Publications by authors named "Richard W Willy"

43 Publications

Peak and Per-Step Tibial Bone Stress During Walking and Running in Female and Male Recreational Runners.

Am J Sports Med 2021 Jun 2:3635465211014854. Epub 2021 Jun 2.

School of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, Montana, USA.

Background: Athletes, especially female athletes, experience high rates of tibial bone stress injuries (BSIs). Knowledge of tibial loads during walking and running is needed to understand injury mechanisms and design safe running progression programs.

Purpose: To examine tibial loads as a function of gait speed in male and female runners.

Study Design: Controlled laboratory study.

Methods: Kinematic and kinetic data were collected on 40 recreational runners (20 female, 20 male) during 4 instrumented gait speed conditions on a treadmill (walk, preferred run, slow run, fast run). Musculoskeletal modeling, using participant-specific magnetic resonance imaging and motion data, was used to estimate tibial stress. Peak tibial stress and stress-time impulse were analyzed using 2-factor multivariate analyses of variance (speed*sex) and post hoc comparisons (α = .05). Bone geometry and tibial forces and moments were examined.

Results: Peak compression was influenced by speed ( < .001); increasing speed generally increased tibial compression in both sexes. Women displayed greater increases in peak tension ( = .001) and shear ( < .001) than men when transitioning from walking to running. Further, women displayed greater peak tibial stress overall ( < .001). Compressive and tensile stress-time impulse varied by speed ( < .001) and sex ( = .006); impulse was lower during running than walking and greater in women. A shear stress-time impulse interaction ( < .001) indicated that women displayed greater impulse relative to men when changing from a walk to a run. Compared with men, women displayed smaller tibiae ( < .001) and disproportionately lower tibial forces (≤ .001-.035).

Conclusion: Peak tibial stress increased with gait speed, with a 2-fold increase in running relative to walking. Women displayed greater tibial stress than men and greater increases in stress when shifting from walking to running. Sex differences appear to be the result of smaller bone geometry in women and tibial forces that were not proportionately lower, given the womens' smaller stature and lower mass relative to men.

Clinical Relevance: These results may inform interventions to regulate running-related training loads and highlight a need to increase bone strength in women. Lower relative bone strength in women may contribute to a sex bias in tibial BSIs, and female runners may benefit from a slower progression when initiating a running program.
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http://dx.doi.org/10.1177/03635465211014854DOI Listing
June 2021

The Effect of Footwear, Running Speed, and Location on the Validity of Two Commercially Available Inertial Measurement Units During Running.

Front Sports Act Living 2021 26;3:643385. Epub 2021 Apr 26.

Menrva Research Group, Schools of Mechatronic Systems Engineering and Engineering Science, Simon Fraser University, Metro Vancouver, BC, Canada.

Most running-related injuries are believed to be caused by abrupt changes in training load, compounded by biomechanical movement patterns. Wearable technology has made it possible for runners to quantify biomechanical loads (e.g., peak positive acceleration; PPA) using commercially available inertial measurement units (IMUs). However, few devices have established criterion validity. The aim of this study was to assess the validity of two commercially available IMUs during running. Secondary aims were to determine the effect of footwear, running speed, and IMU location on PPA. Healthy runners underwent a biomechanical running analysis on an instrumented treadmill. Participants ran at their preferred speed in three footwear conditions (neutral, minimalist, and maximalist), and at three speeds (preferred, +10%, -10%) in the neutral running shoes. Four IMUs were affixed at the distal tibia (IMeasureU-Tibia), shoelaces (RunScribe and IMeasureU-Shoe), and insole (Plantiga) of the right shoe. Pearson correlations were calculated for average vertical loading rate (AVLR) and PPA at each IMU location. The AVLR had a high positive association with PPA (IMeasureU-Tibia) in the neutral and maximalist ( = 0.70-0.72; ≤ 0.001) shoes and in all running speed conditions ( = 0.71-0.83; ≤ 0.001), but low positive association in the minimalist ( = 0.47; < 0.05) footwear condition. Conversely, the relationship between AVLR and PPA (Plantiga) was high in the minimalist ( = 0.75; ≤ 0.001) condition and moderate in the neutral ( = 0.50; < 0.05) and maximalist ( = 0.57; < 0.01) footwear. The RunScribe metrics demonstrated low to moderate positive associations ( = 0.40-0.62; < 0.05) with AVLR across most footwear and speed conditions. Our findings indicate that the commercially available Plantiga IMU is comparable to a tibia-mounted IMU when acting as a surrogate for AVLR. However, these results vary between different levels of footwear and running speeds. The shoe-mounted RunScribe IMU exhibited slightly lower positive associations with AVLR. In general, the relationship with AVLR improved for the RunScribe sensor at slower speeds and improved for the Plantiga and tibia-mounted IMeasureU sensors at faster speeds.
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http://dx.doi.org/10.3389/fspor.2021.643385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107270PMC
April 2021

