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

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Static measures of foot posture are regularly used as part of a clinical examination to determine the need for foot level interventions. This is based on the premise that pronated and supinated foot postures may be risk factors for or associated with lower limb injury. This systematic review and meta-analysis investigates foot posture (measured statically) as a potential risk factor for lower limb overuse injuries. A systematic search was performed using Medline, CINAHL, Embase, SportDiscus in April 2014, to identify prospective cohort studies that investigated foot posture and function as a risk factor for lower limb overuse injury. Eligible studies were classified based on the method of foot assessment: (i) static foot posture assessment; and/or (ii) dynamic foot function assessment. This review presents studies evaluating static foot posture. The methodological quality of included studies was evaluated by two independent reviewers, using an adapted version of the Epidemiological Appraisal Instrument (EAI). Where possible, effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data. Meta-analysis was performed where injuries and outcomes were considered homogenous. Twenty-one studies were included (total n = 6,228; EAI 0.8 to 1.7 out of 2.0). There was strong evidence that a pronated foot posture was a risk factor for medial tibial stress syndrome (MTSS) development and very limited evidence that a pronated foot posture was a risk factor for patellofemoral pain development, although associated effect sizes were small (0.28 to 0.33). No relationship was identified between a pronated foot posture and any other evaluated pathology (i.e. foot/ankle injury, bone stress reactions and non-specific lower limb overuse injury). This systematic review identified strong and very limited evidence of small effect that a pronated foot posture is a risk factor for MTSS and patellofemoral pain respectively. Evaluation of static foot posture should be included in a multifactorial assessment for both MTSS and patellofemoral pain, although only as a part of the potential injury risk profile. Whilst the included measures are clinically applicable, further studies are required to determine their relationship with dynamic foot function.
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R E V I E W Open Access
Foot posture as a risk factor for lower limb
overuse injury: a systematic review and
meta-analysis
Bradley S Neal
1,2
, Ian B Griffiths
1
, Geoffrey J Dowling
3
, George S Murley
3,4
, Shannon E Munteanu
3,4
,
Melinda M Franettovich Smith
5
, Natalie J Collins
6
and Christian J Barton
1,2,4,7*
Please see related article: http://www.jfootankleres.com/content/7/1/53
Abstract
Background: Static measures of foot posture are regularly used as part of a clinical examination to determine the
need for foot level interventions. This is based on the premise that pronated and supinated foot postures may be
risk factors for or associated with lower limb injury. This systematic review and meta-analysis investigates foot
posture (measured statically) as a potential risk factor for lower limb overuse injuries.
Methods: A systematic search was performed using Medline, CINAHL, Embase, SportDiscus in April 2014, to identify
prospective cohort studies that investigated foot posture and function as a risk factor for lower limb overuse injury.
Eligible studies were classified based on the method of foot assessment: (i) static foot posture assessment; and/or
(ii) dynamic foot function assessment. This review presents studies evaluating static foot posture. The methodological
quality of included studies was evaluated by two independent reviewers, using an adapted version of the
Epidemiological Appraisal Instrument (EAI). Where possible, effects were expressed as standardised mean
differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data. Meta-analysis was
performed where injuries and outcomes were considered homogenous.
Results: Twenty-one studies were included (total n = 6,228; EAI 0.8 to 1.7 out of 2.0). There was strong evidence
that a pronated foot posture was a risk factor for medial tibial stress syndrome (MTSS) development and very
limited evidence that a pronated foot posture was a risk factor for patellofemoral pain development, although
associated effect sizes were small (0.28 to 0.33). No relationship was identified between a pronated foot posture
and any other evaluated pathology (i.e. foot/ankle injury, bone stress reactions and non-specific lower limb overuse
injury).
Conclusion: This systematic review identified strong and very limited evidence of small effect that a pronated foot
posture is a risk factor for MTSS and patellofemoral pain respectively. Evaluation of static foot posture should be
included in a multifactorial assessment for both MTSS and patellofemoral pain, although only as a part of the
potential injury risk profile. Whilst the included measures are clinically applicable, further studies are required to
determine their relationship with dynamic foot function.
Keywords: Lower extremity, Foot, Pronation, Supination, Prospective studies, Risk factors, Musculoskeletal diseases,
Review
* Correspondence: christian@completesportscare.com.au
1
Pure Sports Medicine, London, UK
2
Centre for Sports and Exercise Medicine, Queen Mary University of London,
London, UK
Full list of author information is available at the end of the article
JOURNAL OF FOOT
AND ANKLE RESEARCH
? 2014 Neal et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55
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Background
Identifying lower extremity musculoskeletal injury risk
factors is important for sports medicine clinical practice
and research, potentially allowing for the development
of more effective and efficient prevention and manage-
ment strategies. Several risk factors have been suggested
to increase lower extremity injury risk, including in-
creased body mass index [1], female sex [2] and altered
hip mechanics [3].
Foot pronation as a potential lower extremity overuse
injury risk factor has received great attention in research
and clinical practice. Historically, foot mechanics are
considered to contribute to lower extremity malalign-
ment and pathology proximal to the foot via joint
coupling with tibial internal rotation [4]. Research has
suggested that rearfoot motion (eversion) closely corre-
sponds with tibial motion (internal rotation) [5,6] and is
potentially associated with transverse plane rotations at
the hip [7]. Based on this model of lower extremity joint
coupling, there has long been a theoretical link between
foot pronation and lower extremity pathologies includ-
ing exercise related lower extremity injury, medial tibial
stress syndrome (MTSS) and patellofemoral pain [1,8,9].
At the other end of the spectrum increased foot supi-
nation has been linked to lower extremity injury via a
mechanism of increased limb stiffness and subsequent
vertical loading rates [10].
Considering the hypothesised link between foot pos-
ture and lower extremity injury, static foot posture is
frequently assessed in the clinical setting, with a belief
that this may provide indications for biomechanical in-
terventions (e.g. foot orthoses). Commonly employed as-
sessment methods to assess foot posture include, but are
not limited to, navicular drop, resting calcaneal eversion,
the longitudinal arch angle and the Foot Posture Index
(FPI) [11].
Two recent reviews have evaluated the relationship
between foot posture and lower extremity injury [11,12].
Tong and Kong [11] concluded that both ?pronated?and
?supinated?foot types are significantly associated with
lower extremity injury, although the strength of this re-
lationship was low, and the authors did not provide a
breakdown of individual pathologies or outcome mea-
sures. Additionally, this review included studies that
were not prospective in nature, which limits the ability
to differentiate between cause and effect. Chuter and
Janse de Jonge?s [12] narrative review suggested that ex-
cessive foot pronation increased the risk of exercise re-
lated lower leg pain and MTSS, but not patellofemoral
pain. However, this review was not systematic in nature,
making conclusions potentially open to bias. Addition-
ally, Chuter and Janse de Jonge [12] focused on dynamic
function, and did not include studies related to static
foot posture.
To the authors?knowledge, there has not been a sys-
tematic review investigating the relationship between
static foot posture or dynamic foot function and lower
extremity injury development using only prospectively
designed studies. Therefore, the aim of this systematic
review was to (i) identify and appraise the current evi-
dence for the prospective link between foot posture and
lower limb overuse injury and (ii) provide guidance for
future research in this area. This paper, focusing on
static foot posture measures, represents the first compo-
nent of a two-part systematic review on foot function-
related risk factors for lower limb overuse injury.
Methods
The protocol for this systematic review was developed
using guidelines provided by the Preferred Reporting of
Systematic Reviews and Meta-Analysis (PRISMA) State-
ment [13] (Additional file 1).
Search strategy
MEDLINE, CINAHL, Embase, SPORTDiscus and Goo-
gle Scholar were searched from inception until April
2014. Medical Subject Headings (MeSH) were exploded
to encompass relevant subheadings, as well as relevant
keywords (Additional file 2). The search strategy limited
findings to adult human participants and English lan-
guage publications. We hand searched reference lists of
identified systematic and narrative reviews and contacted
field experts (e.g. physiotherapists, podiatrists) regarding
known important publications. Additionally, a cited ref-
erence search for each included paper was undertaken in
Google Scholar.
