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Sports Medicine
Published in: Sports Medicine 5/2017

01-05-2017 | Systematic Review

Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury

Authors: Adam Hulme, Rasmus Oestergaard Nielsen, Toomas Timpka, Evert Verhagen, Caroline Finch

Published in: Sports Medicine | Issue 5/2017

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Abstract

Background

Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking.

Objectives

Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI.

Methods

We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case–control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from ≥800 m to ≤42.2 km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials.

Results

Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies.

Conclusions

A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.
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Literature
1.
Tonoli C, Cumps E, Aerts I, et al. Incidence, risk factors and prevention of running related injuries in long-distance running: a systematic review. Sport Geneeskunde. 2010;43(5):12–8.
2.
Videbæk S, Bueno AM, Nielsen RO, et al. Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports Med. 2015;45(7):1017–26.PubMedPubMedCentralCrossRef
3.
Kluitenberg B, van Middelkoop M, Diercks R, et al. What are the differences in injury proportions between different populations of runners? A systematic review and meta-analysis. Sports Med. 2015;45(8):1143–61.PubMedPubMedCentralCrossRef
4.
Hoeberigs JH. Factors related to the incidence of running injuries: a review. Sports Med. 1992;13(6):408–22.PubMedCrossRef
5.
van Mechelen W. Running injuries: a review of the epidemiological literature. Sports Med. 1992;14(5):320–35.PubMedCrossRef
6.
Johnston CA, Taunton JE, Lloyd-Smith DR, et al. Preventing running injuries: practical approach for family doctors. Can Fam Physician. 2003;49:1101–9.PubMedPubMedCentral
7.
8.
Ryan MB, Maclean CL, Taunton JE. A review of anthropometric biomechanical, neuromuscular, and training related factors associated with injury in runners. Int Sport Med J. 2006;7(2):120–37.
9.
Fredericson M, Misra AK. Epidemiology and aetiology of marathon running injuries. Sports Med. 2007;37(4–5):437–9.PubMedCrossRef
10.
Wen DY. Risk factors for overuse injuries in runners. Curr Sports Med Rep. 2007;6(5):307–13.PubMed
11.
van Gent RN, Siem D, van Middelkoop M, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469–80.PubMedPubMedCentralCrossRef
12.
Zadpoor AA, Nikooyan AA. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clin Biomech. 2011;26(1):23–8.CrossRef
13.
Nielsen RO, Buist I, Sørensen H, et al. Training errors and running related injuries: a systematic review. Int J Sports Phys Ther. 2012;7(1):58–74.PubMedPubMedCentral
14.
Newman P, Witchalls J, Waddington G, et al. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013;4:229–41.PubMedPubMedCentralCrossRef
15.
Saragiotto BT, Yamato TP, Hespanhol LC, et al. What are the main risk factors for running related injuries? Sports Med. 2014;44(8):1153–63.PubMedCrossRef
16.
17.
van der Worp H, Vrielink JW, Bredeweg SW. Do runners who suffer injuries have higher vertical ground reaction forces than those who remain injury-free? A systematic review and meta-analysis. Br J Sports Med. 2016;50(8):450–7.PubMedCrossRef
18.
19.
20.
21.
22.
23.
Macera CA, Pate RR, Powell KE, et al. Predicting lower-extremity injuries among habitual runners. Arch Intern Med. 1989;149(11):2565–8.PubMedCrossRef
