Skip to main content

Table 3 PEO (Population, Exposure, Observation) Table; description of included articles

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

Author, Year of publication

Population

N (gender)

Follow up

Exposure (Clinical Measure)

Observation (Injury Definition)

Buist et al., 2010 [36]

532 novice runners

(226 male, 306 female);

8 or 13-week program

Range of motion with universal goniometer:

Internal and external ROM of the hip: assessed in supine and the tested hip and knee flexed to 90°

Ankle dorsal flexion- measured both with the knee fully extended and flexed to 90° passively, in supine position.

Alignment: Navicular drop- assessed by measuring the change in the height of the navicular tuberosity between sitting with the subtalar joint in neutral position and standing, weight-bearing with the subtalar joint in relaxed stance, measurements were made twice for each foot, results were averaged

Self-reported musculoskeletal pain of the lower extremity or back causing a restriction of running for at least 1 week, i.e. 3 scheduled consecutive training sessions.

Finnoff et al., 2011 [39]

98 high school cross country and track athletes

(53 male and 45 female);

Cross country and/or track season

Leg Length- measuring from anterior superior iliac spine (ASIS) to a point 2 cm proximal to the apex of medial malleolus

Muscle strength with HHD for break test:

Hip flexion- seated hip flexion to 120° with HHD on distal aspect of thigh

Hip Extension- extend test hip to a neutral position with the knee extended while maintaining neutral hip rotation with HHD against the subject’s posterior calcaneus

Hip External Rotation- seated knees were also flexed 90° with the hip in neutral rotation with HHD positioned 2 cm proximal to the apex of the medial malleolus

Hip Internal rotation- position identical to the one used for hip external rotation strength testing with HHD positioned 2 cm proximal to the apex of the lateral malleolus

Hip Abduction- 30° abduction with neutral hip flexion, extension, rotation) HHD positioned 2 cm proximal to the apex of lateral malleolus

Hip Adduction- neutral flexion, extension, rotation (subject allowed to grasp table for trunk stability). Strength test was performed with the HHD placed 2 cm proximal to the medial malleolus

Pain- Visual Analogue Scale (10 cm)

ATC monitored and evaluated by physician investigators:

ITBS suspected with lateral knee pain, local tenderness over lateral knee where ITB crosses over condyle, exacerbated by flexion and extension while applying pressure

PFP suspected with anterior knee pain, exacerbated by deep knee flexion and/or climbing stairs, and by reproduction of pain with at least one of following: 1) pressure over distal quadriceps with active contraction and 2) direct palpation of medial and lateral patellar facets

Hespanhol Junior et al., 2016 [16]

89 recreational runners (68 male/21 female);

12 weeks

Leg Length: in a supine position, lower limbs relaxed. Measuring tape was used to determine the real length of the lower limbs i.e., the length between the ASIS of the hemipelvis to the center of the ipsilateral medial malleolus of both lower limbs. The lower limb length discrepancy was considered normal when lower than 1.0 cm

Q-angle: In sports clothes and standing barefoot in an orthostatic position. A straight line was traced using a ruler from the ASIS to the center of the patella, and a second line was traced from the center of the patella to the tibial tuberosity. The angle formed by the intersection of these two lines constitutes the Q-angle, which was measured by a universal goniometer. Values between 10° and 15° were considered normal for both genders

Missed at least one training session due to musculoskeletal pain

(Biweekly questionnaire reporting musculoskeletal pain, number of training sessions missed, pain intensity (10 point numerical pain rating scale), description (type and anatomical location) of new injury)

Luedke et al., 2015 [38]

68 High school runners (16 male, 47 female);

Interscholastic cross-country season

Muscle strength with HHD for bilateral peak isometric strength (2 trials):

Hip abduction- sidelying, non-test limb was positioned in 30–45° of hip flexion and 90° of knee flexion, pelvis was stabilized to the table using a strap, test hip was in 0° of extension and abducted to parallel with the table and HHD was placed just proximal to the lateral malleolus on the test limb

Knee Extension: seated at the end of a table with the test knee at 45° of flexion, stabilizing strap was placed around the thighs and table, resistance applied to the anterior aspect of the tibia 5 cm proximal to the ankle joint

Knee Flexion - prone and the test knee flexed to 45°, stabilizing strap was placed around the pelvis and table with resistance applied to the posterior aspect of the tibia 5 cm proximal to the ankle joint

Injury- required athlete to be removed from practice or competitive event, or miss a subsequent practice/competitive event

PT or LAT determine injury:

Knee pain 1. Pain around ant aspect of knee 2) insidious onset 3) no incidence of trauma

Shin injury 1) continuous or intermittent shin pain 2) exacerbated by weight bearing activities 3) local pain with palpation along tibia

Plisky et al., 2007 [37]

105 high school cross country runners (59 male, 46 female);

13 week cross country season

Alignment:

Navicular drop (normalized to full foot length and truncated foot length) - in unilateral standing position, the runner’s foot placed subtalar neutral, ruler was placed next to the medial foot perpendicular to the floor and was read (mm) at the height of the navicular tubercle, 2 measurements were recorded, relaxing in between, and the difference value was documented as navicular drop (Runners were allowed to maintain their balance by placing a hand on a handrail during unilateral stance)

PT and ATC examined runner for MTSS criteria 1) continuous or intermittent pain in the tibial region, exacerbated by weight bearing activities 2) local pain with palpation along distal 2/3 of posterior medial tibia

Ramskov et al., 2013 [41]

59 novice runners

(31 male, 28 female);

10 weeks

Alignment: Foot Posture Index [43].

Q angle- center of the goniometer placed upon the middle of the patella, one arm of the goniometer placed along the line connecting ASIS with the middle of patella, other arm was placed along the line connecting the middle of patella and the tibial tuberosity

Injury: Any running-related injury to lower extremity or lower back that causes at least one week of restricted running

Diagnoses by physiotherapist ~ 1 week after injury; if extensive exam needed referred to university hospital medical center division of sports traumatology

Yagi et al., 2013 [40]

230 high school runners (134 male, 96 females); 3 years

Range of motion:

Hip rotation- measured with the hip and knee flexed at 90° in the sitting position; the hip and knee were rotated internally and externally to firm end feel with the angles relative to the initial position.

Ankle dorsiflexion-measure in two positions with knee in extension and 90° flexion; ankle was passively moved into dorsiflexion from a neutral-starting position until a firm end feel was elicited (examiner first identified the neutral position of the subtalar joint and then kept the neutral position while dorsiflexing the foot until a firm end point was felt)

Flexibility:

Straight leg raising – supine, passively into hip flexion until firm resistance was felt and the pelvis tilted posteriorly

Alignment (knee varus or valgus and ankle eversion inversion in standing closed feet),

Navicular drop test-distance between the navicular tuberosity and the floor during [1] quiet tandem stance with the subtalar joint placed in neutral, and no load on the foot, and [2] relaxed tandem stance with full load on the foot

Q angle- center axis of a long-arm goniometer placed over the center of the patella, proximal tibia was palpated, and the lower goniometer arm was aligned along the patellar tendon to the tibial tubercle, upper arm of the goniometer was pointed directly at the anterior superior iliac spine

Strength: Hip abduction isometric break test with HHD

Could not run for 7 days due to shin pain - radiographs taken (if reinjured counted in study as additional subject) and diagnosis by sports physician

  1. NR not reported, m/wk. miles per week, yr. year, ROM range of motion, HHD Hand held dynamometer, MTSS medial tibial stress syndrome, SF stress fracture