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Runners are particularly prone to developing overuse injuries. The most common runningrelated injuries include medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, patellar tendinopathy, iliotibial band syndrome, tibial stress fractures, and patellofemoral pain syndrome. Two of the most significant risk factors appear to be injury history and weekly distance. Several trials have successfully identified biomechanical risk factors for specific injuries, with increased ground reaction forces, excessive foot pronation, hip internal rotation and hip adduction during stance phase being mentioned most oft en. However, evidence on interventions for lowering injury risk is limited, especially regarding exercise-based interventions. Biofeedback training for lowering ground reaction forces is one of the few methods proven to be effective. It seems that the best way to approach running injury prevention is through individualized treatment. Each athlete should be assessed separately and scanned for risk factors, which should be then addressed with specific exercises. This review provides an overview of most common running-related injuries, with a particular focus on risk factors, and emphasizes the problems encountered in preventing running-related injuries.
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Monten. J. Sports Sci. Med. 6 (2017) 2: 67–74 | UDC 796.412.5:613.64 67
Common Running Overuse Injuries and
Prevention
Žiga Kozinc1 and Nejc Šarabon1
Affiliations: 1University of Primorska, Faculty of Health Sciences, Izola, Slovenia
Correspondence: Nejc Šarabon, University of Primorska, Faculty of Health Sciences, Polje 42, 6310 Izola, Slovenia.
E-mail: nejc.sarabon@fvz.upr.si
ABSTRACT Runners are particularly prone to developing overuse injuries.  e most common running-
related injuries include medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, patellar
tendinopathy, iliotibial band syndrome, tibial stress fractures, and patellofemoral pain syndrome. Two of the
most signi cant risk factors appear to be injury history and weekly distance. Several trials have successfully
identi ed biomechanical risk factors for speci c injuries, with increased ground reaction forces, excessive
foot pronation, hip internal rotation and hip adduction during stance phase being mentioned most o en.
However, evidence on interventions for lowering injury risk is limited, especially regarding exercise-based
interventions. Biofeedback training for lowering ground reaction forces is one of the few methods proven
to be e ective. It seems that the best way to approach running injury prevention is through individualized
treatment. Each athlete should be assessed separately and scanned for risk factors, which should be then
addressed with speci c exercises.  is review provides an overview of most common running-related
injuries, with a particular focus on risk factors, and emphasizes the problems encountered in preventing
running-related injuries.
KEY WORDS Runners, Exercise, Pain, Risk factors, Injury mechanism, Preventive methods.
Introduction
Running is among most popular physical activities, which may be attributed to its accessibility, inexpensiveness
and numerous positive e ects. It has been shown, for example, to lower diabetes, hypertension and
hypercholesterolemia risk (Williams &  ompson, 2013).
Although being a non-contact, submaximal, and continuous activity, running nonetheless elicits a considerable
amount of injuries. Runners are particularly prone to sustaining overuse injuries, which occur due to frequent
submaximal strain and/or inadequate recovery of the tissues involved (DiFiori et al., 2014). Several risk factors
for developing running-related injuries have been investigated, and can be roughly divided into intrinsic
(e.g. individual’s abilities, anthropometric characteristics, and cognitive properties) and extrinsic (e.g. ground
surface, footwear and training load) (Johnston, Taunton, Lloyd-Smith, & McKenzie, 2003).
Various strategies for running injury prevention are applied by coaches and runners themselves (e.g.
stretching, warm-up, technique training). In this review, we will discuss the most common running injuries,
underlying mechanisms, risk factors, and preventative strategies.
Biomechanics of Running
In this chapter, we will brie y review some biomechanical properties of running, focusing on aspects and
parameters relevant to injury development and prevention.
Running cycle and joint kinematics
e running cycle consists of two fundamental phases: the stance phase and the swing phase. In kinematic
Accepted a er revision: May 13 2017 | First published online: September 01 2017
© 2017 by the author(s). License MSA, Podgorica, Montenegro.  is article is an open access article distributed under the
terms and conditions of the Creative Commons Attribution (CC BY).
Con ict of interest: None declared.
REVIEW ARTICLE
@MJSSMontenegro
RUNNING INJURY PREVENTION
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68 UDC 796.412.5:613.64
RUNNING INJURY PREVENTION | Ž. KOZINC & N. ŠARABON
analysis, the  rst contact with the ground (foot-strike) marks the beginning of the cycle for the leg (Anderson,
1996). From this point on, the muscles contract eccentrically to absorb landing forces.  e moment of transition
into concentric contraction and force generation is called “mid-stance” (also mid-support). Concluding the
stance phase is the point of take-o , the last instant of foot touching the surface. Joint positions, velocity, and
other kinematic variables are usually measured at these three crucial moments (Novacheck, 1998).
Most of the joint motion during the running cycle occurs in the sagittal plane.  e pelvic range of motion is
minimal (approximately 10°), which provides stability and e ciency (Novacheck, 1998). Hip range of motion
rarely exceeds 40° (Pink, Perry, Houglum, & Devine, 1994). Peak extension (around 10°) occurs at the take-o .
Typical peak hip  exion is around 30° (Nicola & Jewison, 2012).  e knee is  exed to 20-25° at the foot strike,
reaches 45°  exion in mid-stance and then extends to approximately 25° of  exion at take-o (Novacheck,
1998). In the case of striking heel- rst (which most long-distance runners do), there is up to 10° ankle
dorsi exion at foot strike, and some plantar  exion must happen initially. A erwards, the ankle moves into 20°
of dorsi exion during amortization and then into 20° plantar  exion during propulsion (Dugan & Bhat, 2005).
Abnormal kinematic parameters in the frontal plane (especially excessive ranges of motion) are most o en
linked to injury development. In the amortization phase, the pelvis drops to the side of the swing leg (generally
not over 10°) and then returns to a neutral position throughout the propulsion phase (Nicola & Jewison,
2012). To compensate for this, the trunk is  exed laterally, to the side of the stance leg. Hip abduction and
adduction both reach up to 10°. Peak adduction is achieved at the mid-stance, while peak abduction is the
highest at the middle of the swing phase (Novacheck, 1998).  e ankle is inversed (6 to 8°) at foot-strike, then
it moves to 8° of eversion through the amortization phase (Nicola & El Shami, 2012).  e eversion range of
motion during stance phase is the main determinant of the foot pronation. Anything over 9° of eversion is
considered moderate pronation, while 13° or more is labelled high pronation (Morley et al., 2010).
Horizontal movements are, like those in the frontal plane, smaller than sagittal movements (Novacheck, 1998).
