Abstract
Background
Overuse injuries are multifactorial resulting from cumulative loading. Therefore, clear differences between normal and at-risk individuals may not be present for individual risk factors. Using a holistic measure that incorporates many of the identified risk factors, focusing on multiple joint movement patterns may give better insight into overuse injuries. Lower body stiffness may provide such a measure.
Objective
To identify how risk factors for Achilles tendon injuries influence measures of lower body stiffness.
Methods
SPORTDiscus, Web of Science, CINAHL and PubMed were searched for Achilles tendon injury risk factors related to vertical, leg and joint stiffness in running athletes.
Results
Increased braking force and low surface stiffness, which were clearly associated with increased risk of Achilles tendon injuries, were also found to be associated with increased lower body stiffness. High arches and increased vertical and propulsive forces were protective for Achilles tendon injuries and were also associated with increased lower body stiffness. Risk factors for Achilles tendon injuries that had unclear associations were also investigated with the evidence trending towards an increase in leg stiffness and a decrease in ankle stiffness being detrimental to Achilles tendon health.
Conclusion
Few studies have investigated the link between lower body stiffness and Achilles injury. High stiffness is potentially associated with risk factors for Achilles tendon injuries although some of the evidence is controversial. Prospective injury studies are needed to confirm this relationship. Large amounts of high-intensity or high-speed work or running on soft surfaces such as sand may increase Achilles injury risk. Coaches and clinicians working with athletes with new or reoccurring injuries should consider training practices of the athlete and recommend reducing speed or sand running if loading is deemed to be excessive.
Similar content being viewed by others
References
Vleck V, Garbutt G. Overuse injury prevalence and associated risk factors in male national squad and club triathletes training for the 1.5 km, 40 km, 10 km, triathlon. J Sports Sci. 1998;16(1):66.
Vleck VE, Garbutt G. Injury and training characteristics of male elite, development squad, and club triathletes. Int J Sports Med. 1998;19(1):38–42.
Lersch C, Grötsch A, Segesser B, et al. Influence of calcaneus angle and muscle forces on strain distribution in the human achilles tendon. Clin Biomech. 2012;27(9):955–61.
Bojsen-Møller J, Hansen P, Aagaard P, et al. Differential displacement of the human soleus and medial gastrocnemius aponeuroses during isometric plantar flexor contractions in vivo. J Appl Physiol. 2004;97(5):1908–14.
Farris DJ, Trewartha G, Polly McGuigan M. Could intra-tendinous hyperthermia during running explain chronic injury of the human achilles tendon? J Biomech. 2011;44(5):822–6.
Wilson AM, Goodship AE. Exercise-induced hyperthermia as a possible mechanism for tendon degeneration. J Biomech. 1994;27(7):899–905.
Wyndow N, Cowan SM, Wrigley TV, et al. Neuromotor control of the lower limb in achilles tendinopathy: Implications for foot orthotic therapy. Sports Med. 2010;40(9):715–27.
Wren TAL, Lindsey DP, Beaupré GS, et al. Effects of creep and cyclic loading on the mechanical properties and failure of human achilles tendons. Ann Biomed Eng. 2003;31(6):710–7.
Ericson MO, Ekholm J, Svensson O, et al. The forces of ankle joint structures during ergometer cycling. Foot Ankle Int. 1985;6(3):135–42.
Giddings VL, Beaupre GS, Whalen RT, et al. Calcaneal loading during walking and running. Med Sci Sports Exerc. 2000;32(3):627–34.
Gregor R, Komi P, Järvinen M. Achilles tendon forces during cycling. Int J Sports Med. 1987;8(S1):S9–14.
Lorimer AV, Hume PA. Achilles tendon injury risk factors associated with running. Sports Med. 2014;44(10):1459–72.
Davids K, Button C, Bennett S. Physical constraints on coordination: Dynamical systems theory. Dynamics of skill acquisition: A constraints-led approach. Champaign: Human Kinetics; 2008. p. 29–53.
