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The prevention of shin splints in sports: A systematic review of literature
Abstract
To review the published and unpublished evidence regarding risk factors associated with shin splints, assess the effectiveness of prevention strategies, and offer evidence-based recommendations to coaches, athletes, and researchers.
We searched electronic data bases without language restriction, identified citations from reference sections of research papers retrieved, contacted experts in the field, and searched the Cochrane Collaboration. Of the 199 citations identified, we emphasized results of the four reports that compared methods to prevent shin splints. We assessed the methodologic quality of these reports by using a standardized instrument.
The use of shock-absorbent insoles, foam heel pads, heel cord stretching, alternative footwear, as well as graduated running programs among military recruits have undergone assessment in controlled trials. There is no strong support for any of these interventions, and each of the four controlled trials is limited methodologically. Median quality scores in these four studies ranged from 29 to 47, and serious flaws in study design, control of bias, and statistical methods were identified.
Our review yielded little objective evidence to support widespread use of any existing interventions to prevent shin splints. The most encouraging evidence for effective prevention of shin splints involves the use of shock-absorbing insoles. However, serious flaws in study design and implementation constrain the work in this field thus far. A rigorously implemented research program is critically needed to address this common sports medicine problem.
... A common source of pain is the central section of the medial tibia. On the other hand, shin splints can affect the entire length of the leg [10]. It is usual to describe lateral side soreness as dull and unpleasant. ...
... Of the population, females (55.3%) were more likely to use a splint than males (44.7%). Shin splints are more common among marathon runners, depending on the duration of pain and the shoe surface [10]. ...
... Sudden progression in the exercise program, such as an increase in length and intensity, could be associated with this condition [6]. Running on uneven or hard surfaces and wearing unsuitable running shoes (with limited shock absorption) could play a role in the disaster [10]. Among the most typically reported intrinsic variables are biomechanical anomalies such as foot arch deformities, excessive pronation of the foot, and uneven leg length [13]. ...
Leg pain caused by recurrent stressors is known as shin pain, also known as the medial tibial stress syndrome (MTSS). Athletes, particularly runners, are more vulnerable. As a result, runners devote little time to practice and avoid exercises completely. The precise cause is yet to be identified. Microdamage caused by recurrent stressors has been proposed as the fundamental mechanism in other investigations. Gender, navicular bone loss, higher body mass index, activities of high intensity, and increased range in external hip rotation in males are all risk factors. A common complaint is a bilateral pain in the distal leg, primarily on the anterior and medial sides. Pain is exacerbated by activity and eased by relaxation. Particularly, pain and swelling in the posterior and medial aspects of the tibia, as well as other causative symptoms, may be discovered during the examination. To rule out alternate origins of the same symptoms, imaging modalities such as computed tomography, radiography, bone scintigraphy, and magnetic resonance imaging might be used. Preventative measures include shock-absorbing insoles, repetitive stress avoidance, and effective treatment of repetitive stress disorder and anatomical abnormalities. Rest, ice, and pain medications are the most common treatments.
... It has been suggested to abandon the use of 'shin splints' and use MTSS instead, as it better describes the location and pathophysiology of the disorder [2,4,5,[7][8][9][10][11] . MTSS differentiates clinically from several other terms surrounding exercise-induced lower leg pain including: tibial stress fractures [2,3,5,12,13] , compartment syndrome [3,5,7,10,14] , periostitis [5,10,12,15] , and popliteal artery entrapment [3,5] . ...
... Over 100 different risk factors have been previously acknowledged with MTSS [4] . Several risk factors repeatedly showing strong associations with the development of MTSS or tibial stress fractures include: previous similar injuries [2,5,[15][16][17] , body mass index (BMI) [3,4,9] , navicular drop [4,6,7,[9][10][11]15,18,19] , running technique [5,11,14,20] , hip internal and external ROM [4,9,15,18,21] , plantar flexion strength [2,5,15] , ankle dorsiflexion ROM [2,5,19,22] , and female gender [2,3,5,19,21,23] . Given the overall body of literature associated with different symptoms, we sought to further understand any residual impact previous MTSS diagnosis could have on several of the above mentioned risk factors, while including biomechanical and neuromuscular performance tasks in track and field athletes medically cleared to participate in a collegiate season. ...
... Over 100 different risk factors have been previously acknowledged with MTSS [4] . Several risk factors repeatedly showing strong associations with the development of MTSS or tibial stress fractures include: previous similar injuries [2,5,[15][16][17] , body mass index (BMI) [3,4,9] , navicular drop [4,6,7,[9][10][11]15,18,19] , running technique [5,11,14,20] , hip internal and external ROM [4,9,15,18,21] , plantar flexion strength [2,5,15] , ankle dorsiflexion ROM [2,5,19,22] , and female gender [2,3,5,19,21,23] . Given the overall body of literature associated with different symptoms, we sought to further understand any residual impact previous MTSS diagnosis could have on several of the above mentioned risk factors, while including biomechanical and neuromuscular performance tasks in track and field athletes medically cleared to participate in a collegiate season. ...
Medial tibial stress syndrome (MTSS) is a common lower extremity
injury in track and field athletes. Many risk factors are
associated with MTSS, and lower extremity performance may
become altered in athletes suffering from prior symptoms, potentially
increasing risk of future injury. The purpose of this study
was to first examine the effect a prior history of MTSS has on
lower-extremity measures, per gender, in collegiate level track
and field athletes, and then determine if such measures predict
future injury. Fifty-three healthy Division III collegiate track and
field athletes (mean age = 19.40 ± 1.13 years) completed an injury
history questionnaire along with five preseason lower-extremity
functional tests including: ankle dorsiflexion (DF), single-leg
anterior reach (SLAR), two timed single-leg balance (SLBAL)
tests on a force plate, and single-leg hop for distance (SLH). Performance
data were compared across gender and questionnaire
data regarding injury history and occurrence of MTSS. Fifteen
subjects (28%) reported previous MTSS symptoms within the
last 2 years. Chi-square analyses revealed females experienced
more diagnoses compared to males (p = .03). Independent t-tests
revealed differences between gender on all SLBAL tests, as
males performed better on all recorded measures (p < .001 – p
= .003). No significant differences were noted in lower-extremity
performance tests between subjects with and without prior
MTSS injuries. Regression analyses using postseason injury
questionnaire data revealed prior MTSS injuries had 17.3 higher
odds of experiencing MTSS during the season (adjusted odds
ratio [AOR] = 17.33, 95% CI: 3.5 - 86.4; p = .001).
... [5] At present, there is no universally accepted consensus on either the etiology or treatment of this condition. [6] The treatment of shin splints focuses on providing symptomatic relief and modifying the risk factors. In clinical practice, the use of various modalities to treat symptoms is common. ...
... In clinical practice, the use of various modalities to treat symptoms is common. [6] The acute pain associated with shin splints is treated with the RICE (Rest, Ice, Compression and Elevation) regimen. The use of manual therapy techniques such as digital ischemic pressure, transverse friction massage, and sustained myofascial tension has also been advocated. ...
... It is suggested that MTSS is a consequence of repetitive stress imposed by impact forces that eccentrically fatigue the muscle of leg and reduce their shock absorption ability resulting in transmission of excess forces on the bone leading to periostitis, enthesis, fibrositis, myositis, traction periostitis, tenosynovitis, and tendonitis of the tibialis anterior, tibialis posterior, soleus, or flexor hallucis longus muscles. [6] Increased pronation is known to increase the ground reaction forces and thus is considered as associated with the genesis of MTSS. Griebert et al. [1] have shown that KT application reduced the rate of medial loading in participants with history of MTSS. ...
BACKGROUND: Kinesio taping (KT) has emerged as a popular treatment for several health conditions. It is suggested that application of K-tape may prove beneficial in relieving symptoms of shin splints. OBJECTIVE: The aim of this pilot study was to gather preliminary evidence about the effectiveness of KT in shin splints. METHODOLOGY: This prospective case-control study was conducted for 3 days on thirty active sports persons afflicted with shin splints (M = 22, F = 8; mean age 19 ± 2.59; duration of symptoms 48.16 ± 13.42 days) assigned randomly into three equal groups. The intervention in control group consisted of 10 min of ice massage followed by 10 min of transcutaneous electrical nerve stimulation. In KT group, Y-strip K-tape was applied to the lower leg using the technique described by Griebert et al. that had shown a reduction in medial loading in medial tibial stress syndrome. In rigid tape (RT) group, white nonelastic adhesive tape cut into a Y-shape similar to KT strip was applied. Outcome measures were duration of 50 m sprint, volume of limb, and pain response at rest, during resisted isometric contraction (RIC) of select muscles, and after completion of 50 m sprint. Two ways repeated measure ANOVA with time as the repeated factor was conducted for each outcome measure with level of significance set at 0.05. RESULTS: Between the group difference for age (F = 0.35, P = 0.70) and duration of symptom (F = 0.40, P = 0.67) were not significant. The day-by-group interaction was not significant for any outcome measure. For the patient-reported parameters, i.e., pain at rest, pain at RIC, and pain at 50 m sprint, the main effects were significant (P ≤ 0.05) for time but not for groups. CONCLUSION: Any benefits of KT over and above RT and control group were not observed in active players presenting with symptoms of shin splints.
... [5] At present, there is no universally accepted consensus on either the etiology or treatment of this condition. [6] The treatment of shin splints focuses on providing symptomatic relief and modifying the risk factors. In clinical practice, the use of various modalities to treat symptoms is common. ...
... In clinical practice, the use of various modalities to treat symptoms is common. [6] The acute pain associated with shin splints is treated with the RICE (Rest, Ice, Compression and Elevation) regimen. The use of manual therapy techniques such as digital ischemic pressure, transverse friction massage, and sustained myofascial tension has also been advocated. ...
... It is suggested that MTSS is a consequence of repetitive stress imposed by impact forces that eccentrically fatigue the muscle of leg and reduce their shock absorption ability resulting in transmission of excess forces on the bone leading to periostitis, enthesis, fibrositis, myositis, traction periostitis, tenosynovitis, and tendonitis of the tibialis anterior, tibialis posterior, soleus, or flexor hallucis longus muscles. [6] Increased pronation is known to increase the ground reaction forces and thus is considered as associated with the genesis of MTSS. Griebert et al. [1] have shown that KT application reduced the rate of medial loading in participants with history of MTSS. ...
... Coexistence and interrelationships of these entities is acknowledged but not clearly understood. 1 ...
... Individuals identifi ed as at risk would likely benefi t from modifi cation of their training loads in order to mitigate against development of symptoms and associated morbidity. 1 Interventions such as the use of impact absorbing inner soles, stretching, bracing, electrotherapies and soft tissue massage still lack supportive evidence. 1 12 13 ...
... Repeat for each leg. 1 Hop and Hold Tests: Hop, turn and hold 2 seconds every 2 nd apex of a hexagon. Complete 6 hops each direction on each leg. ...
