The effect of pelvic stabilization training on dynamic knee valgus, activity and muscles strength around the pelvis

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In addition, non-contact ACL tears during sport activity are often caused by muscles weakness around the pelvis. Therefore, reinforcing the pelvic stabilizing muscles may counterbalance dynamic knee valgus (DKV). The aim of this research is to increase the activity of the pelvic stabilizing muscles through a specific exercise program and to investigate its effect of DKV after six-week pelvic stabilization training. Methods 22 subjects (male/female: 16/6) participated in the study. Before and after the training, DKV was determined on both sides using a Kinect camera, muscles activity and strength was measured by EMG system and wireless dynamometer. Results DKV decreased from 3.15–1.03% for the left knee and from 3.89–1.26% for the right knee. The magnitude of change was significant (p < 0.001). Conclusions Strengthening the pelvic stabilization muscles induced a substantial improvement in knee valgus, and thus reduced the risk of developing cruciate ligament injuries. This study provides a direct link between an easy diagnosed predisposing factor a common sports injury, and offers a simple countermeasure in the form of specific exercises, that may be included against ACL injuries. pelvic stabilization training dynamic knee valgus kinect muscles Figures Figure 1 1. Background Pelvic instability is often associated with lower limb joint angular deviations and particularly causes valgus shift of the knee under load. Dynamic knee valgus is an abnormal position of the lower-extremity, when knees tilt inward during physical activity. The mentioned phenomenon is often observed as musculoskeletal disorder in different sports and daily life. As the knee stabilizer muscles originate from the pelvis, there is a considerable interaction between the knee joint, the pelvis and the hip joint [ 1 ]. In addition, non-contact anterior cruciate ligament (ACL) ruptures during sports activities are often caused by pelvic muscle weakness and dynamic valgus position. ACL injuries are widespread in the world. In the United States each year 1 out of 3500 people suffer from ACL injury. Studies showed that the most common reasons for dynamic knee valgus are the lack of appropriate gluteus strength, [ 2 , 4 ] weak quadriceps [ 5 ] or weak hamstring muscles [ 6 ]. Several studies showed that weakness of m. gluteus medius and m. gluteus maximus can lead to an increased dynamic knee valgus position [ 7 , 8 ]. Excessive knee valgus is a predisposing factor for osteoarthritis (OA), patellofemoral pain syndrome and ACL rupture [ 9 , 10 , 11 ] and may also lead to sport injuries. Several studies show that ski, ball games and martial arts are the most dangerous types of sports regarding knee injuries [ 10 , 12 ]. Around 70% of all ACL injuries are coming from sports participation, especially skiing, football, soccer, baseball and basketball [ 13 ]. ACL rupture alone is also known as predisposing factor for knee osteoarthritis [ 14 ]. It is worth to note that, ACL-injured athletes develop knee osteoarthritis symptoms earlier than those without ACL injuries [ 15 ]. Moreover, there is a strong relationship between the lower extremity valgus during dynamic activities and lower extremity injuries such as patellofemoral pain syndrome or anterior cruciate ligament injury [ 16 ]. In 2018 Dix et al. found a relationship between hip muscle strength and dynamic lower extremity valgus [ 16 ]. Therefore, reinforcing the physiological function of the pelvic stabilizing muscles may counterbalance dynamic knee valgus. Functional stabilization training, which include hip muscle strengthening, lower limb and trunk movement control exercises, modified the knee kinematics in the frontal plane during single leg squat by recreational female athletes with patello-femoral pain syndrome (PFPS). Another study [ 17 ] showed significantly reduced knee valgus angle during step tasks by athletes with PFPS after an eight-week hip and quadriceps exercise program. Most studies [ 5 ] reported that exercise intervention program can have a significant positive effect on improving dynamic knee valgus. Several other studies show that preventive training programs can decrease the incidence of non-contact lower limb, knee, ACL or ankle injuries. At the same time there is a need to determine exactly the essential elements of a successful training program [ 18 ]. There are several methods to evaluate the dynamic knee valgus in an office setting. Our study used the Kinect Azure 3D camera, which can detect joints and capture motion without markers. This study aimed to increase the activity of the pelvic stabilizing muscles through a specific exercise program and to investigate its effect on dynamic knee valgus under load. 2. Methods Participants Twenty-two (male/female: 15/7; Age = 34.3 ± 8.9 yrs.) healthy and physically active participants were involved in the study. Subjects were selected whose relative knee valgus exceeded more, than 2 units. The overall well-being of the subjects was evaluated by the standard SF-36 score [ 19 ], the level of sports activity was assessed by the Tegner score [ 20 ] and subjective knee function by the Lysholm score [ 21 ]. Anthropometric data and the baseline characteristics are summarized in Table 1 . Table 1 Participant’s anthropometric characteristics. Anthropometric parameters value mean ± SD Age (yrs) 34.3 ± 8.9 Sex (male/female) 15/ 7 Height (cm) 177.2 ± 7.3 Weight (kg) 75.4 ± 9.9 BMI (kg×m − 2 ) 24.0 ± 2.5 dominant leg (left/right) 6 / 16 All subjects provided written informed consent. The experimental procedures were approved by the ethics committee (Ethical license number: TE-KEB/22/2021). Procedures measurements Microsoft Kinect Azure camera system Kinematic parameters were assessed with a Microsoft Azure Kinect camera system (Microsoft Corp. Redmond, WA USA). Kinect Azure contains an RGB (red, green and blue) camera and a three dimensional infrared depth sensor, thus it is able to measure the full body kinematics. Kinect Azure estimates 3 coordinates of every major joint of the human body in 3 planes without any marker. Kinect is a useful tool for lower limb examinations, as cost-effective, quick, easy and user-friendly. During the examination, the camera was setup 250 cm away from the subjects and 100 cm height from the ground, thus provided ideal circumstances to capture a full-body image. The valgus data were collected with the help of a custom software (Dynaknee, OrthoSera Kft, Budapest, Hungary) for Windows 10 operation system that allowed data management, recording and analysis. Electromyography (EMG) Gluteus maximus, medius and vastus medialis muscle EMG signals were acquired with a NeuroTrac Simplex 1 channel EMG device. The acquisition protocol comprised 5 cycles of a 5 s maximal isometric contraction and a subsequent 5 s relaxation phases. The cycle-averaged EMG amplitudes recorded according to the manufacturer’s guidelines in mV. Maximum isometric muscle force measurements Maximum isometric force of the gluteus maximus, gluteus medius and the biceps femoris muscles were registered with a Hoggan MicroFET 3 wireless dynamometer. Participants applied pressure for 