The Effectiveness of Gait Retraining on Running Kinematics, Kinetics, Performance, Pain, and Injury in Distance Runners: A Systematic Review With Meta-analysis

Running-Centred Injury Prevention Support: A Scoping Review on Current Injury Risk Reduction Practices for Runners

Background: Runners have not benefited from the same reduction in injury rates seen in injury prevention studies conducted in other sports. Objectives: The purpose of this scoping review was to identify and map injury risk reduction practices for running-related injury (RRI), methods of delivery and understand the views of experts and runner's preferences in reducing RRI. Design: Scoping review. Methods: We conducted systematic database searches of MEDLINE, CINAHL and SPORTDiscus from 2000 to April 2024. Eligible studies included injury prevention strategies for RRI. Data synthesis was conducted according to PRISMA Extension for Scoping Reviews using Joanna Briggs Institute framework methodology. Extracted data were mapped and coded from intervention studies, expert opinions and reviews, and inductive thematic analysis created subthemes and themes from prospective cohorts, qualitative studies and surveys. Results: A total of 3777 studies were identified, and 106 studies met the inclusion criteria. In intervention studies, supervision and support appeared critical for better effect. Key injury prevention topics were strengthening, gait re-education and wearables, graduated running programmes, footwear, recovery and educational advice. A multifactorial approach considering individual risk profiles was recommended by experts, but there was a disparity in what runners do to reduce injury risk compared to expert advice, with actions appearing to be related to self-efficacy rather than avoidance. Conclusion: This scoping review highlighted runners require individualized, supported and multifactorial approaches for injury risk reduction, and runners seek knowledge on purpose. We found runners injury risk reduction practices should begin early with youth runners and facilitating this through coaching supervision is likely to support behaviour change. Strategies such as gait retraining, wearables and recovery need further exploration but provide promising strategies runners may engage with more. As runners are likely to choose familiar options minimally impacting lifestyle and running, they should be provided with education but need support with their choices to influence beliefs.

The Effects of Running Foot Strike Manipulation on Pelvic Floor Muscle Activity in Healthy Nulliparous Females

Vertical loading rate (VLR) and pelvic floor muscle activity (PFA) increase with running velocity, which may indicate a relationship between VLR and PFA. Foot strike pattern has been shown to influence VLR while running, but little is known about its influence on PFA. Twenty healthy women ran on a treadmill for 2 conditions: with a rearfoot strike and with a forefoot strike. PFA was measured with electromyography. Running kinematics associated with VLR were collected using inertial measurement units and tibial accelerometers. Change scores between conditions were calculated for average PFA and running kinematics: peak vertical tibial acceleration, vertical excursion of the center of mass (VO), and cadence. Paired t tests assessed differences between running conditions for all variables. Pearson correlations assessed the relationships between changes in PFA and running kinematics. PFA was significantly higher during the forefoot compared with the rearfoot strike condition. Change in vertical tibial acceleration was positively correlated with change in PFA during the right stance. Change in cadence was negatively correlated, and change in vertical excursion of the center of mass was positively correlated with change in PFA during left stance. The average PFA increased during the forefoot strike pattern condition. Changes in PFA were correlated with changes in running kinematics associated with VLR.

Prevalence and Risk Factors for Musculoskeletal Pain when Running During Pregnancy: A Survey of 3102 Women

BACKGROUND

Musculoskeletal pain while running is a concern to women during pregnancy and can lead to running cessation. To support women who wish to run during pregnancy, it is essential to understand the sites, severities and personal risk factors associated with musculoskeletal pain.

OBJECTIVE

The aim was to investigate prevalence and risk factors for musculoskeletal pain when running during pregnancy.

METHODS

An online survey was completed by women who had a child in the past 5 years and ran prior to and during pregnancy. Pain frequency informed prevalence rates by body site, and logistic regression odds ratios (ORs) and 95% confidence intervals were calculated.

RESULTS

A total of 3102 women of 23 ethnicities from 25 countries completed the survey. Women were 22-52 years old when they gave birth and ran 2-129 km/week during the 0.5-35 years before the birth of their youngest child. Women ran significantly less distance and less often during pregnancy than before pregnancy. Most women (86%) experienced pain while running during pregnancy (59% pelvis/sacroiliac joint, 52% lower back, 51% abdomen, 44% breast, 40% hip). The highest prevalence of severe-to-worst pain was at the pelvis/sacroiliac joint (9%). Women at greatest risk of pain while running during pregnancy had a previous injury (OR = 3.44) or were older (OR = 1.04). Women with a previous child were less likely to experience breast pain (OR = 0.76) than those running during their first pregnancy.

