so.
The study conducted by Moen et al took maximal calf
girth and skin-fold measurements to determine lean calf
girth.

The corrected lean calf girth was calculated by

subtracting the skin-fold thickness (fat tissue
composition) using a skin-fold caliper from the maximal
calf girth (absolute tissue composition) of the relaxed
calf obtained through use of a tape measure at the greatest
circumference of the muscle belly between the ankle and
knee joints.4
Although calf girth measurements using a tape measure
is accepted as the sole determinant of isolated girth

42
measurements, there are multiple, accurate methods to take
skin-fold measurements.

A study conducted by Selkow et al

compared the validity of skin-fold calipers to ultrasound
imaging techniques based on the assumption that there is
greater risk of human error using skin-fold calipers to
determine subcutaneous fat thickness.7
This study aimed to determine a relationship between
thigh fat-thickness using both methods at four sites.

The

results indicate ultrasound imaging and skin-fold caliper
values were strongly correlated among individuals with less
subcutaneous fat-thickness.

However, measurements taken

manually on individuals with overall greater subcutaneous
fat thicknesses tended to overestimate the values in
comparison to the ultrasound imaging technique.

The

results indicate greater room for human error with the
calipers used on individuals with greater subcutaneous fat.7
There are several variations and limitations within
this study.

The study conducted their experiment on

‘healthy adults.’7 We can assume an even greater validity of
the calipers used on elite athletes because of their
increased physical fitness level and generalized lower BMI
values in contrast to the average adult.

Therefore, a

basic assumption of this experimental procedure is that the
elite subjects will have decreased subcutaneous fat in

43
comparison to the “healthy adult”.

Therefore, measurements

of localized subcutaneous fat thickness using the skin-fold
calipers on elite athletes is even less likely to
overestimate subcutaneous fat thicknesses.

Furthermore,

the site location will vary between the studies.

The lower

leg has a smaller circumference than the thigh and
therefore has fewer adipose cells to store subcutaneous
fat.

The skin-fold calipers will provide greater validity

measuring locations with less area to store fat deposits.
The use of a skin-fold caliper would be a valid measurement
tool to determine isolated subcutaneous fat of the lower
leg.

Body Mass Index Determination

This research design will also include whole Body Mass
Index measurements using a hand-held BMI digital analyzer.
The purpose of the BMI measurement within this experiment
is to standardize calf girth measurements between athletes
of various body fat percentages.
Body Mass Index is a type of body composition analysis
commonly used as a determinant of an individual’s health
status.

Body Mass Index is a measure of a person’s weight

(kg) relative to their height (m2).

Adult BMI measurements

44
are put into categories according to the Center for Disease
Control and Prevention as a predictor of disease and
longevity.

Reed et al. believes that BMI should be a

supplement to other simple measures of body composition and
body fat distribution due to its limitations.

The review

conducted by Reed et al highlights findings from multiple
studies that BMI is not a suitable predictor of health,
disease and mortality for individuals in the midrange of
BMI measurements.

Therefore, an additional method will be

used in order to determine body composition of the
individuals in this study.8
Body Mass Index can be determined through a multitude
of techniques.
validity.

As expected, some methods produced greater

The gold standard for measuring body composition

is hydrostatic weighing (HW).

However, this method is time

consuming, expensive and can cause undue stress to subjects
compared to alternative methods.

Unick et al compared the

accuracy of more readily available body composition
analyzers, specifically bioelectrical impedance analysis
(BIA) to skin-fold and hydrostatic weighing techniques.9
Unick et al found significant correlations between BIA
and skin-fold values in comparison to hydrostatic weighing
for male and female high school aged participants.
However, females did show less validity among measurements

45
of fat free mass (FFM) between both bioelectrical impedance
analysis and hydrostatic weighing.

Males showed a

significant difference between FFM through skin-fold
measurements alone compared to HW.

In its entirety, BIA is

a valid measurement tool for assessing body composition
when compared to the gold standard.