5 s against the sensor of the dynamometer. On alternating sides, the procedure was repeated 3 times/side and the average force on each side is reported in N. Force measurements were carried out with the help of two physiotherapists, who assisted fixing the participant’s pelvis in the optimal position isolating the examined muscle during the procedure. Dynamic knee valgus assessment Participants performed ten single-leg squats on each side. Subject movement was recorded and analysed with a Kinect Azure camera and the Dynaknee software 22. Knee valgus quantification was performed at 15% of the maximum squat depth expressed in % of lower limb length. Inclusion criteria of the study was a minimum 2% knee horizontal shift, again expressed as % of lower limb length. Intervention Participants performed a six-week pelvic stabilization training to strengthen the m. gluteus maximus, medius and m. vastus medialis obliquus, as well as to harmonize quadriceps to hamstring ratio. The training program consisted of three different phases. In each phase four training sessions were held with progressive exercises. First phase : the goal was to reach local segmental control by activating the transverse abdominal and multifidus muscles on one hand and to maintain physiologic lumbar lordosis on the other. Gluteus maximus and medius activation was achieved without increasing lumbar extension and synergic muscle involvement. Vastus medialis activation was achieved by strengthening the quadriceps femoris muscle. Second phase : Progression was maintained by increasing the repetition number, the complexity of the tasks, changing the tempo and involving unstable surfaces. Third phase : difficulty of the tasks was further increased. Statistical methods Distribution of all measured parameters deviated from normal according Shapiro-Wilk tests. Therefore, the planned paired comparisons were performed with non-parametric Wilcoxon signed rank tests. For statistical evaluations outlier values were included in the calculations. Statistical significance was considered when p < 0.05. Data analysis was performed with R (version 4.1.2). 3. Results While Tegner scores did not change from the pre- and posttest evaluations indicating general activity levels, Lysholm scores describe knee pain complaints improved after the training session. Moreover, overall well-being SF-36 survey scores also improved by the second evaluation. Questionnaires scores are summarized in Table 2. Table 2 . Participant’s status before and after the training protocol. Knee status is qualified by the Lysholm score, level of physical activity by Tegner score. General well-being was assessed by the SF-36 battery. Numbers displayed as mean ± standard deviation. Wilcoxon signed rank test. NS – non significant. Questionnaires Pre test Post test Difference p Lysholm 89.7 ± 10.4 94.7 ± 10.6 5.1 0.014 Tegner 4.4 ± 1.6 4.3 ± 1.9 0.1 NS SF-36 survey physical functioning 95.0 ± 8.4 97.0 ± 4.9 -2 NS role limitations due to physical health 90.2 ± 26.9 98.9 ± 5.2 -8.7 NS role limitations due to emotional problem 79.7 ± 35.9 89.9 ± 27.4 -10.1 NS energy / fatigue 64.3 ± 19.0 75.9 ± 18.9 -11.5 0.003 emotional well-being 76.9 ± 13.6 84.2 ± 14.2 -7.3 0.046 social functioning 81.0 ± 19.9 88.6 ± 19.6 -7.6 NS Pain 76.5 ± 20.1 92.3 ± 12.0 -15.8 0.002 general health 81.7 ± 14.7 87.4 ± 13.7 -5.7 0.003 Measurement results are displayed as median and IQR. As a result of training program, the EMG amplitudes were increased considerably on both sides. We observed the least change (38 mV) in case of the right gluteus maximus, while the right vastus medialis EMG increased the most (98 mV). EMG results are summarized in Table 3. Table 3 Change of EMG amplitudes (measured in mV) throughout our test protocol. D and ND stand for dominant and non-dominant side. Muscle side Pre test Post test difference p median IQR median IQR Gluteus maximus D 121 149.5 165 198.5 44 < 0.001 ND 119 131.0 195 145.5 76 < 0.001 gluteus medius D 170 168.0 236 183.0 66 < 0.001 ND 172 132.0 234 187.0 62 < 0.001 vastus medialis D 218 140.0 316 173.5 98 < 0.001 ND 216 136.5 271 161.5 55 < 0.001 Pre- and post-training contractile force of the gluteus maximus, gluteus medius and biceps femoris muscles displayed in Table 4. As anticipated, the training program increased muscle force in all muscles. Table 4 Change of muscle strength (measured in N) throughout our test protocol. D and ND stand for dominant and non-dominant side. Muscle side Pre test Post test difference p median IQR median IQR gluteus maximus D 228 86.0 269 100.0 41 < 0.05 ND 235 82.5 271 97.0 36 < 0.05 gluteus medius D 112 29.0 142 29.5 30 < 0.001 ND 113 34.5 152 34.5 39 < 0.001 biceps femoris D 127 57.5 165 44.5 38 < 0.001 ND 129 51.5 145 48.0 16 < 0.001 The extent of the relative dynamic knee valgus during single-leg squat tests reduced significantly after the 6 week-long training program.The participant’s left knee relative latero-medial movement reduced by 2.12%, while this reduction was 2.63% in the right knee. The dynamic knee valgus data is shown in the Figure. 4. Discussion The aim of this study was to evaluate the influence of an in-house developed pelvic stabilization training program on dynamic knee valgus. Rationale of this program is based on previous results which pointed out the importance of the interdependency between pelvic muscle force – knee valgus deviation – activity-mediated lower limb injury axis [ 7 , 8 , 16 ]. Evaluation strategy contained both subjective and objective measurement techniques. Our results indicated that there was no change of physical activity before and after the training protocol as reflected from the acquired Tegner scores. Several studies have examined the impact of pelvic and core training on sport activity levels, as measured by the Tegner Activity Scale (TAS), particularly in active individuals and those undergoing rehabilitation. Notably, core stabilization exercises following anterior cruciate ligament (ACL) reconstruction have been shown to significantly improve Tegner scores compared to standard rehabilitation protocols [ 22 ].However, in healthy athletic populations, core training appears to have limited effect on increasing activity levels. A meta-analysis by Prieske et al. (2023) [ 23 ] concluded that although core strength programs significantly improve balance and trunk endurance, they do not meaningfully enhance sport-specific performance metrics that would translate into higher Tegner ratings. This findings suggest that while pelvic and core interventions are beneficial in rehabilitation settings, their ability to elevate activity levels in already active individuals is limited unless combined with sport-specific training stimuli [ 23 ]. Regarding subjective evaluation of knee status an improvement was recorded by 5.1 points according to pre- and posttest Lysholm questionnaires. Status of the general well-being also increased based on the SF-36 battery results. Jung et al. (2022) [ 24 ] revealed that incorporating core strengthening into post-injury rehabilitation programs resulted in significant enhancements in knee function, a decrease in pain, and improved joint stability—all of which were reflected in elevated Lysholm scores. Although it is less frequently examined in isolation, training of the hip and