Optimal Load for Managing Low-Risk Tibial and Metatarsal Bone Stress Injuries in Runners: The Science Behind the Clinical Reasoning.

J Orthop Sports Phys Ther 2021 May 7:1-28. Epub 2021 May 7.

School of Physical Therapy and Health Sciences, University of Montana, Missoula, MT.

Background: Low-risk bone stress injuries (BSIs) of the tibia and metatarsal diaphysis account for >50% of BSIs in runners. They interrupt training and are managed using non-invasive approaches. The desire by all involved is for a speedy, but safe return to running.

Clinical Question: What is the optimal load to manage low-risk tibial and metatarsal BSIs and safely return to running?

Key Results: Optimal load can be guided by knowledge of the BSI healing process and is symptom driven. At all stages, the optimal load does not produce symptoms during, after, or the day following loading.

Clinical Application: A period of initial load reduction, via partial- or non-weightbearing, is typically needed to alleviate presenting symptoms. Analgesics or NSAIDs may be used short-term (<7 days), but only in the presence of resting and/or night pain. Healing supplements (e.g. low-intensity pulsed ultrasound and/or recombinant parathyroid hormone therapy) may be attempted to influence tissue healing. Athletes can maintain cardiopulmonary fitness via cross-training, while simultaneously addressing musculoskeletal fitness. A return-to-run program can be initiated once an athlete is pain-free with daily activities for 5 consecutive days. Progress is directed by symptom provocation and initially focuses on increasing running volume before speed. Continue optimal loading following return to running and consider including jump training and/or gait retraining to reduce subsequent BSI risk. The optimal loading approach to managing low-risk tibial and metatarsal BSIs is clinically successful, but requires further scientific validation. .
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http://dx.doi.org/10.2519/jospt.2021.9982DOI Listing
May 2021

When progressing training loads, what are the considerations for healthy and injured athletes?

Br J Sports Med 2021 Apr 9. Epub 2021 Apr 9.

Physical Therapy and Movement Science, University of Montana Missoula, Missoula, Montana, USA.

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http://dx.doi.org/10.1136/bjsports-2020-103769DOI Listing
April 2021

Preventing Bone Stress Injuries in Runners with Optimal Workload.

Curr Osteoporos Rep 2021 Feb 26. Epub 2021 Feb 26.

School of Physical Therapy & Health Sciences, University of Montana, Missoula, MT, USA.

Bone stress injuries (BSIs) occur at inopportune times to invariably interrupt training. All BSIs in runners occur due to an "error" in workload wherein the interaction between the number and magnitude of bone tissue loading cycles exceeds the ability of the tissue to resist the repetitive loads. There is not a single optimal bone workload, rather a range which is influenced by the prevailing scenario. In prepubertal athletes, optimal bone workload consists of low-repetitions of fast, high-magnitude, multidirectional loads introduced a few times per day to induce bone adaptation. Premature sports specialization should be avoided so as to develop a robust skeleton that is structurally optimized to withstand multidirectional loading. In the mature skeleton, optimal workload enables gains in running performance but minimizes bone damage accumulation by sensibly progressing training, particularly training intensity. When indicated (e.g., following repeated BSIs), attempts to reduce bone loading magnitude should be considered, such as increasing running cadence. Determining the optimal bone workload for an individual athlete to prevent and manage BSIs requires consistent monitoring. In the future, it may be possible to clinically determine bone loads at the tissue level to facilitate workload progressions and prescriptions.
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http://dx.doi.org/10.1007/s11914-021-00666-yDOI Listing
February 2021

Fear of movement and (re)injury is associated with condition specific outcomes and health-related quality of life in women with patellofemoral pain.

