ReviewBiomechanical risk factors for running-related injury differ by sample population: A systematic review and meta-analysis
Introduction
Several theories have been postulated as to the etiology of running related injury (RRI) including impact forces (Hreljac, 2004), foot pronation (Davis, 2014), foot strike pattern (Lieberman et al., 2010), and hip muscle function (Barton et al., 2013). This has led to a preponderance of biomechanical studies aiming to identify the specific factors present in individuals' running mechanics that may be related to the development of RRIs. However, many of these studies have been either retrospective or cross-sectional in nature and therefore have limited their ability to determine these as etiological factors in RRI.
Previous reviews have investigated the biomechanical factors that have been related to specific RRIs including patellofemoral pain (Neal et al., 2016), iliotibial band syndrome (Aderem and Louw, 2015), Achilles tendinopathy (Ogbonmwan et al., 2018), and lower extremity tendinopathies (Mousavi et al., 2019), as well as RRI in general (Van Der Worp et al., 2016). These studies have identified some factors that appear to be important to RRI, however, each of these reviews have included both prospective and retrospective studies which limit the ability to conclude if such factors precede RRI development. Further, many of these reviews have only examined particular biomechanical characteristics (Van Der Worp et al., 2016) which may fail to see the interaction between those variables of interest and other joint kinematic and kinetic factors. Some studies have only investigated particular injury types (Aderem and Louw, 2015; Neal et al., 2016; Ogbonmwan et al., 2018) which may result in attributing those biomechanical factors to one type of injury rather than evaluating their overall role in RRI.
Although the biomechanical factors identified in these studies may be important to address clinically in runners who currently have pain or injury with running since successful treatment strategies have been implemented addressing these factors (Cheung and Davis, 2011; Neal et al., 2016; Willy et al., 2012), without further rigorous studies indicating which specific biomechanical factors during running precede RRI, it is very difficult to construct appropriate injury prevention programs for runners. Further, making modifications to running form in runners who have not had previous running injury runs the risk of becoming “guess work” in clinical settings. Therefore, further evidence from prospective studies should support such modifications to running mechanics.
One recent review examined the biomechanical factors associated with RRI from only prospective studies (Ceyssens et al., 2019). It was reported that many biomechanical variables had inconsistent findings across studies which those authors hypothesized were due to heterogeneity in the sample populations, methodologies employed, and outcome variables examined. They also reported that the findings from single studies require further verification in future studies through the use of prospective study designs. Since the sample investigated has been emphasized in other systematic reviews to explain the differences in incidence rates (Videbæk et al., 2015) and injury proportions and locations among runners (Kluitenberg et al., 2015), pooled analyses from similar samples may help further guide these efforts to more precisely define which biomechanical factors are relevant to RRI.
Previous work has examined injury incidence rates (Kluitenberg et al., 2015; Videbæk et al., 2015) and have provided the crucial first step of injury prevention models (van Mechelen et al., 1992). The second step is to study the etiological factors related to RRI. Ceyssens et al. (2019) have attempted to identify biomechanical factors in the etiology of RRI, however, no quantitative synthesis of their results were presented. We believe that completing a quantitative synthesis when possible within the identified samples of runners may provide additional insight into etiological factors in RRI and guide future research efforts.
Thus, the aim of this systematic review is to identify which biomechanical factors during running have prospective evidence linking them to the etiology of RRI in experienced runners. A secondary aim was to complete a meta-analysis on those variables reported in at least two studies with a similar sample that will investigate to what degree within that sample these biomechanical variables are related to RRI.
Section snippets
Search strategy
An independent search was completed in January of 2019 through MEDLINE, CINAHL, and PubMed using a broad strategy to try and maximize potential hits. Search terms included (Biomechanics OR Biomechanical) AND (running OR runners) AND (injury) AND (prospective or cohort) (Fig. 1). Reference lists from identified articles and from other systematic reviews were screened to identify other potential articles not identified through this search strategy.
Inclusion and exclusion criteria
Only prospective studies investigating running
Results
A total of 13 studies were identified and considered eligible for review (Fig. 1). Five studies investigated biomechanical factors associated with any RRI (Davis et al., 2016; Dudley et al., 2017; Kuhman et al., 2016; Messier et al., 2018; Napier et al., 2018), three studies investigated patellofemoral pain (Eskofier et al., 2012; Noehren et al., 2013; Stefanyshyn et al., 2006), two studies investigated iliotibial band syndrome (Hamill et al., 2008; Noehren et al., 2007), one study investigated
Discussion
The primary aim of this review was to provide quantitative estimates of evidence present regarding the biomechanical factors relevant to the etiology of RRI to help guide future research efforts investigating mechanisms of injury and the development of RRI prevention programming. There appears to be a paucity of prospective studies available at this time making it difficult to draw definitive conclusions. Further, those studies available have examined different study samples and employed
Conclusion
Features regarding different running samples such as competition level, sex, and likely footstrike pattern may influence the biomechanical variables associated with RRI. Hip adduction and reduced ankle/rearfoot eversion appear related to RRI in female recreational runners most of whom employed a rearfoot strike pattern. The role of vertical loading rates in injury etiology remains unclear. There is a clear need for continued efforts and collaboration to help elucidate the etiological factors
Disclosure statement
The authors do not have any conflicts of interest related to the conduction of this study or the publication of this data.
Acknowledgements
The authors would like to acknowledge the work of Andrew Borgert, PhD for his assistance with statistical analysis and Ann Emmel of the Gundersen Health Sciences Library for her assistance with literature searching.
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