JOURNAL of MEDICINE and LIFE

JML | REVIEW

Role of kinetic chain in sports performance and injury risk:

a narrative review
Haifa Saleh Almansoof1, Shibili Nuhmani1* , Qassim Muaidi1

Authors Affiliation
1. Department of Physical Therapy, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam,
Kingdom of Saudi Arabia

* Corresponding Author: DOI

Shibili Nuhmani 10.25122/jml-2023-0087
Department of Physical Therapy, College of Applied Medical Sciences,
Imam Abdulrahman Bin Faisal University, Dammam, Dates
Kingdom of Saudi Arabia Received: 21 March 2023
Email: snuhmani@iau.edu.sa Accepted: 2 May 2023

ABSTRACT
The kinetic chain refers to the body's intricate coordination of various segments to perform a specific activity in-
volving precise positioning, timing, and speed. This process is based on task-oriented and activity-specific pre-pro-
grammed muscle activation patterns enhanced by repeated practice. It demands muscular eccentric strength, joint
flexibility, and musculotendinous elastic energy storage. The body core (lumbopelvic–hip complex) forms the kinetic
chains’ central point of activities in most sports because it facilitates load transfers to and from the limbs. The kinetic
chain relationship with fascia, peripheral nerves, and tensegrity is fundamental to holistic human body movements.
The kinetic chain function demands neuromuscular, sensorimotor, and neurocognitive control. Any blockage or de-
fect in the kinetic chain can develop compensatory patterns, high demands on distal parts, and overuse and overload
injuries. Taking a holistic approach and evaluating the integrity of the kinetic chain in athletes can significantly en-
hance efforts to improve sports performance and mitigate injury risk.

KEYWORDS: eccentric strength, neurocognitive control, muscle activation, injury risk

INTRODUCTION legiate female athletes, lower neurocognitive function has been

associated with a shift toward dominant muscle activity patterns
The interconnected musculoskeletal kinetic chain is a com- in the quadriceps [9]. This alteration in kinetic chain muscle ac-
plex motor unit and the base of human movements [1, 2]. The tivities can increase the risk of anterior cruciate ligament (ACL)
kinetic chain is the sequenced and coordinated activation of injuries [10].
body segments that puts the terminal/distal part at the optimal
timing in the optimal position with the optimal speed to per- Kinetic chain, fascia, and neural tissue
form the required athletic activity [3].
The human body's ability to perform complex tasks relies on The fascia is a fibrous connective tissue that forms an exten-
the intricate coordination of various dynamic systems, the neu- sive web-like network throughout the body, supporting the spine
romuscular and sensorimotor control systems being essential for and facilitating the transfer of loads between the core and limbs
this task [4]. These systems are responsible for processing envi- [11]. This interconnected network of fascial tissues significantly
ronmental input, employing feedforward [5, 6] and feedback influences the biomechanics of the body. Research has shown a
loops [7]. The kinetic chain energy transfer across the body is positive, strong, and significant correlation between the density of
a mechanism that engages the neuromuscular coordination of myofibroblasts and contractile response in these tissues. This sug-
the body’s segments, allowing for sequential movements [8]. gests that myofascial tissue tension is actively regulated by myofi-
The contribution of more body segments in the total force out- broblasts and has the potential to impact the dynamic functioning
put production leads to a higher potential velocity at the distal of the musculoskeletal system. The influence of myofascial tissues
part [8]. Therefore, when the muscle chains are used in ways is high enough to potentially affect motoneuronal coordination.
that disturb the parallel agonist/antagonist co-contraction, the Myofascial chains explain why muscles in the human body do not
highly sensory muscle chains can disrupt movements. function as isolated units but instead operate in an interconnected
The neurocognitive function integrates and processes visu- manner, forming a systemic and continuous network [12]. A sys-
al focus, self-monitoring, agility, dual-tasking, accurate motor tematic review concluded that several muscular myofascial chains
performance, reaction time, and speed. In the context of col- are anatomically strongly evidenced [12]. These integrated myo-