core in patients suffering from patellofemoral pain syndrome has also been linked to functional advancements in the aspects measured by the Lysholm scale [ 25 ]. Electromyographic evaluation of the trained muscle groups increased without exception. Higher EMG amplitudes indicate the recruitment of larger number of motoric units during muscle contractions. This finding is reflected in the increased observed isometric muscle force after training compared to the pretest values. As expected our pelvic stabilization training protocol increased core pelvic muscle performance evaluated by both EMG and isometric force measurements. Bilateral stabilization of the pelvis – hip – knee axis resulted significantly attenuated dynamic, horizontal knee displacement throughout the entire squat course. Previous studies have shown that exercises like pelvic tilts, bridges, and side-lying hip abductions enhance gluteal muscle activation as assessed by surface EMG, which suggests improved neuromuscular recruitment [ 26 , 27 ]. Furthermore, training protocols that focus on the pelvis have been associated with increased maximal voluntary isometric contraction (MVIC) strength of the gluteus medius, thereby contributing to enhanced hip and pelvic control during dynamic movements [ 28 ]. The improvement in gluteal strength and activation resulting from pelvic training has been correlated with better lower extremity alignment, a reduction in knee valgus during various activities, and a lower risk of injury [ 29 ]. Consequently, pelvic training represents a significant intervention for optimizing gluteal muscle function and improving overall lower limb mechanics. However, despite the widespread endorsement of pelvic training for the enhancement of gluteal muscle EMG activity and strength, certain studies [ 27 , 30 ] raise concerns regarding the consistency and functional significance of these alterations and they underscore the necessity of incorporating pelvic training into comprehensive, sport-specific programs to facilitate its application to functional performance. Dynamic knee valgus is determined at 15% of single leg squat depth (relative to lower limb length) on the way down. Based on our earlier findings knee valgus tendencies are already evident at this level and well tolerable even for pre/postoperative patients with knee problems [ 31 ]. Pelvic and core training enhance dynamic knee valgus by improving the strength of hip abductors and external rotators, as well as neuromuscular control, which are essential for stabilizing the pelvis and regulating femoral movement, specific pelvic exercises are effective in restoring appropriate hip and pelvic mechanics, which in turn reduces knee valgus angles and may lower the risk of injury [ 32 , 33 ]. Improvements in neuromuscular timing and proprioception further enhance knee joint alignment during movement [ 34 ]. There is systematic evidence that supports the efficacy of hip and core strengthening interventions in reducing dynamic knee valgus in both healthy individuals and clinical populations [ 35 ]. Due to the reduction of dynamic knee valgus and especially knee valgus at 15% squat depth, we can lower the probability to develop further lower extremity injuries, such as acute, non-contact ACL ruptures during dynamic activities and/or osteoarthritic processes on the long run and a development of patello-femoral pain syndrome. Dynamic knee valgus is a complex functional problem therefore it is clinically important to identify the main causes and the solutions of this compensatory movement and to adapt these findings individually. As limitations, this study did not include ankle measurements, which could be a limitation of the study, as it is known that ankle deficits could also cause changes in dynamic knee valgus. In future investigations we could focus also in ankle corrections, however this study was focusing on pelvic stabilization. 5. Conclusions Based on our results pelvic stabilization training has good benefits on dynamic knee valgus, strength, and muscle activity around the pelvis. Thus, pelvis stabilization training is highly recommended for ACL injured athletes to prevent possible re-traumatization. Abbreviations ACL: Anterior cruciate ligament DKV: Dynamic knee valgus MVIC: Maximal voluntary isometric contraction PFPS: Patello-femoral pain syndrome TAS: Tegner Activity Scale Declarations ● Ethics approval and consent to participate All adult participants completed an informed consent form prior to data collection and voluntarily enrolled in the research study. For instances where participants were under the age of 18, informed assent was obtained together with informed consent from their parents or legal guardians. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the Health Research Ethics Committee of the Hungarian university of sports science (ethics number: TE-KEB/22/2021). ● Consent for publication Not applicable. ● Availability of data and materials The datasets used during the current study are available from the corresponding author on reasonable request. ● Competing Interests The authors declare no competing interests. ● Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. ● Authors' contributions Conceived and designed the experiments, M.A, W.G, M.H and L.Z; performed the experiments and in-tervention, M.A, W.G, D.M; analyzed the data, T.H, M.H; wrote the original paper W.G.; wrote and checked the revised paper, M.A, B.S; supervision: M.A, M.H and Z.L. 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Cite Share Download PDF Status: Published Journal Publication published 29 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 13 Oct, 2025 Reviews received at journal 12 Oct, 2025 Reviews received at journal 11 Oct, 2025 Reviewers agreed at journal 03 Oct, 2025 Reviews received at journal 26 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviewers invited by journal 17 Sep, 2025 Editor assigned by journal 17 Sep, 2025 Editor invited by journal 26 Aug, 2025 Submission checks completed at journal 26 Aug, 2025 First submitted to journal 26 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7240993","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":519922516,"identity":"0e738842-5835-4ba9-97a9-9151edb4f289","order_by":0,"name":"Mira Ambrus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYFACHgjFxsDA+IDBhiGBJC3MBgfSSNEC0iVBlBb+aWePfeb5wxDNJ334WfWHBIY8gwMEtEjczkuezdvGkNvGl2Z240ACQzFBLQy3c4yZeRuAWngYzG4c/MGQuIGQFnmQFqDDgFrYvxUAbSGsxQCshQ2khceMgSgthkC/MM5tkwBpKZY4kyCROJOQFrnbuYcZ3vyxyZ3fw77xQ0WCTWIfIS1QIIHBGAWjYBSMglFACQAATYc+Pu/trpkAAAAASUVORK5CYII=","orcid":"","institution":"Hungarian University of Sports Science","correspondingAuthor":true,"prefix":"","firstName":"Mira","middleName":"","lastName":"Ambrus","suffix":""},{"id":519922517,"identity":"4386c0ca-f24b-43c9-8446-febcd7e4ad9d","order_by":1,"name":"Wolf Gabriella","email":"","orcid":"","institution":"Semmelweis University","correspondingAuthor":false,"prefix":"","firstName":"Wolf","middleName":"","lastName":"Gabriella","suffix":""},{"id":519922518,"identity":"29687dc6-c55d-45fd-b8a8-8c254f687b75","order_by":2,"name":"Dóra Molnár","email":"","orcid":"","institution":"Hungarian University of Sports