Response of Knee Joint Biomechanics to Landing Under Internal and External Focus of Attention in Female Volleyball Players.

The aim of this study was to examine the effect of attentional focus instructions on the biomechanical variables associated with the risk of anterior cruciate ligament injury of the knee joint during a drop landing task using a time series analysis. Ten female volleyball players (age: 20.4 ± 0.8 years, height: 169.7 ± 7.1 cm, mass: 57.6 ± 3.1 kg, experience: 6.3 ± 0.8 years) performed landings from a 50 cm height under three different attentional focus conditions: (1) external focus (focus on landing as soft as possible), (2) internal focus (focus on bending your knees when you land), and (3) control (no-focus instruction). Statistical parameter mapping in the sagittal plane during the crucial first 30% of landing time showed a significant effect of attentional focus instructions. Despite the similarity in landing performance across foci instructions, adopting an external focus instruction promoted reduced vertical ground reaction force and lower sagittal flexion moment during the first 30% of execution time compared to internal focus, suggesting reduced knee loading. Therefore, adopting an external focus of attention was suggested to reduce most biomechanical risk variables in the sagittal plane associated with anterior cruciate ligament injuries, compared to internal focus and control condition. No significant differences were found in the frontal and horizontal planes between the conditions during this crucial interval.

External focus of attention enhances arm velocities during volleyball spike in young female players.

The aim of this study was to investigate the effect of different volleyball-specific attentional focus instructions on arm velocities of a volleyball spike in young female volleyball players using the Statistical Parametric Mapping method. Twelve young female volleyball players (13.6 ± 0.6 years old, 1.8 ± 0.8 years of experience in volleyball training) were asked to perform a volleyball spike in a standing position in three different attentional focus conditions including internal focus (IF, i.e., pull back your elbow prior to transfer momentum), external focus, (EF, i.e., imagine cracking a whip to transfer momentum), and control (CON, i.e., no-focus instruction). A Qualisys 3D motion capture-system was used to track reflective markers attached to the arm, forearm, and hand. Consequently, four phases of the volleyball spike including wind-up, cocking, acceleration, and follow-through were analyzed. A one-way repeated-measure ANOVA using one-dimensional statistical parametric mapping (SPM1d) showed that players achieved greater velocities in the hand (p < 0.01), forearm (p < 0.01), and arm (p < 0.01) using the EF instructions from the start of the wind-up phase to the acceleration phase. Post-hoc (SPM1d-t-tests-paired) analyses indicated significantly greater arm, forearm, and hand velocities during the EF condition, compared to CON (p < 0.01, p < 0.01, and p < 0.01 respectively) and IF (p < 0.01, p < 0.01, and p < 0.01 respectively) conditions. These findings suggest that EF instructions had an immediate impact on increasing volleyball spike velocity from the start of the wind-up phase to the acceleration phase prior to ball contact.

Running and Physical Activity in an Air-Polluted Environment: The Biomechanical and Musculoskeletal Protocol for a Prospective Cohort Study 4HAIE (Healthy Aging in Industrial Environment-Program 4).

Far too little attention has been paid to health effects of air pollution and physical (in)activity on musculoskeletal health. The purpose of the Healthy aging in industrial environment study (4HAIE) is to investigate the potential impact of physical activity in highly polluted air on musculoskeletal health. A total of 1500 active runners and inactive controls aged 18-65 will be recruited. The sample will be recruited using quota sampling based on location (the most air-polluted region in EU and a control region), age, sex, and activity status. Participants will complete online questionnaires and undergo a two-day baseline laboratory assessment, including biomechanical, physiological, psychological testing, and magnetic resonance imaging. Throughout one-year, physical activity data will be collected through Fitbit monitors, along with data regarding the incidence of injuries, air pollution, psychological factors, and behavior collected through a custom developed mobile application. Herein, we introduce a biomechanical and musculoskeletal protocol to investigate musculoskeletal and neuro-mechanical health in this 4HAIE cohort, including a design for controlling for physiological and psychological injury factors. In the current ongoing project, we hypothesize that there will be interactions of environmental, biomechanical, physiological, and psychosocial variables and that these interactions will cause musculoskeletal diseases/protection.

The effect of long-term volleyball training on the level of somatic parameters of female volleyball players in various age categories.