Physiother Theory Pract 2020 Oct 27:1-10. Epub 2020 Oct 27.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Australia.

Objectives: Investigate the association of fear of movement and (re)injury with clinical outcomes in women with patellofemoral pain (PFP).

Methods: This cross-sectional study included 92 women with PFP who completed the TAMPA scale for kinesiophobia. The TAMPA score and its two subscales - activity avoidance and somatic focus were correlated with BMI, physical activity level, pain catastrophizing scale, health-related quality of life, pain sensitivity via pressure pain threshold, self-reported disability, and worst knee pain in last month.

Results: Greater fear of movement and (re)injury, activity avoidance, and somatic focus were correlated with lower local pain sensitivity (rho = -0.29 to -0.55), lower health-related quality of life (rho = -0.38 to -0.42), greater pain catastrophizing (rho = 0.41 to 0.47), and greater self-reported disability (rho = -0.31 to -0.52). Greater fear of movement and (re)injury and activity avoidance were correlated with adjacent and remote pain sensitivity (rho = -0.24 to -0.39). Greater fear of movement and (re)injury and somatic focus were correlated with greater worst knee pain in last month (rho = 0.21 to 0.32). Fear of movement and (re)injury predicted pain measures, disability, and health-related quality of life (p ≤ 0.010).

Conclusion: The relationship of greater fear of movement and (re)injury with greater disability, pain catastrophizing, pain sensitization, and poorer health-related quality of life highlights the potential importance of considering this psychological feature of PFP during assessment and management.
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http://dx.doi.org/10.1080/09593985.2020.1830323DOI Listing
October 2020

Moving Beyond Weekly "Distance": Optimizing Quantification of Training Load in Runners.

J Orthop Sports Phys Ther 2020 10 1;50(10):564-569. Epub 2020 Aug 1.

Background: Quantifying total running distance is valuable, as it comprises some aspects of the mechanical/neuromuscular, cardiovascular, and perceptual/psychological loads that contribute to training stress and is partially predictive of distance-running success. However, running distance is only one aspect contributing to training stress.

Clinical Question: The purpose of this commentary is to highlight (1) problems with only using running distance to quantify running training and training stress, (2) the importance of alternative approaches to quantify and monitor training stress, (3) moderating factors (effect-measure modifiers) of training loads, and (4) the challenges of monitoring training stress to assess injury risks.

Key Results: Training stress is influenced by external (ie, application of mechanical load) and internal (ie, physiological/psychological effort) training load factors. In running, some commonly used external load factors include volume and pace, while physiological internal load factors include session rating of perceived exertion, heart rate, or blood lactate level. Running distance alone might vastly obscure the cumulative training stress on different training days and, ultimately, misrepresent overall training stress. With emerging and novel wearable technology that quantifies external load metrics beyond volume or pace, the future of training monitoring should have an ever-increasing emphasis on biomechanical external load metrics, coupled with internal (ie, physiological/psychological) load metrics.

Clinical Application: It may be difficult to change the running culture's obsession with weekly distance, but advanced and emerging methods to quantify running training discussed in this commentary will, with research confirmation, improve training monitoring and injury risk stratification. .
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http://dx.doi.org/10.2519/jospt.2020.9533DOI Listing
October 2020

Pain and disability in women with patellofemoral pain relate to kinesiophobia, but not to patellofemoral joint loading variables.

Scand J Med Sci Sports 2020 Nov 27;30(11):2215-2221. Epub 2020 Jul 27.

Department of Physiotherapy, School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Brazil.

Background: Altered patellofemoral joint (PFJ) loading and elevated kinesiophobia are commonly reported in people with patellofemoral pain (PFP). However, the relative relationship of these physical-psychological variables with pain and disability in people with PFP is unknown.

Aim: To explore the relationship of PFJ loading during stair ascent and kinesiophobia, with self-reported pain and disability in women with PFP.