Science","correspondingAuthor":false,"prefix":"","firstName":"Dóra","middleName":"","lastName":"Molnár","suffix":""},{"id":519922519,"identity":"1ed65ddf-98a3-4906-8484-2f2f1fca749c","order_by":3,"name":"Badis Soussi","email":"","orcid":"","institution":"Hungarian University of Sports Science","correspondingAuthor":false,"prefix":"","firstName":"Badis","middleName":"","lastName":"Soussi","suffix":""},{"id":519922520,"identity":"3ce47b57-22fe-4b98-bc48-a51bb091d879","order_by":4,"name":"Tamás Horváth","email":"","orcid":"","institution":"Hungarian University of Sports Science","correspondingAuthor":false,"prefix":"","firstName":"Tamás","middleName":"","lastName":"Horváth","suffix":""},{"id":519922521,"identity":"20ae29b0-7b66-4195-9f23-be0729faf610","order_by":5,"name":"Mónika Horváth","email":"","orcid":"","institution":"Semmelweis University","correspondingAuthor":false,"prefix":"","firstName":"Mónika","middleName":"","lastName":"Horváth","suffix":""},{"id":519922522,"identity":"7ed99789-62bc-4c28-9679-43a201d6f886","order_by":6,"name":"Zsombor Lacza","email":"","orcid":"","institution":"Hungarian University of Sports Science","correspondingAuthor":false,"prefix":"","firstName":"Zsombor","middleName":"","lastName":"Lacza","suffix":""}],"badges":[],"createdAt":"2025-07-29 08:38:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7240993/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7240993/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-026-09556-9","type":"published","date":"2026-01-29T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92277046,"identity":"3d12a11f-a4c9-474c-9343-eb704371ffe5","added_by":"auto","created_at":"2025-09-26 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15:34:03","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111833,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7240993/v1/18bbc6011b34332103dcaa1d.html"},{"id":92276976,"identity":"e158e83b-8970-44d4-a870-f516473ef093","added_by":"auto","created_at":"2025-09-26 15:33:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28431,"visible":true,"origin":"","legend":"\u003cp\u003eDynamic knee valgus during single-leg squat test before (white boxes)\u003c/p\u003e\n\u003cp\u003eand after (grey boxes) our training protocol at 15% of squat depth. D stands for\u003c/p\u003e\n\u003cp\u003edominant, ND for the non-dominant side. Whiskers extend 1.5 x IQR. Dots\u003c/p\u003e\n\u003cp\u003erepresent outlier values.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7240993/v1/6db8d5e21193a624bd7573fa.png"},{"id":101690443,"identity":"3b6d77a4-0b80-4ad6-873f-409b037eb96f","added_by":"auto","created_at":"2026-02-02 16:03:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":723818,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7240993/v1/16b06bf2-45ea-4c5b-a5b5-a59d7bdae1ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of pelvic stabilization training on dynamic knee valgus, activity and muscles strength around the pelvis","fulltext":[{"header":"1. Background","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePelvic instability is often associated with lower limb joint angular deviations and particularly causes valgus shift of the knee under load. Dynamic knee valgus is an abnormal position of the lower-extremity, when knees tilt inward during physical activity. The mentioned phenomenon is often observed as musculoskeletal disorder in different sports and daily life. As the knee stabilizer muscles originate from the pelvis, there is a considerable interaction between the knee joint, the pelvis and the hip joint [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, non-contact anterior cruciate ligament (ACL) ruptures during sports activities are often caused by pelvic muscle weakness and dynamic valgus position. ACL injuries are widespread in the world. In the United States each year 1 out of 3500 people suffer from ACL injury. Studies showed that the most common reasons for dynamic knee valgus are the lack of appropriate gluteus strength, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] weak quadriceps [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] or weak hamstring muscles [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Several studies showed that weakness of m. gluteus medius and m. gluteus maximus can lead to an increased dynamic knee valgus position [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Excessive knee valgus is a predisposing factor for osteoarthritis (OA), patellofemoral pain syndrome and ACL rupture [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and may also lead to sport injuries. Several studies show that ski, ball games and martial arts are the most dangerous types of sports regarding knee injuries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Around 70% of all ACL injuries are coming from sports participation, especially skiing, football, soccer, baseball and basketball [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. ACL rupture alone is also known as predisposing factor for knee osteoarthritis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It is worth to note that, ACL-injured athletes develop knee osteoarthritis symptoms earlier than those without ACL injuries [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, there is a strong relationship between the lower extremity valgus during dynamic activities and lower extremity injuries such as patellofemoral pain syndrome or anterior cruciate ligament injury [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In 2018 Dix et al. found a relationship between hip muscle strength and dynamic lower extremity valgus [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, reinforcing the physiological function of the pelvic stabilizing muscles may counterbalance dynamic knee valgus. Functional stabilization training, which include hip muscle strengthening, lower limb and trunk movement control exercises, modified the knee kinematics in the frontal plane during single leg squat by recreational female athletes with patello-femoral pain syndrome (PFPS). Another study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] showed significantly reduced knee valgus angle during step tasks by athletes with PFPS after an eight-week hip and quadriceps exercise program. Most studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] reported that exercise intervention program can have a significant positive effect on improving dynamic knee valgus. Several other studies show that preventive training programs can decrease the incidence of non-contact lower limb, knee, ACL or ankle injuries. At the same time there is a need to determine exactly the essential elements of a successful training program [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. There are several methods to evaluate the dynamic knee valgus in an office setting. Our study used the Kinect Azure 3D camera, which can detect joints and capture motion without markers.\u003c/p\u003e\u003cp\u003eThis study aimed to increase the activity of the pelvic stabilizing muscles through a specific exercise program and to investigate its effect on dynamic knee valgus under load.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-two (male/female: 15/7; Age\u0026thinsp;=\u0026thinsp;34.