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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 16  |  Issue : 1  |  Page : 32-40

Exercise-related leg pain and risk factors in inter university distance runners


Department of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar, Punjab, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Sarika Chaudhary
Faculty of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.173468

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  Abstract 

Context: Understanding the concept of prevalence and risk factors of exercise-related leg pain (ERLP) in distance runners. Aims: To find out the prevalence and in the seasonal incidence of ERLP in inter university distance runners. To investigate risk factors for developing ERLP. Settings and Design: The present cross-sectional study conducted at the track and field in Guru Nanak Dev University and other universities in Punjab. Materials and Methods: A total 70 athletes (40 male, 30 female) were participated voluntarily. Precompetitive demographic, basic anthropometric, training parameters and ERLP history data were collected from the initial questionnaire. Foot type and plantar flexor endurance were measured from each individual using navicular drop test, standard heel raise test, and runners were tracked throughout the session to note the percentage of in seasonal ERLP. Statistical Analysis Used: Chi-square and odds ratio was applied to find out the risk factors of ERLP. Results: Overall 48.57% male and 37.14% female athletes had a history of ERLP and 14.2% athletes did not have any history of ERLP out of 70 athletes. Among them 81.4% (57) athletes completed postseasonal questionnaire, out of 57 athlete's 42.1% (24) male and 28% (16) female athletes developed in seasonal ERLP, bilateral lower leg pain was the most common presentation. There was a significant difference seen between ERLP history (1-month) and body mass index (BMI) within seasonal ERLP (P < 0.02), (P < 0.04), as compared to 6 and 12 month history of ERLP. Conclusions: The results of the present study conclude that BMI and ERLP history (1-month) was the only risk factor for in the seasonal development of ERLP in distance runners.

  Abstract in Arabic 

:السياق
مفهوم انتشار وعوامل الخطر من ممارسة ألم في الساق ذات الصلة في عدائي المسافات الطويلة
:الأهداف
معرفة مدى انتشار وحدوث في الموسميERLP بين عدائي المسافات الجامعة. للتحقق من عوامل الخطر لتطوير ERLP
:الضبط والتصميم
أجريت دراسة مقطعية في ألعاب القوى في جامعة "جورو ناناك ديف" وغيرها من الجامعات في ولاية البنجاب.
شارك مجموع 70 رياضيا (40 ذكور، 30 إناث) تطواعيا: المواد والأساليب
تنافسية ديموغرافية مسبقة، الكائن البشري ، حيث تم جمع المعلوماتو التداريب والبيانات التاريخ منذ البداية
يتم قياس نوع القدم وقدرة التحمل من كل فرد باستخدام اختبار السقوط، حيث يتم تتبع معاير اختبار كعب مع ملاحظة نسبةRLP الموسمية.
تم تطبيق الإحصائيات لمعرفة عوامل الخطر منERLP: الإحصائيات المستخدمة
:النتائج
48.57٪ ذكور و 37.14٪ من الإناث و 14.2٪ الرياضيين لم يكن لديهم أي تاريخ ERLP من 70 الرياضيين. من بينهم 81.4٪ (57) الرياضيين الانتهاء استبيان آخر الموسمية، من بين 57 الرياضي 42.1٪ (24) من الذكور و 28٪ (16) اللاعبات وضعت في RLP الموسمية، وكان الألم الثنائي أسفل الساق العرض الأكثر شيوعا. كان هناك اختلاف كبير بين التاريخ ينظر RLP ومؤشر كتلة الجسم مع في RLP الموسمية (P <0.02)، (P <0.04)، بالمقارنة مع سن السادس و 12 شهرا من تاريخها.
:الاستنتاجات
نستخلص من نتائج الدراسة أن، BMI والتاريخ ىERLP (شهر واحد) يعتبران من اكثر عوامل التي تهدد التنمية الموسمية لERLP في عدائي المسافات الطويلة.
:الكلمات المفتاحية
عدائي المسافات الطويلة و عوامل الخطر ممارسة ذات الصلة ألم في الساق