Davids K, Glazier P, Araujo D, et al. Movement systems as dynamical systems: the functional role of variability and its implications for sports medicine. Sports Med. 2003;33(4):245–60.
Hamill J, Palmer C, Van Emmerik RE. Coordinative variability and overuse injury. Sports Med Arthrosc Rehabil Ther Technol. 2012;4(1):45.
Hamill J, van Emmerik RE, Heiderscheit BC, et al. A dynamical systems approach to lower extremity running injuries. Clin Biomech. 1999;14(5):297–308.
Debenham JR, Travers MJ, Gibson W, et al. Achilles tendinopathy alters stretch shortening cycle behaviour during a sub-maximal hopping task. J Sci Med Sport. 2016;19(1):69–73.
Blickhan R. The spring-mass model for running and hopping. J Biomech. 1989;22(11–12):1217–27.
McMahon TA, Cheng GC. The mechanics of running: how does stiffness couple with speed? J Biomech. 1990;23(S1):65–78.
Seyfarth A, Geyer H, Günther M, et al. A movement criterion for running. J Biomech. 2002;35(5):649–55.
Duysens J, Van de Crommert HWAA. Neural control of locomotion part 1: the central pattern generator from cats to humans. Gait Posture. 1998;7(2):131–41.
Ijspeert AJ. Central pattern generators for locomotion control in animals and robots: a review. Neural Networks. 2008;21(4):642–53.
Higgins JP, Green S, Collaboration C. Cochrane handbook for systematic reviews of interventions. Chichester: Wiley; 2008.
Maher CG, Sherrington C, Herbert RD, et al. Reliability of the pedro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.
Bizzini M, Childs JD, Piva SR, et al. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33(1):4–20.
Dunlap WP, Cortina JM, Vaslow JB, et al. Meta-analysis of experiments with matched groups or repeated measures designs. Psychol Methods. 1996;1(2):170–7.
Cavanagh PR, Kram R. Stride length in distance running: Velocity, body dimensions, and added mass effects. Med Sci Sports Exerc. 1989;21(4):467–79.
Bramble DM, Lieberman DE. Endurance running and the evolution of homo. Nature. 2004;432(7015):345–52.
Hopkins WG, Marshall SW, Batterham AM, et al. Progressive statistics for studies in sports medicine and exercise science. Med Sci Sports Exerc. 2009;41(1):3–13.
Girard O, Millet G, Slawinski J, et al. Changes in running mechanics and spring-mass behaviour during a 5-km time trial. Int J Sports Med. 2013;34(9):832–40.
Rabita G, Couturier A, Lambertz D. Intrinsic ankle and hopping leg-spring stiffness in distance runners and aerobic gymnasts. Int J Sports Med. 2011;32(7):552–8.
Dutto DJ, Smith GA. Changes in spring-mass characteristics during treadmill running to exhaustion. Med Sci Sports Exerc. 2002;34(8):1324–31.
Girard O, Micallef J-P, Millet GP. Changes in spring-mass model characteristics during repeated running sprints. Eur J Appl Physiol. 2011;111(1):125–34.
Ferris DP, Liang K, Farley CT. Runners adjust leg stiffness for their first step on a new running surface. J Biomech. 1999;32(8):787–94.
Ferris DP, Louie M, Farley CT. Running in the real world: adjusting leg stiffness for different surfaces. Proc Biol Sci. 1998;265(1400):989–94.
Kerdok AE, Biewener AA, McMahon TA, et al. Energetics and mechanics of human running on surfaces of different stiffnesses. J Appl Physiol. 2002;92(2):469–78.
Farley CT, Houdijk HHP, Van Strien C, et al. Mechanism of leg stiffness adjustment for hopping on surfaces of different stiffnesses. J Appl Physiol. 1998;85(3):1044–55.
Ferris DP, Farley CT. Interaction of leg stiffness and surface stiffness during human hopping. J Appl Physiol. 1997;82(1):15–22.