Internal hip rotation and consequential knee valgus are most o en discussed in terms of injury development
(Powers, 2003). Horizontal knee and ankle motion are minimal in normal running kinematics (Nicola &
Jewison, 2012).
Muscle Work
e muscle activation pattern changes with running velocity and ground slope, yet the main force generators
remain the same. Hip extensors are active in the second part of the swing phase and throughout the stance
phase. Knee extensors, ankle plantar  exors, and hip abductors are active throughout the stance phase. Hip
exors propagate the leg forwards a er the take-o .  e glutes and the hamstrings pull the body forwards,
while quadriceps and ankle plantar  exors generate more of an upward force. As noted before, there is
an eccentric contraction occurring in the amortization phase. Muscles and tendons lengthen, absorbing
the forces of the landing. Due to elastic properties, tendons return up to 95% of the energy stored in the
amortization phase (Novacheck, 1998). Quadriceps seem to be the largest power contributor in amortization,
while the most work in propulsion phase is generated by plantar  exors (Hamner, Seth, & Delp, 2010).
Foot-strike problems
Ground reaction forces are a major concern in running. Several trials have been conducted to investigate
di erent interventions for minimizing these forces. Striking heel- rst is particularly problematic, as the  rst
part of the impact cannot be absorbed by the dorsi exors and is, therefore, transmitted to passive tissues
and muscles higher in the kinetic chain (Verdini, Marcucci, Benedetti, & Leo, 2006). Looking at force curve
(Figure 1), there are two peaks in the case of heel strike.  e height of the  rst peak should be as low as
FIGURE 1 Comparison of ground
reaction forces between heel strike
and forefoot strike technique
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RUNNING INJURY PREVENTION | Ž. KOZINC & N. ŠARABON
possible or even absent (which it is, in good running technique). Additionally, the average and the maximum
slope of the curve (rate of vertical loading) before the  rst peak should also be noted.  e reduction of all
these three parameters is the primary goal when discussing lowering ground reaction forces (Zadpoor &
Nikooyan, 2011). Striking heel- rst not only increases the mechanical stress; it also causes the loss of energy.
In the case of the proper technique, plantar  exors start to contract eccentrically immediately a er the  rst
touching the ground, and the energy absorbed is returned later in full amount.  e heel strike impedes this,
since some degree of plantar  exion must happen  rst so that the front of the foot also reaches the ground,
and some energy is lost (Novacheck, 1998).
Most common running injuries
Sport-related injuries are classi ed as acute (also traumatic) or chronic (also overuse). Acute injuries occur due
to sudden trauma (e.g. leg bone fracture caused by opponents’ foul in soccer or sudden hamstring tear during
sprinting). Chronic injuries develop gradually as a result of accumulating microtrauma, which is caused by
repeated submaximal strain (Roos & Marshall, 2014). Depending on the appearance of pain, chronic injuries
are further classi ed into four stages (McCarty, Walsh, Hald, Peter, & Mellion, 2010):
- Stage 1: Pain, present only a er activity;
- Stage 2: Pain, present during activity, not impairing performance;
- Stage 3: Pain, present during activity, impairing performance;
- Stage 4: Ceaseless pain, not receding even with rest
A recent meta-analysis showed an incidence of 2.5 injuries per 1000 hours of exposure in long-distance track
and  eld athletes. However, novice runners are at much higher risk, with an incidence of 33 injuries per
1000 hours of exposure (Videbaek, Bueno, Nielsen, & Rasmussen, 2015). Another review investigated the
incidence of individual injuries.  e highest incidence was reported for medial tibial stress syndrome (MTSS;
13.6-20.0%), Achilles tendinopathy (9.1-10.9%), patellar tendinopathy (5.5-22.7%), plantar fasciitis (4.5-
10.0%), ankle sprain (10.9-15.0%), iliotibial band syndrome (1.8-9.1%), hamstring injury (10.9%) and tibial
stress fracture (9.1%) (Lopes, Junior, Yeung, & Costa, 2012). In ultra-distance runners, Achilles tendinopathy
and patellofemoral syndrome (PFS) are most common.  e relatively low reported incidence of the latter
(5.5%) was based on only one study in this review.
Medial tibial stress syndrome
Also commonly referred to as shin splints, MTSS is especially prevalent in military personnel (Sharma,
Weston, Batterham, & Spears, 2014), yet also frequent in runners. It is loosely de ned as a pain on the inner
side of the tibia.  e pain is di use and not localized, as in tibial stress fractures.  e onset of MTSS usually
happens in the early stages of the season, or anytime the volume and intensity of training increases suddenly
(Putukian, McCarty, & Sebastianelli, 2010).  e pain is worsened by exercise.
e exact mechanism for developing MTSS is still to be determined. Most textbooks state that the pain
originates from the periosteum along the medial tibia. Several trials have been conducted in order to link
a speci c muscle to MTSS.  e con icting evidence gathered has led to mixed opinions among experts
(Franklyn & Oakes, 2015). However, we know more about risk factors. Increased hip external rotation during
the stance phase (in males only), higher body mass index, prior use of orthotics, navicular drop (indicator
of resting foot pronation) and fewer years of training experience were all linked to higher risk for sustaining
MTSS (Newman, Witchalls, Waddington, & Adams, 2013). Interestingly, females are at higher risk than males
are. Newman and colleagues (2013) pointed out that this may indicate a bone-related mechanism behind
MTSS development, since women have been shown to have lower bone mineral density.
Treatment of MTSS is dependent on the severity of the injury. Rest alone can cure most cases. Athletes are
recommended to participate in cross-training activities that do not overload the area (e.g. swimming) in
order to maintain their  tness until the injury ceases.  ey should then return to running and running-
involving activities gradually. Some may bene t from stretching, if there are de cits in the range of motion.
Implementation of proprioceptive training and ankle strengthening exercises is also encouraged (Galbraith
& Lavallee, 2009).
Tendon injuries
Terminology on tendon injuries is inconsistent and o en confusing. Tendinopathy is an umbrella term,
describing painful conditions in tendons and surrounding areas due to overuse (Rees, Ma ulli, & Cook, 2009).
Other terms should be used a er histopathological con rmation. Tendinitis is an injury with accompanying
in ammation of the tendon (Andres & Murrell, 2008). Tendinosis is de ned as a degenerative injury of the
tendon with no or few in ammation cells present. Along with changes in the collagen matrix, there is an
increased vessel and nerve ingrowth (Ackermann & Renstrom, 2012). Other conditions a ecting the tendon
include tenosynovitis (in ammation of tendon’s synovia (a tendon’s sheath)) and peritendinitis (in ammation
of muscle-tendon junction and paratendon (the tissue  lling the interstices of the fascial compartment in
which a tendon is situated)) (Kurppa, Waris, & Rokkanen, 1979). Age and gender, among others, seem to be
important risk factors for sustaining a tendinopathy, with males and the elderly being at higher risk (Rees et
al., 2009).