24.
Walter SD, Hart LE, McIntosh JM, et al. The Ontario cohort study of running-related injuries. Arch Intern Med. 1989;149(11):2561–4.PubMedCrossRef
25.
Kelsey JL, Bachrach LK, Procter-Gray E, et al. Risk factors for stress fractures among young female cross-country runners. Med Sci Sports Exerc. 2007;39(9):1457–63.PubMedCrossRef
26.
Nielsen RO, Buist I, Parner ET, et al. Predictors of running-related injuries among 930 novice runners: a 1-year prospective follow-up study. Orthop J Sports Med. 2013;1(1):1–7.CrossRef
27.
Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2013. doi:10.​1136/​bjsports-2013-092202.
28.
Nielsen RO, Parner ET, Nohr EA, et al. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44(10):739–47.PubMedCrossRef
29.
Wen DY, Puffer JC, Schmalzried TP. Injuries in runners: a prospective study of alignment. Clin J Sport Med. 1998;8(3):187–94.PubMedCrossRef
30.
van Middelkoop M, Kolkman J, van Ochten J, et al. Risk factors for lower extremity injuries among male marathon runners. Scand J Med Sci Sports. 2008;18(6):691–7.PubMedCrossRef
31.
Buist I, Bredeweg SW, Lemmink KAPM, et al. Predictors of running-related injuries in novice runners enrolled in a systematic training program: a prospective cohort study. Am J Sports Med. 2010;38(2):273–80.PubMedCrossRef
32.
Hirschmüller A, Frey V, Konstantinidis L, et al. Prognostic value of Achilles tendon doppler sonography in asymptomatic runners. Med Sci Sports Exerc. 2012;44(2):199–205.PubMedCrossRef
33.
Bredeweg SW, Kluitenberg B, Bessem B, et al. Differences in kinetic variables between injured and noninjured novice runners: a prospective cohort study. J Sci Med Sport. 2013;16(3):205–10.PubMedCrossRef
34.
van Middelkoop M, Kolkman J, van Ochten J, et al. Course and predicting factors of lower-extremity injuries after running a marathon. Clin J Sport Med. 2007;17(1):25–30.PubMedCrossRef
35.
Hespanhol Junior LC, Pena Costa LO, Lopes AD. Previous injuries and some training characteristics predict running-related injuries in recreational runners: a prospective cohort study. J Physiother. 2013;59(4):263–9.PubMedCrossRef
36.
Malisoux L, Ramesh J, Mann R, et al. Can parallel use of different running shoes decrease running-related injury risk? Scand J Med Sci Sports. 2013;25(1):110–5.PubMedCrossRef
37.
Nielsen RO, Bertelsen ML, Parner ET, et al. Running more than three kilometers during the first week of a running regimen may be associated with increased risk of injury in obese novice runners. J Orthop Sports Phys Ther. 2014;9(3):338–45.
38.
39.
Bennett JE, Reinking MF, Rauh MJ. The relationship between isotonic plantar flexor endurance, navicular drop, and exercise-related leg pain in a cohort of collegiate cross-country runners. Int J Sports Phys Ther. 2012;7(3):267–78.PubMedPubMedCentral
40.
Fields KB, Delaney M, Hinkle SJ. A prospective study of type A behaviour and running injuries. J Fam Pract. 1990;30(4):425–9.PubMed
41.
Buist I, Bredeweg SW, Bessem B, et al. Incidence and risk factors of running-related injuries during preparation for a 4-mile recreational running event. Br J Sports Med. 2010;44(8):598–604.PubMedCrossRef
42.
Taunton JE, Ryan MB, Clement DB, et al. A prospective study of running injuries: the Vancouver Sun Run “In Training” clinics. Br J Sports Med. 2003;37(3):239–44.PubMedPubMedCentralCrossRef
43.
Satterthwaite P, Norton R, Larmer P, et al. Risk factors for injuries and other health problems sustained in a marathon. Br J Sports Med. 1999;33(1):22–6.PubMedPubMedCentralCrossRef
44.
