Running-Related Biomechanical Risk Factors for Overuse Injuries in Distance Runners: A Systematic Review Considering Injury Specificity and the Potentials for Future Research

Abstract

Background: Running overuse injuries (ROIs) occur within a complex, partly injury-specific interplay between training loads and extrinsic and intrinsic risk factors. Biomechanical risk factors (BRFs) are related to the individual running style. While BRFs have been reviewed regarding general ROI risk, no systematic review has addressed BRFs for specific ROIs using a standardized methodology.

Objective: To identify and evaluate the evidence for the most relevant BRFs for ROIs determined during running and to suggest future research directions.

Design: Systematic review considering prospective and retrospective studies. (PROSPERO_ID: 236,832).

Data sources: PubMed. Connected Papers. The search was performed in February 2021.

Eligibility criteria: English language. Studies on participants whose primary sport is running addressing the risk for the seven most common ROIs and at least one kinematic, kinetic (including pressure measurements), or electromyographic BRF. A BRF needed to be identified in at least one prospective or two independent retrospective studies. BRFs needed to be determined during running.

Results: Sixty-six articles fulfilled our eligibility criteria. Levels of evidence for specific ROIs ranged from conflicting to moderate evidence. Running populations and methods applied varied considerably between studies. While some BRFs appeared for several ROIs, most BRFs were specific for a particular ROI. Most BRFs derived from lower-extremity joint kinematics and kinetics were located in the frontal and transverse planes of motion. Further, plantar pressure, vertical ground reaction force loading rate and free moment-related parameters were identified as kinetic BRFs.

Conclusion: This study offers a comprehensive overview of BRFs for the most common ROIs, which might serve as a starting point to develop ROI-specific risk profiles of individual runners. We identified limited evidence for most ROI-specific risk factors, highlighting the need for performing further high-quality studies in the future. However, consensus on data collection standards (including the quantification of workload and stress tolerance variables and the reporting of injuries) is warranted.

Fig. 1

Flow-chart of the identification process. The numbers for articles per injury do not sum up to the total number of articles because some studies have addressed multiple running-related injuries

Fig. 2

Graphic representation of the evidence associated with running-related risk factors that have passed our predefined relevance criterion (at least a significant difference in one prospective study or two retrospective studies). Dot size scales with Downs & Black quality rating of the studies (i.e., the bigger a dot, the higher the quality rating of the study). The number in the dots is the risk of bias score of the study. The green color represents a study that had found a significant difference between a group of injured runners compared to control. Red colors represent a study that could not find a significant difference between groups. Black circles around dots indicate a prospective study design (no circles = retrospective study design)

Fig. 3

Overview of the evidence associated with running-related risk factors that have passed our predefined relevance criterion (at least a significant difference in one prospective study or two retrospective studies). ITB Iliotibial band. ↑ indicates that runners suffering from a running overuse injury had higher values of this biomechanical risk factor compared to non-injured runners. ↓ indicates that runners suffering from a running overuse injury had lower values of this biomechanical risk factor compared to non-injured runners. ↑↓ indicates conflicting evidence (i.e., at least one study showing higher and one study showing lower values of this biomechanical risk factor in injured compared to non-injured runners)