Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors

Medial Tibial Stress Syndrome (Shin Splint): Prevalence, Causes, Prevention, and Management in Saudi Arabia

Background/aims Medial tibial stress syndrome (MTSS), also known as "shin splint", is most often described as exertional leg pain along the shinbone (tibia), which occurs due to the inflammation of the muscles, tendons, and bone tissue in this area. This study aims to assess the prevalence, risk factors, and their association with the development of MTSS, as well as the effective treatments that reduce pain and improve functions among the Saudi general population. Materials and method The present cross-sectional study was conducted on the general population of Saudi Arabia through an electronic survey over a period of three months. The study sample of 443 patients was deemed and considered. The study included participants from the general population in Saudi Arabia above the age of 18. A structured self-response questionnaire was given to the participants after institutional research ethical approval was obtained for the study. Results Among the 443 participants, the majority were male (n = 228, 51.5%), aged 18-29 (n = 227, 51.2%), and residing in the central region of Saudi Arabia (n = 398, 89.8%). Most participants reported engaging in sporting activities (n = 211, 47.6%), with high-intensity training being the most common (n = 93, 44.1%). Only a small proportion (n = 8, 1.8%) reported a previous diagnosis of MTSS. Analysis revealed associations between MTSS prevalence and certain demographic factors, including walking surface preferences and engagement in specific sports. Treatment strategies for MTSS included rest, ice application, physiotherapy, and pain-relieving medication, with varying degrees of satisfaction and recurrence rates among participants. Conclusion The study provides valuable insights into the prevalence, risk factors, management, and preventive measures related to MTSS among the Saudi general population. While certain demographic factors and exercise practices were associated with MTSS prevalence, effective treatment options such as rest, physiotherapy, and appropriate footwear were reported. Moreover, adherence to preventive measures such as stretching, proper footwear selection, and gradual training progression may help mitigate the risk of MTSS development.

Risk Factors for Running-Related Injury in High School and Collegiate Cross-country Runners: A Systematic Review

OBJECTIVE: To summarize and describe risk factors for running-related injuries (RRIs) among high school and collegiate cross-country runners. DESIGN: Descriptive systematic review. LITERATURE SEARCH: Four databases (Scopus, SPORTDiscus, CINAHL, Cochrane) were searched from inception to August 2023. STUDY SELECTION CRITERIA: Studies assessing RRI risk factors in high school or collegiate runners using a prospective design with at least 1 season of follow-up were included. DATA SYNTHESIS: Results across each study for a given risk factor were summarized and described. The NOS and GRADE frameworks were used to evaluate quality of each study and certainty of evidence for each risk factor. RESULTS: Twenty-four studies were included. Overall, study quality and certainty of evidence were low to moderate. Females or runners with prior RRI or increased RED-S (relative energy deficiency in sport) risk factors were most at risk for RRI, as were runners with a quadriceps angle of >20° and lower step rates. Runners with weaker thigh muscle groups had increased risk of anterior knee pain. Certainty of evidence regarding training, sleep, and specialization was low, but suggests that changes in training volume, poorer sleep, and increased specialization may increase RRI risk. CONCLUSION: The strongest predictors of RRI in high school and collegiate cross-country runners were sex and RRI history, which are nonmodifiable. There was moderate certainty that increased RED-S risk factors increased RRI risk, particularly bone stress injuries. There was limited evidence that changes in training and sleep quality influenced RRI risk, but these are modifiable factors that should be studied further in this population. J Orthop Sports Phys Ther 2024;54(2):1-13. Epub 16 November 2023. doi:10.2519/jospt.2023.11550.

Outpatient Runners Clinic Visit Trends and Injury Characteristics Among 392 Child and Adolescent Patients: A 10-year Chart Review

OBJECTIVE

To evaluate clinic visits and running-related injury (RRI) characteristics among child and adolescent runners seeking care at an outpatient clinic over a 10-year time frame.

DESIGN

Retrospective chart review.

SETTING

Outpatient hospital-affiliated Injured Runners Clinic.

PATIENTS

Children and adolescent runners (6-17 years) with RRIs.

INDEPENDENT VARIABLES

We examined electronic medical records (EMRs) among child and adolescent patients in the hospital database from 2011 to 2021 to obtain RRI characteristics and key demographic factors.

MAIN OUTCOME MEASURES

We assessed volume and frequency of patient visits to the clinic by RRI characteristics. Chi square analyses were used to compare the proportion of clinic visits over time and injury trends by body region and diagnosis.

RESULTS

There were 392 patients (sex: 277 F; mean age: 16.1 ± 1.3 years) and an average of 5 clinic visits per diagnosis (5 ± 4 visits; min: 1 visit, max: 31 visits). Number of visits generally increased over time up to 2016 but declined most drastically during the years of the pandemic (2020-2021; χ 2 = 644, P < 0 .001). Of the 654 new injury diagnoses, 77.68% were attributed to repetitive stress. Bone stress injuries to the tibia were the most common RRI (χ 2 = 1940, P < 0 .001; N = 132; 20.2% of all injuries) and constituted most of the clinic visits (χ 2 = 9271, P < 0 .001; N = 591; 25.4% of all visits).

CONCLUSION

We identified that adolescents with overuse injuries, particularly bone stress injuries to the tibia, constituted most of the visits to the outpatient healthcare setting. Clinicians should emphasize injury prevention efforts in clinical practice to reduce RRI burden.

Running towards injury? A prospective investigation of factors associated with running injuries

BACKGROUND

Given the high incidence and heavy burden of running related injuries, large-scale, prospective multifactorial investigations examining potential risk factors are warranted. This study aimed to identify factors associated with running related injuries and to evaluate their potential in injury screening.

STUDY DESIGN

Prospective cohort study.

MATERIALS AND METHODS

Two hundred and seventy-four recreational runners were recruited. Clinical measures (strength, range of motion, foot position), injury and training history (via questionnaire), impact loading (via accelerometery) and running technique measures were collected at baseline. Runners were tracked for injury for one year via fortnightly check-ins. A binary logistic regression, (injury versus no injury), was performed for each variable univariably, and then adjusting for age, sex and mileage. A multivariable regression was also performed to evaluate the model's discriminative ability.

RESULTS

Of the 225 runners included in the final analysis 52% experienced a running related injury. Injury history in the past year, less navicular drop, and measures of running technique (knee, hip, and pelvis kinematics) were associated with increased odds of injury (p < .05). The multivariable logistic regression model was statistically significant, χ2(11) = 56.45, p < .001, correctly classifying 74% of cases with a sensitivity and specificity of 72% and 76%, respectively. The area under the receiver operating characteristic curve was 0.79 (CI95% = 0.73-0.85), demonstrating acceptable discriminative ability.

CONCLUSIONS

This study found a number of clinical and running technique factors to be associated with prospective running related injuries among recreational runners. With the exception of injury history, the factors identified as being significantly associated with injury may be modifiable and therefore, could form the basis of interventions. Range of motion, spatiotemporal parameters and strength measures were not associated with injury and thus their utilisation in injury prevention practices should be reconsidered.

Chronic diseases and allergies are risk factors predictive of a history of Medial Tibial Stress Syndrome (MTSS) in distance runners: SAFER study XXIV

BACKGROUND

Medial Tibial Stress Syndrome (MTSS) is one of the most common causes of exercise-associated lower leg pain in distance runners.

