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RESEARCH
CORRESPONDING AUTHOR:
Zixiang Gao
Faculty of Engineering,
University of Pannonia, H-8201
Veszprém, Hungary; Savaria
Institute of Technology,
Eötvös Loránd University,
Szombathely, Hungary
gaozixiang0111@outlook.com
KEYWORDS:
Asymmetry; Athletes;
Competitive sports; Gait; Upper
limb
TO CITE THIS ARTICLE:
Gao, Z. (2022). The Effect of
Application of Asymmetry
Evaluation in Competitive
Sports: A Systematic Review.
Physical Activity and Health,
6(1), pp. 257–272. DOI: https://
doi.org/10.5334/paah.215
The Effect of Application
of Asymmetry Evaluation
in Competitive Sports:
A Systematic Review
ZIXIANG GAO
ABSTRACT
It has been widely asserted that the two side human body asymmetries are detrimental
to the health and performance alike of athletes in training and competition. The
current systematic review aims to promote a more refined understanding of bilateral
asymmetry in competitive sports and explore the application of asymmetric assessment
to performance, injury and rehabilitation. A systematic review of the articles was
undertaken using the Web OF Science, ScienceDirect and PubMed databases in May
2022, retrieving a total of 386 studies published in all years. The study quality scoring
system developed was used by two evaluators to assess the grading article quality.
Twenty-two articles fulfilled our eligibility criteria. The average quality assessment
rate for selected articles in this systematic review is 94.4 ± 6.3% (from 0.78 to
1.00). Articles investigated the effect of the application of asymmetry evaluation in
one of the following sports types: gait related sports, upper limb sports, ball sports
and multifarious sports. Asymmetry has a positive effect on physical performance
in athletes engaged in upper limb movements, but it may lead to potential risk of
injures in gait-related sports. When examining bilateral asymmetries among athletes
in multifarious sports, the studies were primarily used to investigate the relationship
between injury rehabilitation and return-to sport, with mixed findings. Further
research needs to determine the possible injury-inducing threshold of asymmetry in
multifarious sports and the detailed relationship between bilateral asymmetry and
sports performance.
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INTRODUCTION
Symmetry has long been regarded as a synonym for health in sports training (Brown et al.,
2017b), therapy (Botelho et al., 2017) and daily practice (Parrington and Ball, 2016). However,
the movement and posture of human does not conform to the concept of complete symmetry
(Tomkinson and Olds, 2000). Asymmetry may be widespread even in high-performance sports
(Maloney, 2019). Movement symmetry is an essential technical parameter in some competitive
sports, such as sprint running (Haugen et al., 2018), walking race (Tucker and Hanley, 2017)
and rugby (Brown et al., 2017a). In addition, most athletes have dominant limbs for certain
tasks, and these preferences may be determined by different motor tasks (Maloney, 2019).
Asymmetry of athletes is one of the main causes of musculoskeletal diseases, sports injuries
and poor performance (Bishop et al., 2018). Although bilateral asymmetry is widely believed to
be detrimental to sports performance of athletes, previous studies does not fully support this
association (Afonso et al., 2020). Therefore, the athletes and coaches would benefit from an
biomechanical examination of quantitative asymmetry of the bilateral movement or posture,
rather than depending exclusively on subjective determination during daily training (Maloney,
2019; Xiang et al., 2022; Xu et al., 2022; Yahya et al., 2022).
Quantification of bilateral asymmetries has been widely examined in the available studies as
well as the quantification method is not uniform (Bishop et al., 2018). Asymmetrical gait may
be associated with injury risk, athletic performance, and the legality of the movement (Tucker
and Hanley, 2017), although contradictory findings have been reported. The literature reports
that the associated symptoms may occur only when the degree of asymmetry exceeds certain
thresholds (Bishop et al., 2018). Previous studies have shown a potential relationship between
athletes’ limb asymmetry greater than 15% and the occurrence of sports injuries (Barber et
al., 1990, Grindem et al., 2011). In addition, other researchers have set asymmetry of less
than 10% as the goal for discharge and returning to the sport of athletes with unilateral limb
injury (Kyritsis et al., 2016, Rohman et al., 2015). Trivers et al. (Trivers et al., 2013) reported that
symmetry can be identified as one of the indicators of early talent recognition in athletes. A
long-term Jamaican study observed that the athletes’ knee asymmetry at age 8 could predict
their sprint performance 14 years later (Trivers et al., 2013). On the other hand, opponents
argue that musculoskeletal coordination forms the basis for the symmetry of an athlete’s static
and dynamic movements (Preatoni et al., 2013). In practice, interpreting motor coordination
is more complex than classical biomechanical measurements (Warmenhoven et al., 2018).
Therefore, athletes performing an action with bilateral asymmetry may cause a decrease in
biomechanical parameters of one or both sides. For example, water rowing is widely evaluated
by bilateral continuous variables of force symmetry rather than coordination (Afonso et al.,
2020). These findings suggest that asymmetry is an adaptive consequence magnified with
long-term physical activity participation (Maloney, 2019). One of the causes of bilateral
asymmetry is an abnormality of the spine (Vincent and Vincent, 2019). The pressure generated
during movement is transferred to the spine to stabilize the upper body and keep it balanced
and upright. Therefore, biomechanical assessment of athletes’ bilateral symmetry is the main
method to develop recovery strategies to restore normal function in clinical practice.
Limited literature suggests that greater than 10% power and force asymmetry of the bilateral
lower extremity can reduce the change of direction speed times (Hoffman et al., 2007) and
jumping performance (Bell et al., 2014), indicating that increased asymmetry can impair
athletic performance. In addition, previous scholars have reported that legal and effective
walking techniques require certain gait symmetry, so it is essential to monitor the differences
between limbs during training (Preatoni et al., 2010). Tomkinson et al (Tomkinson et al., 2003)
have reported that the athletes who are symmetrical can improve the sport performance.
Although further research is needed into the relationship between symmetry and athletic
performance, the potential applications of this research should also be considered. On the other
hand, opponents argue that bilateral asymmetry may negatively affect athletic performance
(Maloney, 2019). Loturco and colleagues (Loturco et al., 2019) analyzed the relationship between
vertical asymmetry and basal performance in high level female soccer players and they found
that bilateral countermovement jump (CMJ) performance was significantly associated with
strength on sprinting and squat tests, while asymmetry of unilateral squat jump (USJ) was not
associated with athletic performance. Radzak (Radzak et al., 2017), for example, has found
that asymmetries in the running gait may be beneficial after neuromuscular fatigued. This is
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due to the higher mechanical efficiency of intra-limb asymmetry than symmetry, although
limited data in previous study support this view (Afonso et al., 2020). However, the increase of
excessive asymmetry may also produce adverse effects such as sports injuries.
