Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion

Running with injury: A study of UK novice and recreational runners and factors associated with running related injury

OBJECTIVES

To investigate the incidence and type of running related injuries in novice and recreational UK runners, and identify factors associated with injury.

DESIGN

Retrospective cross-sectional study.

METHODS

Novice and recreational runners were recruited through UK parkrun to complete a web-based survey. 1145 respondents reported information on demographics, personal characteristics, and running training characteristics (training goal, novice runners' training plans, frequency of running, running experience, running terrain). Current and previous injuries were self-reported and questions from the Oslo Sports Trauma Centre Questionnaire for overuse injury were completed. Chi-squared tests and binomial logistic regression were performed.

RESULTS

570 runners had a current injury and 86% were continuing to run despite their injury causing pain, directly affecting their performance and causing a reduction of running volume. In the first year of running, runners using a self-devised training programme were more likely to be injured compared with using a structured programme such as Couch to 5K. Running experience of over 2 years was protective (OR 0.578-0.65). Males were 1.45 times more likely to be injured. Other factors associated with current injury were wearing orthotics (OR 1.88), and lack of previous injuries in the past 12 months (OR 1.44).

CONCLUSIONS

More experienced runners have a lower rate of injury. A novice runner should use a recognised structured training programme. These results suggest that graduated loading is important for novice runners, and that load modification may be important whilst recovering from an injury, however full recovery from previous injury may prevent future injury.

Development, content validity and test-retest reliability of the Lifelong Physical Activity Skills Battery in adolescents

Numerous skill batteries assess fundamental motor skill (e.g., kick, hop) competence. Few skill batteries examine lifelong physical activity skill competence (e.g., resistance training). This study aimed to develop and assess the content validity, test-retest and inter-rater reliability of the "Lifelong Physical Activity Skills Battery". Development of the skill battery occurred in three stages: i) systematic reviews of lifelong physical activity participation rates and existing motor skill assessment tools, ii) practitioner consultation and iii) research expert consultation. The final battery included eight skills: grapevine, golf swing, jog, push-up, squat, tennis forehand, upward dog and warrior I. Adolescents (28 boys, 29 girls; M = 15.8 years, SD = 0.4 years) completed the Lifelong Physical Activity Skills Battery on two occasions two weeks apart. The skill battery was highly reliable (ICC = 0.84, 95% CI = 0.72-0.90) with individual skill reliability scores ranging from moderate (warrior I; ICC = 0.56) to high (tennis forehand; ICC = 0.82). Typical error (4.0; 95% CI 3.4-5.0) and proportional bias (r = -0.21, p = .323) were low. This study has provided preliminary evidence for the content validity and reliability of the Lifelong Physical Activity Skills Battery in an adolescent population.

Changes in gluteal muscle forces with alteration of footstrike pattern during running

Gait retraining is a common form of treatment for running related injuries. Proximal factors at the hip have been postulated as having a role in the development of running related injuries. How altering footstrike affects hip muscles forces and kinematics has not been described. Thus, we aimed to quantify differences in hip muscle forces and hip kinematics that may occur when healthy runners are instructed to alter their foot strike pattern from their habitual rear-foot strike to a forefoot strike. This may gain insight on the potential etiology and treatment methods of running related lower extremity injury. Twenty-five healthy female runners completed a minimum of 10 running trials in a controlled laboratory setting under rear-foot strike and instructed forefoot strike conditions. Kinetic and kinematic data were used in an inverse dynamic based static optimization to estimate individual muscle forces during running. Within subject differences were investigated using a repeated measures multi-variate analysis of variance. Peak gluteus medius and minimus and hamstring forces were reduced while peak gluteus maximus force was increased when running with an instructed forefoot strike pattern. Peak hip adduction, hip internal rotation, and heel-COM distance were also reduced. Therefore, instructing habitual rearfoot strike runners to run with a forefoot strike pattern resulted in changes in peak gluteal and hamstring muscle forces and hip kinematics. These changes may be beneficial to the development and treatment of running related lower extremity injury.

Shoe cushioning, body mass and running biomechanics as risk factors for running injury: a study protocol for a randomised controlled trial

INTRODUCTION

Repetitive loading of the musculoskeletal system is suggested to be involved in the underlying mechanism of the majority of running-related injuries (RRIs). Accordingly, heavier runners are assumed to be at a higher risk of RRI. The cushioning system of modern running shoes is expected to protect runners again high impact forces, and therefore, RRI. However, the role of shoe cushioning in injury prevention remains unclear. The main aim of this study is to investigate the influence of shoe cushioning and body mass on RRI risk, while exploring simultaneously the association between running technique and RRI risk.

METHODS AND ANALYSIS

This double-blinded randomised controlled trial will involve about 800 healthy leisure-time runners. They will randomly receive one of two running shoe models that will differ in their cushioning properties (ie, stiffness) by ~35%. The participants will perform a running test on an instrumented treadmill at their preferred running speed at baseline. Then they will be followed up prospectively over a 6-month period, during which they will self-report all their sports activities as well as any injury in an internet-based database TIPPS (Training and Injury Prevention Platform for Sports). Cox regression analyses will be used to compare injury risk between the study groups and to investigate the association among training, biomechanical and anatomical risk factors, and injury risk.

ETHICS AND DISSEMINATION

The study was approved by the National Ethics Committee for Research (Ref: 201701/02 v1.1). Outcomes will be disseminated through publications in peer-reviewed journals, presentations at international conferences, as well as articles in popular magazines and on specialised websites.

TRIAL REGISTRATION NUMBER

NCT03115437, Pre-results.

Rehabilitation and Prevention of Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy (PHT) comprises a small but significant portion of hamstring injuries in athletes, especially runners. PHT is a chronic condition that is clinically diagnosed but can be supported with imaging. The main presenting complaint is pain in the lower gluteal or ischial region that may or may not radiate along the hamstrings in the posterior thigh. There is little scientific evidence on which to base the rehabilitation management of PHT. Treatment is almost always conservative, with a focus on activity modification, addressing contributing biomechanical deficiencies, effective tendon loading including eccentric training, and ultrasound-guided interventional procedures which may facilitate rehabilitation. Surgery is limited to recalcitrant cases or those involving concomitant high-grade musculotendinous pathology. The keys to PHT management include early and accurate diagnosis, optimal rehabilitation to allow for a safe return to preinjury activity level, and preventative strategies to reduce risk of reinjury.

Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial

Design

Single-blind randomised clinical trial.

Objective

To compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP).

Methods

Sixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8 and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0 and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance.

Results

No significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8 and T20 compared with T0 (p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%).

Conclusion

Even though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP.

Trial registration number

ClinicalTrials.gov (NCT02352909).

Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis

OBJECTIVE

To produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.

DESIGN

A systematic review of exercises used in overhead athletes including case studies and clinical commentaries.

DATA SOURCES

MEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.

METHODS

We examined data from randomised controlled trials and prospective cohort (level I-IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A-F) recommendations (Centre for Evidence-Based Medicine).

RESULTS

There were 33 unique exercises in six level I-IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90^o of elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.

CONCLUSIONS AND RELEVANCE

Overall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.