Moritz CT, Farley CT. Passive dynamics change leg mechanics for an unexpected surface during human hopping. J Appl Physiol. 2004;97(4):1313–22.
Baltich J, Maurer C, Nigg BM. Increased vertical impact forces and altered running mechanics with softer midsole shoes. PLoS ONE. 2015;10(4):e0125196.
Williams DS III, Davis IM, Scholz JP, et al. High-arched runners exhibit increased leg stiffness compared to low-arched runners. Gait Posture. 2004;19(3):263–9.
Arampatzis A, Bruggemann GP, Metzler V. The effect of speed on leg stiffness and joint kinetics in human running. J Biomech. 1999;32(12):1349–53.
Hobara H, Inoue K, Gomi K, et al. Continuous change in spring-mass characteristics during a 400 m sprint. J Sci Med Sport. 2010;13(2):256–61.
Morin J-B, Jeannin T, Chevallier B, et al. Spring-mass model characteristics during sprint running: correlation with performance and fatigue-induced changes. Int J Sports Med. 2006;27(2):158–65.
Kuitunen S, Komi PV, Kyrolainen H. Knee and ankle joint stiffness in sprint running. Med Sci Sports Exerc. 2002;34(1):166–73.
Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med. 1986;14(2):151–5.
Hobara H, Kanosue K, Suzuki S. Changes in muscle activity with increase in leg stiffness during hopping. Neurosci Lett. 2007;418(1):55–9.
Morin JB, Samozino P, Zameziati K, et al. Effects of altered stride frequency and contact time on leg-spring behavior in human running. J Biomech. 2007;40(15):3341–8.
Hayes PR, Caplan N. Leg stiffness decreases during a run to exhaustion at the speed at VO 2max. Eur J Sport Sci. 2014;14(6):556–62.
Hobara H, Inoue K, Muraoka T, et al. Leg stiffness adjustment for a range of hopping frequencies in humans. J Biomech. 2010;43(3):506–11.
Hoffrén M, Ishikawa M, Rantalainen T, et al. Age-related muscle activation profiles and joint stiffness regulation in repetitive hopping. J Electromyogr Kinesiol. 2011;21(3):483–91.
Austin GP, Tiberio D, Garrett GE. Effect of frequency on human unipedal hopping. Percept Motor Skill. 2002;95(3):733–40.
Farley CT, Gonzalez O. Leg stiffness and stride frequency in human running. J Biomech. 1996;29(2):181–6.
Hunter JP, Marshall RN, McNair PJ. Interaction of step length and step rate during sprint running. Med Sci Sports Exerc. 2004;36(2):261–71.
Hobara H, Inoue K, Kanosue K. Effect of hopping frequency on bilateral differences in leg stiffness. J Appl Biomech. 2013;29(1):55–60.
Hobara H, Inoue K, Omuro K, et al. Determinant of leg stiffness during hopping is frequency-dependent. Eur J Appl Physiol. 2011;111(9):2195–201.
Demirbüken İ, Yurdalan SU, Savelberg H, et al. Gender specific strategies in demanding hopping conditions. J Sports Sci Med. 2009;8(2):265–70.
Hobara H, Kato E, Kobayashi Y, et al. Sex differences in relationship between passive ankle stiffness and leg stiffness during hopping. J Biomech. 2012;45(16):2750–4.
Granata KP, Padua DA, Wilson SE. Gender differences in active musculoskeletal stiffness. Part ii. Quantification of leg stiffness during functional hopping tasks. J Electromyogr Kinesiol. 2002;12(2):127–35.
Padua DA, Arnold BL, Perrin DH, et al. Fatigue, vertical leg stiffness, and stiffness control strategies in males and females. J Athl Train. 2006;41(3):294–304.
Oliver JL, Smith PM. Neural control of leg stiffness during hopping in boys and men. J Electromyogr Kinesiol. 2010;20(5):973–9.