AIM

To identify risk factors predictive of a history of MTSS in distance runners entering the Two Oceans Marathon races (21.1 km and 56 km).

DESIGN

Cross-sectional study.

SETTING

2012 to 2015 Two Oceans Marathon races (21.1 km and 56 km).

PARTICIPANTS

Consenting race entrants.

METHODS

106,743 race entrants completed an online pre-race medical screening questionnaire. 76,654 consenting runners (71.8%) were studied. 558 verified MTSS injuries were reported in the previous 12 months. Risk factors predictive of a history of MTSS were explored using uni - & multivariate analyses: demographics (race distance, sex, and age groups), training/racing history, history of chronic diseases, allergies, and medication use.

RESULTS

Independent risk factors predictive of a history of MTSS (adjusted for sex, age group, and race distance) were a higher chronic disease composite score (PR = 3.1 times increase risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001). Chronic diseases (PR > 2) predictive of a history of MTSS were: symptoms of CVD (PR = 4.2; p < 0.0001); GIT disease (PR = 3.3; p < 0.0001); kidney/bladder disease (PR = 3.3; p < 0.0001); nervous system/psychiatric disease (PR = 3.2; p < 0.0001); respiratory disease (PR = 2.9; p < 0.0001) a history of CVD (PR = 2.9; p < 0.0001); and risk factors of CVD (PR = 2.4; p < 0.0001) (univariate analysis). Average running speed was associated with higher risk of MTSS.

CONCLUSION

Novel independent risk factors predictive of a history of MTSS in distance runners (56 km, 21.1 km) were multiple chronic diseases and a history of allergies. Identifying athletes at higher risk for MTSS can guide healthcare professionals in their prevention and rehabilitation efforts.

Biomechanical characteristics of the lower extremities during running in male long-distance runners with a history of medial tibial stress syndrome: a case control study

BACKGROUND

Medial tibial stress syndrome (MTSS) is a running-related injury of the lower extremities. After returning to competition, there are often recurring episodes of MTSS. Therefore, it is important to prevent the onset and recurrence of MTSS among long-distance runners. This case-control study aimed to compare the kinematics and kinetics of runners with and without previous MTSS during running to clarify the biomechanical characteristics of the lower extremity of runners with previous MTSS.

METHODS

Thirteen male long-distance runners aged over 18 years and asymptomatic at the time of measurement were divided into an MTSS group and a non-MTSS group based on their history of MTSS as reported in a questionnaire. The kinetics and kinematics of running were analyzed when participants ran at a speed of 2.0 ± 0.2 m/s by a three-dimensional motion analysis system and two force plates. Data regarding the joint angles, moments, and powers of the ankle, knee, and hip during the stance phase while running were extracted and compared between the two groups using the Mann-Whitney U test.

RESULTS

Of the 13 participants, 5 and 8 were included in the MTSS (10 legs) and non-MTSS (16 legs) groups, respectively. The ankle maximum eversion moment was significantly larger in the MTSS group than in the non-MTSS group (p = 0.04). There were no significant differences in other parameters.

CONCLUSIONS

This study found that the ankle maximum eversion moment during the stance phase of running was larger in the MTSS group than in the non-MTSS group. Even after the disappearance of the symptoms of MTSS, the running biomechanics of participants with previous MTSS differed from those of participants without previous MTSS.

Relationship between attachment site of tibialis anterior muscle and shape of tibia: anatomical study of cadavers

BACKGROUND

Tibialis anterior (TA) muscle is the largest dorsiflexor of the ankle joint and plays an important role during gait movement. However, descriptions of the TA attachment site are inconsistent even among major anatomy textbooks, and its origin, especially the attachment site for the tibia, has not been reported in detail. This study is the first experimental attempt to investigate the origin of the TA in detail, paying particular attention to the relationship with the shape of the tibia, including sex differences.

METHODS

Forty legs (20 males, 20 females) from twenty Japanese cadavers were examined. Gross anatomical examination of the TA's attachment site to the tibia and the tibia's shape was performed.

RESULTS

The location of the distal end of the TA's attachment on tibia was significantly more distal in males than in females (p < 0.01). The anterior border of the tibia had a gentle S-like curve, with a medially convex curve in the proximal region and a laterally convex curve in the distal region in frontal plane. The most protruding point of the distal curve of the anterior border located significantly more proximal in females than in males (p = 0.02).

CONCLUSIONS

There were sex differences in the distal end of the attachment site on tibia of the TA and the shape of the tibia. Consequently, the variations in the attachment site of TA were considered to provide for differences in function of TA. In males, the TA may enable advantageous power exertion, whereas in females it may work efficiently for dorsiflexion of ankle, respectively. Sex differences in TA's attachment site and the shape of the tibia may be involved in gait movement as well as frequency of lower leg disorders such as chronic exertional compartment syndrome.

Adiposity as a Risk Factor for Sport Injury in Youth: A Systematic Review

OBJECTIVE

To determine whether high or low adiposity is associated with youth sport-related injury.

DATA SOURCES

Ten electronic databases were searched to identify prospective studies examining the association between adiposity [body mass index (BMI) or body fat] and a future time-loss or medical attention sport-related musculoskeletal injury or concussion in youth aged 20 years and younger. Two independent raters assessed the quality (Downs and Black criteria) and risk of bias (Joanna Briggs Institute Critical Appraisal Tool). Random-effects meta-analyses were used to calculate pooled odds ratio [95% confidence interval (CI)] of injury.

MAIN RESULTS

Of 11 424 potentially relevant records, 38 articles were included with 17 eligible for meta-analyses. In qualitative synthesis, no clear association was identified between adiposity and any sport injury; however, 16/22 studies identified high adiposity as a significant risk factor for lower-extremity injury. Meta-analyses revealed higher BMI in youth with any sport-related injury and lower BMI in youth who developed a bone stress injury (BSI) compared with noninjured controls. The pooled OR (95% CI) examining the association of BMI and injury risk (excluding bone injury) was 1.18 (95% CI: 1.03-1.34). A major source of bias in included articles was inconsistent adjustment for age, sex, and physical activity participation.

CONCLUSIONS

Level 2b evidence suggests that high BMI is associated with greater risk of youth sport injury, particularly lower-extremity injury and excluding BSI or fracture. Although pooled mean differences were low, anthropometric risk of injury seems to be dependent on type and site of injury in youth sport.

The reliability of wearable commercial sensors for outdoor assessment of running biomechanics: the effect of surface and running speed

The aim of this study was to investigate the reliability of running biomechanics assessment with a wearable commercial sensor (RunScribeTM). Participants performed multiple 200-m runs over sand, grass and asphalt ground at the estimated 5-km tempo, with an additional trial with 21-km tempo at the asphalt. Intra-session reliability was excellent for all variables at 5-km pace (intra-class coefficient correlation (ICC) asphalt: 0.90-0.99; macadam: 0.94-1.00; grass: 0.92-1.00), except for shock (good; ICC = 0.83), and contact time and total power output (moderate; ICC = 0.68-0.71). Coefficient of variation (CV) were mostly acceptable in all conditions, except for horizontal ground reaction force (GRF) rate in asphalt 5-km pace trial (CV = 24.5 %), power (CV = 14.3 %) and foot strike type (CV = 30.9 %) in 21-km pace trial, and horizontal GRF rate grass trial (CV = 15.7 %). Inter-session reliability was high or excellent for the majority of the outcomes (ICC≥0.85). Total power output (ICC = 0.56-0.65) and shock (ICC = 0.67-0.75) showed only moderate reliability across all conditions. Power (CV = 12.5-13.8 %), foot strike type (CV = 14.9-29.4 %) and horizontal ground reaction force rate (CV = 12.4-36.4 %) showed unacceptable CV.