The aim of the work presented in this thesis was to review the current differential diagnoses that present as chronic exertional leg pain, and to investigate Medial Tibial Stress Syndrome (MTSS) as the most common condition in this group of diagnoses. The thesis explores, in turn; the risk factors associated with development of MTSS, the utility of a screening test for predicting those at risk of developing MTSS, the reliability of a commonly-used method for classifying and evaluating running technique modifications, and the effectiveness of extracorporeal shockwave intervention for MTSS. A systematic review and meta-analysis of prospective risk factors for MTSS indicated that female gender, a previous history of MTSS, fewer years of running experience, orthotic use, increased Body Mass Index, an increased navicular drop, and increased external rotation hip range of motion in males were all significantly associated with an increased risk of developing MTSS in runners. As a consequence of identifying each of these risk factors, a foundation for better understanding of the causative mechanisms associated with development of MTSS can be developed that will inform future risk factor analysis and preventative screening efforts. A new continuum model for MTSS is presented as a basis for further research efforts. The prospective study of a cohort of military trainees presented in this thesis identified two clinical tests that in asymptomatic individuals predict those who are more likely to develop MTSS into the future. Together these tests represent an additional tool for preventive countermeasures for a condition that is difficult to treat and commonly recurs. Running technique “errors” are frequently attributed as being causal factors in the onset of MTSS, and as a consequence interventions aimed at “correcting” running technique are often employed in clinical practice. There is a paucity of evidence on the reliability of methods for classifying and evaluating outcomes in aspects of running technique, and this is particularly so in relation to clinical settings. A reliability study of visually-based methods for classifying footstrike and knee valgus in two speeds of running gait conducted here highlights the necessity for judgements to be based on laboratory methods rather than solely visual observation when running technique modifications are being implemented and evaluated. Currently, there is insufficient evidence supporting the efficacy of any specific intervention for MTSS. Previous research has suggested extracorporeal shockwave therapy to be one of the more promising interventions. A pilot randomised double blind sham controlled trial was carried out, and it revealed no difference between sham dose and therapeutic dose for runners experiencing MTSS. An observed reduction in bone pain associated with the sham dose therapy suggests, however, that there may be an effect associated with low dose. Further research is required that includes a no treatment control and higher numbers of participants in order to more fully understand the effectiveness of no treatment, low dose and standard dose shockwave therapy in MTSS. The findings from this project, in conjunction with work on other bone conditions, indicate the need for future research to consider the complex interactions of bone and muscle in response to mechanosensory inputs. Consistent with this, a theory of network disruption within bone is proposed to explain the recalcitrant nature of MTSS, its unique signs and symptoms, and its potential causes.
... Individuals with MTSS demonstrate heightened peak soleus muscle activity [8]. Preventive measures for MTSS often involve activities, such as strengthening the soleus, managing hyperpronation, using insoles, and engaging in low-intensity exercises [9,10]. ...
... The inclusion criteria comprised the following items: College-level soccer players aged 18-25 years, of both genders, diagnosed with MTSS based on Yates and White criteria, experiencing pain in the posterior medial part of the tibia during exercise and exhibiting an area of diffuse pain on palpation measuring at least 5 cm; sustained pain lasting for at least 3 weeks; pain triggered by exercise, occurring during and after exercise; unilateral pain; presence of a palpable taut band within the soleus muscle and recognition of current pain complaint through pressure on the tender nodule, alongside painful limitation to the full stretch range of motion of the soleus muscle at the ankle joint. Meanwhile, participants were excluded if they had a tibial stress fracture, compartment syndrome, peripheral vascular disease, nerve entrapment syndrome, soleus muscle strain, history of adverse reactions to needling or injections, were on anticoagulant therapy or had thrombocytopenia, or had skin infections [10,16]. ...
Introduction: This study investigates the impact of dry needling on myofascial trigger points in the soleus muscles among soccer players with medial tibial stress syndrome (MTSS). Materials and Methods: Soccer players diagnosed with MTSS were enlisted and randomly divided into two groups (11 participants in the experimental group [Group 1] and 11 participants in the control group [Group 2]). Pre-intervention measurements included repeated shuttle sprint ability, MTSS score, and pain pressure threshold (PPT) for both groups. In the experimental group, dry needling was performed on the soleus muscle, followed by active stretching and cryotherapy. The control group underwent active stretching of the soleus muscle and cryotherapy exclusively. Post-intervention measurements of repeated shuttle sprint ability, MTSS score, and PPT were taken for both groups after 2 days. Results: The experimental group exhibited a statistically significant improvement in PPT, MTSS score, and repeated shuttle sprint ability. Conversely, within the control group, statistically significant changes were observed only in PPT values through paired t-test assessment. Between-group analysis using an independent t-test revealed significant enhancement in PPT (P=0.000) and MTSS score (P=0.01) within the experimental group compared to the control group. Conclusion: Addressing myofascial trigger points in the soleus muscle through dry needling offers a more effective approach to treating MTSS than relying solely on muscle stretching.
... Female athletes are at higher risk of injuries in sport. Knee ligament injuries are up to six times more likely to occur in females than males (Hewett et al., 2010) and overuse syndromes such as shin splints (Medial Tibial Stress Syndrome or MTSS) and heel pain (plantar fasciopathy) are seen with far greater frequency in female athletes engaging in high impact sports compared to their male counterparts (Koester, 2000;Thacker et al., 2002). Young female athletes may also experience stress urinary incontinence (SUI) during high impact activities (Casey & Temme, 2017). ...
... Knee ligament tears (Toth & Cordasco, 2001) Patellar tendinopathy (Grau et al., 2008) Incontinence (Rortveit et al., 2003) Hip Hip impingement (Nakano et al., 2017) Stress urinary incontinence (Joseph et al., 2021) Ankle Ankle sprains (Hosea et al., 2000) Back pain (Fett et al., 2017) Foot Plantar fasciopathy (Scher et al., 2009) *Hypermobility (Quatman et al., 2008) Hamstring Groin Shin splints (MTSS and stress fractures) (Dugan & Weber, 2007;Reinking et al., 2017;Thacker et al., 2002) *Knee valgus (Kirkendall & Garrett, 2000;Utturkar et al., 2013) Elbow * Hypermobility and knee valgus are not injuries, but risk factors for musculoskeletal injury Reviews of MASS injuries included numerous calls for improved injury surveillance. Injury studies are generally either survey based -suffering from selection bias and depending on recollection of participants -or competition-based -suffering from a lack of clinical detail or long-term impact. ...
Despite a focus on contact injuries in martial arts, many injuries are non-contact, from ligament tears to ankle sprains, and could be prevented with appropriate prehabilitation. With an emphasis on tradition, recreational martial arts clubs have not yet widely adopted modern prehabilitation exercises. We reviewed the literature to identify injury prevalence and mechanism in martial arts striking sports (MASS). Given the lack of data on female martial artists, we also reviewed common injuries in female athletes. We then identified sport-specific evidence-based interventions using a combination of literature review and Physiotec and filtered this through the constraints of recreational MASS environments to develop a cohesive, useable prehabilitation programme. We propose a programme of 12 exercises for injury prevention (MASS-12). We emphasise the importance of biomechanical retraining to prevent common injuries in martial arts. Hip-knee-ankle alignment is key to injury prevention in MASS, while improved injury surveillance is needed for future intervention.
... Shin splint syndrome was first described as "pain and discomfort in the leg from recurrent exercise on hard surfaces, or due to strong, excessive use of foot flexures" by the American Medical Association in 1966. (8) There is little histological proof of periostitis. Three patients with inflammation or vasculitis discovered in the fascia following biopsy are described in two publications from the 1980s. ...
... (9) Shin splint syndrome is a significant performance-impairing ailment among athletes that calls for thorough research despite the fact that its pathogenesis is still unknown. (8) Unrepaired microdamage buildup in the cortical bone of the distal tibia is connected to the pathophysiologic mechanism that underlies MTSS. The tendinous attachments of the soleus, flexor digitorum longus, and posterior tibialis commonly coexist with an overlaying periostitis at the site of bone damage. ...
Background: shin splints are depicting a condition in which leg torment and distress in distal posteromedial part of leg is brought about by dreary action and it rejects reasons for torment because of stress cracks or because of ischemia. Purpose of study: Study aimed to find the prevalence of shin splints among treadmill users in gym. Materials & Methods: The study was observational cross-sectional survey. Purposive sampling was done. 152 data were collected from different gyms of Lahore, Faisalabad and Sargodha, Pakistan. Both male and females aged 18-25 years with duration of gym from last 6 months at least 3 days a week and currently using gym were included in study while person with any physical and anatomical disability or history of surgery of lower limb and systemic illness. (e.g., deep venous thrombosis) were excluded from study. Data was analyzed using SPSS V 23. Descriptive statistics in form of frequency and percentages was presented. Pie and bar charts were plotted. Data was collected through self-devised questionnaire and Medial Tibial Stress Syndrome Score and Ankle Brachial Index and Shin Palpation Test were applied Results: Mean age of participants was 21 years. Out of 140 participants after systemic disease exclusion 87% participants felt pain in lower leg. While 57.1 (n=80) showed some or moderate arterial diseases when evaluated through Ankle Brachial Index. 17.9% (n=25) showed positive shin palpation indicating shin splints. Shin splints were twice as likely to occur in physically active people who had previously reported a running-related injury. To stop the problem from worsening, it is crucial to determine whether treadmill users have shin splints. This study was carried out in Sargodha, Punjab, to discover shin splints in treadmill users. The purpose of this study was to shed light on the frequency and origin of shin splints among treadmill users. Athletes who experience medial shin pain (MSP) may be unable to run. The incidence especially among treadmill users was not previously investigated. Since there was no literature on the population chosen, this topic was chosen. Conclusion: Use of treadmill is one of causes of shin splint and factors associated were duration of treadmill use and supervised use of treadmill while person with shin splint have pain during walking, sporting and running activities which reduced activities. Keywords: Shin Splints, Medial Tibial Stress Syndrome, Treadmill, Gym.
... 1,2 TSS arises from musculotendinous inflammation and is typically diagnosed by pain in the lower leg when fracture and ischemic disorder have been ruled out. 3 As one of the most common athletic injuries, the prevalence of TSS in runners is estimated at 6% to 20%. 1,4 In the US military, musculoskeletal injuries, including TSS, are the leading cause of medically evacuated nonbattle injuries. 5 Running, particularly on hard or uneven terrain, is the primary risk factor for TSS. ...
... 6,7 Other risk factors for TSS are pluripotent and include increased body mass index, preexisting or prior musculotendinous injuries, abnormally pronated foot, excessive internal/ external rotation of the hips, type of shoe worn, and poor conditioning prior to starting a new training regimen. 1,2,[8][9][10][11] Military personnel frequently experience unaccustomed training rigors when starting as new recruits or following a leave period, which may predispose them to TSS. A diagnosis of TSS can negatively impact mission readiness by preventing pain-free activity, precipitating the need for effective treatment options. ...
Context:
Tibial stress syndrome (TSS) is an overuse injury of the lower extremities. There is a high incidence rate of TSS among military recruits. Compression therapy is used to treat a wide array of musculoskeletal injuries. The purpose of this study was to investigate the use of compression therapy as a treatment for TSS in military service members.
Design:
A parallel randomized study design was utilized.
Methods:
Military members diagnosed with TSS were assigned to either a relative rest group or compression garment group. Both groups started the study with 2 weeks of lower extremity rest followed by a graduated running program during the next 6 weeks. The compression garment group additionally wore a shin splints compression wrap during the waking hours of the first 2 weeks and during activity only for the next 6 weeks. Feelings of pain, TSS symptoms, and the ability to run 2 miles pain free were assessed at baseline, 4 weeks, and 8 weeks into the study.
Results:
Feelings of pain and TSS symptoms decreased during the 8-week study in both groups (P < .05), but these changes were not significantly different between groups (P > .05). The proportion of participants who were able to run 2 miles pain free was significantly different (P < .05) between the 2 groups at the 8-week time point with the compression garment group having a significantly increased ability to complete the run without pain.