Volleyball is an exceedingly popular physical activity in the adolescent population, especially with females. The study objective was to assess the effect of volleyball training and natural ontogenetic development on the somatic parameters of adolescent girls. The study was implemented in a group of 130 female volleyball players (aged 12.3 ± 0.5 - 18.1 ± 0.6 years) along with 283 females from the general population (aged 12.3 ± 0.5 - 18.2 ± 0.5 years). The measured parameters included: body height (cm), body mass (kg), body fat (kg, %), visceral fat (cm2), body water (l), fat free mass (kg) and skeletal muscle mass (kg, %). Starting at the age of 13, the volleyball players had significantly lower body fat ratio and visceral fat values than those in the general population (p < 0.001 in body fat % and p < 0.01 in visceral fat). In volleyball players, the mean body fat (%) values were 17.7 ± 6.6 in 12-year-old players, 16.7 ± 4.9 in 13-year-old players, 18.5 ± 3.9 in 16-year-old players, and 19.3 ± 3.1 in 18-year-old players. In the general population, the mean body fat (%) values were 19.6 ± 6.3 in 12-year-old girls, 21.7 ± 6.4 in 13-year-old girls, 23.4 ± 6.1 in 16-year-old girls, and 25.8 ± 7.0 in 18-year-old girls. The visceral fat (cm2) mean values were 36.4 ± 19.3 in 12-year-old players, 39.2 ± 16.3 in 13-year-old players, 45.7 ± 14.7 in 16-year-old players, and 47.2 ± 12.4 in 18-year-old players. In the general population, the mean visceral fat (cm2) values were 41.4 ± 21.1 in 12-year-old girls, 48.4 ± 21.5 in 13-year-old girls, 58.0 ± 24.7 in 16-year-old girls, and 69.1 ± 43.7 in 18-year-old girls. In volleyball players, lower body fat ratio corresponded with a higher skeletal muscle mass ratio. The differences found in skeletal muscle mass ratio were also significant starting at the age of 13 (p < 0.001). The mean skeletal muscle mass (%) values were 44.1 ± 3.4 in 12-year-old volleyball players, 45.4 ± 2.5 in 13-year-old players, 45.0 ± 2.2 in 16-year-old players, and 44.7 ± 1.8 in 18-year-old players. In the general population, the mean skeletal muscle mass (%) values were 42.8 ± 3.2 in 12-year-old girls, 42. ± 4.1 in 13-year-old girls, 41.9 ± 3.3 in 16-year-old girls, and 40.6 ± 3.7 in 18-year-old girls. Differences in body composition between the individual age groups were similar between the volleyball players and girls in the general population. The results indicate that regular volleyball training influences the body composition of young females however the development of body composition parameters is subject to their ontogenetic development.

Children's Single-Leg Landing Movement Capability Analysis According to the Type of Sport Practiced.

(1) Background: Understanding children's motor patterns in landing is important not only for sport performance but also to prevent lower limb injury. The purpose of this study was to analyze children's lower limb joint angles and impact force during single-leg landings (SLL) in different types of jumping sports using statistical parametric mapping (SPM). (2) Methods: Thirty children (53.33% girls, M = 10.16 years-old, standard deviation (SD) = 1.52) divided into three groups (gymnastics, volleyball and control) participated in the study. The participants were asked to do SLLs with the dominant lower limb (barefoot) on a force plate from a height of 25 cm. The vertical ground reaction force (GRF) and lower limb joint angles were assessed. SPM{F} one-way analysis of variance (ANOVA) and SPM{t} unpaired t-tests were performed during the landing and stability phases. (3) Results: A significant main effect was found in the landing phase of jumping sport practice in GRF and joint angles. During the stability phase, this effect was exhibited in ankle and knee joint angles. (4) Conclusions: Evidence was obtained of the influence of practicing a specific sport in childhood. Child volleyball players performed SLL with lower impact force and higher knee flexion than child gymnasts. Training in specific jumping sports (i.e., volleyball and gymnastics) could affect the individual capacity to adapt SLL execution.

Associated ACL risk factors differences during an unanticipated volleyball blocking movement.

