Association between the Foot Posture Index and running related injuries: A case-control study

Predictors of Running-Related Injury Among Recreational Runners: A Prospective Cohort Study of the Role of Perfectionism, Mental Toughness, and Passion in Running

BACKGROUND

The health benefits associated with recreational running are challenged by the occurrence of running-related injuries (RRIs). Effective preventive measures require knowledge of sport injury etiology. Psychological factors such as perfectionism, mental toughness, and passion are believed to predispose to sports injury by influencing training behaviors, motivation to run, and suppression of feelings of fatigue and pain. Yet their association with RRIs are understudied.

HYPOTHESIS

Perfectionism, mental toughness, and passion predict an increased risk of RRIs in recreational runners.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 143 recreational runners (age 34.9 ± 13.9 years, 37% women) with a response rate of 76.5% answered an online questionnaire about their characteristics, running behaviors, and psychological variables (perfectionism, mental toughness, and running passion) as well as a sports injury survey. Then, as a primary outcome, RRIs were recorded biweekly for 6 months. The incidence of injuries was expressed as RRI per 1000 hours of running. The association between predictive factors and RRIs was estimated using logistic regression.

RESULTS

The incidence of RRIs during follow-up was 5.16 per 1000 hours of running. The knee was the location injured most often (26.4%), followed by the foot (18.9%) and lower leg (13.2%). Higher obsessive passion (OP) for running (odds ratio [OR], 1.11; 95% CI, 1.04-1.20) and perfectionistic concerns (OR, 1.22; CI,1.05-1.41) were associated with a greater risk of RRIs, as were previous injury (OR, 2.49; CI,1.10-5.70), weekly running distance (OR,1.10; CI, 1.03-1.16), and both supinated (OR, 4.51; CI, 1.11-18.30) and pronated (OR, 3.55; CI, 1.29-9.80) foot type. Following a running schedule (OR, 0.24; CI, 0.09-0.66) was associated with a lower risk of RRIs.

CONCLUSION

History of previous RRI, pronated and supinated foot type, weekly running distance, perfectionistic concerns, and OP increased RRI risk in recreational runners. Following a running schedule was a protective factor.

CLINICAL RELEVANCE

Multiple factors, including runners' psychological characteristics, predict RRIs. These findings can inform the development of injury risk management strategies.

Comparison of foot kinematics and ground reaction force characteristics during walking in individuals with highly and mildly pronated feet

BACKGROUND

Individuals with highly pronated feet (PF) are more prone to lower extremity injuries than those with mildly PF. However, whether foot kinematics and ground reaction force (GRF) characteristics differ according to the severity of PF deformity is unclear.

RESEARCH QUESTION

Are there differences in foot kinematics and GRF characteristics during walking between individuals with mildly PF and those with highly PF?

METHODS

Ten individuals with mildly PF and 10 with highly PF (six-item foot posture index scores: 6-9 and 10-12 points, respectively) participated in this study. A three-dimensional motion analysis system measured participants' foot kinematics and GRF characteristics during gait trials.

RESULTS

Participants with highly PF exhibited significantly lower medial longitudinal arch heights than those with mildly PF from 0 % to 90 % of the stance phase (p < 0.05). No significant differences were observed in any of the angles between the foot segments. Additionally, participants with highly PF exhibited significantly larger posterior GRF than those with mildly PF from 2 % to 7 % of the stance phase (p < 0.05). Participants with highly PF also exhibited significantly larger anterior GRF than those with mildly PF, from 62 % to 82 % of the stance phase (p < 0.05).

SIGNIFICANCE

The results of this study suggest that the more severe the PF deformity, the more inefficient the foot ground force transmission, and the stronger the load applied to the foot. These results may be related to the higher incidence of lower extremity injuries in individuals with highly PF than in those with mildly PF.