Adolescent Running Biomechanics - Implications for Injury Prevention and Rehabilitation

Global participation in running continues to increase, especially amongst adolescents. Consequently, the number of running-related injuries (RRI) in adolescents is rising. Emerging evidence now suggests that overuse type injuries involving growing bone (e.g., bone stress injuries) and soft tissues (e.g., tendinopathies) predominate in adolescents that participate in running-related sports. Associations between running biomechanics and overuse injuries have been widely studied in adults, however, relatively little research has comparatively targeted running biomechanics in adolescents. Moreover, available literature on injury prevention and rehabilitation for adolescent runners is limited, and there is a tendency to generalize adult literature to adolescent populations despite pertinent considerations regarding growth-related changes unique to these athletes. This perspective article provides commentary and expert opinion surrounding the state of knowledge and future directions for research in adolescent running biomechanics, injury prevention and supplemental training.

Association between abductor hallucis abductory force and navicular drop index, a predictive correlational study

The role of intrinsic muscles of the foot in the medial longitudinal arch mechanism was investigated in several recent studies. It is determined that the abductor hallucis muscle (AHM) has an important role in dynamic support of the arch. Objective of our preliminary study was to establish a relationship between the navicular drop index (NDI) and the AHM abduction force. A single group exploratory design was used. The participants were 127 athletes aged 8-16 years (m/f 74/53; 11.99 ± 2.11 years; 156.21 cm ± 15.51 cm; 47.61 kg ± 13.96 kg; 2-5 training h/week), examined at a regular sport medical checkup. Abductor hallucis force was measured by a digital Algometer FPX 25/220, which is a newly developed approach that should be properly assessed in further studies to establish standardization and qualification of the algometer for this specific use. Navicular drop test has been performed as originally developed by Brody. Data were analyzed using Student's t-test, Mann-Whitney U test, contingency coefficients and logistic regression. Average NDI was found to be significantly different comparing the group with positive abduction force and the group that cannot perform the active abduction. Logistic regression indicated that the variable representing impossible active abduction was significantly associated with NDI. Preliminary results showed that there was a strong relationship between the hallux active abduction force and NDI in young athletes: the higher abduction force correlates to lower NDI. To determine clinical relevance of our investigation, further study is planned in which hallux active abduction force and NDI would be compared and correlated pre- and postspecific strengthening program.

Influence of Sex on Current Methods of Adjusting Saddle Height in Indoor Cycling

ABSTRACT

Encarnación-Martínez, A, Ferrer-Roca, V, and García-López, J. Influence of sex on current methods of adjusting saddle height in indoor cycling. J Strength Cond Res 35(2): 519-526, 2021-The popularity of indoor cycling has increased in fitness centers, and therefore, proper bike fitting is important to avoid biomechanical-related injuries. However, no previous studies have compared the biomechanical kinematics of various existing protocols of saddle-height adjustment in indoor cycling. Furthermore, it was not clear if these protocols were appropriate for both men and women, as these equations were primarily obtained in male cyclists. Therefore, lower-limb joint kinematics were compared among 4 different protocols of saddle-height adjustment (1-Preferred, 2-Ferrer-Roca et al., 3-Lemond & Guimard, and 4-Static Goniometry) in 30 experienced indoor-cycling subjects (15 men and 15 women). Only 20-33% of the women had a knee extension while pedaling within the recommended range for each of the different protocols except for the preferred adjustment (73% were within). By contrast, all the protocols were moderately suitable for men (47-60% were within the recommended range). A multiple linear equation to estimate the recommended saddle height in both men and women (R2 = 0.917, p = 0.001) was obtained from the following variables: inseam length, stature, foot length, and knee angle. The differences in the findings between men and women may be partially explained by differences in anatomical structures, as well as the male-based equations, which argues the need for future investigations in female cyclists.

Sex-Specific Differences in Running Injuries: A Systematic Review with Meta-Analysis and Meta-Regression

BACKGROUND

Running is a popular sport with high injury rates. Although risk factors have intensively been investigated, synthesized knowledge about the differences in injury rates of female and male runners is scarce.

OBJECTIVE

To systematically investigate the differences in injury rates and characteristics between female and male runners.

METHODS

Database searches (PubMed, Web of Science, PEDro, SPORTDiscus) were conducted according to PRISMA guidelines using the keywords "running AND injur*". Prospective studies reporting running related injury rates for both sexes were included. A random-effects meta-analysis was used to pool the risk ratios (RR) for the occurrence of injuries in female vs. male runners. Potential moderators (effect modifiers) were analysed using meta-regression.

RESULTS

After removal of duplicates, 12,215 articles were screened. Thirty-eight studies were included and the OR of 31 could be pooled in the quantitative analysis. The overall injury rate was 20.8 (95% CI 19.9-21.7) injuries per 100 female runners and 20.4 (95% CI 19.7-21.1) injuries per 100 male runners. Meta-analysis revealed no differences between sexes for overall injuries reported per 100 runners (RR 0.99, 95% CI 0.90-1.10, n = 24) and per hours or athlete exposure (RR 0.94, 95% CI 0.69-1.27, n = 6). Female sex was associated with a more frequent occurrence of bone stress injury (RR (for males) 0.52, 95% CI 0.36-0.76, n = 5) while male runners had higher risk for Achilles tendinopathies (RR 1. 86, 95% CI 1.25-2.79, n = 2). Meta-regression showed an association between a higher injury risk and competition distances of 10 km and shorter in female runners (RR 1.08, 95% CI 1.00-1.69).

CONCLUSION

Differences between female and male runners in specific injury diagnoses should be considered in the development of individualised and sex-specific prevention and rehabilitation strategies to manage running-related injuries.

Multifactorial Determinants of Running Injury Locations in 550 Injured Recreational Runners

PURPOSE

Despite the health benefits of running, the prevalence of running-related injuries (RRI) remains high. The underlying risk factors between these injuries are still not well understood. Therefore, the aim of this study was to compare biomechanical, anthropometric, and demographic injury risk factors between different locations in injured recreational runners.

METHODS

In this retrospective case-control analysis, 550 injured runners (49.6% female) with a medically diagnosed RRI were included. All runners had undergone an instrumented treadmill analysis to determine habitual footstrike pattern, vertical instantaneous load rate, peak vertical ground reaction force (vGRF) and cadence. Injuries were classified by location according to a recent consensus statement. A logistic regression model was used to determine the association between the biomechanical parameters and RRI locations. Because injuries can be associated with age, sex, and body mass index, these variables were also entered into the logistic regression.

