A prospective study on gait-related intrinsic risk factors for lower leg overuse injuries

Testing protocols and measurement techniques when using pressure sensors for sport and health applications: A comparative review

Plantar pressure measurement systems are routinely used in sports and health applications to assess locomotion. The purpose of this review is to describe and critically discuss: (a) applications of the pressure measurement systems in sport and healthcare, (b) testing protocols and considerations for clinical gait analysis, (c) clinical recommendations for interpreting plantar pressure data, (d) calibration procedures and their accuracy, and (e) the future of pressure sensor data analysis. Rigid pressure platforms are typically used to measure plantar pressures for the assessment of foot function during standing and walking, particularly when barefoot, and are the most accurate for measuring plantar pressures. For reliable data, two step protocol prior to contacting the pressure plate is recommended. In-shoe systems are most suitable for measuring plantar pressures in the field during daily living or dynamic sporting movements as they are often wireless and can measure multiple steps. They are the most suitable equipment to assess the effects of footwear and orthotics on plantar pressures. However, they typically have lower spatial resolution and sampling frequency than platform systems. Users of pressure measurement systems need to consider the suitability of the calibration procedures for their chosen application when selecting and using a pressure measurement system. For some applications, a bespoke calibration procedure is required to improve validity and reliability of the pressure measurement system. The testing machines that are commonly used for dynamic calibration of pressure measurement systems frequently have loading rates of less than even those found in walking, so the development of testing protocols that truly measure the loading rates found in many sporting movements are required. There is clear potential for AI techniques to assist in the analysis and interpretation of plantar pressure data to enable the more complete use of pressure system data in clinical diagnoses and monitoring.

Gait retraining targeting foot pronation: A systematic review and meta-analysis

Foot pronation is a prevalent condition known to contribute to a range of lower extremity injuries. Numerous interventions have been employed to address this issue, many of which are expensive and necessitate specific facilities. Gait retraining has been suggested as a promising intervention for modifying foot pronation, offering the advantage of being accessible and independent of additional materials or specific time. We aimed to systematically review the literature on the effect of gait retraining on foot pronation. We searched four databases including PubMed, Web of Science, Scopus and Embase from their inception through 20 June 2023. The Downs and Black appraisal scale was applied to assess quality of included studies. Two reviewers screened studies to identify studies reporting the effect of different methods of gait-retraining on foot pronation. Outcomes of interest were rearfoot eversion, foot pronation, and foot arch. Two authors separately extracted data from included studies. Data of interest were study design, intervention, variable, sample size and sex, tools, age, height, weight, body mass index, running experience, and weekly distance of running. Mean differences and 95% confidence intervals (CI) were calculated with random effects model in RevMan version 5.4. Fifteen studies with a total of 295 participants were included. The results of the meta-analysis showed that changing step width does not have a significant effect on peak rearfoot eversion. The results of the meta-analysis showed that changing step width does not have a significant effect on peak rearfoot eversion. Results of single studies indicated that reducing foot progression angle (MD 2.1, 95% CI 0.62, 3.58), lateralizing COP (MD -3.3, 95% CI -4.88, -1.72) can effectively reduce foot pronation. Overall, this study suggests that gait retraining may be a promising intervention for reducing foot pronation; Most of the included studies demonstrated significant improvements in foot pronation following gait retraining. Changing center of pressure, foot progression angle and forefoot strike training appeared to yield more favorable outcomes. However, further research is needed to fully understand its effectiveness and long-term benefits.

A Data-Driven Approach for Fatigue Detection during Running Using Pedobarographic Measurements

Background

Detecting fatigue at the early stages of a run could aid training programs in making adjustments, thereby reducing the heightened risk of injuries from overuse. The study aimed to investigate the effects of running fatigue on plantar force distribution in the dominant and nondominant feet of amateur runners.

Methods

Thirty amateur runners were recruited for this study. Bilateral time-series plantar forces were employed to facilitate automatic fatigue gait recognition using convolutional neural network (CNN) and CNN-based long short-term memory network (ConvLSTM) models. Plantar force data collection was conducted both before and after a running-induced fatigue protocol using a FootScan force plate. The Keras library in Python 3.8.8 was used to train and tune deep learning models.

Results

The results demonstrated that more mid-forefoot and heel force occurs during bilateral plantar and less midfoot fore force occurs in the dominant limb after fatigue (p < 0.001). The time of peak forces was significantly shortened at the midfoot and sum region of the nondominant foot, while it was delayed at the hallux region of the dominant foot (p < 0.001). In addition, the ConvLSTM model showed higher performance (Accuracy = 0.867, Sensitivity = 0.874, and Specificity = 0.859) in detecting fatigue gait than CNN (Accuracy = 0.800, Sensitivity = 0.874, and Specificity = 0.718).

Conclusions

The findings of this study could offer empirical data for evaluating risk factors linked to overuse injuries in a single limb, as well as facilitate early detection of fatigued gait.