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fascial connections among muscles play a significant role in main- Repetitive movements, a common requirement in nearly all
taining the stability of the human skeleton [13, 14]. sports, can impact the fascia surrounding overused muscles, caus-
Muscles tend to work synergistically, functioning as bigger an- ing it to shorten and thicken while elongating in other areas [28].
atomical interlinked chains [15]. Myofascial chains are distinct Muscles execute movements in kinetic chains, although the muscle
muscle groups united by the fascial system [12]. The superficial function is not usually tested in its kinetic chain [29, 30]. Isolat-
back line (one of the myofascial chains) involves the plantar fascia, ed tests do not examine the movement patterns related to kinetic
Achilles tendon, triceps surae, hamstrings, sacrotuberous ligament, chains [31]. The full functionality of fascia in a specific chain is
and erector spinae [16] that can facilitate effective force transmis- manifested by permitting all the muscles to activate and hold the
sion between the core and limbs through its anatomical integration body in the chain test position [31]. Myofascial chain restrictions
[17]. The thoracolumbar fascia connects the lower limbs (through are manifested as the inability to hold the position and/or discom-
its attachment with the gluteus maximus) and the upper limbs fort in keeping the position [31].
(through its attachment with the latissimus dorsi) [18], permitting
the core to help in coordinated kinetic chain movements, such as Kinetic chain and bio-tensegrity
throwing [19]. The thoracolumbar fascia attaches to the transverse
abdominus and internal oblique muscles, offering the lumbar spine Human movement is multisystemic and complex [1]. Under-
three-dimensional support and core stability [19]. It forms a stabi- standing how these systems interact in human movement can
lizing ‘ring’ surrounding the abdomen, made of the thoracolum- enhance our understanding of injury causes, prevention, and
bar fascia, the abdominal fascia, and the oblique muscles, acting rehabilitation [1]. This perspective views human movement as
like a stabilizing corset [20]. In addition, the thoracolumbar fascia a holistic, interconnected, complex system rooted in bio-tenseg-
channels load transmissions between the limbs and core [21]. rity [1]. Bio-tensegrity is a concept where the bones are joined/
In the lower limb, the long head of the biceps femoris is in conti- linked with multiple viscoelastic myofascial chains with mus-
nuity with the sacrotuberous ligament, which in turn is connected cle tone maintained in a tension-dependent manner [1]. The
to the thoracolumbar fascia [11]. Research has shown that when tensegrity concept can explain how the human kinetic chain is
the biceps femoris tendon is pulled laterally, it can displace the interconnected and interdependent [13, 17]. Tensegrity con-
interspinous ligament between the fifth lumbar vertebra and the cepts regard the musculoskeletal system as a series of elements
first sacral vertebra, highlighting the load-transferring role of these that resist compression (i.e., the bones) and are interconnected
fascial connections even between distant body areas and joints by a continuous network of viscoelastic elements (i.e., the mus-
[11]. A dissection study has revealed various continuous fascial culotendinous system), which provides constant elastic tension
connections between the pelvis and the feet, including the iliotib- within the system, both at rest and during movement [13, 32,
ial band, femoral intermuscular septa, crural fascia, and crural 33]. The design of the bio-tensegrity system is evident in the
intermuscular septa [22]. These fascial connections can transfer continuous adjustments made by the entire musculoskeletal sys-