Methods: Fifty-seven women with PFP completed the Tampa Scale for Kinesiophobia, a Visual Analog Scale (0-100 mm) for pain during stair ascent, and the Anterior Knee Pain Scale (disability). Stair ascent mechanics were assessed via three-dimensional motion analysis while participants ascended an instrumented seven-step staircase. Peak PFJ contact force and stress, and PFJ contact force and stress loading rates were estimated using a musculoskeletal model. The relationships of PFJ kinetics during stair ascent and kinesiophobia, with the Anterior Knee Pain Scale (disability) and pain during stair ascent, were evaluated with Spearman rank correlation. Variables (kinetics and kinesiophobia) significantly correlating with the dependent variables (pain and disability) were inserted in linear regression models.

Results: Kinesiophobia was moderately associated with self-reported pain (rho = 0.37) and disability (rho = -0.58) in women with PFP. No PFJ loading variables were found to be associated with self-reported pain or disability (P > .05). Kinesiophobia explained 14% of the variance of participants' pain while ascending stairs and 33% of the variance of participant's self-reported disability.

Conclusion: Addressing kinesiophobia during treatment of women with PFP may be important to reduce self-reported pain and disability.
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http://dx.doi.org/10.1111/sms.13767DOI Listing
November 2020

Infographic. Running myth: switching to a non-rearfoot strike reduces injury risk and improves running economy.

Br J Sports Med 2021 Feb 18;55(3):175-176. Epub 2020 May 18.

La Trobe Sports and Exercise Research Centre, La Trobe University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1136/bjsports-2020-102262DOI Listing
February 2021

Gait Retraining as an Intervention for Patellofemoral Pain.

Curr Rev Musculoskelet Med 2020 Feb;13(1):103-114

School of Physical Therapy & Health Sciences, University of Montana, Missoula, MT, USA.

Purpose Of Review: Movement retraining in rehabilitation is the process by which a motor program is changed with the overall goal of reducing pain or injury risk. Movement retraining is an important component of interventions to address patellofemoral pain. The purpose of this paper is to review the methods and results of current retraining studies that are aimed at reducing symptoms of patellofemoral pain.

Recent Findings: The majority of studies reviewed demonstrated some improvement in patellofemoral pain symptoms and overall function. However, the degree of improvement as well as the persistence of improvement over time varied between studies. The greatest pain reduction and persistent changes were noted in those studies that incorporated a faded feedback design including between 8 and 18 sessions over 2-6 weeks, typically 3-4 sessions per week. Additionally, dosage in these studies increased to 30-45 min during later sessions, resulting in 177-196 total minutes of retraining. In contrast, pain reductions and persistence of changes were the least in studies where overall retraining volume was low and feedback was either absent or continual. Faulty movement patterns have been associated with patellofemoral pain. Studies have shown that strengthening alone does not alter these patterns, and that addressing the motor program is needed to effect these changes. Based upon the studies reviewed here, retraining faulty patterns, when present, appears to play a significant role in addressing patellofemoral pain. Therefore, movement retraining, while adhering to basic motor control principles, should be part of a therapist's intervention skillset when treating patients with PFP.
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http://dx.doi.org/10.1007/s12178-020-09605-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083994PMC
February 2020

Use of Wearables: Tracking and Retraining in Endurance Runners.

Curr Sports Med Rep 2019 Dec;18(12):437-444

School of Physical Therapy & Health Sciences, University of Montana, Missoula, MT.

Wearable devices are ubiquitous among runners, coaches, and clinicians with an ever-increasing number of devices coming on the market. In place of gold standard measures in the laboratory, these devices attempt to provide a surrogate means to track running biomechanics outdoors. This review provides an update on recent literature in the field of wearable devices in runners, with an emphasis on criterion validity and usefulness in the coaching and rehabilitation of runners. Our review suggests that while enthusiasm should be tempered, there is still much for runners to gain with wearables. Overall, our review finds evidence supporting the use of wearables to improve running performance, track global training loads applied to the runner, and provide real-time feedback on running speed and run cadence. Case studies illustrate the use of wearables for the purposes of performance and rehabilitation.
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http://dx.doi.org/10.1249/JSR.0000000000000667DOI Listing
December 2019

Is Motorized Treadmill Running Biomechanically Comparable to Overground Running? A Systematic Review and Meta-Analysis of Cross-Over Studies.

