The relationship between lower-extremity stress fractures and the ground reaction force: A systematic review

Department of Biomechanical Engineering, Delf University of Technology, The Netherlands.
Clinical biomechanics (Bristol, Avon) (Impact Factor: 1.97). 01/2011; 26(1):23-8. DOI: 10.1016/j.clinbiomech.2010.08.005
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lower-limb stress fracture is one of the most common types of running injuries. There have been several studies focusing on the association between stress fractures and biomechanical factors. In the current study, the ground reaction force and loading rate are examined. There is disagreement in the literature about whether the history of stress fractures is associated with ground reaction forces (either higher or lower than control), or with loading rates.
a systematic review of the literature was conducted on the relationship between the history of tibial and/or metatarsal stress fracture and the magnitude of the ground reaction force and loading rate. Fixed-effect meta-analysis techniques were applied to determine whether or not the ground reaction force and/or loading rate are different between the stress fracture and control groups.
thirteen articles were identified through a systematic search of the literature. About 54% of these articles reported significantly different vertical ground reaction force and/or loading rate between the stress fracture and control groups. Other studies (~46%) did not observe any significant difference between the two groups. Meta-analysis results showed no significant differences between the ground reaction force of the lower-limb stress fracture and control groups (P>0.05). However, significant differences were observed for the average and instantaneous vertical loading rates (P<0.05).
the currently available data does not support the hypothesis that there is a significant difference between the ground reaction force of subjects experiencing lower-limb stress fracture and control groups. Instead, the vertical loading rate was found to be significantly different between the two groups.

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Available from: Amir A. Zadpoor,
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    • "current finding that the LR was greater in RFS running compared to imposed FFS is consistent with previous findings (Giandolini et al., 2013; Lieberman et al., 2010). Greater LRs have been linked to running related injuries, particularly tibial stress fractures (Milner et al., 2006; Zadpoor & Nikooyan, 2011). Although still no causal relationships have been established, the greater LR found observed in RFS may be related to the higher injury rates observed in habitual RFS runners (Daoud et al., 2012). "
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    ABSTRACT: The purpose of this study was to investigate the interaction of foot strike and common speeds on sagittal plane ankle and knee joint kinetics in competitive RFS runners when running with a RFS pattern and an imposed FFS pattern. Sixteen competitive habitual male RFS runners ran at two different speeds (i.e., 8min•mile-1 and 6min•mile-1) using their habitual RFS and an imposed FFS pattern. A repeated measures ANOVA was used to assess a potential interaction between strike pattern and speed for selected ground reaction force (GRF) variables and, sagittal plane ankle and knee kinematic and kinetic variables. No foot strike and speed interaction was observed for any of the kinetic variables. Habitual RFS yielded a greater loading rate of the vertical GRF, peak ankle dorsiflexor moment, peak knee extensor moment, peak knee eccentric extensor power, peak dorsiflexion and sagittal plane knee ROM compared to imposed FFS. Imposed FFS yielded greater maximum vertical GRF, peak ankle plantarflexor moment, peak ankle eccentric plantarflexor power, and sagittal plane ankle ROM compared to habitual RFS. Consistent with previous literature, imposed FFS in habitual RFS reduces eccentric knee extensor and ankle dorsiflexor involvement but produce greater eccentric ankle plantarflexor action compared to RFS. These acute differences between strike patterns were independent of running speeds equivalent to typical easy and hard training runs in competitive male runners. Current findings along with previous literature suggest differences in lower extremity kinetics between habitual RFS and imposed FFS running are consistent among a variety of runner populations.
    European Journal of Sport Science 08/2015; · 1.55 Impact Factor
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    • "A recent systematic review of the tibial stress fracture literature examined the relationship between the vertical ground reaction and stress fracture. This meta-analysis suggested that the vertical ground reaction forces during running were not greater in runners with stress fracture; however, average and instantaneous vertical loading rates associated with the impact peak during the stance phase did tend to be greater in those individuals with a history of stress fracture (Zadpoor and Nikooyan, 2011). Other measures of external load, including the peak free moment (Pohl et al., 2008) and the direction of the mediolateral ground reaction force relative to vertical have also been linked to tibial stress fracture (Creaby and Dixon, 2008). "
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    ABSTRACT: Combinations of smaller bone geometry and greater applied loads may contribute to tibial stress fracture. We examined tibial bone stress, accounting for geometry and applied loads, in runners with stress fracture. 23 runners with a history of tibial stress fracture & 23 matched controls ran over a force platform while 3-D kinematic and kinetic data were collected. An elliptical model of the distal 1/3 tibia cross section was used to estimate stress at 4 locations (anterior, posterior, medial and lateral). Inner and outer radii for the model were obtained from 2 planar x-ray images. Bone stress differences were assessed using two-factor ANOVA (α=0.05). Key contributors to observed stress differences between groups were examined using stepwise regression. Runners with tibial stress fracture experienced greater anterior tension and posterior compression at the distal tibia. Location, but not group, differences in shear stress were observed. Stepwise regression revealed that anterior-posterior outer diameter of the tibia and the sagittal plane bending moment explained >80% of the variance in anterior and posterior bone stress. Runners with tibial stress fracture displayed greater stress anteriorly and posteriorly at the distal tibia. Elevated tibial stress was associated with smaller bone geometry and greater bending moments about the medial-lateral axis of the tibia. Future research needs to identify key running mechanics associated with the sagittal plane bending moment at the distal tibia as well as to identify ways to improve bone geometry in runners in order to better guide preventative and rehabilitative efforts. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Clinical biomechanics (Bristol, Avon) 08/2015; DOI:10.1016/j.clinbiomech.2015.07.012 · 1.97 Impact Factor
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    • "Barefoot runners may switch from a RFSP to NRFSP due to increased heel sensitivity for vibration stimuli [46]. Zadpoor and Nikooyan [15] postulated that the central nervous system uses muscle input and changes in kinematics to keep ground reaction forces (GRFs) and level of vibrations of the human body within a narrow range regardless of shoe hardness during running. Contrary to this theory, Hamill et al. [13] and Chambon et al. [19] have proposed that FSP is more affected by the heel to toe drop rather than by the thickness of the shoe. "
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    ABSTRACT: Claims of injury reduction related to barefoot running has resulted in interest from the running public; however, its risks are not well understood for those who typically wear cushioned footwear. Examine how plantar loading changes during barefoot running in a group of runners that ordinarily wear cushioned footwear and demonstrate a rearfoot strike pattern (RFSP) without cueing or feedback alter their foot strike pattern and plantar loading when asked to run barefoot at different speeds down a runway. Forty-one subjects ran barefoot at three different speeds across a pedography platform which collected plantar loading variables for 10 regions of the foot; data were analyzed using two-way mixed multivariate analysis of variance (MANOVA). A significant foot strike position (FSP)×speed interaction in each of the foot regions indicated that plantar loading differed based on FSP across the different speeds. The RFSP provided the highest total forces across the foot while the pressures displayed in subjects with a non-rearfoot strike pattern (NRFSP) was more similar between each of the metatarsals. The majority of subjects ran barefoot with a NRFSP and demonstrated lower total forces and more uniform force distribution across the metatarsal regions. This may have an influence in injuries sustained in barefoot running. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Foot 02/2015; 25(2). DOI:10.1016/j.foot.2015.02.001
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