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RUNNING INJURY PREVENTION | Ž. KOZINC & N. ŠARABON
Achilles tendinopathy is most prevalent among runners. It is further classi ed into two major categories based
on location: insertional and non-insertional. Patellar tendinopathy is sometimes called jumper’s knee, since it is
common in sports involving frequent jumping (e.g. volleyball, basketball). However, it is also common in runners.
Several biomechanical risk factors have been linked to development of both aforementioned conditions.  ese
include unequal leg length, poor plantar  exor  exibility, strength imbalances, sudden changes in training
load, inappropriate footwear, poor running technique and excessive foot pronation during stance phase, with
the latter perhaps being the most signi cant in Achilles tendinopathy. In patellar tendinopathy, the volume
of training (particularly the volume of jumping tasks) seems to play a much bigger role (Rutland et al., 2010).
Plantar fasciitis
Plantar fasciitis is one of the most common causes of pain in the foot. In the general population, it is most
frequent at ages 40-60, whereas runners are at the greatest risk at younger ages. Pain is usually limited to
the posterior part of the foot, under the heel. It is exacerbated while taking the  rst few steps a er longer
inactivity (Waclawski, Beach, Milne, Yacyshyn, & Dryden, 2015).  e origin of the pain is the plantar fascia, a
connective tissue spanning from the inferior surface of the calcaneus towards the bones in the front of the foot.
It was thought that plantar fasciitis is caused by the in ammation of the fascia. Today, the majority of experts
believe that degenerative changes are responsible for the onset of injury. A study by Lemont, Ammirati, and
Usen (2003) showed an absence of in ammation in samples collected during plantar fasciitis surgery. As with
tendinopathies, the dilemma of in ammation versus degenerative changes is not entirely closed, but does lean
to the degeneration theory side.
Knowledge of the predictors for sustaining plantar fasciitis is limited. A recent meta-analysis found only an
increased body mass index to postulate a higher risk. Other frequently listed risk factors include excessive
foot pronation during the stance phase, high foot arch and tight Achilles tendon (Go & Crawford, 2011).
Many interventions for treating plantar fasciitis have been advocated, but few have been proven e ective.
Stretching of the Achilles tendon and plantar fascia is generally a good idea, along with strengthening calf
muscles. Other non-surgical treatment options are corticosteroid injections, plantar iontophoresis, and
extracorporeal shock wave therapy (Molloy, 2012).
Iliotibial band syndrome
Iliotibial band (ITB) syndrome is an injury o en associated with running, though it is also common in
cycling, weight li ing, skiing, and soccer (Lucas, 1992). ITB is a connective tissue on the lateral aspect of the
leg, extending from the pelvis to the knee, entering the lateral tibial condyle. It encompasses the m. tensor
fascia latae and is connected to the muscles of the gluteal region and to the lumbar fascia.  e pain in ITB
syndrome is present around the lateral side of the distal femur, between the lateral femoral condyle and ITB.
ITB syndrome was strongly believed to be caused by repeated rubbing of the band over the lateral femoral
epicondyle during  exion-extension cycle, which would cause in ammation of the local bursa or the band
itself. In the past decade, several authors have expressed disagreement with this theory. Fairclough et al.
(2007), for example, pointed out that ITB movement across the epicondyle is probably an illusion and that
only a tension shi from anterior to posterior part of the distal ITB occurs. However, they stated that some
medial-lateral movement is present. When the tract moves medially, it compresses the intermediary tissues,
which are highly innervated; therefore, they are a good candidate for a pain source.
Kinematic risk factors, associated with ITB syndrome include excessive hip adduction, excessive peak knee
internal rotation, and excessive peak trunk ipsilateral  exion during stance phase (Aderem & Louw, 2015).
Fredericson et al. (2000) found that long distance runners with ITB syndrome had lower hip abduction
strength of the a ected leg compared to the una ected leg and compared to una ected runners. In contrast,
Grau, Krauss, Maiwald, Best, and Horstmann (2008) found no di erence in either abduction or adduction
strength comparing runners with ITB syndrome with controls. A trial by Willy and Davis (2011) may support
this.  eir hip-strengthening intervention signi cantly increased hip abduction and external rotation
strength but did not correct the excessive hip adduction during the stance (all the participants in the study
were exhibiting increased hip adduction prior to intervention).
Other more or less proven risk factors are tightness of the ITB, increased knee  exion range of motion during
stance phase and the dominance of the quadriceps over the hamstrings (Lavine, 2010).
Patellofemoral syndrome
As with many other conditions, there is a lack of universal de nition for PFS. It can be described as a painful
condition that involves patella and patellar retinaculum, with no apparent speci c cause (Holmes & Clancy,
1998). It is o en mistaken for patellar chondromalacia, a condition with similar symptoms, but di erentiated
from PFS by patellar cartilage damage and so ening (Salehi, Khazaeli, Hatami, & Malekpour, 2010).  e term
“runner’s knee” is o en used when referring to PFS, but we do not recommend using it, since it has been
attributed to other conditions. PFS is characterized by pain around patella and sometimes by crepitation in
the knee.  e pain is exacerbated with squatting, running, cycling and sitting with  exed knees for prolonged
period (Heintjes et al., 2004).
UDC 796.412.5:613.64 71
RUNNING INJURY PREVENTION | Ž. KOZINC & N. ŠARABON
e primary culprit for PFS development is probably patellar maltracking. In the majority of cases, the patella
is translated laterally during knee  exion.  e causes of maltracking are a matter of debate. Pal et al. (2011)
found that delayed activation of vastus medialis is one of the possibilities. Maltracking can also be a result of
structural abnormalities, such as the increased Q-angle (the angle between femur and tibia). However, of all
known risk factors, dynamic knee valgus should perhaps be the primary concern, as it could be eliminated
or minimized with proper interventions (Ford et al., 2015). Increased foot pronation during the stance phase
and weakness of the hip abductors can both elicit a knee valgus, and both were found to be a predictor for PFS.
Moreover, women exhibit knee valgus more o en and have a signi cantly higher risk for PFS (Petersen et al.,
2014).  is is another reason to consider dynamic valgus when attempting to treat or prevent PFS.
PFS is mostly treated conservatively. Sometimes, it recedes with su cient rest and progressive return to
activity. Recommendations for exercise selection are mixed. In their systematic review, Bolgla and Boling
(2011) concluded that quadriceps strengthening is the only proven method for eliminating PFS. Hip
strengthening protocols also appear promising.
