Research PaperOpen Access

Relationship between plantar pressure distribution and sagittal spinal curvatures among handball players: A cross-sectional study

Amr A. Abdel-aziem

https://orcid.org/0000-0001-8448-9218

Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Giza, Egypt

Department of Physical Therapy, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia

E-mail Address: amralmaz@cu.edu.eg

E-mail Address: amralmaz@yahoo.com

Corresponding author.

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Mariam A. Ameer

https://orcid.org/0000-0002-1996-5131

Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Giza, Egypt

Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Sakaka, AlJouf, Saudi Arabia

E-mail Address: mariam_ameer7@hotmail.com

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Ammar M. Al Abbad

https://orcid.org/0009-0000-7506-8059

Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Sakaka, AlJouf, Saudi Arabia

E-mail Address: aalabbad@ju.edu.sa

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, and

Maher A. Mahdi

https://orcid.org/0009-0006-3890-2212

Department of Foreign Languages, College of Arts, Taif University, Taif, Saudi Arabia

E-mail Address: mahermahdi@gmail.com

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https://doi.org/10.1142/S1013702525500040Cited by:0 (Source: Crossref)

Abstract

Background: Handball affects the spinal anterior–posterior curvatures and disturbs the foot plantar pressure which provides insights into alterations in an individual’s posture. However, little is known about how the mal-alignment affects the distribution of plantar pressure.

Objective: To investigate the relationship between the thoracic kyphosis angle, and plantar pressure distribution among handball players.

Methods: Sixty male handball players were distributed into two groups based on their thoracic kyphosis angles. Group A: 28 handball players with an angle greater than 44^∘ (kyphotic group), and group B: 32 handball players with an angle equal to or less than 44^∘ (normal group). The Formetric III 4D spine and DIERS Pedoscan devices were used to measure the trunk anthropometry and plantar pressure distribution. The Pearson correlation test was used to explore the relationship between the kyphosis angle and plantar pressure distribution.

Results: Group A was significantly taller, had longer trunk length, greater lumbar lordosis angles, and forefoot plantar pressure (FPP), and less rearfoot plantar pressure (RPP) than group B ( $p < 0.05$ ). They showed a highly significant positive correlation between the thoracic kyphosis angle and FPP, and a highly significant negative correlation with the RPP ( $r = 0.672$ , $- 0.650$ , respectively). There was no correlation between the lumbar lordosis angle and FPP or RPP ( $r = 0.025$ , $- 0.045$ , respectively).

Conclusion: Handball players with greater thoracic kyphosis angle have greater lumbar lordosis angle. Increasing the thoracic kyphosis angle is strongly associated with increased FPP and decreased RPP. While there is no relationship between the lumbar lordosis angle and FPP or RPP.

Keywords:

Introduction

Adult spinal deformities are a prevalent medical condition that has a noteworthy and measurable effect on health-related quality of life.¹ Kyphosis, or the thoracic spine’s convex curvature, is regarded as “normal” when it falls between 20^∘ and 40^∘.² Hyperkyphosis is the term used to characterise the curve when it exceeds 40^∘.^3,4,5 A recent narrative review suggested raising the cutoff point for normality to 50^∘,3 which was linked to a poorer quality of life, and an increased risk of falling.^3,5

Asymmetries in the trunk and unequal muscle strength are common in many sports; these may be brought on by unequal loads placed on the spine or by particular unilateral muscular training in specific sports,⁶ which creates imbalances on both sides of the body.⁷ Players of handball, volleyball, and taekwondo are likely to have different spinal anterior–posterior curvatures, with more thoracic kyphosis angle than lumbar lordosis angle,⁸ where the largest values were noted in the superior-thoracic region and the lowest ones in the lumbar-sacral section.^8,9 These segmental asymmetries in athletes may make them more prone to injury.⁹

In clinical practice, foot pressure receptors play a critical role in determining the ideal equilibrium responses and shaping the correct erect body posture. Moreover, their stimulation has significant impacts on enhancing body equilibrium.¹⁰ During walking, the posture symmetry is essential for the proper movement of the COG.¹¹ Pressure receptors on the feet detect changes in the COG, and reflex movements are then triggered to keep the body balanced.¹² The plantar pressure distribution can help with training and rehabilitation to prevent body imbalances and sports-related injuries.^13,14