Keywords: Distance runners, exercise-related leg pain, risk factors


How to cite this article:
Chaudhary S, Bellam MB, Shenoy S. Exercise-related leg pain and risk factors in inter university distance runners. Saudi J Sports Med 2016;16:32-40

How to cite this URL:
Chaudhary S, Bellam MB, Shenoy S. Exercise-related leg pain and risk factors in inter university distance runners. Saudi J Sports Med [serial online] 2016 [cited 2023 Feb 8];16:32-40. Available from: https://www.sjosm.org/text.asp?2016/16/1/32/173468


  Introduction Top


Running is the most common physical activity of many healthy individuals and competitive runners as well as other sports persons to improve their cardiorespiratory fitness. Lower extremity injuries are more common in distance runners. The incidence of lower extremity injuries in long distance runners ranged from 19.4% to 79.3%. Most of running-related injuries are overuse injuries and cause of injury is often multifactorial. The lower leg has been reported to the common site of injury in long distance runners ranging from 9.0% to 32.2% compared to foot (3.9–39.3%), ankle (3.9–16.6%), and knee (7.2%–50%) van Gent et al.[1]

Exercise-related leg pain (ERLP) and shin splints are nonspecific terms used to describe lower leg injuries. ERLP is described as a regional pain syndrome, is located between knee and ankle associated with exercises Bennett et al.[2] Reinking et al.[3] studied the occurrence of ERLP among 125 high schools cross country runners, over 82.4% reported a history of ERLP. Bilateral leg pain was the most common presentation. The pain has an effect their participation of training in 58.4% of athletes and 48% of athletes reported in seasonal ERLP. Another study, who reported the incidence rates of running injuries in marathon runners and their risk factors. The incidence of lower extremity injuries as high as 90% those training for marathon Fredericson et al.,[4] (2007). The incidence of overuse lower leg injuries ranges from 26.3% to 38.8% in collegiate cross country runners Bennett et al.[2] This shown that the incidence of ERLP was greater in distance runners, needs early identification of risk factors and prevention.

Training errors

Adequate training program plays a major role in the prevention of athletic injury and training may cause injury Best and Garrett (1993).[5] Training errors alone or in a combination of other risk factors may be responsible to develop injuries in athletes Lysholm and Wiklander (1987).[6] The important training errors include increase running distance, fast progression, high-intensity training, hill training, poor running style, and fatigue Pope et al.,[7] (1996). Specific injuries may occur with training errors Knutzen and Hart (1996).[8] Ilio-tibial band syndrome was associated with severe training session Mc Nicol et al.[9] and hill and interval training were associated with knee problems Pretorius et al.,[10] (1986). The incidence of running injury was greater in men, whose mileage was 30–39 miles per week and in women, whose mileage range was 40–49 miles per week. Training pace was not significantly related to the injury Walter et al.,[11] (1989). Recreational runners, who run once a week more than 8 km or more had a greater risk to develop injury than those who run all year Walter et al.,[11] (1989). There was no significant difference between the occurrence of running injuries and hill training in athletes Jacob and Berson (1986).[12] The training should be progressed gradually to prevent training related injuries and alternate day rest should be given to the beginners and the speed and training mileage should be increased slowly to remain injury free van Mechelen (1992).[13] Macera et al.,[14] reported that overuse injuries were common whose weekly training mileage was >40 miles and previous injury. Few studies reported that there was no association between running experience and training mileage with and without ERLP Reinking et al.;[15] Reinking et al.[3] At the same time, another survey reported that an ERLP history, training mileage >15 miles per week and <3 years running experience were the most common risk factors for developing ERLP in community runners Reinking et al.,[16] (2013).