Eligibility criteria
A single investigator (GJD) exported all studies identified
by the search strategy to Endnote version X5 (Thomson
Reuters, Philadelphia). Initial eligibility criteria were:
(i) prospective cohort study design; (ii) quantitative
measurement of foot posture or function at baseline
(static or dynamic); and (iii) prospective collection of
specific or non-specific lower limb overuse injury sur-
veillance data over a specified time period. No exclusion
was made relative to any given population. Two authors
(BSN and IBG) reviewed all abstracts to determine eligi-
bility. Full texts were screened to confirm eligibility, and
where there was uncertainty regarding eligibility from
the abstract alone. A third reviewer (CJB) was available
for any discrepancies.
Studies that fulfilled the initial eligibility criteria were
separated into those that investigated static measures of
foot posture and those that investigated dynamic mea-
sures of foot posture (i.e. measured during walking or
running). This review focused on static measures, while
dynamic measures are addressed in the accompanying
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paper [14]. Any study that included both static and dy-
namic measures of the foot was included, but only data
pertaining to static measures was used for this part of
the review. Studies that included static foot posture mea-
sures that were not quantitative in nature were excluded
[15-25]. We defined specific lower limb overuse injuries
as those with a single diagnosis and non-specific lower
limb overuse injuries as those without a specific diagno-
sis or where multiple overuse injuries were pooled.
Quality assessment
The Epidemiological Appraisal Instrument (EAI) [26] was
used to evaluate the methodological quality of the included
studies. The EAI was designed specifically for cohort
studies and consists of 43 items across five domains ?
(i) reporting, (ii) subject/record selection, (iii) measure-
ment quality, (iv) data analysis and (v) generalisation of re-
sults [26]. Individual items were scored as ?Yes?(score
of 2), ?Partial?(score of 1), ?No?(score of 0), ?Unable to
determine?(score of 0) or ?Not Applicable?(item ex-
cluded). Previous studies have found the EAI to have ad-
equate external validity and good to excellent intra-rater
(Kappa coefficient range 52 to 60), and inter-rater (Kappa
coefficient = 90% [95% CI; 87-92%]) reliability [26]. The
wording of the 43 items was modified slightly for this re-
view to improve clarity and rater interpretation. To main-
tain validity, no items were removed (Additional file 3).
Two raters (BSN and IBG) who were blind to the
author and publication details independently evaluated
each study. Discrepancies between the raters were
resolved during a consensus meeting. Average scores
across the 43 items were calculated, with a maximum
possible score of 2.0. Studies were then classified as high
quality (1.4), moderate quality (1.1 to <1.4), or poor
quality (<1.1) [26].
Data management
Data regarding study characteristics were extracted from
each study by two independent investigators (BSN and
IBG). This included publication details (year, author,
country), participant characteristics (number of parti-
cipants injured and uninjured, age, sex, eligibility cri-
teria, population [i.e. military]) and study methods (foot
posture measurement, examiner details, injury outcome,
duration of study, covariates investigated) (Table 1). For
continuous scaled foot posture variables means and
standard deviations (SD) were extracted for injured and
uninjured participants. For nominal scaled variables raw
counts of injured and uninjured participants (e.g. injury
incidence in categories of foot types) were extracted.
Corresponding authors were contacted for additional
data if adequate data were not provided in the publica-
tion. For studies that described particular foot posture
variables but did not publish data, this was recorded as
?not reported?(NR) and it was assumed that no signifi-
cant differences were observed between those who were
injured and uninjured.
Statistical methods
Inter-rater reliability of EAI scores between the two raters
was evaluated descriptively using percentage agreement.
Differences between scores for ?Yes?,?Partial?,?No?,and
?Unable to determine?were calculated, with perfect agree-
ment indicated by zero difference. Ratings for the ?not
applicable?response were excluded from analysis, as no
rater interpretation was required.
Extracted means and SD?s for continuous scaled
variables were used to calculate standardised mean dif-
ferences (SMD) with 95% confidence intervals (CI?s).
Extracted nominal scaled data was used to caclulate risk
ratios (RR) with 95% CI?s. Data for men and women
were analysed separately where this information was
provided. Data for right feet only were entered when
studies provided a breakdown for both feet, to maintain
independence of data [27]. All analyses were completed
in Review Manager 5.0 (The Cochrane Collaboration,
Copenhagen, Denmark). Meta-analysis (data pooling)
was performed where homogeneity between studies was
deemed to be adequate (i.e. outcome measures were
performed and reported in a similar fashion for the
same pathology). The level of statistical heterogeneity for
pooled data was established using I
2
statistics and asso-
ciated p values (heterogeneity defined as I
2
> 50%) [28].
Calculated individual or pooled SMDs were cate-
gorised as small (0.59), medium (0.60 to 1.19) or large
(1.20) [29]. A RR > 1.0 indicated that the lower limb
overuse injury was more likely to be found in partici-
pants with the risk factor present. A small effect was in-
dicated by a RR 2.0, and a large effect 4.0 [29]. Effects
were considered to be statistically significant if the asso-
ciated 95% CI for SMD did not contain zero, and the
95% CI for RR did not contain one.
Evidence-based recommendations
Based on previous work by van Tulder et al. [30], levels
of evidence were assigned for each foot posture measure
evaluated, incorporating statistical outcomes and metho-
dological quality of included studies.
Strong evidence
Pooled results derived from three or more studies, in-
cluding a minimum of two high quality studies that are
statistically homogenous; may be associated with a sta-
tistically significant or non-significant pooled result.
Moderate evidence
Statistically significant pooled results derived from mul-
tiple studies that are statistically heterogeneous, including
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Table 1 Summary of study characteristics
Population Observation period
(activity, duration)
Injury outcome Injured group Uninjured group Foot posture measure
N total
(n females)
Age
(mean ? SD)
N total
(n females)
Age
(mean ? SD)
Bennett et al., 2001 [31] Cross country runners 8 weeks Medial tibial stress
syndrome
15 (13) 15.3 (?1.0) 21 (8) 15.7 (?1.5) Resting calcaneal position
(degrees)
Yates and White, 2004 [32] Naval recruits 10 weeks basic training Medial tibial stress
syndrome
40 (18) NR 84 (22) NR FPI-8
Burne et al., 2004 [33] Military cadets 12 months Medial tibial stress
syndrome
23 (11) NR 135 (25) NR Resting calcaneal position
(degrees)
Willems et al., 2006 [34] Physical education students 12 months Medial tibial stress
syndrome
46 (29) NR 354 (130) NR Resting calcaneal position
(degrees)
Reinking, 2006 [35] Female collegiate athletes One athletic season Medial tibial stress
syndrome
20 (20) NR 56 (56) NR Navicular drop
Reinking et al., 2007 [36] Collegiate athletes One athletic season Medial tibial stress
syndrome
60 (31) NR 28 (13) NR Navicular drop
Plisky et al., 2007 [37] High school runners 13 weeks Medial tibial stress
syndrome
16 (11) NR 88 (29) NR Navicular drop
Hubbard et al., 2009 [38] Collegiate athletes One athletic season Medial tibial stress
syndrome
29 (9) 19 (?0.98) 117 (72) 19.9 (?1.8) Navicular drop
Bennett et al., 2012 [39] Cross country runners Cross country season Medial tibial stress
syndrome
26 (13) NR NR 33 (15) Navicular drop
Yagi et al., 2013 [40] High school runners 3 years Medial tibial stress
syndrome
102 (44) NR 142 (54) NR Navicular drop
Hetresoni et al., 2006 [41] Infantry recruits 14 weeks basic training Patellofemoral
pain
61 (NR) NR 344 (NR) NR Resting calcaneal position
(degrees)
Thijs et al., 2008 [42] Recreational runners 10 weeks Patellofemoral
pain
17 (16) 39.4 (?10.3) 85 (73) 37.6 (?9.4) FPI-6
Boling et al., 2009 [43] Naval recruits 1-2.5 years Patellofemoral
pain
40 (16) NR 1279 (489) NR Navicular drop
Beynnon et al., 2001 [44] Collegiate athletes One college season Foot/ankle injury 20 (13) NR 98 (55) NR Longitudinal arch angle
Cain et al., 2007 [45] Male Futsal players One Futsal season Foot/ankle injury 33 (0) NR 43 (0) NR FPI-6
Winfield et al., 1997 [46] Female marines 10 weeks basic training Bone stress
reaction
12 (12) NR 89 (89) NR Subtalar joint ROM
(Goniometry)
Kaufman et al., 1999 [47] Male Navy Seal candidates 2 Years LL overuse injury 149 (0) NR 300 (0) NR Longitudinal arch angle
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Table 1 Summary of study characteristics (Continued)
Burns et al., 2005 [48] Triathletes 10 weeks LL overuse injury 37 (NR) NR 91 (NR) NR FPI-8
Rauh et al., 2010 [49] Female marines 13 weeks LL overuse injury 104 (110) NR 644 (634) NR Longitudinal arch angle
Buist et al., 2010 [50] Novice runners 13 weeks LL overuse injury 100 NR 476 NR Navicular drop
Nielsen et al., 2014 [51] Novice runners 12 Months LL overuse injury 252 (NR) NR 478 (NR) NR FPI-6
LL = lower limb; NR = not reported; FPI = foot posture index.
