Overuse Injuries In Runners Research Articles

Cross-cultural adaptation and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients

BackgroundAchilles tendinopathy is the predominant overuse injury in runners. To further investigate this overload injury in transverse and longitudinal studies a valid, responsive and reliable outcome measure is demanded. Most questionnaires have been developed for English-speaking populations. This is also true for the VISA-A score, so far representing the only valid, reliable, and disease specific questionnaire for Achilles tendinopathy. To internationally compare research results, to perform multinational studies or to exclude bias originating from subpopulations speaking different languages within one country an equivalent instrument is demanded in different languages. The aim of this study was therefore to cross-cultural adapt and validate the VISA-A questionnaire for German-speaking Achilles tendinopathy patients.MethodsAccording to the "guidelines for the process of cross-cultural adaptation of self-report measures" the VISA-A score was cross-culturally adapted into German (VISA-A-G) using six steps: Translation, synthesis, back translation, expert committee review, pretesting (n = 77), and appraisal of the adaptation process by an advisory committee determining the adequacy of the cross-cultural adaptation. The resulting VISA-A-G was then subjected to an analysis of reliability, validity, and internal consistency in 30 Achilles tendinopathy patients and 79 asymptomatic people. Concurrent validity was tested against a generic tendon grading system (Percy and Conochie) and against a classification system for the effect of pain on athletic performance (Curwin and Stanish).ResultsThe "advisory committee" determined the VISA-A-G questionnaire as been translated "acceptable". The VISA-A-G questionnaire showed moderate to excellent test-retest reliability (ICC = 0.60 to 0.97). Concurrent validity showed good coherence when correlated with the grading system of Curwin and Stanish (rho = -0.95) and for the Percy and Conochie grade of severity (rho 0.95). Internal consistency (Cronbach's alpha) for the total VISA-A-G scores of the patients was calculated to be 0.737.ConclusionThe VISA-A questionnaire was successfully cross-cultural adapted and validated for use in German speaking populations. The psychometric properties of the VISA-A-G questionnaire are similar to those of the original English version. It therefore can be recommended as a sufficiently robust tool for future measuring clinical severity of Achilles tendinopathy in German speaking patients.

Effect of shoe type on plantar pressure: A gender comparison

Despite the differences in materials, racing flats have begun to be used not only for racing, but also for daily training. As there are data suggesting a gender difference in overuse injuries in runners, shoe choice may affect loading patterns during running. The purpose was to determine differences in plantar pressure between genders when running in training shoes and racing flats. In-shoe plantar pressure data were collected from 34 subjects (17m, 17f) who ran over-ground in both a racing flat and training shoe. Contact area (CA), maximum force (MF), and contact time under the entire foot and beneath eight foot regions were collected. Each variable was analyzed using a shoe by gender repeated measures ANOVA ( α = 0.05). In men, MF was increased in the racing flats ( p = 0.016) beneath the medial midfoot (MMF), yet was increased beneath the medial forefoot (MFF) in the training shoe ( p = 0.018). Independent of gender, CA was decreased in the racing flats beneath the entire foot ( p = 0.029), the MMF ( p = 0.013), and the MFF ( p = 0.030), and increased beneath the lateral forefoot (LFF) ( p = 0.023). In the racing flats, MF was increased beneath the entire foot ( p < 0.001) and the LFF ( p < 0.001). Independent of the shoe, CA was decreased in men beneath the MFF ( p = 0.007) and middle forefoot ( p < 0.001), while MF was increased in the LFF ( p = 0.002). The LFF is an area of increased stress fracture risk in men. Based on the gender differences in loading, running shoe design should be gender specific in an attempt to prevent injuries.

Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study

Background and objectivesTreatment of chronic running-related overuse injuries by orthopaedic shoe orthoses is very common but not evidence-based to date.HypothesisPolyurethane foam orthoses adapted to a participant's barefoot plantar pressure distribution...