Within the previous studies, a stronger topic surrounding patients or rehabilitated people to
have been explored then the participants of athletes. Asymmetry of the bilateral body has been
evidenced to be indicative of movement function (Nigg, 2007). Therefore, The symmetry of
biomechanical parameters were often used in the clinical and motion capacity assessment, which
was important for restoration of abnormal function through appropriate of treatment strategies
(Tomkinson and Olds, 2000, Botelho et al., 2017). Increased symmetry is considered by clinicians
to be a sign of successful recovery and can increase the confidence of athletes to return to sport
safely and effectively (Bishop et al., 2018). The degree of asymmetry determines whether an
athlete may have a potential injury risk (Parrington and Ball, 2016, Jordan et al., 2015). Asymmetry
of bilateral loading can contribute to the increase of unilateral limb damage such as ACL injuries,
especially in female athletes (Hewett et al., 2013, Mokhtarzadeh et al., 2017). The non-contact
injury rates in soccer were 68% in non-dominant limbs for females and 74% in dominant limbs
for males (Montalvo et al., 2019). Similarly, Brown and Brughelli (Brown and Brughelli, 2014) used
symmetry of lower limbs as a decisive factor in assessing rugby players’ return-to-sport status.
Asymmetrical gaits often cause increased work on one limb in motor techniques, which may
damage one limb due to excessive load (Exell et al., 2012b). Schache et al. (Schache et al., 2009)
observed a soccer player with a unilateral hamstring strain due to a 5.7° difference in peak knee
extension between legs and a 7% vertical peak force during the swing. However, the methods used
to assess symmetry vary greatly, so caution should be exercised when establishing a correlation
between asymmetry and injury (Maloney, 2019). Previous research has shown that when
asymmetry exceeds a certain threshold, it can negatively impact an athlete’s health, although it
may be beneficial for specific athletic performance (Afonso et al., 2020). However, these thresholds
are still an unsolved problem in current studies and may vary between individuals and individual
states. Therefore, these complex explanations should be considered in future studies. By better
understanding of the effects of limbs asymmetry on athletes’ physical activities can provide an
important basis for coaches and athletes to design training strategies and rehabilitation testing.
Although previous studies generally believe that bilateral asymmetry in competitive sports
has a negative impact on sports performance and is positively correlated with a sports injury,
studies do not fully support this association. In addition, few attempts have been made in
the literature to distinguish between asymmetries of different exercise types. Therefore, this
review aims to promote a clearer understanding of intra-limb asymmetry in competitive sports
as well as to summarize their correlation with sports performance measurement and sports
injuries. It also analyzes the evaluation methods of athletes’ asymmetry in competitive sports.
METHODS
SEARCH STRATEGY AND DATA SOURCES
Current systematic review was conducted based on the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis guidelines (PRISMA). A thorough computer-aided literature search
of the database of PubMed (all years), Web OF Science (1960-present) and ScienceDirect (all
years) were performed until 19 February 2022, to identify all relevant studies, using the keywords
(‘biomechanics’ OR ‘kinetics’ OR ‘kinematics’) AND (‘symmetry’ OR ‘asymmetry’ OR ‘symmetric’)
AND (‘athlete’ OR ‘player’ OR ‘competition’ OR ‘match’). The effects of symmetry assessment on
different modes of competitive performance and injury are discussed by searching the articles
related to the application of symmetry in competitive sports.
REGISTRATION
We have registered this study on the International Platform of Registered Systematic Review
and Meta-analysis Protocols (INPLASY, Registration number: INPLASY202280023).
SELECTION CRITERIA AND DATE COLLECTION PROCESS
Studies that meet the following criteria were excluded: (1) Participants were included in
recreational sports groups rather than competitive athletes; (2) The athletes had a physical
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injury during the test. (3) Studies that scored less than 75%. Endnote X9 (Thomson Reuters,
Carlsbad, California, USA) was used to perform article collation, and duplicate articles delete
functions.
QUALITY ASSESSMENT
The assessment scheme for the quality of these literatures was based on a established scales
used in sports science. This method is commonly used to check literatures conducted in an
exercise-based training environment (Brughelli et al., 2008). This quality system developed
by Black et al., 2016 was used by a evaluator to assess the grading article quality (Black et
al., 2016). The articles were evaluated using 9 different criteria(Score: 0–2), and total(Score:
0–18): (1) Inclusion criteria stated(Score: 0–2); (2) Subjects assigned appropriately (random/
equal baseline); (3) Intervention described;(4) Dependent variables defined; (5) Assessments
practical; (6) Training duration practical (acute vs. long term);(7) Statistics appropriate (variability,
repeated measures); (8) Results detailed (mean, standard deviation, percent change, effect
size); (9) Conclusions insightful(clean concise, future directions). Where each criterion is graded
from 0(no) to 1(maybe) or 2(yes). In order to ensure the fairness of the quality assessment of
the included studies, we evaluated the scores as a percentage (Range: 0–100%).
RESULTS
SEARCH RESULTS
A total of 386 articles were initially returned, as shown in Figure 1. Any competitive athlete-related
articles were included in the initial collection process and engender a total of 31 literatures.
After identification, screening, and applying the exclusion and inclusion criteria, 22 articles were
included in this study. A total 22 articles that included the ultimate investigation (The specific
research methods were shown in Tables 1–4), 8 of these articles focused on asymmetry in gait
related sports, 7 examined asymmetry in upper limb sports, 3 of these studies attend to ball
players asymmetries, and 4 related asymmetries in multifarious sports players. The specific
athlete categories of sports studies include: sprinting players (6), multifarious sports players
(4), soccer (2), Walking race players (1), Long-distance running players (1), Rowing players (1),
archers (1), overhead sports player (1), cricket (1), Racing wheelchair player (1), paralympic
powerlifting (1), pole vault player (1), rugby player (1).
Figure 1 Flowchart of the
studies found and screened in
this systematic review.
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STUDY QUALITY
As shown in Tables 1–4, the average quality assessment rate for selected articles in this
systematic review is 94.4 ± 6.3%. Each of these literatures illustrated the inclusion criteria in
their studies, respectively. The best-reported criteria were “Results detailed” and “Conclusions
insightful” and the least reported criterion was “Inclusion criteria stated”. As shown in
Figure 2(A), the grade of average quality assessment of “Training Duration practical”, “Statistics
appropriate”, and “Results Detailed” was 2 (yes). The grade of “Inclusion criteria stated” and
“Intervention described” in ball sports is the lowest (average quality = 1.33).
BASIC CHARACTERISTICS OF INCLUDED STUDIES
Furthermore, as shown in Tables 1–4, we identified 8 studies related to the asymmetry in gait
related sports. Moreover, 7 of 22 articles investigating the asymmetry in upper limb sports. In
addition, 4 studies involved athletes in multifarious competitive sports. We identified 3 (2 soccer
and 1 rugby) studies related to the asymmetry in ball sport athletes. As shown in Figure 2(B),
we identified 6 studies on the variables of asymmetry on sprinter and 4 on multifarious sports.
The number of analyzed the variates of kinetic and kinematics asymmetries was the highest
among all the included studies, 14 and 13, respectively. 9 studies analyzed the asymmetry
of spatiotemporal variables (Figure 2(C)). In addition, SA was used as an assessment tool
for asymmetry in 8 studies, and 6 studies used the method of SI (3 studies) and two side
differences (3 studies), respectively. 5 of 22 articles used general statistical check approaches
to identify bilateral asymmetries, ANOVA (2 studies), N-K procedures (1 study), FANOVA (1
study), W M-Pairs Signed (1 study) and Separate analyses of variance (1 study), as shown in
Figure 2(D).