CONCLUSION

Healthcare practices to reduce pain should focus on regions of greatest musculoskeletal change during pregnancy, specifically the pelvis, lower back and abdomen. Efforts to support women to run for longer throughout pregnancy should focus on pain at the pelvis and breasts.

Cues to land softly and quietly result in acute reductions in ground reaction force loading rates in runners

BACKGROUND

A common gait retraining goal for runners is reducing vertical ground reaction force (GRF) loading rates (LRs), which have been associated with injury. Many gait retraining programs prioritize an internal focus of attention, despite evidence supporting an external focus of attention when a specific outcome is desired (e.g., LR reduction).

RESEARCH QUESTION

Does an external focus of attention (using cues for quiet, soft landings) result in comparable reductions in LRs to those achieved using a common internal focus (forefoot striking while barefoot)?

METHODS

This observational study included 37 injured runners (18 male; mean age 36 (14) years) at the OMITTED Running Center. Runners wore inertial measurement units over the distal-medial tibia while running on an instrumented treadmill at a self-selected speed. Data were collected for three conditions: 1) Shod-Control (wearing shoes, without cues); 2) Shod-Quiet (wearing shoes, cues for quiet, soft landings); and 3) Barefoot-FFS (barefoot, cues for forefoot strike (FFS)). Within-subject variables were compared across conditions: vertical instantaneous loading rate (LR, primary outcome); vertical stiffness during initial loading; peak vertical GRF; peak vertical tibial acceleration (TA); and cadence.

RESULTS

Vertical LR, stiffness, and TA were lower in the Shod-Quiet compared to Shod-Control p < 0.001). Peak vertical GRF and cadence were not different between Shod-Quiet and Shod-Control. Reductions in stiffness and LR were similar between Shod-Quiet and Barefoot-FFS, and GRF in Barefoot-FFS remained similar to both shod conditions. However, runners demonstrated additional reductions in TA and increased cadence when transitioning from Shod-Quiet to the Barefoot-FFS condition (p < 0.05).

SIGNIFICANCE

These results suggests that a focus on quiet, soft landings may be an effective gait retraining method for future research.

A One Session Gait Retraining Protocol with Metronome Augmentation Increases Cadence in Novice and Recreational Runners

Background

Running is a common leisure physical activity that carries a risk for running related injury (RRI). Non-experienced runners are more likely to sustain RRIs. One form of gait retraining focuses on increasing cadence to improve running biomechanics related to RRI. Protocols for increasing cadence must be pragmatic to be implemented into clinical practice.

Hypothesis/Purpose

The purpose of this study was to determine if a pragmatic protocol including one instructional session, followed by independent gait retraining with metronome augmentation resulted in increased cadence and altered biomechanics in novice and recreational runners.

Study Design

Randomized Controlled Trial.

Methods

Thirty-three novice or recreational adult runners completed a 12 Minute Cooper Run on an indoor track. Variables measured during the 12 Minute Cooper Run included distance, rate of perceived exertion (RPE), heart rate (HR), and 3-D biomechanics using inertial measurement units (IMUs). After baseline testing, the intervention group received instruction and five minutes of gait retraining at a cadence set 5-10% higher than baseline with metronome augmentation (Pro Metronome- Tempo, Beat; by Xiao Yixiang). They then ran two to three times a week for two weeks up to 30 minutes per session with the metronome set at the new cadence. After two weeks, repeat testing using the same protocol was completed. A Mann-Whitney U test analyzed differences between groups.

Results

Cadence at one minute (p = 0.037) and average cadence over the entire run (p=0.002) increased in the intervention group only with a large effect size (Cohens d = 0.837). No other group differences were found.

Conclusion

A pragmatic gait retraining protocol with metronome augmentation including one instructional and four to six independent sessions over a two-week duration increased cadence without negative effects on HR, RPE, distance. Biomechanics did not change with this intervention. Further research with pragmatic gait retraining protocols that increase cadence are needed with larger sample sizes, repeated measures over time, across runners of various abilities and experience levels.

Level of Evidence

Level 2.

Foot and Ankle Muscle Isometric Strength in Nonrearfoot Compared With Rearfoot Endurance Runners

Background

Transitioning to a forefoot strike pattern can be used to manage running-related knee injuries. However, adopting a nonrearfoot strike induces a higher load on foot and ankle structures than rearfoot strike. Sufficient foot muscle strength is also necessary to prevent excessive longitudinal arch (LA) deformation when running with nonrearfoot strike. The aim of this study was to investigate the potential differences in foot-ankle muscle strength between RF and NRF runners.