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 yrs.) healthy and physically active participants were involved in the study. Subjects were selected whose relative knee valgus exceeded more, than 2 units. The overall well-being of the subjects was evaluated by the standard SF-36 score [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e], the level of sports activity was assessed by the Tegner score [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] and subjective knee function by the Lysholm score [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Anthropometric data and the baseline characteristics are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant\u0026rsquo;s anthropometric characteristics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnthropometric parameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003evalue\u003c/p\u003e\n \u003cp\u003emean \u0026plusmn; SD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.3 \u0026plusmn; 8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15/ 7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177.2 \u0026plusmn; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.4 \u0026plusmn; 9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg\u0026times;m\u003csup\u003e\u0026minus;\u0026thinsp;2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edominant leg (left/right)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 / 16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAll subjects provided written informed consent. The experimental procedures were approved by the ethics committee (Ethical license number: TE-KEB/22/2021).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003emeasurements\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMicrosoft Kinect Azure camera system\u003c/p\u003e\n \u003cp\u003eKinematic parameters were assessed with a Microsoft Azure Kinect camera system (Microsoft Corp. Redmond, WA USA). Kinect Azure contains an RGB (red, green and blue) camera and a three dimensional infrared depth sensor, thus it is able to measure the full body kinematics. Kinect Azure estimates 3 coordinates of every major joint of the human body in 3 planes without any marker. Kinect is a useful tool for lower limb examinations, as cost-effective, quick, easy and user-friendly. During the examination, the camera was setup 250 cm away from the subjects and 100 cm height from the ground, thus provided ideal circumstances to capture a full-body image. The valgus data were collected with the help of a custom software (Dynaknee, OrthoSera Kft, Budapest, Hungary) for Windows 10 operation system that allowed data management, recording and analysis.\u003c/p\u003e\n \u003cp\u003eElectromyography (EMG)\u003c/p\u003e\n \u003cp\u003eGluteus maximus, medius and vastus medialis muscle EMG signals were acquired with a NeuroTrac Simplex 1 channel EMG device. The acquisition protocol comprised 5 cycles of a 5 s maximal isometric contraction and a subsequent 5 s relaxation phases. The cycle-averaged EMG amplitudes recorded according to the manufacturer\u0026rsquo;s guidelines in mV.\u003c/p\u003e\n \u003cp\u003eMaximum isometric muscle force measurements\u003c/p\u003e\n \u003cp\u003eMaximum isometric force of the gluteus maximus, gluteus medius and the biceps femoris muscles were registered with a Hoggan MicroFET 3 wireless dynamometer. Participants applied pressure for 5 s against the sensor of the dynamometer. On alternating sides, the procedure was repeated 3 times/side and the average force on each side is reported in N. Force measurements were carried out with the help of two physiotherapists, who assisted fixing the participant\u0026rsquo;s pelvis in the optimal position isolating the examined muscle during the procedure.\u003c/p\u003e\n \u003cp\u003eDynamic knee valgus assessment\u003c/p\u003e\n \u003cp\u003eParticipants performed ten single-leg squats on each side. Subject movement was recorded and analysed with a Kinect Azure camera and the Dynaknee software 22. Knee valgus quantification was performed at 15% of the maximum squat depth expressed in % of lower limb length. Inclusion criteria of the study was a minimum 2% knee horizontal shift, again expressed as % of lower limb length.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eParticipants performed a six-week pelvic stabilization training to strengthen the m. gluteus maximus, medius and m. vastus medialis obliquus, as well as to harmonize quadriceps to hamstring ratio. The training program consisted of three different phases. In each phase four training sessions were held with progressive exercises. \u003cstrong\u003eFirst phase\u003c/strong\u003e: the goal was to reach local segmental control by activating the transverse abdominal and multifidus muscles on one hand and to maintain physiologic lumbar lordosis on the other. Gluteus maximus and medius activation was achieved without increasing lumbar extension and synergic muscle involvement. Vastus medialis activation was achieved by strengthening the quadriceps femoris muscle. \u003cstrong\u003eSecond phase\u003c/strong\u003e: Progression was maintained by increasing the repetition number, the complexity of the tasks, changing the tempo and involving unstable surfaces. \u003cstrong\u003eThird phase\u003c/strong\u003e: difficulty of the tasks was further increased.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDistribution of all measured parameters deviated from normal according Shapiro-Wilk tests. Therefore, the planned paired comparisons were performed with non-parametric Wilcoxon signed rank tests. For statistical evaluations outlier values were included in the calculations. Statistical significance was considered when p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Data analysis was performed with R (version 4.1.2).\u003c/p\u003e\n\u003c/div\u003e\n"},{"header":"3. Results","content":"\u003cdiv\u003e\n \u003cp\u003eWhile Tegner scores did not change from the pre- and posttest evaluations indicating general activity levels, Lysholm scores describe knee pain complaints improved after the training session. Moreover, overall well-being SF-36 survey scores also improved by the second evaluation. Questionnaires scores are summarized in Table 2.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Participant\u0026rsquo;s status before and after the training protocol. Knee status is qualified by\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ethe Lysholm score, level of physical activity by Tegner score. General well-being was assessed\u003c/p\u003e\n \u003cp\u003eby the SF-36 battery. Numbers displayed as mean \u0026plusmn; standard deviation. Wilcoxon signed rank test.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNS \u0026ndash; non significant.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuestionnaires\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDifference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLysholm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89.7 \u0026plusmn; 10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94.7 \u0026plusmn; 10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTegner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSF-36 survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ephysical functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95.0 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e97.0 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erole limitations due to physical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e90.2 \u0026plusmn; 26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98.9 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erole limitations due to emotional problem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e79.7 \u0026plusmn; 35.