It is necessary for athletes to constantly improve their motor skills, technique, and tactics, which can result in a significant overload of the musculoskeletal system, especially the foot area. Foot defects that can alter plantar pressure may affect gait biomechanics, resulting in the ineffective performance of motor activities and a significant load on the athletes’ locomotor system which inversely affecting the player performance.¹⁵

Handball, which was viewed as a sport with unilateral loading,¹⁶ has an impact on the anterior–posterior curvatures of the spinal column.⁸ The taller the handball players, the greater the thoracic kyphosis¹⁷ and the lesser lumbar lordosis than the normal non-athletic subjects.¹⁸ Variations in the plantar pressure distribution may have an impact on athletes’ performance, and body anthropometry has a significant impact on playing skills.^15,19 The handball players with kyphotic posture have forward displacement of their centre of gravity (COG),^8,18 which perturbs the postural control,⁵ and disturbs the zplantar pressure distribution and foot load patterns.²⁰ So, the subjects with kyphotic posture increase the duration of heel contact to maintain their anterior–posterior stability.²¹

Esparza et al.²² reported that future research should look at how diverse sports affect plantar pressure because lower extremity injuries from non-body contact are much more common and could be exacerbated by repetitively high loads on the foot. Recent studies showed that taller handball players have greater thoracic kyphosis angle and forefoot plantar pressure (FPP) and less rearfoot plantar pressure (RPP) in comparison to non-athletes,²³ and shorter handball players.²⁴ It was reported that preserving the normal values of the thoracic kyphosis and lumbar lordosis angles is essential to maintain the functionality level, emotional health,²⁵ and standing stability by limiting the excursion of the centre of foot pressure,^5,26 and disturbance of the plantar pressure distribution.²⁰ However, there are no reports concerning the effect of the spinal curvature angles on the plantar pressure distribution. So, this study investigated the relationship between the thoracic kyphosis angle and plantar pressure distribution among handball players.

Methods

Participants

Sixty handball players participated in this cross-sectional study which was conducted between November 2022 and January 2023. Based on a pilot study with 10 participants, the sample size was determined using the G*Power 3.1 software (five subjects in each group) to determine the effect size before beginning the real research. Sixty participants were chosen based on the calculations of $power = 0.80$ , effect $size = 0.65$ , and $alpha = 0.05$ . They were divided into two groups: group A consisted of 28 handball players with thoracic kyphosis angle greater than 44^∘, and group B consisted of 32 handball players with thoracic kyphosis angle equal to or less than 44^∘.⁴

The handball players were recruited from five different local sporting clubs. Eight participants out of 68 who were initially assessed for eligibility did not meet the inclusion criteria, which were: (1) six days a week, 120 min of training, and (2) their training extended from three to six years. Before conducting the evaluation methods, a meeting was held to acquire this information. Participants were disqualified from this study if they had a history of neurological conditions, back or lower extremity surgery, confirmed scoliosis, congenital spine abnormalities, balance issues, or any kind of foot deformities. Each participant provided written consent, and the research methodology was carried out in accordance with the Helsinki Declaration and accepted by the ethics committee of the Faculty of Physical Therapy, Cairo University (P.T.REC.012/003752).

Procedures

The optical measurements of the spine were taken using the DIERS Formetric (four dimensions [4D], International GmbH, Schlangenbad, Model No. 1010112157, Germany). The Formetric system provides a 4D image of the spine using a raster stereographic technique and DiCAM v2.2.0. The system has excellent inter- and intra-rater reliability and a highly accepted validity when compared to X-ray images.^27,28,29 A flat whiteboard was used during the calibration of the stereographic projector/camera which was done daily with consideration of the participant’s body height, where the cameras and resulting strobes were modified to get the highest possible photographic resolution.²⁷

The formetric system creates white lights and parallel horizontal lines that run through the participant’s back, from the cervical vertebrae to the dimples of the lumbar region. The system was used to measure the trunk length from C7-VP (VP: vertebral prominence) to the lumbar-DM (DM: point lies between the left and right dimples of the lumbar region). Additionally, the thoracic kyphosis and lumbar lordosis angles were measured with a precision of depth error (z-axis) of 0.25mm and lateral error (x/y-axis) of 0.20mm. The trial was deemed invalid whenever a participant spoke, moved a body part, or changed positions.³⁰ By modifying the camera’s contrast and brightness, the image quality was improved. The black and white positive images were digitised and edited to lessen the quantity of data. An automated 3D model of the spine was created in order to calculate the kyphosis and lordosis angles. The image that is being shown is the mean of all photographs that were acquired for the 4D average measurements.^27,30 Consequently, there is just one image in the final product (Fig. 1). The participant’s head should be facing forward, his eyes should be open, and he should only be wearing pants (no clothing is worn from the neck to the two lumbar dimples).²⁷

Fig. 1. The percent of plantar pressure distribution of feet quadrants with 4D average of the spine.