Effects of arch support doses on the center of pressure and pressure distribution of running using statistical parametric mapping

Insoles with an arch support have been used to address biomechanical risk factors of running. However, the relationship between the dose of support and running biomechanics remains unclear. The purpose of this study was to determine the effects of changing arch support doses on the center of pressure (COP) and pressure mapping using statistical parametric mapping (SPM). Nine arch support variations (3 heights * 3 widths) and a flat insole control were tested on fifteen healthy recreational runners using a 1-m Footscan pressure plate. The medial-lateral COP (COPML) coordinates and the total COP velocity (COPVtotal) were calculated throughout the entirety of stance. One-dimensional and two-dimensional SPM were performed to assess differences between the arch support and control conditions for time series of COP variables and pressure mapping at a pixel level, respectively. Two-way ANOVAs were performed to test the main effect of the arch support height and width, and their interaction on the peak values of the COPVtotal. The results showed that the COPVtotal during the forefoot contact and forefoot push off phases was increased by arch supports, while the COP medial-lateral coordinates remained unchanged. There was a dose-response effect of the arch support height on peak values of the COPVtotal, with a higher support increasing the first and third valleys but decreasing the third peak of the COPVtotal. Meanwhile, a higher arch support height shifted the peak pressure from the medial forefoot and rearfoot to the medial arch. It is concluded that changing arch support doses, primarily the height, systematically altered the COP velocities and peak plantar pressure at a pixel level during running. When assessing subtle modifications in the arch support, the COP velocity was a more sensitive variable than COP coordinates. SPM provides a high-resolution view of pressure comparisons, and is recommended for future insole/footwear investigations to better understand the underlying mechanisms and improve insole design.

Biomechanical and Musculoskeletal Measurements as Risk Factors for Running-Related Injury in Non-elite Runners: A Systematic Review and Meta-analysis of Prospective Studies

BACKGROUND

Running-related injury (RRI) is highly prevalent among recreational runners and is a key barrier to participation. Atypical lower limb alignment and mechanical function have been proposed to play a role in development of lower extremity injury. The purpose of this study was to investigate relationships between incidence of running-related injury (RRI) in non-elite runners with biomechanical and musculoskeletal variables.

METHODS

A systematic review and meta-analysis of prospective studies. Published research indexed in MEDLINE, EMBASE, CINAHL, SPORTDiscus, AMED, and The Cochrane library until 13th January 2021, grey literature, and reference lists of included studies were screened to identify prospective studies of non-elite adult runners that measured a relationship between biomechanical or musculoskeletal measures and incidence of RRI.

RESULTS

Thirty studies (3404 runners), testing over 100 discrete biomechanical and musculoskeletal risk factors for RRI, were included. Nineteen studies were pooled in twenty-five separate meta-analyses. Meta-analysis of four studies detected significantly less knee extension strength among runners who developed a RRI (SMD - 0.19, 95% CI - 0.36 to - 0.02, p = 0.03), though this may not be clinically important. A meta-analysis of two studies detected significantly lower hip adduction velocity among runners who developed a RRI (MD - 12.80, 95% CI - 25.22 to - 0.38, p = 0.04). Remaining meta-analyses found no significant relationship between biomechanical or musculoskeletal variables and RRI.

CONCLUSION

This systematic review and meta-analysis found the currently available literature does not generally support biomechanical or musculoskeletal measures as risk factors for RRI in non-elite runners. While meta-analysis findings for knee extension strength and hip adduction velocity as risk factors for RRI were statistically significant, the associated trivial to small effects sizes suggest these findings should be treated with caution. Until further evidence emerges, recommendations for injury prevention in non-elite runners cannot be made based on biomechanical and musculoskeletal measurements alone.

Prolonged Running Using Bionic Footwear Influences Lower Limb Biomechanics

The running biomechanics of unstable shoes have been well investigated, however, little is known about how traditional neutral shoes in combination with unstable design elements and scientifically (bionic) designed shoes influence prolonged running biomechanics. The purpose of this study was to investigate biomechanical changes for a typical 5 km run and how footwear technology may affect outcomes. Sixteen healthy male recreational heel strike runners participated in this study, and completed two prolonged running sessions (neutral shoe session and bionic shoe session), with 7 to 10 days interval between sessions. A two-way repeated-measures analysis of variance (ANOVA, shoe × time) was conducted to determine any differences in joint biomechanics. Main effects for shoe type were observed at the ankle, knee and hip joints during the stance phase. In particular, decreased range of motion (ROM) was observed using the bionic shoes for all three joints, and the joint moments also had significant changes except for the frontal plane of the hip. Main effects for time were also observed at the ankle, knee and hip joints. The ROM of the sagittal plane in the knee and hip decreased post-5 km running. The reduction of ankle dorsiflexion, hip flexion, hip adduction and hip internal rotation angles were observed post-5 km running, as well as the increase of ankle eversion and external rotation, knee adduction and internal rotation angles. The kinetics also exhibited significant differences between pre-5 km running and post-5 km running. The interaction effects only existed in the ROM of the hip sagittal plane, hip adduction angle and hip internal rotation angle. The results suggested that bionic shoes could be beneficial for strengthening muscle control, enhancing postural stability and proprioceptive ability. Footwear personalization could be a solution that benefits runners, reduces injury risk and improves running performance.