Bio-mechanics of foot

The human foot is increasingly studied as a multi segmental structure with complex three-dimensional kinematics Chenung et al.,[17] (2005); Nester et al., (2007).[18] There are three types foot categories, viz. neutral, pronated, and supinated foot. In pronated foot, the calcaneus is everted, and arch is low and in supinated foot, the calcaneus is inverted and arch height is high. Neutral foot is characterized by the bisection of the posterior surface of the calcaneus close to perpendicular to the ground and arch height is normal Ledoux et al.,[19] (2006). During stance phase, the foot must able to adapt to the ground surface, helps in shock absorption Tiberio et al.[20] Proper foot motion, mainly sub talar pronation and supination is critical to achieve these functions. During weight bearing the foot moves into pronation and achieve maximum pronation in mid stance, with pronation the mid tarsals joints unlocks and the foot becomes more flexible to adjust to the underlying surface and assisting in balance. Conversely, the mid tarsal joint becomes locked in supination to optimize adaptability versus stability as needed. Foot mal alignment like pronation and supination that negatively affect the foot mobility, it may diminish the ability of the lower leg to function optimally during weight-bearing stance Tiberio et al.[20] Pronation and supination of the foot and ankle cause obligate motion in the entire lower limb kinetic chain. Although a physiological amount of pronation required, hyper pronation causes increased ground reaction forces (GRFs) in the medial aspect of the lower limb kinetic chain such as medial tibia. Muscles may need to work harder to control the excessive pronation and internal rotation of the tibia and femur. Excessive supination is more common and leads to increased forces on the lateral aspect of the kinetic chain Tiberio et al.[20]

Foot posture and mobility may influence the function of lower limb and may, therefore, play a greater role in predisposition of overuse injuries Dahle et al.,[21] (1991); Nigg et al.,[22] (1993); Cowan et al.;[23] Murley et al.[24] 2009 observed any change in the foot posture changes the lower limb kinetic chain function and associated with risk of injury. A number of different methods have been described in the literature to quantify and classify standing foot posture. Several techniques have been used including visual observation Dahle et al.,[21] (1991); Cowan et al.,[23] (1993) various footprint parameters measures frontal plane heel position Cavanagh PR and Rodegers MM (1994).[25] and assessment of the position of the navicular tuberosity Mueller et al.[26] But still considerable disagreement was there regarding the most appropriate method for categorizing foot type need for better foot measures expressed due to the absence of adequately validated method for quantifying variation in foot posture in the clinical setting Razeghi et al.[27]

Foot type and exercise-related leg pain

Several studies focused on ERLP in collegiate cross country runners and their risk factors. There is a conflict of evidence regarding foot type (pronated, neutral and supinated) in the etiology of ERLP. Excessive pronation is the potential risk factor in the development of exercises related leg pain in runners Bennett et al.[2] Most of the studies use navicular drop (ND) test as a measure of pronation had reported the significant relationship to ERLP and medial tibial stress syndrome (MTSS) Reinking.[28] Few studies have reported an association between a supinated foot and exercises related leg pain Burns et al.,[29] (2005); Korpelainen et al.[30] Some studies found that no relation between foot type and exercises related leg pain Michelson et al.[31] Runners are prone to develop musculoskeletal injuries, and chances of reoccurrence are more Morley et al.,[32] (2010). The relation between running mechanics and overuse injuries are not well-understood. Hence, it is essential to understand the biomechanics, which may predispose and cause injury to athletes. Several studies had focused on atypical subtalar joint compensatory motion as a risk factor for contributing to overuse injury in lower extremity James et al,[33] Bates et al.[34] (1982); Messier et al.,[35] (1991). Foot pronation is a combination of calcaneal eversion, forefoot abduction, and dorsi flexion to help in shock absorption while running Morley et al.,[32] (2010). During running, the GRFs are absorbed by supporting structures along with pronation of the foot and reducing the impact of forces. These forces are directly absorbed by supporting structures without sub talar pronation causing greater stress James and Bates;[34] Chu et al.,[36] (1986). Excessive pronation of foot may lead to overuse injuries in lower extremities. But there is limited evidence that for a direct relationship between the pronated foot type and frequency of running injuries Morley et al.,[32] (2010). Nigg et al.[22] reported excessive foot pronation along with other anatomical and biomechanical factors, which may further lead to running injuries. Morley et al.,[32] (2010) examined the relationship between the medio-lateral GRFs and pronation to investigate the difference between medio-lateral GRF with different degrees of pronation and conclude that the peak GRF occurred with peak eversion than peak lateral GRF. The study has shown that pronation of foot was necessary to dissipate the impact of loading. Increased pronation was a protective mechanism to alternate high impact forces. The impact of forces for prolonged time may cause overuse injuries commonly seen in distance runners. The excessive pronation during running reduces the impact of loading, but the pronation should end before the mid stance. The severe pronated foot has a greater risk of injury due to larger torques generated during running.

Navicular drop test was first described by Brody (NDT 1982), used ND test in the evaluation of the amount of pronation of a runner foot. According to the values of ND below 10 mm should be considered as normal in range and above 10 mm should be considered as abnormal. One more study, on subjects with and without lower extremity injury and concluded in findings that an ND value Six to Nine mm comes under range of normality and the values of ND > 10 mm have considered abnormal Loudon et al.,[37] (1996).

Plantar flexor endurance and exercise-related leg pain

The possible cause for ERLP is the failure of planter flexors to absorb GRF during running Burne et al.;[38] Madeley et al.[39] Madeley et al.[39] examined the relationship between isotonic endurance of ankle planter flexors endurance (PFE) with MTSS group and control group, they found a significance difference in ankle planter flexor endurance in MTSS group when compared to control group. At the same time another study, who reported that there is no significant relation between plantar flexor endurance (PFE) and ERLP Bennett et al.[2] Moller et al.,[40] (2003) investigated the endurance of plantar flexors using isokinetic dynamometer and standard heel raise test, they found that results were equally similar, both tests were significantly reliable for measuring PFE.

It is widely thought that the foot type has implications on lower extremity overuse injuries, and muscular endurance may influence the lower limb bio-mechanics. This may make the athlete to develop overuse injuries. Few studies have focused on the risk factors for ERLP. The purpose of this study is to bridge the literature gap in this aspect. Gender, weight, height, body mass index (BMI), training parameters, and previous history of pain showed a relation with ERLP. In lieu at the hypothesis of the present study was designed, foot type, PFE may the risk factors of ERLP.


  Materials and Methods Top


Selection of subjects and study setting: A voluntary follow-up study was carried out on young adult athletes (age range 18–24 years) from Punjab (inter university level players). The study group was comprised of a total of 70 athletes (males 57.10% and females 42.80%). The study was ethically approved by Institutional Ethics Committee of the Guru Nanak Dev University, Amritsar. A questionnaire was designed on the basis of preliminary study, and the consent was signed by the study participants. Anthropometric measurements (height and weight) were measured with the help of anthropometric rod and weighing machine and information about the lifestyle pattern of the participants were noted on the proforma. The procedure was explained to the athletes and coach before study. The inclusion criteria for the study were based on the age range 18–24 years, those with and without ERLP and they should regularly participate in the training sessions. The athletes those who had past 1-year surgical history, recent lower extremity injuries and those who did not participate in precompetitive season and regular training sessions were excluded from the study. Preseason questionnaire was explained and completed by athletes, which includes basic demographic and anthropometric data, ERLP history, training parameters, and orthotic use. The testing procedure included foot posture assessment measured using FPI-6 and ND test conducted on 3 consecutive days to increase the intra-rater reliability. PFE was measured by standard single leg heel raise test. Athletes were tracked throughout the season and completed the postseasonal questionnaire at the end of the season to see the in the seasonal incidence of ERLP.

Data collection

Data were collected from the athletic field and track, Guru Nanak Dev University, Amritsar, and other universities in Punjab.