Unick et al suggests

further investigation into the assessment of mean FFM
amongst high school aged females.9 Bioelectrical impedance
analysis will be used in this research design to determine
body mass index.
Bioelectrical impedance analysis conducts a small
amount of electrical current through the body.

The amount

of resistance to the flow of the current generated by the
device reveals whole body fat percentage.

The electrical

current flows more easily through bodily tissues saturated
with water due to the increased presence of electrolytes.
Lean tissue contains large amounts of water in comparison
to fat tissue allowing for easier conduction of the
current. As a result, the BIA differentiates between lean
and fat tissue content.

The percentage of body fat

revealed through BIA is a measurement of the total
resistance to the electrical current.10

46

Disability Indexes

Researchers often use a Disability Index as a form of
diagnostic tool to categorize subjects into various groups.
Wikstrom et al used scores on the Foot and Ankle Disability
Index (FADI) to group individuals currently suffering from
chronic ankle instability based on lingering residual
symptoms from individuals who suffered acute injury with no
current instability.11 The Disability Index questionnaire
such as the FADI has proven to be a valid diagnostic tool.
Wikstrom et al found a high correlation between patients’
perceptual disability scores using the FADI and objective
measurements involving radiographic images and the singlelegged hop stabilization test.11 Disability Indexes have
been established as a valid tool in conducting research.
The Lower Limb Functional Index (LLFI) is a type of
Disability Index used to determine the extent of lower limb
deficiencies in activities of daily living based solely on
patient reporting.

Gabel et al assessed the limitations of

the LLFI in comparison to the Lower Extremity Functional
Scale (LEFS) because of its established validity.12

47
The validity of the two scales was assessed on floor
and ceiling effects, missing responses and criterion
validity. The LLFI findings presented no floor or ceiling
effects based on visual examination, missing responses left
no questionnaires invalid in comparison to 10% of the LEFS
questionnaires and construct validity between disability
indexes was high.

Furthermore, Gabel et al found that the

LLFI questionnaire was completed and scored more quickly
and slightly more readable.

The increased efficiency of

the LLFI in comparison to the LEFS made the decision to use
this Disability Index a logical choice.12

Triceps Surae Strength Testing

It is often assumed that larger muscle size is
positively correlated to increased muscular strength. As
previously discussed, researchers attempted to increase
accuracy of lean calf tissue calculations by subtracting
skin-fold measurements from circumferential measurements.4
Once a crude measurement of lean tissue mass is obtained
one can compare these values with measurements of muscular
strength to determine an objective relationship based on
quantitative data.

48
The researchers cannot assume that subjects with
increased lean calf mass are definitively stronger than
subjects with smaller measurements.

Ross et al

investigated the test-retest reliability of the Standing
Heel-Rise Test through a repeated-measures analysis of
variance.

Subjects performed end range of motion plantar

flexion of the ankle joint, also standardized for
individual range of motion, to the rhythm of a metronome
until standards were no longer met to continue on.

In

order to account for additional support through forward
leaning during the test, subjects held a hand dynamometer
against the wall on the opposite side of the leg being
tested.

Pressure from forward leaning was standardized

between subjects allowing no greater than 2% of the
individual’s body weight.

All subjects underwent two

testing sessions separated by seven days in order to
compare the maximal standing heel-rise repetitions
performed.13
ANOVA analysis showed high test-retest reliability,
indicating that the Standing Heel-Rise Test can be used as
a sufficient measure of calf muscular endurance.13 Both the
gastrocnemius and soleus muscles are stressed by this test.
Svantesson et al suggests the potential of The Standing
Heel Rise Test to determine which plantar flexor reaches

49
fatigue first by the type of contraction performed within
the test.