Conclusions:
Although perceptions of pain at rest were not different between groups, the functional ability of running 2 miles pain free was significantly improved in the compression garment group. These findings suggest that there is a moderate benefit to using compression therapy as an adjunct treatment for TSS, promoting a return to training for military service members.
... Extrinsic factors (Box 1.1), including training errors, contribute to SF development. These factors describe abrupt increases in training intensity, high impact training load, including abrupt increased distance, pace, volume, intensity, or cross training delivered over undulating training environment and progression too soon without adequate recovery time for adaptation (3,15,29,(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59). Increasing running distance was found to be associated with an increased rate of SFs. ...
... The method used to calculate incidence rate of SFs has considerable variation depending on the country, organisation, study design and periods of evaluation among studies (21,54). It appears in the literature that there was no standardised incidence reporting system adopted in the published literature and instead an organisational reporting system was used (51)(52)(53)(54)(55)(56)(57)(58)(59)(60). ...
Background: Stress fractures (SF) are an overuse bone injury that disproportionately affects military and athletic populations. The treatment of SF requires long term rehabilitation and is costly.
Objectives: To update the current evidence on SF treatment modalities and recovery timeframes for military populations.
Methods: A systematic review study design was conducted and reported using PRISMA guidelines. Medline, EMBASE, CINHAL and Cochrane database were searched using a predefined search strategy. All randomised control trials, quasi-interventions, single arm intervention, prospective or retrospective studies evaluating SF treatment in military populations and written in English were eligible for inclusion. Systematic review, case studies, opinion and SF treatment in civilian population were excluded. A single author evaluated the Risk of Bias (RoB) judgement on retrieved articles.
Results: Eight studies met the inclusion criteria, three were Randomised Control
Trials (RCT) and five were non-randomised: two prospective and three retrospective studies. The retrieved studies were broadly categorised into adjunctive, conservative and surgical treatment modalities. The RoB varied, and not a single included study was free from a RoB. There is a low quality of evidence from RCT that the application of ultrasound and brace have a favourable effect on recovery rehabilitation timeframe, and very low quality of evidence to determine the conservative and surgical effective treatment modalities to accelerate healing and return to duty in the treatment of SF in the military population.
Conclusion: Multifaceted intervention modalities were used; however, there is insufficient evidence to recommend any SF treatment modalities. Further studies with prospective RCT are recommended to establish the most effective SF treatment modalities in the military population.
... It may be seen unilaterally, although more frequently both legs are affected, with one leg being more severe than the other. It is an extremely common complaint among runners that becomes progressively worse with repetitive impact activities, frequently leading to athletes having to curtail their activity (11)(12)(13)(14). MTSS is clearly located along the shin with little or no radiation. ...
... Currently, little evidence exists in the literature to support the use of the most commonly applied interventions for the treatment of MTSS (13). Traditional treatments include local cryotherapy, stretching and strengthening of gastrocnemius-soleus musculature, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), iontophoresis with calcium or corticosteroids, modification of training regimens, orthotic devices to correct for biomechanical abnormalities, and rest (10,(21)(22)(23)(24)(25)(26). ...
El síndrome de estrés medial de la tibia (SEMT) constituye una de las afecciones más comunes del miembro inferior. Los resultados obtenidos con terapias convencionales en esta patología son dispares. La infiltración local de corticoides ha mostrado producir efectos favorables en el tratamiento de diversos problemas musculoesqueléticos. El efecto de la infiltración local multipuntual de un corticoide en combinación con un anestésico se estudió en 47 pacientes (29 hombres y 18 mujeres, con una edad media de 23.8) afectos de SEMT. La consulta directa y el examen físico se emplearon para valorar los resultados. Los pacientes fueron valorados una vez a la semana tras la primera aplicación durante las primeras cuatro semanas y 3 meses después del tratamiento. El nivel de actividad en ausencia de síntomas fue registrado en cada caso. Los resultados de la infiltración multipuntual se determinaron comparando los niveles de actividad en ausencia de síntomas preintervención y posintervención y la capacidad de los deportistas para volver a los niveles de actividad presintomáticos. Los resultados sugieren que este tratamiento reduce el tiempo de recuperación y mejora los resultados funcionales.
... For MTSS 306 articles comprised eight systematic reviews and A c c e p t e d M a n u s c r i p t 8 two critique of other systematic reviews, which were added. Of these, six were about risk factors [31][32][33][34][35][36], one about treatment [37], one about epidemiology [14], and one about prevention [38]. Out of 556 articles dealing with stress fractures of the leg seven were systematic reviews and two more were found by a hand search. ...
... Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronationcontrol insoles, and graduated running programs were advocated [38]. However, systematic review of these studies were all related and specific to military basic training. ...
Introduction:
The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'.
Aim:
To review clinical entities that come under the umbrella term Exercise-induced leg pain (EILP) based on current literature.
Materials and methods:
We systematically searched the literature. Specifically, systematic reviews were included.
Conclusions:
Current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.
... Left untreated, the condition may progress to a full stress fracture (Mokha, Winters, Kostishak, Valovich McLeod, & Welch, 2014;Winters et al., 2013) that needs extended periods (4 to 8 weeks) for recovery. There is thus an urgent need to treat and prevent MTSS in physically active people (Mokha et al., 2014;Thacker, Gilchrist, Stroup, & Kimsey, 2002;Winters et al., 2013). ...
... Although several treatment methods have been successful in pain relief (Galbraith & Lavallee, 2009;Newman, Waddington, & Adams, 2017;Thacker et al., 2002), none of them have been effective in managing the cause of MTSS (Winters et al., 2013). However, some techniques, such as foot orthoses, and strengthening and stretching exercises (Moen et al., 2009;Rome, Handoll, & Ashford, 2005) that modify lower limb biomechanics can be expected to effectively manage and/or prevent MTSS. ...
Excessive foot pronation during gait is a risk factor in medial tibial stress syndrome (MTSS). Arch-support foot-orthoses are commonly used to manage overpronation, but it is unknown whether it is effective to manage MTSS. The present study investigated the effects of bilateral foot orthoses during running on dynamic foot-pressure distribution patterns in recreational runners with MTSS. Fifty novice (started within the last 4 months) runners diagnosed with MTSS (20.7 ± 2.2 years; 71.1 ± 8.6 kg; 1.78 ± 0.07 m; mean ± SD) and 50 anthropometrically-matched healthy novice runners (21.9 ± 2.4 years; 71.4 ± 8.8 kg; 1.73 ± 0.07 m) participated in this study. The dynamic foot-pressure distribution during running with and without bilateral arch-support foot-orthoses was measured using pedobarography. MTSS novice runners have more medially directed pressures during the touchdown phase of the forefoot flat (p = 0.009) and heel off (p = 0.009), and a lateral pressure distribution during forefoot push-off phase (p = 0.007) during running than healthy runners. When using the arch-support foot-orthoses the foot-pressure distribution during all phases was not significantly different from that seen in participants without MTSS. These findings indicate that during running the medial shift of foot pressures during the loading response phase and the lateral shift during the propulsion phase of foot roll-over in MTSS are effectively corrected by using arch-support foot-orthoses. The use of such arch-support orthoses may thus be an effective tool to normalize foot-pressure distribution patterns during running, indicating the potential to treat and prevent MTSS in recreational runners.
... 9,10 Management starts with prevention. 11 Prior systematic review included four low-quality clinical trials assessing the role of shock-absorbing insoles, heel pads, Achilles stretching, proper footwear, and graduated running programs in preventing shin splints. This study did not find sufficient objective evidence to support the widespread use of either of the preventive measures. ...
A 28-year-old woman presented with left leg pain, persisting for five months. The pain, localized to the anterior compartment of the leg, is exacerbated with activity. Examination revealed tenderness over the muscle bulk adjacent to the anterior tibial crest. Lower limb radiography was unremarkable, but a bone scan confirmed the diagnosis of shin splint (medial tibial stress syndrome). Despite various treatment modalities, including conservative measures and surgical fasciotomy, no treatment has shown clear superiority over others. Extracorporeal shock wave therapy (ESWT) demonstrated promising results; however, the quality of supporting studies was limited. This case highlights the challenges in managing shin splints and underscores the need for further research to determine the most effective treatment options.
... 6,7 Management starts with prevention. 8 The prior systematic review included four low-quality clinical trials assessing the role of shock-absorbing insoles, heel pads, Achilles stretching, proper footwear, and graduated running programs in preventing shin splints. This study did not find sufficient objective evidence to support the widespread use of either of the preventive measures. ...
SurgiColl What is the best treatment option for a shin splint? We used the evidence-based format to find the best evidence for treating shin splints. We searched PubMed for (shin splint) OR (medial tibial stress syndrome) OR (chronic exertional compartment syndrome) OR (tibial stress fracture) AND (treatment). Based on the quality of evidence, we included level 1 (systematic review and randomized clinical trial (RCT)) and level 2 (non-randomized clinical trial) studies. We found and included one systematic review, 6 RCTs, and two non-randomized clinical trials. The search was done in July 2021. Shin splint seems to be a self-limiting condition, which does not accumulate with age. No treatment has proven to be superior to a control group. Extracorporeal shock wave therapy is the only treatment that showed encouraging results. However, the qualities of these studies were questionable.
... Brushøj et al 2008 23 Dijksma, 2020 119 Gross and Liu 2003 67 Knapik, 2006 128 McDevitt et al 2004 102 Milgrom et al 2005 62 Mundermann et al 2001 103 Pope, 1999 101 Thacker et al 2002 91 MSK-I, musculoskeletal injury; MSK-IMPP, musculoskeletal injury mitigation and prevention programme. proactively identify and mitigate potential barriers, and promote further leadership buy-in and support. ...
Introduction
Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities.
Methods
A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified.
Results
From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions.
Conclusion
Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.
... competition, MTSS often recurs [3]. MTSS incidence in runners with an MTSS history in one season is about twice that of runners without such a history [4,5]. ...
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.
... Many different causes can be blamed, including adjusted or weak calf muscles, worn or incorrectly adjusted operating shoes, or soccer boots 39 . Other causes may include too much training that is carried out on hard surfaces where the greatest shock is applied to the body or in a change in the training load or in the types of exercises carried out 40 . ...
Football is the most popular sport worldwide, played by athletes of all ages, it is associated with a high injury rate. The injuries occur during football games and practice due to a combination of high speed and full contact. The authors of different studies showed in their results that the incidence of football injuries a range from 0.5 to 45 injuries per 1000 hours of practice and games. Football injuries most commonly affect the knee and ankle joints, muscles, and ligaments of the thigh and calf. Most commonly affected region is lower extremity with an incidence of 61% to 90%. There are two types of risk factors intrinsic and extrinsic risk factors which are responsible for football injury. We found through this review of literature that ankle injuries are the most common injuries in football players. Other injuries which is also common in football players are such as, ligament of knee, hamstring strain, football concussion, wrist injury.
... Even in refractory cases, treatment regimens remain limited and are primarily targeted towards symptom management. 3 Rest, ice, elevation, compression, non-steroidal anti-inflammatories, massage therapy, dry needling, and various other techniques have been described for acute treatment. [4][5][6][7][8][9] Beyond the acute phase, therapies include splinting, bracing, crutches, shockwave, and physiotherapy with proprioceptive training. ...