Stress fractures
Repeated submaximal loading on the bones can result in stress fractures. Microscopic injuries develop and
accumulate over time, leading to macro-structural breakdown. Stress fractures are most frequent in lower
limbs and spine.  e pain associated with a stress fracture is usually localized and subsides with rest. Progress
through successive workouts is common. Runners and military recruits are at highest risk (Welck, Hayes,
Pastides, Khan, & Rudge, 2015). Additionally, females are a ected much more o en than males are (with
estimated incidences of 9.8% and 6.5%, respectively) (Wentz, Liu, Haymes, & Ilich, 2011).  is may be
attributed to gender-related risk factors, such as the female athlete triad (a syndrome of three interrelated
conditions: amenorrhea, eating disorders, and low bone mineral density) (Nattiv et al., 2007).
Tibial stress fractures are most prevalent in runners (Lopes et al., 2012). As said before, if the pain is spread
over a larger surface of the tibia, it is more likely to be caused by MTSS. Heel-strike technique and increased
ground reaction forces are most o en linked to increased incidence for sustaining tibial stress fractures.
Milner, Ferber, Pollard, Hamill, and Davis (2006) found female runners with tibial stress fracture history to
exhibit increased ground reaction force-related parameters (instantaneous and average vertical loading rates,
and tibial shock, i.e. a measure of peak positive acceleration of the tibia).  e same conclusions were reached
in a research design for runners in general (Davis, Milner, & Hamill, 2004).
Prevention of Running Injuries
We have seen that many injuries share common risk factors, with ground reaction forces, excessive foot
pronation, and excessive hip adduction during stance phase being mentioned the most o en. Some problemat ic
kinematic abnormalities are shown in Figure 2. One might suspect that designing prevention program should
be fairly straightforward, or that there are many interventions proven to lower running injury risks.
FIGURE 2 Kinematic parameters,
associated with increased injury risk
Legend:
1 – Pelvic drop
2 – Hip adduction
3 – Knee valgus
4 – Foot pronation
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Possibly the most comprehensive review of the literature, regarding running injury prevention, is the one
done by Yeung, Yeung, and Gillespie (2011).  ey focused only on so -tissue injuries but included a wide
range of interventions in their systematic search and further analysis. Twenty- ve trials were identi ed, with
the participants being military recruits (19 trials), runners (3 trials), prisoners (2 trials) and soccer referees
(1 trial). Strong evidence for a preventative e ect was found only for wearing a knee brace.  ere was also
some moderate evidence for the e ectiveness of heel pads. No evidence was found to support the preventative
e ects of stretching, strengthening or balance exercises.  e authors concluded that the evidence for the
e ectiveness of interventions for preventing running injuries is weak and limited. Enke and Gallas (2012)
reviewed the literature on treating and preventing four of the more common running injuries: MTSS, PFS,
ITB syndrome, and Achilles tendinitis. Concerning prevention, they concluded that individualized programs
should be formed, based on the risk factors an athlete is exhibiting. Craig (2008) focused on prevention
of MTSS in his systematic review.  e interventions found were shock-absorbing insoles, foam heel pads,
Achilles tendon stretching, footwear selection, and graduated running programs. None of these prevention
methods was e ective. Shock-absorbing insoles were the most promising.
Additionally, Saragiotto et al. (2014) reviewed the studies that investigated risk factors for sustaining running-
related injuries in general.  e main risk factor identi ed was a previous injury. Weekly distance, weekly
training frequency, and increased Q-angle were the only other risk factors identi ed in at least two trials.
Reducing training volume is probably an e ective, but impractical method for most runners, especially
professionals. Rudzki (1997) showed that reducing the running distance (and adding more weighted
marching instead) results in lower injury rates among military recruits.  ese ndings are clearly not relevant
for runners, but if they are able to a ord some cross-training, they could lower the injury risk.
Certainly, there are interventions that could bene t almost all runners. For instance, lowering ground
reaction forces is a good idea in general. Clansey, Hanlon, Wallace, Nevill, and Lake (2014) successfully
reduced ground reaction forces-related parameters with gait retraining method.  ey used what is referred
to as biofeedback or real-time feedback method. Participants ran on a treadmill, receiving information about
peak tibial acceleration.  ey were instructed to correct the technique in a way to minimize this parameter.
A er only six 20-minute sessions spread over three weeks, peak tibial acceleration and both average and
instantaneous vertical force loading rates were signi cantly decreased. Crowell and Davis (2011) managed to
lower the same three parameters in their trial. What is more, the reductions were preserved until one-month
follow-up measurements. It seems that feedback methods could provide an e ective way to lower ground
reaction forces and thus reducing injury risk.
Sharma et al. (2014) combined biofeedback methods with an exercise program.  is combination substantially
reduced the incidence for sustaining MTSS among military recruits over 26 weeks of a military training
program.  e exercises used were (unlike in most other, unsuccessful, trials) judiciously chosen. Some good
examples include bird dog, single-leg squats, drop jumps, single-leg hops, star-excursion stability exercise
(touching several marked points on the ground with the free leg in single-leg stance), hip  exors stretch, hip
extensors stretch and ankle plantar  exors stretch.
Snyder, Earl, O’Connor, and Ebersole (2009) conducted an interesting trial. Participants underwent a six-
week resistance training intervention (3 training sessions per week) that included three exercises in one-
legged support: pelvic rotation in the frontal plane, and two hip rotation exercises, with di erent directions
of the load applied by cables. Participants exhibited lower foot pronation but greater hip adduction range of
motion during running a er the intervention.  is is another indication that prior assessment of the athlete
should be carried out in order to identify which (if any) risk factors he/she is exhibiting.  is intervention
may bene t runners with excessive pronation but may do even more harm to those exhibiting excessive hip
adduction. Another important aspect of individualized treatment is footwear selection. Motion control shoes,
for instance, do reduce injury rates, but only in runners with excessive foot pronation (Malisoux et al., 2016).
Since the greatest risk factors for sustaining running-related injury are mostly unmodi able (e.g. previous
injury, training volume), it seems that individualized treatment is the best approach to prevention. Every
individual needs to be assessed in order to  nd risk factors he/she is exhibiting.  en, these factors should be
addressed with appropriate interventions. Such an approach would likely be more e ective than generalized
prevention programs.
Conclusion
Runners are particularly prone to developing overuse injuries. Evidence regarding prevention methods is
weak and limited, with only a few interventions showing bene ts. Two of the greatest risk factors are previous
injury and training volume. We obviously cannot control the  rst, while training volume may be modi able
in recreational runners. It seems that designing individualized prevention programs is the best bet for now.
