title: Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review.
abstract: BACKGROUND
  Dynamic foot function is considered a risk factor for lower limb overuse injuries including Achilles tendinopathy, shin pain, patellofemoral pain and stress fractures. However, no single source has systematically appraised and summarised the literature to evaluate this proposed relationship. The aim of this systematic review was to investigate dynamic foot function as a risk factor for lower limb overuse injury.
  
  
  METHODS
  A systematic search was performed using Medline, CINAHL, Embase and SportDiscus in April 2014 to identify prospective cohort studies that utilised dynamic methods of foot assessment. Included studies underwent methodological quality appraisal by two independent reviewers using an adapted version of the Epidemiological Appraisal Instrument (EAI). Effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data.
  
  
  RESULTS
  Twelve studies were included (total n = 3,773; EAI 0.44 to 1.20 out of 2.00, representing low to moderate quality). There was limited to very limited evidence for forefoot, midfoot and rearfoot plantar loading variables (SMD 0.47 to 0.85) and rearfoot kinematic variables (RR 2.67 to 3.43) as risk factors for patellofemoral pain; and plantar loading variables (forefoot, midfoot, rearfoot) as risk factors for Achilles tendinopathy (SMD 0.81 to 1.08). While there were significant findings from individual studies for plantar loading variables (SMD 0.3 to 0.84) and rearfoot kinematic variables (SMD 0.29 to 0.62) as risk factors for 'non-specific lower limb overuse injuries', these were often conflicting regarding different anatomical regions of the foot. Findings from three studies indicated no evidence that dynamic foot function is a risk factor for iliotibial band syndrome or lower limb stress fractures.
  
  
  CONCLUSIONS
  This systematic review identified very limited evidence that dynamic foot function during walking and running is a risk factor for patellofemoral pain, Achilles tendinopathy, and non-specific lower limb overuse injuries. It is unclear whether these risk factors can be identified clinically (without sophisticated equipment), or modified to prevent or manage these injuries. Future prospective cohort studies should address methodological limitations, avoid grouping different lower limb overuse injuries, and explore clinically meaningful representations of dynamic foot function.
authors.affiliation: Department of Podiatry, Faculty of Health Sciences, La Trobe University, Melbourne, Australia.
authors.forename: Geoffrey J
authors.initials: GJ
authors.lastname: Dowling
authors.affiliation: Department of Podiatry, Faculty of Health Sciences, La Trobe University, Melbourne, Australia ; Lower Extremity and Gait studies program, Faculty of Health Sciences, La Trobe University, Melbourne, Australia.
authors.forename: George S
authors.initials: GS
authors.lastname: Murley
authors.affiliation: Department of Podiatry, Faculty of Health Sciences, La Trobe University, Melbourne, Australia ; Lower Extremity and Gait studies program, Faculty of Health Sciences, La Trobe University, Melbourne, Australia.
authors.forename: Shannon E
authors.initials: SE
authors.lastname: Munteanu
authors.affiliation: School of Physiotherapy, Australian Catholic University, Brisbane, Australia.
authors.forename: Melinda M Franettovich
authors.initials: MM
authors.lastname: Smith
authors.affiliation: Pure Sports Medicine, London, UK ; Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK.
authors.forename: Bradley S
authors.initials: BS
authors.lastname: Neal
authors.affiliation: Pure Sports Medicine, London, UK.
authors.forename: Ian B
authors.initials: IB
authors.lastname: Griffiths
authors.affiliation: Lower Extremity and Gait studies program, Faculty of Health Sciences, La Trobe University, Melbourne, Australia ; Pure Sports Medicine, London, UK ; Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK ; Complete Sports Care, Melbourne, Australia.
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Barton
authors.affiliation: Department of Mechanical Engineering, Melbourne School of Engineering, The University of Melbourne, Melbourne, Australia.
authors.forename: Natalie J
authors.initials: NJ
authors.lastname: Collins
keywords: Biomechanics; Kinematics; Musculoskeletal diseases; Plantar pressures; Prospective studies; Review