Periostitis is characterized by periosteal inflammation surrounding tubular bones. The pathophysiology is now considered to be multifactorial and a spectrum of disorders, recently being redefined as medial tibial stress syndrome (MTSS). Current treatment modalities include preventative and conservative measures, such as activity modification and footwear alterations. There is a paucity of literature for more invasive treatments, such as steroid injections. In conflict with the currently available limited literature, this study reports a case of recurrent tibial periostitis due to blunt trauma treated with steroid injections resulting in symptom resolution and no adverse events. While this case may suggest a therapeutic role for steroids in the treatment of MTSS from blunt trauma, it also highlights the need for additional studies to elucidate the safety profile and therapeutic efficacy of steroid injections.
... 122,191 There is limited evidence available to be able to make any conclusions regarding groin, 39,62 shoulder, 16 and elbow 47 injuries and shin splints. 234 There are several limitations of this study. There were a number of overlapping studies between systematic reviews and meta-analyses, which may have resulted in more weight being placed on the strength of evidence for certain topics than was truly warranted. ...
Background
A large volume of systematic reviews and meta-analyses has been published on the effectiveness of sports injury prevention programs.
Purpose
To provide a qualitative summary of published systematic reviews and meta-analyses that have examined the effectiveness of sports injury prevention programs on reducing musculoskeletal injuries.
Study Design
Systematic review; Level of evidence, 4.
Methods
We searched the PubMed, CINAHL, EMBASE, and the Cochrane databases for systematic reviews and meta-analyses that evaluated the effectiveness of sports injury prevention programs. We excluded published abstracts, narrative reviews, articles not published in English, commentaries, studies that described sports injury prevention strategies but did not assess their effectiveness, studies that did not assess musculoskeletal injuries, and studies that did not assess sports-related injuries. The most relevant results were extracted and summarized. Levels of evidence were determined per the Oxford Centre for Evidence-Based Medicine, and methodological quality was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews, revised version).
Results
A total of 507 articles were retrieved, and 129 were included. Articles pertaining to all injuries were divided into 9 topics: sports and exercise in general (n = 20), soccer (n = 13), ice hockey (n = 1), dance (n = 1), volleyball (n = 1), basketball (n = 1), tackle collision sports (n = 1), climbing (n = 1), and youth athletes (n = 4). Articles on injuries by anatomic site were divided into 11 topics: general knee (n = 8), anterior cruciate ligament (n = 34), ankle (n = 14), hamstring (n = 11), lower extremity (n = 10), foot (n = 6), groin (n = 2), shoulder (n = 1), wrist (n = 2), and elbow (n = 1). Of the 129 studies, 45.7% were ranked as evidence level 1, and 55.0% were evidence level 2. Based on the AMSTAR-2, 58.9% of the reviews reported a priori review methods, 96.1% performed a comprehensive literature search, 47.3% thoroughly described excluded articles, 79.1% assessed risk of bias for individual studies, 48.8% reported a valid method for statistical combination of data (ie, meta-analysis), 45.0% examined the effect of risk of bias on pooled study results, and 19.4% examined the risk for publication bias.
Conclusion
This comprehensive review provides sports medicine providers with a single source of the most up-to-date publications in the literature on sports injury prevention.
... Several biomechanical factors have been linked to shin splints, including ND, plantar flexion ROM and increased hip rotation ROM [12,46]. One of the main characteristics of shin splints is ND beyond the normal range, which may alter plantar pressure distribution and undermine lower extremity function. ...
Background:
Shin splint is one of the most common sports injuries after strenuous exercise. Kinesiology taping (KT) is a popular noninvasive remedy used in sports-related disorders, with the potential effects of relieving pain, facilitating proprioception, modulating muscle activation and correcting abnormal movement patterns. However, the exact efficacy of KT on shin splints is still unknown, and previous findings are inconsistent. Hence, this study aimed to conduct a systematic review to evaluate the current status of relevant evidence on its efficacy.
Methods:
The review was performed according to the PRISMA guidelines, and a systematic search of the literature was conducted in December 2020. Electronic databases, Embase, Scopus, Medline, Web of Science, PubMed and Biomed Central were searched for the identification of pertinent studies with pre-defined key terms on shin splints and KT.
Results:
Four studies with a total sample size of 141 participants were included and analyzed. Two studies had within-subject designs, whereas the other two were randomized clinical trials. Although the positive results of KT were reported by the studies, methodological quality varied from poor to moderate according to the Physiotherapy Evidence Database Scale or Non-Randomized Studies-of Interventions.
Conclusion:
In conclusion, this review revealed that the efficacy of KT on shin splints remains not clear. Evidence that supports its effectiveness in individuals with shin splints is currently limited. Further studies with good methodological quality and study design are warranted.
... All participants received a multimodal therapeutic intervention, including ice for approximately 10 to 15 minutes applied to the affected area directly after each run, ankle stretching and strengthening exercises, and extracorporeal shockwave therapy. 5,6,9,10 We asked participants to follow a gradual walk-to-run protocol intended to return them to a level of function consistent with their operational requirements. 2,29 Walk-to-run programs theoretically impart stress to remodeling bone and soft tissue, ensuring optimal strength and tissue integrity in accordance with the dictates of Wolff's law. ...
Objective: Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners.
Design: A prospective randomized controlled trial.
Setting: Sport training and medical centers.
Participants: Fifty female recreational runners with MTSS were randomized into 2 groups.
Interventions: Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy.
Main outcome measures: Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18.
Results: Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18.
Conclusions: Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.
... Modalities include icing [19], non-steroidal anti-in ammatory drugs (NSAIDs), stretching and orthotics [20], and modi cation of biomechanical factors. Thacker et al. found little evidence to support any of these management strategies [21]. A recent cohort study suggests that low-energy extracorporeal shockwave therapy could be used to treat chronic MTSS [22]. ...
Background: Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6%-16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degree of success. In recalcitrant cases, surgery is often the only option.
Objective: To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant Medial Tibial Stress Syndrome decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up sport.
Design: Prospective case series
Setting: Private specialist Centre
Patients: Eighteen patients: fifteen male and three female; (mean age=31.2 years) with MTSS were referred from sports injury clinics across the UK, having failed all available conservative treatment.
Intervention: An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of symptomatic area.
Main Outcome Measures: Pain was assessed using a 10-cm visual analogue scale (VAS) at baseline, short-term, medium-term (mean 18 weeks) and long-term (mean one year) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up.
Results: Patients reported a significant (p<0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium-term follow-up and median return to sport score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported.
Conclusions: Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term. More robust trials are required to validate these findings.
Clinical Relevance: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant Medial Tibial Stress Syndrome.
... Extrinsic risk factors include sportsrelated factors, equipment, training area, and weather conditions 3 . Intrinsic risk factors include age, sex, height, body weight, body fat ratio, physical defects/anatomical variation (femoral neck anteversion, genu valgum, pes cavus, hyperpronation, joint laxity, uneven leg length), physical fitness level (aerobic endurance, fatigue, flexor-extensor muscle strength and balance, muscle/joint flexibility, athletic ability/coordination), and physiological factors 3,4,6 . In spite of identified risk factors, there is insufficient knowledge about the pathogenesis of this condition 3,4 . ...
Abstract
Purpose: The purpose of this study is to compare some anatomical features and ankle isokinetic muscle strength of adolescent athletes with medial tibial stress syndrome (MTSS) and healthy control group and to examine the adequacy of ‘tibial facial traction theory in the development of MTSS.
Materials and Methods: Adolescent athletes who had been diagnosed with MTSS during the season and healthy control group participants were included in the study. Demographic data and training details of the athletes were recorded. The MTSS score was used to determine the severity of the injury. The navicular drop test, lower extremity length measurement, and isokinetic muscle strength measurement were performed.
Results: The complaint duration of the patients with MTSS (n:21) was 1.8 ± 1.8 months and the MTSS score was 3.9 ± 2.2. The control group (n:12) and the athletes diagnosed with MTSS had similar demographic characteristics and training details. There was no difference between the groups in terms of navicular drop and lower extremity length. There was no ‘lower extremity difference’ for right and left extremities. According to the results of the isokinetic muscle strength test in plantarflexion and dorsiflexion direction, there was no difference between the groups in terms of muscle strength at both low and high angular speeds.
Conclusion: ‘The tibial traction theory’ does not sufficiently explain the pathogenesis of MTSS. Studies which evaluate isokinetic muscle strength and perform real-time dynamic analysis on the track are required to make recommendations for ideal protection and rehabilitation in cases of MTSS.
... according to Table iV mean amounts of minerals in the two study groups did not differ significantly (P>0.05). This finding is consistent with the results of Reinking et al. 19 Table iV also indicates that the relationship between body fat percentage and the incidence of Shin Splints was not significant which is consistent with the findings of Thacker et al. 2 results from the present study showed that the amount of minerals, body fat percentage and the anthropometric characteristics evaluated in this study may not be regarded as risk factors for the Shin Splints. ...
... Similarly, in the study on Australian pre-professionals, authors reported ankle as the most commonly injured location (25% of all injuries) [9], and this finding is in accordance with reports from UK Centers for Advanced Training [10]. Interestingly, in the previously cited study on the ballet professional company, authors reported highest prevalence of lower leg injuries (i.e., calf injuries) both in males and females [6], which indirectly confirms our previous discussion on inconsistency in dancing surfaces as a risk factor for injury occurrence [27]. ...
Professional ballet is a highly challenging art, but studies have rarely examined factors associated with injury status in ballet professionals. This study aimed to prospectively examine gender-specific correlates of injury occurrence and time-off from injury in professional ballet dancers over a one-year period. The participants were 99 professional ballet dancers (41 males and 58 females). Variables included: (i) predictors: sociodemographic data (age, educational status), ballet-related factors (i.e., experience in ballet, ballet status), cigarette smoking, alcohol drinking, and consumption of illicit drugs; and (ii) outcomes: injury occurrence and time-off from injury. Participants were questioned on predictors at the beginning of the season, while data on outcomes were collected continuously once per month over the study period. Dancers reported total of 196 injuries (1.9 injuries (95% CI: 1.6–2.3) per dancer in average), corresponding to 1.4 injuries per 1000 dance-hours (95% CI: 1.1–1.7). In females, cigarette smoking was a predictor of injury occurrence in females (OR: 4.33, 95% CI: 1.05–17.85). Alcohol drinking was a risk factor for absence from dance in females (OR: 1.29, 95% CI: 1.01–4.21) and males (OR: 1.21, 95% CI: 1.05–3.41). Less experienced dancers were more absent from dance as a result of injury than their more experienced peers (Mann-Whitney Z: 2.02, p < 0.04). Ballet dancers and their managers should be aware of the findings of this study to make informed decisions on their behavior (dancers) or to initiate specific programs aimed at the prevention of substance use and misuse in this profession (managers).
... 9,47 Finally, although preventive interventions using heel pad/lift or orthotics to correct leg-length inequality are commonly used, recent evidence examining their protective effectiveness in minimizing injury in running and other sport populations appears equivocal. [48][49][50][51][52][53] While this particular study did not address whether heel pad/lift or orthotic use played a protective effect in RRI among high school runners with leg-length inequality, it still behooves future prospective studies to determine their role as an injury prevention measure. ...
Background:
Participation in high school cross-country continues to increase with over 492,000 participants during the 2016-17 cross-country season. Several studies have indicated a high incidence of running-related injuries (RRI) in high school cross-country runners. Risk factors for RRI can be divided between intrinsic and extrinsic risk factors. Intrinsic risk factors such as structural asymmetries have received less attention in recent years.
Purpose:
The primary purposes of the current study were to (1) describe the prevalence of leg-length inequality among female and male high school cross-country runners, and (2) to determine whether leg-length inequality was associated with increased RRI in female and male high school cross-country runners.