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at least one high quality study; or from multiple moderate
quality or low quality studies which are statistically
homogenous.
Limited evidence
Results from one high quality study or multiple moderate
or low quality studies that are statistically heterogeneous.
Very limited evidence
Results from one moderate quality study or one low
quality study.
No evidence
Pooled results insignificant and derived from mul-
tiple studies regardless of quality that are statistically
heterogeneous.
Results
Search results
The electronic database search yielded a total of 33,518
citations across the two parts of this systematic review
(static foot posture and dynamic foot function). Follow-
ing the sequential review of titles, abstracts and full
texts, as well as removing studies that were not pro-
spective cohort studies, 32 studies that evaluated static
measures of foot posture were identified [15-25,31-51]
(Figure 1). Full text versions of these were assessed for
eligibility based on static foot posture assessment, and
21 studies met the eligibility criteria [31-51], which were
grouped according to injury type.
Quality assessment of included studies
Based on EAI evaluation, quality scores ranged from 0.8
to 1.7 (out of a possible score of 2.0), with the majority
of studies included in this review being of moderate
Records identified by search strategy:
8,300 Medline and Embase
11,616 SportDiscus
13,602 CINAHL
35,518 titles and abstracts screened
67 studies relating to static foot posture
35,437 excluded no relevance to research question
32 studies relating to static foot posture
35 studies excluded as not prospective in study design
21 studies investigated quantitative static foot
posture and overuse injury
11 excluded due to non-quantitative method of foot posture
81 full text obtained
14 excluded as relating to dynamic foot function
Figure 1 Search results throughout the review process.
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quality (MQ) (n = 13, 62%) [31-34,36,40,42-45,47,49,50]
(Additional file 4). Five studies (24%) were classified as
high quality (HQ) [35,37,39,48,51], and three studies
(14%) as low quality (LQ [38,41,46]). In terms of inter-
rater reliability across 35 items included in the quality
assessment, 14 items had perfect or near perfect agree-
ment. That is, these items were awarded the same score
or there was a maximum of one point difference in sco-
ring. For a further 15 items, the raters had near perfect
agreement for >80% of the studies reviewed. Item 35
(?is prior history of disease and/or symptoms collected
and included in the analysis?) displayed the lowest agree-
ment, with perfect or near perfect agreement for only 11
of 21 studies. Percentage agreement across the 35 items
ranged from 33% to 100%.
Common themes relating to categories of methodo-
logical quality were identified using the EAI [26]. High
quality studies scored well for relevant descriptions (e.g.
hypothesis, risk factors, participants), statistical para-
meters and result reporting, as well as adherence to pro-
spective methodology. Poor quality studies generally
failed to perform a power calculation with regards
to sample size [31-36,38,40,42-50]; demonstrated inad-
equate or absent reporting of reliability and validity, both
for outcome measure [31-34,38,40-42,44-47,49-51] and
injury determinant [31-36,38,39,41-46,48-50]; inadequate
or absent description of intrinsic and extrinsic variables
[39,41,43,46,47]; and inadequate adjustment for these
variables [31,32,36,39,41-44,46,47].
Study characteristics
Foot posture variables as risk factors for lower limb overuse
injuries
The 21 included studies incorporated a total of 6,228
participants. The participant population varied, with
ten studies investigating recreational level runners
[34-38,40,42,44,50,51], seven studies investigating mili-
tary personnel [32,33,41,43,46,47,49], two studies in-
vestigating cross-country runners [31,39], and single
studies investigating futsal players [45] and triathletes
[48]. The types and incidence of lower limb overuse in-
jury were: MTSS 11.5% to 44.1% [31-40,49]; patellofe-
moral pain 3.0% to 15.7% [41-43]; foot and ankle injury
16.9% to 32.0% [44,45]; bone stress reaction 11.5% [46]
and a pooled group of non-specific lower limb overuse
injuries 13.9% to 37.5% [47-51].
Outcome measure of choice varied
Eight studies investigated navicular drop [35-40,43,50],
five studies investigated the foot posture index [32,42,
45,48,51], four studies investigated resting calcaneal pos-
ition [31,33,34,41], three studies investigated the longi-
tudinal arch angle [44,47,49] and one study investigated
subtalar joint goniometry [46].
Medial tibial stress syndrome (MTSS)
Eleven studies [31-40,49] investigated foot posture as a
risk factor for the development of MTSS, nine of which
provided data suitable for meta-analysis [31,32,34-40,49].
Strong evidence from continuous scaled measures of
foot posture (including navicular drop, calcaneal ever-
sion and FPI) indicated that individuals exhibiting a
more pronated foot posture were more likely to develop
MTSS (3 HQ [35,37,39], 4 MQ [31,34,36,40] and 1 LQ
[38]), with a small but significant pooled SMD (I
2
= 0%,
p= 0.56, SMD 0.28, 0.14 to 0.42) (Figure 2). When strati-
fying for foot posture measure, a significant risk asso-
ciation was seen for all three measures, including the
FPI (very limited evidence, medium SMD 0.62, 0.23
to 1.02), calcaneal eversion (limited evidence; I
2
= 0%,
p= 0.51; small SMD 0.33, 0.05 to 0.61), and navicular
drop (Strong evidence; I
2
= 0%, p= 0.82; small SMD 0.19,
0.01 to 0.36). Limited evidence from pooled dichotom-
ous measures (2 MQ [36,49]) indicated no association
between foot type (defined by navicular drop magnitude
> 10 millimeters) and increased risk of MTSS develop-
ment (RR 1.09, 0.78 to 1.52) (Figure 3).
Patellofemoral pain
Four studies [41-43,49] investigated foot posture as a
risk factor for the development of patellofemoral pain,
three of which provided data suitable for effect size
calculation [42,43,49]. Very limited evidence from con-
tinuous measures indicated that individuals exhibiting
increased pronated foot posture measured using navicular
drop are more likely to develop patellofemoral pain (1 MQ
[43]), with a small SMD (0.33, 0.02 to 0.65) (Figure 4).
Limited evidence from pooled dichotomous measures
(2 MQ [42,49]) indicated no association between a pro-
natedfootposture(definedbyFPIandnaviculardrop)
and increased risk of patellofemoral pain development
(RR 1.22, 0.73 to 2.02) (Figure 5).
Foot/ankle injury
Two studies [44,45] investigated foot posture as a risk
factor for the development of foot/ankle injury (defined
as any tissue damage, pain and/or physical complaint of
the ankle affecting performance or limiting sporting par-
ticipation [45]). One study provided data suitable for risk
ratio calculation [44] (Figure 6). Very limited evidence
from dichotomous measures (1 MQ [44]) indicated no
association between foot posture (defined by longitu-
dinal arch angle) and increased risk of foot/ankle injury
development (RR 0.92, 0.38 to 2.24).
Bone stress reaction
One study investigated foot posture as a risk factor for
the development of bone stress reaction, using subtalar
joint goniometry [46]. This measured the gross total
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range of rearfoot motion from supination to pronation
in a non-weight bearing position, with a higher available
range indicating increased static pronation. We were
unable to calculate effect sizes due to inadequate data
reporting.