The effect of changing mediolateral center of pressure on rearfoot eversion during treadmill running

INTRODUCTION

Atypical rearfoot eversion is an important kinematic risk factor in running-related injuries. Prominent interventions for atypical rearfoot eversion include foot orthoses, footwear, and taping, yet a running gait retraining is lacking. Therefore, the aim was to investigate the effects of changing mediolateral center of pressure (COP) on rearfoot eversion, subtalar pronation, medial longitudinal arch angle (MLAA), hip kinematics and vertical ground reaction force (vGRF).

METHODS

Fifteen healthy female runners underwent gait retraining under three conditions. Participants were instructed to run normally, on the lateral (COP lateral) and medial (COP medial) side of the foot. Foot progression angle (FPA) was controlled using real-time visual feedback. 3D measurements of rearfoot eversion, subtalar pronation, MLAA, FPA, hip kinematics, vGRF and COP were analyzed. A repeated-measures ANOVA followed by pairwise comparisons was used to analyze changes in outcome between three conditions. Data were also analyzed using statistic parameter mapping.

RESULTS

Running on the lateral side of the foot compared to normal running and running on the medial side of the foot reduced peak rearfoot eversion (mean difference (MD) with normal 3.3°, p < 0.001, MD with COP medial 6°, p < 0.001), peak pronation (MD with normal 5°, p < 0.001, MD with COP medial 9.6°, p=<0.001), peak MLAA (MD with normal 2.3°, p < 0.001, MD with COP medial 4.1°, p < 0.001), peak hip internal rotation (MD with normal 1.8°, p < 0.001), and peak hip adduction (MD with normal running 1°, p = 0.011). Running on the medial side of the foot significantly increased peak rearfoot eversion, pronation and MLAA compared to normal running.

SIGNIFICANCE

This study demonstrated that COP translation along the mediolateral foot axis significantly influences rearfoot eversion, MLAA, and subtalar pronation during running. Running with either more lateral or medial COP reduced or increased peak rearfoot eversion, peak subtalar pronation, and peak MLAA, respectively, compared to normal running. These results might use as a basis to help clinicians and researchers prescribe running gait retraining by changing mediolateral COP for runners with atypical rearfoot eversion or MLAA.

Risk factors for overuse injuries in short- and long-distance running: A systematic review

PURPOSE

The aim of this study was to review information about risk factors for lower extremity running injuries in both short-distance (mean running distance ≤20 km/week and ≤10 km/session) and long-distance runners (mean running distance >20 km/week and >10 km/session).

METHODS

Electronic databases were searched for articles published up to February 2019. Prospective cohort studies using multivariable analysis for the assessment of individual risk factors or risk models for the occurrence of lower extremity running injuries were included. Two reviewers independently selected studies for eligibility and assessed risk of bias with the Quality in Prognostic Studies Tool. The GRADE approach was used to assess the quality of the evidence.

RESULTS

A total of 29 studies were included: 17 studies focused on short-distance runners, 11 studies focused on long-distance runners, and 1 study focused on both types of runners. A previous running-related injury was the strongest risk factor for an injury for long-distance runners, with moderate-quality evidence. Previous injuries not attributed to running was the strongest risk factor for an injury for short-distance runners, with high-quality evidence. Higher body mass index, higher age, sex (male), having no previous running experience, and lower running volume were strong risk factors, with moderate quality evidence, for short-distance runners. Low-quality evidence was found for all risk models as predictors of running-related injuries among short- and long-distance runners.

CONCLUSION

Several risk factors for lower extremity injuries have been identified among short- and long-distance runners, but the quality of evidence for these risk factors for running-related injuries is limited. Running injuries seem to have a multifactorial origin both in short- and long-distance runners.

The Prevalence of Injuries and Traumas in Elite Goalball Players

Background: The last decade has seen the dynamic development of Paralympic sport, including the development of training facilities and training methods that allow for the achievement of results at the highest level in this group. This may be associated with an increased risk of injury and traumas. This study aimed to evaluate the prevalence and locations of injuries and the types of trauma suffered by goalball players. Methods: The study covered 43 players (24 women and 19 men) of the Goalball European Championship. A questionnaire survey was conducted. Results: The injuries were reported by 44%. Most often they concerned the upper limbs (92%). Positive correlations were found between age and prevalence of pelvis and knee joint injuries, whereas negative correlations occurred between competitive experience and the prevalence and location of injuries in the area of the upper limb. The highest percentage of trauma was found for epidermal abrasions, contusions, and dislocations. A negative correlation was observed between age and the prevalence of epidermal abrasions, whereas a positive correlation occurred between age and the prevalence of sprains and dislocations. The competitive experience was negatively correlated with the prevalence of abrasions and contusions and positively correlated with the prevalence of sprains and dislocations. A statistically significant correlation was found between body mass (BM) and the prevalence of injuries. In 23% of cases, training was interrupted for more than one month, whereas in 43%, the break was below one month. Conclusions: Playing position in goalball does not affect the prevalence of injuries and traumas, while body mass has a moderate effect on the prevalence of these events. The age of the subjects and their sports experience impact significantly on the prevalence and types of injuries.

