Running Injuries A Review of the Epidemiological Literature

ABSTRACT Running is associated with a higher take chances of overuse injury than other forms of aerobic exercise such as walking, pond and cycling. An accurate description of the proportion of running injuries per anatomical location and where possible, per specific pathology, for both genders is required. The aim of this review was to determine the proportion of lower limb running injuries by anatomical location and by specific pathology in male and female runners (≥800m - ≤ marathon). The preferred reporting items for systematic reviews and meta-analyses guidelines were followed for this review. A literature search was performed with no restriction on publication yr in Web of Science, Scopus, Sport-Discus, PubMed, and CINAHL up to July 2017. Retrospective, cross-exclusive, prospective and randomised-controlled studies which surveyed injury data in runners were included. 36 studies were included to report the overall proportion of injury per anatomical location. The overall proportion of injury past specific pathology was reported from 11 studies. The knee (28%), talocrural joint-foot (26%) and shank (sixteen%) deemed for the highest proportion of injury in male and female runners, although the proportion of knee injury was greater in women (forty% vs. 31%). Relative to women, men had a greater proportion of talocrural joint-foot (26% vs. 19%) and shank (21% vs. sixteen%) injuries. Patellofemoral pain syndrome (PFPS; 17%), Achilles tendinopathy (AT; 10%) and medial tibial stress syndrome (MTS; 8%) deemed for the highest proportion of specific pathologies recorded overall. There was insufficient data to sub-dissever specific pathology between genders. The predominate injury in female runners is to the human knee. Male person runners have a more even distribution of injury between the knee, shank and ankle-foot complex. There are several methodological issues, which limit the interpretation of epidemiological information in running injury. Cardinal words: Running, injury, injury prevention, epidemiology Primal Points The highest proportion of running injury occurs from the articulatio genus downwards. The tiptop iii anatomical locations for running injuries are common to both genders merely women seem to suffer more knee injuries relative to men. Injuries reported using medical diagnosis appear to mirror the anatomical locations most commonly injured. Greater standardisation of injury audit tools are required in order to exist able to perform meta-assay on the prevalence and incidence of injury in runners. Running is associated with a higher risk of overuse injury (Bertola et al., 2014 ; Hauret et al., 2015 ; Salmon et al., 2014 ) than other forms of aerobic exercise such as walking, swimming and cycling. To unlock the total potential of running every bit a sport or a vehicle to amend wellness there is a need to empathise the aetiology of injury. In any sport, this procedure begins past gaining an understanding of the most frequent injuries associated with that sport (Fitzharris et al., 2017 ). Preferably, injury epidemiology would be synthesized from loftier quality studies, using standardised definitions, by way of systematic review and meta-analysis. This poses a challenge to researchers due to the heterogeneity of studies in the literature, which are affected by differences in written report populations, designs and injury or exposure definitions. The most recent systematic reviews on running injury (Kluitenberg et al., 2015 ; Lopes et al., 2012 ; Nielsen et al., 2012 ; van der Worp et al., 2015 ; Videbaek et al., 2015 ) accept highlighted issues such as a lack of standardised injury definitions, the nomenclature of a runner, and the recording of exposure. To minimise the effect of study heterogeneity on the outcome variable of interest, authors of systematic reviews accept used strict inclusion-exclusion criteria to respond specific questions about running injury epidemiology or injury epidemiology in specific types of runners. This results in a smaller number of studies existence included for review. Reviews that focus on injury incidence crave accurate estimates of exposure (van der Worp et al., 2015 ; Videbaek et al., 2015 ). Reviews that focus on the prevalence of specific injuries or injuries in a specific population of runners, are limited to those studies including a medical diagnosis or specific type of runner (Kluitenberg et al., 2015 ; Lopes et al., 2012 ). An alternative approach, admitting less sensitive and potentially discipline to greater bias, is to employ a wide inclusion criteria. This would allow inclusion of a larger population (i.e. recreational, amateur, elite, triathlon, orienteering), and