Sports Med 2020 Apr;50(4):785-813

School of Physical Therapy and Rehabilitation Sciences, University of Montana, Missoula, MT, USA.

Background: Treadmills are often used in research, clinical practice, and training. Biomechanical investigations comparing treadmill and overground running report inconsistent findings.

Objective: This study aimed at comparing biomechanical outcomes between motorized treadmill and overground running.

Methods: Four databases were searched until June 2019. Crossover design studies comparing lower limb biomechanics during non-inclined, non-cushioned, quasi-constant-velocity motorized treadmill running with overground running in healthy humans (18-65 years) and written in English were included. Meta-analyses and meta-regressions were performed where possible.

Results: 33 studies (n = 494 participants) were included. Most outcomes did not differ between running conditions. However, during treadmill running, sagittal foot-ground angle at footstrike (mean difference (MD) - 9.8° [95% confidence interval: - 13.1 to - 6.6]; low GRADE evidence), knee flexion range of motion from footstrike to peak during stance (MD 6.3° [4.5 to 8.2]; low), vertical displacement center of mass/pelvis (MD - 1.5 cm [- 2.7 to - 0.8]; low), and peak propulsive force (MD - 0.04 body weights [- 0.06 to - 0.02]; very low) were lower, while contact time (MD 5.0 ms [0.5 to 9.5]; low), knee flexion at footstrike (MD - 2.3° [- 3.6 to - 1.1]; low), and ankle sagittal plane internal joint moment (MD - 0.4 Nm/kg [- 0.7 to - 0.2]; low) were longer/higher, when pooled across overground surfaces. Conflicting findings were reported for amplitude of muscle activity.

Conclusions: Spatiotemporal, kinematic, kinetic, muscle activity, and muscle-tendon outcome measures are largely comparable between motorized treadmill and overground running. Considerations should, however, particularly be given to sagittal plane kinematic differences at footstrike when extrapolating treadmill running biomechanics to overground running. Protocol registration CRD42018083906 (PROSPERO International Prospective Register of Systematic Reviews).
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http://dx.doi.org/10.1007/s40279-019-01237-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069922PMC
April 2020

Infographic running myth: static stretching reduces injury risk in runners.

Br J Sports Med 2020 Sep 6;54(17):1058-1059. Epub 2019 Nov 6.

Physical Therapy and Movement Science, University of Montana, Missoula, Montana, USA.

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http://dx.doi.org/10.1136/bjsports-2019-101169DOI Listing
September 2020

Infographic. Running myth: strength training should be high repetition low load to improve running performance.

Br J Sports Med 2020 Jul 25;54(13):813-814. Epub 2019 Sep 25.

Physical Therapy and Movement Science, University of Montana, Missoula, Montana, USA.

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http://dx.doi.org/10.1136/bjsports-2019-101168DOI Listing
July 2020

Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study.

Phys Ther Sport 2019 Nov 14;40:107-116. Epub 2019 Aug 14.

Sports and Exercise Medicine. Queen Mary University of London, London, UK; Department of Physiotherapy, Monash University, Australia. Electronic address:

Objectives: To examine the feasibility of recommended education and exercise supplemented by a hopping intervention implemented based on self-reported pain over 12 weeks for recreational runners with Achilles tendinopathy.

Design: Single cohort feasibility study.

Setting: One private physiotherapy clinic in Melbourne, Australia.

Participants: Fifteen male recreational runners with midportion Achilles tendinopathy.

Main Outcome Measures: Recruitment and adherence measures, adverse events, intervention acceptability and treatment effect trends were measured at baseline, 4 and 12 weeks.

Results: Recruitment (100%), retention (87%) and follow-up (93%) rates were high. Exercise adherence was 70% (SD = 12.7) but fidelity was 50% (SD = 13.9). Three participants suffered adverse events (undertaking activities contrary to advice). Participants reported the education package, perceived benefit, and feedback frequency as intervention enablers; while the onerous time commitment was regarded a barrier. At 12 weeks, five participants were satisfied and eight very satisfied, while VISA-A had improved 24 ± 20.65 points (μ2 = 0.740).