The lateral tilt of the arms accompanied by trunk lateral tilt is a typical blocking manoeuvre in volleyball. However, during this unanticipated blocking movement, an associated risk of ACL injury may result. The aim of the present study was to compare associative ACL risk factors at the initial contact and the first and second peak of VGRF during an unanticipated blocking movement with different arm positions. Synchronized kinematic and kinetic data were collected for each trial of each condition. Student paired t-tests and effect size were used to determine differences between two conditions (S - with arms straight up from the body) and (T - with the arms and trunk laterally tilted). The results showed that the T condition significantly decreases knee flexion, increases VGRF at the foot contact, first peak force and increases the valgus moment at the first peak force. The values of the associated risk factors for a non-contact ACL injury appear to be related to the tilted arm position accompanied by trunk tilt towards to right lower limb during landing. The players should be taught to land with greater knee flexion and, if possible, a double-leg landing to decrease right lower limb loading during the blocking manoeuvre.

Blocking landing techniques in volleyball and the possible association with anterior cruciate ligament injury.

The number and type of landings performed after blocking during volleyball matches has been related to the potential risk of ACL injury. The aim of the present study was to determine whether gender affects the frequency of specific blocking landing techniques with potential risk of ACL injury from the perspective of foot contact and subsequent movement after the block used by volleyball players during competitive matches. Three matches involving four female volleyball teams (fourteen sets) and three matches involving four male volleyball teams (thirteen sets) in the Czech Republic were analyzed for this study. A Pearson chi-square test of independence was used to detect the relationship between gender and different blocking techniques. The results of the present study showed that gender affected single-leg landings with subsequent movement in lateral direction and double-leg landings. Although the total number of landings was lower for male athletes than for female athletes, a larger portion of male athletes demonstrated single leg landings with a subsequent movement than female athletes. Single leg landings with a subsequent movement have a higher potential risk of ACL injury.

Do athletes alter their running mechanics after an Achilles tendon rupture?

BACKGROUND: Over the past thirty years, there has been dramatic increase in incidence of Achilles tendon rupture in the athletic population. The purpose of this study was to compare the lower extremity mechanics of Achilles tendon ruptured runners with healthy controls. METHODS: The participants with a past history of an Achilles tendon repair (n = 11) and healthy control (n = 11) subgroups were matched on sex, age, type of regular physical activity, mass, height, footfall pattern and lateral dominancy. Running kinetics and kinematics of the ankle, knee and hip were recorded using a high-speed motion capture system interfaced with a force platform. Achilles tendon length was measured using ultrasonography. Main outcome measures were lower extremity joint angles and moments during stance phase of running and Achilles tendon lengths. RESULTS: Athletes from Achilles tendon group had an affected gastro-soleus complex. Athletes with history of Achilles tendon rupture had reduced ankle range of motion during second half of the stance phase of running (Δ7.6°), an overextended knee during initial contact (Δ5.2°) and increased affected knee range of motion (Δ4.4°) during the first half of stance phase on their affected limb compared to the healthy control group. There was a 22% increase in the maximal hip joint moment on contralateral side of the Achilles tendon group compared to the healthy controls. CONCLUSION: These results suggest a compensation mechanism, relatively extended knee at initial ground contact against the deficit in the muscle-tendon complex of the triceps surae. Overextension during sporting activities may place the knee at risk for further injury. Avoidance of AT lengthening and plantarflexion strength deficit after surgery and during rehabilitation might help to manage AT rupture since these factors may be responsible for altered running kinematics.

Technique Selection 'the Coaches Challenge' Influencing Injury Risk During the First Contact Hand of the Round off Skill in Female Gymnastics.

The importance of technique selection on elbow injury risk has been identified for the key round off skill in female gymnastics, with a focus on the second contact limb. The aim of this study was to shift the focus to the first contact limb and investigate the biomechanical injury risk during parallel and T-shape round-off (RO) techniques. Seven international-level female gymnasts performed 10 trials of the RO to back-handspring with parallel and T-shape hand positions. Synchronized kinematic (3D motion analysis system; 247 Hz) and kinetic (two force plates; 1235 Hz) data were collected for each trial. The t-test with effect size statistics determined differences between the two techniques. No significant differences were found for vertical, anterior posterior and resultant ground reaction force, elbow joint kinematics and kinetics. Specifically, the results highlighted that change in technique in RO skills did not influence first contact limb elbow joint mechanics and therefore, injury risk. The findings of the present study suggest the injury potential of this skill is focused on the second limb during the parallel technique of this fundamental gymnastic skill.

