Do alterations in muscle strength, flexibility, range of motion, and alignment predict lower extremity injury in runners: a systematic review

Christopher, Shefali M.; McCullough, Jeremy; Snodgrass, Suzanne J.; Cook, Chad

doi:10.1186/s40945-019-0054-7

Archives of Physiotherapy

Table 2 Clinical measures and the reported predictive statistics in the 7 studies investigated in this review

From: Do alterations in muscle strength, flexibility, range of motion, and alignment predict lower extremity injury in runners: a systematic review

Author, year	Statistical Analysis	Assessment Method	Values (uninjured)	Values (injured)	Association Statistic, 95% Confidence Interval; p-value
Hip Strength
Hip abduction (GRADE- Very low +++O) ^b,c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	2.57(0.53)%	3.14(0.63)%	OR:5.35, 95% CI= 1.46, 19.53; p :<.01
Luedke et al., 2015 [38]	Bivariable logistic regression	Force (N)x resistance moment arm (m)/body mass (kg).	Boys: R = 0.25(0.07) Nm/Kg L = 0.25(0.08) Nm/Kg Girls: R = 0.25(0.08) Nm/Kg L = 0.26(0.07) Nm/Kg	NR	Boys: Shin pain tertiles Weakest:OR:1.25, 95% C=I 0.2, 9.9. Middle: OR 1.00, NA Girls: Shin pain tertiles Weakest OR:1.23, 95% CI= 0.7, 21.6, Middle: OR 2.28, 95% CI= 0.2, 28.0
Hip adduction (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	2.79 (0.61)%	2.87 (0.45)%	OR: 1.23, 95% CI= 0.48, 3.17
Hip abduction to adduction ratio (GRADE- Very low ++O)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	NR	1.12 (0.28)%	1.06 (0.25)%	OR: 14.14, 95% CI= 0.90, 221.06
Hip internal rotation (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	1.68 (0.40)%	1.88 (0.68)%	OR: 2.75, 95% CI= 0.33, 23.17
Hip external rotation (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	1.44 (0.31)%	1.34 (0.26)%	OR: 0.35, 95% CI= 0.03, 4.48
Hip external to internal rotation strength (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	NR	0.87 (0.17)%	0.74 (0.13)%	OR: 0.01, 95% CI= < 0.01, 0.44;p:0.02
Hip flexion (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	2.84 (0.61)%	2.49 (0.92)%	OR: 0.40, 95% CI= 0.05, 3.09
Hip extension (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	(%BWxheight) = Torque(Nxm)× 100/[BW(N)x height(m)]	3.15 (0.79)%	2.87 (0.79)%	OR: 0.64, 95% CI= 0.21, 1.90
Hip flexion to extension strength (GRADE- Very low ++OO)^c,d
Finnoff et al., 2011 [39]	Bivariable logistic regression	NR	0.86 (0.15)%	0.96 (0.13)%	OR: 0.17, 95% CI= 0.021, 5.61
Hip Range of Motion
Hip IR ROM (GRADE- Very low ++OO)^b,c
Buist et al., 2010 [36]	Multivariable logistic regression	Goniometer	Male L = 30.6(8.1)° R = 31.1(8.8)° Female L = 35.9(9.5)° R = 37.7(8.3)°	NR	Male: HR: 1.00 Female HR 0.98 aHR: 0.99, 95% CI= 0.97, 1.01; P:0.08
Yagi et al., 2013 [40]	Multivariable logistic regression	Goniometer	Male: 12.4 (8.7)° Female: 25.5 (9.5)°	Male: MTSS:12.9(5.8)° SF: 7.5 (3.5)° Female: MTSS: 31.1 (9.9)° SF: 20.7(7.6)°	Male MTSS: aOR: 0.99, 95% CI 0.91, 1.08 SF: aOR: 1.26, 95% CI 0.81, 1.96 Female MTSS: aOR 0.91, 95% CI 0.85, 0.99; p:0.02 SF: aOR:1.00, 95% CI 0.88, 1.12
Hip ER ROM (GRADE- Very low ++OO)^b,c
Buist et al., 2010 [36]	Multivariable logistic regression	Goniometer	Male: L = 39.7(11.6)° R = 40.2(12.9)° Female L = 45.7(14.3)° R = 45.8(13.9)°	NR	Male: HR: 1.01 Female: HR:1.00
Yagi et al., 2013 [40]	Multivariable logistic regression	Goniometer	Male: 39.7(8.8)° Female: 35.1 (9.0)°	Male: MTSS: 44.5(8.9)° SF: 40.0(14.1)° Female: MTSS: 37.4 (8.5)° SF: 43.3 (2.9)°	Male: MTSS: aOR: 0.96, 95% CI 0.88, 1.03 SF: aOR: 0.76, 95% CI 0.56, 1.03 Female MTSS: aOR:1.0, 95% CI 0.93, 1.08 SF: aOR:1.0, 95% CI 0.90, 1.11
Hip Alignment
Q angle (GRADE- Very low ++OO)^b,c
Hespanhol junior et al., 2016 [16]	Multivariable logistic regression	Goniometer	10.1(5.1)°	11.8(5.0)°	OR:0.9, 95% CI= 0.8, 1.0