DISCUSSION
The purpose of the current systematic review was to investigate the existing literature on
the application of limbs asymmetry in competitive sports and to discuss the correlation with
sports performance measurement and sports injuries. Inter-limb asymmetry appears to have
a positive effect on physical performance in upper limb movement, while it may cause injury
to occur and have a detrimental effect on performance in gait related sports. However, the
evidence pertaining to inter-limb asymmetry in ball athletes and different athletes is less
conclusive. Mixed results were also found in a specific sport, suggesting that the effects of
bilateral limbs asymmetry on different athletes may be task-specific.
ASYMMETRY IN GAIT RELATED SPORTS
Since the human body is a large and complex system, consequently, gait motion can be realized
in many different ways. For example, the muscle group of the normal leg can compensate for
the other leg with the weak muscle group during gait movement (Levine et al., 2012; Patra et
al., 2022). Therefore, Gait asymmetry can increase the workload of one limb. By analyzing the
gait variability and symmetry of 35 race walkers, Tucker and Hanley reported the asymmetrical
step lengths were persistent in individual athletes, which may be caused by the underlying gait
imbalance (Tucker and Hanley, 2017). Further data has also linked gait asymmetries to sprint
running performance. Brown et al (Brown et al., 2017a) used acceleration and maximal velocity
sprinting to assess athletic performance in thirty male rugby athletes (development-level).
Trivial to small correlations was proved between the Vmax and symmetry angle of vertical and
horizontal force in both acceleration (R2 = 0.021 and 0.100) and maximal velocity sprint phases
(R2 = 0.179 and 0.0002), while the correlations between the symmetry angle in acceleration
and maximal velocity sprint phases were 0.459 for vertical force and 0.721 for horizontal
force. These results suggesting that the asymmetry of vertical and horizontal force may be
the crucial components for acceleration performance in sprinting. However, the relationship
between athlete performance with asymmetries is not clearly stablished. Another similar case
study indicated that asymmetry was negatively associated with a lower risk of injury and high
sprinting performance (Brown et al., 2017b). On the other hand, opponents argue that the
symmetry of kinematic parameters during the stride cycle was no relationship with sprinter
sports performance and the prevalence of injury (Haugen et al., 2018).
Table 1 Summary of study participants, assessment methods, assessment index, asymmetry test/ Metrics Measured and the main findings in gait related sports.
Note: SA Symmetry angle, TD touchdown, LO Liftoff, MTE Maximal Thigh Extension , MTF Maximal Thigh Flexion, SL Step length, SF Step frequency, CT Contact time, FT Flight time, SV Step velocity.
AUTHOR SPORTS PARTICIPANTS ASSESSMENT
METHODS
ASSESSMENT PARAMETERS ASYMMETRY
TESTS /METRICS
MEASURED
FINDINGS QUALITY
SCORE
Tucker and Hanley (2017)
(Tucker and Hanley, 2017)
Walking race n = 35
senior-level (n = 18) and
junior-level (n = 17)
Race walked
(speeds: 103% of the
season’s best time
for 20 km and 10 km,
respectively.)
Spatiotemporal: (SL, SF, CT, FT).
Kinetics: (Impact force; Loading
force; Mid-stance force; Push off force;
Impulse).
SA Twelve athletes were found to
have asymmetrical stride sizes,
which an underlying movement
imbalance could cause.
100%
Haugen et al., 2018
(Haugen et al., 2018)
Sprint Competitive sprinters (n = 22) 2–3 sprints over 20 m. Spatiotemporal: (SV, SL, SF, CT, FT).
Kinematics: (TD angle; thigh angle at
TD; Liftoff angle; Thigh angle at LO; Knee
angle at LO; MTF; Range of thigh motion;
Knee flexion at MTE; ankle velocity.)
Interlimb
asymmetry
No significant correlation
between individual asymmetry
and sprint performance.
100%
Girard et al. (2019)
(Girard et al., 2019)
Long-distance
running
Well-trained, un-injured
distance runners(n = 9)
Running at seven
running velocities
of 60s. (10, 12.5, 15,
17.5, 20, 22.5, and 25
km.h−1)
Spatiotemporal: (SL, SF, CT, FT).
Kinetics:( Mean loading rate; Peak
vertical Forces; Maximal downward
vertical displacement; leg compression;
vertical stiffness; leg stiffness; Braking
phase duration; Peak braking force;
Braking impulse; Push-off duration; Peak
push-off force; Push-off impulse.)
SA Changes in running speed did
not cause changes in bilateral
limb symmetry.
100%
Girard O et al. (2017)
(Girard et al., 2017)
Sprint running Male sprints athletes (n = 13) Five 5-s sprints with
25-s recovery.
Spatiotemporal: (SL, SF, CT, FT, SV).
Kinetics:( Average vertical forces;
Average horizontal forces; Average
total forces; Propulsive power; Peak
vertical forces; Centre of mass vertical
displacement; Leg compression; Vertical
stiffness; Leg stiffness).
Interlimb
asymmetry
There is the asymmetry in
kinematics, kinetics and spring-
mass characteristics during
repeated sprints. Fatigue rates
were similar in both lower limbs.
83%
(Contd.)
AUTHOR SPORTS PARTICIPANTS ASSESSMENT
METHODS
ASSESSMENT PARAMETERS ASYMMETRY
TESTS /METRICS
MEASURED
FINDINGS QUALITY
SCORE
Exell et al. (2012a)
(Exell et al., 2012b)
Sprint running Trained athletes (n = 8) maximal velocity
sprint running
Spatiotemporal: (SL; SF; SV).
Kinetics:( Net horizontal impulse; Net
vertical impulse; Maximum vertical force;
Mean support movement; Network
around the ankle, knee and hip joint.).
Kinematics:( Maximum hip height during
contact; Maximum knee lift during
contact; Minimum knee angle during
swing; Maximum hip angle at end of
contact; Touchdown distance;).
SA The occurrence of significant
asymmetry was athletes specific.
Variability within limbs should
be considered in the asymmetric
analysis.
100%
Exell et al. (2012a)
(Exell et al., 2012a)
Sprint running Male sprint trained athletes
(n = 8)
maximal velocity
sprint running
Spatiotemporal: (SL; SF; SV).
Kinetics: (Net horizontal impulse; Net
vertical impulse; Maximum vertical force;
Mean support moment; Net ankle work;
Net knee word; Net hip work.)
Kinematics:(Maximum hip height;
Minimum knee lift; minimum knee angle;
Maximum hip extension Touchdown
distance;)
SA and Composite
Asymmetry scores.
The individual difference of
lower limb asymmetry among
different sprinters is great.
94%
Brown et al. (2017b)
(Brown et al., 2017b)
Sprint running Mate sprint athlete (n = 1) submaximal sprints
for ~8s at 50, 70 and
80% and a single
short maximal trial
for ~3s.
Kinetics:(Hip relative Horizontal Force;
Hip relative power).
Kinematics: (Hip velocity).
SA Reducing the hip horizontal force
asymmetry can reduce the risk
of injury and increase sprint
performance.
94%
Brown et al. (2017a)
(Brown et al., 2017a)
Sprint running Un-injured male rugby
athletes (n = 30)
8-s sprints. Kinetics:(horizontal force;
vertical force).