Reinking MF, Austin TM, Hayes AM. Exercise-related leg pain in collegiate cross-country athletes: Extrinsic and intrinsic risk factors. J Orthop Sports Phys Ther. 2007;37(11):270–8.CrossRef
45.
Thijs Y, Pattyn E, van Tiggelen D, et al. Is hip muscle weakness a predisposing factor for patellofemoral pain in female novice runners? A prospective study. Am J Sports Med. 2011;39(9):1877–82.PubMedCrossRef
46.
van Ginckel A, Thijs Y, Ghani Zadah Hesar N, et al. Intrinsic gait-related risk factors for Achilles tendinopathy in novice runners: a prospective study. Gait Posture. 2009;29(3):387–91.PubMedCrossRef
47.
Ghani Zadah Hesar N, van Ginckel A, Cools A, et al. A prospective study on gait-related intrinsic risk factors for lower leg overuse injuries. Br J Sports Med. 2009;43(13):1057–61.CrossRef
48.
Thijs Y, De Clercq D, Roosen P, et al. Gait-related intrinsic risk factors for patellofemoral pain in novice recreational runners. Br J Sports Med. 2008;42(6):466–71.PubMedCrossRef
49.
Hootman JM, Macera CA, Ainsworth BE, et al. Predictors of lower extremity injury among recreationally active adults. Clin J Sport Med. 2002;12(2):99–106.PubMedCrossRef
50.
51.
Warren BL, Davis V. Determining predictor variables for running-related pain. Phys Ther. 1988;68(5):647–51.PubMedCrossRef
52.
Myburgh KH, Hutchins J, Fataar AB, et al. Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med. 1990;113(10):754–9.PubMedCrossRef
53.
Miller RH, Lowry JL, Meardon SA, et al. Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Gait Posture. 2007;26(3):407–13.PubMedCrossRef
54.
Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10(3):169–75.PubMedCrossRef
55.
Henriksson BG, Schnell C, Hirschberg LA. Women endurance runners with menstrual dysfunction have prolonged interruption of training due to injury. Gynecol Obstet Invest. 2000;49(1):41–6.CrossRef
56.
Barrow GW, Saha S. Mentrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med. 1988;16(3):209–16.PubMedCrossRef
57.
Ribeiro AP, Trombini-Souza F, Tessutti VD, et al. The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runners. Clin Biomech. 2011;26(2):194–9.CrossRef
58.
Ribeiro AP, Trombini-Souza F, Tessutti VD, et al. Rearfoot alignment and medial longitudinal arch configurations of runners with symptoms and histories of plantar fasciitis. Clinics. 2011;66(6):1027–33.PubMedPubMedCentralCrossRef
59.
Ekenman I, Hassmén P, Koivula N, et al. Stress fractures of the tibia: can personality traits help us detect the injury-prone athlete? Scand J Med Sci Sports. 2001;11(2):87–95.PubMedCrossRef
60.
Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc. 1988;20(5):501–5.PubMedCrossRef
61.
Wen DY, Puffer JC, Schmalzried TP. Lower extremity alignment and risk of overuse injuries in runners. Med Sci Sports Exerc. 1997;29(10):1291–8.PubMedCrossRef
62.
Parker DT, Weitzenberg TW, Amey AL, et al. Group training programs and self-reported injury risk in female marathoners. Clin J Sport Med. 2011;21(6):499–507.PubMedCrossRef
63.
Marti B, Vader JP, Minder CE, Abelin T. On the epidemiology of running injuries. Am J Sports Med. 1988;16(3):285–94.PubMedCrossRef
64.
Marti B. Benefits and risks of running among women: An epidemiologic study. Int J Sports Med. 1988;9(2):92–8.PubMedCrossRef
65.
Rasmussen CH, Nielsen RO, Juul MS, et al. Weekly running volume and risk of running-related injuries among marathon runners. Int J Sports Phys Ther. 2013;8(2):111–20.PubMedPubMedCentral
66.
Lloyd T, Triantafyllou SJ, Baker ER, et al. Women athletes with menstrual irregularity have increased musculoskeletal injuries. Med Sci Sports Exerc. 1986;18(4):374–9.PubMedCrossRef