loads between the pelvis and the feet [23]. Passive neural tissue can tem, creating global patterns during movements [1]. The visco-
also influence the transfer of load between the pelvis and the low- elastic myofascial muscle chains function within a bio-tensegrity
er limb [23]. For instance, higher tension in the sciatic and tibial design that emphasizes the importance of addressing human
nerves was observed when hip flexion and ankle dorsiflexion were movement holistically [1]. The influence of whole-body posi-
combined [24]. Similarly, the combination of hip flexion with the tioning on the range of motion of a single joint illustrates the
knee in an extended position (i.e., long sitting) led to the greatest kinetic chain's function through the myofascial muscle chain [1].
reduction in ankle dorsiflexion [23]. Moreover, knee joint range of
motion (ROM) is reduced when hip flexion and ankle dorsiflexion The kinetic chain and the core
are combined [25]. Since no single muscular structure passes the
lower limb joints, non-muscular structures (i.e., fascia and neural The core (lumbopelvic–hip complex) forms the kinetic chains’
tissues) can alter/control forces working on distal joint mechanics central point of activities in most sports and is essential in injury
[23]. In a sitting position with trunk rotation, significant differences risk mitigation [18]. Core stability is the capability to control
in ankle dorsiflexion ROM can occur due to the tensile force gen- the trunk alignment and movement over the pelvis and lower
erated by trunk rotation being transmitted to the contralateral dis- limbs to permit optimal force and motion generation, transfer,
tal end, thereby altering ankle dorsiflexion ROM [26]. This trans- and control to the distal part in an integrated kinetic chain [18].
mission or propagation of tensile force is facilitated through the Therefore, core stability is crucial to enhance athletic function
myofascial chain and the posterior oblique sling, particularly the efficiency by maximizing the function of the upper and lower
one connecting the trunk with the contralateral triceps surae [26]. limbs’ kinetic chains.
The concept of integrated kinetic chain asserts that muscular The kinetic chain involves the sequential activation of muscles
chains/pathways are interlinked through soft tissue viscoelastic while performing a specific task, relying on pre-programmed
envelopment of polyarticular myofascial chains. The myofascial patterns of muscle activation that are enhanced by repetition
chains can transfer force, provide sensory and neuromotor input, [18]. Muscle activation patterns associated with fast upper-limb
and act like organized muscle synergies. The viscoelastic myofas- movement reveal that the contralateral gastrocnemius/sole-
cial chains work within the model of bio-tensegrity, necessitating us are activated first [34], and then the activation reaches up
eccentric function, end-range motions, joint stability, and elastic (through the core) to the arm [35]. In baseball throwing, the
energy storage. In a study published in 2017, the authors utilized muscle activation for pitching starts from the contralateral exter-
essential myofascial chain/pathway concepts to provide a compre- nal oblique and continues up to the upper limb [35].
hensive illustration of how ROM measurements at a single joint The trunk/core muscle activation patterns enhance the mus-
(specifically, the hip joint) depend on the positioning of the entire cle activation patterns of the limbs in both stability and mobility,
body in postures mimicking those encountered during sports activ- while the distal muscle activity tends to be more specialized for
ities, particularly those related to football [27]. precision tasks [18]. Core muscle activation is pivotal in gener-