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89.9 \u0026plusmn; 27.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eenergy / fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.3 \u0026plusmn; 19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75.9 \u0026plusmn; 18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eemotional well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e76.9 \u0026plusmn; 13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e84.2 \u0026plusmn; 14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esocial functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.0 \u0026plusmn; 19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88.6 \u0026plusmn; 19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e76.5 \u0026plusmn; 20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92.3 \u0026plusmn; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.7 \u0026plusmn; 14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e87.4 \u0026plusmn; 13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eMeasurement results are displayed as median and IQR. As a result of training program, the EMG amplitudes were increased considerably on both sides. We observed the least change (38 mV) in case of the right gluteus maximus, while the right vastus medialis EMG increased the most (98 mV). EMG results are summarized in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eChange of EMG amplitudes (measured in mV) throughout our test protocol. D and ND stand for dominant and non-dominant side.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePre test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePost test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003edifference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGluteus maximus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e198.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003egluteus medius\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e132.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e187.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003evastus medialis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e140.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e173.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e136.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003cp\u003ePre- and post-training contractile force of the gluteus maximus, gluteus medius and biceps femoris muscles displayed in Table 4. As anticipated, the training program increased muscle force in all muscles.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eChange of muscle strength (measured in N) throughout our test protocol. D and ND stand for dominant and non-dominant side.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePre test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePost test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003edifference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003egluteus maximus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003egluteus medius\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ebiceps femoris\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003cp\u003eThe extent of the relative dynamic knee valgus during single-leg squat tests reduced significantly after the 6 week-long training program.The participant\u0026rsquo;s left knee relative latero-medial movement reduced by 2.12%, while this reduction was 2.63% in the right knee. The dynamic knee valgus data is shown in the Figure.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe aim of this study was to evaluate the influence of an in-house developed pelvic stabilization training program on dynamic knee valgus. Rationale of this program is based on previous results which pointed out the importance of the interdependency between pelvic muscle force \u0026ndash; knee valgus deviation \u0026ndash; activity-mediated lower limb injury axis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvaluation strategy contained both subjective and objective measurement techniques. Our results indicated that there was no change of physical activity before and after the training protocol as reflected from the acquired Tegner scores. Several studies have examined the impact of pelvic and core training on sport activity levels, as measured by the Tegner Activity Scale (TAS), particularly in active individuals and those undergoing rehabilitation. Notably, core stabilization exercises following anterior cruciate ligament (ACL) reconstruction have been shown to significantly improve Tegner scores compared to standard rehabilitation protocols [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].However, in healthy athletic populations, core training appears to have limited effect on increasing activity levels. A meta-analysis by Prieske et al. (2023) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] concluded that although core strength programs significantly improve balance and trunk endurance, they do not meaningfully enhance sport-specific performance metrics that would translate into higher Tegner ratings. This findings suggest that while pelvic and core interventions are beneficial in rehabilitation settings, their ability to elevate activity levels in already active individuals is limited unless combined with sport-specific training stimuli [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Regarding subjective evaluation of knee status an improvement was recorded by 5.1 points according to pre- and posttest Lysholm questionnaires. Status of the general well-being also increased based on the SF-36 battery results. Jung et al. (2022) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] revealed that incorporating core strengthening into post-injury rehabilitation programs resulted in significant enhancements in knee function, a decrease in pain, and improved joint stability\u0026mdash;all of which were reflected in elevated Lysholm scores. Although it is less frequently examined in isolation, training of the hip and core in patients suffering from patellofemoral pain syndrome has also been linked to functional advancements in the aspects measured by the Lysholm scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eElectromyographic evaluation of the trained muscle groups increased without exception. Higher EMG amplitudes indicate the recruitment of larger number of motoric units during muscle contractions. This finding is reflected in the increased observed isometric muscle force after training compared to the pretest values. As expected our pelvic stabilization training protocol increased core pelvic muscle performance evaluated by both EMG and isometric force measurements. Bilateral stabilization of the pelvis \u0026ndash; hip \u0026ndash; knee axis resulted significantly attenuated dynamic, horizontal knee displacement throughout the entire squat course. Previous studies have shown that exercises like