RESULTS

Strike pattern and peak vGRF were the only biomechanical variable distinguishing an injury from the group of injuries. A midfoot strike differentiated Achilles tendon injuries (odds ratio [OR], 2.27; 90% confidence interval [CI], 1.17-4.41) and a forefoot strike distinguished posterior lower leg injuries (OR, 2.59; 90% CI, 1.50-4.47) from the rest of the injured group. Peak vGRF was weakly associated with hip injuries (OR, 1.14; 90% CI, 1.05-1.24). Female sex was associated with injuries to the lower leg (OR, 2.65; 90% CI, 1.45-4.87) and hip/groin (OR, 2.22; 90% CI, 1.43-3.45). Male sex was associated with Achilles tendon injuries (OR, 1.923; 90% CI, 1.094-3.378).

CONCLUSIONS

Sex, foot strike pattern, and vGRF were the only factors that distinguished specific injury locations from the remaining injury locations.

Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes

PURPOSE

Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive high-stress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established.

METHODS

Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT).

RESULTS

In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. - 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved.

CONCLUSION

In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence.

LEVEL OF EVIDENCE

III.

Youth running consensus statement: minimising risk of injury and illness in youth runners

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

BACKGROUND

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.

PURPOSE/QUESTIONS

We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.

METHODS

A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.

CONCLUSIONS

Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.

Exploring treatment of medial tibial stress syndrome via posture and the MyoKinesthetic system

INTRODUCTION

A standard treatment protocol for medial tibial stress syndrome (MTSS) has not been identified. Clinical practice focuses on local evaluation and treatment neglecting a global approach. The MyoKinesthetic™ (MYK) System includes a full-body postural assessment to identify compensatory patterns that may lead to MTSS. The purpose of this study was to assess the effects of the MYK System in treating patients diagnosed with MTSS.

METHOD

A multi-site exploratory study was used to assess the effects of the MYK System on perceived pain and disability in patients diagnosed with MTSS. Eighteen physically active patients (6 female, 12 male), ages 18-25 years (19.89 ± 1.32) were treated with the MYK System.

RESULTS

Paired T-tests were utilized to assess change. The change in patient reported pain was statistically significant (t₍₁₇₎ = 10.48, p < .001, Cohen's d = 2.48) and represented an average decrease of 96% in patient reported pain. The change in disablement was statistically significant (t₍₁₇₎ = 7.39, p < .001, Cohen's d = 1.74) and represented an average decrease of 88.2% in patient reported disablement.

DISCUSSION

Participants treated with the MYK System experienced significant improvements and appear to surpass traditional interventions without the need of rest.

CONCLUSION

Implementation of the MYK System to treat MTSS led to significant decreases in patient reported pain and dysfunction. A full-scale clinical investigation of the MYK System is warranted to determine its effects compared to traditional treatment options.

Pediatric Flatfeet-A Disease Entity That Demands Greater Attention and Treatment

Background: Pediatric flatfoot is a common deformity. Unfortunately, the common opinion has been that most children with this faulty foot structure will simply out-grow it, despite no radiographic evidence to support this claim. Every step on a deformed foot leads to excessive tissue strain and further joint damage. Many forms of conservative and surgical treatments have been offered. This study was aimed at investigating the effectiveness of non-surgical and surgical treatment options. Main Text: faulty-foot structure is the leading cause of many secondary orthopedic deformities. A wide range of treatments for pediatric flatfeet have been recommended from the "do-nothing" approach, observation, to irreversible reconstructive surgery. Most forms of conservative care lack evidence of osseous realignment and stability. A conservative surgical option of extra-osseous talotarsal joint stabilization provides patients an effective form of treatment without the complications associated with other irreversible surgical procedures. Conclusion: Pediatric flatfeet should not be ignored or downplayed. The sooner effective treatment is prescribed, the less damage will occur to other parts of the body. When possible, a more conservative corrective procedure should be performed prior to irreversible, joint destructive options.

Forefoot and hindfoot kinematics in subjects with medial tibial stress syndrome during walking and running

Excessive foot pronation during static standing, walking and running has been reported as a contributing factor for the development of medial tibial stress syndrome (MTSS). The motion of foot pronation consists of hindfoot and forefoot motion. However, no previous studies have investigated forefoot and hindfoot kinematics during walking and running in subjects with MTSS. The current study sought to compare hindfoot and forefoot kinematics between subjects with and without MTSS while walking and running. Eleven subjects with MTSS and 11 healthy controls (each group containing 10 males and one female) participated in the current study. Segment angles of the hindfoot and forefoot during walking and running barefoot on a treadmill were recorded using three-dimensional kinematic analysis. An independent t-test was used to compare kinematic data between groups. Subjects with MTSS exhibited significantly greater hindfoot eversion and abduction (p < 0.05) during walking and running than subjects without MTSS, significantly greater forefoot eversion and abduction (p < 0.05) during walking, and significantly greater forefoot abduction during running (p < 0.05). Hindfoot and forefoot kinematics during walking and running were significantly different between subjects with and without MTSS. For prevention and rehabilitation of MTSS, it may be important to focus on not only hindfoot but also forefoot kinematics during both running and walking. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Do alterations in muscle strength, flexibility, range of motion, and alignment predict lower extremity injury in runners: a systematic review

Background

Injury is common in running and seen to impact up to 94% of recreational runners. Clinicians often use alterations from normal musculoskeletal clinical assessments to assess for risk of injury, but it is unclear if these assessments are associated with future injury.

Objectives

To identify alterations in muscle strength, flexibility, range of motion, and alignment that may predict lower extremity injury in runners.

Methods

Articles were selected following a comprehensive search of PubMed, Embase, CINAHL, and SPORTDiscus from database inception to May 2018. Included articles were prospective cohort studies, which specifically analyzed musculoskeletal impairments associated with future running-related injury. Two authors extracted study data, assessed the methodological quality of each study using the Critical Appraisal Tool and assessed the overall quality using the GRADE approach.

Results

Seven articles met the inclusion criteria. There was very low quality of evidence for the 7 identified clinical assessment alteration categories. Strong hip abductors were significantly associated with running-related injury in one study. Increased hip external-to-internal rotation strength and decreased hip internal range of motion were protective for running injury, each in one study. Decreased navicular drop in females had a protective effect for running-related injury in one study.

Conclusions

Due to very low quality of evidence for each assessment, confounders present within the studies, a limited number of studies, different measurement methods among studies, measurement variability within clinical assessments, inconsistent definitions of injury and runner, different statistical modeling, and study bias, caution is suggested in interpreting these results.

A protocol to prospectively assess risk factors for medial tibial stress syndrome in distance runners

Background

Medial tibial stress syndrome (MTSS) is a lower leg injury with a reported incidence rate of up to 35% in active individuals. Although numerous prospective studies have tried to identify risk factors for developing MTSS, managing the syndrome remains difficult. One risk factor yet to be extensively explored in MTSS development is reduced lower leg girth. Further investigation of reduced lower leg girth is required due to the important role lower leg musculature plays in attenuating ground reaction forces during the gait cycle. Therefore, the primary aim of this study is to ascertain whether lower leg muscle morphology and function contribute to the development of MTSS. Our ultimate aim is to identify potential risk factors for MTSS that can be targeted in future studies to better manage the injury or, preferably, prevent individuals developing MTSS.