Ramskov et al., 2013 [41]	Bivariable logistic regression	Goniometer	L = 11.1(4.4)° R = 11.1(5.0)°	L = 8.2(4.5)° R = 9.1(4.5)°	cRR: 1.26, 95% CI= 0.49, 3.23
Leg length (GRADE- Very low +OOO)^d
Hespanhol junior et al., 2016 [16]	Multivariable logistic regression	Measuring Tape	0.5(0.6)cm	0.4(0.6)cm	OR: 1.3, 95% CI= 0.6, 2.7
Hip Flexibility
Straight leg raise (GRADE- Very low ++OO)^c,d
Yagi et al., 2013 [40]	Multivariable logistic regression	Goniometer	Male:74.3(10.4)° Female:76.1 (12.5)°	Male: MTSS:77.6(8.5)° SF:60.0 (14.1)° Female: MTSS:77.7(11.0)° SF:78.3 (7.6)°	Male MTSS: aOR: 0.99, 95% CI= 0.60, 1.29 SF: aOR: 1.38, 95% CI= 1.04, 1.83 Female MTSS: aOR: 0.98, 95% CI= 0.92, 1.05 SF: aOR:1.00, 95% CI= 0.90, 1.11
Knee Strength
Quadriceps strength (GRADE- Very low ++OO)^c,d
Luedke et al., 2015 [38]	Bivariable logistic regression	Force (N)x resistance moment arm (m)/body mass (kg).	Boys: R = 0.31(0.06)Nm/kg L = 0.30(0.05)Nm/kg Girls: R = 0.28(0.04)Nm/kg L = 0.28(0.05)Nm/kg	NR	Boys: Shin pain Tertiles Weakest OR:0.83, 95% CI= 0.1, 6.1 Middle: No injured Girls: NR
Hamstring strength (GRADE- Very low ++OO)^c,d
Luedke et al., 2015 [38]	Bivariable logistic regression	Force (N)x resistance moment arm (m)/body mass (kg).	Boys: R = 0.22(0.06) Nm/kg L = 0.21(0.06) Nm/kg Girls: R = 0.20(0.03) Nm/kg L = 0.20(0.04) Nm/kg	NR	Boys: Shin pain Tertiles Weakest OR:1.20, 95% CI= 0.2, 8.8, Middle: OR: 0.40, 95% CI= 0.1, 5.2 Girls: Shin pain Tertiles Weakest: OR: 1.33, 95% CI= 0.2,16.7 Middle: OR: 0.55, 95% CI= 0.1, 9.9
Ankle Alignment
Navicular drop (GRADE- Very low ++OO)^b,c
Buist et al., 2010 [36]	Multivariable logistic regression	NR	Male: L = 6.6(3.5)mm R = 6.7(3.5)mm Female: L = 6.0(3.1)mm R = 6.2(2.8)mm	NR	Male HR 1.02 Female HR 0.92 aHR- 0.87, 95% CI= 0.77, 0.98; p:0.01
Plisky et al., 2007 [37]	Bivariable logistic regression	Ruler perpendicular to the floor	> 10 mm N Boys: 20(43.5) N Girls:24(40.7) < 10 mm N Boys:26(56.5) N Girls:25(59.3)	N 15.8 N 14.9	OR: 1.0 OR: 0.9, 95% CI= 0.3, 2.8
Yagi et al., 2013 [40]	Multivariable logistic regression	Goniometer	Male: 4.5(3.4)mm Female:4.2(2.4)mm	Male MTSS:4.9(3.0) mm SF: 2.4(3.1)mm Female MTSS:4.9(3.0)mm SF: 3.4(2.9)mm	Male MTSS: aOR:0.93, 95% CI= 0.75, 1.14 SF: aOR: 1.00, 95% CI= 0.71, 1.42 Female MTSS: aOR: 0.90, 95% CI= 0.70, 1.19 SF: aOR: 1.5, 95% CI= 0.95, 2.51
Foot posture index (GRADE- Very low ++OO)^c,d
Ramskov et al., 2013 [41]	Bivariable logistic regression	Method by Redmond et al	N: Very pronated:1 Pronated: 14 Neutral: 79 Supinated: 0 Very supinated: 0	N: Very pronated:3 Pronated: 4 Neutral: 14 Supinated: 0 Very supinated: 0	cRR: 1.65, 95% CI= 0.65, 4.17
Ankle Range of Motion
Ankle dorsiflexion (GRADE- Very low +OOO)^c
Buist et al., 2010 [36]	Multivariable logistic regression	Goniometer	Male: L= KB- 104.7(7.8)° KS-99.2(8.2)° R= KB-104.6(7.5)° KS-99.2(7.8)° Female: L= KB-103.6(11.5)° KS-99.0(10.9)° R= KB-103.8(8.7)° KS- 99.1(9.2)°	NR	Male HR: 1.01(KB) HR: 1.01 (KS) Female HR: 1.00(KB) HR: 1.00 (KS)

OR odds ratio, aOR adjusted odds ratio, HR Hazard ration, aHR adjusted hazard ratio, RR risk ratio, cRR cumulative relative risk, SF stress fracture, MTSS medial tibial stress syndrome, KB knee bent, KS knee straight
GRADE working group grades of evidence: (bolded? heading for below items)
Low quality: Further research is likely to have an important impact on our findings
Very low quality: We are uncertain about the findings
a. Item was downgraded due to risk of bias in methods, recruitment, follow up or selective reporting
b. Item was downgrade due to inconsistency such as difference in measurement method, population, injury definition within the studies included in the outcome
c. Item was downgraded due to indirectness and therefore applicability of findings regarding population or outcomes
d. Item was downgraded due to imprecision (i.e. small sample size < 300)

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