Alterations in Center of Pressure During Single-Limb Loading in Individuals with Patellofemoral Pain

BACKGROUND

Altered foot loading during weightbearing is suggested to play a role in the development of patellofemoral pain (PFP). This study aimed to determine foot-loading characteristics associated with PFP by assessing center of pressure (COP) during single-limb loading in individuals with PFP compared with noninjured controls.

METHODS

Thirty recreationally active patients with PFP and 30 noninjured control participants had barefoot plantar pressure assessed during single-limb squats (SLSs) from which COP parameters (COP velocity and COP index) were obtained. Groups were compared using independent t tests.

RESULTS

Individuals with PFP demonstrated a greater COP index (P = .042), indicating a more lateral foot-loading pattern, and exhibited increased overall COP velocity (P = .013) and anteroposterior COP velocity during SLSs compared with control participants (P = .033).

CONCLUSIONS

Greater lateral foot loading and increased COP velocity during SLSs demonstrated by individuals with PFP may indicate reduced dynamic balance in this patient group, which may be implicated in the development of PFP.

Influence of neutral and stability athletic footwear on lower extremity coordination variability during a prolonged treadmill run in male rearfoot runners

The purpose of this study was to investigate changes in coordination variability (CV) over the course of a prolonged treadmill run and the influence of stability and neutral footwear on CV. Fourteen male habitually rearfoot runners completed two 42 min prolonged running sessions while three-dimensional kinematics and kinetics were recorded. During the first 21 min, participants ran in a neutral shoe (baseline run), then changed into either another neutral shoe of the same construction but another colour or a stability shoe and ran a further 21 min (intervention run). A modified vector coding technique was used to compute thigh-leg, leg-rearfoot and rearfoot-forefoot segment CV. Following the baseline run, thigh flexion/extension-leg flexion/extension, rearfoot inversion/eversion-forefoot plantar flexion/dorsiflexion and rearfoot inversion/eversion-forefoot adduction/abduction CV increased (p < .05). During the intervention run, CV was higher in the neutral shoe compared with the stability shoe for thigh flexion/extension-leg flexion/extension and leg flexion/extension-rearfoot inversion/eversion couplings (p < .05). Lower extremity CV increased or was maintained during a prolonged treadmill run in healthy male rearfoot runners, likely to distribute stresses among the tissues as muscles begin to fatigue. CV increased to a greater extent in neutral compared with stability footwear which may be a result of: (1) the stability shoe acting as a perturbation to the runner and their response is to regulate CV, or; (2) stability footwear provides greater support and consequently, runners do not need to explore additional degrees of freedom to reduce stresses applied to the tissues throughout a prolonged run.

Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury

BACKGROUND

Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking.

OBJECTIVES

Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI.

METHODS

We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case-control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from ≥800 m to ≤42.2 km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials.

RESULTS

Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies.

CONCLUSIONS

A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.

Biomechanical Variations in Female Runner’s Pre and Post Treadmill Running

The growing popularity of endurance sports activities is associated with a growing number of running injuries among recreational runners. The aim of this study was to assess the kinematic and kinetic variation on biomechanical parameters before and after 5km of treadmill running in female runners. Fourteen habitually shod female runners were assessed during treadmill running at their self-selected 5km running speed. A VICON motion analysis system and a Novel Pedar insole plantar pressure measurement system were used to record kinematic and plantar pressure data. Key findings from the study were that the internal and external rotation angle of the ankle, hip and knee while pre-5k running showed significant differences to those evaluated post-5k. The peak values of ground reaction forces (GRF) recorded pre-5k running were larger than the forces measured post-5k running. Combining the inversion and eversion of the ankle in the coronal plane during the pushing off phase, post-5k running showed a bigger eversion angle than pre-5k running. These subtle differences may reflect adaptation of motor control in female runners during long distance running of 5km.

Age-related plantar centre of pressure trajectory changes during barefoot walking

Plantar centre of pressure (COP) variables during gait have been used to predict risk of injury, or consequences thereof. The aim of this study was to determine the effect of age on the COP trajectory during barefoot gait at a self-selected speed. 287 participants (aged 18-80year, 163 women) walked barefoot at self-selected speed across a Footscan^® force platform, completing five trials for each side. COP trajectories were extracted and trajectory-level canonical correlation analysis was used to test their correlation with age. Post hoc linear regressions were performed on the medio-lateral (COPx) and anterior-posterior (COPy) components. The test statistic trajectory exceeded the critical threshold for the left (p=0.001) and right foot (p=0.003). Post hoc analyses showed positive correlation between age and COPx in late stance, placed more laterally with increasing age, while no significant correlation was found for COPy. While no significant correlations were observed for the test statistic trajectory during heel strike and mid-stance, post hoc analysis indicated that the COPx component was placed more laterally at heel strike for the left foot with increasing age (p=0.016). The findings suggest that older individuals tend to push-off with less metatarso-phalangeal dorsiflexion. These results do not necessarily imply that ageing itself causes the observed correlation. Further evidence is needed to determine whether the laterally placed COP during roll-off may be a useful factor for determining risk for falling in the older population, or as a risk for future injuries or overuse disorders.