Methods for gait retraining are showing some promising results for reducing ground impact forces. More
trials to evaluate the e ects of interventions on risk factors are desired, along with incidence studies, to
determine the direct impact of interventions on injury risk.
UDC 796.412.5:613.64 73
RUNNING INJURY PREVENTION | Ž. KOZINC & N. ŠARABON
R E F E R E N C E S
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... Evidence to support that RRIs may be prevented through strength/flexibility/coordination training regimens, stretching exercises, training schedule modification, or insoles, for example, was either weak or absent (Yeung & Yeung, 2001;Yeung et al., 2011). Unfortunately, studies executed after these reviews frequently report similar hardship, as their interventions also regularly fail to reduce the risk of RRIs in spite of promising designs (e.g., Cloosterman et al., 2022;Kozinc & Sarabon, 2017;Bredeweg et al., 2012;Ramskov et al., 2018;Baltich et al., 2016;Fokkema et al., 2019a). ...
... For example, two systematic reviews on RRI interventions found some evidence that altering training frequency, duration, and distance may reduce RRIs (Yeung & Yeung, 2001;Yeung et al., 2011). However, these findings were refuted in a more recent meta-analytic study on the topic (Kozinc & Sarabon, 2017). The challenge of preventing RRIs is further reflected in the GRONORUN studies (e.g., Bredeweg et al., 2012;Buist et al., 2008), the Run Clever trial (Ramskov et al., 2018), and the Calgary study (Baltich et al., 2017). ...
... They mentioned the low adherence of their sample as one possible reason for why the intervention was ineffective, arguing that runners may require a more personalized approach due to the generally individual nature of the sport of running (Fokkema et al., 2019a). In like fashion, a more personalized approach in intervention design has been advocated by review articles on RRI prevention (e.g., Kozinc & Sarabon, 2017;Vannatta et al., 2020). A personalized approach was also employed in one of the few RRI intervention studies to actually be effective in reducing RRIs among a sample of trail runners (Hespanhol et al., 2018). ...
Thesis
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This dissertation discusses whether specific psychological factors contribute to our ability to understand and optimize the health outcomes of running. It provides information on coping, psychological risk profiles, an app intervention, and a self-assessment tool to determine one's risk for adverse health outcomes as a runner.
... Calcaneal spurs found in 45% of patients with (3) and in 10-60% without PF or HP (3)(4)(5), and not found in 46% of patients with painful heel (4), at age 40-60, aggravated while taking the initial few steps after long period of inactivity (6). Several factors can affect PF/HP as long standing (7)(8), Neuromuscular deficit (9), High body mass index (10), Fascial thickening (11), foot pronation, high arch and tight Achilles tendon (12,13), Plantar nerve entrapment (2), Heel pad atrophy (14). Causal relation of spur to pain is contradicted by several studies and findings. ...
... PF/HP treated with local stretching and strengthening (2,13,24,25), NSAIDs, orthoses (2), tape (24), iontophoresis (25,26), and laser (25,28), in addition to platelet-rich plasma (PRP) (29), corticosteroid injections (CI), and extracorporeal shock wave therapy (ECSWT) (21, 27,[29][30][31][32][33][34], and local surgeries (21, 35, 36). Guidelines not recommend electrical stimulation, Ultrasound, or weight loss (24). ...
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Background: Persistence of painful calcaneal spur (PCS) and loss of long-term effect may be related to unrecognized low back pain (LBP), dysfunction and/or lumbosacral radiculopathy (LSR), but prevalence of LBP in PCS patients has not been established. Purpose: to determine the prevalence of LBP among individuals with and without PCS. Methods: A cross-sectional study of individuals with (n = 26) and without (n=27) PCS. X-ray used to determine calcaneal spur. MRI and X-ray (as available), and clinical tests used to determine LBP/pathology/LSR. Results: A greater percentage of individuals with PCS had LBP (88.5% vs. 33% in controls), lumbar pathology (58 vs. 19), and LSR (54 vs. 15). Conclusion: Individuals with painful calcaneal spur had a greater prevalence of LBP/lumbar pathology/LSR. Treatment to address impairments related to lumbar spine may be necessary to enhance the treatment of PCS.
... Risk factors for GORRIs may be internal (intrinsic) or external (extrinsic). 10,11 Internal factors include age, sex, and body mass index, previous injury, physical fitness, and psychological factors. 12 External factors refer to the characteristics of running (volume, intensity, and frequency), the environment, and footwear. ...
... 12 External factors refer to the characteristics of running (volume, intensity, and frequency), the environment, and footwear. [10][11][12][13] Although several risk factors for developing GORRIs have been reported, there are limited studies on risk factors predictive of GORRIs in ultramarathon runners. Most studies explored predictive factors of GORRIs in novice and recreational runners using relatively small sample sizes and data analysis with emphasis on univariate models and do not differentiate between novice, recreational, marathon, or ultramarathon runners. ...
Article
Objectives: To identify risk factors that predict gradual onset running-related injuries (GORRIs) in ultramarathon runners entering a mass community-based event. Design: Descriptive cross-sectional study. Setting: Two Oceans 56 km ultramarathon 2012 to 2015. Participants: Race entrants (n = 42 003) completed a compulsory pre-race medical history questionnaire; 29 585 (70.4%) of entrants consented. Dependent/outcome variable: A history of GORRIs in the past 12 months among race entrants. Main outcome measures: In a multi-variate model, runner demographics, training variables (years of recreational running, weekly running distance, training running speed), history of chronic disease (composite score), and history of allergies were included as factors predicting GORRIs. Prevalence (%) and prevalence ratios (PR, 95% CIs) are reported. Results: The lifetime prevalence of GORRIs in ultramarathon runners was 24.4%. Independent factors predicting GORRIs were: higher chronic disease composite score (PR = 2.05 times increase risk for every 2 additional chronic diseases; P < 0.0001), history of allergies (PR = 1.66; P < 0.0001), increased years of recreational running (PR = 1.07 times increased risk for every 5 year increase in running; P < 0.0001), lower average weekly running distance (PR = 0.98 times decreased risk for every 15 km increase weekly running distance; P < 0.0001), and slower average training running speed (PR = 0.96 times decreased risk for every km/h increase in training running speed; P < 0.0001). Conclusions: Novel risk factors predicting GORRIs are increased number of chronic diseases and a history of allergies. These factors, together with training variables (years of recreational running, weekly running distance, and training running speed) can be targeted to develop and implement injury prevention, treatment, and rehabilitation interventions in ultramarathon runners.