Non-specific lower limb overuse injury
Four studies investigated foot posture as a risk factor for
non-specific lower limb overuse injury [47,48,50,51], two
of which provided data suitable for effect size calculation
[48,51]. Limited evidence from continuous measures indi-
cates no association between individuals exhibiting a more
pronated foot posture (defined by FPI) and injury develop-
ment (1 HQ [48], SMD ?0.50, ?2.28 to 1.28). Limited evi-
dence from dichotomous measures (1 HQ [51]) found no
association between a foot posture (defined by FPI) and
increased risk of non-specific lower limb overuse injury
(RR 1.18, 0.68 to 2.04) (Figure 7).
Discussion
This is the first systematic review and meta-analysis of
prospective research regarding static foot posture and its
relationship to lower limb overuse injury development.
Findings showed that a pronated foot posture was a risk
factor for the development of both MTSS and patellofe-
moral pain. However, associated effect sizes were small,
indicating this relationship is weak and only a part of
the multifactorial etiology.
Across the 21 studies included in this review, four dif-
ferent measures of static foot posture were employed, in-
cluding navicular drop (n = 9), the FPI (n = 5), calcaneal
eversion (n = 4) and the longitudinal arch angle (n = 3).
Figure 2 Forest plot detailing SMD for medial tibial stress syndrome.
Figure 3 Forest plot detailing RR for medial tibial stress syndrome.
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Interestingly, the findings of this review, which link foot
posture measured using navicular drop and FPI to injury
risk (MTSS and patellofemoral pain respectively), are in
conflict with reported findings from two studies that
were not included within the meta-analysis due to an ab-
sence of adequate data [33,41]. Specifically, calcaneal
eversion was reported to be unrelated to both MTSS
[33] and patellofemoral pain [41] risk. These conflicting
findings may be explained by the varying method of foot
posture measurement, and the inferior reliability of the
calcaneal eversion measurement compared to navicular
drop and the FPI [52,53]. They also indicate that calca-
neal eversion may be less sensitive in identifying risk of
lower limb injury development when compared to the
FPI and navicular drop. Further prospective research
concurrently collecting multiple foot posture measures
is needed to confirm this.
Direct comparison of findings with the review of Tong
and Kong [11] is difficult, due to analogous data being
unavailable within their results. They concluded that
both ?high arched?(supinated) and ?flat foot?(pronated)
types are risk factors for lower extremity injury, but did
not provide a breakdown for individual pathologies or
outcome measures. Our findings are in agreement with
the MTSS systematic review of Newman et al. [54],
which reported greater navicular drop magnitude to be a
risk factor (SMD = 0.26 for continuous scaled data; risk
ratio = 1.99 for nominal scaled data). Two additional
studies completed by Reinking and colleagues [35,36]
are included in our review, which may explain the small
variance in our statistical findings (SMD = 0.19) com-
pared to Newman et al. (SMD 0.26) [54]. Importantly,
these additional findings provide further confirmation of
a relationship of small effect between greater navicular
drop and risk of MTSS.
Limited and very limited evidence indicated that static
foot posture may not be a risk factor for the develop-
ment of a pooled group of non-specific lower limb over-
use injuries or foot and ankle injuries, respectively. In
these cases the broad and ambiguous definitions of
pathology may have made determining precise relation-
ships with foot posture difficult. Rather than combining
all lower limb overuse injuries in analyses, future studies
should prioritise evaluation of discrete, well-defined con-
ditions, which will enable more accurate identification of
foot posture risk factors for specific injuries.
Clinical implications
Although a relationship between a pronated foot posture
and greater risk of MTSS and patellofemoral pain was
identified, the associated pooled SMDs indicate a small
effect (0.28 and 0.33, respectively). Therefore, whilst a
pronated foot posture may provide an indication of in-
jury risk, other factors should also be considered. Both
MTSS and patellofemoral pain are considered to have a
multi-factorial etiology [54,55]. It is important that clini-
cians consider additional established risk factor variables
such as altered hip kinematics [3,56], increased body
Figure 4 Forest plot detailing SMD for patellofemoral pain.
Figure 5 Forest plot detailing RR for patellofemoral pain.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 9 of 13
http://www.jfootankleres.com/content/7/1/55
mass index [1] and limited running experience [54] in
evaluating possible risk factors.
Another possible reason for the limited relationship bet-
ween foot posture and injury risk may be the limitation of
static measures to predict dynamic function. This has
been the subject of much research, with differing conclu-
sions drawn regarding any association; seemingly depen-
ding upon the static measure implemented [57-60]. Static
measures of navicular height are not strongly correlated
with dynamic navicular motion [61] and although the FPI
has been shown to correlate with dynamic measures of
foot function, the strength of this correlation has varied
from weak to strong [62,63]. Additionally, Barton et al.
[64] found that dynamic measures were predictive of foot
orthoses outcomes in patellofemoral pain whilst static
measures of foot posture were not. Dynamic measures of
foot function may well have a stronger relationship and as
such may be of greater priority during clinical exami-
nation. This is explored in the accompanying dynamic re-
view [14], which indicates plantar loading variables are
risk factors for both patellofemoral pain and Achilles
tendinopathy.
Limitations and recommendations for future research
Not all studies eligible for inclusion in the current sys-
tematic review provided data suitable for meta-analysis,
and obtaining this through corresponding author contact
was unsuccessful in all instances. Therefore, the meta-
analysis did not encompass all potentially available data,
reducing confidence in its results. Complete reporting of
all available data (i.e. group means, standard deviations,
as well as participant numbers) in future prospective
studies evaluating the potential risk of foot posture to
lower limb injury is encouraged to facilitate future meta-
analyses.
The average methodological quality of studies in this
review was moderate, suggesting a dearth of high quality
research in this area. Less than 50% of the studies
included in this review [33,36,37,39,43,48] reported the
reproducibility of their outcome measures; a metho-
dological limitation that should be addressed in future
research. Additionally, many studies failed to estimate
their sample size based on a power calculation, cite
validity and reliability data for injury determinant, or ad-
equately adjust for covariates. Unfortunately, this further
reduces the confidence in the results of our meta-
analysis, but these methodological issues were taken into
account during the allocation of ?levels of evidence?for
each finding. Future studies should seek to improve
upon the above limitations, as it will increase the
strength of evidence than can be recommended.
Length of follow up varied greatly (eight weeks to three
years), which may have an impact on injury rates and thus
may affect the validity of data pooling. Future studies
should seek to employ a longer duration of follow up with
consideration of multiple time points to facilitate com-
parison between trials. An additional consideration related
to data pooling is the variation in populations studied
(e.g. military and running athletes), which affect loa-
ding volumes and subsequent injury risk. Nonetheless,
Figure 6 Forest plot detailing SMD for foot and ankle injury.
Figure 7 Forest plot detailing SMD for non-specific lower limb overuse injury.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 10 of 13
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considering the paucity of research currently available,
it was felt that the pooling conducted was valuable to
strengthen findings of the review. Only studies from
sporting and military populations were found to be eli-
gible and future studies investigating the impact of foot
posture on injury risk in other occupational settings is
warranted to determine the generalizability of these
findings to other populations.
The majority of findings in this review indicating a link
between foot posture and lower limb injury risk, found a
more pronated foot type to be associated with increased
risk. Interestingly, one of the included studies containing
insufficient data for meta-analysis reported on supinated
foot postures and injury risk [45], reporting that a supi-
nated foot type based on the FPI is a risk factor for foot
and ankle injury. Considering these findings, it is recom-
mended future studies consider categorising individuals
with supinated foot postures to evaluate the potential
link between this foot posture and increased injury risk.
This would allow similar reviews and appropriate meta-
analysis to evaluate the potential link between a supi-
nated foot posture and injury risk.
