A prospective study of gait related risk factors for exercise-related lower leg pain
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.
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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.
References (41)
- et al.
Temporal characteristics of foot rollover during barefoot jogging: reference data for young adults
Gait Posture
(2005) - et al.
Relationship between gait biomechanics and inversion sprains: a prospective study on risk factors
Gait Posture
(2005) - et al.
Ground reaction forces in distance running
J Biomech
(1980) - et al.
Pressure and force distribution characteristics under the normal foot during the push-off phase in gait
Foot
(1999) Tibial stress injuries – an aetiological review for the purposes of guiding management
Sports Med
(1998)Exercise-related lower leg pain: an overview
Med Sci Sports Exerc
(2000)- et al.
Risk factors for lower extremity injury: a review of the literature
Br J Sports Med
(2003) - et al.
The prevention of shin splints in sports: a systematic review of literature
Med Sci Sports Exerc
(2002) Shin splints – a review of terminology
Clin J Sports Med
(1995)- et al.
Etiologic factors associated with selected running injuries
Med Sci Sports Exerc
(1988)
Some biomechanical aspects of the foot and ankle in athletes with and without shin splints
Am J Sports Med
Factors contributing to the development of medial tibial stress syndrome in high school runner
J Orthop Sports Phys Ther
Effect of foot posture on the incidence of medial tibial stress syndrome
Med Sci Sports Exerc
The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits
Am J Sports Med
The influence of foot abduction on differences between two-dimensional and three-dimensional rearfoot motion
Foot Ankle Int
Three-dimensional kinetic analysis of running: significance of secondary planes of motion
Med Sci Sports Exerc
Within-subject variability of plantar pressure patterns in barefoot running
Within-subject variability of lower leg kinematic data during barefoot running
Gait Posture
Lower extremity goniometric measurements: a study to determine their reliability
Archiv Phys Med Rehabil
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