Effects of functional pronator and supinator strength training on shank muscle volume and rearfoot motion in shod running

Numerous studies have discussed excessive pronation and pronation velocities as the primary reason for overuse injuries in running (James and Jones 1990). Therefore the biomechanical influence of r...

Suspected Mechanisms in the Cause of Overuse Running Injuries: A Clinical Review

Context:Various epidemiological studies have estimated that up to 70% of runners sustain an overuse running injury each year. Although few overuse running injuries have an established cause, more than 80% of running-related injuries occur at or below the knee, which suggests that some common mechanisms may be at work. The question then becomes, are there common mechanisms related to overuse running injuries?Evidence Acquisition:Research studies were identified via the following electronic databases: MEDLINE, EMBASE PsycInfo, and CINAHL (1980–July 2008). Inclusion was based on evaluation of risk factors for overuse running injuries.Results:A majority of the risk factors that have been researched over the past few years can be generally categorized into 2 groups: atypical foot pronation mechanics and inadequate hip muscle stabilization.Conclusion:Based on the review of literature, there is no definitive link between atypical foot mechanics and running injury mechanisms. The lack of normative data and a definition of typical foot structure has hampered progress. In contrast, a large and growing body of literature suggests that weakness of hip-stabilizing muscles leads to atypical lower extremity mechanics and increased forces within the lower extremity while running.

The Influence of Matching Populations on Kinematic and Kinetic Variables in Runners With Iliotibial Band Syndrome

The purpose of this study was to assess how participant matching influences biomechanical variables when comparing healthy runners and runners with iliotibial band syndrome (ITBS). We examined 52 healthy runners (CO) and 18 with ITBS, using three-dimensional kinematics and pressure distribution. The study population was matched in three ways and compared with the biomechanical findings: ITBS versus CO I (unmatched), ITBS versus CO II (matched to gender) and ITBS versus CO III (matched to gender, height, and weight). The final number of participants in each group was n = 18. The kinematic variables showed a dependency on the matching process. The largest statistically significant differences (after Bonferroni adjustment) in the frontal and transverse planes were between ITBS and CO III (p = .008). Pressure measurements were also dependent on the matching process, with decreasing and nonsignificant differences (p = .006) between ITBS and CO after refining the process (ITBS vs. CO III). The results of this study and the necessity of matching seem to be plausible (lever arms, different running styles). Data matching is important for understanding overuse injuries in running.

Side-to-side differences in overuse running injury susceptibility: A retrospective study

Despite the number of studies examining factors associated with overuse running injury, little is known about why an individual gets injured on a particular side of the body. Abnormal levels of several strength, structural, kinetic, and kinematic factors have been attributed to injury susceptibility. However, while most studies have compared the injured limb of injured runners to an arbitrary limb of healthy controls, there is some evidence to suggest that injury risk is related to characteristics on both sides of a runner. Therefore, the purpose of this study was to investigate how bilateral characteristics of strength, structural, kinetic, and kinematic factors relate to overuse injury. The first purpose was to compare these factors between the injured and uninjured limbs of runners with a history of injury on only one side of their bodies. The results showed that hip internal rotation range of motion and peak tibial acceleration were both elevated on the side with a history of injury. The second purpose was to compare asymmetry levels between the injured runners and runners who had never sustained a running-related injury. Asymmetry levels were similar between groups for all variables, which suggests that some level of asymmetry is normal. The final purpose of the study was to compare bilateral values of these factors between the injured and uninjured runners. The results showed that hip internal rotation range of motion, as well as the deviation from normal arch height index, were bilaterally elevated in the injured runners. Although peak tibial acceleration was different between sides of the injured runners, it was not bilaterally elevated compared to the uninjured runners. These results support the notion that injury risk may be related to risk factors on both sides.

Risk factors for overuse injuries in runners

There are many suspected risk factors for running-related overuse injuries; however, this remains a difficult area to adequately study. Numerous studies concerning factors that contribute to running injuries now exist in the literature, but inconsistent and sometimes conflicting results are found. This is likely due to different methodologies, definitions, outcome measures, and studied populations. This article reviews and summarizes several relevant studies on this topic, focusing on anatomic (intrinsic) risk factors as well as risk factors related to training (extrinsic). Due to the likely multifactorial nature of running injuries, very few firm conclusions can be made based on the existing studies. Training volume (mileage) and the occurrence of previous injuries seem to be the two most consistent risk factors across epidemiologic studies.