The plantar pressure distribution was measured using the DIERS Pedoscan (RS scan 1.0m, International GmbH, Germany). The system (a 50cm wide platform holding 4,096 pressure sensors, and data gathering frequency was 300Hz) supplied the percent (%) of plantar pressure distribution in four plantar zones (right forefoot, right rearfoot, left forefoot, and left rearfoot) during standing.^17,27 The Pedoscan’s accuracy and reproducibility have been acknowledged in several studies.^27,31,32 The static photos of the feet offer metric data on the front-back and left-right pressure distribution in percent as well as a coloured representation of the feet. The Pedoscan resistive measurement plate undergoes periodic calibration (every 2–3 months) to maintain its sensitivity.³³ The participant was told to stand in a relaxed, upright position on a fixed Pedoscan platform in a dimly lit environment.

The participant stood barefoot on the platform. To provide a quick picture of the proportion foot plantar pressure distribution, the total percent of FPP and RPP was calculated using the pressure maps. The measurement was performed three times for each participant. The average and standard deviation values of the total percentage of FPP and RPP were calculated by the detection of the proportion of four-foot quadrants. The right and left rearfoot pressures were added together to form the percent of the RPP, whereas the right and left forefoot pressures were added together to form the percent of the FPP.^23,24,27

Data analysis

The IBM Statistical Package for the Social Sciences, SPSS version 20 for Windows version 7, was used to perform the data analyses. The distributions of the measured outcomes were shown to be normal by the Shapiro-Wilk test ( $p > 0.05$ ). So, parametric data analysis was conducted. The independent t-test was used to compare the anthropometric measurements, percentage of foot plantar pressure, and spinal sagittal curvatures between the two groups. Correlation analyses were done to look into the potential effects of the thoracic kyphosis and lumbar lordosis angles on the percent of FPP and RPP in both groups using the Pearson correlation test (r). Fixed in 0.05 was the significance level.

Results

The results showed no significant differences between both groups in body mass index (BMI) or age ( $p > 0.05$ ). Group A was significantly taller and heavier than group B ( $p < 0.05$ ), and their trunk length was significantly longer than group B ( $p < 0.05$ ). Group A has a significantly increased lumbar lordosis angle and FPP compared to group B ( $p = 0.001$ ). While the RPP of group A was significantly lower than group B ( $p = 0.001$ ), as shown in Table 1.

**Table 1. The summary of independent t-test comparing the demographic characteristics of the participants.**
Variables	Group A (kyphotic angle greater than 44^∘, $n = 28$ )	Group B (kyphotic angle equal to or less than 44^∘, $n = 32$ )	t-value	p-value
Age (year)	23.45±1.26	23.49±1.76	$- 0.10$	0.918
Weight (kg)	80.35±6.73	70.20±6.16	6.10	0.001*
Height (cm)	180.50±5.82	170.34±6.21	6.48	0.001*
BMI (body weight/height $^{2})$	24.60±1.20	24.31±1.33	0.89	0.379
Trunk length (cm)	46.37±1.35	43.20±2.30	6.60	0.001*
Kyphosis angle (deg)	47.08±2.32	41.21±1.14	12.15	0.001*
Lordosis angle (deg)	30.90±4.78	24.74±4.44	5.17	0.001*
Forefoot plantar pressure (%)	58.29±1.87	52.99±2.83	8.64	0.001*
Rearfoot plantar pressure (%)	40.80±2.00	46.99±2.85	−8.23	0.001*

Notes: Data are presented as mean±standard deviation, * means statistically significant results ( $p < 0.05$ ), BMI: body mass index.

For group A, there was a highly significant positive correlation between thoracic kyphosis angle and percent of FPP, and a highly significant negative correlation between thoracic kyphosis angle and percent of RPP ( $r = 0.672$ , $p = 0.001$ ; $r = - 0.650$ , $p = 0.001$ , respectively). Group B showed a moderately significant positive correlation between the kyphosis angle and percent of FPP, and a moderately significant negative correlation between the kyphosis angle and percent of RPP ( $r = 0.409$ , $p = 0.020$ ; $r = - 0.412$ , $p = 0.019$ , respectively).