Conclusions: A randomised control trial including recommended education and exercise with a pain-guided hopping intervention as treatment for recreational runners with midportion Achilles tendinopathy may be warranted, once strategies to improve adherence and reduce adverse events are addressed.
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http://dx.doi.org/10.1016/j.ptsp.2019.08.007DOI Listing
November 2019

Patellofemoral Pain.

J Orthop Sports Phys Ther 2019 09;49(9):CPG1-CPG95

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. .
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http://dx.doi.org/10.2519/jospt.2019.0302DOI Listing
September 2019

Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis.

Gait Posture 2019 09 12;73:189-201. Epub 2019 Jul 12.

Sports and Exercise Medicine. Queen Mary University of London, United Kingdom; Physiotherapy Department, Barts Health NHS Trust, London, United Kingdom. Electronic address:

Introduction: Biomechanical alterations during running and hopping in people with Achilles tendinopathy (AT) may provide treatment and prevention targets. This review identifies and synthesises research evaluating biomechanical alterations among people with AT during running, jumping and hopping.

Method: MEDLINE, EMBASE, CiNAHL and SPORTDiscus were searched in July 2018 for case control, cross-sectional and prospective studies investigating kinematics, kinetics, plantar pressures and neuromuscular activity in AT participants during running or hopping. Study quality was assessed with a modified version of the Downs and Black quality checklist, and evidence grading applied.

Results: 16 studies reported 249 outcomes, of which 17% differed between groups. Reduced peroneus longus (standardized mean difference [95%CI]; -0.53 [-0.98, -0.09]) and medial gastrocnemius (-0.60 [-1.05, -0.15]) amplitude in AT runners versus control was found (limited evidence). Increased hip adduction impulse 1.62 [0.69, 2.54], hip peak external rotation moment (1.55 [0.63, 2.46] and hip external rotation impulse (1.45 [0.55, 2.35]) was found in AT runners versus control (limited evidence). Reduced anterior (-0.94 [-1.64, -0.24] and greater lateral (-0.92 [-1.61, -0.22]) displacement of plantar pressure preceded AT in runners (limited evidence). Delayed onsets of gluteus medius (1.95 [1.07, 2.83] and gluteus maximus (1.26 [0.48, 2.05] and shorter duration of gluteus maximus activation (-1.41 [-2.22, -0.61] was found during shod running in the AT group versus control (limited evidence). Earlier offset time of gluteus maximus (-1.03 [-1.79, -0.27] and shorter duration of activation of gluteus medius (-0.18 [-0.24, -0.12] during running in AT runners versus control was found (limited evidence). Reduced leg stiffness was found in the affected side during submaximal hopping (-0.39 [-0.79, -0.00]) (limited evidence).

Conclusion: This review identified potential biomechanical treatment targets in people with AT. The efficacy of treatments targeting these biomechanics should be assessed.

Systematic Review Registry: PROSPERO registration number: CRD42016048636.
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http://dx.doi.org/10.1016/j.gaitpost.2019.07.121DOI Listing
September 2019

The Cognitive Demands of Gait Retraining in Runners: An EEG Study.

J Mot Behav 2020 22;52(3):360-371. Epub 2019 Jul 22.

3Department of Kinesiology, East Carolina University, Greenville, North Carolina, USA.

High impact forces during running have been associated with tibial stress injuries. Previous research has demonstrated increasing step rate will decrease impact forces during running. However, no research has determined the cognitive demand of gait retraining. The primary purpose was to determine the cognitive demand and effectiveness of field-based gait retraining. We hypothesized that in-field gait retraining would alter running mechanics without increasing cognitive workload as measured by EEG following learning. Runners with a history of tibial injury completed a gait retraining protocol which included a baseline run, retraining phase, practice phase, and re-assessment following retraining protocol. Results demonstrated an increase in the theta, beta, and gamma power within prefrontal cortex during new learning and corresponding return to baseline following skill acquisition and changes across alpha, beta, gamma, mu, and theta in the motor cortex ( < .05). In the midline superior parietal cortex, spectral power was greater for theta activity during new learning with a corresponding alpha suppression. Overall, the results demonstrated the use of EEG as an effective tool to measure cognitive demand for implicit motor learning and the effectiveness of in-field gait retraining.
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http://dx.doi.org/10.1080/00222895.2019.1635983DOI Listing
May 2021

Running Biomechanics in Individuals with Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Sports Med 2019 Sep;49(9):1411-1424

Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, G1M 2S8, Canada.