The effect of three surface conditions, speed and running experience on vertical acceleration of the tibia during running

Research has focused on parameters that are associated with injury risk, e.g. vertical acceleration. These parameters can be influenced by running on different surfaces or at different running speeds, but the relationship between them is not completely clear. Understanding the relationship may result in training guidelines to reduce the injury risk. In this study, thirty-five participants with three different levels of running experience were recruited. Participants ran on three different surfaces (concrete, synthetic running track, and woodchip trail) at two different running speeds: a self-selected comfortable speed and a fixed speed of 3.06 m/s. Vertical acceleration of the lower leg was measured with an accelerometer. The vertical acceleration was significantly lower during running on the woodchip trail in comparison with the synthetic running track and the concrete, and significantly lower during running at lower speed in comparison with during running at higher speed on all surfaces. No significant differences in vertical acceleration were found between the three groups of runners at fixed speed. Higher self-selected speed due to higher performance level also did not result in higher vertical acceleration. These results may show that running on a woodchip trail and slowing down could reduce the injury risk at the tibia.

Spatiotemporal Gait Parameters as Predictors of Lower-Limb Overuse Injuries in Military Training

The study objective was to determine whether spatiotemporal gait parameters could predict lower-limb overuse injuries in cohort of combat soldiers during first year of military service. Newly recruited infantry soldiers walked on a treadmill at a 15° incline with a fixed speed of 1.67 m/sec while wearing a standard military vest with a 10 kg load. Stride time variability, stride length variability, step length asymmetry, and the duration of the loading response phase of the gait cycle were measured. Injury data on 76 soldiers who did not report musculoskeletal complaints at initial screening were collected one year after recruitment. Multiple logistic regression analyses were conducted to determine the predictive effect of the gait parameters on lower-limb injuries. Twenty-four soldiers (31.6%) had overuse injuries during the first year after recruitment. Duration of the loading response was a significant predictor of general lower-limb injury (p < 0.05), as well as of foot/ankle and knee injuries (p < 0.05, p < 0.01, resp.). A cutoff value of less than 12.15% for loading response duration predicted knee injuries with 83% sensitivity and 67% specificity. This study demonstrates the utility of spatiotemporal gait evaluation, a simple screening tool before military training, which may help to identify individuals at risk of lower-limb overuse injuries.

Effects of running-induced fatigue on plantar pressure distribution in novice runners with different foot types

This study aimed to assess the effects of running-induced fatigue on plantar pressure parameters in novice runners with low and high medial longitudinal arch. Plantar pressure data from 42 novice runners (21 with high, and 21 with low arch) were collected before and after running-induced fatigue protocol during running at 3.3m/s along the Footscan(®) platform. Peak plantar pressure, peak force and force-time integral (impulse) were measured in ten anatomical zones. Relative time for foot roll-over phases and medio-lateral force ratio were calculated before and after the fatigue protocol. After the fatigue protocol, increases in the peak pressure under the first-third metatarsal zones and reduction under the fourth-fifth metatarsal regions were observed in the low arch individuals. In the high arch group, increases in peak pressure under the fourth-fifth metatarsal zones after the running-induced fatigue was observed. It could be concluded that running-induced fatigue had different effects on plantar pressure distribution pattern among novice runners with low and high medial longitudinal foot arch. These findings could provide some information related to several running injuries among individuals with different foot types.

Plantar pressure measurements and running-related injury: A systematic review of methods and possible associations

Pressure-sensitive measuring devices have been identified as appropriate tools for measuring an array of parameters during running. It is unclear which biomechanical characteristics relate to running-related injury (RRI) and which data-processing techniques are most promising to detect this relationship. This systematic review aims to identify pertinent methodologies and characteristics measured using plantar pressure devices, and to summarise their associations with RRI. PubMed, Embase, CINAHL, ScienceDirect and Scopus were searched up until March 2015. Retrospective and prospective, biomechanical studies on running using any kind of pressure-sensitive device with RRI as an outcome were included. All studies involving regular or recreational runners were considered. The study quality was assessed and the measured parameters were summarised. One low quality, two moderate quality and five high quality studies were included. Five different subdivisions of plantar area were identified, as well as five instants and four phases of measurement during foot-ground contact. Overall many parameters were collated and subdivided as plantar pressure and force, plantar pressure and force location, contact area, timing and stride parameters. Differences between the injured and control group were found for mediolateral and anteroposterior displacement of force, contact area, velocity of force displacement, relative force-time integral, mediolateral force ratio, time to peak force and inter-stride correlative patterns. However, no consistent results were found between studies and no biomechanical risk patterns were apparent. Additionally, conflicting findings were reported for peak force in three studies. Based on these observations, we provide suggestions for improved methodology measurement of pertinent parameters for future studies.