Footfall patterns of a runner with an Achilles tendon rupture.

PURPOSE: This study aims to compare the load and the length of previously ruptured and healthy Achilles tendon (AT) of a recreational runner who used different footfall patterns on each limb during running. METHODS: A 41-year-old recreational athlete with a ruptured AT participated in this report. Two force plates and a high-speed motion capture system were used to collect ground reaction force and kinematic data in shod and barefoot running conditions. AT length was measured using ultrasonography and an infrared camera system. AT force was estimated as the active plantar flexion moment divided by AT moment arm during stance phase. RESULTS: The participant used a rearfoot pattern on the affected limb and a forefoot/midfoot pattern on the unaffected limb during shod running, and a forefoot/midfoot pattern during barefoot running. There was no difference between the length of the affected and the unaffected AT. During shod running, the maximal AT force and loading rate were lower in the affected AT versus the unaffected AT. During barefoot running, the affected maximal AT force and loading rate were greater than the unaffected AT. CONCLUSION: Footfall patterns can be an adaptation to reduce the loading on a previously injured AT. It appears that runners may consider using a rearfoot footfall pattern during running to reduce the stress on the AT.

The influence of hand positions on biomechanical injury risk factors at the wrist joint during the round-off skills in female gymnastics.

The aim of this study was to examine the biomechanical injury risk factors at the wrist, including joint kinetics, kinematics and stiffness in the first and second contact limb for parallel and T-shape round-off (RO) techniques. Seven international-level female gymnasts performed 10 trials of the RO to back handspring with parallel and T-shape hand positions. Synchronised kinematic (3D motion analysis system; 247 Hz) and kinetic (two force plates; 1235 Hz) data were collected for each trial. A two-way repeated measure analysis of variance (ANOVA) assessed differences in the kinematic and kinetic parameters between the techniques for each contact limb. The main findings highlighted that in both the RO techniques, the second contact limb wrist joint is exposed to higher mechanical loads than the first contact limb demonstrated by increased axial compression force and loading rate. In the parallel technique, the second contact limb wrist joint is exposed to higher axial compression load. Differences between wrist joint kinetics highlight that the T-shape technique may potentially lead to reducing these bio-physical loads and consequently protect the second contact limb wrist joint from overload and biological failure. Highlighting the biomechanical risk factors facilitates the process of technique selection making more objective and safe.

Identification of types of landings after blocking in volleyball associated with risk of ACL injury.

Landing with a low knee flexion angle after volleyball block jumps may be associated with an increased risk of anterior cruciate ligament (ACL) injury. The aim of the present study was to identify the types of volleyball landings after blocks where the knee flexion angle is found to be under a critical knee flexion angle value of 30° at the instant of the first peak of the ground reaction force (GRF). Synchronized kinematic and kinetic data were collected for each trial. T-tests were used to determine if each knee flexion angle at the instant of the peak GRF was significantly different from the critical value of 30°. A repeated measures ANOVA was used to compare knee flexion angle, time to first peak and the magnitude of the first peak of the resultant GRF and knee stiffness. Significantly lower knee flexion angles were found in the "go" landing (p = .01, ES = 0.6) and the "reverse" landing (p = .02, ES = 0.6) only. The results for knee flexion angle and GRF parameters indicated a significant difference between a "reverse" and "go" and other types of landings, except the "side stick" landing for GRF. The "reverse" and "go" landings may present a risk for ACL injury due to the single-leg landing of these activities that have an associated mediolateral movement.

Effect of an Arm Swing on Countermovement Vertical Jump Performance in Elite Volleyball Players: FINAL.

The aim of this study was to determine how elite volleyball players employed the arm swing (AS) to enhance their jump performance. The study assessed how the AS influenced the duration and magnitude of the vertical ground reaction force (VGRF) during the main phases (preparatory, braking and accelerating) of the countermovement vertical jump (CMVJ), the starting position of the body at the beginning of the accelerating phase and the moment when the AS began contributing to increasing the jump height. Eighteen elite volleyball players performed three CMVJs with and without an AS. Kinetics and kinematics data were collected using two Kistler force plates and the C-motion system. The time and force variables were evaluated based on the VGRF, and the position of the body and the trajectory of the arm movement were determined using kinematic analysis. The AS improved the CMVJ by increasing the jump height by 38% relative to jumping without an AS. The AS significantly shortened the braking phase and prolonged the accelerating phase, however, it did not influence the preparatory phase or the overall jump duration. The AS also significantly increased the average force during the accelerating phase as well as the accelerating impulse. The AS upward began at 76% into the overall jump duration. The AS did not influence the body position at the beginning of the accelerating phase. These findings can be used to improve performance of the CMVJ with the AS and in teaching beginning volleyball players proper jumping technique.