Background: A return to running after anterior cruciate ligament reconstruction (ACL-R) is critical to the clinical success of any cutting and pivoting athlete who wishes to return to sport. Knowledge of specific alterations during running after ACL-R is required to optimise rehabilitation for improving outcomes and long-term disability.

Objective: The objective of this systematic review was to summarise kinematic, kinetic and muscle activation data during running after ACL-R and the intrinsic factors (e.g. surgical technique and strength asymmetries) affecting running biomechanics.

Methods: MEDLINE, EMBASE, SPORTDiscus and CINAHL databases were searched from inception to 10 December, 2018. The search identified studies comparing kinematic, kinetic or muscle activation data during running between the involved limb and contralateral or control limbs. Studies analysing the effect of intrinsic factors in the ACL-R group were also included. Risk of bias was assessed, qualitative and quantitative analyses performed, and levels of evidence determined.

Results: A total of 1993 papers were identified and 25 were included for analysis. Pooled analyses reported a deficit of knee flexion motion and internal knee extension moment, compared with both contralateral or control limbs, during the stance phase of running from 3 months to 5 years after ACL-R (strong evidence). Inconsistent results were found for both peak vertical ground reaction force and impact forces after ACL-R. Patellofemoral and tibiofemoral joint contact forces differed from both contralateral or control limbs up until at least 2.5 years after ACL-R and moderate evidence indicated no difference for muscle activations during moderate speed running. Quadriceps and hamstring strength asymmetries, and knee function, but not surgical techniques, were likely to be associated with both knee kinematics and kinetics during running after ACL-R.

Conclusion: After ACL-R, knee flexion motion and internal knee extension moment are the most affected variables and are consistently smaller in the injured limb during running when pooling evidence. Clinicians should be aware that these deficits do not appear to resolve with time and, thus, specific clinical interventions may be needed to reduce long-term disability.

Systematic Review Registration: Registered in PROSPERO 2017, CRD42017077130.
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http://dx.doi.org/10.1007/s40279-019-01120-xDOI Listing
September 2019

A Systematic Review and Meta-Analysis of Crossover Studies Comparing Physiological, Perceptual and Performance Measures Between Treadmill and Overground Running.

Sports Med 2019 May;49(5):763-782

Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.

Background: Treadmills are routinely used to assess running performance and training parameters related to physiological or perceived effort. These measurements are presumed to replicate overground running but there has been no systematic review comparing performance, physiology and perceived effort between treadmill and overground running.

Objective: The objective of this systematic review was to compare physiological, perceptual and performance measures between treadmill and overground running in healthy adults.

Methods: AMED (Allied and Contemporary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health), EMBASE, MEDLINE, SCOPUS, SPORTDiscus and Web of Science databases were searched from inception until May 2018. Included studies used a crossover study design to compare physiological (oxygen uptake [[Formula: see text]O], heart rate [HR], blood lactate concentration [La]), perceptual (rating of perceived exertion [RPE] and preferred speed) or running endurance and sprint performance (i.e. time trial duration or sprint speed) outcomes between treadmill (motorised or non-motorised) and overground running. Physiological outcomes were considered across submaximal, near-maximal and maximal running intensity subgroups. Meta-analyses were used to determine mean difference (MD) or standardised MD (SMD) ± 95% confidence intervals.