Pilot Study: The Relationship between Foot Posture and Movement Quality in Non-Professional Male Football Players

(1) Background: This study focusses on establishing the relationship between quality of movement (based on the functional movement screen, or FMS) and foot posture (based on the foot posture index, or FPI-6). We hypothesised that a poor FMS test score may be derived from the foot position in the space measured by FPI-6. (2) Methods: a quasi-experimental and cross-sectional study was designed to analyse foot posture in 30 healthy football players, using the foot posture index and the functional movement screen. (3) Results: No significant relationships were found between movement quality and foot posture. Poor movement quality is present in more than half of all foot positions, supination, pronation, and neutral. Good quality seems to be more associated with a neutral foot position (23.3%) and supinated (16.6%) than a pronated foot position (6.6%). (4) Conclusions: this study found no relationship between the two tests; therefore, we cannot demonstrate that foot posture is relevant in the quality of the movement of the football players studied.

Translation, Cross-Cultural Adaptation, and Validation of the Foot Posture Index (FPI-6)-Italian Version

Since foot posture is one of the main predictors of lower limb musculoskeletal injuries, it is crucial to use appropriate tools to define the foot's posture. The Foot Posture Index is, therefore, a reliable method to measure foot posture and is widely known and used in clinics and research. This study aimed to translate the Foot Posture Index 6 (FPI6) into Italian and to assess its psychometric properties. Translation and cross-cultural adaptation were obtained using a popular guideline. Two examinators assessed 68 subjects, and data were collected to test intra/inter-rater reliability, internal consistency and cross-cultural validity. The Italian version of FPI6 showed excellent inter- and intra-rater reliability (ICC 0.96 and 0.97), and Cronbach's alpha coefficient was 0.9, thus showing excellent internal consistency. The FPI-6 version has proved to be reliable in terms of inter- and intra-rater reliability and can, therefore, be used in clinical practice and scientific research.

Differences in the coordination and its variability among foot joints during running in neutral foot and flatfoot

Flatfoot is a well-known foot deformity, with a prevalence of 11.2%-29.0% among adults. Running injuries can occur in individuals with flatfoot; however, the underlying mechanism remains unknown. We investigated the coordination pattern and variability among foot joints while running by comparing participants with neutral foot and with flatfoot. Participants with neutral foot (n = 15) and flatfoot (n = 15) were asked to run at their preferred speed. Using the modified vector coding technique, the coupling angle between the foot joints, representing interjoint coordination, was calculated and categorized into four coordination patterns. The standard deviation of the coupling angle was computed to measure the coordination variability during the stance phase. There were no differences in the spatiotemporal parameters (speed, step length, and cadence) between the groups. In the sagittal rearfoot and sagittal midfoot coordination patterns, the flatfoot group showed a significantly greater proportion of anti-phase with proximal dominancy and a lower proportion of in-phase with proximal dominancy than the neutral foot group during early stance. Coordination variabilities between the sagittal rearfoot and sagittal midfoot (midstance), between the sagittal midfoot and sagittal forefoot (early stance), and between the frontal rearfoot and sagittal midfoot (midstance) were greater in the flatfoot group than in the neutral foot group. This may explain why those with flatfoot are likely to experience running injuries.

Effect of Arch Height Flexibility in Individuals With Flatfoot on Abductor Hallucis Muscle Activity and Medial Longitudinal Arch Angle During Short Foot Exercises

Flatfoot presents decreased medial longitudinal arch (MLA), and such foot deformity involves intrinsic foot muscles dysfunction. Flatfoot can be classified into flexible and stiff types according to arch height flexibility (AHF). Short foot exercise (SFE) is an intrinsic foot muscle strengthening exercise, which is reportedly effective against flatfoot. However, its effectiveness against flexible or stiff types in flatfoot is unclear. We examined the effect of AHF in individuals with flatfoot during abductor hallucis muscle (AbH) activity and medial longitudinal arch during SFE. Foot alignment was assessed using the arch height index during standing, and individuals with flatfoot (N = 16) were recruited. The AbH activity and MLA angle during SFE while maintaining single-leg standing were assessed. The relationship between AHF and AbH activity and between AHF and MLA angle ratio was analyzed using correlation coefficients. Additional correlations between AHF and AbH activity were observed with the outliers removed. There were no correlations between AHF and AbH muscle activity and between AHF and MLA angle ratio. However, with the 2 outliers removed, moderate correlations between AHF and AbH activity were significant (r = 0.64, p = .01). AbH activity during SFE increased in individuals with flatfoot for high AHF (flexible type). Thus, SFE may be more effective for individuals with flatfoot having a high AHF. These findings may be helpful when making decisions for surgery and rehabilitation.

