Epidemiology of ankle and foot overuse injuries in sports: A systematic review

Studies regarding ankle and foot overuse injuries are quite diverse in research methodology, data reporting, and outcomes. The aims of this systematic review were to analyze the methodology of published studies regarding ankle and foot overuse injuries in different sports disciplines and to summarize epidemiological data of ankle and foot overuse injuries. Four electronic databases, PubMed (MEDLINE), EMBASE, CINAHL, and SPORTDiscus^® were systematically searched up to June 2011. A total of 89 articles on 23 sports disciplines were included in this review. Soccer, running, and gymnastics were the most frequently studied sports. Achilles tendinopathy, plantar fasciitis, and stress fracture were the most frequently studied injuries. Study design and reporting methods were heterogeneous. Most studies suffered from a weak methodology and poor reporting. The most common weaknesses were lack of a clear case definition, describing assessment procedures and reporting sample characteristics. Due to methodological heterogeneity of studies, inter‐sports and intra‐sports comparisons and meta‐analysis were not possible. Methodology of most studies on incidence and prevalence of ankle and foot overuse injuries is insufficient. Based on the results, we recommend authors to clearly define cases, describe assessment procedures and report sample characteristics adequately.     

The association between lower extremity strength ratios and the history of injury in collegiate athletes

ContextStrength ratios are important because imbalances in opposing muscle groups can cause articular instability and subsequently increase the risk of musculoskeletal injury (MSKI). Therefore, the purpose of this study was to evaluate the association between lower extremity (LE) musculoskeletal isometric strength ratios and the history of LE MSKI.ParticipantsOne hundred eighty-two NCAA Division 1 soccer, football, volleyball, and basketball athletes.InterventionsAll isometric strength assessments were measured bilaterally using a handheld dynamometer. Strength assessments included: ankle inversion/eversion, ankle dorsiflexion/plantarflexion, knee flexion/extension, hip abduction/adduction, and hip external/internal rotation. LE MSKI history was collected through self-report; a report of the LE MSKI sustained in the one year prior to testing were collected.ResultsThe hip external/internal rotation ratio was statistically significant for side to side differences in the non-injured (NINJ) group (p = 0.001). The dominant leg of the NINJ group had a mean external/internal rotation ratio of 1.109 ± 0.221, and the non-dominant leg had a mean ratio of 1.177 ± 0.208.ConclusionsThere were no statistically significant differences between the injured (INJ) and NINJ groups. This could indicate that injury history does not play a role in current strength ratios and could suggest that the athletes in the INJ group are performing successful rehabilitation for their injuries.     

Lower extremity overuse injuries in pediatric athletes: clinical presentation,imaging findings,and treatment

Paralleling the growing popularity of organized sports among pediatric athletes, the stress and intensity of training regimens has escalated the frequency and severity of pediatric overuse injuries. It is essential that radiologists have a thorough knowledge of the pathogenesis of these injuries and of their characteristic patterns with different imaging techniques in order to appropriately diagnose overuse injuries in the pediatric skeleton. Knowledge of the classification, mechanism, clinical and imaging manifestations of acute and chronic overuse injuries of the lower extremities common among pediatric athletes can assist in imaging-based diagnosis and characterization of injury.     

Prevalence and incidence of lower extremity injuries in male marathon runners

The aim of this study is to describe the prevalence and incidence of lower extremity injuries occurring before and during the Rotterdam marathon, and to evaluate the impact of the injuries. A cohort study was compiled of recreational male participants in the 2005 Rotterdam marathon. Demographic data and information on previous injuries were obtained from participants using a baseline questionnaire. Information on injuries sustained shortly before or during the marathon was obtained from a post-race questionnaire. Seven hundred and twenty-five (48.3%) participants returned the baseline questionnaire. The 1-year prevalence of running injuries was 54.8%. In the post-race questionnaire, 15.6% of all respondents reported at least one new lower extremity injury in the month preceding the Rotterdam marathon. The incidence of lower extremity injuries occurring during the marathon was 18.2%; most of these injuries occurred in the calf, knee and thigh. Immediately after the marathon the median score of pain intensity at rest was 2 points vs 4.5 points during physical exercise. Hence we can conclude that running injuries are very common among recreational male marathon runners. However, the pain severity and consequences for work and daily activities seem to be relatively low 1 week after the marathon.     