pelvic tilts, bridges, and side-lying hip abductions enhance gluteal muscle activation as assessed by surface EMG, which suggests improved neuromuscular recruitment [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, training protocols that focus on the pelvis have been associated with increased maximal voluntary isometric contraction (MVIC) strength of the gluteus medius, thereby contributing to enhanced hip and pelvic control during dynamic movements [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The improvement in gluteal strength and activation resulting from pelvic training has been correlated with better lower extremity alignment, a reduction in knee valgus during various activities, and a lower risk of injury [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Consequently, pelvic training represents a significant intervention for optimizing gluteal muscle function and improving overall lower limb mechanics. However, despite the widespread endorsement of pelvic training for the enhancement of gluteal muscle EMG activity and strength, certain studies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] raise concerns regarding the consistency and functional significance of these alterations and they underscore the necessity of incorporating pelvic training into comprehensive, sport-specific programs to facilitate its application to functional performance.\u003c/p\u003e\u003cp\u003eDynamic knee valgus is determined at 15% of single leg squat depth (relative to lower limb length) on the way down. Based on our earlier findings knee valgus tendencies are already evident at this level and well tolerable even for pre/postoperative patients with knee problems [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Pelvic and core training enhance dynamic knee valgus by improving the strength of hip abductors and external rotators, as well as neuromuscular control, which are essential for stabilizing the pelvis and regulating femoral movement, specific pelvic exercises are effective in restoring appropriate hip and pelvic mechanics, which in turn reduces knee valgus angles and may lower the risk of injury [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Improvements in neuromuscular timing and proprioception further enhance knee joint alignment during movement [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. There is systematic evidence that supports the efficacy of hip and core strengthening interventions in reducing dynamic knee valgus in both healthy individuals and clinical populations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDue to the reduction of dynamic knee valgus and especially knee valgus at 15% squat depth, we can lower the probability to develop further lower extremity injuries, such as acute, non-contact ACL ruptures during dynamic activities and/or osteoarthritic processes on the long run and a development of patello-femoral pain syndrome. Dynamic knee valgus is a complex functional problem therefore it is clinically important to identify the main causes and the solutions of this compensatory movement and to adapt these findings individually.\u003c/p\u003e\u003cp\u003eAs limitations, this study did not include ankle measurements, which could be a limitation of the study, as it is known that ankle deficits could also cause changes in dynamic knee valgus. In future investigations we could focus also in ankle corrections, however this study was focusing on pelvic stabilization.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBased on our results pelvic stabilization training has good benefits on dynamic knee valgus, strength, and muscle activity around the pelvis. Thus, pelvis stabilization training is highly recommended for ACL injured athletes to prevent possible re-traumatization.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACL: Anterior cruciate ligament\u003c/p\u003e\n\u003cp\u003eDKV: Dynamic knee valgus\u003c/p\u003e\n\u003cp\u003eMVIC: Maximal voluntary isometric contraction\u003c/p\u003e\n\u003cp\u003ePFPS: Patello-femoral pain syndrome\u003c/p\u003e\n\u003cp\u003eTAS: Tegner Activity Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e● Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll adult participants completed an informed consent form prior to data collection and voluntarily enrolled in the research study. For instances where participants were under the age of 18, informed assent was obtained together with informed consent from their parents or legal guardians. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the Health Research Ethics Committee of the Hungarian university of sports science (ethics number: TE-KEB/22/2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Competing Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceived and designed the experiments, M.A, W.G, M.H and L.Z; performed the experiments and in-tervention, M.A, W.G, D.M; analyzed the data, T.H, M.H; wrote the original paper W.G.; wrote and checked the revised paper, M.A, B.S; supervision: M.A, M.H and Z.L. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e● Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants for their tireless efforts and contribution towards this study.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFlandry F, Hommel G. Normal anatomy and biomechanics of the knee. \u003cem\u003eSports Med Arthrosc\u003c/em\u003e. 2011;19(2):82-92. doi:10.1097/JSA.0b013e318210c0aa\u003c/li\u003e\n\u003cli\u003eHollman JH, Galardi CM, Lin I-H, Voth BC, Whitmarsh CL. Frontal and transverse plane hip kinematics and gluteus maximus recruitment correlate with frontal plane knee kinematics during single-leg squat tests in women. \u003cem\u003eClin Biomech\u003c/em\u003e. 2014;29(4):468-474. doi:10.1016/j.clinbiomech.2013.12.017\u003c/li\u003e\n\u003cli\u003ePetersen W, Ellermann A, G\u0026ouml;sele-Koppenburg A, et al. 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A retrospective study of mechanisms of anterior cruciate ligament injuries in high school basketball, handball, judo, soccer, and volleyball. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2019;98(26):e16030. doi:10.1097/MD.0000000000016030\u003c/li\u003e\n\u003cli\u003eJeffrey D. Placzek DAB. \u003cem\u003eOrthopaedic Physical Therapy Secrets\u003c/em\u003e. 3rd ed. Elsevier Inc.; 2017.