Study design:
Prospective observational cohort study.
Methods:
Three hundred ninety-three (222 males, 171 females) athletes competing in high school cross-country running were followed, prospectively. The runners' right and left leg-lengths were measured with a standard cloth tape measure in a supine position. Incidence of low back/lower extremity RRI during practices or competitive events was monitored using the Daily Injury Report.
Results:
A similar percentage of leg-length inequality greater than 0.5 cm was found among female (19.3%) and male (22.1%) runners. No statistically significant associations were found between leg-length inequality and (RRI) for female or male runners, with the exception that after adjusting for BMI, males with a leg-length inequality > 1.5 cm were over seven times more likely to incur a lower leg RRI (Adjusted Odds Ratio = 7.47; 95%CI: 1.5, 36.9; p = 0.01) than males with a leg-length inequality < 0.5 cm. Side of RRI was not associated with side of longer limb length.
Conclusions:
While leg-length inequality was not associated with RRI, in general, males with a leg-length inequality > 1.5 cm were at greater likelihood of sustaining a lower leg RRI.
Level of evidence:
2b.
... Investigation of the risk factors is a vital component of injury prevention [4]. Risk factors may be sub-divided as either intrinsic or extrinsic [19][20][21][22][23][24][25][26][27][28]. Although the precise mechanisms of causation are yet to be fully understood there is widespread recognition of multi-factorial risk factor at play [20,21]. ...
Background: Musculoskeletal Injury (MSKI), a common problem in both military and physically active civilian populations, has been suggested to result from both extrinsic and intrinsic factors. Objective: To investigate prospectively whether gait biomechanics, aerobic fitness levels and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training. Methods: British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables , smoking habit, aerobic fitness as measured by a 1.5 mile run time and initial military selection test (combination of fitness, Trainability score) were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period. Result: Incidence rate of MSKI over a 26 week training period was 41.28% (95 % CI: 37.28-45.40%). The injured group had a higher medial plantar pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%. Conclusion: The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.
... Investigation of the risk factors is a vital component of injury prevention [4]. Risk factors may be sub-divided as either intrinsic or extrinsic [19][20][21][22][23][24][25][26][27][28]. Although the precise mechanisms of causation are yet to be fully understood there is widespread recognition of multi-factorial risk factor at play [20,21]. ...
Background:
Musculoskeletal injury (MSKI), a common problem in both military and physically active civilian populations has been suggested to result from both extrinsic and intrinsic factors.
Objective:
This study was to investigate prospectively whether gait biomechanics, aerobic fitness level and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training.
Method:
British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables, smoking habit, aerobic fitness as measured by a 1.5 mile run time and military selection test were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period.
Result:
Incidence rate of MSKI over a 26 week training period was 41.28% ( 95% CI: 37.28 - 45.40%). The injured group had a higher medial pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%.
Conclusion:
The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.
... 17 As the review included studies of only 'low to moderate' quality, the authors acknowledged more data are required. Thacker et al. 18 also proposed rigorous research to address common sports medicine problems, as the absolute and relative effectiveness of many interventions remain poorly understood. 19 No RCTs have compared differing SAIs within a UK military clinical setting, and there is currently no consolidated UK military policy concerning the use of SAIs. ...
Objectives
To assess the benefits, if any, of the use of shock absorbing insoles in reducing lower limb injury among Air Force recruits, and to assess the differences, if any, in the efficacy of two commonly available shock absorbing insoles.
Design
Randomized controlled trial. Setting: RAF Halton, UK. Site of all basic training for RAF personnel. Participants: 1205 recruits participating in basic training between 17 September 2003 and 7 April 2004. Interventions: Participants were randomized to receive either standard issue Saran non-shock absorbing insoles, or shock absorbing Sorbothane or Poron insoles, on a 1:1:1 basis.
Main Outcome Measures
The primary outcome measure was withdrawal from training for lower limb injury. The two primary comparisons were shock absorbing insole versus non-shock absorbing insole, and Sorbothane versus Poron (comparison of different shock absorbing insoles). Secondary outcomes were medical withdrawals for reasons other than those qualifying for the primary outcome measure.
Results
When comparing the non-shock absorbing insole to the shock absorbing insoles 72/401 participants (18.0%) allocated to Saran insoles were removed from training because of a qualifying lower limb injury, compared with 149/ 804 (18.5%) allocated to the shock absorbing insole (Sorbothane or Poron), odds ratio 1.04 (95% CI 0.75 to 1.44; P=0.87). When comparing the two shock absorbing insole 73/ 421 participants (17.3%) randomized to Sorbothane were removed from training because of a qualifying lower limb injury, compared with 76/383 for Poron (19.8%), odds ratio 0.85 (95% CI 0.58 to 1.23; P=0.37).
Conclusions
Similar rates of lower limb injuries were observed for all insoles (shock absorbing and non-shock absorbing) in the trial. The trial provides no support for a change in policy to the use of shock absorbing insoles for military recruits.
... [9] Nevertheless, some authors suggested that MTSS preventive programs for individuals with increased ND may include pronation-control devices. [9,10] Sports taping has long been used by elite athletes to provide mechanical support to the musculoskeletal system, [11] and several authors reported that taping could control the ND. [12,13] However, objective evidence supporting that sports taping restricts ND is extremely limited. ...
Medial tibial stress syndrome (MTSS) is one of the most common exercise-induced leg pain. The navicular drop (ND) was identified as a risk factor for MTSS. This study aimed to evaluate the short-term effects of sports taping applied to the supporting lower leg during sitting, standing, walking, and jogging to restrict the ND in healthy elite athletes.
Twenty-four healthy elite athletes without a history of exercise-induced pain or injuries in the lower limbs participated in this study (median age: 21.00 years; 1st--3rd quartiles; 19.25–22.00). The 4 taping conditions were used: rigid taping (RT), kinesiology taping (KT), placebo taping (PT), and non-taping (NT). The order of taping techniques was randomly assigned. Normalized navicular height (NH), ND, and normalized ND evaluated using 3-dimensional motion analysis, and normalized peak plantar pressure (PP) were compared in 4 taping conditions during sitting, standing, walking, and jogging.
During sitting, the normalized NH of RT is higher than that of NT, KT, and PT (χ² = 17.30, P = .001), while during jogging, the normalized NH of RT is higher than that of NT and PT (χ² = 10.55, P = .014). The normalized peak PP of NT is higher than that of PT (χ² = 8.871, P = .031) in the lateral midfoot region.
This study showed the RT technique maintained NH during sitting and jogging, and the RT technique could be an effective preventive and treatment strategy for MTSS.
Objective
Medial tibial stress syndrome (MTSS) is common and often difficult to treat. The purpose of this study was to examine the effect of a lower leg brace on MTSS symptoms compared to a placebo.
Methods
A pilot of a prospective double-blinded randomised placebo-controlled trial conducted in two private sports medicine practices. Included were those with symptomatic MTSS lasting 6 weeks or more. Excluded were those with other lower limb pathologies. Fourteen participants formed the study cohort who wore the brace or placebo. The brace applied counterforce pressure to the musculotendinous junctions of the soleus, compressed periosteum at the distal third of the posteromedial tibia and applied inferomedial torsion to the soleus muscle. Additional treatment modalities were recorded. Participants completed a standardised MTSS Severity Score at 0–6, 8, 12 and 24 weeks and recorded return to full activity.
Results
The brace group demonstrated a significantly reduced MTSS severity score from 5 to 24 weeks (p<0.03) and had returned to full activity within 5 weeks. MTSS score in the placebo group remained unchanged (p >0.05), all participants experienced MTSS recurrence and none returned to full activity over 24 weeks.
Conclusion
The lower leg brace demonstrated a reduction in MTSS symptoms from 5 weeks that was sustained over 6 months with a lower rate of MTSS recurrence compared with the placebo. If similar results are seen in a larger cohort, it has potential to benefit patients with MTSS as an adjunct to current treatment modalities. Further investigation regarding efficacy is needed.
Trial registration number
ACTRN12620000906954.
Cimnastik, dünya çapında yüksek katılım oranına sahip olimpik bir spor branşıdır. Uluslararası Cimnastik Federasyonu, artistik, ritmik, trampolin, aerobik ve akrobatik cimnastik olmak üzere 6 disiplin tanımlamıştır. Cimnastiğin en popüler alt disiplini olan artistik cimnastik branşında diğer spor branşlarıyla kıyaslandığında daha fazla yaralanma gözlenmektedir. Erken yaşlardan itibaren başlanılan yoğun antrenmanlar, sporcularda ayak ve ayak bileği bölgesinde çeşitli kas-iskelet sistemi patolojilerine neden olabilmekte, yaralanmayı takiben uzun süreli performans kayıpları görülebilmekte ve sporcuların kariyeri olumsuz etkilenebilmektedir. Artistik cimnastikçilerde ayak ve ayak bileğinde yaralanmaya yol açabilecek risk faktörlerinin tespiti ve bunların önlenmesine yönelik antrenman programının planlanması ve müdahale stratejilerinin geliştirilmesi gerekmektedir. Bu çalışmanın amacı, artistik cimnastikçilerde ayak ve ayak bileği yaralanmalarını ve bunlara neden olabilecek risk faktörlerini incelemektir. Bu çalışma için PubMed ve Web of Science veri tabanları kullanılarak 2000-2022 yılları arasında “artistik cimnastik”, “cimnastikçilerde yaralanma”, “medial tibial stres sendromu”, “ayak-ayak bileği yaralanması”, “aşil tendon yaralanması” anahtar kelimeleri ile tüm İngilizce ve Türkçe çalışmalar tarandı, toplam 92 bilimsel çalışma incelendi.
Objectives To improve the protective capacity of conventional ethylene-vinyl acetate mouthguards, some authors have suggested reinforcement with a hard material to distribute impact energy more widely. The research question for this systematic review was: 'does the inclusion of a hard insert in mouthguards improve the protection of anterior teeth from a direct blow?'Data sources Three bibliographic databases (PubMed/Medline, Ovid/Embase and the Cochrane CENTRAL databases) were searched up to 20 February 2021. Additional searches included hand searching of key articles and journals.Data selection A systematic search of the literature included studies where the intervention was the incorporation of hard material into sports mouthguards and where the comparator was conventional mouthguard material. Eligibility required the use of anatomical specimens or anatomical analogues which included or represented anterior maxillary teeth. Twelve eligible publications were identified.Data extraction Data extraction was first carried out independently by two reviewers. Discrepancies were resolved by discussion.Data synthesis Results of individual studies were conflicting and methodological diversity created difficulty in making a synthesis of results. All studies employed low-energy impacts that did not represent the potentially high-energy impacts encountered in sport.Conclusion The efficacy of hard inserts in sports mouthguards has not been demonstrated.
Objective
Conceptualisation of a clinically-relevant group of conditions as a region-based, load-related musculoskeletal pain condition (‘tibial loading pain’) to enable identification of evidence of treatment effect from load-modifying interventions.
Design
Systematic review and evidence synthesis based on a developed and justified theoretical position.
Methods
Musculoskeletal pain localised to the tibial (shin) region and consistent with clinical presentations of an exercise/activity-related onset mechanism, was conceptualised as a group of conditions (‘tibial loading pain’) that could be reasoned to respond to load modifying interventions. Five databases were searched for randomised controlled studies investigating any load-modifying intervention for pain in the anterior-anteromedial lower leg (shin). Study quality was evaluated (ROB-2) and level of certainty for the findings determined using the GRADE method.
