Elsevier

Gait & Posture

Volume 23, Issue 1, January 2006, Pages 91-98
Gait & Posture

A prospective study of gait related risk factors for exercise-related lower leg pain

https://doi.org/10.1016/j.gaitpost.2004.12.004Get rights and content

Abstract

The purpose of this study was to determine prospectively gait related risk factors for exercise-related lower leg pain (ERLLP) in 400 physical education students. Static lower leg alignment was determined, and 3D gait kinematics combined with plantar pressure profiles were collected. After this evaluation, all sports injuries were registered by the same sports physician during the duration of the study. Forty six subjects developed ERLLP and 29 of them developed bilateral symptoms thus giving 75 symptomatic lower legs. Bilateral lower legs of 167 subjects who developed no injuries in the lower extremities served as controls. Cox regression analysis revealed that subjects who developed ERLLP had an altered running pattern before the injury compared to the controls and included (1) a significantly more central heel-strike, (2) a significantly increased pronation, accompanied with more pressure underneath the medial side of the foot, and (3) a significantly more lateral roll-off. These findings suggest that altered biomechanics play a role in the genesis of ERLLP and thus should be considered in prevention and rehabilitation.

Introduction

Exercise-related lower leg pain (ERLLP) is a common and enigmatic overuse problem in athletes and military populations [1]. Runners, track athletes and athletes participating in jumping sports are frequently diagnosed with ERLLP which is usually induced by repetitive tibial strain imposed by loading during intensive, weight bearing activities. A variety of categories can be labeled under this broad terminology of ERLLP and includes pathologies or terms such as shin splints, shin pain, medial tibial stress syndrome (MTSS), periostitis, compartment syndrome and stress fractures. However, the term ERLLP will be used in this paper as used by Brukner [2], as it adequately describes the clinicopathological features of the condition, while remaining appropriate for each term.

Generally, the most effective treatment for ERLLP is considered to be rest, often for prolonged periods [1]. This will significantly disrupt an active lifestyle, and sometimes end activity-related careers entirely. Therefore, analyses of risk factors for ERLLP are required as a prerequisite to the development of prevention programs.

Murphy et al. [3] recently reviewed the literature on risk factors for lower extremity injuries and demonstrated that our understanding of injury causation is limited. They concluded that more prospective studies are needed, emphasizing the need for proper design and sufficient sample sizes. In the literature, several aetiological factors have been suggested to induce ERLLP, which include in isolation or in combination, changes in training, activity type, intensity and frequency, footwear, and terrain as extrinsic (environmental related) risk factors [1], [4]. As intrinsic risk factors, lack of running experience, poor physical condition, previous injury, decreased muscle strength, muscle fatigue, inflexibility, malalignment and adverse biomechanics have been quoted [1], [4], [5]. Retrospective studies have noted excessive dynamic foot pronation in subjects with a history of ERLLP [6], [7]. In addition, static foot posture in subjects with ERLLP also showed a pronated foot alignment [8], [9], [10].

However, cross-sectional studies only allow clinicians to establish relationships but longitudinal prospective studies can investigate cause and effect relationships. Hitherto, no studies have been published on dynamic biomechanical intrinsic risk factors of ERLLP prospectively. The purpose of this prospective cohort investigation was to determine gait related risk factors for ERLLP in a young physically active population.

Section snippets

Subjects

The subjects were 400 physical education students (241 men, 159 women; age range: 17–28 years; mean age: 18.4 ± 1.1 years), who were freshman in 2000–2001 (n = 121), 2001–2002 (n = 133) and 2002–2003 (n = 146) in Physical Education at the Ghent University, Belgium. All signed informed consent and the Ethical Committee of the Ghent University Hospital approved the study. Gait pattern and static alignment of the students were evaluated at the beginning of their education. Before testing, all students

Results

During this study, 46 (11.5%, 17 males and 29 females) of the 400 subjects developed ERLLP. Twenty-nine developed bilateral symptoms. Consequently, the injury group comprised 75 symptomatic lower legs (35 left and 40 right). Fig. 4 displays the survival curve of the students for developing ERLLP.

Table 2 summarizes the significant results from the univariate Cox regression analysis. From all measured alignment characteristics, only extension range of motion at the first metatarsophalangeal joint

Discussion

The present investigation is the first study to determine dynamic biomechanical intrinsic risk factors of ERLLP prospectively. The overall incidence of ERLLP reported in our population (11.5%) is comparable with previous reports [8], [22]. The increased incidence in women (18% versus 7% in men) is in accordance with other studies [8], [10]. This study reveals that the running pattern of subjects who develop ERLLP differed from subjects who remained injury free. Summarized, these altered

Conclusion

This is the first prospective study that identified a central heel-strike, an excessive eversion and an increased lateral roll-off as risk factors for ERLLP. Prevention programmes should examine these parameters and adapt them to reduce the incidence of ERLLP. In addition, treatment of ERLLP should consider altering these parameters. In the literature, it has been suggested that orthotic inserts, taping and antipronation shoes can limit pronation [4], [40], [41] which may reduce the incidence,

Acknowledgements

This research was supported by BOF-RUG 01109001. The authors acknowledge Dr. Jan Verstuyft for data collection of injury occurrence, Ing. Pierre Van Cleven for technical support in data collection of plantar pressure and kinematics and Friso Hagman for model building.

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