... Running-related injuries remain a major problem for runners [109], and the best approach to prevention is still largely equivocal [37,39]. The most prevalent running-related injuries are medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, patellar tendinopathy, iliotibial band syndrome, stress fractures of the tibia, and patellofemoral pain syndrome [28,110]. Very recently, a study conducted on more than 4000 runners reported virtually no benefit of a comprehensive prevention program on injury risk [111]. ...
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It is well-accepted that at least a certain amount of resistance exercise (RE) is recommended for most endurance athletes. In this review, we aim to summarize the evidence regarding the effects of RE on running economy, running biomechanics, and running-related injury risk in endurance runners. The evidence robustly shows that lower limb RE is effective for improving running economy and performance, with a combination of strength and plyometric training being recommended to improve RE. Isometric training is also emerging as a possible alternative to implement during periods of high overall training load. Lower limb RE may change some aspects of joint kinematics during running; however, the evidence regarding the effects on kinetics is limited. Lower limb RE may help reduce running-related injury risk, but further evidence is needed.
... From top to bottom, the entire system can be divided into a system layer [14], control layer [15], and device layer [16]. Among them, the communication interconnection between the system layer and the control layer is based on various communication interfaces, and the control layer and the device layer are directly connected to the hardware based on the terminal board [17]. The system layer refers to the characteristics of the multilevel state shown by the various elements of the system in the system structure. ...
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In recent years, the performance of sports dance in China has become better and better. Naturally, the technical requirements for this dance are getting higher and higher, and the number and intensity of training have also increased, which has led to increasing injuries in sports dance. This article is based on visual sensor images to analyze and study the common injuries and prevention of sports dance practitioners. It is aimed at providing a certain reference basis for athletes’ injuries, so that dance practitioners and coaches can better master sports dance training and teaching. Injury-related rules and prevention reduce the injury rate. This article puts forward the related technology of a visual sensor image and applies its technology to the prevention and research of common injuries in sports dance. At the same time, it analyzes the causes of sports dance practitioners’ injuries and seeks economical and affordable massage techniques for prevention, and the method of treatment provides protection for dance practitioners. The experimental results in this article show that the Tuina group cured 15 subjects, 41 subjects were markedly effective, 13 subjects were improved, and 6 subjects were unhealed. The total effective rate was 92%.
... Compared to plyometric or sprint training, HIIT using a stationary bicycle has the advantage of being able to monitor the heart rate response in real time and it is easy to observe the training effect according to the absolute training intensity [18]. Moreover, training using a stationary bicycle can be useful for soccer players even to prevent occupational overuse syndrome [19]. ...
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Cardiorespiratory fitness, anaerobic power, and lower extremity strength are essential for soccer players at all levels. An effective program should be developed to improve physical strength for adolescent soccer players who need to combine academic and technical training. This study analyzed the impact of short-term high intensity interval training (HIIT) training and traditional moderate intensity continuous training (MICT) on adolescent soccer players. Participants included 56 adolescent soccer players who were divided into HIIT and MICT groups. The training program was conducted 3 times a week for 4 weeks using cycle ergometer. Each session included the same resistance training program, and the characteristics of HIIT and MICT were applied to improve cardiorespiratory fitness and anaerobic power. Body composition analysis, graded exercise test for peak oxygen uptake (VO2 peak), Wingate anaerobic power test, and isokinetic knee strength test were performed. VO2 peak was improved in HIIT and MICT, but anaerobic threshold and heart rate recovery significantly improved in the HIIT group. Wingate anaerobic peak power had increased significantly in sets 1, 2, and 3 in the HIIT group, but showed significant improvement only in set 1 in the MICT group. The isokinetic strength improved significantly in the HIIT group at 60°/s and in the MICT group at 240°/s. There was no significant change in body composition in either group. In conclusion, short-term HIIT administered to adolescent soccer players effectively improved cardiorespiratory fitness in HIIT and MICT groups. While HIIT increased anaerobic threshold and power, MICT effectively improved muscle endurance. Short-term intensive training can be considered a time-efficient training strategy.
... Despite its pervasiveness, running can be performed in a wide variety of different 'styles' [2], [3], often as a result of different physiological/biomechanical factors [4], training [5], and even the intention of the runner. These variations can play major roles in energy expenditure [6], speed/endurance [7], and even injury [2], [8], [9]. ...
Preprint
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Automatic classification of running styles can enable runners to obtain feedback with the aim of optimizing performance in terms of minimizing energy expenditure, fatigue, and risk of injury. To develop a system capable of classifying running styles using wearables, we collect a dataset from 10 healthy runners performing 8 different pre-defined running styles. Five wearable devices are used to record accelerometer data from different parts of the lower body, namely left and right foot, left and right medial tibia, and lower back. Using the collected dataset, we develop a deep learning solution which consists of a Convolutional Neural Network and Long Short-Term Memory network to first automatically extract effective features, followed by learning temporal relationships. Score-level fusion is used to aggregate the classification results from the different sensors. Experiments show that the proposed model is capable of automatically classifying different running styles in a subject-dependant manner, outperforming several classical machine learning methods (following manual feature extraction) and a convolutional neural network baseline. Moreover, our study finds that subject-independent classification of running styles is considerably more challenging than a subject-dependant scheme, indicating a high level of personalization in such running styles. Finally, we demonstrate that by fine-tuning the model with as few as 5% subject-specific samples, considerable performance boost is obtained.
... This may be the cause of some overuse running injuries that are more prevalent in females because time to maximum rearfoot eversion has often been linked to overuse running injuries (Ferber, et al., 2009). Women are more prone to tibial stress syndrome and tibial stress fractures (Fernández & Rojano, 2020;Kozinc & Šarabon, 2017;Taunton, et al., 2002) and Becker et al. (2017) and Fernández and Rojano (2020) suggest that eversion later in stance may be one of the biomechanical factors related to this type of injury risk. Sakaguchi et al. (2014) also found a later occurrence of peak eversion in female runners but the differences between males and females were not significant and effect sizes were small. ...