The activation of the gastrocnemius and soleus

can be isolated during the concentric and eccentric
components of plantar flexion. The Standing Heel Rise Test
may aid in identifying which plantar flexor requires
additional muscular strengthening exercises to improve
athletic performance.14 The Standing Heel Rise Test has the
capability to quantify isolated calf muscular endurance as
well as differentiate between plantar flexors reaching
their prospective failure point.13,

14

Summary

The literature review provides evidence of a
relationship between lean calf girth and anterior shin pain
that deserves further investigation.

The high prevalence

of anterior shin pain among the athletic population
warrants research into any possible contributing factor.
The strengths and weaknesses of previously conducted
research will guide this particular study.

The literature

review will aid in the development of a concise procedure
that identifies any relationship between lean calf girth
and anterior shin pain.

This particular study will control

for potential variables in order to focus solely on the

50
implications of lean calf girth on anterior shin pain.

The

findings of this particular study will contribute to
further research into this relationship or narrow down the
possible risk factors associated with anterior shin pain.
The results of this study may require changes in training
techniques to reduce or increase the lean tissue
composition of the lower leg.

51

APPENDIX B
The Problem

52
STATEMENT OF THE PROBLEM

The purpose of the study was to examine the
relationship between lean calf girth, calf strength and
anterior shin pain.

It is important to examine this

relationship because anterior shin pain affects a large
percentage of athletes and inhibits their ability to
perform at their best.

If we know excessive or reduced

amounts of lean calf girth can lead to the development of
anterior shin pain we can modify training techniques to
counteract its development.

Definition of Terms
The following definitions of terms are defined for
this study:
1)

Anterior Shin Pain
Pain on the distal medial 1/3 of the anterior tibia.

2)

Lean Calf Girth
The average calf girth (mm) minus the average calf
skin-fold (mm).

3)

Lower Leg Functional Index
The tool used in this study to determine the presence
and severity of anterior shin pain among subjects.

53
4)

Single Leg Heel Rise Test
The tool used in this study to assess lower leg
muscular endurance by performing as many single leg
calf raises to the beat of a metronome until reaching
fatigue, becoming out of synch with the metronome,
flexing of the knee joint or excessive forward lean.

5)

Dominant Leg
The leg the subject would use to kick a soccer ball.

6)

Muscular Endurance
Performing high repetitions at a sub-maximal effort.

Basic Assumptions
The following are basic assumptions of this study:
1)

The subjects were honest when they completed their
Lower Limb Functional Indexes.

2)

The subjects performed to the best of their ability
during the Single Leg Heel Rise Test.

3)

Subjects did not eat or drink within the hour and
voided their bladder thirty minutes prior to
calculating their BMI.

4)

Researchers were consistent and trained properly in
performing calf girth measurements, skin fold
measurements and Single Leg Heel Rise testing.

54

Limitations of the Study
The following are possible limitations of the study:
1)

An unequal number of males and females to complete all
phases of testing.

2)

Human error related to taking skin-fold measurements.

3)

The inability to extrapolate results found in this
study of Division II athletes at California University
of PA to all athletes.

4)

Inability to control the training level of the
subjects at the time of testing.

Delimitations of the Study
1)

California University of Pennsylvania NCAA Division II
athletes that completed at least one season of their
prospective sport were included in the study.

2)

Subjects did not suffer lower extremity injury six
months prior to the time this study was conducted.

3)

Calf girth measurements were standardized for subjects
using BMI analysis.

4)

Subjects included in this study participate in
athletics that require lower extremity impact forces.

5)

Subjects confirmed maintaining hydration guidelines
prior to BIA.

55

Significance of the Study
The findings of this study did not reveal a
relationship between lean calf girth, muscular endurance
scores and Lower Limb Functional Index scores.

None of the

hypotheses proved to be statistically significant.
However, subjects with a history of anterior shin pain did
reveal a lower mean lean calf girth than subjects without a
history of anterior shin pain.

This finding suggests

further research be conducted to determine the relationship
between lean calf girth and anterior shin pain.

Further

study can be performed to determine if an appropriate ratio
of lean muscle mass exists between the plantar flexors for
optimal efficiency.