Toward improved understanding of foot shape, foot posture, and foot biomechanics during running: A narrative review

The current narrative review has explored known associations between foot shape, foot posture, and foot conditions during running. The artificial intelligence was found to be a useful metric of foot posture but was less useful in developing and obese individuals. Care should be taken when using the foot posture index to associate pronation with injury risk, and the Achilles tendon and longitudinal arch angles are required to elucidate the risk. The statistical shape modeling (SSM) may derive learnt information from population-based inference and fill in missing data from personalized information. Bone shapes and tissue morphology have been associated with pathology, gender, age, and height and may develop rapid population-specific foot classifiers. Based on this review, future studies are suggested for 1) tracking the internal multi-segmental foot motion and mapping the biplanar 2D motion to 3D shape motion using the SSM; 2) implementing multivariate machine learning or convolutional neural network to address nonlinear correlations in foot mechanics with shape or posture; 3) standardizing wearable data for rapid prediction of instant mechanics, load accumulation, injury risks and adaptation in foot tissue and bones, and correlation with shapes; 4) analyzing dynamic shape and posture via marker-less and real-time techniques under real-life scenarios for precise evaluation of clinical foot conditions and performance-fit footwear development.

Notes from the Field: The Construction of a Logistical Model for Sports-Related Injury Risk Assessment. A Cross-Sectional Pilot Study

Handball is a high-intensity contact sports activity characterized by repetitive movements, leading to sport-specific muscle patterns. However, at some stage, this pattern may turn into imbalance, predisposing athletes for injuries. The complexity of muscular interactions often makes it difficult to see a whole picture of an athlete's postural disorders and assess them within the framework of his stereotyped movements. We attempted to find an association between the muscle pattern and the number of injuries in a limited group of handball players by constructing a static logistical model. The constructed decision table of the static logistical model included seven conditional attributes of the muscle imbalance as preconditions for injury development and one decision attribute representing the number of experienced injuries of 25 university handball players. The findings displayed a sport-specific pattern of muscle alignment in athletes without or only one injury. However, all players with repetitive injuries had unilateral m. gluteus maximus weakness. In the latter case, impaired core body musculature can lead to increased share forces and stress for the gluteus maximus muscle leading to weakness of this crucial dynamic stabilizer. The logistical model allowed defining muscle imbalance associated with sports-related injuries in a limited group of athletes.

Symptomatic and asymptomatic pronated feet show differences in the forefoot abduction motion during jogging, but not in the arch deformation

Pronated feet have been associated with higher risks of running-related overuse injuries than neutral feet. However, it remains unclear why some pronated feet develop running-related injuries, while others do not. This study aimed to examine the differences in foot kinematics during jogging among individuals with symptomatic pronated feet (SP), asymptomatic pronated feet (AP) and asymptomatic neutral feet (AN). Thirty-nine recreational runners were recruited and classified into the SP, AP and AN groups. Statistical parametric mapping (SPM) and ANOVA were used to identify kinematic differences among three groups. The SPM results showed that the SP had larger forefoot abduction than the AN and AP during jogging, while three groups had similar rearfoot eversion during jogging. Both the AP and SP had larger forefoot sagittal range of motion (ROM) (mean difference = 3.5 and 4.8 deg, respectively) and smaller rearfoot sagittal ROM (mean difference = 5.0 and 3.5 deg, respectively) than the AN. Forefoot abduction during jogging may have the potential to identify pronated feet at greater risk of injury. Pronated feet, symptomatic or not, have comparable large forefoot sagittal ROM, i.e., arch deformation, compared to neutral feet. The findings could have implications for the injury aetiology and intervention strategies for SP.

Foot Orthoses Enhance the Effectiveness of Exercise, Shockwave, and Ice Therapy in the Management of Medial Tibial Stress Syndrome

OBJECTIVE

Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners.

DESIGN

A prospective randomized controlled trial.

SETTING

Sport training and medical centers.

PARTICIPANTS

Fifty female recreational runners with MTSS were randomized into 2 groups.