67.
McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the Masters runners. Clin J Sport Med. 2006;16(2):149–54.PubMedCrossRef
68.
McKelvie SJ, Valliant PM, Marjatta E. Physical training and personality factors as predictors of marathon time and training injury. Percept Mot Skills. 1985;60(2):551–66.PubMedCrossRef
69.
Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med. 1986;14(2):151–5.PubMedCrossRef
70.
Gerlach KE, White SC, Burton HW, et al. Kinetic changes with fatigue and relationship to injury in female runners. Med Sci Sports Exerc. 2005;37(4):657–63.PubMedCrossRef
71.
Chang W, Shih Y, Chen W. Running injuries and associated factors in participants of ING Taipei Marathon. Phys Ther Sport. 2012;13(3):170–4.PubMedCrossRef
72.
Haglund-Åkerlind Y, Eriksson E. Range of motion, muscle torque and training habits in runners with and without Achilles tendon problems. Knee Surg Sports Traumatol Arthrosc. 1993;1(3–4):195–9.PubMedCrossRef
73.
Duffey MJ, Martin DF, Cannon W, et al. Etiologic factors associated with anterior knee pain in distance runners. Med Sci Sports Exerc. 2000;32(11):1825–32.PubMedCrossRef
74.
Bennell K, Crossley K, Jayarajan J, et al. Ground reaction forces and bone parameters in females with tibial stress fracture. Med Sci Sports Exerc. 2004;36(3):397–404.PubMedCrossRef
75.
Lopes AD, Costa LOP, Saragiotto BT, et al. Musculoskeletal pain is prevalent among recreational runners who are about to compete: an observational study of 1049 runners. J Physiother. 2011;57(3):179–82.PubMedCrossRef
76.
Valliant PM. Personality and injury in competitive runners. Percept Mot Skills. 1981;53(1):251–3.PubMedCrossRef
77.
Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc. 1995;27(7):951–60.PubMedCrossRef
78.
Niemuth PE, Johnson RJ, Myers MJ, et al. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med. 2005;15(1):14–21.PubMedCrossRef
79.
Marti B, Rehmann R. Determinants of physician visit rates among joggers: multivariate analysis of 4000 participants in a popular race. Soz Praventivmed. 1987;32(4–5):204–6.PubMed
80.
Grimston SK, Engsberg JR, Kloiber R, et al. Bone mass, external loads, and stress fracture in female runners. J Appl Biomech. 1991;7(3):293–302.
81.
Messier SP, Davis SE, Curl WW, et al. Etiologic factors associated with patellofemoral pain in runners. Med Sci Sports Exerc. 1991;23(9):1008–15.PubMedCrossRef
82.
Reinking MF, Hayes AM. Intrinsic factors associated with exercise-related leg pain in collegiate cross-country runners. Clin J Sport Med. 2006;16(1):10–4.PubMedCrossRef
83.
McQuade KJ. A case-control study of running injuries: comparison of patterns of runners with and without running injuries. J Orthop Sports Phys Ther. 1986;8(2):81–4.PubMedCrossRef
84.
McCrory JL, Martin DF, Lowry RB, et al. Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exerc. 1999;31(10):1374–81.PubMedCrossRef
85.
Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int. 2008;29(7):671–6.PubMedCrossRef
86.
Caselli MA, Longobardi SJ. Lower extremity injuries at the New York City marathon. J Am Podiatr Med Assoc. 1997;87(1):34–7.PubMedCrossRef
87.
Fonsesca M, Palma A, Araujo C, et al. Association of different factors with the prevalence of injuries in runners of Rio de Janeiro’s half marathon. J Exerc Physiol Online. 2015;18(2):58–65.
88.
Theisen D, Malisoux L, Genin J, et al. Influence of midsole hardness of standard cushioned shoes on running-related injury risk. Br J Sports Med. 2013;48(5):371–6.PubMedCrossRef
