Interventions for preventing lower limb soft-tissue running injuries

 

Abstract

Background

Overuse soft-tissue injuries occur frequently in runners. Stretching exercises, modification of training schedules, and the use of protective devices such as braces and insoles are often advocated for prevention. This is an update of a review first published in 2001.

Objectives

To assess the effects of interventions for preventing lower limb soft-tissue running injuries.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011); The Cochrane Library 2010, Issue 4; MEDLINE (1966 to January 2011); EMBASE (1980 to January 2011); and international trial registries (17 January 2011).

Selection criteria

Randomised or quasi-randomised trials evaluating interventions to prevent lower limb soft-tissue running injuries.

Data collection and analysis

Two authors independently assessed risk of bias (relating to sequence generation, allocation concealment, blinding, incomplete outcome data) and extracted data. Data were adjusted for clustering if necessary and pooled using the fixed-effect model when appropriate.

Main results

We included 25 trials (30,252 participants). Participants were military recruits (19 trials), runners from the general population (three trials), soccer referees (one trial), and prisoners (two trials). The interventions tested in the included trials fell into four main preventive strategies: exercises, modification of training schedules, use of orthoses, and footwear and socks. All 25 included trials were judged as 'unclear' or 'high' risk of bias for at least one of the four domains listed above.

We found no evidence that stretching reduces lower limb soft-tissue injuries (6 trials; 5130 participants; risk ratio [RR] 0.85, 95% confidence interval [95% CI] 0.65 to 1.12). As with all non-significant results, this is compatible with either a reduction or an increase in soft-tissue injuries. We found no evidence to support a training regimen of conditioning exercises to improve strength, flexibility and coordination (one trial; 1020 participants; RR 1.20, 95% CI 0.77 to 1.87).

We found no evidence that a longer, more gradual increase in training reduces injuries in novice runners (one trial; 486 participants; RR 1.02, 95% CI 0.72 to 1.45). There was some evidence from a poor quality trial that additional training resulted in a significant increase in the number of naval recruits with shin splints (one trial; 1670 participants; RR 2.02, 95% CI 1.11 to 3.70). There was limited evidence that injuries were less frequent in prisoners when running duration (one trial; 69 participants; RR 0.41, 95% CI 0.21 to 0.79) or frequency (one trial; 58 participants; RR 0.19, 95% CI 0.06 to 0.66) were reduced.

Patellofemoral braces appear to be effective for preventing anterior knee pain (two trials; 227 participants; RR 0.41, 95% CI 0.24 to 0.67).

Custom-made biomechanical insoles may be more effective than no insoles for reducing shin splints (medial tibial stress syndrome) in military recruits (one trial; 146 participants; RR 0.24, 95% CI 0.08 to 0.69).

We found no evidence in military recruits that wearing running shoes based on foot shape, rather than standard running shoes, significantly reduced rate of running injuries (2 trials; 5795 participants; Rate Ratio 1.03, 95% CI 0.93 to 1.14).

Authors' conclusions

Overall, the evidence base for the effectiveness of interventions to reduce soft-tissue injury after intensive running is very weak, with few trials at low risk of bias. More well-designed and reported RCTs are needed that test interventions in recreational and competitive runners.

 

Plain language summary

Interventions for preventing lower limb soft-tissue injuries in runners

Lower limb soft-tissue injuries are common in runners. Most running-related injuries are overuse injuries and the causes of these injuries are often multifactorial. Prevention strategies attempt to target modifiable risk factors. We included 25 trials with 30,252 participants in this review. Only three of the trials recruited runners from the general population, and one recruited soccer referees. Nineteen trials involved service personnel (Army, Marines, Naval personnel etc) undertaking basic training which includes intensive periods of running, along with other activities. Two trials were conducted in prisons.

The included trials tested four categories of interventions: exercises, modification of training schedules, use of orthoses, and footwear and socks.

In the following results, where there is "no evidence" that an intervention worked, the results were compatible with either a reduction or an increase in the number of soft-tissue injuries.

There is no evidence that improving physical attributes by exercises (stretching or conditioning exercises) reduces lower limb soft-tissue injuries.

With regards to the modification of training schedules, there is no evidence that a longer training programme with a gradual increase in the amount of running is more effective than a shorter training programme for preventing injuries in novice runners training for a four-mile recreational run. Having a longer build-up in training intensity may even result in an increase in sore shins in people undergoing military training. There is limited evidence from two poor quality trials conducted in prisons for the effectiveness of decreased frequency or duration of running but these results may not apply to runners in general, or military recruits.

Knee braces may reduce the frequency of anterior knee pain. Custom-made biomechanical insoles may be more effective than no insoles for reducing shin splints (medial tibial stress syndrome) in military recruits. There is no evidence to support the use of shoe insoles for the reduction of other lower limb soft-tissue injuries, whether they are individually prescribed to suit foot shape or off-the-shelf.

There is no evidence that running shoes prescribed to suit individual foot shape are better than standard running shoes for preventing injuries in military recruits.