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ating rotational torques around the spine, typically initiating on proximal-to-distal energy flow from the trunk to the lower limb
the contralateral side to produce force and rotational movement to execute angular motions to contact the ball. The strategies
[35, 36]. Furthermore, core muscle activation provides stiffness involved in whole-body energy transfer during instep kicking in-
to the torso, forming a base against which limb musculature can clude energy absorption by the support limb, the formation of
be stabilized while contracting [20, 36]. an eccentric 'tension arc' between the torso and kicking hip, and
Core proximal activation is essential for facilitating coordinat- its concentric release, along with proximal-to-distal sequencing
ed movements of distal segments [18]. Core proximal activation of the kicking limb during the downswing [49]. In maximal in-
provides the precision and stability for the whip-cracking-like step soccer kicking, skilled athletes exhibited greater trunk rota-
upper extremity distal segment maximal force (e.g., when throw- tion range of motion and speed, resulting in higher ball velocity
ing a ball, the core muscles stabilize the trunk to give the need- compared to novice athletes [50].
ed base for the arm to throw the ball with force and precision). For baseball pitching to occur, a complex muscle activation se-
The upper extremity distal part is smaller than the proximal part quence along the kinetic chain generates and efficiently transfers
and, therefore, has a minimal moment of inertia, which allows the required energy for executing a baseball throw [51]. The ki-
higher velocity summation. Consequently, the combination of netic chain influences the activation of the scapular musculature
core activation and hand minimal moment of inertia can allow (serratus anterior) throughout the practice of knee push-up-plus
the ball to be thrown with high precision, power, and acceler- exercises. Electromyography studies have demonstrated that
ation [18]. The core also helps control force. In kicking, max- ipsilateral lower-limb extension amplifies the activation of the
imum force at the foot is generated by the propagated moment serratus anterior, whereas contralateral lower-limb extension re-
after the hip joint flexion [3]. The periscapular and core mus- duces its activation [52]. Consciously contracting the abdominal
cle activation represents almost 85% of the muscle activation muscles was an effective strategy to magnify the serratus anterior
needed to control the forward-moving upper limb [37]. It was and lower trapezius activity (as proven by the electromyographi-
found that tennis players with lower knee flexion ROM during cal readings) during the push-up plus phase [53].
the back-swing phase of the serve action had 23–27% greater Efficient energy transfers involve the sequential transfer of
shoulder rotation, horizontal adduction stress, and elbow valgus energy from the larger and more proximal parts of the body to
stress [38]. The possible explanation was that the lower knee the smaller terminal parts [49]. Efficient energy transfers along
flexion ROM caused breakage in the kinetic chain and less con- the kinetic chain were linked to a lower risk of injury and higher
tribution from the hip and core [38]. performance [49] because a synchronized kinetic chain can re-
duce joint loads, enhance velocity, and increase force production
Kinetic chain and sports performance throughout the motion [54]. Higher-level players use shoulder
and wrist power better by effectively engaging the entire body
Sports performance depends on relevant kinematic and kinet- kinetic chain [55]. This power generation process during throw-
ical variables [39]. Sports performance improvement is correlat- ing starts in the lower limbs and core, where large and powerful
ed with injury prevention [39]. The kinetic chain refers to the muscles are located [56]. Around half of the force production
sequential activation of task-specific body segments, enabling throughout the throwing motion occurs in the hip and trunk
efficient generation, summation, and transfer of mechanical en- [51]. The lower-limb-generated force is transferred through the
ergy to support functional movement patterns [40, 41]. Kinetic trunk to the scapula of the throwing/accelerating arm [51]. Mo-
chain inefficiency occurs when there is a defect or disruption at bility restriction and kinematics alteration in the hip and trunk
any point within the chain, which affects the transfer of energy are linked to a throwing mechanics breakdown (loss of energy
or force to nearby segments [40, 41]. The defect in the kinetic production) and shoulder and elbow injuries [57, 58]. The mo-
chain places additional demands on the remaining segments of bility restriction causes a loss of energy production and conse-
the chain to compensate for the energy loss [40]. This compen- quent larger force production role on the arm, placing abnormal
sation has been identified as a contributing factor that increases and damaging stresses on the soft tissues [51, 59, 60].
the risk of shoulder pain and injury during overhead sports ac-
tivities [40, 42]. In the dominant tasks of the upper extremity, Kinetic chain and sports injuries
the energy generation and production are in a proximal-to-dis-
tal sequenced pattern [43]. For example, during a tennis serve, Sports injuries are complex phenomena due to the interplay of
approximately 50%–55% of the total required kinetic energy various risk factors or predictors (known as the risk profile) that
is generated from the legs and trunk [41, 44]. In elite handball can lead to compensatory patterns and eventual injuries [7]. The
players, the main determinant of the throwing velocity is the ability to predict and prevent sports injury depends on identifying
lower-limb peak power [45]. Moreover, lower limb peak power these risk patterns (risk profile) through a non-linear and complex
was strongly correlated with the sprint-swim speed in freestyle system approach [7]. In the kinetic chain, disruptions at proximal
swimmers [46]. Furthermore, lower limb musculature mass and links can increase demands on more distal segments, requiring
contraction velocity correlate significantly with the performance enhanced functional abilities in those areas and making them
of javelin throwing [47]. more susceptible to injuries [39, 61, 62].
The muscle activation sequence in striking and throwing skills Deficits in the kinetic chain links in the trunk and lower limbs
follows a proximal-to-distal direction. The "tension arc" travels were present in approximately 50% of cases involving injuries to
along the body from the contralateral arm on the non-kick- the superior glenohumeral labrum anterior and posterior regions
ing side to the kicking leg as it extends and abducts, resulting in throwing shoulders [57]. In individuals with chronic ankle in-
in trunk rotation [48]. The forward movement of the kicking stability, changes in ankle-joint kinetics, including a decrease in
limb and the contralateral arm releases this tension arc, allow- ankle-eversion moment and an increase in ankle plantar-flexion
ing it to shorten and demonstrate the stretch-shortening cycle moment, were observed during side-cutting task performance.
[48]. For kicking to happen, the trunk generates a sequential Additionally, increased hip joint stiffness was observed [63]. Such