What are the Differences in Injury Proportions Between Different Populations of Runners? A Systematic Review and Meta-Analysis

BACKGROUND

Many runners suffer from injuries. No information on high-risk populations is available so far though.

OBJECTIVES

The aims of this study were to systematically review injury proportions in different populations of runners and to compare injury locations between these populations.

DATA SOURCES

An electronic search with no date restrictions was conducted up to February 2014 in the PubMed, Embase, SPORTDiscus and Web of Science databases. The search was limited to original articles written in English. The reference lists of the included articles were checked for potentially relevant studies.

STUDY ELIGIBILITY CRITERIA

Studies were eligible when the proportion of running injuries was reported and the participants belonged to one or more homogeneous populations of runners that were clearly described. Study selection was conducted by two independent reviewers, and disagreements were resolved in a consensus meeting.

STUDY APPRAISAL AND SYNTHESIS METHODS

Details of the study design, population of runners, sample size, injury definition, method of injury assessment, number of injuries and injury locations were extracted from the articles. The risk of bias was assessed with a scale consisting of eight items, which was specifically developed for studies focusing on musculoskeletal complaints.

RESULTS

A total of 86 articles were included in this review. Where possible, injury proportions were pooled for each identified population of runners, using a random-effects model. Injury proportions were affected by injury definitions and durations of follow-up. Large differences between populations existed. The number of medical-attention injuries during an event was small for most populations of runners, except for ultra-marathon runners, in which the pooled estimate was 65.6%. Time-loss injury proportions between different populations of runners ranged from 3.2% in cross-country runners to 84.9% in novice runners. Overall, the proportions were highest among short-distance track runners and ultra-marathon runners.

LIMITATIONS

The results were pooled by stratification of studies according to the population, injury definition and follow-up/recall period; however, heterogeneity was high.

CONCLUSIONS

Large differences in injury proportions between different populations of runners existed. Injury proportions were affected by the duration of follow-up. A U-shaped pattern between the running distance and the time-loss injury proportion seemed to exist. Future prospective studies of injury surveillance are highly recommended to take running exposure and censoring into account.

Injuries in runners; a systematic review on risk factors and sex differences

BACKGROUND

The popularity of running continues to increase, which means that the incidence of running-related injuries will probably also continue to increase. Little is known about risk factors for running injuries and whether they are sex-specific.

OBJECTIVES

The aim of this study was to review information about risk factors and sex-specific differences for running-induced injuries in adults.

SEARCH STRATEGY

The databases PubMed, EMBASE, CINAHL and Psych-INFO were searched for relevant articles.

SELECTION CRITERIA

Longitudinal cohort studies with a minimal follow-up of 1 month that investigated the association between risk factors (personal factors, running/training factors and/or health and lifestyle factors) and the occurrence of lower limb injuries in runners were included.

DATA COLLECTION AND ANALYSIS

Two reviewers' independently selected relevant articles from those identified by the systematic search and assessed the risk of bias of the included studies. The strength of the evidence was determined using a best-evidence rating system. Sex differences in risk were determined by calculating the sex ratio for risk factors (the risk factor for women divided by the risk factor for men).

MAIN RESULTS

Of 400 articles retrieved, 15 longitudinal studies were included, of which 11 were considered high-quality studies and 4 moderate-quality studies. Overall, women were at lower risk than men for sustaining running-related injuries. Strong and moderate evidence was found that a history of previous injury and of having used orthotics/inserts was associated with an increased risk of running injuries. Age, previous sports activity, running on a concrete surface, participating in a marathon, weekly running distance (30-39 miles) and wearing running shoes for 4 to 6 months were associated with a greater risk of injury in women than in men. A history of previous injuries, having a running experience of 0-2 years, restarting running, weekly running distance (20-29 miles) and having a running distance of more than 40 miles per week were associated with a greater risk of running-related injury in men than in women.

CONCLUSIONS

Previous injury and use of orthotic/inserts are risk factors for running injuries. There appeared to be differences in the risk profile of men and women, but as few studies presented results for men and women separately, the results should be interpreted with caution. Further research should attempt to minimize methodological bias by paying attention to recall bias for running injuries, follow-up time, and the participation rate of the identified target group.

Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review

Background

Dynamic foot function is considered a risk factor for lower limb overuse injuries including Achilles tendinopathy, shin pain, patellofemoral pain and stress fractures. However, no single source has systematically appraised and summarised the literature to evaluate this proposed relationship. The aim of this systematic review was to investigate dynamic foot function as a risk factor for lower limb overuse injury.

Methods

A systematic search was performed using Medline, CINAHL, Embase and SportDiscus in April 2014 to identify prospective cohort studies that utilised dynamic methods of foot assessment. Included studies underwent methodological quality appraisal by two independent reviewers using an adapted version of the Epidemiological Appraisal Instrument (EAI). Effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data.