Kinematics:(maximal velocity).
SA The kinetic asymmetry can
improve sprint performance.
94%
Table 2 Summary of study participants, assessment methods, assessment index, asymmetry test/ Metrics Measured and the main findings in upper limb sports.
Note: ANOVA Analysis of variance, FANOVA Functional analysis of variance, LBP low back pain, SA Symmetry angle, SL Step length, SF Step frequency, SV Step velocity, SI Symmetry index.
AUTHOR SPORTS PARTICIPANTS ASSESSMENT METHOD ASSESSMENT PARAMETERS ASYMMETRY
TESTS /METRICS
MEASURED
FINDINGS QUALITY SCORE
Warmenhoven et al.
(2018) (Warmenhoven et
al., 2018)
Rowing n = 27 national-
level (n = 14) and
international level
(n = 13)
Row for 1000 m (250m×4, stroke
rates: 20, 24, 28, and 32 strokes
per minute))
Kinetics:(propulsive pin
forces).
SI Asymmetry may lead to better
performance in rowing.
94%
Sanchis-Sanchis et al.
(2020) (Sanchis-Sanchis
et al., 2020)
archers males (n = 18) and
females (n = 12)
archers
The skin temperature of the trunk
and upper limbs was measured
pre, post and after 10 min of a
simulated archery competition.
Anthropometry: (trunk skin
temperature; upper limbs skin
temperature).
The difference
between the two
sides
The asymmetry of skin temperature
caused by Archery exercise is a
major factor in maintaining muscle
vitality and postural performance.
94%
Oyama et al. (2008)
(Oyama et al., 2008)
overhead
sports
Athlete (n = 43,
including 15
baseball pitchers, 15
volleyball players,
and 13 tennis
players.)
Electromagnetic tracking device
to measure both side scapular
position and orientation.
Kinematics:(Scapular upward-
downward and internal-
external rotation angle;
Scapular anterior-posterior tilt
angle;
Scapular protraction-
retraction angle;
Scapular elevation-depression
angle;).
Separate
analyses of
variance.
The dominant lateral shoulder
blades of overhead athletes
have more internally rotated and
anteriorly tilted. This asymmetry
may be normal.
89%
Gray et al. (2016)
(Gray et al., 2016)
Cricket adolescent provincial
league specialist fast
bowlers (n = 25, 16
with and 9 without
LBP)
Supine (Static ultrasound images) Anthropometry:( Muscle
thickness of internus
abdominis; obliquus externus
and transversus abdominis).
ANOVA The asymmetry of abdominal
muscle thickness in fast bowlers
is caused by the asymmetric
biomechanical characteristics of
the sport.
100%
Goosey et al. (1998)
(Goosey and Campbell,
1998)
Racing
wheelchair
Endurance-trained
wheelchair racers
(n = 7)
The athletes pushing their own
racing wheelchairs at 6.58 ms-1
Spatiotemporal:(Cycle time;
time spent in contact whit the
hand rim).
Kinematics: (Range of elbow
flexion;
Elbow orientation;)
Wilcoxon
Matched-Pairs
Signed-Ranks
tasks.
The symmetry exists during
wheelchair propulsion in the elbow
movement pattern for trained
wheelchair racers.
94%
Dalla Bernardina et al.
(2021) (Ramos Dalla
Bernardina et al., 2021)
Paralympic
powerlifting
Paralympic
powerlifting athletes
(n = 10, 8 men and 2
women)
Kinematic of athletes performing
in bench press at submaximal
intensities (50% and 90% of the
one-repetition maximum).
Kinematics:(Linear velocity). FANOVA Asymmetry exists in the higher
effort of disabled weightlifting tasks.
100%
Panoutsakopoulos et al.,
2021 (Panoutsakopoulos
et al., 2021)
Pole vault Pole vaulters (n =
24, 11 males and 13
females)
The athlete attempts to
complete the pole vault as best
he can, recording the last eight
steps near the start of the jump.
Spatiotemporal: (SL; SF; SV). SA There were significant gender
differences in the asymmetry of
step frequency and step length.
94%
Table 3 Summary of study participants, assessment methods, assessment index, asymmetry test/ Metrics Measured and the main findings in ball sports.
Note: SA Symmetry angle, ANOVA Analysis of variance.
AUTHOR SPORTS PARTICIPANTS ASSESSMENT METHOD ASSESSMENT PARAMETERS ASYMMETRY
TESTS /METRICS
MEASURED
FINDINGS QUALITY
SCORE
Teixeira et al (2008)
(Teixeira and Teixeira,
2008)
indoor
soccer
6-year-old (n = 8),
8-year-old (n = 8) and
10-year-old (n = 8)
indoor soccer players
Leg preference was
evaluated separately for
three task categories:
balance stabilization, soccer
related mobilization, and
general mobilization.
Functional variables:(averaged scores for
the three tasks preference).
Kinematics:(Peak ankle, knee and hip
velocity and peak delay).
Repeated measures
ANOVA and
Newman-Keuls
procedures
Age had no effect on leg
preference. There was a similar
increase in leg performance from
ages 6-8 to 10.
89%
Fousekis et al. (2010)
(Fousekis et al., 2010)
Soccer Soccer players (n = 100) Isokinetic concentric and
eccentric strength of ankle
and knee muscles be
performed.
Kinetics:(Knee Extension torque;
Knee flexion torque;
Ankle Dorsal flexion torque;
Ankle Planter flexion torque;
Knee strength ratios).
The difference
between the two
sides
There is the asymmetry in the
strength adaptation of knee joint
and ankle joint in football players.
More experienced player can more
easily handle the risk of injury
caused by asymmetry.
94%
Brown and Brughelli
(2014) (Brown and
Brughelli, 2014)
Rugby Professional rugby
league player (n = 1)
Lower limbs isokinetic
strength and sprint kinetics
be performed.
Kinetics: (Keen and Hip Extension and
flexion torque).
Kinematics: (angle of peak torque).
SA The reduction of asymmetry can
be used as an indicator of athletes’
return to sport.
83%
Table 4 Summary of study participants, assessment methods, assessment index, asymmetry test/ Metrics Measured and the main findings in multifarious sports.
Note: SI Symmetry index, SMT Spinal Manipulative Therapy, DVJ Dorp vertical jump, ACLR Anterior Cruciate Ligament Reconstruction, LSI Limb Symmetry index, CT Contact time, IC Initial contact. vGRF Vertical
ground reaction force.
STUDY SPORTS PARTICIPANTS ASSESSMENT
METHOD
ASSESSMENT PARAMETERS ASYMMETRY
TESTS /METRICS
MEASURED
FINDINGS QUALITY
SCORE
Alvarenga et al. (2019)
(Alvarenga et al., 2019)
multifarious
sports
n = 13(9 women, 4 men) Static Position, Free
squat, CMJ.
Kinetics: (Peak vGRF). SI SMT intervention changed static
symmetry greatly, but did not
change dynamic symmetry
significantly.
78%
Paterno et al. (2010)
(Paterno et al., 2010)
multifarious
sports
Athletes after ACLR (n = 56,
35 female, 21 male) and
return to sport.