Navicular drop test

Navicular drop is the difference between the height of the navicular tuberosity in sub talar joint neutral and the height of the navicular tuberosity in relaxed stance, was measured bilaterally as first described by Bennett et al.[2] Each individual was asked to stand on barefoot, and weight was equally distributed on both legs. In standing position, the most prominent point of the navicular tuberosity was located and marked with pen, then by using the card, we measured the distance from floor to the navicular tuberosity which was previously marked. Subjects were then asked to stand on the leg being tested with the opposite knee flexed, and the hip maintained in neutral. Then we were requested to the subject to do internal and external of tibia by applying cues to lower leg, to achieve sub talar joint in neutral position then again we measured the distance from floor to navicular tuberosity. Finally, we measured the difference between original neutral height to abnormal height in millimeter using scale. If the value is below 10 mm that indicates normal or neutral foot and difference more than 10 mm indicates pronated foot Bennett et al.[2]

Plantar flexor endurance test

The isotonic PFE using standard single leg heel raise test performed at a speed of 1 repetition of heel raise for every 2 s. The subjects were standing on barefoot in relaxed stance position, feet at shoulder width a part and arms placed straight forward with full elbow, wrist and finger extended position and finger tips were slightly touching the wall. They were asked to assume a single leg stance and asked to perform heel raise without bending their knee and arms. Meanwhile, the examiner assured the subject may maintain balance without change of position, and placed two parallel uprights so that the dorsal aspect of the foot contacted a 0.5 mm piece of nylon threads just distal to the anterior tibia. The subject was instructed to use their fingertips for balance while keeping the upper extremities in the starting test position. Then the subject was to do one heel raise in every 2 s according to the metronome beep and subject should be instructed to touch the parallel bar in each repetition. The test was performed on the both legs with an interval of 1 min rest. The test was dismissed when one of the following occurred: (1) Knee flexion, (2) elbow or wrist flexion three times, (3) failure to contact the string for three successive repetitions, (4) inability to continue the test due to fatigue. The number of heel-rise repetitions was recorded, and the subject was allowed to take rest for 60 s before testing the opposite leg. A value of 25 repetitions is considered normal for males and females based on Bennett et al.[2] study. We grouped the subjects categorically based on a normal (≥25 heel-rise repetitions) or below normal (<25 heel-rise repetitions) based on PFE test result.

Pre- and post-season questionnaire

The questionnaire includes demographic and basic anthropometric parameters (age, gender, weight, height), training parameters (raining surface, mileage per week, warm up and cool down), history of ERLP, location of ERLP, impact of ERLP on training/competition activity and orthotic use Reinking et al.,[16] (2013).

Data analysis

Statistical tests were Chi-square test used to summarize the percentage of athletes in pain, no pain and dropout groups, and percentage distribution in ERLP history and location of pain groups with all variables. Student's t-test and ANOVA were conducted to see the difference between pain, no pain and dropout groups with foot type and PFE. Odd's ratio was applied to find the risk factors in relation to in seasonal ERLP. Chi-square test and Odd's ratio were conducted using a medical calculator and both ANOVA and Student's t-test was applied using SPSS software version 19.0 IBM.


  Results Top


Overall 48.57% male and 37.14% female athletes had a history of ERLP and 14.28% athletes did not have any history of ERLP out of 70 athletes. Among them 57 (81.4%) athletes completed post seasonal questionnaire, remaining 13 athletes (7 male and 6 female) placed under dropout group. In dropout group both sexes were almost equal. Out of 57 athletes 42% (24) male and 28% (16) female athletes developed in seasonal ERLP, bilateral lower leg pain was the most common presentation (P< 0.02) [Table 1]. There were no significance difference seen in foot type measured by ND-test and plantar flexor endurance those with and without ERLP (P > 0.05) [Table 2].
Table 1: Anthropometric, clinical history, and training parameter variables in various studied groups viz. no ERLP, ERLP, and dropout groups

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Table 2: Clinical testing variables in various studied groups (no ERLP, ERLP, and dropout groups)

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At the same time there was a significant difference seen with medial pain in association with ERLP history category (P< 0.03) [Table 3]. The mean of ND-test for right leg was slightly greater (10.68 ± 0.25) in those athletes with in seasonal occurrence of ERLP then those without ERLP. At the same time the mean of left ND (11.55 ± 0.26) was slightly higher than the mean of right ND but there were no significant difference seen between the athletes with and without ERLP in relation to navicular drop (P > 0.05) [Table 4]. The mean of PFE for right leg was almost equal for those who had (24.65 ± 0.08) and had not (24.82 ± 0.10) seasonal incidence of ERLP. There were no significance difference seen between right and left PFE and at the same time those with and without in seasonal ERLP in relation to plantar flexor endurance (P > 0.05) [Table 5].
Table 3: Percentage of all variables with four groups of history of ERLP (no pain, 1-, 6-, and 12-month)