Article
Full-text available
Running gait cycle begins when one foot comes in contact with the ground and ends when the same foot contacts the ground again. In a running gait cycle each lower limb has a stance phase and a swing phase. During the stance phase eversion of the subtalar joint is one of the mechanisms used to absorb impact forces. However, excessive rearfoot eversion may contribute to overuse running injuries of the lower limb. It is necessary to provide additional insight on sex differences or differences between dominant and non-dominant limbs in the different phases of the running gait cycle, as well as in the movements of the subtalar joint in the coronal plane. Therefore, the aim of the current study was to determine bilateral asymmetries, sex differences and peak eversion angle in the running gait cycle of recreational runners. 20 recreational runners aged 20 – 28 years (10 males and 10 females) were recorded on a treadmill at a running speed between 11 km/h and 12 km/h with high speed camera at 300 Hz. Males and females showed no significant differences between limbs in any of the variables of interest, indicating no bilateral asymmetries in running gait cycle. Female runners demonstrated a greater time to peak eversion than male runners (36.92 ± 5.79% vs 26.37 ± 5.12%, p < .01) and this may be related to some overuse running injuries that are more prevalent in females. The data obtained in this study may serve as a useful reference for future research. Resumen. Un ciclo de carrera comienza cuando un pie contacta con el suelo y termina cuando el mismo pie contacta con el suelo de forma consecutiva. En un ciclo de carrera cada extremidad inferior tiene una fase de apoyo y una fase de vuelo. Durante la fase de apoyo la pronación de la articulación subastragalina es uno de los mecanismos para absorber las fuerzas de impacto. Sin embargo, una excesiva pronación puede predisponer a lesiones por sobreuso de la extremidad inferior. Son necesarias investigaciones adicionales sobre las diferencias por sexos y las asimetrías en las diferentes fases del ciclo de carrera, así como en los movimientos de la articulación subastragalina. Por tanto, el propósito del presente estudio fue determinar las asimetrías, las diferencias por sexos y la máxima pronación en un ciclo de carrera de corredores recreativos. 20 corredores recreativos de entre 20 y 28 años (10 hombres y 10 mujeres) fueron grabados corriendo en tapiz rodante entre 11 km/h y 12 km/h con una cámara de alta velocidad a 300 Hz. No existieron asimetrías en el ciclo de carrera pues no se encontraron diferencias significativas entre la pierna dominante y la no dominante en ninguna variable. La máxima pronación fue más tardía en mujeres que en hombres (36.92 ± 5.79% vs 26.37 ± 5.12%, p < .01), lo que puede estar relacionado con la mayor prevalencia de ciertas lesiones de la extremidad inferior en mujeres. Los resultados obtenidos en este estudio pueden servir de referencia para futuras investigaciones.
... Achilles tendinopathy (AT) is a common problem seen in the clinical setting amongst athletic populations, particularly in runners (de Jonge et al., 2011;Kozinc & Sarabon, 2017;Lopes et al., 2012). Alterations in neuromuscular function, intra-tendon fluid dynamics and biochemical interactions have all been suggested to contribute to structural changes and the onset of symptoms (O'Neill et al., 2015;Malliaras, 2017). ...
Article
Objectives To determine the thermal patterning of the Achilles tendon following bodyweight resistance exercise with and without blood-flow restriction (BFR). Design Cross-sectional Setting Research laboratory Participants Twelve asymptomatic recreational runners (Age: 37±10, Height: 169±20, Mass: 73.8±13.4). Main Outcome Measures Thermograms were taken pre and post exercise with and without a BFR cuff on separate legs. BFR cuff pressure was set at 80% maximal arterial occlusion pressure determined using doppler via the tibial artery. Linear mixed-effects models were used to assess the effect of BFR and time post-exercise on skin-temperature (Tskin). Results A lower Tskin was seen following BFR exercise at the tendon insertion (P=0.002), but not at the free tendon (P=0.234), or the musculotendinous junction (P=0.933). A significant effect of time upon changes in Tskin was observed in both BFR and non-BFR groups (P=0.002). No interaction of time and BFR were observed on changes in Tskin (P=0.726). Conclusion Region specific changes in Tskin were found, with greater and longer reductions observed at the insertion of the Achilles following BFR exercise before returning to baseline. These findings could have implications for the programming of BFR exercise on tendon health. Future research should observe for differences between symptomatic and healthy tendons.
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Background/aim: This randomised controlled trial investigated if the usage of running shoes with a motion control system modifies injury risk in regular leisure-time runners compared to standard shoes, and if this influence depends on foot morphology. Methods: Recreational runners (n=372) were given either the motion control or the standard version of a regular running shoe model and were followed up for 6 months regarding running activity and injury. Foot morphology was analysed using the Foot Posture Index method. Cox regression analyses were used to compare injury risk between the two groups, based on HRs and their 95% CIs, controlling for potential confounders. Stratified analyses were conducted to evaluate the effect of motion control system in runners with supinated, neutral and pronated feet. Results: The overall injury risk was lower among the participants who had received motion control shoes (HR=0.55; 95% CI 0.36 to 0.85) compared to those receiving standard shoes. This positive effect was only observed in the stratum of runners with pronated feet (n=94; HR=0.34; 95% CI 0.13 to 0.84); there was no difference in runners with neutral (n=218; HR=0.78; 95% CI 0.44 to 1.37) or supinated feet (n=60; HR=0.59; 95% CI 0.20 to 1.73). Runners with pronated feet using standard shoes had a higher injury risk compared to those with neutral feet (HR=1.80; 95% CI 1.01 to 3.22). Conclusions: The overall injury risk was lower in participants who had received motion control shoes. Based on secondary analysis, those with pronated feet may benefit most from this shoe type.
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Background: Iliotibial band syndrome is the second most common running injury. A gradual increase in its occurrence has been noted over the past decade. This may be related to the increasing number of runners worldwide. Since the last systematic review, six additional papers have been published, providing an opportunity for this review to explore the previously identified proximal risk factors in more detail. The aim of this systematic review is thus to provide an up to date quantitative synthesis of the trunk, pelvis and lower limb biomechanical risk factors associated with Iliotibial band syndrome in runners and to provide an algorithm for future research and clinical guidance. Methods: An electronic search was conducted of literature published up until April 2015. The critical appraisal tool for quantitative studies was used to evaluate methodological quality of eligible studies. Forest plots displayed biomechanical findings, mean differences and confidence intervals. Level of evidence and clinical impact were evaluated for each risk factor. A meta-analysis was conducted where possible. Result: Thirteen studies were included (prospective (n = 1), cross-sectional (n = 12)). Overall the methodological score of the studies was moderate. Female shod runners who went onto developing Iliotibial band syndrome presented with increased peak hip adduction and increased peak knee internal rotation during stance. Female shod runners with Iliotibial band syndrome presented with increased: peak knee internal rotation and peak trunk ipsilateral during stance. Conclusion: Findings indicate new quantitative evidence about the biomechanical risk factors associated with Iliotibial band syndrome in runners. Despite these findings, there are a number of limitations to this review including: the limited number of studies, small effect sizes and methodological shortcomings. This review has considered these shortcomings and has summarised the best available evidence to guide clinical decisions and plan future research on Iliotibial band syndrome aetiology and risk.