Single limb dynamic
postural stability test.
Kinematic and kinetic
analysis during DVJ
maneuver.
Kinetics:( Transverse plane hip net
moment impulse; sagittal plane knee
moments at initial contact).
Kinematics:(2-dimensional frontal plane
knee joint range of motion).
The difference
between two
limbs.
Greater asymmetry in internal
knee extensor moment at initial
contact during DVJ maneuver of
ACLR athletes.
100%
Kotsifaki et al. (2022)
(Kotsifaki et al., 2022)
multifarious
sports
Male athletes (n = 47, 24
athletes after ACLR and 23
healthy male)
Triple-hop test. Spatiotemporal: (CT).
Kinetics:(Knee extension moment;
Hip, knee, ankle and total work).
Kinematics:(Hip, knee, ankle, trunk and
anterior pelvic tilt angle).
SI The triple hop symmetry for
distance masked important
deficits in knee joint work and
other biomechanical parameters
in ACLR athletes.
100%
Morishige et al. (2019)
(Morishige et al., 2019)
multifarious
sports
Female collegiate (n = 23,
basketball players, n = 15;
soccer players, n = 8) and
recreational athletes (n = 19,
basketball players, n = 10;
volleyball players, n = 9;).
DVJ Kinetics: (Peak vGRF).
Kinematics:(Knee joint angle of IC and
peak value; Knee joint moment within 40
milliseconds from IC).
Two-tailed paired
t-tests
The degree of asymmetry of knee
abduction Angle of leisure and
college athletes is the opposite.
100%
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In addition, Exell and colleagues used asymmetry composite scores to quantify the intra-limb
asymmetry in eight male sprint athletes and reported that asymmetrical measures exist for
inter-participant differences (Exell et al., 2012a). A similar study compared and evaluated the
spatiotemporal parameters and GRF asymmetries of 18 elderly and 17 young walkers and found
that although there was no overall mean asymmetry, the individual analysis found asymmetries
of several athletes (SA ≥ 1.2%) (Tucker and Hanley, 2017), This is somewhat supported by Girard
who highlighted the relatively large range of asymmetries between individuals should be taken
into account in the analysis (Girard et al., 2019). Therefore, these findings should be interpreted
with caution, significant asymmetrical variables may be athletes specific, and therefore, intra-
limb variability should be included in asymmetrical analyses to avoid misleading results (Exell
et al., 2012b). In addition, Previous studies have hypothesized that gait asymmetry may be due
to running fatigue (Brown et al., 2017a). Girard and colleagues have examined whether inter-
limb asymmetry in lower limb mechanics increases with fatigue and found that similar fatigue
rates exist in bilateral lower limbs during sprinting exercise (Girard et al., 2017). Consequently,
the cause of bilateral lower extremity asymmetry should be the focus of future research.
ASYMMETRIES IN UPPER LIMB SPORTS
The asymmetry of human body structure will cause the asymmetry of bilateral limb function.
Similarly, asymmetrical movement over a long period of time can promote structural
asymmetry. This potentially vicious cycle may have a negative impact on athletes’ training
efficiency, so exploring the causes of asymmetry should be the focus of future research.
Previous studies have reported that dexterity is one of the important causes of upper extremity
gross anatomical asymmetry (Auerbach and Raxter, 2008). Oyama et al. (Oyama et al., 2008)
assessed the asymmetry of bilateral scapular position and orientation in 3 groups of healthy
overhead athletes (13 tennis players,15 baseball pitchers and 15 volleyball players). More
internally rotated (p < 0.01) and anteriorly tilted (p < 0.01) of the scapula was showed on the
dominant side of the overhead athletes and a more protracted of the scapula position occurred
on the dominant side of the tennis players (p < 0.05). These results indicate that the cause of
the asymmetry may be related to the athletic attributes of the athletes, and clinicians should be
cautious in evaluating the asymmetry of the upper limbs in such athletes. However, the authors
did not analyze the correlation between asymmetry and exercise experience, and more future
research would be required to confirm this suggestion. More definite conclusion have been
discribed for the Paralympic powerlifting athletes. Dalla Bernardina and colleagues (Ramos
Dalla Bernardina et al., 2021) analyzed functional asymmetries during different submaximal
intensities (50% and 90% of the one-repetition maximum, 1RM) using linear velocity.
Powerlifting performed symmetrically at 50% of 1RM. In comparison, significant asymmetry
in favour of the dominant limb occurred at 90% of 1RM. By comparing the sensitivity of ANOVA
Figure 2 Characteristic
information: (A) Study Quality
assessment. (B) The number
of each sport category. (C)
the number of each test
parameter. (D) The number
of each asymmetry metrics
measured.
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and FANOVA to body asymmetry, the authors found that the latter is the most suitable for
examining the asymmetry of the performance of paralympic weightlifters. However, Further
research is needed to confirm the relationship between bilateral asymmetry and weightlifting
performance. Similar disparate findings have been reported for racing wheelchair propulsion.
Goosey reported that no statistical difference was found in the elbow height, elbow angular
displacement and propulsion phase of the racing wheelchair athletes.
For sports requiring a high level of the unilateral upper extremity, such as archery, previous
studies have shown that the nature of the movement leads to an asymmetry in skin temperature.
The authors point out that the asymmetry of different temperatures can reflect the muscle
activation of archers and make an important contribution to their posture. The influence of
exercise experience on skin temperature needs to be further explored in combination with
neuromuscular signal analysis. Asymmetry is generally thought to affect athletic performance
negatively, but the scientific evidence to support this claim is insufficient. In addition,
asymmetric types are usually not defined. Warmenhoven et al. (Warmenhoven et al., 2018)
noted that high-level rowers are more likely to use adaptive asymmetric strategies for rowing,
suggesting that asymmetries have a functional role in a rowing movement. However, more
scientific evidence is needed to determine whether asymmetry boosts rowing performance.
Gender differences is also widely believed to be an important reason for individual differences
in asymmetric parameters. Male pole vaulters with greater explosive power have greater step
length and step frequency asymmetry during competition. This gender difference could be
attributed to the athletes’ physical condition and pole characteristics. Gray et al. (Gray et al.,
2016) By comparing abdominal muscle thickness asymmetry in fast bowling players with
and without LBP, athletes with LBP had more symmetrical abdominal muscle size. However,
whether this phenomenon has clinical significance remains unclear.
ASYMMETRIES IN BALL SPORTS
Although associative studies may indicate the potential influence of asymmetries assessment
on return-to-sport status, it is important to consider degree of asymmetry related to the
degree of rehabilitation. The findings of Brown and Brughelli suggest that a multi-component
strength and dynamics assessment strategy can be used to reflect more fully the changes in
athletes’ symmetry. This finding can provide evidence for the development of return-to-sport
for athletes with different types of injuries (Brown and Brughelli, 2014). However, the specific
symmetry recovery threshold of return to competition should be the focus of future research.