Methods

A cross-sectional study including 40 RF and 40 NRF runners was conducted. The foot posture and the maximal voluntary isometric strength (MVIS) of 6 foot-ankle muscles were measured. The footstrike pattern was determined using a 2-D camera during a self-paced run on a treadmill.

Results

NRF had higher MVIS for ankle plantar flexor (+12.5%, P = .015), ankle dorsiflexor (+17.7%, P = .01), hallux flexor (+11%, P = .04), and lesser toe flexor (+20.8%, P = .0031). We found a small positive correlation between MVIS of ankle plantar flexor with MVIS of hallux flexor (r = 0.26; P = .01) and lesser toe flexor (r = 0.28; P = .01).

Conclusion

In this cross-sectional study, we found that NRF runners on average have a higher MVIS of hallux and lesser toe flexor compared with RF runners. NRF runners also have a higher MVIS of ankle plantar flexor and dorsiflexor than RF runners. We found only a small correlation between ankle plantar flexor and foot muscle strength.

Level of Evidence

Level III, case-control study.

Wearables for running gait analysis: A study protocol

Quantitative running gait analysis is an important tool that provides beneficial outcomes to injury risk/recovery or performance assessment. Wearable devices have allowed running gait to be evaluated in any environment (i.e., laboratory or real-world settings), yet there are a plethora of different grades of devices (i.e., research-grade, commercial, or novel multi-modal) available with little information to make informed decisions on selection. This paper outlines a protocol that will examine different grades of wearables for running gait analysis in healthy individuals. Specifically, this pilot study will: 1) examine analytical validity and reliability of wearables (research-grade, commercial, high-end multimodal) within a controlled laboratory setting; 2) examine analytical validation of different grades of wearables in a real-world setting, and 3) explore clinical validation and usability of wearables for running gait analysis (e.g., injury history (previously injured, never injured), performance level (novice, elite) and relationship to meaningful outcomes). The different grades of wearable include: (1) A research-grade device, the Ax6 consists of a configurable tri-axial accelerometer and tri-axial gyroscope with variable sampling capabilities; (2) attainable (low-grade) commercial with proprietary software, the DorsaVi ViMove2 consisting of two, non-configurable IMUs modules, with a fixed sampling rate and (3) novel multimodal high-end system, the DANU Sports System that is a pair of textile socks, that contain silicone based capacitive pressure sensors, and configurable IMU modules with variable sampling rates. Clinical trial registration: Trial registration: NCT05277181.

Cumulative patellofemoral force and stress are lower during faster running compared to slower running in recreational runners

Management strategies for patellofemoral pain often involve modifying running distance or speed. However, the optimal modification strategy to manage patellofemoral joint (PFJ) force and stress accumulated during running warrants further investigation. This study investigated the effect of running speed on peak and cumulative PFJ force and stress in recreational runners. Twenty recreational runners ran on an instrumented treadmill at four speeds (2.5-4.2 m/s). A musculoskeletal model derived peak and cumulative (per 1 km of continuous running) PFJ force and stress for each speed. Cumulative PFJ force and stress decreased with faster speeds (9.3-33.6% reduction for 3.1-4.2 m/s vs. 2.5 m/s). Peak PFJ force and stress significantly increased with faster speeds (9.3-35.6% increase for 3.1-4.2 m/s vs. 2.5 m/s). The largest cumulative PFJ kinetics reductions occurred when speeds increased from 2.5 to 3.1 m/s (13.7-14.2%). Running at faster speeds increases the magnitude of peak PFJ kinetics but conversely results in less accumulated force over a set distance. Selecting moderate running speeds (~3.1 m/s) with reduced training duration or an interval-based approach may be more effective for managing cumulative PFJ kinetics compared to running at slow speeds.

The "impacts cause injury" hypothesis: Running in circles or making new strides?

Some of the earliest biomechanics research focused on running and the ground reaction forces generated with each step. Research in running gait accelerated in the 1970's as the growing popularity in running increased attention to the musculoskeletal injuries sustained by runners. Despite decades of high-quality research, running remains the most common cause of exercise-related musculoskeletal injuries and rates of overuse running-related injuries (RRI) have not appreciably declined since the research began. One leading area of running gait research focuses on discrete variables derived from the vertical ground reaction force, such as the vertical loading rate. Across sub-disciplines of running gait research, vertical loading rate is often discussed as the primary and undisputed variable associated with RRI despite only low to moderate evidence that retrospectively or prospectively injured runners generate greater vertical loading rates than uninjured counterparts. The central thesis of this review is that relying on vertical loading rate is insufficient to establish causal mechanisms for RRI etiology. To present this argument, this review examines the history of the 'impacts cause injury' hypothesis, including a historical look at ground reaction forces in human running and the research from which this hypothesis was generated. Additionally, a synthesis of studies that have tested the hypothesis is provided and recommendations for future research are discussed. Although it is premature to reject or support the 'impacts cause injury' hypothesis, new knowledge of biomechanical risk factors for RRI will remain concealed until research departs from the current path or adopts new approaches to previous paradigms.