\u003c/li\u003e\n\u003cli\u003eS\u0026ouml;derman T, Wretling M-L, H\u0026auml;nni M, et al. Higher frequency of osteoarthritis in patients with ACL graft rupture than in those with intact ACL grafts 30 years after reconstruction. \u003cem\u003eKnee Surgery, Sport Traumatol Arthrosc\u003c/em\u003e. 2020;28(7):2139-2146. doi:10.1007/s00167-019-05726-6\u003c/li\u003e\n\u003cli\u003eLohmander LS, \u0026Ouml;stenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. \u003cem\u003eArthritis Rheum\u003c/em\u003e. 2004;50(10):3145-3152. doi:10.1002/art.20589\u003c/li\u003e\n\u003cli\u003eDix J, Marsh S, Dingenen B, Malliaras P. The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. \u003cem\u003ePhys Ther Sport Off J Assoc Chart Physiother Sport Med\u003c/em\u003e. 2019;37:197-209. doi:10.1016/j.ptsp.2018.05.015\u003c/li\u003e\n\u003cli\u003eBaldon R de M, Serr\u0026atilde;o FV, Scattone Silva R, Piva SR. Effects of Functional Stabilization Training on Pain, Function, and Lower Extremity Biomechanics in Women With Patellofemoral Pain: A Randomized Clinical Trial. \u003cem\u003eJ Orthop Sport Phys Ther\u003c/em\u003e. 2014;44(4):240-251. doi:10.2519/jospt.2014.4940\u003c/li\u003e\n\u003cli\u003eSahabuddin FNA, Jamaludin NI, Amir NH, Shaharudin S. The effects of hip- and ankle-focused exercise intervention on dynamic knee valgus: a systematic review. van den Bogert A, ed. \u003cem\u003ePeerJ\u003c/em\u003e. 2021;9:e11731. doi:10.7717/peerj.11731\u003c/li\u003e\n\u003cli\u003eLins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. \u003cem\u003eSAGE Open Med\u003c/em\u003e. 2016;4:205031211667172. doi:10.1177/2050312116671725\u003c/li\u003e\n\u003cli\u003eTegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 1985;198:43-49. doi:10.1097/00003086-198509000-00007\u003c/li\u003e\n\u003cli\u003eLysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 1982;10(3):150-154. doi:10.1177/036354658201000306\u003c/li\u003e\n\u003cli\u003eKaur, D., Gupta, R., \u0026amp; Shikha. (2015). Core stabilization exercises after ACL reconstruction surgery provide better outcomes: A randomized controlled trial. International Journal of Physiotherapy, 2(6), 899\u0026ndash;904. https://doi.org/10.15621/ijphy/2015/v2i6/80746\u003c/li\u003e\n\u003cli\u003ePrieske, O., Muehlbauer, T., Borde, R., Gube, M., Bruhn, S., Behm, D. G., \u0026amp; Granacher, U. (2023). Effects of core strength training on sport performance in youth athletes: A meta-analysis. 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Medicine \u0026amp; Science in Sports \u0026amp; Exercise, 39(8), 1227\u0026ndash;1232. https://doi.org/10.1249/mss.0b013e3180601115\u003c/li\u003e\n\u003cli\u003eBullock, G. S., Shultz, S. J., Schmitz, R. J., \u0026amp; Nguyen, A. D. (2017). The effect of hip and core strengthening on gluteus medius activation during walking in healthy adults: A randomized controlled trial. Journal of Orthopaedic \u0026amp; Sports Physical Therapy, 47(5), 321\u0026ndash;328. https://doi.org/10.2519/jospt.2017.7136\u003c/li\u003e\n\u003cli\u003eUhl\u0026aacute;r \u0026Aacute;, Ambrus M, K\u0026eacute;kesi M, et al. Kinect Azure\u0026ndash;Based Accurate Measurement of Dynamic Valgus Position of the Knee\u0026mdash;A Corrigible Predisposing Factor of Osteoarthritis. \u003cem\u003eAppl Sci\u003c/em\u003e. 2021;11(12). doi:10.3390/app11125536\u003c/li\u003e\n\u003cli\u003ePowers, C. M. (2010). The influence of abnormal hip mechanics on knee injury: A biomechanical perspective. Journal of Orthopaedic \u0026amp; Sports Physical Therapy, 40(2), 42\u0026ndash;51. https://doi.org/10.2519/jospt.2010.3337\u003c/li\u003e\n\u003cli\u003eMyer, G. D., Ford, K. R., Brent, J. L., Hewett, T. E. (2013). The relationship of hamstrings and quadriceps strength to anterior cruciate ligament injury risk in female athletes: A systematic review. Journal of Orthopaedic \u0026amp; Sports Physical Therapy, 43(9), 619\u0026ndash;627.\u003c/li\u003e\n\u003cli\u003eZazulak, B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., \u0026amp; Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. The American Journal of Sports Medicine, 35(7), 1123\u0026ndash;1130.\u003c/li\u003e\n\u003cli\u003eSugimoto, D., Myer, G. D., McKeon, J. M., \u0026amp; Hewett, T. E. (2015). Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: A systematic review and meta-analysis. Sports Medicine, 45(6), 787\u0026ndash;799.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pelvic stabilization training, dynamic knee valgus, kinect, muscles","lastPublishedDoi":"10.21203/rs.3.rs-7240993/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7240993/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePelvic instability is often associated with angular deviations of lower limb and often causes valgus shift of the knee joint under load. In addition, non-contact ACL tears during sport activity are often caused by muscles weakness around the pelvis. Therefore, reinforcing the pelvic stabilizing muscles may counterbalance dynamic knee valgus (DKV). The aim of this research is to increase the activity of the pelvic stabilizing muscles through a specific exercise program and to investigate its effect of DKV after six-week pelvic stabilization training.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e22 subjects (male/female: 16/6) participated in the study. Before and after the training, DKV was determined on both sides using a Kinect camera, muscles activity and strength was measured by EMG system and wireless dynamometer.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDKV decreased from 3.15\u0026ndash;1.03% for the left knee and from 3.89\u0026ndash;1.26% for the right knee. The magnitude of change was significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eStrengthening the pelvic stabilization muscles induced a substantial improvement in knee valgus, and thus reduced the risk of developing cruciate ligament injuries. This study provides a direct link between an easy diagnosed predisposing factor a common sports injury, and offers a simple countermeasure in the form of specific exercises, that may be included against ACL injuries.\u003c/p\u003e","manuscriptTitle":"The effect of pelvic stabilization training on dynamic knee valgus, activity and muscles strength around the pelvis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 15:31:29","doi":"10.21203/rs.3.rs-7240993/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T12:44:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T02:09:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T08:22:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6710137517141893496829329633007400561","date":"2025-10-03T13:12:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T06:22:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T07:52:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102956294611810805519067679159802014341","date":"2025-09-20T01:28:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154669185824909953017941728464504839942","date":"2025-09-18T05:24:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30425272155191083363850806442215110719","date":"2025-09-17T18:43:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166891726957364577444984312624889705198","date":"2025-09-17T17:24:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-17T17:19:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-17T05:02:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-26T12:02:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T11:14:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-08-26T11:11:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5940efa-8381-49c2-98bd-a612a14c61a0","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:00:38+00:00","versionOfRecord":{"articleIdentity":"rs-7240993","link":"https://doi.org/10.1186/s12891-026-09556-9","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-01-29 15:58:08","publishedOnDateReadable":"January 29th, 2026"},"versionCreatedAt":"2025-09-26 15:31:29","video":"","vorDoi":"10.1186/s12891-026-09556-9","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09556-9","workflowStages":[]},"version":"v1","identity":"rs-7240993","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7240993","identity":"rs-7240993","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}