Overall, the evidence for the effectiveness of interventions to reduce lower-limb pain and injury after intensive running is very weak. More trials, designed, conducted and reported to contemporary standards, would be required to confirm these findings, especially in recreational or competitive runners, rather than military recruits.

 

Resumen

Antecedentes

Intervenciones para prevenir lesiones de los tejidos blandos de miembros inferiores durante el trote

Las lesiones de tejidos blandos por uso excesivo ocurren con frecuencia en los corredores. A menudo se recomienda como prevención los ejercicios de elongación, la modificación de los esquemas de entrenamiento y el uso de dispositivos protectores como rodilleras y plantillas. Ésta es una actualización de una revisión publicada por primera vez en 2001.

Objetivos

Evaluar los efectos de las intervenciones para la prevención de lesiones de los tejidos blandos de miembros inferiores durante el trote.

Estrategia de búsqueda

Se hicieron búsquedas en el registro especializado del Grupo Cochrane de Lesiones Óseas, Articulares y Musculares (Cochrane Bone, Joint and Muscle Trauma Group) (marzo 2011); The Cochrane Library 2010, número 4; MEDLINE (1966 hasta enero 2011); EMBASE (1980 hasta enero 2011); y en registros internacionales de ensayos (17 enero 2011).

Criterios de selección

Ensayos aleatorios o cuasialeatorios que evaluaban intervenciones para prevenir lesiones de los tejidos blandos de miembros inferiores durante el trote.

Obtención y análisis de los datos

Dos revisores evaluaron de forma independiente el riesgo de sesgo (en relación con la generación de la secuencia, la ocultación de la asignación, el cegamiento, los datos de resultado incompletos) y extrajeron los datos. Los datos se adaptaron para la asignación por grupos y se agruparon mediante un modelo de efectos fijos cuando fue apropiado.

Resultados principales

Se incluyeron 25 ensayos (30 252 participantes). Los participantes eran reclutas militares (19 ensayos), corredores de la población general (tres ensayos), árbitros de fútbol (un ensayo) y prisioneros (dos ensayos). Las comparaciones evaluadas en los ensayos incluidos pueden dividirse en cuatro grandes estrategias de prevención: ejercicios, modificación de los esquemas de entrenamiento, uso de ortesis, y calzado y calcetines. Los 25 ensayos incluidos recibieron la calificación de riesgo de sesgo “incierto” o “alto” en al menos uno de los cuatro dominios enumerados anteriormente.

No se hallaron pruebas de que la elongación reduzca las lesiones de los tejidos blandos de miembros inferiores (6 ensayos; 5130 participantes; cociente de riesgos [CR] 0,85; intervalo de confianza [IC] del 95%: 0,65 a 1,12). Al igual que en todos los resultados no significativos, esta cifra es compatible tanto con una reducción como con un aumento de las lesiones de tejidos blandos. No se hallaron pruebas que apoyen un régimen de entrenamiento de ejercicios de acondicionamiento para mejorar la fuerza, la flexibilidad y la coordinación (un ensayo; 1020 participantes; CR 1,20; IC del 95%: 0,77 a 1,87).

No se hallaron pruebas de que un aumento más gradual, más prolongado, del entrenamiento reduzca las lesiones en los corredores principiantes (un ensayo; 486 participantes; CR 1,02; IC del 95%: 0,72 a 1,45). Un ensayo de calidad deficiente aportó algunas pruebas de que el entrenamiento adicional dio lugar a un aumento significativo del número de reclutas navales que presentó síndrome de estrés medial de la tibia (un ensayo; 1670 participantes; CR 2,02; IC del 95%: 1,11 a 3,70). Se encontraron pruebas limitadas de que las lesiones fueron menos frecuentes en los prisioneros cuando se redujo la duración (un ensayo; 69 participantes; RR 0,41; IC del 95%: 0,21 a 0,79) o la frecuencia del trote (un ensayo; 58 participantes; RR 0,19; IC del 95%: 0,06 a 0,66).

Las rodilleras femororrotulianas parecen ser efectivas para prevenir el dolor anterior de rodilla (dos ensayos; 227 participantes; CR 0,41; IC del 95%: 0,24 a 0,67).

Las plantillas biomecánicas hechas a medida pueden ser más efectivas que ninguna plantilla para reducir la periostitis tibial (síndrome de estrés medial de la tibia) en los reclutas militares (un ensayo; 146 participantes; CR 0,24; IC del 95%: 0,08 a 0,69).

No se hallaron pruebas en los reclutas militares de que el uso de calzado para correr basado en la forma del pie, en lugar de calzado para correr estándar, reduzca de manera significativa la tasa de lesiones durante el trote (2 ensayos; 5795 participantes; proporción de la tasa: 1,03; IC del 95%: 0,93 a 1,14).

Conclusiones de los autores

En términos generales, la base de pruebas sobre la efectividad de las intervenciones para reducir las lesiones de tejidos blandos después del trote intensivo es muy débil, con pocos ensayos con bajo riesgo de sesgo. Se necesitan más ECA, bien diseñados y notificados, que evalúen intervenciones en corredores recreativos y competitivos.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano