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

Journal of Foot and Ankle Research, Dec 2014

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.

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

Journal of Foot and Ankle Research Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis Bradley S Neal 0 1 Ian B Griffiths 1 Geoffrey J Dowling 2 George S Murley 2 6 Shannon E Munteanu 2 6 Melinda M Franettovich Smith 5 Natalie J Collins 4 Christian J Barton 0 1 3 6 0 Centre for Sports and Exercise Medicine, Queen Mary University of London , London , UK 1 Pure Sports Medicine , London , UK 2 Department of Podiatry, Faculty of Health Sciences, La Trobe University , Melbourne , Australia 3 Complete Sports Care , Melbourne , Australia 4 Department of Mechanical Engineering, Melbourne School of Engineering, The University of Melbourne , Melbourne , Australia 5 School of Physiotherapy, Australian Catholic University , Brisbane , Australia 6 Lower Extremity and Gait studies program, Faculty of Health Sciences, La Trobe University , Melbourne , Australia 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. Lower extremity; Foot; Pronation; Supination; Prospective studies; Risk factors; Musculoskeletal diseases; Review Background Identifying lower extremity musculoskeletal injury risk factors is important for sports medicine clinical practice and research, potentially allowing for the development of more effective and efficient prevention and management strategies. Several risk factors have been suggested to increase lower extremity injury risk, including increased body mass index [ 1 ], female sex [ 2 ] and altered hip mechanics [ 3 ]. Foot pronation as a potential lower extremity overuse injury risk factor has received great attention in research and clinical practice. Historically, foot mechanics are considered to contribute to lower extremity malalignment and pathology proximal to the foot via joint coupling with tibial internal rotation [ 4 ]. Research has suggested that rearfoot motion (eversion) closely corresponds with tibial motion (internal rotation) [ 5,6 ] and is potentially associated with transverse plane rotations at the hip [7]. Based on this model of lower extremity joint coupling, there has long been a theoretical link between foot pronation and lower extremity pathologies including exercise related lower extremity injury, medial tibial stress syndrome (MTSS) and patellofemoral pain [ 1,8,9 ]. At the other end of the spectrum increased foot supination has been linked to lower extremity injury via a mechanism of increased limb stiffness and subsequent vertical loading rates [ 10 ]. Considering the hypothesised link between foot posture and lower extremity injury, static foot posture is frequently assessed in the clinical setting, with a belief that this may (...truncated)


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Bradley S Neal, Ian B Griffiths, Geoffrey J Dowling, George S Murley, Shannon E Munteanu, Melinda M Franettovich Smith, Natalie J Collins, Christian J Barton. Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis, Journal of Foot and Ankle Research, 2014, pp. 55, 7, DOI: 10.1186/s13047-014-0055-4