Group A has no correlation between the lumbar lordosis angle and percent of FPP and RPP ( $r = 0.025$ , $p = 0.898$ ; $r = - 0.045$ , $p = 0.822$ , respectively). The trunk length showed a highly significant positive correlation with the percent of FPP and a highly significant negative correlation with the percent of RPP ( $r = 0.709$ , $p = 0.001$ ; $r = - 0.786$ , $p = 0.001$ , respectively). Group B showed a moderately significant positive correlation between the lumbar lordosis angle and percent of FPP, and a moderately significant negative correlation between the lumbar lordosis angle and percent of RPP ( $r = 0.429$ , $p = 0.014$ ; $r = - 0.423$ , $p = 0.016$ , respectively). The trunk length showed a highly significant positive correlation with the percent of FPP and a highly significant negative correlation with the percentage of RPP ( $r = 0.866$ , $p = 0.001$ ; $r = - 0.870$ , $p = 0.001$ , respectively), as shown in Table 2.

**Table 2. Correlations matrix of the body height, trunk length, spinal curvatures, and percentage of plantar pressure.**
		Group A (kyphotic angle greater than 44^∘, $n = 28$ )		Group B (kyphotic angle equal to or less than 44^∘, $n = 32$ )
		FPP (%)	RPP (%)	FPP (%)	RPP (%)
Kyphosis angle (deg)	r	0.672*	−0.650*	0.409*	−0.412*
	$p -$ value	0.001	0.001	0.020	0.019
Lordosis angle (deg)	r	0.025	−0.045	0.429*	−0.423*
	$p -$ value	0.898	0.822	0.014	0.016
Trunk length (cm)	r	0.709**	−0.786**	0.866**	−0.870*
	$p -$ value	0.001	0.001	0.001	0.001

Notes: r: Pearson’s correlation coefficient, FPP: forefoot plantar pressure, RPP: rarefoot plantar pressure, *Correlation is significant at $p < 0.05$ ; **Correlation is significant at $p < 0.01$ .

Discussion

The results of this study revealed that the handball players with thoracic kyphosis angle greater than 44^∘ (kyphotic group) were taller, had longer trunk length and had a greater lumbar lordosis angle compared to handball players with a thoracic kyphosis angle equal to or less than 44^∘ (normal group), which was consistent with the previous research works.^8,9 A recent review study showed that the athletes frequently experience spinal curvature disorders in the sagittal and frontal planes,³⁴ and the prevalence of combined hyperkyphosis and hyperlordosis was 30% in the basketball players.³⁵ These findings were supported by Hershkovich et al.³⁶ who showed a correlation between body height and the risk of spinal abnormalities. Thus, the degree of spinal abnormalities is likewise positively correlated with body height, which indicates a great impact of body height on increasing thoracic kyphosis. This result agreed with the findings indicated that taller male handball players have a greater kyphosis angle than smaller counterparts with the same training level.^23,37 However, a recent study³⁸ showed no correlation between the thoracic kyphosis and lumbar lordosis angles in young male adults who had a similar body height to the participants of group A of this study (kyphotic angle greater than 44^∘), this contradiction may be attributed to its participants were non-athletes.

It is reported that the handball players have deepened thoracic kyphosis, similar to volleyball players. The handball and volleyball players have kyphotic postures which tend to be greater than untrained subjects.^23,39 This may be explained by the players’ forward bend with rounded backs, protruding arms, and shoulders,⁴⁰ and the effect of body height on thoracic kyphosis which may be worse in a tall person.^24,41 A recent study⁴² reported that the angle of thoracic kyphosis was enlarged in 12% of handball players, this may return to the biomechanical compensation through increasing the thoracic kyphosis angle to gain a spinal balance.⁴³ Other studies^18,24 reported that taller handball players have longer trunk length and greater thoracic kyphosis angle. Additionally, sports training and anthropometric factors may also be responsible for the observed changes in the anterior–posterior spinal curvatures,^40,43 which was consistent with Zeyland-Malawka⁴⁴ who reported that athletes from a variety of sports, including handball, hockey, fencing, judo, weightlifting, and ice skating, had higher degrees of lordosis than non-training controls, and that handball and fencing players had the highest kyphosis angles.