Methods

This study will be prospective in design and will recruit asymptomatic distance runners. All participants will be tested at base line and participants will have their training data longitudinally tracked over the following 12 months to assess any individuals who develop MTSS symptoms. At base line, outcome measures will include bilateral measures of lower limb anthropometry; cross sectional area (CSA) and thickness of the tibialis anterior, peroneals, flexor digitorum longus, flexor hallucis longus and thickness of soleus, medial and lateral head of gastrocnemius. Tibial bone speed of sound, ankle dorsiflexion range of motion, strength of the six previously described muscles, foot alignment and ankle plantar flexor endurance will also be assessed. Participants will also complete a treadmill running protocol where three-dimensional kinematics, plantar pressure distribution and electromyography data will be collected.

Discussion

This study will aim to identify characteristics of individuals who develop MTSS and, in turn, identify modifiable risk factors that can be targeted to prevent individuals developing this injury.

Body Mass Index as a Predictor of Injuries in Athletics

The quest to identify injury risk factors in sports has been an ongoing and well-researched field in the world of sports medicine. Knowing some of these factors helps keep sports participation safe. Both intrinsic and extrinsic factors have been studied. Body mass index (BMI) is widely known to contribute to several medical conditions. Its association with some sports injuries has been established but the information is vast, with few studies that are randomized controlled trials. It is important to analyze these studies and confirm whether BMI is a predictor of lower-extremity injuries. Such knowledge allows for better effective treatment and prevention strategies. This article will summarize current evidence of association between BMI and lower-extremity injuries in athletes and whether BMI is a predictor of lower-extremity injuries.

Shockwave treatment for medial tibial stress syndrome in military cadets: A single-blind randomized controlled trial

Medial tibial stress syndrome (MTSS) is a common injury in athletes and soldiers. Several studies have demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) in athletes with MTSS.

OBJECTIVE

To assess whether one session of focused ESWT is effective in the treatment of military cadets with MTSS.

DESIGN

A randomized, prospective, controlled, single-blind, parallel-group clinical study.

LEVEL OF EVIDENCE

Ib.

SETTING

Military School of Cadets of the Colombian Army.

METHODS

Forty-two military cadets with unilateral chronic MTSS were randomly assigned to either one session of focused electromagnetic ESWT (1500 pulses at 0.20 mJ/mm²) plus a specific exercise programme (muscle stretching and strengthening exercises) or the exercise programme alone. The primary endpoint was change in asymptomatic running test (RT) duration at four weeks from baseline. Secondary endpoints were changes in the visual analogue scale (VAS) after running and modified Roles and Maudsley (RM) score also at four weeks from baseline.

RESULTS

ESWT patients were able to run longer. Mean RT after four weeks was 17 min 33 s (SE: 2.36) compared to 4 min 48 s (SE: 1.03) in the exercise-only group (p = 0.000). Mean VAS after running was 2.17 (SE: 0.44) in the ESWT group versus 4.26 (SE: 0.36) in the exercise-only group (p = 0.001). The ESWT group had a significantly higher RM score, with excellent or good results for 82.6% of patients vs. 36.8% in the exercise-only group (p = 0.002). No significant adverse effects of ESWT were observed.

CONCLUSION

A single application of focused shockwave treatment in combination with a specific exercise programme accelerates clinical and functional recovery in military cadets with MTSS.

Biomechanical Factors Associated With Achilles Tendinopathy and Medial Tibial Stress Syndrome in Runners

BACKGROUND

There is disagreement in the literature regarding whether the excessive excursion or velocity of rearfoot eversion is related to the development of 2 common running injuries: Achilles tendinopathy (AT) and medial tibial stress syndrome (MTSS). An alternative hypothesis suggests that the duration of rearfoot eversion may be an important factor. However, the duration of eversion has received relatively little attention in the biomechanics literature.

HYPOTHESIS

Runners with AT or MTSS will demonstrate a longer duration of eversion but not greater excursion or velocity of eversion compared with healthy controls.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-two runners participated in this study (13 with AT, 8 with MTSS, and 21 matched controls). Participants were evaluated for lower extremity alignment and flexibility, after which a 3-dimensional kinematic and kinetic running gait analysis was performed. Differences between the 2 injuries and between injured and control participants were evaluated for flexibility and alignment, rearfoot kinematics, and 3 ground-reaction force metrics. Binary logistic regression was used to evaluate which variables best predicted membership in the injured group.

RESULTS

Injured participants, compared with controls, demonstrated higher standing tibia varus angles (8.67° ± 1.79° vs 6.76° ± 1.75°, respectively; P = .002), reduced static dorsiflexion range of motion (6.14° ± 5.04° vs 11.19° ± 5.10°, respectively; P = .002), more rearfoot eversion at heel-off (-6.47° ± 5.58° vs 1.07° ± 2.26°, respectively; P < .001), and a longer duration of eversion (86.02% ± 15.65% stance vs 59.12% ± 16.50% stance, respectively; P < .001). There were no differences in the excursion or velocity of eversion. The logistic regression (χ² = 20.84, P < .001) revealed that every 1% increase in the duration of eversion during the stance phase increased the odds of being in the injured group by 1.08 (95% CI, 1.023-1.141; P = .006).

CONCLUSION

Compared with healthy controls, runners currently symptomatic with AT or MTSS have a longer duration of eversion but not greater excursion or velocity of eversion.

CLINICAL RELEVANCE

Static measures of the tibia varus angle and dorsiflexion range of motion, along with dynamic measures of the duration of eversion, may be useful for identifying runners at risk of sustaining AT or MTSS.

Ankle and toe muscle strength characteristics in runners with a history of medial tibial stress syndrome

Background

A high proportion of flexor digitorum longus attachment is found at the posteromedial border of the tibia, which is the most common location of medial tibial stress syndrome (MTSS). Therefore, plantar flexion strength of the lesser toes could be related to MTSS; however, the relationship between MTSS and muscle strength of the hallux and lesser toes is not yet evaluated due to the lack of quantitative methods. This study investigated the muscle strength characteristics in runners with a history of MTSS by using a newly developed device to measure the muscle strength of the hallux, lesser toes, and ankle.

Methods

This study comprised 27 collegiate male runner participants (20.0 ± 1.6 years, 172.1 ± 5.1 cm, 57.5 ± 4.0 kg). Maximal voluntary isometric contraction (MVIC) torque of the plantar flexion, dorsiflexion, inversion, and eversion of the ankle were measured by using an electric dynamometer. MVIC torque of the 1st metatarsophalangeal joint (MTPJ) and 2nd–5th MTPJ were measured by using a custom-made torque-measuring device. MVIC torques were compared between runners with and without a history of MTSS.

Results

MVIC torque of the 1st MTPJ plantar flexion was significantly higher in runners with a history of MTSS than in those without it. In contrast, there were no significant differences in the MVIC torque values of the 2nd–5th MTPJ plantar flexion and each MVIC torque of the ankle between runners with and without a history of MTSS.

Conclusion

A history of MTSS increased the isometric FHL strength.

Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors

CONTEXT

Medial tibial stress syndrome (MTSS) is a common condition in active individuals and presents as diffuse pain along the posteromedial border of the tibia.