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Table 4: Comparison of mean values of right and left ND with all studied groups (no pain, pain, and dropout)

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Table 5: Comparison of right and left PFE mean values with all studied groups (no pain, pain, and dropout)

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There were no significant difference seen with gender, training mileage and running experience in association to those with and without ERLP (P > 0.05) [Table 6]. There was a significant difference seen with BMI and ERLP one month history (P< 0.04, P< 0.02) in relation to athletes with and without in seasonal ERLP [Table 6]. There was significance difference was seen in ERLP history with in seasonal ERLP. Especially those who had 1 month history were more significantly related with in seasonal ERLP when compared to 6 and 12 month history of ERLP [Table 6].
Table 6: OR was conducted for seasonal occurrence of ERLP in athletes with all base line and testing variables

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  Discussion Top


Several studies have focused on risk factors of ERLP in distance runners. They have identified extrinsic and intrinsic risk factors but the literature has shown controversial results. The present study is focused on few risk factors to find out their association with ERLP in inter university distance runners. This study has tried to bridge the literature gap in this aspect.

The results of present study have shown that 85.7% (34 male and 26 female out of 70) athletes had a history ERLP prior to the competitive season and in seasonal incidence of ERLP was 57% (24 male and 16 female), bilateral leg pain was most common presentation. The present results were consistent with Reinking et al.,[3] (2010), who reported 82.4% (103 out of 125) athletes had a history of ERLP prior to the season and 48% reported in seasonal incidence of ERLP and bilateral lower leg pain was most common presentation. There was a difference observed in case of in seasonal incidence of ERLP which is more than a study done by Reinking et al.[3] study, it may be due to individual difference.

The results of the current study showed that the male athlete had a higher incidence of ERLP as compared to the female athlete, but there was no significance difference seen with gender in those with and without ERLP. The results of present study were in agreement with several studies, which showed that there was no gender difference with development of ERLP Reinking;[28] Reinking et al.,[3] (2010); Bennett et al.;[2] Reinking et al.,[16] (2013). At the same time, few studies reported that female athletes were at greater risk to develop in seasonal than male athletes Clement et al.;[41] Bennett et al.;[42] Sallis et al.;[43] and Plisky et al.[44] In the present study, both genders were equally developed ERLP and showed no significant difference with regard to ERLP.

There was a significant difference observed between BMI and ERLP. The results were in accordance with a previous study where higher BMI were related to the development of ERLP in high school athletes Plisky et al.[44] at the same few studies reported that higher BMI, low BMI, and physical fitness of athletes may develop ERLP, high percentage of body results in greater forces on soft tissue and low body fat than normal may also develop injuries, female athletes commonly exhibit this type of bimodal character Bennel et al.,[45] (1997); Neely et al.,[46] (1998); Reinking et al.[15] But previous studies reported that there was no significance difference seen between those with and without ERLP in relation to BMI (Reinking, 2006;[28] Reinking et al.,[3] 2010; Bennett et al., 2012;[2] Reinking et al.,[16] 2013). The results may be due to individual differences.