To improve the clinical applicability of results achieved,
future studies should seek to describe participants in rela-
tion to both intrinsic (e.g. body mass index) and extrinsic
(e.g. footwear) covariates and report risk factor statistics
based on combining static foot posture data with such co-
variates. In comparison to nominal scaled outcome mea-
sures, continuous scaled outcome measures appear to be
stronger predictors of injury development, particularly in
relation to a pronated foot posture. However, because it is
simpler to relate injury risk to a defined value, nominal
scaled measures may be more applicable when screening
for injury risk in clinical practice. Future studies that use
both continuous scaled and nominal scaled data from an
outcome measure (where possible) may be useful in this
regard, to allow for both statistical and clinical conclusions
to be reached.
Conclusions
Strong and very limited evidence indicates that a pro-
nated foot posture increases the risk of MTSS and patel-
lofemoral pain, respectively. However, this relationship is
of small effect, indicating that a pronated foot posture
may only be a minor component of the injury risk pro-
file for these conditions. Foot posture was not found to
be associated with the risk of foot and ankle injury, bone
stress reactions or a pooled group of non-specific lower
limb overuse injuries, although caution with inter-
pretation is needed here since only very limited to
limited evidence exists. Of the measures used in the cur-
rently available prospective research, it appears that
navicular drop and FPI can predict lower limb overuse
injury, however dynamic measures of foot function may
display stronger relationships with injury risk. Static
measures of foot posture should be used as part of a
multifactorial injury risk assessment and not considered
in isolation.
Additional files
Additional file 1: PRISMA statement checklist.
Additional file 2: Search strategy.
Additional file 3: Epidemiological Appraisal Instrument used to rate
the quality of the 21 included studies.
Additional file 4: Results from quality assessment using the
Epidemiological Appraisal Instrument (21 included studies).
Competing interests
The authors declare that they have no competing interests.
Authors?contributions
GSM, MMFS, BSN, IBG, CJB, SEM and NJC conceived the idea for this review.
GSM, MMFS, BSN, IBG designed and piloted the search strategy. GJD
undertook the search. Title and abstracts were reviewed by BSN and IBG.
Quality appraisal was undertaken by BSN and IBG. Study information
extracted by BSN and IBG. Data was extracted and meta-analysis was
completed by BSN and CB. The manuscript was drafted by BSN, IBG, CJB,
GJD, GSM, MMFS, SEM and NJC. All authors have read and approved the final
manuscript.
Author details
1
Pure Sports Medicine, London, UK.
2
Centre for Sports and Exercise Medicine,
Queen Mary University of London, London, UK.
3
Department of Podiatry,
Faculty of Health Sciences, La Trobe University, Melbourne, Australia.
4
Lower
Extremity and Gait studies program, Faculty of Health Sciences, La Trobe
University, Melbourne, Australia.
5
School of Physiotherapy, Australian Catholic
University, Brisbane, Australia.
6
Department of Mechanical Engineering,
Melbourne School of Engineering, The University of Melbourne, Melbourne,
Australia.
7
Complete Sports Care, Melbourne, Australia.
Received: 27 August 2014 Accepted: 30 November 2014
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Cite this article as: Neal et al.:Foot posture as a risk factor for lower
limb overuse injury: a systematic review and meta-analysis. Journal of
Foot and Ankle Research 2014 7:55.
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... Human foot posture can be classified according to whether an individual has normal (neutral-arched), pronated (low-arched, flat or pes planus), or supinated (higharched or pes cavus) feet [1]. Pronated or supinated feet are associated with altered lumbosacral alignment and function in the lower extremity, according to the joint coupling and closed-kinematic chain model [2][3][4]. Furthermore, pronated or supinated feet have been recognised as a predisposing factor for exercise-related lower limb injuries and chronic nonspecific low back pain [2][3][4]. Therefore, a screening assessment of foot posture should be conducted in asymptomatic individuals. ...
... Pronated or supinated feet are associated with altered lumbosacral alignment and function in the lower extremity, according to the joint coupling and closed-kinematic chain model [2][3][4]. Furthermore, pronated or supinated feet have been recognised as a predisposing factor for exercise-related lower limb injuries and chronic nonspecific low back pain [2][3][4]. Therefore, a screening assessment of foot posture should be conducted in asymptomatic individuals. This will lead to knowledge of selecting appropriate shoes for each individual, as well as exercise programs or foot orthoses for pronated or supinated feet to prevent sportsrelated lower limb injuries and low back pain. ...
... Based on the anatomical alignment and/or anthropometrics of the foot, clinical non-radiographic measurement methods and parameters have been developed and commonly used to classify static foot posture and establish foot-related musculoskeletal disorders in clinics and research studies [1,4,5]. Reliability and validity studies have approved of such methods and parameters [6][7][8]. ...
Full-text available
Article
Background Various clinical measures of static foot posture have been developed and used. However, consensus among clinical measures to classify foot posture remains to be established. Therefore, this study aimed to determine the level of agreement as a reliability component between two common clinical methods in asymptomatic adults: the normalised navicular height truncated (NNHt) and the Foot Posture Index-6 (FPI-6). Methods The NNHt and FPI-6 were conducted on 102 asymptomatic adults. The measurement sequence was randomly arranged for each participant. Weighted Kappa (Kw) was used to determine the agreement between the methods. Results Both the NNHt and FPI-6 achieved similar foot posture distributions: approximately 40–50% of the participants had a normal foot, approximately 40% had a pronated foot and approximately 10–20% had a supinated foot. The agreement between the methods to classify foot posture was excellent (Kw = 0.84). Conclusions The present study found excellent agreement between two commonly used clinical measures. This finding highlights the NNHt and FPI-6 consensus for foot posture classification in asymptomatic adults.
... 37 A symptomatic flatfoot has been associated with an increased prevalence of lower extremity disorders such as Achilles tendinopathy, patellofemoral pain syndrome, and/or knee osteoarthritis. 11,17,21,38 In these studies, the higher prevalence of lower extremity disorders in individuals with flatfoot were associated with changes in lower extremity alignment such as internal rotation of the tibia and femur, varus knee alignment, talonavicular abduction, and subtalar eversion during locomotion. 11,12,17,19,21,22,32,38 In theory, changes in lower extremity alignments change the load distribution on related structures, and it causes morphologic adaptation on related structures. ...
... 11,17,21,38 In these studies, the higher prevalence of lower extremity disorders in individuals with flatfoot were associated with changes in lower extremity alignment such as internal rotation of the tibia and femur, varus knee alignment, talonavicular abduction, and subtalar eversion during locomotion. 11,12,17,19,21,22,32,38 In theory, changes in lower extremity alignments change the load distribution on related structures, and it causes morphologic adaptation on related structures. There are limited studies investigating the differences in morphology of tendons and cartilage in lower extremity in asymptomatic individuals with flatfoot. ...
... 20,36 Consequently, this may result in decreased loads on the Achilles tendon and adaptive changes in the Achilles tendon thickness. 21 On the other hand, a thinner Achilles tendon could increase predisposition to Achilles tendon pathologies in individuals with flatfoot. 3,35 Further studies are needed to investigate whether nonpathologic tendon thickness is associated with injury risk. ...
Article
Background: Changes in lower extremity alignment in individuals with flatfoot may be associated with differences in morphology of the tendons or cartilage in lower extremities. The purpose of the present study was to investigate the potential association of flatfoot with the morphology of the Achilles tendon, patellar tendon, and femoral cartilage. Methods: This study was conducted with 40 participants with flatfoot (28 females, 12 males) and 40 participants with a normal foot posture (28 females, 12 males). The thickness of the Achilles tendon (at points 2 and 3 cm proximal to the superior aspect of the calcaneus), patellar tendon (at the inferior pole of the patella and 1 cm proximal of the inferior pole of the patella), and femoral cartilage (at the intercondylar area, medial condyle, and lateral condyle) was measured by an ultrasonography device. Results: The Achilles tendon thickness at 2 cm (P = .009) and 3 cm (P = .010) proximal of the superior aspect of the calcaneus was on average 4% to 6% lower in individuals with flatfoot compared with controls. The cartilage thickness at the intercondylar area (P = .005) and medial condyle (P = .018) was on average 8% to 12% greater in individuals with flatfoot; however, the cartilage thickness at the lateral condyle and patellar tendon thickness was similar in both groups. Conclusion: The results obtained suggest that foot posture is associated with the morphology of the Achilles tendon and femoral cartilage.