OBJECTIVE

To use cross-sectional, case-control, and cohort studies to identify significant MTSS risk factors.

DATA SOURCES

Bibliographic databases (PubMed, Scopus, CINAHL, SPORTDiscus, EMBASE, EBM Reviews, PEDRo), grey literature, electronic search of full text of journals, manual review of reference lists, and automatically executed PubMed MTSS searches were utilized. All searches were conducted between 2011 and 2015.

STUDY SELECTION

Inclusion criteria were determined a priori and included original research with participants' pain diffuse, located in the posterior medial tibial region, and activity related.

STUDY DESIGN

Systematic review with meta-analysis.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Titles and abstracts were reviewed to eliminate citations that did not meet the criteria for inclusion. Study characteristics identified a priori were extracted for data analysis. Statistical heterogeneity was examined using the I2 index and Cochran Q test, and a random-effects model was used to calculate the meta-analysis when 2 or more studies examined a risk factor. Two authors independently assessed study quality.

RESULTS

Eighty-three articles met the inclusion criteria, and 22 articles included risk factor data. Of the 27 risk factors that were in 2 or more studies, 5 risk factors showed a significant pooled effect and low statistical heterogeneity, including female sex (odds ratio [OR], 2.35; CI, 1.58-3.50), increased weight (standardized mean difference [SMD], 0.24; CI, 0.03-0.45), higher navicular drop (SMD, 0.44; CI, 0.21-0.67), previous running injury (OR, 2.18; CI, 1.00-4.72), and greater hip external rotation with the hip in flexion (SMD, 0.44; CI, 0.23-0.65). The remaining risk factors had a nonsignificant pooled effect or significant pooled effect with high statistical heterogeneity.

CONCLUSION

Female sex, increased weight, higher navicular drop, previous running injury, and greater hip external rotation with the hip in flexion are risk factors for the development of MTSS.

Running Injuries During Adolescence and Childhood

The popularity of running among young athletes has significantly increased over the past few decades. As the number of children who participate in running increases, so do the potential number of injuries to this group. Proper care of these athletes includes a thorough understanding of the unique physiology of the skeletally immature athlete and common injuries in this age group. Treatment should focus on athlete education, modification of training schedule, and correction of biomechanical deficits contributing to injury. Early identification and correction of these factors will allow a safe return to running sports.

Gender differences of muscle and crural fascia origins in relation to the occurrence of medial tibial stress syndrome

Although women reportedly have a higher prevalence of medial tibial stress syndrome (MTSS) than men, the possible role of gender-based anatomical differences has not been investigated. The aim of the present study was to investigate the presence of gender-based differences in the range of muscle attachments along the entire medial tibia, the proportion of muscle attachment at the middle and distal thirds of the medial margin of the tibia, the structure of the crural fascia, and chiasm position. The specimens were 100 legs of 55 Japanese cadavers. Statistical analysis was carried out using a chi-square test to compare anatomical features between the sexes. The flexor digitorum longus (FDL) had a higher proportion of attachment to the middle and distal thirds of the medial margin of the tibia than the soleus (SOL; P < 0.001). The proportion of the SOL attachment to the middle and distal thirds of the medial margin of the tibia was 33.3% in men and 72.5% in women (P < 0.001). The soleal aponeurosis was not observed in any specimen. In all specimens the FDL formed the top layer of both chiasms. These results suggest that the higher prevalence of MTSS reported among women may be the result of gender-based anatomical differences.

Studying the Relation Between Medial Tibial Stress Syndrome and Anatomic and Anthropometric Characteristics of Military Male Personnel

BACKGROUND

Medial Tibial Stress Syndrome (MTSS) is common among military recruits and to our knowledge; the factors that might put the military recruits at higher risk of incidence of MTSS are not well known.

OBJECTIVES

This study was done to investigate the association between some anthropometric and anatomical factors and the prevalence of MTSS among military recruits.

PATIENTS AND METHODS

One hundred and eighty one randomly selected military recruits were included in this cross sectional study. Using history taking and physical examinations they were tested for MTSS. Accordingly the subjects were assigned to the case (those with MTSS) and control groups (normal healthy subjects). Using standard guidelines, the anthropometric and anatomical criteria of the subjects were measured. The correlation between the measurements and the prevalence of MTSS was tested using statistical analysis.

RESULTS

Data of all the 181 subjects with the mean age of 30.7 ± 4.68 years were Included in the final analysis. The prevalence of MTSS was found to be 16.6% (30 people). Internal and external rotation range of motion, iliospinale height, the score of navicular drop test, and the trochanteric tibial lateral length were significantly different between healthy subjects and patients with MTSS (P < 0.05).

DISCUSSION

The prevalence of MTSS was relatively lower in this study comparing to other studies on military personnel. It was not probably due to type of military shoes or exercise area surface (none of them were standardized); it could be due to low intensity trainings and the long intervals between training sessions.

Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments

Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes and military recruits. Characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, in most cases it is also an injury involving underlying cortical bone microtrauma, although it is not clear if the soft tissue or cortical bone reaction occurs first. Nuclear bone scans and magnetic resonance imaging (MRI) can both be used for the diagnosis of MTSS, but the patient’s history and clinical symptoms need to be considered in conjunction with the imaging findings for a correct interpretation of the results, as both imaging modalities have demonstrated positive findings in the absence of injury. However, MRI is rapidly becoming the preferred imaging modality for the diagnosis of bone stress injuries. It can also be used for the early diagnosis of MTSS, as the developing periosteal oedema can be identified. Retrospective studies have demonstrated that MTSS patients have lower bone mineral density (BMD) at the injury site than exercising controls, and preliminary data indicates the BMD is lower in MTSS subjects than tibial stress fracture (TSF) subjects. The values of a number of tibial geometric parameters such as cross-sectional area and section modulus are also lower in MTSS subjects than exercising controls, but not as low as the values in TSF subjects. Thus, the balance between BMD and cortical bone geometry may predict an individual's likelihood of developing MTSS. However, prospective longitudinal studies are needed to determine how these factors alter during the development of the injury and to find the detailed structural cause, which is still unknown. Finite element analysis has recently been used to examine the mechanisms involved in tibial stress injuries and offer a promising future tool to understand the mechanisms involved in MTSS. Contemporary accurate diagnosis of either MTSS or a TSF includes a thorough clinical examination to identify signs of bone stress injury and to exclude other pathologies. This should be followed by an MRI study of the whole tibia. The cause of the injury should be established and addressed in order to facilitate healing and prevent future re-occurrence.

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.

Middle school injuries: a 20-year (1988-2008) multisport evaluation

CONTEXT

Data on the incidence of injury in middle school sports are limited.

OBJECTIVE

To describe overall, practice, and game injury rate patterns in 29 middle school sports.

DESIGN

Descriptive epidemiology study.

SETTING

Injury data collected over a 20-year period (1988-2008) at a single school.

PATIENTS OR OTHER PARTICIPANTS

Boy (n = 8078) and girl (n = 5960) athletes participating in 14 and 15 middle school sports, respectively.