Risk Factors for Overuse Injuries in Runners

Risk Factors for Overuse Injuries in Runners

Are knee mechanics during early stance related to tibial stress fracture in runners?

Tibial stress fractures are a serious overuse injury in runners. Greater vertical loading rates and tibial shock have been found in runners with previous tibial stress fracture compared to controls. The timing of these variables occurs very early in the stance phase and suggests that conditions shortly after footstrike may be important in determining injury risk. The purpose of this study was to further investigate lower extremity mechanics in early stance in runners with a history of tibial stress fracture. In addition, the relationships between these variables were explored. Twenty-three runners with a history of tibial stress fracture were investigated. They were compared with 23 age and mileage matched control subjects with no previous lower extremity bony injuries. Data were collected as subjects ran at 3.7 m/s. All variables of interest were computed over the period from footstrike to the impact peak of the vertical ground reaction force. Independent t-tests and effect sizes were used to assess the differences between the groups. Pearson Product Moment correlations were used to determine whether initial stance variables were related to tibial shock in the two groups. Sagittal plane knee stiffness was significantly greater in the tibial stress fracture group. Stiffness was also positively correlated with shock. Knee excursion, knee angle at footstrike and shank angle at footstrike were not different between groups. These findings provide further support for the relationship between mechanics during initial loading and tibial stress fractures in runners. This relationship may be important in terms of retraining gait to reduce the risk of stress fracture in runners.

Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners

To investigate the influence of a custom foot orthotic intervention on the lower extremity dynamics in healthy runners. Three-dimensional kinematics and kinetics were collected on 15 female runners (>15 miles per week) while each performed the over-ground running trials in either a shoe only or a shoe+custom foot orthotic condition. Kinematic and kinetic variables were analyzed using Paired Sample t-tests. Custom foot orthotics are frequently prescribed treatment modality for the management of overuse running injuries. Although it is generally accepted that a custom foot orthotic intervention produces positive clinical outcomes, it remains unclear what influence this therapeutic modality has on the dynamics of the lower extremity. Each subject performed five acceptable over-ground running trials (3.6 m s(-1) +/-5%) with and without the custom foot orthotic intervention in a running shoe. Selected maximum ankle and knee joint angles and moments were measured during the stance phase. While wearing the custom foot orthotic, subjects exhibited significantly decreased maximum values in rearfoot eversion angle, rearfoot eversion velocity and internal ankle inversion moment. In this sample of healthy female runners, the custom foot orthotic intervention led to significant decreases in maximum values for ankle dynamics in the frontal plane and in the sagittal plane of the knee joint. Relevance It remains unclear how a custom foot orthotic intervention influences lower extremity dynamics to produce positive clinical outcomes. Furthering our understanding of the dynamic influence will not only inform improved prescription and manufacturing practices but may provide insight into the mechanisms that cause overuse injuries.

The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome

Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and 'rolls over') the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30 degrees of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.