... De nombreuses variations anatomiques ont été incriminées comme facteurs de risque pour les pathologies du complexe cheville-pied (68)(172) (259). Certains profils biomécaniques pourraient entraîner des contraintes anormales sur les structures neuromusculo-squelettiques au niveau du pied (86). ...
... De nombreuses variations anatomiques ont été incriminées comme facteurs de risque pour les pathologies du complexe cheville-pied (68)(172) (259). Certains profils biomécaniques pourraient entraîner des contraintes anormales sur les structures neuromusculo-squelettiques au niveau du pied. ...
Thesis
INTRODUCTION : In the military environment, the function of the foot is constrained by the daily wearing of combat boots, a veritable orthopedic brace. A significant segment of the military population reports shoe-related foot disorders and pain, but there is little research evaluating the effects of military footwear on the development of these disorders, both internationally and in the Algerian context. The main objective of this work was to evaluate the effects of regular wearing of Rangers type military footwear on the soldier's foot, by studying the incidence of musculoskeletal and skin disorders affecting the ankle-foot complex during a 12-month follow-up period, and by comparing foot health status before and after wearing military footwear. SUBJECTS AND METHODS : This is a prospective study of the longitudinal type on a population of young male adults following their training in a military school in the south-east of Algeria. These new recruits were observed for a period of twelve months with regular wearing of Rangers type military footwear. This follow-up period extends from T0 to T12 knowing that T0 corresponds to the date of incorporation, and T12 corresponds to twelve months after the start of military training. During this period, we recorded all the cases consulting for a problem of the foot or the ankle, on a register created especially for this purpose. Foot status was analyzed at T0 and at T12 using three evaluation methods : clinical, podoscopic and functional. The footprint taken by the electronic podoscope was analyzed by calculating the Chippaux Smirak Index (CSI) and measuring the Alpha angle (α) of hallux valgus and the Beta angle (ß) of quintus varus of the two feet. To assess the functional impact, we opted for the use of the scale "Lower Extremity Functional Scale" in its Arabic version (LEFS-Ar). Furthermore, a comparative analysis before after wearing the shoe was carried out for the different parameters studied. RESULTS : 426 soldiers are participating in this study, of which 384 have completed all stages of the protocol. In this young adult population (mean age = 19.5 ± 0.89 years), the cumulative incidence of all foot and ankle disorders was estimated at 80.5%. The incidence of musculoskeletal disorders is higher than that of dermatological disorders (64.6% versus 38.5%). The main risk factors retained are footwear mismatch, obesity, lower limb misalignments, lower limb previous injuries, and anatomical shape of the foot. Abstract The comparison of foot statue before and after wearing combat boots (T0/T12) showed a significant upward trend in the prevalence of the majority of foot disorders. This difference concerns the musculoskeletal disorders such as hallux valgus, quintus varus, claw toes and overlapping toes, and the dermatological disorders such as corns, calluses, blisters, wounds, and onychodystrophies. Comparative analysis of the T0/T12 footprint indicates a significant increase in the CSI (p < 0.001), the Alpha angle (α) of hallux valgus on the left foot (p < 0.005), and the Beta angle (ß) quintus varus on both feet (p < 0.001). Regarding the evolution of the functional state from T0 to T12, we observe a very significant regression (p < 0.005) in the LEFS-Ar score. DISCUSSION & CONCLUSION: These results confirm that podiatric disorders remain fairly common among military personnel. Its frequency seems to worsen with the wearing of Rangers type military footwear. These epidemiological data, obtained in a completely original way, can help in the planning of future prevention interventions. Keywords: Military footwear, foot deformities, musculoskeletal disorders, footprint, Chippaux Smirak Index, Lower Extremity Functional Scale, Algeria
... Flexible flatfoot predisposes to other conditions, such as low back pain, patellofemoral pain syndrome, Achilles tendinopathy, plantar fasciitis, medial tibial stress syndrome, and knee osteoarthritis [8,9]; so, it would be essential to be considered in the assessment and causative management of these musculoskeletal conditions as well. Furthermore, healthy people and athletes should notice foot and ankle deformations like the flexible flatfoot to prevent daily and sports injuries. ...
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PurposeThe purpose of the study is to compare the effectiveness of the tibialis posterior Kinesio taping and fibularis longus Kinesio taping on the foot posture, physical performance, and dynamic balance in young women with flexible flatfoot.Methods Twenty-four subjects were recruited for the study. They were randomly divided into groups (A = 12, B = 12). In group A, Kinesio taping was applied on the tibialis posterior, and in group B, Kinesio taping was applied on the fibularis longus and remained for 30 min. Outcome measures were the navicular drop test (NDT), foot posture index (FPI), timed up and go (TUG) test, and Y-balance test. The pre- and post-treatment results were compared for each group; between-group differences were determined as well.ResultsFor group A, NDT, FPI, and TUG test changed significantly (P = 0.01, P = 0.001, P = 0.006, respectively). For group B, the FPI score decreased (P = 0.03), and the Y-balance test in the anterior direction improved significantly (P = 0.01). Any variables have not shown a significant difference between groups (P > 0.05).Conclusion Kinesio taping of the tibialis posterior and fibularis longus can improve foot posture in young women with flexible flatfoot. Also, physical performance and dynamic balance improved by Kinesio taping of the tibialis posterior and the fibularis longus, respectively. In addition to the tibialis posterior, we found that the fibularis longus muscle can be considered a therapeutic target for managing flexible flatfoot in healthy young women.
... The MLA is critical for shock absorption and propulsion during movement [2], and its dysfunction Open Access *Correspondence: shunto@waseda.jp 2 Faculty of Sport Sciences, Waseda University, 2-579-15 Mikajima, Tokorozawa, Saitama 359-1192, Japan Full list of author information is available at the end of the article Page 2 of 10 Hikawa et al. BMC Sports Science, Medicine and Rehabilitation (2022) 14:193 can result in chronic sports disorders such as medial tibial stress syndrome and plantar fasciitis [3,4]. Flat foot rehabilitation is an important treatment option. ...
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Background A flat foot is a common cause of chronic sports injuries and therefore many opportunities for arch support interventions exist. However, young athletes change their foot morphology due to developmental influences even without intervention. Therefore, developmental influences need to be considered when examining the effects of arch support, but there have not been sufficient longitudinal studies to date. This study aimed to determine the effect of the arch support intervention by performing a 9-weeks arch support intervention on the foot morphology and cross-sectional area of the foot muscles in flat-footed young athletes. Thirty-one elementary school boys (Age 11.4 ± 0.5 years, Height 145.2 ± 7.4 cm, Weight 38.8 ± 8.3 kg, BMI 18.2 ± 2.2 kg/m²) with a decreased medial longitudinal arch in the foot posture index were selected as participants from a local soccer club and randomly divided into two groups. Methods In one group, in the intervention period, an existing arch supporter was used to provide arch support, while in the other group, no special intervention was provided in the observation period. To account for developmental effects, the intervention study was conducted as an 18-weeks crossover study in which the intervention and observational phases were switched at 9 weeks after the intervention. Foot morphology was assessed using a three-dimensional foot measuring machine, and the cross-sectional area (CSA) of the internal and external muscles of the foot was assessed using an ultrasound imaging device. We examined the effect of the intervention by comparing the amount of change in the measurement results between the intervention and observation periods using corresponding t-tests and Wilcoxon signed-rank sum test, analysis of covariance methods. Results After adapting the exclusion criteria, 14 patients (28 feet) were included in the final analysis. The CSA of the abductor hallucis muscle (ABH) increased 9.7% during the intervention period and 3.0% during the observation period (p = 0.01). The CSA of the flexor digitorum longus muscle (FDL) increased 7.7% during the intervention period and 4.2% during the observation period (p = 0.02). Conclusion A 9-weeks arch supporter intervention may promote the development of the ABH and FDL CSA in young flat-footed soccer players.
... FFF patients were shown to have thicker plantar fascia and significantly higher rates of plantar fasciitis [7]. Additionally, low arch height and over-pronated mid-and hindfoot-related tibia internal rotation will cause knee joint valgus [8,9], thus increasing the patellofemoral joint contact force [9], which may result in patellofemoral joint pain [10] and patella tendinopathy [11]. Meanwhile, increased knee valgus moment will cause higher joint contact force, accelerate knee joint lateral compartment cartilage wear, and increase the risk of knee joint valgus osteoarthritis [12][13][14]. ...