MAIN OUTCOME MEASURE(S)

Injury status and athlete-exposures (AEs) were collected by certified athletic trainers. Incidence rates per 1000 AEs (injuries/AEs) were calculated for overall incidence, practices and games, injury location, injury type, and injury severity (time lost from participation). Rate ratios (RRs) and 95% confidence intervals (CIs) were used to compare injury rates for sex-matched sports.

RESULTS

Football had the highest injury rate for all injuries (16.03/1000 AEs) and for time-loss injuries (8.486/1000 AEs). In matched middle school sports, girls exhibited a higher injury rate for all injuries (7.686/1000 AEs, RR = 1.15, 95% CI = 1.1, 1.2) and time-loss injuries (2.944/1000 AEs, RR = 1.09, 95% CI = 1.0, 1.2) than boys (all injuries: 6.684/1000 AEs, time-loss injuries: 2.702/1000 AEs). Girls had a higher injury rate during practices (3.30/1000 AEs) than games (1.67/1000 AEs, RR = 1.97, 95% CI = 1.7, 2.4) for all sports. Only gymnastics (RR = 0.96, 95% CI = 0.3, 3.8) had a higher game injury rate for girls. Practice and game injury rates were nearly identical for boys in all sports (RR = 0.99, 95% CI = 0.9, 1.1). Only football (RR = 0.49, 95% CI = 0.4, 0.6) and boys' wrestling (RR = 0.50, 95% CI = 0.3, 0.8) reported higher game injury rates. Tendinitis injuries accounted for 19.1% of all middle school injuries.

CONCLUSIONS

The risk for sport-related injury at the middle school level was greater during practices than games and greater for girls than boys in sex-matched sports. Conditioning programs may be needed to address the high rate of tendinitis injuries.

Arch-Taping Techniques for Altering Navicular Height and Plantar Pressures During Activity

CONTEXT

Arch tapings have been used to support the arch by increasing navicular height. Few researchers have studied navicular height and plantar pressures after physical activity.

OBJECTIVE

To determine if taping techniques effectively support the arch during exercise.

DESIGN

Crossover study.

SETTING

Athletic training research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-five individuals (13 men, 12 women; age = 20.0 ± 1.0 years, height = 172.3 ± 6.6 cm, mass = 70.1 ± 10.2 kg) with a navicular drop of more than 8 mm (12.9 ± 3.3 mm) volunteered.

INTERVENTION(S)

All individuals participated in 3 days of testing, with 1 day for each tape condition: no tape, low dye, and navicular sling. On each testing day, navicular height and plantar pressures were measured at 5 intervals: baseline; posttape; and after 5, 10, and 15 minutes of running. The order of tape condition was counterbalanced.

MAIN OUTCOME MEASURE(S)

The dependent variables were navicular height in millimeters and plantar pressures in kilopascals. Plantar pressures were divided into 5 regions: medial forefoot, lateral forefoot, lateral midfoot, lateral rearfoot, and medial rearfoot. Separate repeated-measures analyses of variance were conducted for each dependent variable.

RESULTS

Navicular height was higher immediately after application of the navicular-sling condition (P = .004) but was reduced after 5 minutes of treadmill running (P = .12). We observed no differences from baseline to posttape for navicular height for the low-dye (P = .30) and no-tape conditions (P = .25). Both the low-dye and navicular-sling conditions increased plantar pressures in the lateral midfoot region compared with the no-tape condition. The low-dye condition created decreased pressure in the medial and lateral forefoot regions compared with the no-tape condition. All changes were identified immediately after application and were maintained during running. No changes were noted in plantar pressures for the no-tape condition (P > .05).

CONCLUSIONS

Both taping techniques effectively changed plantar pressures in the lateral midfoot, and these changes were sustained throughout the 15 minutes of exercise.

Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis

Background

Static measures of foot posture are regularly used as part of a clinical examination to determine the need for foot level interventions. This is based on the premise that pronated and supinated foot postures may be risk factors for or associated with lower limb injury. This systematic review and meta-analysis investigates foot posture (measured statically) as a potential risk factor for lower limb overuse injuries.

Methods

A systematic search was performed using Medline, CINAHL, Embase, SportDiscus in April 2014, to identify prospective cohort studies that investigated foot posture and function as a risk factor for lower limb overuse injury. Eligible studies were classified based on the method of foot assessment: (i) static foot posture assessment; and/or (ii) dynamic foot function assessment. This review presents studies evaluating static foot posture. The methodological quality of included studies was evaluated by two independent reviewers, using an adapted version of the Epidemiological Appraisal Instrument (EAI). Where possible, effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data. Meta-analysis was performed where injuries and outcomes were considered homogenous.

Results

Twenty-one studies were included (total n = 6,228; EAI 0.8 to 1.7 out of 2.0). There was strong evidence that a pronated foot posture was a risk factor for medial tibial stress syndrome (MTSS) development and very limited evidence that a pronated foot posture was a risk factor for patellofemoral pain development, although associated effect sizes were small (0.28 to 0.33). No relationship was identified between a pronated foot posture and any other evaluated pathology (i.e. foot/ankle injury, bone stress reactions and non-specific lower limb overuse injury).

Conclusion

This systematic review identified strong and very limited evidence of small effect that a pronated foot posture is a risk factor for MTSS and patellofemoral pain respectively. Evaluation of static foot posture should be included in a multifactorial assessment for both MTSS and patellofemoral pain, although only as a part of the potential injury risk profile. Whilst the included measures are clinically applicable, further studies are required to determine their relationship with dynamic foot function.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-014-0055-4) contains supplementary material, which is available to authorized users.

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.

Treatment of medial tibial stress syndrome according to the fascial distortion model: a prospective case control study

Medial tibial stress syndrome (MTSS) is a common problem among athletes and soldiers. There is no proven theory that could explain the pathophysiology of shin splints. The therapies described so far are time-consuming and involve a high risk of relapse. The method according to the fascial distortion model (FDM) addresses local changes in the area of the lower leg fascia. It is suited to reduce pain and functional impairments associated with this symptom complex by applying targeted manual techniques. 32 patients (male: 30; female: 2) participated in this study. Visual analogue scale (VAS) was used for the quantification of pain. Scores were also given to rate the maximum painless exercise tolerance of the patients. Subsequently treatment of the crural fascia was performed. Patients retested ability of running and jumping. Therapy was continued until full exercise tolerance or painlessness was reached. A significant reduction of the VAS pain score from 5.2 to 1.1 could be achieved (P < 0.001). The impairment of exercise tolerance could be reduced from 7 to 2 points (P < 0.001). The duration of treatment was 6.3 (SD: 4.3) days on average. The FDM therapy is a potential effective method for acute treatment of MTSS.

The relationship between shin splints with anthropometric characteristics and some indicators of body composition

BACKGROUND

Medial tibial stress syndrome (MTSS), commonly known as "shin splints," is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes. The aim of this study was to study the relationship between Shin splints, anthropometric characteristics and some indicators of body composition.

METHODS

In this descriptive-comparative study, 35 students of physical education were evaluated in two groups: Shin Splints group ([N.=17], mean [±SD] height and weight, 161.52±5.32 and 56.85±9.30 respectively) and healthy group ([N.=18], mean [±SD] height and weight, 162.75±3.85 and 54.73±6.36 respectively). Anthropometric and body composition characteristic of both groups were studied under identical conditions. Independent t-test was performed in order to analyze the data.