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altered lower-limb kinetics and movement patterns may increase strength of serratus anterior and moderately with that of triceps
the risk of recurrent lateral ankle sprains [63]. Soccer players brachii [73].
were eight times more prone to hamstring strain injury if their
hamstring muscles were activated after the lumbar erector spinae The Bunkie test
(normally, the hamstring is to be activated before the erector spi-
nae) during prone hip extension (mid-range and end-range) [64]. The Bunkie test examines kinetic chains across the fascia and
The kinetic chain concept implies that the disorder of a joint detects the apparent restrictions in the kinetic chains along the fas-
can precipitate injuries to other joints (usually distal to the joint cia lines [31]. Mayer's anatomy trains serve as the foundation for
involved) [65]. Athletes who are landing with altered lower-limb the kinetic chains employed in this test [29]. Each kinetic chain is
mechanics (with dynamic knee valgus, tibia internal rotation, and associated with a particular testing position, with both the right
pronated feet) have a high risk of sustaining acute ACL non-con- and left sides of the body being evaluated. Participants are re-
tact injury [66] and anterior knee pain as overuse injury [65, 67, quired to maintain the testing position for 40 seconds. There is
68]. In alpine skiers, tibia internal rotation with a knee full exten- a significant correlation between performance constructs (agility,
sion or flexion beyond 90° was linked to a non-contact ACL in- speed, explosive power, and muscle endurance) and performance
jury [66]. More proximally, impaired trunk control, motion, and in the Bunkie test in healthy rugby players [31].
body-weight shift on the lower limb were linked to a high risk of
ACL non-contact injuries [66]. Closed kinetic chain dynamic lower extremity stability
(CKCLE) (developed by Lee, Hwang, Jung, Ahn, and Kwon,
2020)
Kinetic chain-related clinical tests
The closed kinetic chain upper extremity stability test The closed kinetic chain dynamic lower extremity stability (CK-
(CKCUES test)/ Davis test CLE) test is a novel test examining the functional performance
and assessing antigravity posterolateral hip musculature function.
The closed kinetic chain upper extremity stability test (CKCUES During this test, individuals are instructed to lift one foot, touch
test) is a valuable, cost-effective clinical tool for evaluating shoulder it to the opposite knee, and then lower it back to the floor while
performance [69]. It provides quantitative data for assessing upper isometrically maintaining the bridging position. This motion is re-
extremity function in a closed kinetic chain context [54]. This test peated for 20 seconds, and the score is based on the number of
targets explicitly the stability of the scapular muscles, making it touches achieved in that time frame. There is a positive and signifi-
useful for evaluating scapular stability [70]. Furthermore, it deter- cant correlation between the strength of the supporting lower-limb
mines the upper limb function, progression in rehabilitation, and hip extensors, abductors, and external rotators and the number of
return-to-sport judgment [71]. The CKCUES test shows strong foot touches completed in 20 seconds [74].
reliability and validity [71] and is designed to be user-friendly for
clinicians, making it easy to administer and comprehend [72]. The Closed kinetic chain lower extremity stability test
test score is determined by counting the number of times the indi- (CKCLEST) (developed by Arikan, Maras, Akaras, Citaker,
vidual, while in a plank position, is touched by their swinging hand and Kafa, 2021)
and supporting hand [72]. Its performance strongly correlates with
the isokinetic strength of shoulder flexors and elbow extensors at The closed kinetic chain lower extremity stability test (CK-
180°/s for men [71]. It is strongly associated with the isometric CLEST) is a novel, easy, and cost-effective performance-based

Figure 1. Summary of kinetic chain implications and elements related to injury and sports performance

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