89.
Cobb KL, Bachrach LK, Sowers M, et al. The effects of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc. 2007;39(9):1464–73.PubMedCrossRef
90.
Buist I, Bredeweg SW, van Mechelen W, et al. No effect of a graded training program on the number of running-related injuries in novice runners. Am J Sports Med. 2008;36(1):33–9.PubMedCrossRef
91.
Bredeweg SW, Zijlstra S, Bessem B, et al. The effectiveness of a preconditioning programme on preventing running-related injuries in novice runners: a randomised controlled trial. Br J Sports Med. 2012;46(12):865–70.PubMedCrossRef
92.
Ryan M, Elashi M, Newsham-West R, et al. Examining injury risk and pain perception in runners using minimalist footwear. Br J Sports Med. 2014;48:1257–62.PubMedCrossRef
93.
Ryan MB, Valiant GA, McDonald K, et al. The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial. Br J Sports Med. 2010;45(9):715–21.PubMedCrossRef
94.
van Mechelen W, Hlobil H, Kemper HCG, et al. Prevention of running injuries by warm-up, cool-down, and stretching exercises. Am J Sports Med. 1993;21(5):711–9.PubMedCrossRef
95.
Jakobsen BW, Krøner K, Schmidt A, et al. Prevention of injuries in long-distance runners. Knee Surg Sports Traumatol Arthrosc. 1994;2(4):245–9.PubMedCrossRef
96.
Yamato TP, Saragiotto BT, Lopes AD. A consensus definition of running-related injury in recreational runners: a modified Delphi approach. J Orthop Sports Phys Ther. 2015;45(5):375–80.PubMedCrossRef
97.
Finch CF, Cook J. Categorising sports injuries in epidemiological studies: the subsequent injury categorisation (SIC) model to address multiple, recurrent and exacerbation of injuries. Br J Sports Med. 2013;48(17):1276–80.PubMedPubMedCentralCrossRef
98.
Hreljac A, Marshall RN, Hume PA. Evaluation of lower extremity overuse injury potential in runners. Med Sci Sports Exerc. 2000;32(9):1635–41.PubMedCrossRef
99.
Malisoux L, Nielsen RO, Urhausen A, et al. A step towards understanding the mechanisms of running-related injuries. J Sci Med Sport. 2014;18(5):523–8.PubMedCrossRef
100.
Buist I, Bredweg SW, Lemmink KAMP, et al. The GRONORUN study: is a graded training program for novice runners effective in preventing running related injuries? Design of a randomized controlled trial. BMC Musculoskelet Disord. 2007;8(24):1–8.
101.
Nielsen RO, Malisoux L, Møller M, et al. Shedding light on the etiology of sports injuries: a look behind the scenes of time-to-event analyses. J Orthop Sports Phys Ther. 2016;46(4):300–11.PubMedCrossRef
102.
103.
104.
Cobb KL, Bachrach LK, Greendale G, et al. Disordered eating, menstrual irregularity, and bone mineral density in female runners. Med Sci Sports Exerc. 2003;35(5):711–9.PubMedCrossRef
105.
Saragiotto BT, Yomato TP, Lopes AD. What do recreational runners think about risk factors for running injuries? A descriptive study of their beliefs and opinions. J Orthop Sports Phys Ther. 2014;44(10):733–8.PubMedCrossRef
106.
Hulme A, Finch CF. The epistemic basis of distance running injury research: a historical perspective. J Sport Health Sci. 2016;5(2):172–5.CrossRef
Metadata
Title
Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury
Authors
Adam Hulme
Rasmus Oestergaard Nielsen
Toomas Timpka
Evert Verhagen
Caroline Finch
Publication date
01-05-2017
Publisher
Springer International Publishing
Published in
Sports Medicine / Issue 5/2017
Print ISSN: 0112-1642
Electronic ISSN: 1179-2035
DOI
https://doi.org/10.1007/s40279-016-0636-4

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