The athlete will benefit the most from

greater understanding of risk factors to anterior shin
pain.

56

APPENDIX C
Additional Methods

57

APPENDIX C1
Informed Consent Form

58

The Relationship Between Lower Leg Lean Tissue,
Functional Index Scores and Triceps Surae Endurance in
Athletes

Page1

Informed Consent Form
1. Caitlin Kamide, who is a Graduate Athletic Training Student at California University
of Pennsylvania, has requested my participation in a research study at California
University of Pennsylvania. The title of the research is The Relationship Between Lower
Leg Lean Tissue, Lower Leg Functional Index Scores and Triceps Surae Endurance in
Athletes.
2. I have been informed that the purpose of this study is to determine any relationship
between the variables: lean calf tissue mass, Lower Limb Functional Index Scores and
Triceps Surae endurance scores. I understand that I must be 18 years of age or older to
participate. I understand that I have been asked to participate along with other varsity
athletes participating on the football, volleyball, Men’s and Women’s soccer and
basketball teams and track and field at California University of Pennsylvania. I
understand that I must have completed at least seventy-five percent of one competitive
season of my sport at the collegiate level. I understand that to participate in data
collection I can confirm I am not currently suffering from and have had no lower
extremity injury in the 6 months prior to the time of testing. I confirm that I am not
currently pregnant and in the event I do become pregnant I will immediately notify the
Primary Researcher. I understand that the Principal Investigator will terminate my
participation if circumstances such as unexpected pregnancy arise due to the potential
risk to the unborn child.
3. I have been invited to participate in this research project. My participation is voluntary
and I can choose to discontinue my participation at any time without penalty or loss of
benefits. My participation will involve calf girth measurements, calf skin fold
measurements, height and weight measurements, providing demographic information
pertinent to Body Mass Index calculation such as age and gender, Bioelectrical
Impedance Analysis using a hand-held dynamometer, the Standing Heel Rise Test for
Triceps Surae endurance calculation and completion of the Lower Limb Functional
Index. First, the subjects will complete their individual Lower Limb Functional Index.
Once subjects are deemed eligible for participation all anthropometric measurements will
be taken during one meeting. On the final day of testing, subjects will complete the

59

The Relationship Between Lower Leg Lean Tissue,
Functional Index Scores and Triceps Surae Endurance in
Athletes

Page2

Standing Heel Rise Test. All testing materials will be completed over the course of three
days.
4. I understand there are foreseeable risks or discomforts to me if I agree to participate in
the study. I understand that there is risk of soft tissue damage, muscle soreness, muscle
cramping, loss of balance, falling and the possibility of experiencing fatigue during
testing. With participation in a research program such as this there is always the potential
for unforeseeable risks, such as a subject experiencing exaggerated fatigue due to
sickness at the time of testing. I understand that the Lower Limb Functional Index
requires that I am honest to my best knowledge in its completion. I understand that
demographic information will be required to calculate Body Mass Index using the handheld Bioelectrical Impedance Analyzer. I understand that calf skinfold measurements
and calf girth measurements will be required as part of the data collection and temporary
tissue alteration is a possible risk. I understand the Principal Investigator will inform me
of any significant new findings developed during the research that may affect me and
influence my willingness to continue participation.
5. I understand that, in case of injury, I can expect to receive treatment or care in Hamer
Hall’s Athletic Training Facility. This treatment will be provided by the researcher,
Caitlin Kamide, under the supervision of the CalU athletic training faculty, all of whom
can administer emergency care.1 Additional services needed for prolonged care will be
referred to the attending staff at the Downey Garofola Health Services located on
campus. I understand, in case of prolonged stress, there is on campus counseling services
available in Carter Hall Room G-53.
6. There are no feasible alternative procedures available for this study.
7. I understand that the possible benefits of my participation in the research is the better
understanding of etiological factors contributing to chronic or acute bouts of anterior shin
pain and that my participation may aid in the alteration of training techniques to reduce
the likelihood of its future development in athletes.
8. I understand that the results of the research study may be published but my name or
identity will not be revealed. Only aggregate data will be reported. In order to maintain
confidentially of my records, Caitlin Kamide will maintain all documents in a secure
location on campus and password protect all electronic files so that only the student
researcher and research advisor can access the data. Each subject will be given a specific
subject number to represent his or her name so as to protect the anonymity of each
subject.

