Sports Medicine

, Volume 26, Issue 6, pp 395–413 | Cite as

Biomechanical Risk Factors for Exercise-Related Lower Limb Injuries

  • Fiona G. Neely
Review Article

Abstract

There is a significant risk of injury when undertaking physical activities. Abnormal biomechanics of the lower limb has been implicated as a causative factor for injury. Although there have been a large number of studies in this field, many lack consistency of definitions and methodology. A large number of these studies have been retrospective, and it is often impossible to identify the baseline population.

The evidence suggests that limitation of range of ankle dorsiflexion, limitation of range of hip eversion, excessive joint laxity, leg length discrepancy, an excessively supinated or pronated foot, excessively high or low arches of the foot and a large Q-angle are risk factors for injury. On the other hand, there is little convincing evidence that an abnormal range of ankle plantar flexion, genu varum or valgum or undue muscle tightness may be potential risk factors.

All of these biomechanical abnormalities need further evaluation as potential risk factors for injury. Any trials undertaken must endeavour to define and describe their methods fully, and ensure that their results are reproducible.

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References

  1. 1.
    Cowan DN, Jones BH, Tomlinson JP, et al. The epidemiology of physical training injuries in U.S. army infantry trainees: methodology, population and risk factors. US Army Research Institute of Environmental Medicine Technical Report T4–89: 1988Google Scholar
  2. 2.
    Jones BH, Knapik JJ, Reynolds KL, et al. Cigarette smoking, physical fitness and injuries in infantry soldiers. Am J Prev Med 1994; 10: 145–50PubMedGoogle Scholar
  3. 3.
    Jones BH, Vogel JA, Manikowski R, et al. Incidence of and risk factors for injury and illness amoung male and female army basic trainees. US Army Research Institute of Environmental Medicine Technical Report T19–88, 1988Google Scholar
  4. 4.
    Knapik JJ, Jones BH, Reynolds KL, et al. Physical fitness, age and injury incidence in infantry soldiers. J Occup Med 1993; 35: 598–603PubMedGoogle Scholar
  5. 5.
    Van Mechelen W. Can running injuries be effectively prevented? Sports Med 1995; 19: 161–5PubMedGoogle Scholar
  6. 6.
    Vogel JA, Vanggaard L, Hentze-Eriksen T. Injuries related to physical training. NATO Defence Research Group RSG 17 AC/243 (Panel 8) TR/16, 1994: 121–45Google Scholar
  7. 7.
    Van Mechelen W. Running injuries – a review of the epidemiological literature. Sports Med 1992; 14: 320–35PubMedGoogle Scholar
  8. 8.
    Macera CA. Lower extremity injuries in runners – advances in prediction. Sports Med 1992; 13: 50–7PubMedGoogle Scholar
  9. 9.
    Blair SN, Kohl HW, Goodyear NN. Rates and risks for running and exercise injuries: studies in three populations. Res Q Exerc Sport 1987; 58: 221–8Google Scholar
  10. 10.
    Box CJ. A survey of overuse lower limb injuries in army recruit training – phase 2. Army Personnel Research Establishment Report AP 9/12 405/5/10, 1989Google Scholar
  11. 11.
    Harwood AG, Box CJ, Freeland WA, et al. A survey of overuse lower limb injuries in army recruits. Army Personnel Research Establishment Report AP 9/12 404/5/10, 1989Google Scholar
  12. 12.
    Jones BH, Cowan DN, Tomlinson JP, et al. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc 1993; 25: 197–203PubMedGoogle Scholar
  13. 13.
    Reynolds K, Pollard JA, Cunero J, et al. Frequency of training and past injuries as risk factors for injuries in infantry soldiers. Med Sci Sports Exerc 1996; S40 (29 May): 235Google Scholar
  14. 14.