Lower extremity mechanics during landing after a volleyball block as a risk factor for anterior cruciate ligament injury.

OBJECTIVES: To compare lower extremity mechanics and energy absorption during two types of landing after a successful or unsuccessful block in volleyball and assess the risks of anterior cruciate ligament (ACL) injury. DESIGN: Cohort study. SUBJECTS: Fourteen elite male volleyball players (aged 24.5 ± 4.6 years; height 1.94 ± 0.06 m; mass 86.6 ± 7.6 kg). INTERVENTIONS: Subjects were required to land on force platforms using stick landing or step-back landing (with the right lower extremity stepping back away from the net) techniques after performing a standing block jump movement. MAIN OUTCOME MEASURES: Vertical ground reaction force (body weight); knee flexion (degrees); knee moments (Nm/kg); and hip, knee and ankle energy absorption (J/kg). RESULTS: The right lower extremity showed a greater first peak of vertical ground reaction force, a greater valgus moment, lower energy absorption by the knee, and higher energy absorption by the hip and ankle joints during step-back landing. CONCLUSIONS: The lower extremity may be exposed to a greater risk of ACL injury when stepping back from the net during the initial impact phase after a step-back landing.

Musculoskeletal loading during the round-off in female gymnastics: the effect of hand position.

Chronic elbow injuries from tumbling in female gymnastics present a serious problem for performers. This research examined how the biomechanical characteristics of impact loading and elbow kinematics and kinetics change as a function of technique selection. Seven international-level female gymnasts performed 10 trials of the round-off from a hurdle step to flic-flac with 'parallel' and 'T-shape' hand positions. Synchronized kinematic (3D-automated motion analysis system; 247 Hz) and kinetic (two force plates; 1,235 Hz) data were collected for each trial. Wilcoxon non-parametric test and effect-size statistics determined differences between the hand positions examined in this study. Significant differences (p < 0.05) and large effect sizes (ES > 0.8) were observed for peak vertical ground reaction force (GRF), anterior-posterior GRF, resultant GRF, loading rates of these forces and elbow joint angles, and internal moments of force in sagittal, transverse, and frontal planes. In conclusion, the T-shape hand position reduces vertical, anterior-posterior, and resultant contact forces and has a decreased loading rate indicating a safer technique for the round-off. Significant differences observed in joint elbow moments highlighted that the T-shape position may prevent overloading of the joint complex and consequently reduce the potential for elbow injury.

Ground Reaction Force and Valgus Knee Loading during Landing after a Block in Female Volleyball Players.

A non-contact anterior cruciate ligament (ACL) injury is both a serious and very common problem in volleyball. The aim of the study was to determine the association between stick, step-back, and run-back landings after a block and select risk factors of ACL injuries for female professional volleyball players. The research sample involved fourteen female professional volleyball players. Two force plates were used to determine ground reaction forces. Eight infrared cameras were employed to collect the kinematic data. The one-factor repeated-measures analysis of variance, where the landing type was the factor, was used for comparing the valgus moment and ground reaction force on the right lower limb. ANOVA showed that the type of landing has a main effect on the valgus moment on the right lower limb (F) = 5.96, p = 0.019df = 1.18, partial η(2) = 0.239 and SP = 0.693). Furthermore, it did not show a main effect on the vertical reaction force on the right lower limb ((F)=2.77, p=0.090, df=1.55, partial η(2)= 0.128 and SP=0.448). The highest valgus moment occurred during the run-back landing. This moment, however, did not have any effect within the first 100 ms after initial contact with the ground, but rather upon the subsequent motion carried out when stepping back off the net. A comparison between a run-back landing and a step-back landing showed relevant higher values of vertical ground reaction forces during the run-back landing.

Lower extremity power during the squat jump with various barbell loads.