60

The Relationship Between Lower Leg Lean Tissue,
Functional Index Scores and Triceps Surae Endurance in
Athletes

Page3

9. I have been informed that I will not be compensated for my participation nor will there
be any costs incurred on my behalf.
10. I have been informed that any questions I have concerning the research study or my
participation in it, before or after my consent, will be answered by:
Caitlin Kamide, LAT, ATC
STUDENT/PRIMARY RESEARCHER
KAM5655@calu.edu
203-592-6353
Dr. Edwin Zuchelkowski
RESEARCH ADVISOR
Zuchelkowski@calu.edu
(724) 938-4202
11. I understand that written responses may be used in quotations for publication but my
identity will remain anonymous.
12. I have read the above information and am electing to participate in this study. The
nature, demands, risks, and benefits of the project have been explained to me. I
knowingly assume the risks involved, and understand that I may withdraw my consent
and discontinue participation at any time without penalty or loss of benefit to myself. I
understand the Principal Researcher may terminate my participation at any time without
warning. In signing this consent form, I am not waiving any legal claims, rights, or
remedies. A copy of this consent form will be given to me upon request.
13. This study has been approved by the California University of Pennsylvania
Institutional Review Board.
14. The IRB approval dates for this project are from: 02/15/13 to 02/14/14.
Subject's signature:___________________________________
Date:____________________
Witness signature:___________________________________
Date:____________________

61

The Relationship Between Lower Leg Lean Tissue,
Functional Index Scores and Triceps Surae Endurance in
Athletes

Page4

Reference:
1. Prentice, WE. Arnheim’s Principles of Athletic Training: A Competency Based
Approach. 13th ed. New York, New York: The McGraw-Hill Companies, Inc; 2009.

62

APPENDIX C2
Institutional Review Board Approval–
California University of Pennsylvania

63
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair

Dear Ms. Kamide:
Please consider this email as official notification that your proposal titled "The
relationship between lower leg lean tissue, functional index scores, and triceps surae
endurance in athletes” (Proposal #12-024) has been approved by the California
University of Pennsylvania Institutional Review Board as amended.
The effective date of the approval is 2-15-2013 and the expiration date is 2-14-2014 .
These dates must appear on the consent form .
Please note that Federal Policy requires that you notify the IRB promptly regarding any
of the following:
(1) Any additions or changes in procedures you might wish for your study (additions or
changes must be approved by the IRB before they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are necessitated by any
events reported in (2).
(4) To continue your research beyond the approval expiration date of 2-14-2014 you
must file additional information to be considered for continuing review. Please contact
instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

64

APPENDIX C3
Preliminary Questionnaire

65

NAME and EMAIL:
DATE:
Please answer the following preliminary questions before completing the Lower
Limb Functional Index.
1. What is your class rank? (i.e. freshman, sophomore etc.)

2. What varsity sport do you participate in?

3. Are you currently in season?

4. Have you suffered any lower extremity injury within the last 6 months?
Identify the affected leg/side.

5. Have you experienced a lower extremity injury more than 6 months ago?
Briefly explain “Yes” answers by indicating type of injury and severity.
Identify the affected leg/side.