    Jones BH, Vogel JA. Running versus marching as a risk factor for injuries in recruit training. NATO Defence Research Group RSG 17 2nd Meeting: 1989Google Scholar
  15. 15.
    Owen JP. Lower limb survey in army recruits. Farnborough: Defence Research Agency, 1996Google Scholar
  16. 16.
    Rayson MP, Holliman DE, Mason MJ, et al. The physical demands of basic training in British army recruits: a pilot study. Farnborough: Defence Research Agency PLSD/CHS5/ CR96/019, 1996Google Scholar
  17. 17.
    Baumhauer JF, Alosa DM, Renstrom PAFH, et al. A prospective study of ankle injury risk factors. Am J Sports Med 1995; 23: 564–70PubMedGoogle Scholar
  18. 18.
    Gross MT. Lower quarter screening for skeletal malalignment – suggestions for orthotics and shoewear. Foot/Ankle Ther Res 1995; 21: 389–405Google Scholar
  19. 19.
    Hughes LY. Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures. J Orthop Sports Phys Ther 1985; 7: 96–101PubMedGoogle Scholar
  20. 20.
    Jackson DW, Jarrett H, Bailey D, et al. Injury prediction in the young athlete: a preliminary report. Am J Sports Med 1978; 6: 6–14PubMedGoogle Scholar
  21. 21.
    Messier SP, Pittala KA. Aetiological factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20: 501–5PubMedGoogle Scholar
  22. 22.
    Montgomery LC, Nelson FRT, Norton JP, et al. Orthopaedic history and examination in the aetiology of overuse injuries. Med Sci Sports Exerc 1989; 21: 237–43PubMedGoogle Scholar
  23. 23.
    Gollnick PD, Karpovich PV. Electromagnetic study of locomotion and some athletic movements. Res Q 1964; 35: 357–69PubMedGoogle Scholar
  24. 24.
    Mann RA, Hagy J. Biomechanics of walking, running and sprinting. Am J Sports Med 1980; 8: 345–50PubMedGoogle Scholar
  25. 25.
    Magee DJ. Orthopaedic physical assessment. Philadelphia (PA): W.B. Saunders Company, 1987: 245–74Google Scholar
  26. 26.
    Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. Los Angeles (CA): Clinical Biomechanics Corp., 1977: 127–63Google Scholar
  27. 27.
    Subotnick SI. Normal biomechanics and clinical biomechanics. In: Subotnick SI, editor. Sports medicine of the lower extremity. New York: Churchill Livingstone, 1989: 129–69Google Scholar
  28. 28.
    Sinning WE, Forsyth HL. Lower limb actions while running at different velocities. Med Sci Sports Exerc 1970; 2: 28–34Google Scholar
  29. 29.
    Cowan DN, Jones BH. Running exposure, training injuries and physical fitness [abstract]. Med Sci Sports Exerc 1996; S40 (29 May): Abstract 236Google Scholar
  30. 30.
    Moss RI, DeVita P, Dawson ML. A biomechanical analysis of patellofemoral stress syndrome. J Athlet Train 1992; 27: 64–9Google Scholar
  31. 31.
    Milgrom C, Finestone A, Eldad A, et al. Patellofemoral pain caused by overactivity – a prospective study of risk factors in infantry recruits. J Bone Joint Surg 1991; 73A: 1041–3PubMedGoogle Scholar
  32. 32.
    Elveru RA, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting – subtalar and ankle joint measurements. Phys Ther 1988; 68: 673–7Google Scholar
  33. 33.
    Brody DM. Running injuries. Clin Symp 1980; 32: 1–36PubMedGoogle Scholar
  34. 34.
    Crane L. Femoral torsion and its relation to toeing-in and toeingout. J Bone Joint Surg 1959; 41A: 421–8PubMedGoogle Scholar
  35. 35.
    Apley AG, Solomon L. Apley’s system of orthopaedics and fractures. Oxford: Butterworth Heinemann Ltd, 1993: 437Google Scholar
  36. 36.
    Fairbank JCT, Pynsent PB, Van Poortvliet JA, et al. Mechanical factors in the incidence of knee pain in adolescent and young adults. J Bone Joint Surg 1984; 66: 685–93Google Scholar
  37. 37.
    Root ML, Orien WP, Weed JH, et al. Biomechanical examination of the foot. Los Angeles (CA): Clinical Biomechanics Corp., 1971Google Scholar
  38. 38.
    Giladi M, Milgrom C, Stein M. External rotation of the hip: a predictor of risk for stress fractures. Clin Orthop 1987; 216: 131–4PubMedGoogle Scholar
  39. 39.
    Subotnick SI. Sports specific biomechanics. In: Subotnick SI, editor. Sports medicine of the lower extremity. New York: Churchill Livingstone, 1989: 210–1Google Scholar
  40. 40.
    Kujala UM, Kvist M, Osterman K, et al. Factors predisposing army conscripts to knee exertion injuries incurred in a physical training program. Clin Orthop 1986; 210: 203–12PubMedGoogle Scholar
  41. 41.
    Sikorski JM, Peters J, Watt I. The importance of femoral rotation in chondromalacia patellae as shown by serial radiography. J Bone Joint Surg 1979; 61B: 435–42Google Scholar
  42. 42.
    Finestone A, Shiamkovitch N, Eldad A, et al. Risk factors for stress fractures amoung Israeli infantry recruits. Mil Med 1991; 156: 528–30PubMedGoogle Scholar
  43. 43.
    Iseki J, Fujikawa K. Clinical pictures of the osteoarthritis in the knee joint. J Jpn Orthop Assoc 1980; 54: 563Google Scholar
  44. 44.
    Mann RA, Baxter DE, Lutter LE. Running symposium. Foot Ankle 1981; 1: 190–224PubMedGoogle Scholar
  45. 45.
    Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes – a study of 320 cases. Am J Sports Med 1987; 15: 46–58PubMedGoogle Scholar
  46. 46.
    Cooke TDV, Price N, Fisher B, et al. The inwardly pointing knee – an unrecognized problem of external rotational malalignment. Clin Orthop 1990; 260: 56–60PubMedGoogle Scholar
  47. 47.
    Dalton SE. Overuse injuries in adolescent athletes. Sports Med 1992; 13: 58–70PubMedGoogle Scholar
  48. 48.
    Cowan DN, Jones BH, Frykman PN, et al. Lower limb morphology and risk of overuse injury amoung male infantry trainees. Med Sci Sports Exerc 1996; 28: 945–52PubMedGoogle Scholar
  49. 49.
    Milgrom C, Stein M, Steinberg R, et al. Stress fractures and tibial bone width – a risk factor. J Bone Joint Surg 1987; 69B: 326–9Google Scholar
  50. 50.
    Carter C, Sweetnam R. Familial joint laxity and recurrent dislocation of the patella. J Bone Joint Surg 1958; 40B: 664–7Google Scholar
  51. 51.
    Lysens R, Steverlynck A, Van den Auweele Y, et al. The predictability of sports injuries. Sports Med 1984; 1: 6–10Google Scholar
  52. 52.
    Nicholas JA. Injuries to knee ligaments. JAMA 1970; 212: 2236–9PubMedGoogle Scholar
  53. 53.
    Reider B, Marshall JL, Warren RF. Clinical characteristics of patellar disorders in young athletes. Am J Sports Med 1981; 9: 270–4PubMedGoogle Scholar
  54. 54.
    Rossiter ND, Galbraith KA. The incidence of hypermobility in a military population [abstract]. Meeting of the Combined Services Orthopaedic Society; 1996 Jun 7; Aldershot, UK, 165Google Scholar
  55. 55.
    Taimela S, Kujala UM, Osterman K. Intrinsic risk factors and athletic injuries. Sports Med 1990; 9: 205–15PubMedGoogle Scholar
  56. 56.
    Kannus VPA, Nittymaki S. Which factors predict outcome in the nonoperative treatment of patellofemoral pain syndrome? A prospective follow-up study. Med Sci Sports Exerc 1994; 26: 289–96PubMedGoogle Scholar
  57. 57.
    Ekstrand J, Gillquist J. Soccer injuries and their mechanism: a prospective study. Med Sci Sports Exerc 1983; 15 (3): 267–70PubMedGoogle Scholar
  58. 58.
    Kirby RL, Simms FC, Symington VD, et al. Flexibility and musculoskeletal syptomatology in female gymnasts and age matured controls. Am J Sports Med 1981; 9 (160): 160–4PubMedGoogle Scholar
  59. 59.
    Grana W, Moretz JA. Ligamentous laxity in secondary school athletes. JAMA 1978; 240: 1975–6PubMedGoogle Scholar
  60. 60.
    Sullivan D, Warren R, Pavlov H, et al. Stress fractures in 51 runners. Clin Orthop 1984; 187: 188–92PubMedGoogle Scholar
  61. 61.
    Smith AD, Stroud L, McQueen C. Flexibility and anterior knee pain in adolescent elite figure skaters. J Paediatr Orthop 1991; 11: 77–82Google Scholar
  62. 62.
    Cahill BR, Griffith EH. Effect of pre-season conditioning on the incidence and severity of high school football knee injuries. Am J Sports Med 1978; 6: 180–4PubMedGoogle Scholar
  63. 63.
    Gogia PP, Braatz JH. Validity and reliability of leg length measurements. J Orthop Sports Phys Ther 1986; 8: 185–8PubMedGoogle Scholar
  64. 64.
    Friberg O, Kvist M. Leg length inequality in athletes. In: Bachl N, Prokop L, Suckert R, editors. Current topics in sports medicine. Vienna: Urban and Schwarzenberg, 1984: 984–92Google Scholar
  65. 65.
    Beal MC. The short leg problem. J Am Osteopath Assoc 1977; 76: 745–51PubMedGoogle Scholar
  66. 66.
    Subotnick SI. The short leg syndrome. J Am Podiatr Assoc 1976; 66: 720–3Google Scholar
  67. 67.
    Blustein SM, D’Amico JC. Limb length discrepancy: identification, clinical significance and management. J Am Podiatr Med Assoc 1985; 75: 200–6PubMedGoogle Scholar
  68. 68.
    Giles LGF, Taylor JR. Low back pain associated with leg length inequality. Spine 1981; 6: 510–21PubMedGoogle Scholar
  69. 69.
    Amstutz HC, Sakai DM. Equalization of leg length. Clin Orthop 1978; 136: 2–5PubMedGoogle Scholar
  70. 70.
    Bloedel PK, Hauger B. The effects of limb length discrepancy on subtalar joint kinematics during running. J Orthop Sports Phys Ther 1995; 22: 60–4PubMedGoogle Scholar
  71. 71.
    DeMoya RG. A biomechanical comparison of the running shoe and the combat boot. Mil Med 1982; 147: 380–3PubMedGoogle Scholar
  72. 72.
    Donatelli R. Abnormal biomechanics of the foot and ankle. J Orthop Sports Phys Ther 1987; 9: 11–6PubMedGoogle Scholar
  73. 73.
    Subotnick SI. The biomechanics of running. Sports Med 1985; 2: 144–53PubMedGoogle Scholar
  74. 74.
    Winter DA, Bishop PJ. Lower extremity injury: biomechanical factors associated with chronic injury to the lower extremity. Sports Med 1992; 14: 149–56PubMedGoogle Scholar
  75. 75.
    Scott SH, Winter DA. Talocrural and talocalcaneal joint kinematics during stance phase of gait. Biomechanics 1991; 24: 743–52Google Scholar
  76. 76.
    McPoil T, Cornwall MW. Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot Ankle 1994; 15: 141–5PubMedGoogle Scholar
  77. 77.
    James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978; 6: 40–50PubMedGoogle Scholar
  78. 78.
    Donatelli R. Normal biomechanics of the foot and ankle. J Orthop Sports Phys Ther 1985; 7: 91–5PubMedGoogle Scholar
  79. 79.
    Vitisalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Prev Med 1983; 11: 125–30Google Scholar
  80. 80.
    Elveru RA, Rothstein JM, Lamb RL, et al. Methods for taking subtalar joint measurements – a clinical report. Phys Ther 1988; 68: 678–82PubMedGoogle Scholar
  81. 81.
    Franco AH. Pes cavus and pes planus – analyses and treatment. Phys Ther 1987; 67: 688–94PubMedGoogle Scholar
  82. 82.
    Kannus VPA. Evaluation of abnormal biomechanics of the foot and ankle in athletes. Br J Sports Med 1991; 26: 83–9Google Scholar
  83. 83.
    Dahle JK, Mueller M, Delitto A. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991; 14: 70–4PubMedGoogle Scholar
  84. 84.
    Sommer HM, Vallentyne SW. Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995; 27: 800–4PubMedGoogle Scholar
  85. 85.
    Beckett ME, Massie DL, Bowers KD, et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athlet Train 1992; 27: 58–62Google Scholar
  86. 86.
    DeLacerda FG. A study of anatomical factors involved in shinsplints. J Orthop Sports Phys Ther 1980; 2: 55–9PubMedGoogle Scholar
  87. 87.
    Gould N. Evaluation of hyperpronation and pes planus in adults. Clin Orthop 1983; 181: 37–45PubMedGoogle Scholar
  88. 88.
    Picciano AM, Rowlands MS, Worrell T. Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test. J Orthop Sports Phys Ther 1993; 18: 553–8PubMedGoogle Scholar
  89. 89.
    Garbolosa JC, McClure MH, Catlin PA. The frontal plane relationship of the forefoot to the rearfoot in an asymptomatic population. J Orthop Sports Phys Ther 1994; 20: 200–6Google Scholar
  90. 90.
    Hawes M, Sovak D. Quantitative morphology of the human foot in a North American population. Ergonomics 1994; 37: 1213–26PubMedGoogle Scholar
  91. 91.
    Hawes M, Sovak D, Nachbauer W, et al. Footprint parameters as a measure of arch height. Foot Ankle 1992; 13: 22–6PubMedGoogle Scholar
  92. 92.
    Bensel CK. The effects of tropical and leather combat boots on lower extremity disorders amoung US marine corps recruits. United States Army Natick Research and Development Laboratories Report TR 76–49-CEMEL: 1976Google Scholar
  93. 93.
    Bensel CK, Kish RN. Lower extremity disorders among men and women in army basic training and effects of two types of boots. United States Army Natick Research and Development Laboratories Report TR 83/026: 1983Google Scholar
  94. 94.
    Hopper D, Elliott B. Lower limb and back injury patterns of elite netball players. Sports Med 1993; 16: 148–62PubMedGoogle Scholar
  95. 95.
    Subotnick SI. The flat foot. Phys Sports Med 1981; 9: 85–91Google Scholar
  96. 96.
    Giladi M, Milgrom C, Stein M, et al. The low arch, a protective factor in stress fractures – a prospective study of 295 military recruits. Orthop Rev 1985; 14: 709–12Google Scholar
  97. 97.
    Jones BH, Cowan DN. Foot morphologic characteristics and the risk of exercise related injury. Arch Fam Med 1993; 2: 773–7PubMedGoogle Scholar
  98. 98.
    Nigg BM, Cole GK, Nachbauer W. Effects of arch height of the foot on angular motion of the lower extremities in running. J Biomech 1993; 26: 909–16PubMedGoogle Scholar
  99. 99.
    Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: aetiology and treatment. Am J Sports Med 1984; 12: 179–84PubMedGoogle Scholar
  100. 100.
    Weil LS, Moore JW, Kratzer CD, et al. A biomechanical study of the lateral ankle sprains in basketball. J Am Podiatr Assoc 1979; 69: 687–90Google Scholar
  101. 101.
    Insall J, Falvo KA, Wise DA. Chondromalacia patellae. J Bone Joint Surg 1976; 58A: 1–8PubMedGoogle Scholar
  102. 102.
    Aglietti P, Insall J, Cerulli G. Patellar pain and incongruence: 1. Measurements of incongruence. Clin Orthop 1983; 176: 217–24PubMedGoogle Scholar
  103. 103.
    Horton MG, Hall TL. Quadriceps femoris angle: normal values and relationship with gender and selected skeletal measures. Phys Ther 1989; 69: 897–901PubMedGoogle Scholar
  104. 104.
    Caylor D, Fites R, Worrell TW. The relationship between quadriceps angle and anterior knee pain syndrome. J Orthop Sports Phys Ther 1993; 17: 11–6PubMedGoogle Scholar
  105. 105.
    Davidson K. Patellofemoral pain syndrome. Am Fam Phys 1993; 48: 1254–62Google Scholar
  106. 106.
    Messier SP, Davis SE, Curl WW, et al. Aetiological factors associated with patellofemoral pain in runners. Med Sci Sports Exerc 1991; 23: 1008–15PubMedGoogle Scholar
  107. 107.
    Huberti HH, Hayes WC. Patellofemoral contact pressures. J Bone Joint Surg 1984; 66A: 715–24PubMedGoogle Scholar
  108. 108.
    Yates C, Grana W. Patellofemoral pain: a prospective study. Othopaedics 1986; 9: 663–7Google Scholar
  109. 109.
    Lindberg U. The patellofemoral pain syndrome [dissertation]. Linkoping: University of Linkoping, Sweden, 1986Google Scholar

Copyright information

© Adis International Limited 1998

Authors and Affiliations

  • Fiona G. Neely
    • 1
  1. 1.Centre for Human SciencesDefence Evaluation and Research AgencyFarnboroughEngland

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