a broader classification of injury (i.e. hip, genu, talocrural joint and foot). Subsequently, sub-group analyses tin exist performed from studies that clearly describe injury per gender or specific pathology. Gaining a wide understanding of the proportion of running injuries could provide a foundation for the investigation of risk factors associated with running injuries. Furthermore, cognition of the anatomical locations most commonly affected may assist with the development of standardised study procedures in relation to reporting injury prevalence and incidence. A number of running injury epidemiology studies have recently been published (Altman and Davis, 2016 ; Hespanhol Inferior et al., 2016 ; Hespanhol Junior et al., 2017b ; Kerr et al., 2016 ; Malisoux et al., 2016b ; Smits et al., 2016 ; van der Worp et al., 2016 ), therefore the chief aim of this review was to determine the proportion of injuries in male and female runners by anatomical site. A secondary aim was to specify pathologies (self-reported or reported by a health care practitioner), where possible. Data sources and search strategy This review was prepared and conducted co-ordinate to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines (Moher et al., 2009 ). The aim of the search strategy was to find published retrospective, cross-exclusive, prospective and randomised-controlled studies that provided survey data. The following electronic databases were searched (from inception) without appointment restriction to July 2017; and included Web of Scientific discipline (n = 194), Scopus (n = 215), SportDiscus (n = 72), PubMed (north = 691), SCIELO (n = v) and CINAHL (n = 57). The last electronic search was conducted on 01/07/2018. Search terms included running* (Boolean Phrase); injury* (Boolean Phrase); prevalence* (Boolean Phrase). In improver, manual searches of the reference lists of four recent running injury systematic reviews (Kluitenberg et al., 2015 ; Lopes et al., 2012 ; van der Worp et al., 2015 ; Videbaek et al., 2015 ) were undertaken past a single author (PF). All citations were imported to EndNote X7 (Thomson Reuters, USA) and duplicates removed past PF. Manufactures were screened by championship, abstract and finally full text, according to predetermined written report criteria (Figure 1). Three authors (PF, CW and KS) independently reviewed all titles and abstracts, and selected those for inclusion. Disagreement was resolved via consensus and a third author (MIJ) was to be consulted if no agreement was reached. Total texts were reviewed by ane author (PF) to determine which studies met the inclusion criteria. No mitt-search of specific sports medicine journals was performed. Inclusion and exclusion criteria The inclusion criteria were: (1) published peer-reviewed prospective cohort; retrospective accomplice; cross-sectional; or randomised controlled studies, (ii) reported running injury information in adult (mean age: ≥18 years) runners, (novice, recreational, apprentice, elite runners, triathletes and orienteers) competing in distances ≥800m - ≤ marathon), (3) provided the anatomical location of lower limb running injury separate to other injuries/illness (e.grand. upper body), (iv) written in English, (5) interventions that did not alter the volume of running undertaken, use strategies designed to directly alter hurting, and did not report a difference in running related injury (RRI) between intervention and control groups (e.thou. the influence of footwear on running injury), (6) included shod injuries split up to barefoot injuries in studies investigating these conditions, (vii) not duplicate publications or multiple studies on the aforementioned accomplice, (8) did not include service personnel (eastward.thousand. law, fire service, armed forces) (nine) separated lower limb running injuries from other lower limb injuries (east.g. triathlon injuries divided into swim, bike and running), (x) did not recruit participants with a specific type of injury, (11) did not depict rails and field competition injuries, (12) presented data as running injury or whatever lower limb pain regardless of its interference with running. Data extraction Data from included studies were extracted by a single author (PF), and checked past MIJ. A standardised data extraction sail was developed by PF (available on request) where the post-obit data related to study characteristics and injury were extracted: (one) author, yr, (2) runner type, (3) gender, age, (4) injury definition, yeah/no, (5) study design, (6) time period for retrospective/prospective assay (7) gender separate of injuries, yep/no, (8) sampling method, (9) vi-month or 12-month follow upwards for prospective or