Sports disciplines are typically separated into two categories: asymmetric sports like tennis, fencing, handball and javelin throwing, and symmetric sports like gymnastics and running.^16,45,46,47 A review study reported that the asymmetric stress of sports will almost certainly result in asymmetric adaptations and proposed a novel kind of functional asymmetry known as “sporting asymmetry” which must be connected to players’ sustained participation in their sport.⁴⁸ Consequently, a recent study compared between symmetric sports group (track and field running athletes) and the asymmetric sports group (tennis athletes) after six months of sports practice reported statistical differences between both groups for the pelvic antero–retroversion and right lateral deviation,⁴⁹ which was consistent with the present findings. So, multimodal training program is useful to rectify the sagittal thoracic curvature in asymmetric sports.⁵⁰

The FPP of group A was higher than group B, and the RPP of group A was lower than group B. This finding is supported by the previous study which showed the almost equal pressure distribution between the two sides of the body and the higher pressure distribution between the forefoot and rearfoot in healthy adults.^24,51 Besides, the current findings were consistent with Braz and Carvalho⁵² who justified the greater plantar pressure on the forefoot in football players because of the varus mal-alignment and a supine distribution of plantar bases. Furthermore, the current findings are supported by a recent study that showed that the body height correlated negatively with the mean plantar pressure of the foot between the start and end of the loading support phase of the gait cycle.⁵³ Taller individuals are known to have altered gait characteristics, such as a decrease in cadence due to longer steps, a decrease in ankle velocity due to fewer steps, and an increase in stride length and time.⁵⁴

The trunk length showed a highly positive correlation with the percent of FPP and a highly negative correlation with the percent of RPP in both groups, which was supported by the findings of a recent study showing that handball players have a greater FPP compared to non-athlete subjects.²³ Furthermore, it was reported that increasing the body height of the handball players is associated with increasing the trunk length,¹⁸ and the taller handball players have an increased FPP compared to shorter ones.²⁴ The greater FPP and lesser RPP could be attributed to the increased lumbar lordosis and thoracic kyphosis associated with increased bilateral foot pronation,⁵⁵ which develops a higher foot pressure in the forefoot.⁵⁶

According to Winter¹¹ any alteration in the upper torso’s position causes the body mass centre to shift, moving through the hip and ankle joints to the plantar portion of the foot and altering the distribution of load. Furthermore, Żurawski et al.⁵⁷ found that postural abnormalities in the sagittal plane had a considerable effect on the foot load proportions. For group A, there was a high positive relationship between the kyphosis angle and percent of FPP and a high inverse relationship between the kyphosis angle and the percent of RPP, and group B showed relationships similar to group A, but to a lesser extent “moderate”. These findings were in line with a recent study that showed a strong positive association between the percent of FPP and thoracic kyphosis of handball players.²³ Besides, there was a positive relationship between the kyphosis angle and percent of FPP. As well, the level of lordosis angle correlated positively with the forefoot load.⁵⁷ In the same context, Souza et al.’s research demonstrated a rise in the thoracic kyphosis angle and a rise in forefoot load.⁵⁸ According to Draus et al.²⁷ there is a 10% increase in forefoot load for every 1.8^∘ increase in thoracic kyphosis. Recently, it was reported that increasing the kyphosis and lordosis angles was positively associated with the FPP and negatively associated with the RPP in static conditions.⁵⁷

Wojtków et al.⁵⁹ reported a moderate relationship between the load carried by the individuals’ left lower limb’s forefoot and rearfoot, and the thoracolumbar spine’s inclination, thoracic kyphosis, and lumbar lordosis angles. The percent of weight transferred by the left lower leg of girls’ hind feet increases with increasing kyphosis and lordosis angles. As a result of shifting of the COG forward, a greater angle of inclination in the thoracolumbar segment, however, was associated with a greater load imparted by the forefoot of the left lower leg as well. On the other hand, Afjaei et al.⁶⁰ showed a typical plantar pressure pattern in people with various lumbar lordosis angles and there is no change in the percent of plantar pressure distribution which contradicted this study.