Results

Twelve studies were included (total n = 3,773; EAI 0.44 to 1.20 out of 2.00, representing low to moderate quality). There was limited to very limited evidence for forefoot, midfoot and rearfoot plantar loading variables (SMD 0.47 to 0.85) and rearfoot kinematic variables (RR 2.67 to 3.43) as risk factors for patellofemoral pain; and plantar loading variables (forefoot, midfoot, rearfoot) as risk factors for Achilles tendinopathy (SMD 0.81 to 1.08). While there were significant findings from individual studies for plantar loading variables (SMD 0.3 to 0.84) and rearfoot kinematic variables (SMD 0.29 to 0.62) as risk factors for ‘non-specific lower limb overuse injuries’, these were often conflicting regarding different anatomical regions of the foot. Findings from three studies indicated no evidence that dynamic foot function is a risk factor for iliotibial band syndrome or lower limb stress fractures.

Conclusion

This systematic review identified very limited evidence that dynamic foot function during walking and running is a risk factor for patellofemoral pain, Achilles tendinopathy, and non-specific lower limb overuse injuries. It is unclear whether these risk factors can be identified clinically (without sophisticated equipment), or modified to prevent or manage these injuries. Future prospective cohort studies should address methodological limitations, avoid grouping different lower limb overuse injuries, and explore clinically meaningful representations of dynamic foot function.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-014-0053-6) contains supplementary material, which is available to authorized users.

Contributions of lower extremity kinematics to trunk accelerations during moderate treadmill running

Background

Trunk accelerations during running provide useful information about movement economy and injury risk. However, there is a lack of data regarding the key biomechanical contributors to these accelerations. The purpose was to establish the biomechanical variables associated with root mean square (RMS) accelerations of the trunk.

Methods

Eighteen healthy males (24.0 ± 4.2 yr; 1.78 ± 0.07 m; 79.7 ± 14.8 kg) performed treadmill running with high resolution accelerometer measurement at the lumbar spine and full-body optical motion capture. We collected 60 sec of data at three speeds (2.22, 2.78, 3.33 m∙s⁻¹). RMS was calculated for medio-lateral (ML), anterio-posterior (AP), vertical (VT), and the resultant Euclidean scalar (RES) acceleration. From motion capture, we calculated 14 kinematic variables, including mean sagittal plane joint angles at foot contact, mid-stance, and toe-off. Principal components analysis (PCA) was used to form independent components comprised of combinations of the original variables. Stepwise regressions were performed on the original variables and the components to determine contributions to RMS acceleration in each axis.

Results

Significant speed effects were found for RMS-accelerations in all axes (p < 0.05). Regressions of the original variables indicated from 4 to 5 variables associated with accelerations in each axis (R² = 0.71 to 0.82, p < 0.001). The most prominent contributing variables were associated with the late flight and early stance phase. PCA reduced the data into four components. Component 1 included all hip angles before mid-stance and component 2 was primarily associated with propulsion. Regressions indicated key contributions from components 1 and 2 to ML, VT, and RES acceleration (p < 0.05).

Conclusions

The variables with highest contribution were prior to mid-stance and mechanically relate to shock absorption and attenuation of peak forces. Trunk acceleration magnitude is associated with global running variables, ranging from energy expenditure to forces lending to the mechanics of injury. These data begin to delineate running gait events and offer relationships of running mechanics to those structures more proximal in the kinetic chain. These relationships may provide insight for technique modification to maximize running economy or prevent injury.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-162) contains supplementary material, which is available to authorized users.

Predictors of calf cramping in rugby league

Exercise-associated muscle cramps (EAMC) in the calf are common in rugby league. To date, the etiology and predictors of calf cramping are poorly understood. The aim of this study was to undertake a prospective investigation to identify predictors of calf cramping in rugby league players. Demographic and anthropometric data and calf cramp and injury history were collected in the preseason. Hydration status, number of games played, and calf cramps were recorded on game days. Male rugby league players (n = 103, mean age 18.8 ± 4.1 years) were classified as either EAMC (experienced at least 1 incident of calf cramps in the season) or no EAMC (no calf cramps). The following were investigated as possible predictors of EAMC using logistic regression modeling: competition level, age, ethnicity, playing position, history of cramping, precramping, low back pain, foot orthotic usage, foot posture, foot strike, muscle flexibility, calf girth, hydration status, and number of games played. Half the players, n = 52, experienced at least 1 incidence of calf cramping. Playing in a senior competition level (odds ratio: 0.21; 95% confidence interval: 0.06-0.75; p = 0.016), a history of calf cramping (10.85; 2.16-54.44; p = 0.004), and a history of low back pain resulting in missed field minutes (4.50, 1.37-14.79; p = 0.013) were found to predict EAMC. This study suggests that there is a high incidence of calf cramping in rugby league, especially at senior competition levels, and supports preseason screening in senior players to idetify those at risk of calf cramping and the development of possible preventative strategies.