Hobara H, Kobayashi Y, Yoshida E, et al. Leg stiffness of older and younger individuals over a range of hopping frequencies. J Electromyogr Kinesiol. 2015;25(2):305–9.
Diss C, Gittoes MJ, Tong R, et al. Stance limb kinetics of older male athletes endurance running performance. Sports Biomech. 2015;24:1–10.
Divert C, Mornieux G, Freychat P, et al. Barefoot-shod running differences: shoe or mass effect? Int J Sports Med. 2008;29(6):512–8.
Lussiana T, Hebert-Losier K, Millet GP, et al. Biomechanical changes during a 50-min run in different footwear and on various slopes. J Appl Biomech. 2016;32(1):40–9.
Bishop M, Fiolkowski P, Conrad B, et al. Athletic footwear, leg stiffness, and running kinematics. J Athl Train. 2006;41(4):387–92.
Chambon N, Delattre N, Gueguen N, et al. Is midsole thickness a key parameter for the running pattern? Gait Posture. 2014;40(1):58–63.
Logan S, Hunter I, Hopkins JT, et al. Ground reaction force differences between running shoes, racing flats, and distance spikes in runners. J Sports Sci Med. 2010;9(1):147–53.
Kuitunen S, Ogiso K, Komi P. Leg and joint stiffness in human hopping. Scand J Med Sci Sport. 2011;21(6):e159–67.
Müller R, Grimmer S, Blickhan R. Running on uneven ground: leg adjustments by muscle pre-activation control. Hum Mov Sci. 2010;29(2):299–310.
Hobara H, Kimura K, Omuro K, et al. Differences in lower extremity stiffness between endurance-trained athletes and untrained subjects. J Sci Med Sport. 2010;13(1):106–11.
Roschel H, Barroso R, Tricoli V, et al. Effects of strength training associated with whole-body vibration training on running economy and vertical stiffness. J Strength Cond Res. 2015;29(8):2215–20.
Choukou M-A, Laffaye G, Heugas-De Panafieu A-M. Sprinter’s motor signature does not change with fatigue. Eur J Appl Physiol. 2012;112(4):1557–68.
Degache F, Guex K, Fourchet F, et al. Changes in running mechanics and spring-mass behaviour induced by a 5-hour hilly running bout. J Sports Sci. 2013;31(3):299–304.
Hunter I, Smith GA. Preferred and optimal stride frequency, stiffness and economy: changes with fatigue during a 1-h high-intensity run. Eur J Appl Physiol. 2007;100(6):653–61.
Millet GY, Divert C, Banizette M, et al. Changes in running pattern due to fatigue and cognitive load in orienteering. J Sports Sci. 2010;28(2):153–60.
Morin J, Tomazin K, Edouard P, et al. Changes in running mechanics and spring–mass behavior induced by a mountain ultra-marathon race. J Biomech. 2011;44(6):1104–7.
Morin J-B, Samozino P, Millet GY. Changes in running kinematics, kinetics, and spring-mass behavior over a 24-h run. Med Sci Sports Exerc. 2011;43(5):829–36.
Morin J-B, Tomazin K, Samozino P, et al. High-intensity sprint fatigue does not alter constant-submaximal velocity running mechanics and spring-mass behavior. Eur J Appl Physiol. 2012;112(4):1419–28.
Degache F, Morin JB, Oehen L, et al. Running mechanics during the world’s most challenging mountain ultra-marathon. Int J Sports Physiol Perform. 2015. doi:10.1123/ijspp.2015-0238.
Lazzer S, Taboga P, Salvadego D, et al. Factors affecting metabolic cost of transport during a multi-stage running race. J Exp Biol. 2014;217(Pt 5):787–95.
Le Meur Y, Thierry B, Rabita G, et al. Spring-mass behaviour during the run of an international triathlon competition. Int J Sports Med. 2013;34(8):748–55.