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Insoles play an important role in the conservative treatment of functional flat foot. The features of 3D-printed insoles are high customizability, low cost, and rapid prototyping. However, different designed insoles tend to have different effects. The study aimed to use 3D printing technology to fabricate three different kinds of designed insoles in order to compare the biomechanical effects on the lower extremities in flat foot participants. Ten participants with functional flat foot were recruited for this study. Data were recorded via a Vicon motion capture system and force plates during walking under four conditions: without insoles (shoe condition), with auto-scan insoles (scan condition), with total contact insoles (total condition), and with 5-mm wedge added total contact insoles (wedge condition). The navicular height, eversion and dorsiflexion angles of the ankle joint, eversion moment of the ankle joint, and adduction moment of the knee joint were analyzed, and comfort scales were recorded after finishing the analysis. Compared to the shoe condition, all three 3D printed insoles could increase the navicular height and ankle dorsiflexion angle and improve comfort. Among the three insoles, the wedge condition was the most efficient in navicular height support and increasing the ankle dorsiflexion angle.
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Current narrative review has explored known associations between foot shape, posture, and foot conditions during running. The arch index was found as a useful metric of foot posture but less useful in developing and obese individuals. Care shall be taken when using foot posture index to associate pronation with injury risk, and Achilles Tendon angle and longitudinal arch angle is needed to elucidate risk. Statistical shape modelling (SSM) may derive learnt information from population-based inference and fill in missing data from personalised information. Bone shapes and tissue morphology have been associated with pathology, gender, age, and height and may develop rapid population-specific foot classifiers. Based on this review, future studies are suggested to conduct around, 1) tracking the internal multi-segmental foot motion and mapping the biplanar 2D motion to 3D shape motion with SSM; 2) implementing multivariate machine learning or convolutional neural network to address non-linear correlations in foot mechanics with shape or posture; 3) standardizing wearable data for rapid prediction of instant mechanics, load accumulation, injury risks and adaptation in foot tissue and bones, and correlation with shapes; 4) analysing dynamic shape and posture via marker-less and real-time techniques under real-life scenarios for precise evaluation of clinical foot conditions and performance-fit footwear development.
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Insoles with an arch support have been used to address biomechanical risk factors of running. However, the relationship between the dose of support and running biomechanics remains unclear. The purpose of this study was to determine the effects of changing arch support doses on the center of pressure (COP) and pressure mapping using statistical parametric mapping (SPM). Nine arch support variations (3 heights * 3 widths) and a flat insole control were tested on fifteen healthy recreational runners using a 1-m Footscan pressure plate. The medial-lateral COP (COP ML) coordinates and the total COP velocity (COPV total) were calculated throughout the entirety of stance. One-dimensional and two-dimensional SPM were performed to assess differences between the arch support and control conditions for time series of COP variables and pressure mapping at a pixel level, respectively. Two-way ANOVAs were performed to test the main effect of the arch support height and width, and their interaction on the peak values of the COPV total. The results showed that the COPV total during the forefoot contact and forefoot push off phases was increased by arch supports, while the COP medial-lateral coordinates remained unchanged. There was a dose-response effect of the arch support height on peak values of the COPV total , with a higher support increasing the first and third valleys but decreasing the third peak of the COPV total. Meanwhile, a higher arch support height shifted the peak pressure from the medial forefoot and rearfoot to the medial arch. It is concluded that changing arch support doses, primarily the height, systematically altered the COP velocities and peak plantar pressure at a pixel level during running. When assessing subtle modifications in the arch support, the COP velocity was a more sensitive variable than COP coordinates. SPM provides a high-resolution view of pressure comparisons, and is recommended for future insole/footwear investigations to better understand the underlying mechanisms and improve insole design.
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Background Prefabricated and customized insoles are used in clinical practice to reduce foot pronation. Although data exist on the effects at key points within the stance phase, exploring the impact of different insoles using time series analysis may reveal more detail about their efficacy. Research question What are the effects revealed by a time series analysis of arch-supported prefabricated insoles (PREFABRICATED) versus arch-supported prefabricated insoles customized with a 6º medial wedge (CUSTOMIZED) on the lower limb biomechanics during walking, stepping up and down tasks in individuals with pronated feet? Methods Nineteen individuals with excessive foot pronation performed walking, stepping up and down tasks using three insoles: CONTROL (flat insole), CUSTOMIZED, and PREFABRICATED. Angles and moments of ankle and knee coronal and hip transverse planes were compared between conditions using statistical parametric mapping (SPM). Results For walking, CUSTOMIZED reduced ankle eversion moment compared to CONTROL during midstance and PREFABRICATED during propulsion. CUSTOMIZED decreased KAM during midstance and propulsion compared to PREFABRICATED. Compared to CONTROL, CUSTOMIZED and PREFABRICATED reduced hip internal rotation during propulsion and loading response, respectively. CUSTOMIZED decreased eversion movement during midstance and propulsion for the stepping up task. PREFABRICATED reduced eversion movement during midstance in comparison to CONTROL. For the stepping down task, CUSTOMIZED increased eversion movement during propulsion compared to PREFABRICATED. CUSTOMIZED reduced hip internal rotation angle for stepping up task during propulsion, decreased medial rotation movement during midstance compared to CONTROL, and reduced medial rotation during midstance compared to PREFABRICATED. CUSTOMIZED increased KAM for stepping up and down tasks during propulsion. Significance These findings suggest that both CUSTOMIZED and PREFABRICATED reduce foot pronation. However, non-local effects, such as changes in KAM and hip internal rotation, were seen only in the CUSTOMIZED. Therefore, CUSTOMIZED may be preferable if the objective is to modify the knee and hip mechanics.
Conference Paper
The internal forces and stresses in the tissue are important as they are linked to the risk of mechanical trauma and injuries. Despite their value, the internal stresses and forces cannot be directly measured in-vivo. A previously validated 3D finite element model (FEM) was constructed using Magnetic Resonance Imaging (MRI) of a person with diabetes and hammer toe deformity. The foot model simulated at five different instances during the stance phase of gait. The internal stress distribution on the talus that was obtained using the FEM simulation, was used to calculate the joint reaction force at the ankle joint. In addition, the musculoskeletal model (MSM) of the participant with hammer toe foot was developed based on the gait analysis and was used to determine the muscle forces and joint reactions. The result showed that the vertical reaction forces obtained from the FEM and MSM follow a similar trend through the stance phase of gait cycle and are significantly correlated (R=0.99). The joint reaction forces obtained through the two methods do not differ for the first 25% of the gait cycle, while the maximum difference was ~0.7 Body weight that was observed at 50% of the stance phase. Clinical Relevance: Finite element modeling and musculoskeletal simulation can shed light on the internal forces in the ankle in pathological conditions such as hammer toe. The similarities and differences observed in the joint reaction forces calculated from the two methods can have implications in assessing the interventions in a clinic.
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Dynamic foot function is considered a risk factor for lower limb overuse injuries including Achilles tendinopathy, shin pain, patellofemoral pain and stress fractures. However, no single source has systematically appraised and summarised the literature to evaluate this proposed relationship. The aim of this systematic review was to investigate dynamic foot function as a risk factor for lower limb overuse injury. A systematic search was performed using Medline, CINAHL, Embase and SportDiscus in April 2014 to identify prospective cohort studies that utilised dynamic methods of foot assessment. Included studies underwent methodological quality appraisal by two independent reviewers using an adapted version of the Epidemiological Appraisal Instrument (EAI). Effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data. Twelve studies were included (total n = 3,773; EAI 0.44 to 1.20 out of 2.00, representing low to moderate quality). There was limited to very limited evidence for forefoot, midfoot and rearfoot plantar loading variables (SMD 0.47 to 0.85) and rearfoot kinematic variables (RR 2.67 to 3.43) as risk factors for patellofemoral pain; and plantar loading variables (forefoot, midfoot, rearfoot) as risk factors for Achilles tendinopathy (SMD 0.81 to 1.08). While there were significant findings from individual studies for plantar loading variables (SMD 0.3 to 0.84) and rearfoot kinematic variables (SMD 0.29 to 0.62) as risk factors for 'non-specific lower limb overuse injuries', these were often conflicting regarding different anatomical regions of the foot. Findings from three studies indicated no evidence that dynamic foot function is a risk factor for iliotibial band syndrome or lower limb stress fractures. This systematic review identified very limited evidence that dynamic foot function during walking and running is a risk factor for patellofemoral pain, Achilles tendinopathy, and non-specific lower limb overuse injuries. It is unclear whether these risk factors can be identified clinically (without sophisticated equipment), or modified to prevent or manage these injuries. Future prospective cohort studies should address methodological limitations, avoid grouping different lower limb overuse injuries, and explore clinically meaningful representations of dynamic foot function.