Impact of biomechanics on therapeutic interventions and rehabilitation for major chronic musculoskeletal conditions: A 50-year perspective

The pivotal role of biomechanics in the past 50 years in consolidating the basic knowledge that underpins prevention and rehabilitation measures has made this area a great spotlight for health practitioners. In clinical practice, biomechanics analysis of spatiotemporal, kinematic, kinetic, and electromyographic data in various chronic conditions serves to directly enhance deeper understanding of locomotion and the consequences of musculoskeletal dysfunctions in terms of motion and motor control. It also serves to propose straightforward and tailored interventions. The importance of this approach is supported by myriad biomechanical outcomes in clinical trials and by the development of new interventions clearly grounded on biomechanical principles. Over the past five decades, therapeutic interventions have been transformed from fundamentally passive in essence, such as orthoses and footwear, to emphasizing active prevention, including exercise approaches, such as bottom-up and top-down strengthening programs for runners and people with osteoarthritis. These approaches may be far more effective inreducing pain, dysfunction, and, ideally, incidence if they are based on the biomechanical status of the affected person. In this review, we demonstrate evidence of the impact of biomechanics and motion analysis as a foundation for physical therapy/rehabilitation and preventive strategies for three chronic conditions of high worldwide prevalence: diabetes and peripheral neuropathy, knee osteoarthritis, and running-related injuries. We conclude with a summary of recommendations for future studies needed to address current research gaps.

Running gait modifications can lead to immediate reductions in patellofemoral pain

Gait modifications are commonly advocated to decrease knee forces and pain in runners with patellofemoral pain (PFP). However, it remains unknown if clinicians can expect immediate effects on symptoms. Our objectives were (1) to compare the immediate effects of gait modifications on pain and kinetics of runners with PFP; (2) to compare kinetic changes in responders and non-responders; and (3) to compare the effects between rearfoot strikers (RFS) and non-RFS. Sixty-eight runners with PFP (42 women, 26 men) ran normally on a treadmill before testing six modifications: 1- increase step rate by 10%; 2- 180 steps per minute; 3- decrease step rate by 10%; 4- forefoot striking; 5- heel striking; 6- running softer. Overall, there were more responders (pain decreased ≥1/10 compared with normal gait) during forefoot striking and increasing step rate by 10% (both 35%). Responders showed greater reductions in peak patellofemoral joint force than non-responders during all conditions except heel striking. When compared with non-RFS, RFS reduced peak patellofemoral joint force in a significant manner (P < 0.001) during forefoot striking (partial η ² = 0.452) and running softer (partial η ² = 0.302). Increasing step rate by 10% reduced peak patellofemoral joint force in both RFS and non-RFS. Forty-two percent of symptomatic runners reported immediate reductions in pain during ≥1 modification, and 28% had reduced pain during ≥3 modifications. Gait modifications leading to decreased patellofemoral joint forces may be associated with immediate pain reductions in runners with PFP. Other mechanisms may be involved, given that some runners reported decreased symptoms regardless of kinetic changes.

Clinical Application of Gait Retraining in the Injured Runner

Despite its positive influence on physical and mental wellbeing, running is associated with a high incidence of musculoskeletal injury. Potential modifiable risk factors for running-related injury have been identified, including running biomechanics. Gait retraining is used to address these biomechanical risk factors in injured runners. While recent systematic reviews of biomechanical risk factors for running-related injury and gait retraining have been conducted, there is a lack of information surrounding the translation of gait retraining for injured runners into clinical settings. Gait retraining studies in patients with patellofemoral pain syndrome have shown a decrease in pain and increase in functionality through increasing cadence, decreasing hip adduction, transitioning to a non-rearfoot strike pattern, increasing forward trunk lean, or a combination of some of these techniques. This literature suggests that gait retraining could be applied to the treatment of other injuries in runners, although there is limited evidence to support this specific to other running-related injuries. Components of successful gait retraining to treat injured runners with running-related injuries are presented.