Żurawski et al.⁵⁷ reported that the distribution of ground reaction forces (GRFs) on the feet is linearly related to the magnitude of lumbar lordosis and thoracic kyphosis angles, which was similar to the plantar pressure distribution. In a static condition, increasing the kyphosis and lordosis angles was adversely linked with the heal load and positively associated with the forefoot load. Their findings could be the explanation for the higher percent of FPP and lower percent of RPP of group A compared to group B, which has significantly increased thoracic kyphosis and lumbar lordosis angles and longer trunk length in comparison to group B. So, it can be ruled out that the body weight of group A, which was significantly higher than group B, could be the reason for the difference in the percent of FPP and RPP of both groups. Moreover, there was no significant difference in the BMI of both groups, where a previous study reported that increasing the body weight does not result in a change in the GRF components,⁶¹ although it does lead to an increase in the lumbar lordosis angle.⁶²

The size of the spinal curvature also affected the contact surface of the feet with the ground.⁵⁷ Likewise, Souza et al.⁵⁸ report a substantial association between lumbar lordosis angle, where its increase causes an increase in forefoot load while reducing heel load. These findings are in direct agreement with the findings of this study and the newly released work by Żurawski et al.⁵⁷ According to Mazzocchi et al.⁶³ the reaction consists of shifting the load within the feet toward the forefoot and increasing the pelvic inclination angle. However, those authors believed that the reaction is the outcome of setting reactions that are primarily caused by changes in the angle of thoracic kyphosis and the head position in space. Draus et al.²⁷ computed the impact of lumbar lordosis on the loads on the various foot components and discovered that an increase of 0.8^∘ in lumbar lordosis corresponds to a 10% increase in forefoot load. The hypotension coexisting with a round-concave back explains why both a deepening of lumbar lordosis and an increase in thoracic kyphosis affect the forward shift of the GRFs.⁵⁸

Limitations

This study had many limitations, the study did not include handball players from both genders. Consequently, generalising the results to a larger group is only appropriate in this particular population. Instead of focusing solely on the static condition, it is advised to examine both static and dynamic activities when examining how the thoracic kyphosis angle affects the plantar pressure distribution in handball players. This study did not compare the leading foot and non-leading foot. The study’s findings might not accurately represent how plantar pressure varies during games or training sessions, when its distribution can be affected by muscular fatigue due to prolonged activities. Also, there was no assessment of kinematic and kinetic data, such as GRFs, joint moments, and other angles of the spine. In addition, the impacts of team positioning — specifically, wings, pivots, goals, and backward centres — were not investigated. It has been shown that each handball position necessitates physiological and physical attributes particular to the player’s position.³⁷ It would also be intriguing to assess the spinal curvatures in the frontal plane to rule out scoliosis in handball players. Since the measurements were conducted while the participants were barefoot, the measured outcomes may be different if they were wearing shoes. Wearing shoes affects the distribution of plantar pressure⁶⁴ as well as the mechanics of the lower extremity joints.⁶⁵ Subsequent research ought to evaluate the electromyographic activity of postural muscles, as their activity influences the distribution of plantar pressure and GRFs on the foot. Last but not least, a longitudinal study is required to ascertain the long-term effects of handball players’ kyphosis angles on the evolution of spine and foot asymmetry over time. Therefore, exercises that promote appropriate upper body alignment and body weight distribution on the feet should be incorporated into handball training sessions.

Conclusion

Handball players with greater thoracic kyphosis angle have greater lumbar lordosis angle. Increasing their thoracic kyphosis angle is associated with increased FPP and decreased RPP. While there is no relationship between the lumbar lordosis angle and FPP or RPP. The current findings demonstrate how spinal curvatures may affect foot load patterns. From this point of view, somatic parameters have the potential to dramatically increase the risk of pathomechanics and subsequent injury, as well as postural instability. Owing to asymmetric spine overloads during training, handball coaches should consider frequent posture assessments of their players.

Conflict of Interest

The authors declare no conflict of interest.

Funding/Support

No fund.

Author Contributions

AAA, MAA, and AMA designed the study and were the primary investigators. All authors drafted the initial manuscript, critically reviewed the manuscript for intellectual content, and subsequently revised the manuscript for publication. AAA, MAA, AMA, and MAM read and approved the final version of the manuscript.

Acknowledgement

The authors would like to thank all the athletes who participated in this study.

ORCID

Amr A. Abdel-aziem https://orcid.org/0000-0001-8448-9218

Mariam A. Ameer https://orcid.org/0000-0002-1996-5131

Ammar M. Al Abbad https://orcid.org/0009-0000-7506-8059

Maher A. Mahdi https://orcid.org/0009-0006-3890-2212

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Vol. 45, No. 01

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Received 26 January 2024

Accepted 4 August 2024

Published: 17 September 2024

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