Association between lower extremity muscle strength and acute ankle injury in youth team-sports athletes

ObjectivesTo investigate lower extremity muscle strength as risk factor for an acute ankle injury in youth athletes.DesignCohort study.SettingBasketball and floorball clubs.Participants188 youth (≤21) male and 174 female athletes.Main outcome measures1RM leg press, maximal concentric isokinetic quadriceps and hamstrings as well as maximal isometric hip abductor strength were measured and athletes were followed for an acute ankle injury up to three years. Cox regression models were used in statistical analyses.ResultsIn males, greater 1RM leg press and maximal quadriceps strength increased the risk of any type of acute ankle injury (Hazard ratio [HR] for 1 SD increase, 1.63 [95% CI, 1.12–2.39] and 1.43 [95% CI, 1.01–2.01], respectively). In females, greater 1RM leg press and difference between legs in hip abduction strength increased the risk of acute non-contact ankle injury (HR for 1 SD increase, 1.44 [95% CI, 1.03–2.02] and 1.44 [95% CI, 1.03–2.00], respectively). However, ROC curve analyses showed AUC:s of 0.57–0.64 indicating “fail” to “poor” combined sensitivity and specifity of these tests.ConclusionGreater strength in both sexes along with asymmetry in hip abductor strength in females increased the risk of acute ankle injury.     

Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review

The purpose of this study was to present a systematic overview of published reports on the incidence and associated potential risk factors of lower extremity running injuries in long distance runners. An electronic database search was conducted using the PubMed-Medline database. Two observers independently assessed the quality of the studies and a best evidence synthesis was used to summarise the results. The incidence of lower extremity running injuries ranged from 19.4% to 79.3%. The predominant site of these injuries was the knee. There was strong evidence that a long training distance per week in male runners and a history of previous injuries were risk factors for injuries, and that an increase in training distance per week was a protective factor for knee injuries.     

Association between lower back pain and lower extremity pain among young volleyball players: A cross-sectional study

BackgroundLower back pain (LBP), as well as lower extremity injuries, are major problems among young volleyball players. Nevertheless, only few studies have focused on the relationship between lower extremity injuries and LBP.ObjectiveThis study investigated the association between LBP and lower extremity pain, including knee and ankle pain, among young volleyball players.DesignCross-sectional study.SettingAmateur sports association.ParticipantsElementary and middle school-aged athletes (6–15 years of age).Main outcome measuresLBP and lower extremity pain.ResultsA total of 566 young volleyball players participated in this study. The point prevalence of LBP among young volleyball players was 9.5%. Using absence of lower extremity pain as a reference, the adjusted odds ratio (95% confidence interval) for LBP was 11.07 (5.64–21.71) in the presence of lower extremity pain.ConclusionsLBP is associated with Lower extremity pain among young volleyball players. Careful attention should be paid to lower extremity complaints to prevent and treat LBP among young volleyball players.     

Content validity of the SOS-WRIST questionnaire for timely identification of wrist overuse in young athletes

Objectives: Young athletes do not always seek medical help for overuse wrist injuries, risking invalidating long-term consequences resulting from late diagnosis. This study aimed to develop a questionnaire to identify overuse wrist injuries in young athletes.

Methods: According to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria, items were collected from literature and 6 focus groups of sports physicians and of young athletes with (previous) overuse wrist injuries. An expert panel and 40 Delphi study participants performed item reduction. Young athletes evaluated comprehensiveness during interviews and English translation was performed according to linguistic validation guidelines.

Results: In total 323 items were generated and 110 were marked important by focus group participants. The resulting questionnaire consists of 18 multiple-choice questions about wrist pain during sports (e.g. pain during training, skipping training sessions/elements) and daily life activities (e.g. writing, turning a key), and other symptoms (e.g. reduced strength, swelling).

Conclusion: The SOS-WRIST questionnaire for identification of overuse wrist injuries in young athletes has good content validity. It can be used to promote awareness and timely treatment of overuse wrist injuries in young athletes.     

