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      Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis

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          Abstract

          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 injury).

          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.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13047-014-0055-4) contains supplementary material, which is available to authorized users.

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          Most cited references63

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          A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort.

          Patellofemoral pain syndrome is one of the most common chronic knee injuries; however, little research has been done to determine the risk factors for this injury. Altered lower extremity kinematics and kinetics, decreased strength, and altered postural measurements will be risk factors. Cohort study (prognosis); Level of evidence, 2. A total of 1597 participants were enrolled in this investigation and prospectively followed from the date of their enrollment (July 2005, July 2006, or July 2007) through January 2008, a maximum of 2.5 years of follow-up. Each participant underwent baseline data collection during their pre-freshman summer at the United States Naval Academy. Baseline data collection included 3-dimensional motion analysis during a jump-landing task, 6 lower extremity isometric strength tests, and postural alignment measurements (navicular drop and Q angle). Risk factors for the development of patellofemoral pain syndrome included decreased knee flexion angle, decreased vertical ground-reaction force, and increased hip internal rotation angle during the jump-landing task. Additionally, decreased quadriceps and hamstring strength, increased hip external rotator strength, and increased navicular drop were risk factors for the development of patellofemoral pain syndrome. Multiple modifiable risk factors for patellofemoral pain syndrome pain have been identified in this investigation. To decrease the incidence of this chronic injury, the risk factors for patellofemoral pain syndrome need to be targeted in injury prevention programs. Prevention programs should focus on increasing strength of the lower extremity musculature along with instructing proper mechanics during dynamic movements to decrease the incidence of patellofemoral pain syndrome.
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            Two feet, or one person? Problems associated with statistical analysis of paired data in foot and ankle medicine

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              Predictors of running-related injuries in novice runners enrolled in a systematic training program: a prospective cohort study.

              The popularity of running is still growing. As participation increases, running-related injuries also increase. Until now, little is known about the predictors for injuries in novice runners. Predictors for running-related injuries (RRIs) will differ between male and female novice runners. Cohort study; Level of evidence, 2. Participants were 532 novice runners (226 men, 306 women) preparing for a recreational 4-mile (6.7-km) running event. After completing a baseline questionnaire and undergoing an orthopaedic examination, they were followed during the training period of 13 weeks. An RRI was defined as any self-reported running-related musculoskeletal pain of the lower extremity or back causing a restriction of running for at least 1 week. Twenty-one percent of the novice runners had at least one RRI during follow-up. The multivariate adjusted Cox regression model for male participants showed that body mass index (BMI) (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.05-1.26), previous injury in the past year (HR, 2.7; 95% CI, 1.36-5.55), and previous participation in sports without axial load (HR, 2.05; 95% CI, 1.03-4.11) were associated with RRI. In female participants, only navicular drop (HR, 0.85; 95% CI, 0.75-0.97) remained a significant predictor for RRI in the multivariate Cox regression modeling. Type A behavior and range of motion (ROM) of the hip and ankle did not affect risk. Male and female novice runners have different risk profiles. Higher BMI, previous injury, and previous sports participation without axial loading are important predictors for RRI in male participants. Further research is needed to detect more predictors for female novice runners.
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                Author and article information

                Contributors
                brad.neal@puresportsmed.com
                ian@sportspodiatryinfo.co.uk
                geoff.dowling88@gmail.com
                g.murley@latrobe.edu.au
                s.munteanu@latrobe.edu.au
                Melinda.Smith@acu.edu.au
                n.collins@unimelb.edu.au
                christian@completesportscare.com.au
                Journal
                J Foot Ankle Res
                J Foot Ankle Res
                Journal of Foot and Ankle Research
                BioMed Central (London )
                1757-1146
                19 December 2014
                19 December 2014
                2014
                : 7
                : 1
                : 55
                Affiliations
                [ ]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
                [ ]Lower 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, Australia
                [ ]Complete Sports Care, Melbourne, Australia
                Article
                55
                10.1186/s13047-014-0055-4
                4282737
                25558288
                d2ebd660-4b80-489b-9822-c53922b67a71
                © Neal et al.; licensee BioMed Central. 2014

                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.

                History
                : 27 August 2014
                : 30 November 2014
                Categories
                Review
                Custom metadata
                © The Author(s) 2014

                Orthopedics
                lower extremity,foot,pronation,supination,prospective studies,risk factors,musculoskeletal diseases,review

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