INTERVENTIONS

Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy.

MAIN OUTCOME MEASURES

Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18.

RESULTS

Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18.

CONCLUSIONS

Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.

Evaluation of the Correlation Between Flamenco Dance and Ankle and Foot Posture

BACKGROUND

The practice of flamenco dance involves great biomechanical demands, comparable with a high-performance sport. The technical movements of the footwork tap, the jumps, and the turns increase the prevalence of injuries and pathologic disorders of the foot and lower limb. Limited research has examined adaptation of the foot posture and dorsiflexion of the ankle in flamenco dancing. Therefore, the aim of this study was to evaluate whether the practice of flamenco dancing produces modifications in the ankle's dorsiflexion range of motion, Foot Posture Index, or pronation.

METHODS

A cross-sectional observational study with intentional sampling was performed with 26 individuals (52 feet) in two groups: professional female flamenco dancers (n = 13) and nondancers (n = 13). The participants were assessed in a single session for ankle dorsiflexion, foot pronation (navicular drop test), and foot posture (Foot Posture Index).

RESULTS

Significant differences were found between the two groups for left foot Foot Posture Index (P = .007) and right foot navicular drop test (P = .006).

CONCLUSIONS

The results of this study indicate that flamenco dancing can produce modifications in the Foot Posture Index and foot pronation versus nondancers. Further research is required.

Classification of medial longitudinal arch kinematics during running and characteristics of foot muscle morphology in novice runners with pronated foot

BACKGROUND

Novice runners with pronated feet are at an increased risk of running-related injuries. However, not all runners with pronated feet have increased foot pronation during running. Moreover, although foot muscle morphology is related to static foot alignment, the relationship between foot muscle morphology and foot kinematics during running remains unclear. We aimed to determine foot kinematic patterns during running among novice runners with pronated feet and the presence of a relationship between these foot kinematic patterns and foot muscle morphology.

METHODS

Twenty-one novice runners with pronated feet participated in this study, and data on 39 lower limbs were collected. Data on foot kinematics during running (rearfoot strike) were collected using a three-dimensional motion capture system in terms of navicular height (NH) at initial contact and dynamic navicular drop (DND). A hierarchical cluster analysis method was used to identify the optimal number of clusters based on these two foot-related kinematic variables. Following identification of the clusters, differences in cluster variables and cross-sectional areas of selected foot muscles assessed using ultrasonography in each cluster were examined. The muscles of interest included the abductor hallucis, flexor hallucis brevis and longus, flexor digitorum brevis and longus, and peroneus longus.

RESULTS

Three subgroups were identified based on foot kinematics during running: cluster 1, lowest NH at initial contact and larger DND; cluster 2, moderate NH at initial contact and smaller DND; and cluster 3, highest NH at initial contact and larger DND. Clusters 1 and 3 had a larger abductor hallucis compared with cluster 2, and cluster 3 had a larger flexor hallucis brevis compared with cluster 2.

SIGNIFICANCE

These subgroups may differ in terms of resistance to and type of running-related injury. Moreover, foot kinematics during running is possibly impacted by the morphology and function of medial intrinsic foot muscles.

Forefoot Injuries in Athletes: Integration of the Movement System

Despite the prevalence of forefoot related problems in athletes, there are few comprehensive summaries on examination and intervention strategies for those with forefoot related symptoms. While many factors may contribute to pathology and injury, the presence of abnormal foot alignment can negatively affect lower extremity biomechanics and be associated with injuries. Physical therapists may use the characteristics associated abnormal pronation or abnormal supination to describe the movement system disorder and serve as a guide for evaluating and managing athletes with forefoot pathologies. Athletes with an abnormal pronation movement system diagnosis typically demonstrate foot hypermobility, have decreased strength of the tibialis posterior muscle, and present with a medially rotated lower extremity position. Athletes with abnormal supination movement system diagnosis typically demonstrate foot hypomobility, decreased strength of the fibularis muscles, and a laterally rotated lower extremity position. Interventions of manual therapy, taping, strengthening exercises, and neuromuscular reeducation can be directed at the identified impairments and abnormal movements. The purpose of this clinical commentary is to integrate a movement system approach in pathoanatomical, evaluation, and intervention considerations for athletes with common forefoot pathologies, including stress fractures, metatarsalgia, neuroma, turf toe, and sesamoiditis. By applying a prioritized, objective problem list and movement system diagnosis, emphasis is shifted from a pathoanatomical diagnosis-based treatment plan to a more impairment and movement focused treatment.