Rabita G, Couturier A, Dorel S, et al. Changes in spring-mass behavior and muscle activity during an exhaustive run at vo2max. J Biomech. 2013;46(12):2011–7.
Fourchet F, Girard O, Kelly L, et al. Changes in leg spring behaviour, plantar loading and foot mobility magnitude induced by an exhaustive treadmill run in adolescent middle-distance runners. J Sci Med Sport. 2015;18(2):199–203.
Giovanelli N, Taboga P, Rejc E, et al. Effects of an uphill marathon on running mechanics and lower limb muscles fatigue. Int J Sports Physiol Perform. 2015. doi:10.1123/ijspp.2014-0602.
Lazzer S, Salvadego D, Taboga P, et al. Effects of the etna uphill ultramarathon on energy cost and mechanics of running. Int J Sports Physiol Perform. 2016;10(2):238–47.
Slawinski J, Heubert R, Quievre J, et al. Changes in spring-mass model parameters and energy cost during track running to exhaustion. J Strength Cond Res. 2008;22(3):930–6.
Le Meur Y, Dorel S, Rabita G, et al. Spring–mass behavior and electromyographic activity evolution during a cycle-run test to exhaustion in triathletes. J Electromyogr Kinesiol. 2012;22(6):835–44.
Hoang PD, Herbert RD, Todd G, et al. Passive mechanical properties of human gastrocnemius muscle–tendon units, muscle fascicles and tendons in vivo. J Exp Biol. 2007;210(23):4159–68.
Herbert RD, Clarke J, Kwah LK, et al. In vivo passive mechanical behaviour of muscle fascicles and tendons in human gastrocnemius muscle–tendon units. J Physiol. 2011;589(21):5257–67.
Seynnes OR, Bojsen-Møller J, Albracht K, et al. Ultrasound-based testing of tendon mechanical properties: A critical evaluation. J Appl Physiol. 2014;12(36):20.
van Mechelen W. Running injuries. Sports Med. 1992;14(5):320–35.
Marti B, Vader JP, Minder CE, et al. On the epidemiology of running injuries the 1984 bern grand-prix study. Am J Sports Med. 1988;16(3):285–94.
Di Caprio F, Buda R, Mosca M, et al. Foot and lower limb diseases in runners: assessment of risk factors. J Sports Sci Med. 2010;9(4):587–96.
Hoyt DF, Wickler SJ, Cogger EA. Time of contact and step length: the effect of limb length, running speed, load carrying and incline. J Exp Biol. 2000;203(2):221–7.
Roberts TJ, Konow N. How tendons buffer energy dissipation by muscle. Exerc Sport Sci Rev. 2013;41(4):186–93.
Wyndow N, Cowan SM, Wrigley TV, et al. Triceps surae activation is altered in male runners with achilles tendinopathy. J Electromyogr Kinesiol. 2013;23(1):166–72.
Azevedo LB. Biomechanical variables associated with achilles tendinopathy in runners. Br J Sports Med. 2009;43(4):288–92.
Baur H, Divert C, Hirschmüller A, et al. Analysis of gait differences in healthy runners and runners with chronic achilles tendon complaints. Isokinet Exerc Sci. 2004;12(2):111–6.
Baur H, Muller S, Hirschmuller A, et al. Comparison in lower leg neuromuscular activity between runners with unilateral mid-portion achilles tendinopathy and healthy individuals. J Electromyogr Kinesiol. 2011;21(3):499–505.
Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101.
Padua DA, Carcia CR, Arnold BL, et al. Gender differences in leg stiffness and stiffness recruitment strategy during two-legged hopping. J Motor Behav. 2005;37(2):111–25.
Onambele GL, Narici MV, Maganaris CN. Calf muscle-tendon properties and postural balance in old age. J Appl Physiol. 2006;100(6):2048–56.
Hamill J, Russell EM, Gruber AH, et al. Impact characteristics in shod and barefoot running. Footwear Sci. 2011;3(1):33–40.