Pattern recognition of ITB overuse injuries in running

Pattern recognition of ITB overuse injuries in running

Free moment as a predictor of tibial stress fracture in distance runners

Stress fractures are a common and serious overuse injury in runners, particularly female runners. They may be related to loading characteristics of the lower extremity during running stance. Some tibial stress fractures (TSFs) are spiral in nature and, therefore, may be related to torque. Free moment (FM) is a measure of torque about a vertical axis at the interface with the shoe and ground. Increases in FM variables may be related to a history of TSF in runners. The purpose of this cross-sectional study was to investigate differences in FM between female distance runners with and without a history of TSF and, additionally, to investigate the relationship between absolute FM and the occurrence of TSF. A group of 25 currently uninjured female distance runners with a history of TSF (28±10 years, 46±15 km week −1) and an age- and mileage-matched control group of 25 healthy runners with no previous lower extremity fractures (26±9 years, 46±19 km week −1) participated in this study. Ground reaction forces and foot placement on the force platform were recorded during running at 3.7 m s −1 (±5%). Peak adduction, braking peak and absolute peak FM and impulse were compared between groups using one-tailed t-tests. The predictive value of absolute peak FM was investigated via a binary logistic regression. All variables, except impulse, were significantly greater in runners with a history of TSF. Absolute peak FM had a significant predictive relationship with history of TSF. There is a significant relationship between higher values for FM variables and a history of TSF.

Hip Muscle Weakness and Overuse Injuries in Recreational Runners

To test for differences in strength of 6 muscle groups of the hip on the involved leg in recreational runners with injuries compared with the uninvolved leg and a control group of noninjured runners. Descriptive analysis. : Three outpatient physical therapy clinics in the Minneapolis/St. Paul metropolitan area. Thirty recreational runners (17 female, 13 male) experiencing a single leg overuse injury that presented for treatment between June and September 2002. Thirty noninjured runners (16 female, 14 male) randomly selected from a pool of 46 volunteers from a distance running club served as controls. Self-report demographic information on running habits, leg dominance demonstrated by preferred kicking leg, and injury information. Muscle strength of the 6 major muscle groups of the hip was recorded using a hand-held dynamometer. The highest value of 2 trials was used, and strength values were normalized to body mass(2/3). Results comparing the injured and noninjured groups showed that leg dominance did not influence the leg of injury (chi(2)(1) = 0.134; P = 0.71). Correlations for internal reliability of muscle measurements between trials 1 and 2 with the hand-held dynamometer ranged from 0.80 to 0.90 for the 6 muscle groups measured, and all P values were less than 0.0001. No significant side-to-side differences in hip group muscle strength were found in the noninjured runners (P = 0.62-0.93). Among the injured runners, the injured side hip abductor (P = 0.0003) and flexor muscle groups (P = 0.026) were significantly weaker than the noninjured side. In addition, the injured side hip adductor muscle group was significantly stronger (P = 0.010) than the noninjured side. Duration of symptoms was not a contributing factor to the extent of injury as measured by muscle strength imbalance between injured and uninjured sides. Although no cause-and-effect relationship has been established, this is the first study to show an association between hip abductor, adductor, and flexor muscle group strength imbalance and lower extremity overuse injuries in runners. Because most running injuries are multifaceted in nature, areas secondary to the site of pain, such as hip muscle groups exhibiting strength imbalances, must also be considered to gain favorable outcomes for injured runners. The addition of strengthening exercises to specifically identified weak hip muscles may offer better treatment results in patients with running injuries.

The Influence of Muscle Fatigue on Electromyogram and Plantar Pressure Patterns as an Explanation for the Incidence of Metatarsal Stress Fractures

Background Stress fractures are common overuse injuries in runners and appear most frequently in the metatarsals. Purpose To investigate fatigue-related changes in surface electromyographic activity patterns and plantar pressure patterns during treadmill running as potential causative factors for metatarsal stress fractures. Study Design Prospective cohort study with repeated measurements. Methods Thirty experienced runners volunteered to participate in a maximally exhaustive run above the anaerobic threshold. Surface electromyographic activity was monitored for 14 muscles, and plantar pressures were measured using an in-shoe monitoring system. Fatigue was documented with blood lactate measurements. Results The results demonstrated an increased maximal force (5%, P < .01), peak pressure (12%, P < .001), and impulse (9%, P < .01) under the second and third metatarsal head and under the medial midfoot (force = 7%, P < .05; pressure = 6%, P < .05; impulse = 17%, P < .01) toward the end of the fatiguing run. Contact area and contact time were only slightly affected. The mean electromyographic activity was significantly reduced in the medial gastrocnemius (-9%, P < .01), lateral gastrocnemius (-12%, P < .01), and soleus (-9%, P < .001) muscles. Conclusion The demonstrated alteration of the rollover process with an increased forefoot loading may help to explain the incidence of stress fractures of the metatarsals under fatiguing loading conditions.