retrospective studies respectively, aye/no, (10) the sample included versus analysed, (eleven) injury as self-reported, reported by a health professional person or diagnosed past a medical md (12) injury proportion expressed as a full of all injury, yes/no, (13) consistent style of data collection, yes/no, (14) all injuries reported, yes/no, (fifteen) running injuries carve up, yes/no, (16) anatomical location or specific injury identifiable, aye/no, (17) number of runners, number of injured runners, total injuries, (18) anatomical location of injury, (19) specific type of injury. The primary outcome variable was the proportion of lower limb running injury. Due to the heterogeneity of studies, studies were grouped according to anatomical location, and subsequent sub-group analyses were conducted on information pertaining to specific pathologies. Injuries were categorized past the anatomical regions 'hip' (hip joint/pelvis/groin), 'thigh' (upper leg), 'knee', 'shank' (lower leg), 'talocrural joint-human foot' (including toes) and 'other' (not clear diagnosis/location/upper extremity/illness)(Kluitenberg et al., 2015 ; van Gent et al., 2007 ). Overall injury prevalence was divers as the number of injured runners divided by the total number of runners in the report. This was calculated from 26-studies where injured runners could exist separated from the full number of runners and the full number of running injuries. Descriptive statistics for prevalence were calculated using SPSS. Injury proportions were defined as the total injury number per anatomical region or specific pathology divided by the total number of injuries reported from all sites or pathologies. Specific pathology refers to a pathology with a self-reported or confirmed medical diagnosis. Quality cess Recent systematic reviews on running injury prevalence, incidence and take a chance factors accept used different tools to assess the quality of studies (Lopes et al., 2012 ; Nielsen et al., 2012 ; van der Worp et al., 2015 ; Videbaek et al., 2015 ). Most tools that have been used can exist traced dorsum to epidemiological or occupational studies on full general musculoskeletal pain (van der Worp et al., 2015 ). The tool is often modified to exist more 'running' specific and subsequent running reviews often modify it farther (Nielsen et al., 2012 ; Videbaek et al., 2015 ) or propose their own criteria based on the aims of their review (Lopes et al., 2012 ). A score out of the total number of criteria or a percentage of positive responses (from aye-no answers) are used to express quality (Kluitenberg et al., 2015 ; Nielsen et al., 2012 ; van der Worp et al., 2015 ). The primary purpose of this study was to determine the proportion of injuries at different anatomical locations in runners and where possible specify the pathology responsible. The level of runner, cause, prevalence or incidence of injury were not of involvement thus minimising the importance of methods for randomization for the quality of outcome. Therefore, nosotros used the x yes/no criteria proposed by Lopes et al. ( 2012 ) as their review was mainly concerned with prevalence and also because the 10 criteria also encapsulated seven of the viii criteria recently used past Videbaek et al. ( 2015 ) to conduct a similar review. The simply departure betwixt our quality assessment and that reported by Lopes et al. ( 2012 ) is that where the authors used the words prevalence or incidence, we used the word proportion. Using yep/no criteria a positive score ≥50% is deemed a low take chances of bias (Kluitenberg et al., 2015 ; van der Worp et al., 2015 ). The detailed criteria tin exist viewed within the supplementary material from the authors' (Lopes et al. 2012 ) manuscript but briefly they are as follows: 1) definition of injury reported, yep/no; 2) studies with prospective and cross-sectional designs that nowadays proportion data, yes/no; 3) description of the population or type of runner e.g. 10km, marathon, yes/no; 4) random sampling used (i.e. not a convenience sample), aye/no; 5) information analysis performed on 80% of the participants, yes/no; 6) self-reported injury by the athlete or health care professional, aye/no; 7) consistent mode of data collection, yes/no; viii) diagnosis past a medical md, yes/no; 9) a follow-up of half dozen months for prospective trials or up to 12-months for retrospective trials, yes/no; ten) injury proportion expressed as a proportion of total injuries, yeah/no. Characteristics of included studies The literature search yielded 1282 unique citations, of which 112 full texts were obtained and assessed for eligibility. Of the 112 full-text manufactures, 36 met the eligibility criteria and progressed to information