Results
Six individual studies reporting seven comparisons were included. Interventions included braces, anti-pronation taping, compression stocking and a stretch + strengthening program. All included studies were assessed as having unclear or high risk of bias. The review found no evidence of beneficial effect of any of the load-modifying interventions on self-reported symptoms or function, physical performance or biomechanical measures, apart from a possible benefit of anti-pronation ‘kinesio’ taping. There was very low certainty evidence that kinesio taping improves pain and pain-free hopping distance after one week. The braces were associated with minor adverse effects and problems with acceptability.
Conclusions
None of the treatments investigated by the included studies can be recommended. Conceptualization of the problem as regional, primarily loading-related pain rather than as multiple distinct pathoanatomically-based conditions, and clearer load-modifying hypotheses for interventions are recommended.
Since Pheidippides’ times, the first Marathon runner in history, this running has become an attractive and inspiring activity to many runners around the world. A marathon is a type of endurance race that moves runners’ imagination because it defies athletes’ body limits; it also offers them a fantastic moment of joy and celebration for overcoming this challenge. All of this explains why marathon becomes a passion or sometimes an obsession for many elite and recreational athletes. This chapter explores a runners’ line of thinking; the “Forrest Gump” syndrome; physiological demands in the marathon; relevant clinical injuries in marathon such as dehydration/hyponatremia; sudden cardiac arrest; knee pain; shin pain, and runner’s toe.
Een 24-jarige man was gewend om 1 keer per week een stukje te gaan hardlopen. Dit beviel hem zo goed, dat hij na een half jaar besloot intensief te gaan trainen voor een trimloop van 15 kilometer . Na enkele weken ontstond echter een vervelende onderbeenpijn die na iedere training erger werd. Er was hier sprake van een mediaal tibiaal stresssyndroom, een beruchte aandoening onder hardlopers. De aandoening wordt gekenmerkt door mediale onderbeenpijn en drukpijn op de achterkant van de mediale tibiarand. Het hoofdstuk beschrijft de symptomatologie, oorzaken, risicofactoren en behandelmogelijkheden.
Exercise related leg pain in the military. Treatment of MTSS and CECS, with an emphasis on gait retraining.
The mechanics of gymnastics place extreme loads on many regions of a gymnast’s body. This physical stress along with the scoring and psychological pressures of this sport predisposes participants to injury. Specific injury location and type vary by age, sex, level, event, and environment (competition vs. practice). But, overall, there is a higher prevalence of lower limb injuries (54.1–70.2%) compared to upper limb injuries (17.1–25.0%), with the ankle (10–46%) and knee (5.1–26.2%) being the most commonly injured. This chapter describes over 20 of the most common lower limb injuries seen in gymnasts as well as the mechanical and biological factors that contribute to them. Additionally, reinjury is a common problem in gymnastics, so early detection and proper management are imperative. For these reasons, the clinical skills necessary for diagnosis and the best course of treatment are also detailed.
“Shin” (leg) pain, “shin splints,” and medial tibial stress syndrome, are general terms used to describe pain and lower leg discomfort. It could affect recreational and professional athletes indistinctly, mainly distance runners, athletes of endurance sports, dancers, and the military, confirming that higher physical demands (overload) are closely related to this injury.
The prevention of fragility fractures in bone—pathologic fractures resulting from daily activity and mostly occurring in the elderly population—has been a long-term clinical quest. Recent research indicating that falls in the elderly might be the consequence of fracture rather than its cause has raised fundamental questions about the origin of fragility fractures. Is day-to-day cyclic loading, instead of a single-load event such as a fall, the main cause of progressively growing fractures? Are fragility fractures predominantly affected by bone quality rather than bone mass, which is the clinical indicator of fracture risk? Do osteocytes actively participate in the bone repair process? In this Perspective, we discuss the central role of cyclic fatigue in bone fragility fracture.
Basketball and volleyball are clearly similar sports with regard to their ballistic nature and the need for lateral (side-to-side) movement. The primary difference is that there is no consistent running in volleyball and basketball does not generally involve lunging or diving on a regular basis. Current design strategies in court shoes are aimed at lateral stability, torsional flexibility, cushioning, and traction control to decrease the risk of injury [1].
Medial tibial stress syndrome is one of the most common causes of pain induced by exercise in the lower extremities among practitioners of physical activities and sports. It is a semiotic event produced by repetitive injury of mechanical stress on the medial aspect of the tibia, frequent among the diseases that affect runners and military training; not usually serious, but if not treated properly it can evolve to disabling injuries such as the stress fracture of the tibia. There are risk factors that contribute to the development of the pathology among which include the type of activity, inadequate training techniques, soil conditions, and the type of footwear used, also abnormal pronation of the subtalar joint, the female sex, a high body mass index, and decreased bone mineral density. The diagnosis is usually established through history and physical examination due to X-rays not providing useful information, they only help to establish the differential diagnosis with stress fractures of the tibia and more expensive radiological exams are not justified. The recovery time for those affected by this disease is quite prolonged, and there is the tendency to quit the therapy, preventing the achievement of the proposed therapeutic objectives, the gold standard treatment is physical therapy, however there are other therapeutic modalities with great prospects for the treatment of this nosologic entity, in which Extracorporeal Shock Wave Therapy excels, and although there are scientific studies in this subject, there are not enough. Both the pathophysiology, and the prevention and treatment are still unclear. Due to the above, a review of the state of the art of the fundamental aspects of this pathology is performed.
El síndrome de estrés tibial medial, SETM, una de las causas más comunes de dolor inducido por el ejercicio en las extremidades inferiores entre los practicantes de actividad física y deporte, como corredores y militares en formación, es un evento semiológico producido por lesiones repetitivas de estrés mecánico en la región medial de la tibia. No suele revestir gravedad, pero si no se trata adecuadamente puede evolucionar a lesiones incapacitantes, como la llamada fractura por estrés de la tibia. Existen factores de riesgo que contribuyen al desarrollo de la patología entre los que cabe mencionar el tipo de actividad, las inadecuadas técnicas de entrenamiento, las condiciones del terreno y el tipo de calzado utilizado, también la pronación anormal de la articulación subastragalina, el sexo femenino, un índice de masa corporal elevado, así como la disminución de la densidad mineral ósea. El diagnóstico generalmente se establece a través del interrogatorio y el examen físico, ya que las radiografías solo sirven para descartar fracturas por estrés de la tibia, y exámenes de imágenes más costosos no se justifican. El tiempo de recuperación de los afectados por esta patología es bastante prolongado, lo que propicia la tendencia al abandono del tratamiento y, así, desfavorece la consecución de los objetivos terapéuticos propuestos. El tratamiento estándar de oro es la terapia física; sin embargo, existen otras modalidades terapéuticas con prometedoras perspectivas, entre las que sobresale la terapia por ondas de choque extracorpóreas, respecto de la cual los estudios disponibles son todavía insuficientes, pues tanto la fisiopatología del SETM, como su prevención y su tratamiento aún no están claros. En atención a lo anteriormente expuesto, este artículo presenta una revisión del estado del arte de los aspectos fundamentales de la patología.
Shin splints, an exercise-induced form of lower leg pain, is a common complaint among athletes. Considered an overuse injury that compromises the dense and tough fascial attachments of the tibialis posterior and/or tibialis anterior muscles from the tibia, it responds well to a multiphase treatment plan that incorporates plyometric strengthening and conditioning exercises. Plyometrics may be safely introduced as early as the third or functional phase of recovery. A progressive plyometric program that emphasizes a gradual development of eccentric stress loading to the musculoskeletal components of the deep posterior and anterior muscle compartments of the lower leg is described.
In brief: In this study shoes, floor types, and individual physical differences were evaluated for their effects on aerobic dance injuries. The injury frequency was 75.9% for instructors and 43.3% for students. The shin was the most common site of injury in both groups. Overall, 60% of the injuries in the student group and 52% of injuries in the instructor group occurred below the knee. Most injuries were not debilitating, and few required medical treatment. The authors concluded that resilient but stable floor surfaces, proper shoes, and moderating the frequency of participation can prevent injuries in aerobic dance.
The medial tibial stress syndrome is a symptom com plex seen in athletes who complain of exercise-in duced pain along the distal posterior-medial aspect of the tibia. Intramuscular pressures within the posterior compartments of the leg were measured in 12 patients with this disorder. These pressures were not elevated and therefore this syndrome is not a compartment syndrome. Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.
This study was conducted to determine the nature and the frequency of lower extremity disorders incurred by men and women undergoing Army basic training and to analyze the differential effects of two types of combat boots on lower extremity disorders. The feet and lower legs of 2,074 men and 767 women were examined by medical personnel prior to the initiation of training and on three other occasions over the eight weeks of training. The data from these examinations were augmented by the diagnoses and case dispositions associated with sick call visits for lower extremity problems. It was found that the rates of occurrence of blisters and lace lesions were higher among the test participants who wore hot weather boots than among those who wore black leather boots. Of 27 types of lower extremity disorders diagnosed among the participants, two were incurred only by men and two only by women. The remaining disorders were identified in both sexes and statistical analyses revealed that 12 of these disorders were experienced by a significantly higher proportion of women than men. None of the disorders diagnosed in both sexes were incurred by a significantly higher proportion of men than women. The number of sick call visits and duty restrictions for lower extremity problems were also analyzed as a function of gender and boot type.
In brief: This retrospective survey of the clinical records of 1,650 patients seen from 1978 to 1980 identified 1,819 injuries. Almost 60% of the patients were men, but women under age 30 had the greatest risk of overuse running injuries. The knee was the most commonly injured site, and patellofemoral pain syndrome was the most common injury. Most patients had moderate to severe degrees of varus alignment and subsequent overpronation. Because certain injuries were more frequent in one sex or the other, the authors say future studies should differentiate injuries by sex.
It's easier to prevent running injuries than to treat them. This article helps the physician pinpoint the problem and treat runners without taking them off their feet.
Twenty-five exercisers suffering from shin soreness were interviewed, examined, and monitored to identify factors associated with this injury. Twenty-five uninjured persons who matched the injured subjects in age, sex, and activities served as controls. Injured subjects had a greater range of subtalar joint motion and increased ankle dorsiflexion, reported a significantly lower calcium intake, had raised their training intensity before injury, and were using worn or poorly made shoes when injured. Factors not associated with injury included number of months subjects had participated in weight-bearing exercise, exercise surface, amount of stretching, height-weight ratio, and menstrual status. This study is the first to indicate a possible relationship between nutrition and shin soreness.
Women take the same fitness tests as the men at the US Military Academy, but they are not yet ready to be graded by the same scales.
An 80-item questionnaire was used to study the variations by age and sex in the training habits and injury experience of 688 adult entrants in a 10-mile road race in southern Ontario. The results showed that runners over the age of 30 years tend to train at a slower pace than younger runners. On the average, men trained over somewhat longer distances and at a faster pace than women of the same age, but women ran more times per week. Older athletes tended toward a higher weekly mileage and entered the longer distance races. While 57% of all respondents reported at least one injury during the 12 months preceding our study, there was no significant variation by age or sex.
In brief: Three hundred runners were surveyed about the effectiveness of orthotics in controlling the symptoms and recurrence of overuse and impact shock injuries. The most common overuse injuries in the 146 respondents were knee pain, shinsplints, plantar fasciitis and arch strain, and Achilles tendinitis. The most commonly encountered problems with the orthotics themselves were blister formation, edge irritation, heel slippage from the extra bulk in the shoe, and discomfort from the stiffness of the orthotic. The author feels that orthotics can be of significant therapeutic value in treating abnormal function and preventing its recurrence.