Ground reaction forces during downhill and uphill running

We investigated the normal and parallel ground reaction forces during downhill and uphill running. Our rationale was that these force data would aid in the understanding of hill running injuries and energetics. Based on a simple spring-mass model, we hypothesized that the normal force peaks, both impact and active, would increase during downhill running and decrease during uphill running. We anticipated that the parallel braking force peaks would increase during downhill running and the parallel propulsive force peaks would increase during uphill running. But, we could not predict the magnitude of these changes. Five male and five female subjects ran at 3 m/s on a force treadmill mounted on the level and on 3°, 6°, and 9° wedges. During downhill running, normal impact force peaks and parallel braking force peaks were larger compared to the level. At −9°, the normal impact force peaks increased by 54%, and the parallel braking force peaks increased by 73%. During uphill running, normal impact force peaks were smaller and parallel propulsive force peaks were larger compared to the level. At +9°, normal impact force peaks were absent, and parallel propulsive peaks increased by 75%. Neither downhill nor uphill running affected normal active force peaks. Combined with previous biomechanics studies, our normal impact force data suggest that downhill running substantially increases the probability of overuse running injury. Our parallel force data provide insight into past energetic studies, which show that the metabolic cost increases during downhill running at steep angles.

The Effect of Knee Angle at Contact on Impacts While Running off a Raised Platform

0418 Changes in the knee angle at contact will alter the impact forces and accelerations while running. These variables may influence the potential for overuse injury in runners. PURPOSE: The purpose of this research was to study the effects of changes in knee angle at contact on impact forces and accelerations while running off a 25 cm raised platform. METHODS: Five male and five female subjects (age: 25.3 ± 6.5 years; body mass: 68.6 ± 8.0 kg) completed ten trials in each of four conditions: (1) normal running, (2) normal running off a raised platform, (3) flexed knee running off a raised platform, and (4) extended knee running off a raised platform. Kinematic data were collected at 120 Hz using a Peak Motus motion capture system, ground reaction forces were collected at 3600 Hz using an AMTI force platform, and leg and head acceleration data were collected at 3600 Hz using PCB accelerometers. Subjects were required to maintain a self-selected pace during each trial (average speed: 2.7 ± 0.4 m/s). RESULTS: There were significant changes in knee contact angle between all conditions (17.0 ± 5.8 deg; 13.4 ± 5.1 deg; 20.4 ± 5.2 deg; 10.3 ± 4.4 deg respectively). Thus, subjects were able to voluntarily alter their knee angle at contact. Running off a raised platform significantly increased peak impact forces and extended knee running off the raised platform produced the greatest peak impact forces (1148 ± 133 N; 1825 ± 371 N; 1672 ± 504 N; 2111 ± 456 N respectively). All comparisons were significant except 2 vs 3. On the other hand, flexed knee running off the raised platform produced the greatest peak leg accelerations (7.4 ± 3.1 g; 13.7 ± 4.9 g; 16.1 ± 5.4 g; 13.3+5.2 g respectively). All comparisons were significant except 2 vs 4. Attenuation was significantly different for all comparisons (74.8 ± 10.4 %; 67.9 ± 12.2 %; 84.0 ± 7.1 %; 59.1 ± 14.0 % respectively). CONCLUSIONS: When subjects extend their knee at contact they increase their peak impact force without a corresponding increase in peak impact acceleration. This suggests that the mass that is being accelerated increases when the knee is extended during contact. This reduced the impact attenuation and may have increased the potential for injury to the musculoskeletal system. Further analysis will look at alterations to the internal forces in the body.