Eating behaviours in youths: A comparison between female and male athletes and non‐athletes

This study compared the different factors associated with eating behaviors among young female and male athletes and non‐athletes. A total of 580 female and male athletes and 362 female and male non‐athletes between 10 and 19 years old participated. We used the subscales of the Eating Attitudes Test (EAT‐26) to evaluate the factors associated with unhealthy eating behaviors. We found higher scores for females on the diet subscale compared with males, regardless of athletic group (P < 0.05). Non‐athlete youths scored higher on this subscale compared with male athletes (P < 0.05). Our findings indicate higher scores for female athletes with regard to the bulimia and preoccupation with food subscale compared with other the groups (P < 0.05). Moreover, we observed that non‐athlete males were more likely to engage in binge eating compared with athletes of the same sex (P < 0.05). Finally, females had higher scores on the oral self subscale than males, regardless of athletic group (P < 0.05). We concluded that the factors associated with eating behaviors differ with regard to sex and group.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

Objective. To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. Design and patients. Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18–72 years, average 49 years; 11 women and 9 men). Results. All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. Conclusion. We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.     

Sport-specific biomechanics of spinal injuries in the athlete (throwing athletes, rotational sports, and contact-collision sports)

Athletes consistently recruit or transfer high levels of repetitive force through the spine. Proper force transmission from the legs to the hips and pelvis and through the trunk is vital. Hip and pelvis joint restrictions and muscle strength deficits coupled with poor endurance of the trunk muscle will lead to spinal instability, which is habitually described in symptomatic athletes. A rehabilitation program that targets the unstable base first, and then progresses to strengthening of the pelvis and hips and targets control of movement in a sport-specific approach, should result in pain reduction, skill enhancement, and a safe return to play.     

Sport specialization and sport participation opportunities and their association with injury history in female high school volleyball athletes

ObjectiveDetermine the association of sport specialization in female volleyball athletes with previous injury history and determine the association of sport specialization with volleyball participation opportunities.DesignCross-sectional.SettingRecruitment occurred from 83 Wisconsin high schools during the 2018 volleyball season.ParticipantsFemale volleyball athletes (N = 1,588, grades 9–12, age = 15.6 ± 1.1 years).Main outcomesParticipants completed a pre-season questionnaire soliciting information regarding 1) demographics, 2) sport specialization, 3) sport participation, and 4) sport-related injuries in the previous 12 months. Univariable logistic regression models were used to identify associations with previous injury. Chi-square analyses were used to investigate associations between sport specialization classification and other sport participation opportunities.ResultsBoth moderately and highly specialized athletes were more likely to report a previous injury compared to low specialized athletes (moderate OR: 1.84 [1.29–2.62]; p < 0.001 and high OR: 2.30 [1.64–3.24]; p < 0.001). Highly specialized athletes were more likely to report participating in club volleyball, summer tournaments, and training camps in the past 12 months. Participants who reported participating in club volleyball, summer competitions, and training camps last year were more likely to report an injury.ConclusionsSpecialization was associated with injury history and year-round volleyball opportunities among female adolescent volleyball athletes.     

Neuromuscular training reduces lower limb injuries in elite female basketball players. A cluster randomized controlled trial

The study was a two‐armed, parallel group, cluster randomized controlled trial in which 15 teams (160 players) were assigned to either an experimental group (EG , 8 teams n = 86), which warmed‐up with bodyweight neuromuscular exercises, or a control group (CG , 7 teams, n = 74) that performed standard tactical‐technical exercises before training. All injuries during the 2015‐2016 regular season were counted. Epidemiologic incidence proportion and incidence rate were also calculated. Countermovement jump (CMJ ) and composite Y‐Excursion Balance test (YBT ) were used to assess lower limb strength and postural control. A total of 111 injuries were recorded. Chi‐square test detected statistically significant differences between EG and CG (32 vs 79, P  = .006). Significant differences in the injuries sustained in the EG (21 vs 11, P  = .024) and CG (52 vs 27, P  = .0001) during training and matches, respectively, were observed. Significant differences in post‐intervention injuries were observed between in EG and CG during training (21 vs 52, P  < .0001) and matches (11 vs 27, P  = .006). Significant differences in epidemiologic incidence (0.37 vs 1.07, P  = .023) and incidence rate (1.66 vs 4.69, P  = .012) between the EG and the CG were found. Significant improvement in CMJ (+9.4%, P  < .0001; d  = 1.2) and composite YBT (right: +4.4%, P  = .001, d  = 1.0; left: +3.0%, P  = .003; d  = 0.8) for the EG was noted. Significant differences in post‐intervention CMJ (+5.9%, P  = .004) and composite YBT scores (right, +3.7%, P  = .012; left, +2.3%, P  = .007) between the EG and the CG were observed. Including bodyweight neuromuscular training into warm‐up routines reduced the incidence of serious lower limb injuries in elite female basketball players.     