6. How many seasons at the collegiate level have you actively participated in (at
least 75% of the season)?

66

APPENDIX C4
LOWER LIMB FUNCTIONAL INDEX

67
LOWER LIMB FUNCTIONAL INDEX
NAME:
DATE:

PLEASE COMPLETE: Your leg/s may have suffered anterior shin pain and made it
difficult to do some things you normally did. This list contains sentences athletes
commonly use to describe themselves when suffering from anterior shin pain.
If an item describes your past injury, mark the line with a letter “Y”. If not, mark the line
with a letter “N”. Please answer each question separately for left (L) and right (R) legs.
If an item partly describes your past injury-Use a letter “M” Mark.
DUE TO MY LEG/S:

L

R

___

___1. Outside of school and athletics I stayed at home most of the time.

___

___2. I changed position frequently for comfort.

___

___3. I avoided heavy jobs involving heavy lifting.

___

___4. I rested more often.

___

___5. I got others to do things for me.

___

___6. I had the pain/problem almost all the time.

___

___7. I had difficulty lifting and carrying. (eg, backpacks, shopping bags)

___

___8. The pain was so distracting that it had affected my appetite.

___

___9. My walking or normal recreation or sporting activity was affected.

___

___10. I had difficulty with normal home or family duties and chores.

___

___11. I slept less well.

___

___12. I had discomfort with personal care (eg, washing, hygiene).

68
L

R

___

___13. My regular daily activities (work, school, college life) were affected.

___

___14. I was more irritable and/or bad tempered.

___

___15. I felt weaker and/or stiffer.

___

___16. My transport independence was affected (driving, public transport).

___

___17. I had discomfort with dressing (eg, trousers/pants/shoes and socks).

___

___18. I had difficulty changing directions, twisting or turning.

___

___19. I was unable to move as fast as I would wish.

___

___20. I had difficulty with prolonged or extended standing.

___

___21. I had difficulty bending, squatting, and/or reaching down.

___

___22. I had difficulty with long or extended walks.

___

___23. I had difficulty with steps and stairs.

___

___24. I had difficulty with sitting for prolonged or extended times.

___

___25. I had problems with my balance on uneven surfaces and/or with
unaccustomed footwear.

69

Appendix C5
Individual Data Collection Sheet

70
Data Collection Sheet
Name: __________________
R Leg

L Leg

Skinfold Measurement
Athlete

Skinfold #1

Skinfold #2

Skinfold #3

Average

Girth #2

Girth #3

Average

Calf Girth Measurement
Athlete

Girth #1

Bioelectrical Impedance Analysis
Athlete

Gender

Age

Height

Weight

BMI

Single Heel Rise Test
Athlete

Degrees
Plantar
Flexion

2% Body
Weight

Height of
Surgical
Tubing

# Heel
Rises

71
REFERENCES
1.

Clement DB, Taunton JE, Smart GW et al. A survey of
overuse running injuries. Phys Sportsmed. 1981;9:4758.

2.

Craig, DI. Medial tibial stress syndrome: current
etiological theories part 1-background. Athl Ther
Today. 2008;13(1):17-20.

3.

Johnell O, Rausing A, Wendeberg B, Westlin N.
Morphological bone changes in shin splints. Clin
Orthop Relat Res. 1982;(167):180-184.

4.

Moen M, Bongers T, Backx F, et al. Risk factors and
prognostic indicators for medial tibial stress
syndrome. Scand J Med Sci Sports. 2012;22(1):34-39.

5.

Burne SG, Khan KM, Boudville PB, et al. Risk factors
associated with exertional tibial pain: a twelve
months prospective clinical study. Br J Sports Med.
2004;38(4);441-5.

6.

Schinkel-Ivy A, Burkhart T, Andrews D. Leg tissue mass
composition affects tibial acceleration response
following impact. J Appl Biomech. 2012;28(1):29-40.

7.

Selkow N, Pietrosimone B, Saliba S. Subcutaneous thigh
fat assessment: a comparison of skinfold calipers and
ultrasound imaging. J Athl Train. 2011;46(1):50-54.

8.

Reed J, Buck S, Gronbech C. Questioning body mass
index. Illinois Journal For Health, Physical
Education, Recreation & Dance. 2010;65:45-51.

9.