Exercise-related leg pain history (1-month) had the significant relation (P < 0.02) with the development of in seasonal ERLP as compared to those who had 6 and 12 months of ERLP history. The results of the present study were in accordance with several studies (Reinking et al., 2010;[15] Reinking et al., 2010;[2] Bennett et al., 2012[2]). According to Bennett et al., 2012[2] found that the athletes who had 1 year history have also prone to develop in seasonal occurrence of ERLP (P = 0.001) and those who had 1-month history of ERLP had greater risk to develop in seasonal pain (P = 0.0001). Because of limited sample size we did not find the significant relation of 6 and 12 months history within seasonal ERLP. The results of the current study showed that ERLP 1-month history was the only risk factor for in seasonal pain. There was no significant difference observed in all ERLP history groups (no, 1-,6-, and 12-month history) with all testing variables (ND, PFE). The results were similar to previous studies Bennett et al.;[2] Reinking et al., (2010).[3]

There was significant difference seen between weekly training mileage and running experience those participants with and without ERLP. The results of present in accordance with previous studies reported training mileage and running experience were not common risk factors for developing ERLP in distance runners Reinking et al.,[15] Reinking et al.[3] At the same time, few studies identified that training mileage >40 miles per week may cause overuse injuries Macera et al.,[14] (1989) and training mileage >15 miles per week and <3 years running experience were the most common risk factors for developing ERLP in community runners Reinking et al.[16] Goldberg and Pecora et al.,[47] (1994) reported stress fractures commonly observed in relation to increased training intensity in beginners as compared to experienced runners.

The results of the current study showed that there was no significance difference seen with foot type in those with and without ERLP. This indicates that no association was observed with pronated and supinated foot type with and without ERLP. The results were consistent with previous studies which reported that there was no significant difference between those with and without ERLP for all three foot types Reinking et al.,[3] (2010); Plisky et al.;[44] Reinking et al.;[15] and Reinking MF.[48] (2007). Another study was conducted by Plisky et al., 2007,[44] they measured foot type by ND-test in both a symptomatic and symptomatic athletes but they did not find relation of pronated foot within seasonal ERLP. They found that there was no relationship between pronated foot type with the location of pain (medial, lateral and posterior aspect of the leg). Several studies which found significance relation of pronated foot with development of in seasonal ERLP Reinking et al., (2007); Bennett et al.;[44] Willems et al.;[49] Yates and White (2004)[50] and Zeni et al.[51] At the same time, Korpelainen et al.[30] Burns et al.,[29] (2005) also reported that supinated foot was significantly associated with ERLP. Willems et al.,[49] who worked on kinematics of walking and running and reported that ERLP subjects had a greater foot pronation than those without ERLP, this abnormal foot posture alters the lower extremity bio-mechanics in subjects with ERLP. The evidence of foot type in relation to ERLP was conflicting, and the present study did not find significance relation of pronated and supinated foot type those with and without in seasonal ERLP. It may be due to foot type was measured by static foot postures and the present study was not observed kinematics and kinetics of walking and running.

There was no significant association seen with PFE in those athletes with and without ERLP. The results were in consistent with previous studies, which reported that no relation was found between PFE and in seasonal ERLP Bennett et al.[2] The PFE was important to attenuate GRFs during prolonged running, fatigue of these muscles results in increased forces, this leads to increased tibial tension that may lead to overuse injury but there was no significant difference seen in GRFs after the activity Milgrom et al.[52]

Madeley et al.,[39] measured PFE in both asymptomatic and symptomatic athletes, they observed that the symptomatic group performed less repetition when compared to a symptomatic group. In symptomatic group, the pain may interfere with daily activity, this results in reduced PFE. But in the present study, we included both those with and without ERLP and we did not find any association between PFE and in seasonal pain. These data suggest that reduced PFE was not associated with increased likelihood of pain.


  Conclusion Top


The incidence of in-seasonal ERLP was higher in interuniversity distance runners, and bilateral lower leg pain was most common presentation. ERLP history (1-month) and BMI were the risk factors for in the seasonal development of ERLP. This suggests that identification of athletes with low BMI and a history of ERLP (1-month) prior to the competition may help in prevention and earlier intervention. There was no association find with gender, training mileage, running experience, foot type, and PFE. Sample size was too small, foot type was measured in static posture, bio-mechanics of walking and running were not observed, only selected limited risk factors were observed with ERLP, these are the limitations of the present study.


  Acknowledgments Top


Gratitude is expressed to the subjects who participated in this study as well as for each of the assistant contributed to the data collection. The researchers collected independently, analysed and interpreted the results and have no financial interest in the results of this study.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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