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Patellofemoral pain (PFP) is often seen in physically active individuals and may account for 25-40% of all knee problems seen in a sports injury clinic.1 ,2 Patellofemoral-related problems occur more frequently in women than in men.3 PFP is characterised by diffuse pain over the anterior aspect of the knee and aggravated by activities that increase patellofemoral joint (PFJ) compressive forces, such as squatting, ascending and descending stairs and prolonged sitting, as well as repetitive activities such as running. It, therefore, has a debilitating effect on sufferers’ daily lives by reducing their ability to perform sporting and work-related activities pain free. Dye has described PFP as an orthopaedic enigma, and it is one of the most challenging pathologies to manage.4 Alarmingly, a high number of individuals with PFP have recurrent or chronic pain.5 While physiotherapy interventions for PFP have proven effective compared with sham treatments, treatment results can be disappointing in a proportion of patients. This variability in treatment results may be due to the fact that the underlying factors that contribute to the development of PFP are not being addressed, or are not the same for all patients with PFP. The mission of the 3rd International Patellofemoral Research Retreat was to improve our understanding concerning the factors that contribute to the development and consequently to the treatment of PFP. The 3rd International Patellofemoral Research Retreat was held in Vancouver, Canada, in September 2013, for 3 days: from 18 September to 21 September. After peer-review for scientific merit and relevance to the retreat, 58 abstracts were accepted for the retreat (39 podiums, 8 posters and 11 thematic posters). The podium and poster presentations were grouped into three categories: (1) natural history of PFP and local factors that influence PFP, (2) trunk and distal factors that influence PFP and …
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Medial tibial stress syndrome (MTSS) affects 5%-35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners. Medical research databases were searched for relevant literature, using the terms "MTSS AND prevention OR risk OR prediction OR incidence". A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29-1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56-3.43, P<0.001); fewer years of running experience (SMD -0.74, 95% CI -1.26 to -0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15-2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17-11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08-0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02-0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00-3.96, P=0.05). Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.
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The present study analyzed the impact of the running style and the morphologic and functional characteristics of the foot on the incidence of non-traumatic foot and lower limb disorders in runners. From January 2004 to December 2008, we prospectively examined 166 runners, both recreational and competitive, involved in various running specialities, from three athletics clubs in Northern Italy. They were 86 males and 80 females, with a mean age of 31.1 ± 12.2 years. We considered nontraumatic foot and lower limb diseases reported during the follow-up period, which resulted in a minimum sport rest of two weeks. The incidence of these diseases was examined with respect to general characteristics, type of activity, foot morphology, running style. 59% of athletes reported one or more diseases. The most common were plantar fasciitis (31% of athletes) and Achilles tendinopathies (24%). Overall, the more prone to injuries were males (60.9% of cases), competitive runners (70.9%), middle-distance runners (51.7%), and those using spike shoes (80.3%). Age, body weight and height were not important predictors of running injuries in general. Considering the morphological characteristics of the foot, the most prone to injury were the varus hindfoot (87.5% of cases) and the cavus arch (71.4%). In conclusion, a deep knowledge of the factors predisposing runners to specific diseases, often chronic and highly debilitating for the athlete, may allow implementing effective therapeutic measures.
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Study design: Systematic literature review with meta-analysis. Objectives: To investigate the association between nonneutral foot types (high arch and flatfoot) and lower extremity and low back injuries, and to identify the most appropriate methods to use for foot classification. Methods: A search of 5 electronic databases (PubMed, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses), Google Scholar, and the reference lists of included studies was conducted to identify relevant articles. The review included comparative cross-sectional, case-control, and prospective studies that reported qualitative/quantitative associations between foot types and lower extremity and back injuries. Quality of the selected studies was evaluated, and data synthesis for the level of association between foot types and injuries was conducted. A random-effects model was used to pool odds ratio (OR) and standardized mean difference (SMD) results for meta-analysis. Results: Twenty-nine studies were included for meta-analysis. A significant association between nonneutral foot types and lower extremity injuries was determined (OR = 1.23; 95% confidence interval [CI]: 1.11, 1.37; P<.001). Foot posture index (OR = 2.58; 95% CI: 1.33, 5.02; P<.01) and visual/physical examination (OR = 1.17; 95% CI: 1.06, 1.28; P<.01) were 2 assessment methods using distinct foot-type categories that showed a significant association with lower extremity injuries. For foot-assessment methods using a continuous scale, measurements of lateral calcaneal pitch angle (SMD, 1.92; 95% CI: 1.44, 2.39; P<.00001), lateral talocalcaneal angle (SMD, 1.36; 95% CI: 0.93, 1.80; P<.00001), and navicular height (SMD, 0.34; 95% CI: 0.16, 0.52; P<.001) showed significant effect sizes in identifying high-arch foot, whereas the navicular drop test (SMD, 0.45; 95% CI: 0.03, 0.87; P<.05) and relaxed calcaneal stance position (SMD, 0.49; 95% CI: 0.01, 0.97; P<.05) displayed significant effect sizes in identifying flatfoot. Subgroup analyses revealed no significant associations for children with flatfoot, cross-sectional studies, or prospective studies on high arch. Conclusions: High-arch and flatfoot foot types are associated with lower extremity injuries, but the strength of this relationship is low. Although the foot posture index and visual/physical examination showed significance, they are qualitative measures. Radiographic and navicular height measurements can delineate high-arch foot effectively, with only anthropometric measures accurately classifying flatfoot. Level of evidence: Prognosis, level 2a.
Article
Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement-a reporting guideline published in 1999-there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (www.prisma-statement.org) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
Article
Objective To investigate if running distance to first running-related injury varies between foot postures in novice runners wearing neutral shoes. Design A 1-year epidemiological observational prospective cohort study. Setting Denmark. Participants A total of 927 novice runners equivalent to 1854 feet were included. At baseline, foot posture on each foot was evaluated using the foot-posture index and categorised into highly supinated (n=53), supinated (n=369), neutral (n=1292), pronated (n=122) or highly pronated (n=18). Participants then had to start running in a neutral running shoe and to use global positioning system watch to quantify the running distance in every training session. Main outcome measure A running-related injury was defined as any musculoskeletal complaint of the lower extremity or back caused by running, which restricted the amount of running for at least 1 week. Results During 1 year of follow-up, the 1854 feet included in the analyses ran a total of 326 803 km until injury or censoring. A total of 252 participants sustained a running-related injury. Of these, 63 were bilateral injuries. Compared with a neutral foot posture, no significant body mass index-adjusted cumulative risk differences (RD) were found after 250 km of running for highly supinated feet (RD=11.0% (−10% to 32.1%), p=0.30), supinated feet (RD=−1.4% (−8.4% to 5.5%), p=0.69), pronated feet (RD=−8.1% (−17.6% to 1.3%), p=0.09) and highly pronated feet (RD=9.8% (−19.3% to 38.8%), p=0.51). In addition, the incidence-rate difference/1000 km of running, revealed that pronators had a significantly lower number of injuries/1000 km of running of −0.37 (−0.03 to −0.70), p=0.03 than neutrals. Conclusions The results of the present study contradict the widespread belief that moderate foot pronation is associated with an increased risk of injury among novice runners taking up running in a neutral running shoe. More work is needed to ascertain if highly pronated feet face a higher risk of injury than neutral feet.