LEVEL OF EVIDENCE

5.

Do Injury-Resistant Runners Have Distinct Differences in Clinical Measures Compared with Recently Injured Runners?

INTRODUCTION

Although lower extremity muscle strength, joint motion, and functional foot alignment are commonly used, time-efficient clinical measures that have been proposed as risk factors for running-related injuries, it is unclear if these factors can distinguish injury resistance in runners.

PURPOSE

This study compares clinical measures, with consideration of sex, between recently injured runners (3 months to 1 yr prior), those with a high level of injury resistance who have been uninjured for at least 2 yr, and never-injured runners.

METHODS

Averaged bilateral values and between-limb symmetry angles of lower limb isometric muscle strength, joint motion, navicular drop, and foot posture index (FPI) were assessed in a cohort of recreational runners, and their injury history was recorded. Differences in clinical measures between injury groupings were examined, with consideration of sex.

RESULTS

Of the 223 runners tested, 116 had been recently injured, 61 had been injured >2 yr ago and were deemed to have acquired reinjury resistance, and 46 were never injured. Plantarflexion was greater in both recently injured (P = 0.001) and acquired reinjury resistance runners (P = 0.001) compared with never-injured runners. Recently injured runners displayed higher hip abduction strength compared with never-injured runners (P = 0.019, η2 = 0.038, small effect size). There were no statistically significant differences in the remaining measures between the injury groupings. With the exception of FPI, there was no interaction between sex and injury grouping for any of the measures.

CONCLUSION

Commonly used clinical measures of strength, joint motion, and functional foot alignment were not superior in injury-resistant runners compared with recently injured runners, questioning their relevance in identifying future injury resistance of runners.

Factors Associated With Lower Limb Injuries in Recreational Runners: A Cross-Sectional Survey Including Mental Aspects and Sleep Quality

Knowledge about prevalence and etiology of running-related injuries (RRIs) is important to design effective RRI prevention programs. Mental aspects and sleep quality seem to be important potential risk factors, yet their association with RRIs needs to be elucidated. The aims of this study are to investigate the epidemiology of RRIs in recreational runners and the association of mental aspects, sleep, and other potential factors with RRIs. An internet-based questionnaire was sent to recreational runners recruited through social media, asking for personal and training characteristics, mental aspects (obsessive passion, motivation to exercise), sleep quality, perceived health, quality of life, foot arch type, and RRIs over the past six months. Data were analyzed descriptively and using logistic regression. Self-reported data from 804 questionnaires were analyzed. Twenty-five potential risk factors for RRIs were investigated. 54% of runners reported at least one RRI. The knee was the most-affected location (45%), followed by the lower leg (19%). Patellofemoral pain syndrome was the most-reported injury (20%), followed by medial tibial stress syndrome (17%). Obsessive passionate attitude (odds ratio (OR):1.35; 95% confidence interval (CI):1.18-1.54), motivation to exercise (OR:1.09; CI:1.03-1.15), and sleep quality (OR:1.23; CI:1.15-1.31) were associated with RRIs, as were perceived health (OR:0.96; CI:0.94-0.97), running over 20 km/week (OR:1.58; CI:1.04-2.42), overweight (OR:2.17; CI:1.41-3.34), pes planus (OR:1.80; CI:1.12-2.88), hard-surface running (OR:1.37; CI:1.17-1.59), running company (OR:1.65; CI:1.16-2.35), and following a training program (OR:1.51; CI:1.09-2.10). These factors together explained 30% of the variance in RRIs. A separate regression analysis showed that mental aspects and sleep quality explain 15% of the variance in RRIs. The association of mental aspects and sleep quality with RRIs adds new insights into the multifactorial etiology of RRIs. We therefore recommend that besides common risk factors for RRI, mental aspects and sleep be incorporated into the advice on prevention and management of RRIs.