Coping strategies among long-term injured competitive athletes. A study of 81 men and women in team and individual sports

Differences in personality, mood and coping ability between athletes of a high competitive level with long-term injuries ( n =81), with a mean age of 24.4 years, and a matched non-injured group ( n =64), with a mean age of 24.2 years, were investigated. Three self-rating scales were employed: mood adjective check-list, general coping questionnaire and Karolinska scales of personality. Although no differences in basic personality traits were found, being injured was found to result in a depressed mood state and in the activation of coping strategies directed at receiving help. Comparisons were made between injured male and female athletes as well as between team-sport and individual-sport athletes. Women were found to become more anxious and tense and to have a stronger inclination to use emotion-focused coping strategies. Team-sport athletes were found to cope more in terms of 'passive acceptance' of help from others, whereas individual athletes were found to activate 'problem-solving' strategies in face of a stressor. The results suggest that social aspects of rehabilitative work are important and support the concept that rehabilitative work with long- term injured athletes should be individualized to be maximally effective. They also support the usefulness of cognitive models of the injured athlete's experience of being long-term injured. Such models, however, do not account for differences between the sexes or between individual and team athletes.     

Methodological approaches and rationale for training to prevent anterior cruciate ligament injuries in female athletes

Female athletes have a four- to sevenfold increased risk of anterior cruciate ligament (ACL) injury compared with their male counterparts playing at similar levels in the same sports. The elevated risk of ACL injury in females coupled with the geometric increase in female sports participation in the last 30 years has led to a rapid rise in these injuries. This large increase in ACL injury incidence has fueled studies into both mechanisms of injury and interventions to prevent injury. A review of published multidisciplinary approaches demonstrates that several training protocols have utilized multiple components targeted toward injury prevention training and were able to reduce injury incidence in female athletes. Similar training techniques may also be used to gain improvements in measures of performance. The purpose of this review is to highlight training components that may reduce ACL injury risk and assess their potential for combined use in performance-oriented protocols.     

Investigation of knee control as a lower extremity injury risk factor: A prospective study in youth football

This prospective study in youth football examined the relationship between frontal plane knee projection angle (FPKPA ) during the single‐leg squat and sustaining an acute lower extremity injury or acute non‐contact lower extremity injury. Secondly, side‐to‐side asymmetry in FPKPA and sex as injury risk factors were explored. In addition, we investigated the influence of age, sex, and leg dominance on the FPKPA . A total of 558 youth football players (U11 to U14) participated in the single‐leg squat test and prospective injury registration. FPKPA was not found as a risk factor for injuries at this age. There was no difference in the mean FPKPA between sexes. However, FPKPA was associated with age; oldest subjects displayed the smallest FPKPA . Among boys, the frontal plane knee control improved by age. Among girls, the relationship between age and FPKPA was not as clear, but the oldest girls displayed the smallest mean FPKPA in the study (12.2° ± 8.3°). The FPKPA was greater on the dominant kicking leg compared to the non‐dominant support leg (P  <  .001 for boys, P  =  .001 for girls). However, side‐to‐side asymmetry in FPKPA was not associated with future injuries. In conclusion, frontal plane knee control in the single‐leg squat was not associated with lower extremity injuries among young football players. As the single‐leg squat to 90° knee flexion was too demanding for many subjects, easier single‐leg squat test procedure or a different movement control test, such as a double‐legged squat, could be more suitable for the young football players.