Perry SD, Lafortune MA. Influences of inversion/eversion of the foot upon impact loading during locomotion. Clin Biomech. 1995;10(5):253–7.
Nigg BM. The role of impact forces and foot pronation: a new paradigm. Clin J Sports Med. 2001;11(1):2–9.
Millet GP, Vleck VE. Physiological and biomechanical adaptations to the cycle to run transition in olympic triathlon: review and practical recommendations for training. Br J Sports Med. 2000;34(5):384–90.
Bonacci J, Green D, Saunders PU, et al. Change in running kinematics after cycling are related to alterations in running economy in triathletes. J Sci Med Sport. 2010;13(4):460–4.
Millet GP, Millet GY, Hofmann MD, et al. Alterations in running economy and mechanics after maximal cycling in triathletes: influence of performance level. Int J Sports Med. 2000;21(2):127–32.
Bentley DJ. The physiological responses to running after cycling in elite junior and senior triathletes. Int J Sports Med. 2004;25(3):191–7.
Rendos NK, Harrison BC, Dicharry JM, et al. Sagittal plane kinematics during the transition run in triathletes. J Sci Med Sport. 2013;16(3):259–65.
Chapman AR, Hodges PW, Briggs AM, et al. Neuromuscular control and exercise-related leg pain in triathletes. Med Sci Sports Exerc. 2010;42(2):233–43.
Chapman AR, Vicenzino B, Blanch P, et al. Does cycling effect motor coordination of the leg during running in elite triathletes? J Sci Med Sport. 2008;11(4):371–80.
Heiden T, Burnett A. Triathlon: the effect of cycling on muscle activation in the running leg of an olympic distance triathlon. Sports Biomech. 2003;2(1):35–49.
Lepers R, Bigard AX, Diard J-P, et al. Posture control after prolonged exercise. Eur J Appl Physiol Occup Physiol. 1997;76(1):55–61.
Sainburg RL, Poizner H, Ghez C. Loss of proprioception produces deficits in interjoint coordination. J Neurophysiol. 1993;70(5):2136–47.
McCole SD, Calney K, Conte JC, et al. Energy expenditure during bicycling. J Appl Physiol. 1990;68(2):748–53.
Butler RJ, Crowell HP III, Davis IM. Lower extremity stiffness: implications for performance and injury. Clin Biomech. 2003;18(6):511–7.
Mahieu NN, Witvrouw E, Stevens V, et al. Intrinsic risk factors for the development of achilles tendon overuse injury. A prospective study. Am J Sports Med. 2006;34(2):226–35.
Maquirriain J. Leg stiffness changes in athletes with achilles tendinopathy. Int J Sports Med. 2012;33(7):567–71.
Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the achilles tendon. J Appl Physiol. 2010;108(3):670–5.
Lipfert SW, Günther M, Renjewski D, et al. A model-experiment comparison of system dynamics for human walking and running. J Theor Biol. 2012;292:11–7.
Viale F, Dalleau G, Freychat P, et al. Leg stiffness and foot orientations during running. Foot Ankle Int. 1998;19(11):761–5.
Acknowledgments
Anna Lorimer reviewed the literature as the basis for her later PhD biomechanical studies on the effects of lower limb stiffness on running mechanics and injury. Patria Hume as Anna Lorimer’s PhD supervisor with experience in sports injury biomechanics, reviewed the identified literature and edited the manuscript. Both authors approved the final manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funding
This review was funded by the Auckland University of Technology. Anna Lorimer was funded by a Vice Chandellor’s PhD scholarship.
Conflicts of interest
Anna Lorimer and Patria Hume declare they have no conflicts of interest relevant to the content of this review.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Lorimer, A.V., Hume, P.A. Stiffness as a Risk Factor for Achilles Tendon Injury in Running Athletes. Sports Med 46, 1921–1938 (2016). https://doi.org/10.1007/s40279-016-0526-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40279-016-0526-9