Two studies have examined the performance asymmetries and their association with different
training ages in soccer players, yielding conflicting results. Teixeira et al. (Teixeira and Teixeira,
2008) was evaluated separately balance stabilization, general and soccer related mobilization
of the dominant and non-dominant lower limbs in right-footed soccer players children of
different training ages. The results showed that the lower score of leg preference and the greater
difference between individuals occurred in the stabilization task and training age had no effect
on bilateral limb asymmetry. This finding provides evidence for the amplitude of stabilization of
performance of bilateral lower extremity asymmetry during childhood development. Whereas
Fousekis et al. (Fousekis et al., 2010) Soccer players with longer training age can use their lower
extremities more evenly to deal with musculoskeletal asymmetry and may reduce the risk of
injury. Whether this discrepancy is related to the age of the assessed cohort and the assessed
indicators can be further explored.
ASYMMETRIES IN MULTIFARIOUS SPORTS
Limited data are available on the effect of motor tasks on limb asymmetry. Further studies
in a broad population of athletes are needed to clearly determine whether various body
asymmetries are associated with motor tasks. There were 4 studies included in this review
that did not evaluate the symmetry of a specific type of athletes but recruited different types
of athletes with sports experience as subjects. Liu and Jensen (Paterno et al., 2010) calculated
asymmetry of kinematics and kinetics in 56 athletes who underwent ACLR and found that
asymmetries in sagittal plane knee moments at initial contact during the landing phase of
a DVJ are strong predictors of second ACL injury. This prediction model only applies to the
prediction of secondary ACL injury in athletes who have experienced ACLR, and further
research is needed for the prediction of injury risk in healthy athletes. A similar study assessed
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changes in lower extremity symmetry in athletes who had experienced ACLR after return to
sports criteria and found that patients used hip, pelvis, and trunk compensatory strategies to
address inter-limb differences in knee function (Kotsifaki et al., 2022). A further consideration
for the inducement of asymmetry would be the Athletic level. Minimal literature has focused
on the difference in biomechanical symmetry of lower limbs in athletes of different sports
levels. Morishige et al. (2016) compared the leg asymmetry between 23 female collegiate and
19 recreational athletes during the landing phase of a DVJ, and the results showed that the
asymmetry of bilateral knee abduction Angle was opposite in the two groups. However, further
evidence is needed to determine whether this interesting phenomenon is related to the injury.
The presence of biomechanics asymmetries within athletes has been reported for several
decades. Investigations had previously reported that an increased asymmetry of bilateral
lower limbs was one of the potential causes of spinal abnormalities. However, investigation
of the ameliorating interventions of asymmetry has only recently been examined. Alvarenga
et al. (Alvarenga et al., 2019) reported that the intervention of lumbar SMT can improve the
immediate static asymmetry of athletes, more interventions related to dynamic asymmetry
need to be explored in the future.
CONCLUSIONS
The current review provides an exhaustive summary of the application of asymmetric
assessment in different competitive sports and its relationship with sports performance and
injury. Although asymmetric monitoring may be implemented in low-level sports settings,
some studies of asymmetric assessment of non-athletes may have been excluded. Currently,
in the absence of higher consistency of the results and conclusions of the included studies,
confidence in understanding the relationship between bilateral asymmetry and performance,
injury and function remains limited. Although the results in this review highlight that asymmetry
is detected in the gait-related sports and associated with motion injury, a particular threshold
size of asymmetry may cause damage has not been identified. Asymmetry seems to positively
affect athletic performance, as demonstrated in upper limb athletes, although the conclusions
are not entirely consistent. The cumulative literature suggests that large individual differences
exist in asymmetrical measurement between athletes’ limbs, experience, age, gender and
different sports tasks have also been proved to be the potential causes of asymmetrical
measurement. The results of current systematic review emphasize the complexity of bilateral
asymmetries in athletes of competitive sports. Future studies should aim to investigate specific
asymmetric thresholds that may cause sports damage in different competitive tasks and
assess symmetry’s specific effect on performance.
FUNDING INFORMATION
This study was sponsored by the China Scholarship Council (CSC NO.202108330003).
COMPETING INTERESTS
The author has no competing interests to declare.
AUTHOR AFFILIATIONS
Zixiang Gao orcid.org/0000-0002-4345-8201
Faculty of Engineering, University of Pannonia, H-8201 Veszprém, Hungary; Savaria Institute of
Technology, Eötvös Loránd University, Szombathely, Hungary
REFERENCES
Afonso, J., Bessa, C., Pinto, F., Ribeiro, D., Moura, B., Rocha, T., Vinícius, M., Canário-Lemos, R.,
Peixoto, R., & Clemente, F. M. (2020). Asymmetry as a Foundational and Functional Requirement
in Human Movement: From Daily Activities to Sports Performance. Springer Nature. DOI: https://doi.
org/10.1007/978-981-15-2549-0
Alvarenga, B., Botelho, M., Lara, J., Joao, F., & Veloso, A. (2019). Preliminary Feasibility Study to
Measure the Immediate Changes of Bilateral Asymmetry After Lumbar Spinal Manipulative
270Gao
Physical Activity and
Health
DOI: 10.5334/paah.215
Therapy in Asymptomatic Athletes. J Chiropr Med, 18(3), 205–212. DOI: https://doi.org/10.1016/j.
jcm.2019.08.003
Auerbach, B. M., & Raxter, M. H. (2008). Patterns of clavicular bilateral asymmetry in relation to the
humerus: variation among humans. Journal of human evolution, 54(5), 663–674. DOI: https://doi.
org/10.1016/j.jhevol.2007.10.002
Barber, S. D., Noyes, F. R., Mangine, R. E., & Hartman, W. (1990). Quantitative assessment of functional
limitations in normal and anterior cruciate ligament-deficient knees. Clinical Orthopaedics and
Related Research (1976–2007), 255, 204–214. DOI: https://doi.org/10.1097/00003086-199006000-
00028
Bell, D. R., Sanfilippo, J. L., Binkley, N., & Heiderscheit, B. C. (2014). Lean mass asymmetry influences
force and power asymmetry during jumping in collegiate athletes. Journal of strength and
conditioning research/National Strength & Conditioning Association, 28(4), 884–891. DOI: https://doi.
org/10.1519/JSC.0000000000000367
Bishop, C., Turner, A., & Read, P. (2018). Effects of inter-limb asymmetries on physical and sports
performance: A systematic review. Journal of sports sciences, 36(10), 1135–1144. DOI: https://doi.org
/10.1080/02640414.2017.1361894
Black, G. M., Gabbett, T. J., Cole, M. H., & Naughton, G. (2016). Monitoring workload in throwing-
dominant sports: a systematic review. Sports Medicine, 46(10), 1503–1516. DOI: https://doi.
org/10.1007/s40279-016-0529-6
Botelho, M. B., Alvarenga, B. A., Molina, N., Ribas, M., & Baptista, A. F. (2017). Spinal manipulative
therapy and sports performance enhancement: a systematic review. Journal of manipulative and
physiological therapeutics, 40(7), 535–543. DOI: https://doi.org/10.1016/j.jmpt.2017.03.014
Brown, S. R., & Brughelli, M. (2014). Determining return-to-sport status with a multi-component
assessment strategy: a case study in rugby. Phys Ther Sport, 15(3), 211–5. DOI: https://doi.
org/10.1016/j.ptsp.2014.01.003
Brown, S. R., Cross, M. R., Girard, O., Brocherie, F., Samozino, P., & Morin, J. B. (2017a). Kinetic Sprint
Asymmetries on a non-motorised Treadmill in Rugby Union Athletes. Int J Sports Med, 38(13), 1017–
1022. DOI: https://doi.org/10.1055/s-0043-117607
Brown, S. R., Feldman, E. R., Cross, M. R., Helms, E. R., Marrier, B., Samozino, P., & Morin, J. B. (2017b).
