R E V I E W Open Access
Foot posture as a risk factor for lower limb
overuse injury: a systematic review and
Bradley S Neal
, Ian B Griffiths
, Geoffrey J Dowling
, George S Murley
, Shannon E Munteanu
Melinda M Franettovich Smith
, Natalie J Collins
and Christian J Barton
Please see related article: http://www.jfootankleres.com/content/7/1/53
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
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,
* Correspondence: email@example.com
Pure Sports Medicine, London, UK
Centre for Sports and Exercise Medicine, Queen Mary University of London,
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
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 , female sex  and altered
hip mechanics .
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 . 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 . 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 .
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
Two recent reviews have evaluated the relationship
between foot posture and lower extremity injury [11,12].
Tong and Kong  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  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  focused on dynamic
function, and did not include studies related to static
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.
The protocol for this systematic review was developed
using guidelines provided by the Preferred Reporting of
Systematic Reviews and Meta-Analysis (PRISMA) State-
ment  (Additional file 1).
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
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
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 2 of 13
paper . 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.
The Epidemiological Appraisal Instrument (EAI)  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 . 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 . 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) .
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.
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 . 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
statistics and asso-
ciated p values (heterogeneity defined as I
> 50%) .
Calculated individual or pooled SMDs were cate-
gorised as small (≤0.59), medium (0.60 to 1.19) or large
(≥1.20) . 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 . 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.
Based on previous work by van Tulder et al. , levels
of evidence were assigned for each foot posture measure
evaluated, incorporating statistical outcomes and metho-
dological quality of included studies.
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.
Statistically significant pooled results derived from mul-
tiple studies that are statistically heterogeneous, including
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 3 of 13
Table 1 Summary of study characteristics
Population Observation period
Injury outcome Injured group Uninjured group Foot posture measure
(mean ? SD)
(mean ? SD)
Bennett et al., 2001  Cross country runners 8 weeks Medial tibial stress
15 (13) 15.3 (?1.0) 21 (8) 15.7 (?1.5) Resting calcaneal position
Yates and White, 2004  Naval recruits 10 weeks basic training Medial tibial stress
40 (18) NR 84 (22) NR FPI-8
Burne et al., 2004  Military cadets 12 months Medial tibial stress
23 (11) NR 135 (25) NR Resting calcaneal position
Willems et al., 2006  Physical education students 12 months Medial tibial stress
46 (29) NR 354 (130) NR Resting calcaneal position
Reinking, 2006  Female collegiate athletes One athletic season Medial tibial stress
20 (20) NR 56 (56) NR Navicular drop
Reinking et al., 2007  Collegiate athletes One athletic season Medial tibial stress
60 (31) NR 28 (13) NR Navicular drop
Plisky et al., 2007  High school runners 13 weeks Medial tibial stress
16 (11) NR 88 (29) NR Navicular drop
Hubbard et al., 2009  Collegiate athletes One athletic season Medial tibial stress
29 (9) 19 (?0.98) 117 (72) 19.9 (?1.8) Navicular drop
Bennett et al., 2012  Cross country runners Cross country season Medial tibial stress
26 (13) NR NR 33 (15) Navicular drop
Yagi et al., 2013  High school runners 3 years Medial tibial stress
102 (44) NR 142 (54) NR Navicular drop
Hetresoni et al., 2006  Infantry recruits 14 weeks basic training Patellofemoral
61 (NR) NR 344 (NR) NR Resting calcaneal position
Thijs et al., 2008  Recreational runners 10 weeks Patellofemoral
17 (16) 39.4 (?10.3) 85 (73) 37.6 (?9.4) FPI-6
Boling et al., 2009  Naval recruits 1-2.5 years Patellofemoral
40 (16) NR 1279 (489) NR Navicular drop
Beynnon et al., 2001  Collegiate athletes One college season Foot/ankle injury 20 (13) NR 98 (55) NR Longitudinal arch angle
Cain et al., 2007  Male Futsal players One Futsal season Foot/ankle injury 33 (0) NR 43 (0) NR FPI-6
Winfield et al., 1997  Female marines 10 weeks basic training Bone stress
12 (12) NR 89 (89) NR Subtalar joint ROM
Kaufman et al., 1999  Male Navy Seal candidates 2 Years LL overuse injury 149 (0) NR 300 (0) NR Longitudinal arch angle
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 4 of 13
Table 1 Summary of study characteristics (Continued)
Burns et al., 2005  Triathletes 10 weeks LL overuse injury 37 (NR) NR 91 (NR) NR FPI-8
Rauh et al., 2010  Female marines 13 weeks LL overuse injury 104 (110) NR 644 (634) NR Longitudinal arch angle
Buist et al., 2010  Novice runners 13 weeks LL overuse injury 100 NR 476 NR Navicular drop
Nielsen et al., 2014  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.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 5 of 13
at least one high quality study; or from multiple moderate
quality or low quality studies which are statistically
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
Pooled results insignificant and derived from mul-
tiple studies regardless of quality that are statistically
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
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.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 6 of 13
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 . 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
Foot posture variables as risk factors for lower limb overuse
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  and triathletes
. 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% 
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 .
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
), with a small but significant pooled SMD (I
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
p= 0.51; small SMD 0.33, 0.05 to 0.61), and navicular
drop (Strong evidence; I
= 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).
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
), 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-
and increased risk of patellofemoral pain development
(RR 1.22, 0.73 to 2.02) (Figure 5).
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 ). One study provided data suitable for risk
ratio calculation  (Figure 6). Very limited evidence
from dichotomous measures (1 MQ ) 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 . This measured the gross total
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 7 of 13
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
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 , SMD ?0.50, ?2.28 to 1.28). Limited evi-
dence from dichotomous measures (1 HQ ) 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).
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.
Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 8 of 13
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
 and patellofemoral pain  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  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. ,
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) . 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.
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
mass index  and limited running experience  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  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.
 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 , which indicates plantar loading variables are
risk factors for both patellofemoral pain and Achilles
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-
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
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 , 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.
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
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).
The authors declare that they have no competing interests.
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
Pure Sports Medicine, London, UK.
Centre for Sports and Exercise Medicine,
Queen Mary University of London, London, UK.
Department of Podiatry,
Faculty of Health Sciences, La Trobe University, Melbourne, Australia.
Extremity and Gait studies program, Faculty of Health Sciences, La Trobe
University, Melbourne, Australia.
School of Physiotherapy, Australian Catholic
University, Brisbane, Australia.
Department of Mechanical Engineering,
Melbourne School of Engineering, The University of Melbourne, Melbourne,
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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Neal et al. Journal of Foot and Ankle Research 2014, 7:55 Page 13 of 13