Reliability of a new supination resistance measurement device and validation of the manual supination resistance test

BACKGROUND

Kinematic observations are inconsistent in predicting lower-extremity injury risk, and research suggests that kinetic variables may be more important in this regard. Before kinetics can be prospectively investigated, we need reliable ways of measuring them clinically. A measurement instrument was manufactured that closely mirrors a manual test used to clinically estimate supination resistance force. The reliability of the instrument and the validity of the clinical test were investigated.

METHODS

The left feet of 26 healthy individuals (17 men and 9 women; mean ± SD age, 25.9 ± 9.2 years; mean ± SD weight, 77.7 ± 13.3 kg) were assessed. Foot Posture Index (FPI-6), manual supination resistance, and machine supination resistance were measured. Intrarater and interrater reliability of all of the measurements were calculated. Correlations of the supination resistance measured by the device with FPI-6, the manual supination resistance test, and body weight were investigated.

RESULTS

Interrater reliability of all of the measurements was generally poor. The supination resistance machine correlated highly with the manual supination test for the rater experienced with its use. Supination resistance measurements correlated poorly with the FPI-6 and weakly with body weight.

CONCLUSIONS

The supination resistance machine was shown to have sufficient limits of agreement for the study, but improvements need to be made for more meaningful research going forward. In this study, the force required to supinate a foot was independent of its posture, and approximately 12% of it was explained by body weight. Further work is required with a much larger sample size to build regression models that sufficiently predict supination resistance force and that will be of clinical use. The manual supination test is a valid clinical test for clinicians experienced in its use.

Proximal and distal contributions to lower extremity injury: a review of the literature

Excessive or prolonged foot pronation has been linked to the development of numerous overuse injuries affecting the lower limb. The originally proposed pathomechanical model suggests foot motion affects more proximal structures through disruption of distal to proximal coupling between the foot, tibia, femur, and hip. Research evidence supports the presence of a dynamic coupling mechanism between lower limb segments, however, the direction of the coupling is inconclusive. Recent prospective investigations of the role of the lumbo-pelvic hip complex have identified a strong association between proximal dysfunction and increased risk of lower limb injuries. Strength of muscles of the lumbo-pelvic hip complex (core muscles) is suggested to be essential to controlling hip abduction, subsequent internal rotation of the femur and potentially more distal movement. Proximal muscle weakness and altered motor control have also been implicated in the development of numerous lower limb injuries, many of which have previously been attributed to excessive foot pronation. This review discusses the theoretical basis for the role of proximal and distal structures in biomechanical dysfunction of the lower limb and the development of lower limb overuse injury. Current prospective evidence relating to the contributions of excessive foot pronation and core muscle function to the development of lower extremity injury is evaluated.

The effect of a long-distance run on plantar pressure distribution during running

The purpose of this study was to assess plantar pressure alterations after long-distance running. Prior to and after a 20 km run, force distribution underneath the feet of 52 participants was registered using Footscan(®) pressure plates while the participants ran shod at a constant self-selected pace. Peak force, mean force and impulse were registered underneath different zones of the foot. In addition, temporal data as total foot contact time, time of contact and end of contact were derived for these zones. Furthermore, a medio-lateral pressure distribution ratio was calculated in different phases of the roll-off. After the run, increases in the loading of the forefoot, midfoot and medial heel were noted and decreases in loading of the lateral toes. In the forefoot push off phase a more lateral pressure distribution was observed. The results of this study demonstrated plantar pressure deviations after long-distance running which could give additional information related to several running injuries.

The epidemiology of foot injuries in professional rugby union players

BACKGROUND

Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

METHODS

Medical personnel prospectively recorded injuries in professional Premiership rugby union players in England over four seasons. Injuries to the foot were identified and the time away from training and playing was reported.

RESULTS

A total of 147 foot injuries were sustained resulting in 3542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p=<0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

CONCLUSION

In collision sports such as rugby, some injuries may be inevitable but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed a high proportion of morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.

Foot orthoses in the prevention of injury in initial military training: a randomized controlled trial

BACKGROUND

Overuse lower limb injury is common in incidence and morbidity. Many risk factors, gait related and biomechanical, have been identified, although little conclusive evidence has been found in terms of injury prevention to date.

HYPOTHESIS

Orthoses, as produced by proprietary software interpretation of plantar pressures, are able to reduce injury rates in an "at risk" military population.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Four hundred military officer trainees were assessed by means of pressure plate recording of their contact foot pressures during walking. Participants were risk assessed and randomized to receive or not receive customized orthoses using the D3D system. Both cohorts were followed up for injury through their basic training at the 7-week point.

RESULTS

The orthotic intervention group sustained 21 injuries in total (1 injury per 4666 hours of training), whereas the control group sustained 61 injuries in total (1 injury per 1600 hours of training) (P < .0001), thereby demonstrating an absolute risk reduction of 0.49 from use of the orthoses (P < .0001, chi square; confidence interval, 1.7, 2.4).

CONCLUSION

In this military trainee population, orthoses were effective in the prevention of overuse lower limb injury. This is the first study to identify a positive preventive role of orthoses.