The Potential for a Targeted Strength-Training Program to Decrease Asymmetry and Increase
Performance: A Proof of Concept in Sprinting. Int J Sports Physiol Perform, 12(10), 1392–1395. DOI:
https://doi.org/10.1123/ijspp.2016-0590
Brughelli, M., Cronin, J., Levin, G., & Chaouachi, A. (2008). Understanding change of direction ability
in sport. Sports medicine, 38(12), 1045–1063. DOI: https://doi.org/10.2165/00007256-200838120-
00007
Exell, T. A., Gittoes, M. J., Irwin, G., & Kerwin, D. G. (2012a). Gait asymmetry: composite scores for
mechanical analyses of sprint running. J Biomech, 45(6), 1108–11. DOI: https://doi.org/10.1016/j.
jbiomech.2012.01.007
Exell, T. A., Irwin, G., Gittoes, M. J., & Kerwin, D. G. (2012b). Implications of intra-limb variability on
asymmetry analyses. J Sports Sci, 30(4), 403–9. DOI: https://doi.org/10.1080/02640414.2011.647047
Fousekis, K., Tsepis, E., & Vagenas, G. (2010). Lower limb strength in professional soccer players: profile,
asymmetry, and training age. Journal of Sports Science and Medicine 9(3), 364–373.
Girard, O., Brocherie, F., Morin, J. B., & Millet, G. P. (2017). Lower limb mechanical asymmetry
during repeated treadmill sprints. Hum Mov Sci, 52, 203–214. DOI: https://doi.org/10.1016/j.
humov.2017.02.008
Girard, O., Morin, J. B., Ryu, J., Read, P., & Townsend, N. (2019). Running Velocity Does Not Influence
Lower Limb Mechanical Asymmetry. Front Sports Act Living, 1, 36–47. DOI: https://doi.org/10.3389/
fspor.2019.00036
Goosey, V. L., & Campbell, I. G. (1998). Symmetry of the elbow kinematics during racing wheelchair
propulsion. Ergonomics, 41(12), 1810–20. DOI: https://doi.org/10.1080/001401398185983
Gray, J., Aginsky, K. D., Derman, W., Vaughan, C. L., & Hodges, P. W. (2016). Symmetry, not asymmetry,
of abdominal muscle morphology is associated with low back pain in cricket fast bowlers. J Sci Med
Sport, 19(3), 222–226. DOI: https://doi.org/10.1016/j.jsams.2015.04.009
Grindem, H., Logerstedt, D., Eitzen, I., Moksnes, H., Axe, M. J., Snyder-Mackler, L., Engebretsen, L.,
& Risberg, M. A. (2011). Single-legged hop tests as predictors of self-reported knee function in
nonoperatively treated individuals with anterior cruciate ligament injury. The American journal of
sports medicine, 39(11), 2347–2354. DOI: https://doi.org/10.1177/0363546511417085
Haugen, T., Danielsen, J., Mcghie, D., Sandbakk, O., & Ettema, G. (2018). Kinematic stride cycle
asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters.
Scand J Med Sci Sports, 28(3), 1001–1008. DOI: https://doi.org/10.1111/sms.12953
Hewett, T. E., Di Stasi, S. L., & Myer, G. D. (2013). Current concepts for injury prevention in athletes after
anterior cruciate ligament reconstruction. The American journal of sports medicine, 41(1), 216–224.
DOI: https://doi.org/10.1177/0363546512459638
271Gao
Physical Activity and
Health
DOI: 10.5334/paah.215
Hoffman, J. R., Ratamess, N. A., Klatt, M., Faigenbaum, A. D., & Kang, J. (2007). Do bilateral power
deficits influence direction-specific movement patterns? Research in Sports Medicine, 15(2), 125–132.
DOI: https://doi.org/10.1080/15438620701405313
Jordan, M. J., Aagaard, P., & Herzog, W. (2015). Lower limb asymmetry in mechanical muscle function:
a comparison between ski racers with and without ACL reconstruction. Scandinavian journal of
medicine & science in sports, 25(3), e301–e309. DOI: https://doi.org/10.1111/sms.12314
Kotsifaki, A., Van Rossom, S., Whiteley, R., Korakakis, V., Bahr, R., Sideris, V., Smith, P. G., & Jonkers,
I. (2022). Symmetry in Triple Hop Distance Hides Asymmetries in Knee Function After ACL
Reconstruction in Athletes at Return to Sports. Am J Sports Med, 50(2), 441–450. DOI: https://doi.
org/10.1177/03635465211063192
Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., & Witvrouw, E. (2016). Likelihood of ACL graft rupture: not
meeting six clinical discharge criteria before return to sport is associated with a four times greater
risk of rupture. British journal of sports medicine, 50(15), 946–951. DOI: https://doi.org/10.1136/
bjsports-2015-095908
Levine, D., Richards, J., & Whittle, M. W. (2012). Whittle’s gait analysis, Elsevier health sciences.
Loturco, I., Pereira, L. A., Kobal, R., Abad, C. C., Rosseti, M., Carpes, F. P., & Bishop, C. (2019). Do
asymmetry scores influence speed and power performance in elite female soccer players? Biology of
sport, 36(3), 209–216. DOI: https://doi.org/10.5114/biolsport.2019.85454
Maloney, S. J. (2019). The relationship between asymmetry and athletic performance: A critical review.
The Journal of Strength & Conditioning Research, 33(9), 2579–2593. DOI: https://doi.org/10.1519/
JSC.0000000000002608
Mokhtarzadeh, H., Ewing, K., Janssen, I., Yeow, C.-H., Brown, N., & Lee, P. V. S. (2017). The effect of leg
dominance and landing height on ACL loading among female athletes. Journal of biomechanics, 60,
181–187. DOI: https://doi.org/10.1016/j.jbiomech.2017.06.033
Montalvo, A. M., Schneider, D. K., Webster, K. E., Yut, L., Galloway, M. T., Heidt Jr, R. S., Kaeding, C. C.,
Kremcheck, T. E., Magnussen, R. A., & Parikh, S. N. (2019). Anterior cruciate ligament injury risk
in sport: a systematic review and meta-analysis of injury incidence by sex and sport classification.
Journal of athletic training, 54(5), 472–482. DOI: https://doi.org/10.4085/1062-6050-407-16
Morishige, Y., Harato, K., Kobayashi, S., Niki, Y., Matsumoto, M., Nakamura, M., & Nagura, T. (2019).
Difference in leg asymmetry between female collegiate athletes and recreational athletes during
drop vertical jump. J Orthop Surg Res, 14(1), 424. DOI: https://doi.org/10.1186/s13018-019-1490-5
Nigg, B. M. (2007). Biomechanics of the musculo-skeletal system, John Wiley & Sons Incorporated.