O'TOOLE, M. L. Prevention and treatment of injuries to runners. Med. Sci. Sports Exerc., Vol. 24, No. 9 Supplement, pp. S360-S363, 1992. Key Points: 1) Many otherwise healthy runners are prevented from participating fully in their chosen endurance sport because of overuse injuries. 2) The most important risk factor for incurring an overuse injury is a training error, such as excessive mileage, sudden change in training distance or intensity, too much hard interval training, improper footwear, and running on cambered surfaces. 3) Although the knee is the most frequent site of injury in runners, any part of the lower extremity may be affected. 4) Tendinitis, muscle strain, and stress fractures are the most common overuse injuries in endurance athletes. 5) Prevention of injury through elimination of risk factors is clearly preferable to treatment. If injury does occur, treatment should include appropriate medical care, athlete education, cross-training, specific rehabilitative exercises, and a programmed return to running. (C)1992The American College of Sports Medicine
In brief: Most information about running injuries comes from case reports. Although useful, the case series does not take into consideration the population from which the injuries arose and is therefore an inappropriate method on which to base causal inference. The epidemiological method is a more powerful approach because, by definition, it takes into account the population from which the injuries arose. A review of three epidemiological studies shows that the only reasonably well-established cause of running injuries is the number of miles run per week. More information is needed to establish the relationship between injury and characteristics of the runner, characteristics of running, and characteristics of the running environment. More research on the causes of running injuries is needed and should be directed to those factors over which the runner has control.
Objective: To evaluate the clinical and basic science evidence surrounding the hypothesis that stretching immediately before exercise prevents injury. Data Sources and Selection: MEDLINE was searched using MEDLINE subject headings (MeSH) and textwords for English- and French-language articles related to stretching and muscle injury. Additional references were reviewed from the bibliographies, and from citation searches on key articles. All articles related to stretching and injury or pathophysiology of muscle injury were reviewed. Clinical articles without a control group were excluded. Results: Three (all prospective) of the four clinical articles that suggested stretching was beneficial included a cointervention of warm-up. The fourth study (cross-sectional) found stretching was associated with less groin/buttock problems in cyclists, but only in women. There were five studies suggesting no difference in injury rates between stretchers and nonstretchers (3 prospective, 2 cross-sectional) and three suggesting stretching was detrimental (all cross-sectional). The review of the basic science literature suggested five reasons why stretching before exercise would not prevent injuries. First, in animals, immobilization or heating-induced increases in muscle compliance cause tissues to rupture more easily. Second, stretching before exercise should have no effect for activities in which excessive muscle length is not an issue (e.g., jogging). Third, stretching won't affect muscle compliance during eccentric activity, when most strains are believed to occur. Fourth, stretching can produce damage at the cytoskeleton level. Fifth, stretching appears to mask muscle pain in humans. Conclusion: The basic science literature supports the epidemiologic evidence that stretching before exercise does not reduce the risk of injury.
• This prospective study of 583 habitual runners used baseline information to examine the relationship of several suspected risk factors to the occurrence of running-related injuries of the lower extremities that were severe enough to affect running habits, cause a visit to a health professional, or require use of medication. During the 12-month follow-up period, 252 men (52%) and 48 women (49%) reported at least one such injury. The multiple logistic regression results identified that running 64.0 km (40 miles) or more per week was the most important predictor of injury for men during the follow-up period (odds ratio=2.9). Risk also was associated with having had a previous injury in the past year (odds ratio = 2.7) and with having been a runner for less than 3 years (odds ratio=2.2). These results suggest that the incidence of lower-extremity injuries is high for habitual runners, and that for those new to running or those who have been previously injured, reducing weekly distance is a reasonable preventive behavior.(Arch Intern Med. 1989;149:2565-2568)
Running is one of the most popular leisure sports activities. Next to its beneficial health effects, negative side effects in terms of sports injuries should also be recognised. Given the limitations of the studies it appears that for the average recreational runner, who is steadily training and who participates in a long distance run every now and then, the overall yearly incidence rate for running injuries varies between 37 and 56%. Depending on the specificity of the group of runners concerned (competitive athletes; average recreational joggers; boys and girls) and on different circumstances these rates vary. If incidence is calculated according to exposure of running time the incidence reported in the literature varies from 2.5 to 12.1 injuries per 1000 hours of running. Most running injuries are lower extremity injuries, with a predominance for the knee. About 50 to 75% of all running injuries appear to be overuse injuries due to the constant repetition of the same movement. Recurrence of running injuries is reported in 20 to 70% of the cases. From the epidemiological studies it can be concluded that running injuries lead to a reduction of training or training cessation in about 30 to 90% of all injuries, about 20 to 70% of all injuries lead to medical consultation or medical treatment and 0 to 5% result in absence from work. Aetiological factors associated with running injuries include previous injury, lack of running experience, running to compete and excessive weekly running distance. The association between running injuries and factors such as warm-up and stretching exercises, body height, malalignment, muscular imbalance, restricted range of motion, running frequency, level of performance, stability of running pattern, shoes and inshoe orthoses and running on 1 side of the road remains unclear or is backed by contradicting or scarce research findings. Significantly not associated with running injuries seem age, gender, body mass index, running hills, running on hard surfaces, participation in other sports, time of the year and time of the day. The prevention of sports injuries should focus on changes of behaviour by health education. Health education on running injuries should primarily focus on the importance of complete rehabilitation and the early recognition of symptoms of overuse, and on the provision of training guidelines.
Although participation in many sporting activities has increased dramatically in recent years, the study of injuries sustained during training or participation is still in its infancy.
The most commonly used strategy is to describe the characteristics of a suitable case-series. This approach is relatively easy to implement, can be used to estimate the total morbidity load in a population, and can identify the relative frequency of various types of injury. However, the case series method cannot validly identify risk factors for injury or athletes at high risk; similarly, it cannot be used to estimate the absolute level of risk associated with sports participation. Finally, the population from which the injuries arose is often difficult to identify, and the series may not be representative of all injuries occuring in that population, and this may produce quite misleading results.
In contrast, a variety of epidemiological designs may be employed to address questions of aetiology and to identify high risk groups of athletes. With careful attention to the underlying population denominators, one may estimate the relative or absolute risk of injury for athletes with given risk characteristics, defined by type and intensity of their participation in sports or by their individual physiology. This is achieved by inclusion of suitable control subjects in the epidemiological sample; these controls may be uninjured athletes or random samples of the general population. The comparison of injured and uninjured groups permits valid inferences to be drawn concerning risk factors, avoiding the many potential biases which affect inferences drawn from injured athletes only.
Athletes and soldiers must both develop and maintain high levels of physical fitness for the physically demanding tasks they perform; however, the routine physical activity necessary to achieve and sustain fitness can result in training-related injuries. This article reviews data from a systematic injury control programme developed by the US Army. Injury control requires 5 major steps: (i) surveillance to determine the size of the injury problem; (ii) studies to determine causes and risk factors for these injuries; (iii) studies to ascertain whether proposed interventions actually reduce injuries; (iv) implementation of effective interventions; and (v) monitoring to see whether interventions retain their effectiveness.
Medical surveillance data from the US Army indicate that unintentional (accidental) injuries cause about 50% of deaths, 50% of disabilities, 30% of hospitalisations and 40 to 60% of outpatient visits. Epidemiological surveys show that the cumulative incidence of injuries (requiring an outpatient visit) in the 8 weeks of US Army basic training is about 25% for men and 55% for women; incidence rates for operational infantry, special forces and ranger units are about 10 to 12 injuries/100 soldier-months. Of the limited-duty days accrued by trainees and infantry soldiers who were treated in outpatient clinics, 80 to 90% were the result of training-related injuries.
US Army studies document a number of potentially modifiable risk factors for these injuries, which include high amounts of running, low levels of physical fitness, high and low levels of flexibility, sedentary lifestyle and tobacco use, amongst others. Studies directed at interventions showed that limiting running distance can reduce the risk for stress fractures, that the use of ankle braces can reduce the likelihood of ankle sprains during airborne operations and that the use of shock-absorbing insoles does not reduce stress fractures during training.
The US Army continues to develop a comprehensive injury prevention programme encompassing surveillance, research, programme implementation and monitoring. The findings from this programme, and the general principles of injury control therein, have a wide application in civilian sports and exercise programmes.
A retrospective case-control study into the risk factors for injury during basic military training was conducted at the Recruit Training Unit, Royal Australian Air Force Base Edinburgh, South Australia. Case subjects were recruits suffering a musculoskeletal injury during the course, severe enough to result in backcoursing (being delayed and joining a later course) and usually requiring the loss of 5 days of training. Control subjects were 629 recruits selected randomly from recruits who were not case subjects from the same period of Jan 1, 1985 to Dec 31, 1990. Two hundred thirty-eight cases were identified (2.7% of the recruit population), of which 123 were overuse-type injuries and 115 acute-type injuries. Most injuries occurred in the first 2 weeks of training. Bivariate and logistic regression analysis of possible risk factors for injury was conducted, both for all case subjects and for the subgroup of case subjects with overuse injuries. Statistically significant associations were identified for female gender, body mass index >26.9, winter training, a history of lower limb injury, and the presence of a lower limb deformity. All these associations were stronger for overuse injury, and preenlistment physical activity was also significantly associated with overuse injury. No significant association was found for height, weight, age, smoking, or gender makeup of courses. Most striking was a large rise in overuse injury incidence in women over the period of study, from 0.2% in 1985 to 8.8% in 1990. Reasons for this increase may include "social pathogenesis." (C)1994 The American College of Occupational and Environmental Medicine
Background: It has been hypothesized that a period of rest from running in the early weeks of basic military training will prevent stress fractures among recruits.Design: Modification of running schedules in companies of Army recruits undergoing basic military training was assigned.Setting/ Participants: Six male training companies were enrolled and followed during their 8 weeks of basic military training at Fort Bliss, Texas, in summer/fall 1989.Intervention: Intervention companies were asked to rest from running during the second, third, or fourth week of basic military training.Main outcome measures: Data were collected from questionnaires, anthropometric measurements, Army physical fitness tests, company training logs, and medical record abstraction of all clinic visits.Results: Among the 1357 enrolled male recruits, there were 236 (17%) with overuse injury and 144 (11%) with traumatic injury, resulting in 535 clinic visits and 1927 training days lost. Stress fracture/reaction rates varied from 3 to 8 per 100 recruits among the intervention companies and 2 to 7 per 100 recruits among the non-intervention companies. Total injury rates were 18 to 35 per 100 recruits in the intervention companies and 18 to 29 per 100 recruits in the non-intervention companies.Conclusions: The study provided no evidence for a protective effect on overuse injuries of resting from running for 1 week early in basic military training. There was varied physical training among the companies, however, with variation of injury rates that likely related to factors other than the intervention.
To better estimate rates of certain benefits and risks of recreational running, we sent questionnaires to 1,250 randomly selected male and 1,250 female registrants for a 10-km road race. The response rate was 55% for men and 58% for women. Telephone interviews of a randomly selected group of nonrespondents indicated that the only significant differences between respondents and nonrespondents were that (1) respondents were older than nonrespondents, (2) more male nonrespondents had stopped running during the year after the race, and (3) more male nonrespondents had been hit by thrown objects. One year after the race; 89% of male and 79% of female respondents were still running regularly. Eighty-one percent of men and 75% of women who smoked cigarettes when they began running had stopped smoking after beginning recreational running. Giving up smoking was significantly more common for current runners than for "retired" runners. Weight loss was commonly associated with runningand was greater in those persons who were overweight when they began running. More than a third of respondents had a musculoskeletal injury attributed to running in the year after the race and about one seventh of all respondents sought medical consultation for their injury. The risk of injury increased with increasing weekly mileage. This study uses epidemiologic methods to quantify some of the benefits and risks of running.