Unick J, Utter A, Schumm S, McInnis T. Evaluation of
leg-to-leg BIA in assessing body composition in highschool-aged males and females. Res Sports Med.
2006;14(4):301-313.

10.

Kaminsky, LA. Body Composition: ACSM’s Health-Related
Physical Fitness Assessment Manual. 3rd ed. Baltimore,
MD: Lippincott Williams & Wilkins, a Wolters Kluwer
business; 2010.

11.

Wikstrom E, Tillman M, Chmielewski T, Cauraugh J,
Naugle K, Borsa P. Discriminating between copers and

72
people with chronic ankle instability. J Athl Train.
2012;47(2):136-142.
12.

Gabel C, Melloh M, Burkett B, Michener L. Lower limb
functional index: development and clinimetric
properties. Phys Ther. 2012;92(1):98-110.

13.

Ross M, Fontenot E. Test-retest reliability of the
standing heel-rise test. / Fiabilite du test du talon
leve en position debout, effectue a deux reprises. J
Sport Rehabil. 2000;9(2):117-123.

14.

Svantesson U, Osterberg U, Thomee R, Grimby G. Muscle
fatigue in a standing heel-rise test. Scand J Rehabil
Med. 1998;30:67-72.

73
ABSTRACT
Title:

THE RELATIONSHIP BETWEEN LOWER LEG LEAN
TISSUE, FUNCTIONAL INDEX SCORES AND TRICEPS
SURAE ENDURANCE IN ATHLETES

Researcher:

Caitlin Kamide

Advisor:

Dr. Edwin Zuchelkowski

Date:

May 2013

Research Type: Master’s Thesis
Context:

Minimal research has been conducted to
determine the relationship between lean calf
girth and anterior shin pain. Research has
revealed decreased lean muscle mass as a
possible contributory factor to the lower
leg’s incapacity to adapt to loading forces
and withstand injury.

Objective:

The purpose of this study was to identify
the role, if any, lean calf girth and lower
leg endurance have in the occurrence of
anterior shin pain.

Setting:

The testing was done in Hamer Gymnasium and
Dance Studio on the campus of California
University of Pennsylvania.

Participants:

Fourteen student-athletes from volleyball,
football and men and women’s soccer at
California University of PA volunteered for
this study (10 females, 4 males).

Intervention:

Subjects completed a preliminary
questionnaire, followed by a Lower Limb
Functional Index, height, weight, BIA, calf
girth, calf skinfold and muscular endurance
measurements.

74
Main Outcome Measures:
Three Pearson Product Correlations were
conducted for statistical analysis. The
three variables included subjects’ lean calf
girth, muscular endurance scores and LLFI
scores. Two Independent-Sample t Tests were
conducted to compare muscular endurance
scores and lean calf girth measurements
between subjects that identified and did not
identify a history of anterior shin pain.
Results:

The Pearson Product Correlation comparing
subjects’ average muscular endurance score,
average LLFI score and average lean calf
girth found no significance among the three
variables. The Pearson Product Correlations
comparing muscular endurance score, LLFI
score and lean calf girth in the dominant
leg and non-dominant leg found no
significance among the three variables. An
independent-samples t test comparing the
mean scores of the subjects with and without
a history of anterior shin pain found a
significant difference between the means of
the two groups comparing lean calf girth
(t(16.716) = 3.972, p = .001). An
independent-samples t test comparing the
mean scores of the subjects with and without
a history of anterior shin pain illustrated
no significant difference between the means
of the two groups comparing mean muscular
endurance scores (t(20.582)= .939, p > .05).

Conclusion:

This study revealed subjects with a history
of anterior shin pain have a significantly
lower mean lean calf girth then subjects
without a history of anterior shin pain.
However, comparing average lean calf girth,
average LLFI score and average muscular
endurance score among subjects there is no
statistical significance between the three
variables. There was no significance found
between LLFI score, muscular endurance score
and lean calf girth among subjects when
looking at the dominant or non-dominant leg.

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