extraction. The reasons for the exclusion of specific studies are displayed in the written report period chart (Effigy ane). Of the 36 included studies, 18 were prospective injury audits, 16 were retrospective injury audits, and two were a cross-sectional analyses of electric current injuries. Quantitative analysis Injury proportions past anatomical location were calculated from 10,688 injuries reported from 18,195 runners included in the 36 studies. These proportions were further sub-categorised for females (n = viii studies, 2,279 injuries) and males (due north = 7 studies, 1,875 injuries). Overall injury proportions for specific pathologies were calculated from 3,580 injuries reported by iv,752 runners (northward = 11 studies). There were insufficient information (north = 2 studies) to separate specific pathologies by gender. The overall injury prevalence, calculated from 13,182 runners reporting 5,362 injuries (n = 26 studies), was 42.seven% ± nineteen.8 (range 10 – 92%; 95% confidence interval 34.7% - 50.vii%). Injury proportions by anatomical site Effigy ii displays the proportion of injuries by anatomical location. The knee (28%) and ankle-foot (26%) regions accounted for over half of all the injuries reported (n = 5,816/10,688). The third highest proportion of injury was at the shank (16%). These information indicate that lxx% of all injuries reported were at or below the knee joint. The hip and thigh regions accounted for 14% of injuries. The remaining injuries (other, 15%) were either of unclear location, from the upper extremity, or illness. The proportion of injury per anatomical location did non change when analysed by gender. Injuries to the knee and beneath accounted for the majority of injuries in men (78%) and women (75%). However, the proportions of the three most frequent injuries differ betwixt genders (Figure 3 and Figure 4). Figure 4 illustrates that knee injuries account for xl% of all injuries in women, followed by the ankle-foot (19%) and shank (16%). Injuries are more than evenly weighted in men betwixt articulatio genus (31%), ankle-foot (26%) and shank (21%) (Effigy 3). The hip and thigh regions accounted for 15% and 18% of all injuries in men and women respectively. Injuries classified as 'other' accounted for vi% and 7% of all injuries in men and women respectively. Injury proportions by specific pathology From the iii,580 recorded injuries, 770 were classified as 'other'. The elevation 10 running injuries recorded from the remaining two,810 injuries are displayed in Effigy 5 and expressed as a percentage of all injuries (n = 3,580). The purpose of this review, was to depict the proportion of running injuries by anatomical location and where possible, specific pathology in men and women. There was sufficient literature to satisfy this aim in relation to anatomical location and specific pathology for both genders combined but simply the anatomical location of injury could exist divided by gender. The proportion of running injuries by anatomical site and specific pathology Unsurprisingly, and in agreement with previous reviews on the topic, the majority (~seventy%) of running injuries occur at or below the genu (Kluitenberg et al., 2015 ; Lopes et al., 2012 ). This finding is true for both men and women. The summit ten running injuries, identifiable by specific pathology, support this finding. Even so, although the virtually commonly injured sites in men and women are the same, the proportions for each site differ. The main departure is that women take a larger proportion of knee injuries (40% of all injuries), relative to men, who feel a similar proportion of articulatio genus (31%) and ankle-human foot (26%) injuries. This difference may be due to structural differences betwixt males and females, or functional differences in running biomechanics. For example, it is well established that females have a higher incidence of traumatic knee injury in football and basketball game relative to their male counterparts (Arendt and Dick, 1995 ). This has been suggested to be due to contradistinct neuromuscular command in females arising from a greater Q-angle and a greater reliance on quadriceps muscle activity to control landing using more upright postures (Sigward and Powers, 2006 ). These gender differences will have had an impact on the data we written report for specific pathologies. The ii most mutual running injuries were patellofemoral pain syndrome (PFPS) and Achilles tendinopathy (AT), which is in agreement with previous reports on the prevalence of musculoskeletal injury in runners (Junior et al., 2011 ; Lopes et al., 2012 ). The proportion of PFPS is far in excess of AT (17% (n = 606) vs. 10% (due north = 374)) and may reflect a gender bias due to women having more knee injuries. As, men have a greater proportion of ankle-foot injuries relative to women (26% (n = 494) vs. 19% (n = 434)) which may bespeak that the proportion of AT injuries is male biased. This proffer is supported somewhat past the simply two studies included which differentiated gender when reporting specific pathologies (Nielsen et al., 2014 ; Taunton et al., 2002 ). Taunton et al. ( 2002 ) report gender differences in the proportion of PFPS, AT and plantar fasciitis (PF) reported from an analysis of injuries (north = 2002) obtained from patient records at a sports medicine center. Women had more PFPS than men and less AT and PF. In a smaller sample of injuries (north = 254) obtained prospectively, the proportion of PFPS appears to be greater in women and the proportion of AT and PF divided equally betwixt genders. The proportion of specific pathologies will also be influenced past the variability in time to recover from different running injuries and the likelihood of reoccurrence (Nielsen et al., 2014 ). Methodological issues with the collation and reporting of running injury information Although not an aim of the nowadays review, nosotros were able to report the overall prevalence of injury in runners from 26-studies. The overall prevalence of injury (42.7%) varied greatly (ten – 92%) and is in agreement with estimates previously reported (van der Worp et al., 2015 ; van Gent et al., 2007 ). The extraction of data highlighted the difficulty in reporting accurate estimates of the proportion, prevalence and incidence of running injury from existing literature. We came beyond many of the problems reported by previous systematic reviews, such as a lack of consistency in defining a runner, an injury, and exposure. Additionally and almost notably, nosotros observed a lack of clarity and consistency amidst studies reporting a) the total number of runners, b) the total number of injured runners c) the full number of injuries, and d) the number of new injuries versus recurrent injuries. Although many of the studies included in our review scored well in terms of quality cess (Table 2), information technology is perhaps more informative to have a qualitative discussion of the bug highlighted by Tabular array one and Table 2. This review raises some important considerations for the blueprint and implementation of futurity retrospective, cross-sectional or prospective injury studies. The first consideration is in relation to the definition of a runner. Systematic reviews have reported differences in running injuries betwixt various levels (novice, recreational, apprentice, competitive, elite) of runners only possibly with the exception of aristocracy (professional) and beginner (e.thou. Netherlands Start to Run Programme) these definitions lack objective data to support their validity. An estimate of the book (minutes or distance) and intensity (rate of perceived exertion) of running would allow for an accurate description of runner 'level' in studies. The definition of injury poses a claiming toward comparison research findings not but due to the heterogeneity of definitions used, just considering the link betwixt pain and injury is not as clear in sports where chronic injury predominates. If a study uses a fourth dimension loss definition of injury, such as that used in football (Jones et al., 2018 ), it does non capture sub-clinical pathology which interferes with simply does non prevent running. Recently data has been published demonstrating insidious pathology, which rugby players perceive to interfere with operation even though they are classified every bit uninjured (Partner and Francis, 2018 ). If a study used a definition of symptoms regardless of its interference with running, it may capture data from high performance runners who would not be considered injured in the traditional sense. Whether these symptoms are predictive of future risk of injury is unknown. It would seem pertinent for running injury audits to begin to collect information in relation to pain and fourth dimension-loss injuries in runners. This would begin to shed low-cal on the brunt of pain and injury in running. The anatomical location of injury could be obtained from all studies included in this review but specific pathology could just exist identified from 11 studies. This might exist expected given the challenges in obtaining an accurate diagnosis. Nonetheless, the symptoms and location of many running injuries are quite specific, in particular for medial tibial stress syndrome (MTS), PF and AT. Researchers should possibly consider providing a symptomatic clarification to runners in relation to the almost mutual running injuries to let self-report of specific pathology. An alternating arroyo that would also provide a rough estimate of specific pathology would be to allow cocky-report of a diagnosis and provide an indication of the source of diagnosis (e.g. concrete therapist, medic, friend). Linked to this challenge, is the challenge of providing an accurate estimate of injury between genders. Merely 15 studies could be used to study gender differences in injuries past anatomical location and only 2 reported gender differences for specific pathology. Given the differences in injury proportions between men and women, an important and straightforward way of improving the reporting of information obtained from injury audits is to include gender data. Assuming the definition of a runner and an injury is appropriate, information is collected by anatomical location and specific pathology, for men and women; the major requirement for obtaining accurate estimates of injury prevalence is to report the total number of runners; the total number of injured runners and the full number of injuries. The majority of studies (19/36 studies) included in this review did not report this clearly. Furthermore, first time injuries need to be separated from recurrent injuries in order to provide an accurate estimate of prevalence. Toward the aim of improving incidence data, quantifying exposure in terms of volume and intensity is important and as mentioned before, it would also assist to provide a more accurate description of the runner. In summary, nosotros used broad search criteria to gauge the proportion of running injuries by anatomical location and specific pathologies. For anatomical location these proportions could be farther divided by gender. To the all-time of our knowledge, this is the start review to take this approach. Our findings are in-line with previous research and systematic reviews on the topic. The majority of injuries occur at the knee and below in both genders and this appears to be supported by the proportion of injuries reported by specific pathology. The knee seems to be predominately affected in women. This is also true for males only at that place appears to be a more than even distribution between articulatio genus, shank and foot-talocrural joint complexes. Although not the original aim of this review, a major effect from this review is to highlight the shortcomings in existing methodology and reporting of data which reduces confidence in the data reported by our review and in the reviews of others. Futurity research employing injury audits should seek to address the bug we take raised above. ACKNOWLEDGEMENTS The reported experiments comply with the electric current laws of the land; in which they were performed. The authors take no conflicts of interests to declare. AUTHOR BIOGRAPHY Peter Francis Employment: Musculoskeletal Health Research Grouping, School of Clinical and Applied Sciences, Leeds Beckett University, UK Degree: PhD Research interests: Muscle role, running kinematics, running injury, barefoot running Electronic mail: peter.francis@leedsbeckett.air-conditioning.uk Chris Whatman Employment: Sports Functioning Research Institute New Zealand (SPRINZ), Auckland, New Zealand Degree: PhD Research interests: Sports injury prevention in youth athletes, Player workload and injury adventure, Visual rating of movement tests in athletes. E-mail: chris.whatman@aut.air conditioning.nz Kelly Sheerin Employment: Sports Functioning Inquiry Institute New Zealand (SPRINZ), Auckland, New Zealand Degree: MSc Enquiry interests: Identification, evolution, and optimisation of treatment and rehabilitation protocols for runners. Biomechanical factors related to the treatment and prevention of running injuries. Electronic mail: kelly.sheerin@aut.air conditioning.nz Patria Hume Employment: Sports Operation Research Plant New Zealand (SPRINZ), Auckland, New Zealand Degree: PhD Inquiry interests: Sports injury biomechanics: lower limb injuries; landing injuries; external ankle supports; running mechanics E-mail: patria.hume@aut.ac.nz Marking I. Johnson Employment: Middle for Hurting Enquiry, Schoolhouse of Clinical and Applied Sciences, Leeds Beckett University, Leeds LS1 3HE, UK Degree: PhD Research interests: Factors influencing variability in pain perception between individuals such as gender, age ethnicity, culture, and obesity E-mail: Grand.Johnson@leedsbeckett.ac.u.k. REFERENCES Altman A.R., Davis I.S. (2016) Prospective comparing of running injuries between shod and barefoot runners. British Journal of Sports Medicine 50, 476-480. Arendt Due east., Dick R. (1995) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA information and review of literature. 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