RESULTS

No significant differences were found in anthropometric parameters (thigh length, leg length, foot length and leg circumference) body composition (the amount of minerals and body fat percentage) between the healthy group and the Shin Splints group (P>0.05).

CONCLUSIONS

According to the results of this study, anthropometric characteristics and body composition indicators may not be regarded as a risk factor for shin splints.

Summer training factors and risk of musculoskeletal injury among high school cross-country runners

STUDY DESIGN

Prospective cohort.

OBJECTIVES

To examine the relationship between summer training practices and risk of injury during the first month of a high school interscholastic cross-country season.

BACKGROUND

Several prospective studies have reported a high incidence of injury in adolescent cross-country runners. However, limited reports exist on the role of summer training practices and risk of injury among these runners.

METHODS

Four hundred twenty-one athletes (186 girls, 235 boys) who competed in interscholastic cross-country were followed during a cross-country season. At the start of the season, all participants completed a questionnaire regarding summer training routines. Time-loss, running-related injuries were tracked during the subsequent season. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of initial injury during the first month of the season associated with summer training variables.

RESULTS

Sixty-seven runners (15.9%) had a confirmed injury during the first month of the season, with a higher percent among girls (19.4%) than boys (13.2%) (P = .06). Overall, 60.1% of the participants ran during the summer prior to the season, with a significantly higher percent among girls (71.5%) than boys (51.1%) (P<.0001). Overall, no significant association (OR = 0.9; 95% CI: 0.5, 1.5; P = .90) was found between not running sometime during the preceding summer and increased risk of initial injury during the first month of the season. Among only the runners who ran during the summer, after adjusting for sex and prior injury, first-month injuries were more common among those who did not frequently alternate short and long mileage on different days (OR = 3.0; 95% CI: 1.4, 6.4; P = .005), and/or who ran 8 weeks or fewer (OR = 2.7; 95% CI: 1.2, 5.8; P = .01) during their summer training. Running 8 weeks or fewer (P = .03), not frequently alternating mileage on different days (P = .01), and running a higher percentage of time on predominantly hill (P = .001) and irregular terrains (P = .004) were associated with increased risk of injury for girls.

CONCLUSION

These findings suggest that injuries during the first month of the high school cross-country season may be reduced if runners who participate in summer training activities run a greater number of weeks and frequently vary their daily running mileage during the summer. For girls, training programs that reduce mileage on hills and irregular terrains may help to minimize the occurrence of running-related injury.

LEVEL OF EVIDENCE

Prognosis, level 1b-.

Structural deformation of longitudinal arches during running in soccer players with medial tibial stress syndrome

The purpose of this study was to compare angular change and translational motion from the medial longitudinal arch (MLA) and lateral longitudinal arch (LLA) during running between medial tibial stress syndrome (MTSS) and non-MTSS subjects. A total of 10 subjects volunteered, comprising 5 subjects with MTSS and 5 subjects without injury (non-MTSS) as the control group. All subjects performed the test movement that simulated running. Fluoroscopic imaging was used to investigate bone movement during landing in running. Sagittal motion was defined as the angular change and translational motion of the arch. A Mann-Whitney U-test was performed to determine the differences in the measured values between the MTSS and non-MTSS groups. The magnitude of angular change for the MLA and LLA was significantly greater for subjects with MTSS than for control subjects. Translational motion of the MLA and LLA of the MTSS group was also significantly greater than that of the non-MTSS group (all p < 0.05). Soccer players with MTSS have an abnormal structural deformation of foot during support (or stance) phase of running, with a large decrease in both the MLA and LLA. This abnormal motion could be a risk factor for the development of MTSS in these subjects.

Medial longitudinal arch mechanics before and after a 45-minute run

BACKGROUND

Medial longitudinal arch integrity after prolonged running has yet to be well documented. We sought to quantify changes in medial longitudinal arch kinematics before and after a 45-min run in healthy recreational runners.

METHODS

Thirty runners performed barefoot seated, standing, and running trials before and after a 45-min shod treadmill run. Navicular displacement, arch lengthening, and the arch height index were used to quantify arch deformation, and the arch rigidity index was used to quantify arch stiffness.

RESULTS

There were no statistically significant differences in mean (95% confidence interval) values for navicular displacement (5.6 mm [4.7-6.4 mm]), arch lengthening (3.2 mm [2.6-3.9 mm]), change in arch height index (0.015 [0.012-0.018]), or arch rigidity index (0.95 [0.94-0.96]) after the 45-min run (all multivariate analyses of variance P ≥ .065).

CONCLUSIONS

Because there were no statistically significant changes in arch deformation or rigidity, the structures of a healthy, intact medial longitudinal arch are capable of either adapting to cyclical loading or withstanding a 45-min run without compromise.

The pediatric knee: current concepts in sports medicine

As the popularity and intensity of children's athletics have increased, so has the risk for knee injuries. Fractures of the tibial eminence may be treated operatively or nonoperatively depending on fracture classification, but arthrofibrosis is a potentially significant complication. Anterior cruciate ligament rupture presents treatment challenges as regards the optimal timing and method of reconstruction. A number of novel reconstructive techniques have been developed to minimize risks to the physes in this population. Recent studies have focused on the prognosis, surgical indications, and operative techniques for osteochondritis dissecans in children. A number of authors have also sought to better-define the optimal diagnostic testing and management of patellar dislocation. In this review, we provide an update on current concepts for tibial eminence fractures, anterior cruciate ligament injuries, osteochondritis dissecans of the knee, and patellar dislocation in young athletes.

Overweight and obesity are associated with musculoskeletal complaints as early as childhood: a systematic review

In order to examine (i) the association between weight status and musculoskeletal complaints (MSC) in children, and (ii) whether overweight and obese children have a higher risk of developing MSC than normal-weight children Medline, Embase, Web of Science and Cochrane were searched (all years up to 2 January 2013) for observational studies studying direct associations between body mass index (or weight status) and MSC in children. Forty studies, together studying over one million children, were included. There was moderate quality of evidence that being overweight in childhood is positively associated with musculoskeletal pain (risk ratio [RR] 1.26; 95% confidence interval [CI]: 1.09-1.45). In addition, low quality of evidence was found for a positive association between overweight and low back pain (RR 1.42; 95% CI: 1.03-1.97) and between overweight and injuries and fractures (RR 1.08; 95% CI: 1.03-1.14). Although the risk of developing an injury was significantly higher for overweight than for normal-weight adolescents (RR: 2.41, 95% CI: 1.42 to 4.10), this evidence was of very low quality. Overweight and obesity are associated with musculoskeletal pain, injuries and fractures as early as childhood. More high-quality prospective cohort studies are needed to study the nature of this relationship.

Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis

Background

Medial tibial stress syndrome (MTSS) affects 5%–35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners.

Methods

Medical research databases were searched for relevant literature, using the terms “MTSS AND prevention OR risk OR prediction OR incidence”.

Results

A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29–1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56–3.43, P<0.001); fewer years of running experience (SMD −0.74, 95% CI −1.26 to −0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15–2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17–11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08–0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02–0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00–3.96, P=0.05).

Conclusion

Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.