Oyama, S., Myers, J. B., Wassinger, C. A., Daniel Ricci, R., & Lephart, S. M. (2008). Asymmetric resting
scapular posture in healthy overhead athletes. Journal of Athletic Training, 43(6), 565–570. DOI:
https://doi.org/10.4085/1062-6050-43.6.565
Panoutsakopoulos, V., Theodorou, A. S., Kotzamanidou, M. C., Exell, T. A., & Kollias, I. A. (2021). Gender
differences in pole vault approach run kinematics and step parameter asymmetry during an elite
indoor competition. International Journal of Performance Analysis in Sport, 21(4), 477–490. DOI:
https://doi.org/10.1080/24748668.2021.1917977
Parrington, L., & Ball, K. (2016). Biomechanical Considerations of Laterality in Sport. Laterality in Sports,
279–308. DOI: https://doi.org/10.1016/B978-0-12-801426-4.00013-4
Paterno, M. V., Schmitt, L. C., Ford, K. R., Rauh, M. J., Myer, G. D., Huang, B., & Hewett, T. E. ( 2010).
Biomechanical measures during landing and postural stability predict second anterior cruciate
ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med,
38(10), 1968–78. DOI: https://doi.org/10.1177/0363546510376053
Patra, R., Das, H. C., Jena, S. (2022). Evaluation of the mechanical behaviour of a bipolar hip prosthesis
under transient loading. International Journal of Biomedical Engineering and Technology, 39, 314–326
DOI: https://doi.org/10.1504/IJBET.2022.124190
Preatoni, E., Ferrario, M., Donà, G., Hamill, J., & Rodano, R. (2010). Motor variability in sports: a non-linear
analysis of race walking. Journal of sports sciences, 28(12), 1327–1336. DOI: https://doi.org/10.1080/
02640414.2010.507250
Preatoni, E., Hamill, J., Harrison, A. J., Hayes, K., Van Emmerik, R. E., Wilson, C., & Rodano, R. (2013).
Movement variability and skills monitoring in sports. Sports biomechanics, 12(2), 69–92. DOI: https://
doi.org/10.1080/14763141.2012.738700
Radzak, K. N., Putnam, A. M., Tamura, K., Hetzler, R. K., & Stickley, C. D. (2017). Asymmetry between
lower limbs during rested and fatigued state running gait in healthy individuals. Gait & posture, 51,
268–274. DOI: https://doi.org/10.1016/j.gaitpost.2016.11.005
Ramos Dalla Bernardina, G., Danillo Matos Dos Santos, M., Alves Resende, R., Tulio De Mello, M.,
Rodrigues Albuquerque, M., Augusto Paolucci, L., Carpes, F. P., Silva, A., & Gustavo Pereira De
Andrade, A. (2021). Asymmetric velocity profiles in Paralympic powerlifters performing at different
exercise intensities are detected by functional data analysis. J Biomech, 123, 110523–8. DOI: https://
doi.org/10.1016/j.jbiomech.2021.110523
272Gao
Physical Activity and
Health
DOI: 10.5334/paah.215
TO CITE THIS ARTICLE:
Gao, Z. (2022). The Effect of
Application of Asymmetry
Evaluation in Competitive
Sports: A Systematic Review.
Physical Activity and Health,
6(1), pp. 257–272. DOI: https://
doi.org/10.5334/paah.215
Submitted: 25 September 2022
Accepted: 01 November 2022
Published: 30 November 2022
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Physical Activity and Health is
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Press.
Rohman, E., Steubs, J. T., & Tompkins, M. (2015). Changes in involved and uninvolved limb function
during rehabilitation after anterior cruciate ligament reconstruction: implications for Limb Symmetry
Index measures. The American journal of sports medicine, 43(6), 1391–1398. DOI: https://doi.
org/10.1177/0363546515576127
Sanchis-Sanchis, R., Priego-Quesada, J. I., Ribas-Garcia, V., Carpes, F. P., Encarnacion-Martinez, A.,
& Perez-Soriano, P. (2020). Effects of asymmetrical exercise demands on the symmetry of skin
temperature in archers. Physiol Meas, 41(11), 114002. DOI: https://doi.org/10.1088/1361-6579/
abc020
Schache, A., Wrigley, T., Baker, R., & Pandy, M. (2009). Biomechanical response to hamstring muscle
strain injury: A single case study. Journal of Science and Medicine in Sport, 12, S47–S50. DOI: https://
doi.org/10.1016/j.jsams.2008.12.116
Teixeira, M. C., & Teixeira, L. A. (2008). Leg preference and interlateral performance asymmetry in soccer
player children. Dev Psychobiol, 50(8), 799–806. DOI: https://doi.org/10.1002/dev.20322
Tomkinson, G. R., & Olds, T. (2000). Physiological correlates of bilateral symmetry in humans.
International journal of sports medicine, 21(08), 545–550. DOI: https://doi.org/10.1055/s-2000-8479
Tomkinson, G. R., Popović, N., & Martin, M. (2003). Bilateral symmetry and the competitive standard
attained in elite and sub-elite sport. Journal of Sports Sciences, 21(3), 201–211. DOI: https://doi.org/1
0.1080/0264041031000071029a
Trivers, R., Palestis, B. G., & Manning, J. T. (2013). The symmetry of children’s knees is linked to their
adult sprinting speed and their willingness to sprint in a long-term Jamaican study. PLoS One, 8(8),
e72244. DOI: https://doi.org/10.1371/journal.pone.0072244
Tucker, C. B., & Hanley, B. (2017). Gait variability and symmetry in world-class senior and junior race
walkers. J Sports Sci, 35(17), 1739–1744. DOI: https://doi.org/10.1080/02640414.2016.1235793
Vincent, H. K., & Vincent, K. R. (2019). Rehabilitation and Prehabilitation for Upper Extremity in Throwing
Sports: Emphasis on Lacrosse. Current sports medicine reports, 18(6), 229–238. DOI: https://doi.
org/10.1249/JSR.0000000000000606
Warmenhoven, J., Smith, R., Draper, C., , Harrison, A. J., Bargary, N., & Cobley, S. (2018). Force
coordination strategies in on- water single sculling: Are asymmetries related to better rowing
performance? Scandinavian Journal of Medicine & Science in Sports, 28(4), 1379–1388. DOI: https://
doi.org/10.1111/sms.13031
Xiang, L., Mei, Q., Wang, A., Shim, V., Fernandez, J., & Gu, Y. (2022). Evaluating function in the hallux
valgus foot following a 12-week minimalist footwear intervention: A pilot computational analysis. J
Biomech, 132, 110941. DOI: https://doi.org/10.1016/j.jbiomech.2022.110941
Xu, D., Quan, W., Zhou, H., Sun, D., Baker, J. S., & Gu, Y. (2022). Explaining the differences of gait patterns
between high and low-mileage runners with machine learning. Sci Rep., 12, 2981. DOI: https://doi.
org/10.1038/s41598-022-07054-1
Yahya, U., Senanayake, S. M. N. A., Naim, A. G. (2022). Characterising leg-dominance in healthy
netballers using 3D kinematics-electromyography features’ integration and machine learning
techniques. International Journal of Biomedical Engineering and Technology, 39, 65–92. DOI: https://
doi.org/10.1504/IJBET.2022.123259