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Deficits in proximal hip strength or neuromuscular control may lead to dynamic lower extremity valgus. Measures of dynamic lower extremity valgus have been previously shown to relate to increased risk of several knee pathologies, specifically anterior cruciate ligament ruptures and patellofemoral pain. Therefore, hip-focused interventions have gained considerable attention and been successful in addressing these knee pathologies. The purpose of the review was to identify and discuss hip-focused exercise interventions that aim to address dynamic lower extremity valgus. Previous electromyography, kinematics, and kinetics research support the use of targeted hip exercises with non-weight-bearing, controlled weight-bearing, functional exercise, and, to a lesser extent, dynamic exercises in reducing dynamic lower extremity valgus. Further studies should be developed to identify and understand the mechanistic relationship between optimized biomechanics during sports and hip-focused neuromuscular exercise interventions.
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No systematic review has identified the incidence of running-related injuries per 1000 h of running in different types of runners. The purpose of the present review was to systematically search the literature for the incidence of running-related injuries per 1000 h of running in different types of runners, and to include the data in meta-analyses. A search of the PubMed, Scopus, SPORTDiscus, PEDro and Web of Science databases was conducted. Titles, abstracts, and full-text articles were screened by two blinded reviewers to identify prospective cohort studies and randomized controlled trials reporting the incidence of running-related injuries in novice runners, recreational runners, ultra-marathon runners, and track and field athletes. Data were extracted from all studies and comprised for further analysis. An adapted scale was applied to assess the risk of bias. After screening 815 abstracts, 13 original articles were included in the main analysis. Running-related injuries per 1000 h of running ranged from a minimum of 2.5 in a study of long-distance track and field athletes to a maximum of 33.0 in a study of novice runners. The meta-analyses revealed a weighted injury incidence of 17.8 (95 % confidence interval [CI] 16.7-19.1) in novice runners and 7.7 (95 % CI 6.9-8.7) in recreational runners. Heterogeneity in definitions of injury, definition of type of runner, and outcome measures in the included full-text articles challenged comparison across studies. Novice runners seem to face a significantly greater risk of injury per 1000 h of running than recreational runners.
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Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management. The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.<br /
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• Objective: To provide an overview of the diagnosis and management of common running injuries for the primary care physician. • Methods: Four common running injuries were selected and a literature review was performed regarding the management and prevention of these injuries. • Results: Medial tibial stress syndrome, patellofemoral pain syndrome, iliotibial band syndrome, and Achilles tendinitis are common injuries experienced by runners. The accurate diagnosis and treatment of these injuries is important in returning the injured runner to sport in a safe and timely manner. Most running injuries are related to cumulative microtrauma. Predisposing biomechanical faults, improper footwear, environmental factors, and errors in training are also thought to play a role in running injuries. An individualized and comprehensive rehabilitation plan is crucial not only for treating these injuries, but also in preventing injury recurrence. • Conclusion: Although a comprehensive assessment and treatment plan is necessary to manage common running injuries, further research is needed to refine current rehabilitation protocols and footwear selection recommendations. Copyright 2012 by Turner White Communications Inc. All rights reserved.
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Stress fractures occur as a result of microscopic injuries sustained when bone is subjected to repeated submaximal stresses. Overtime, with repeated cycles of loading, accumulation of such injuries can lead to macro-structural failure and frank fracture. There are numerous stress fractures about the foot and ankle of which a trauma and orthopaedic surgeon should be aware. These include: metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid. Awareness of these fractures is important as the diagnosis is frequently missed and appropriate treatment delayed. Late identification can be associated with protracted pain and disability, and may predispose to non-union and therefore necessitate operative intervention. This article outlines the epidemiology and risk factors, aetiology, presentation and management of the range of stress fractures in the foot and ankle.
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Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes and military recruits. Characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, in most cases it is also an injury involving underlying cortical bone microtrauma, although it is not clear if the soft tissue or cortical bone reaction occurs first. Nuclear bone scans and magnetic resonance imaging (MRI) can both be used for the diagnosis of MTSS, but the patient's history and clinical symptoms need to be considered in conjunction with the imaging findings for a correct interpretation of the results, as both imaging modalities have demonstrated positive findings in the absence of injury. However, MRI is rapidly becoming the preferred imaging modality for the diagnosis of bone stress injuries. It can also be used for the early diagnosis of MTSS, as the developing periosteal oedema can be identified. Retrospective studies have demonstrated that MTSS patients have lower bone mineral density (BMD) at the injury site than exercising controls, and preliminary data indicates the BMD is lower in MTSS subjects than tibial stress fracture (TSF) subjects. The values of a number of tibial geometric parameters such as cross-sectional area and section modulus are also lower in MTSS subjects than exercising controls, but not as low as the values in TSF subjects. Thus, the balance between BMD and cortical bone geometry may predict an individual's likelihood of developing MTSS. However, prospective longitudinal studies are needed to determine how these factors alter during the development of the injury and to find the detailed structural cause, which is still unknown. Finite element analysis has recently been used to examine the mechanisms involved in tibial stress injuries and offer a promising future tool to understand the mechanisms involved in MTSS. Contemporary accurate diagnosis of either MTSS or a TSF includes a thorough clinical examination to identify signs of bone stress injury and to exclude other pathologies. This should be followed by an MRI study of the whole tibia. The cause of the injury should be established and addressed in order to facilitate healing and prevent future re-occurrence.
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Plantar fasciitis (PF) is one of the most common causes of foot pain. Work can involve factors that may predispose to foot pain. To systematically review the evidence of the association between weight bearing (walking or standing) and PF among workers. Literature search of relevant indexing databases from inception to May 2012, grey literature, websites of relevant organizations and reference lists for all identified articles. Two reviewers independently selected studies for full review, assessed methodological quality and graded evidence. Findings were summarized qualitatively. Four studies were included; all were assessed as high or unclear risk of bias. Three studies were case-control studies; two used clinic populations and one used volunteers. The other study was cross-sectional involving the workforce of an assembly plant. A number of associations between PF and risk factors were identified including sex, obesity, foot biomechanics and job factors (e.g. job tenure). Two case-control studies and the cross-sectional study found an association with weight bearing, but the assessment of weight bearing varied (e.g. time on feet, time walking or standing). There was low-quality evidence to confirm a causal relationship (Royal College of General Practitioners (RCGP) * grade). This systematic review found low-quality evidence of an association between PF and weight-bearing tasks such as walking and standing on hard surfaces. The only occupations specifically identified as having higher risk were those associated with the engine assembly plant. Further research is required to fully determine the association between weight bearing and PF. © The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.