The Effect of Knee Angle at Contact on Impacts While Running off a Raised Platform

0418 Changes in the knee angle at contact will alter the impact forces and accelerations while running. These variables may influence the potential for overuse injury in runners. PURPOSE: The purpose of this research was to study the effects of changes in knee angle at contact on impact forces and accelerations while running off a 25 cm raised platform. METHODS: Five male and five female subjects (age: 25.3 ± 6.5 years; body mass: 68.6 ± 8.0 kg) completed ten trials in each of four conditions: (1) normal running, (2) normal running off a raised platform, (3) flexed knee running off a raised platform, and (4) extended knee running off a raised platform. Kinematic data were collected at 120 Hz using a Peak Motus motion capture system, ground reaction forces were collected at 3600 Hz using an AMTI force platform, and leg and head acceleration data were collected at 3600 Hz using PCB accelerometers. Subjects were required to maintain a self-selected pace during each trial (average speed: 2.7 ± 0.4 m/s). RESULTS: There were significant changes in knee contact angle between all conditions (17.0 ± 5.8 deg; 13.4 ± 5.1 deg; 20.4 ± 5.2 deg; 10.3 ± 4.4 deg respectively). Thus, subjects were able to voluntarily alter their knee angle at contact. Running off a raised platform significantly increased peak impact forces and extended knee running off the raised platform produced the greatest peak impact forces (1148 ± 133 N; 1825 ± 371 N; 1672 ± 504 N; 2111 ± 456 N respectively). All comparisons were significant except 2 vs 3. On the other hand, flexed knee running off the raised platform produced the greatest peak leg accelerations (7.4 ± 3.1 g; 13.7 ± 4.9 g; 16.1 ± 5.4 g; 13.3+5.2 g respectively). All comparisons were significant except 2 vs 4. Attenuation was significantly different for all comparisons (74.8 ± 10.4 %; 67.9 ± 12.2 %; 84.0 ± 7.1 %; 59.1 ± 14.0 % respectively). CONCLUSIONS: When subjects extend their knee at contact they increase their peak impact force without a corresponding increase in peak impact acceleration. This suggests that the mass that is being accelerated increases when the knee is extended during contact. This reduced the impact attenuation and may have increased the potential for injury to the musculoskeletal system. Further analysis will look at alterations to the internal forces in the body.

The Effect of Environmental Temperature on the Shock Absorption Capacity of Running Shoes

0092 Various shock absorption systems (SAS) are used in contemporary running shoes to decrease lower extremity overuse injuries in runners. SAS typically include different polymeric materials with temperature sensitive biomechanical properties that may ultimately affect performance. PURPOSE: To determine the effect of temperature changes on the shock absorption capacity of four running shoes constructed with four different SAS. METHODS: Four brands of running shoes representing the most common SAS were chosen: Nike Air Triax (air-fllled units), Asics Gel Cumulus IV (gel-fllled units), Adidas Supernova (ethylene vinyl acetate or EVA), and Adidas A3 (polyurethane foam). One pair of each brand was tested (total of 4 pairs or 8 shoes). The shoes were frozen to −20° C using dry ice and gradually heated to +50° C in a portable incubator. Shoes were tested by an impactor following ASTM Standard F1614-99 at the following temperatures: −20°, −10°, 0°, +10°, +20°, +30°, +40°, +50° Celsius. The impact tester is a free-fall type impactor with instrumented force and position transducers. Output signals from both the force and position transducers were low-pass filtered at 500 Hz and sampled at 1500 Hz. From each data trial, the peak deceleration (G) was determined as an estimate of the shock absorption capacity. To assess the differences between the shoes, a repeated measures analysis of variance was used, the independent variables being the SAS and the temperature. RESULTS: There was a quadratic trend in the curves that differed between the shoe types (p< .001), indicating that for each SAS, the drop of the peak deceleration (G) with the increase of temperature was significant. There was also a significant overall difference when comparing the four different SAS over the temperature range. The polyurethane foam had much higher peak deceleration at cold temperatures than any of the other shoes tested. CONCLUSION: As the ambient temperature gets colder, the shock absorption capacity of the running shoes in the current study decreased. Temperature induced changes were most marked for the polyurethane foam SAS. These findings may have important clinical implications for individuals training in cold environments.