The purpose of this study was twofold: (1) to determine the barbell load that maximised the system power as well as the ankle, knee, and hip joint powers during the squat jump, and (2) to compare the system powers computed from two different methods: the centre of mass (COM) method and the barbell method. Seven male throwers were recruited in this study. The system power (COM method) and the ankle, knee, and hip joint powers were determined with the load incrementally set at 0%, 10%, 30%, 50%, 70%, and 90% of one repetition maximum. The largest system power was observed at the load of 30% (p < 0.008) while the largest ankle and knee powers were observed at 70% and 0% (p < 0.05). The barbell method overestimated the system power (p < 0.001) when compared to the COM method. It was concluded that the barbell method could influence load optimisation in squat jump. The optimal barbell load which maximised the system power did not maximise the ankle, knee, or hip power simultaneously.

Temporal-spatial parameters of gait in transfemoral amputees: Comparison of bionic and mechanically passive knee joints.

BACKGROUND: A symmetrical gait affords the most efficient walking pattern. Bionic prostheses should provide better gait symmetry than mechanically passive prostheses with respect to a nonpathological gait. OBJECTIVES: To compare the basic temporal-spatial parameters of gait in transfemoral amputees fitted with bionic or mechanically passive prosthetic knees with those of subjects with a nonpathological gait. STUDY DESIGN: Three-dimensional gait analysis using an optoelectronic device. METHODS: Eight transfemoral amputees participated in the study. Subjects walked across two dynamometric platforms a total of 15 times. Movement kinematics were measured using optoelectronic stereophotogrammetry. RESULTS: The swing time of the affected limb in patients fitted with a mechanically passive knee joint was longer than that of the nonaffected limb by 0.055 s (effect size = 1.57). Compared with the control group, the swing time of the prosthetic limb in patients fitted with a mechanically passive knee was longer by 0.042 s (effect size = 2.1). Similarly, the stance time of the nonaffected limb was longer by 0.047 s (effect size = 1.07). CONCLUSIONS: Compared with a mechanically passive knee joint, a bionic knee joint evinced gait symmetry. Both the stance time and the swing time for amputees with a bionic knee were similar to those of nonamputees. CLINICAL RELEVANCE: Prosthetists aim to design prostheses that achieve a good symmetry between the healthy and affected limbs. The use of bionic technology achieves a level of symmetry approaching that observed in nonamputees.

The influence of an additional load on time and force changes in the ground reaction force during the countermovement vertical jump.

The aim of this study was to determine how an additional load influences the force-vs-time relationship of the countermovement vertical jump (CMVJ). The participants that took part in the experiment were 18 male university students who played sport recreationally, including regular games of volleyball. They were asked to perform a CMVJ without involving the arms under four conditions: without and with additional loads of 10%, 20%, and 30% of their body weight (BW). The vertical component of the ground reaction force (GRF) was measured by a force plate. The GRF was used to calculate the durations of the preparatory, braking, and acceleration phases, the total duration of the jump, force impulses during the braking and acceleration phases, average forces during the braking and acceleration phases, and the maximum force of impact at landing. Results were evaluated using repeated-measures ANOVA. Increasing the additional load prolonged both the braking and acceleration phases of the jump, with statistically significant changes in the duration of the acceleration phase found for an additional load of 20% BW. The magnitude of the force systematically and significantly increased with the additional load. The force impulse during the acceleration phase did not differ significantly between jumps performed with loads of 20% and 30% BW. The results suggest that the optimal additional load for developing explosive strength in vertical jumping ranges from 20% to 30% of BW, with this value varying between individual subjects.

Running biomechanics in a long-term monitored recreational athlete with a history of Achilles tendon rupture.

This study represented a unique opportunity to understand changes in the human motion biomechanics during basic locomotion within a time interval of 4 years, when the monitored individual regained his original aerobic fitness, running performance and body mass index as prior to the injury. The participant visited the laboratory a month prior to the injury and during 4 years after the surgery. The surgery, subsequent rehabilitation and a 4-year running training programme in the studied recreational athlete did not completely eliminate the consequences of the Achilles tendon rupture. The function muscle deficit is namely manifested by a lower net plantar flexion moment and a lower net-generated ankle joint power during the take-off in the stance phase. The greater dorsal flexion in the affected ankle joint at the first contact with the ground and consequently higher peaks of ground reaction forces during running are consequences of the longer Achilles tendon in the affected lower extremity and weakened calf muscles.