(JAMA 1982;248:3118-3121)
• A cohort of 1680 runners was enrolled through two community road race events and monitored during a 12-month follow-up period for the occurrence of musculoskeletal injuries. Fortyeight percent of the runners experienced at least one injury, and 54% of these injuries were new; the remainder were recurrences of previous injuries. The risk of injury was associated with increased running mileage but was relatively unassociated with other aspects of training, such as usual pace, usual running surface, hill running, or intense training. Injury rates were equal for all age-sex groups and were independent of years of running experience. Runners injured in the previous year had approximately a 50% higher risk for a new injury during follow-up.(Arch Intern Med. 1989;149:2561-2564)
The purpose of this review is to critically evaluate experimental evidence describing the pathology associated with shin splints. Shin splints are defined as medial or posteromedial leg pain which is brought about by walking, running, or related activities and which decreases with rest. The evidence indicates that shin splints may be due to pathology of the posteromedial tibial cortex, the periosteum of the posteromedial tibia, or the crural fascia of the deep posterior compartment of the leg. Research is needed to determine if increased pressure in the deep posterior compartment of the leg or pathology of the muscles, tendons, or interosseous membrane of the leg are associated with shin splints.
We report on three epidemiologic studies of orthopedic injuries in exercisers. One group of 438 men and women ran approximately 25 mi per week; 24% reported an injury during the previous year. Higher weekly running mileage and heavier individuals were more likely to report an injury. Injuries were not associated with speed of running, age, gender, type of surface, time of day, or stretching habit. In a second study, rates of injury for the foot, knee, hip, back, shoulder, and elbow were examined in runner (n =2,102) and nonrunner (n =724) patients at a preventive medicine clinic. Only knee injury rates were significantly higher in runners. Third, participants (n=968) in worksite-sponsored exercise programs were evaluated for orthopedic injuries. Rates of exercise injuries were relatively low (net rate = 12%/year in exercisers). Risk of injury in participants starting a walking, running, or jogging program was associated (p <.05) with age, sex, body mass index, flexibility, cardiorespiratory endurance, and number of sit-ups in 1-min.
Using a survey questionnaire design, we investigated the incidence, site, and nature of jogging injuries among all participants of a popular 16 km race. The response rate was 83.6%. Of 4,358 male joggers, 45.8% had sustained jogging injuries during the 1 year study period, 14.2% had required medical care, and 2.3% had missed work because of jogging injuries. Occur rence of jogging injuries was independently associated with higher weekly mileage (P < 0.001), history of previous running injuries (P < 0.001), and competitive training motivation (P = 0.03). Higher mileage was also associated with more frequent medical consultations due entirely to jogging-related injuries. In 33 to 44 year olds (N = 1,757), the number of years of running was inversely related to incidence of injuries (P = 0.02). Injuries were not significantly related to race running speed, training surface, characteristics of running shoes, or relative weight. Achillodynia and calf muscle symptoms were the two most common overuse injuries and occurred significantly more often among older run ners with increased weekly mileage. We conclude that jogging injuries are frequent, that the number of firmly established etiologic factors is low, and that, in recom mending jogging, moderation should be the watchword.
Overuse injuries of the lower extremity represent a frequent, significant problem. This article discusses management of the most common overuse disorders: anterior tibialis strain, medial tibial stress syndrome, compartment syndrome, stress fractures, and Achilles tendinitis. These injuries often are the culmination of a process (repetitive stress) rather than the result of a single event. Grading injuries on a scale of 1 to 4 according to severity can help determine the correct treatment. The primary treatment goal is to reduce inflammation through icing, rest, and appropriate use of nonsteroidal anti-inflammatory agents. For a safe return to pain-free activity, additional measures are required to correct biomechanical problems, educate the athlete on training techniques, and begin a gradual reconditioning program.
Reports data on the number, severity, and location of gymnastic injuries; events associated with injury occurrence; relationship in time between occurrence and competition; and the perceptions of causes. In addition, the relationships among the psychological factors of trait anxiety, locus of control, self-concept, stressful life events, and the occurrence of athletic injuries were evaluated. The Ss were 41 elite female gymnasts and 5 national-level coaches. Findings show that most injuries occurred during the floor exercise and that the timing of injuries was related to the approach of competition. Stressful life events were significantly related to both the number and severity of injuries. Significant relationships were not found between trait anxiety, locus of control, self-concept, and injury. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A review of the clinical records of two sports physicians identified 1,819 injuries in 1,650 running patients during a two-year period. Men comprised 59.8% of the total patients, and women under age 30 appeared to have the greatest risk of overuse running injuries. The knee was the most common site of complaint, accounting for 41.7% of all injuries. The least frequently involved areas were the lower back (3.7%) and upper leg (3.6% of total injuries). All anatomical regions were equally susceptible to injury in both sexes. Patellofemoral pain syndrome was the most frequent disorder, accounting for 25.8% of all injuries. Most patients had moderate to severe varus alignment and subsequent functional overpronation. Certain injuries were more frequent in one sex or the other, so we believe that our results should prompt other authors to differentiate incidence of injuries by sex in the future.
In North America, estimates of recreational runners have grown from two million in 1970 to 30 million in 1979. In Canada increased interest in running has been sparked by Participaction. Habituation to running is attributed to a sense of wellbeing and increased energy levels, as well as the possibility of reducing the threat of cardiovascular disease. Musculoskeletal injury is common to runners and can be prevented by carefully planned training programs, proper selection of training surface, regular stretching and strength drills, the use of protective footwear and balancing of vulnerable biomechanical alignments with functional orthotics in shoes.
This study identifies the anatomical factors involved in shinsplints. The investigation was confined to the identification of select anatomical factors common to female subjects who develop shinsplints. The height of the longitudinal arch of the foot, pronation of the foot, and ratio of body weight to height was correlated with the incidence of shinsplints. Within the limits of the study, only foot pronation was significantly related to the incidence of shinsplints. J Orthop Sports Phys Ther 1980;2(2):55-59.
The purpose of this review is to critically evaluate experimental evidence describing the pathology associated with shin splints. Shin splints are defined as medial or posteromedial leg pain which is brought about by walking, running, or related activities and which decreases with rest. The evidence indicates that shin splints may be due to pathology of the posteromedial tibial cortex, the periosteum of the posteromedial tibia, or the crural fascia of the deep posterior compartment of the leg. Research is needed to determine if increased pressure in the deep posterior compartment of the leg or pathology of the muscles, tendons, or interosseous membrane of the leg are associated with shin splints. J Orthop Sports Phys Ther 1990;12(3):115-121.
The frequency and nature of exertion pains of the leg in athletes were studied in 2,750 cases of overuse injuries treated at the Sports Clinic of the Deaconess Institute of Oulu, Finland, during the years 1972-1977. 465 cases of exertion pain (18%) were located in the shin. The medial tibial syndrome was the most common overuse injury among these athletes, comprising 9.5% of all exertion injuries and 60% of the leg exertion pains. Together with stress fracture of the tibia, the second most common exertion pain of the leg, it accounted for 75% of the total leg pains. There are certain difficulties in differentiating between the medial tibial syndrome and stress fracture of the tibia. They both occur at the same site with similar symptoms. Radiological examination and isotope scanning are needed. The medial tibial syndrome is an overuse injury at the medial tibial border caused by running exercises. The pain is elicited by exertional ischaemia. The pathogenesis is explained by increased pressure in the fascial compartment of the deep flexor muscles due to prolonged exercise. Similar chronic ischaemic pains from exercise are also found in other fascial compartments of the leg, especially in the anterior compartment. The only treatment needed for stress fractures is rest from training. Fascial compartment pains also usually subside. If chronic fascial syndromes prevent training, fasciotomy is recommended as a reliable method to restore the athlete to normal training without pains.
Joint flexibility and laxity as measured by 5 indices among 2,300 West Point cadets demonstrated no statistical relationship to joint injuries, or the need for surgical intervention resulting from injuries sustained in general athletic competition involving the ankle, knee, shoulder, or elbow. Similarly, no relationships were seen in a high school and collegiate football team. Parameters of flexibility vary significantly among different athletic population groups as related to age, sex, and type of athletic activity in which the individual is participating. In that part of the study conducted during the 1975 football season, the 16PF showed some potential for predicting injuries. However, stronger relationships between predictor and criterion variables must be established in the future before injury predisposition counseling is a possibility. Hopefully, continuing study will bring this into being and will extend to younger and younger individuals and other population groups. This would facilitate the development of an injury profile index to assist in the counseling of athletes into sports where their individual traits are protective and beneficial, rather than detrimental.
During three years, 274 exertion injuries in middle-aged keep-fit athletes were collected. A keep-fit athlete was a person, who regularly took part in noncompetitive sports activities. Exertion injury was a nontraumatic pain syndrome in the musculo-skeletal system. In the material, there were 35 women and 239 men. Most of them were 30--39 years old. Most exertion injuries took place in July, August, and September. About 80% of the patients were joggers. 80% of them had been training regularly for more than one year. At the moment of occurence of the symptoms, 68% of the patients trained 3--5 times a week. Joggers ran approx. 40 km/week. About 30% of the injuries took place in the knee, 24% in the ankle, heel and foot, 17% in the leg, and 9% in the achilles tendon. Almost one fifth of the pain syndromes were chronic in nature. The majority responded well to rest and to conservative treatment. Fifteen cases were treated surgically. Most of the exertion injuries were typical exertion syndromes seen also in competitive athletes. Others were degenerative changes, organic anomalies etc., which revealed their first symptoms during regular keep-fit activities.
We found no basis for increased intercompartmental pressure in either the anterior or posterior compartments as the cause of shin splints. The pain in all 14 of the patients studied was localized to the posterior medial border of the tibia at the origin of the posterior tibial muscle, and evidence of periostitis in this area was seen in two of our patients, suggesting the possible tearing away of the posterior tibial muscle from its origin. Shin splints is a lay term which has assumed medical diagnostic significance and should be removed from common usage by more accurately localizing the focus of pain.
Eighty-seven male inmates from a state prison and 70 inmates from a county jail volunteered as subjects. The subjects, age 20 to 35 yrs, were assigned randomly into a control or exercise group. Their Vo2max and treadmill performance values were determined before and after a 20 week jogging program. Training intensity was between 85 and 90 percent of maximum heart rate and involved workouts 3 days/week for 15, 30, or 45-min duration at the state prison and for 30-min 1, 3, or 5 days/week at the country jail. Cardiorespiratory fitness improved in direct proportion to frequency and duration of training. Injury, occurred in 22%, 24% and 54% of the 15, 30, and 45-min duration groups and in 0%, 12%, and 39% of the 1, 3, and 5-day/week groups, respectively. Attrition resulting from injury occurred in 0%, 0%, and 17% and in 0%, 4%, and 6% of the same respective groups. Attrition due to lack of interest was similar for all training groups (25%), but was significantly lower in the control groups (10%). Although the results showed a greater increase in cardiorespiratory fitness for the 45-min duration and 5-day/week groups, these programs are not recommened for beginning joggers because of the significantly greater percent of injuries.