Results: Thirty-four studies were included. Twelve studies used a 1% grade for the treadmill condition and three used grades > 1%. Similar [Formula: see text]O but lower La occurred during submaximal motorised treadmill running at 0% ([Formula: see text]O MD: - 0.55 ± 0.93 mL/kg/min; La MD: - 1.26 ± 0.71 mmol/L) and 1% ([Formula: see text]O MD: 0.37 ± 1.12 mL/kg/min; La MD: - 0.52 ± 0.50 mmol/L) grade than during overground running. HR and RPE during motorised treadmill running were higher at faster submaximal speeds and lower at slower submaximal speeds than during overground running. [Formula: see text]O (MD: - 1.25 ± 2.09 mL/kg/min) and La (MD: - 0.54 ± 0.63 mmol/L) tended to be lower, but HR (MD: 0 ± 1 bpm), and RPE (MD: - 0.4 ± 2.0 units [6-20 scale]) were similar during near-maximal motorised treadmill running to during overground running. Maximal motorised treadmill running caused similar [Formula: see text]O (MD: 0.78 ± 1.55 mL/kg/min) and HR (MD: - 1 ± 2 bpm) to overground running. Endurance performance was poorer (SMD: - 0.50 ± 0.36) on a motorised treadmill than overground but sprint performance varied considerably and was not significantly different (MD: - 1.4 ± 5.8 km/h).

Conclusions: Some, but not all, variables differ between treadmill and overground running, and may be dependent on the running speed at which they are assessed.

Protocol Registration: CRD42017074640 (PROSPERO International Prospective Register of Systematic Reviews).
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http://dx.doi.org/10.1007/s40279-019-01087-9DOI Listing
May 2019

Effects of Load Carriage and Step Length Manipulation on Achilles Tendon and Knee Loads.

Mil Med 2019 10;184(9-10):e482-e489

Department of Physical Therapy, East Carolina University, Greenville, NC.

Introduction: Longer steps with load carriage is common in shorter Soldiers when matching pace with taller Soldiers whereas shorter steps are hypothesized to reduce risk of injury with load carriage. The effects of load carriage with and without step length manipulation on loading patterns of three commonly injured structures were determined: Achilles tendon, patellofemoral joint (PFJ) and medial tibiofemoral joint (mTFJ).

Materials And Methods: ROTC Cadets (n = 16; 20.1 years ± 2.5) walked with and without load carriage (20-kg). Cadets then altered preferred step lengths ±7.5% with load carriage. Achilles tendon, PFJ and mTFJ loads were estimated via musculoskeletal modeling.

Results: Large increases in peak Achilles tendon load (p < 0.001, d = 1.93), Achilles tendon impulse per 1-km (p < 0.001, d = 0.91), peak mTFJ load (p < 0.001, d = 1.33), and mTFJ impulse per 1-km (p < 0.001, d = 1.49) were noted with load carriage while moderate increases were observed for the PFJ (peak: p < 0.001, d = 0.69; impulse per 1-km: p < 0.001, d = 0.69). Shortened steps with load carriage only reduced peak Achilles tendon load (p < 0.001, d = -0.44) but did not reduce Achilles impulse per km due to the resulting extra steps and also did not reduce peak or cumulative PFJ and mTFJ loads (p > 0.05). Longer steps with load carriage increased PFJ loads the most (p < 0.001, d = 0.68-0.75) with moderate increases in mTFJ forces (p < 0.001, d = 0.48-0.63) with no changes in Achilles tendon loads (p = 0.11-0.20).

Conclusion: A preferred step length is the safest strategy when walking with load carriage. Taking a shorter step is not an effective strategy to reduce loading on the Achilles tendon, PFJ, and mTFJ.
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http://dx.doi.org/10.1093/milmed/usz031DOI Listing
October 2019

The Physiology and Biomechanics of the Master Runner.

Sports Med Arthrosc Rev 2019 Mar;27(1):15-21

Exercise, Sports and Movement Sciences, School of Health Studies, The University of Memphis, Memphis, TN.

The Master runner (age 35 y and above) represents a unique athletic patient. Lifelong participation in endurance running slows the inevitable age-related decline in aerobic function and muscular strength. Still, the Master runner does not escape the inevitable effects of aging. Master runners experience a steady decline in running performance, that is, typical and maximal running speeds, after the age of 50 years of age. Age-related declines in running performance are driven by a host of factors, including declining cardiovascular function, reduced muscular capacity, altered biomechanics, and greater susceptibility to running-related injury. This review discusses age-related changes in physiology, biomechanics, and running injury susceptibility and practical strategies to maximize running participation in the Master runner.
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http://dx.doi.org/10.1097/JSA.0000000000000212DOI Listing
March 2019

Logical fallacies in the running shoe debate: let the evidence guide prescription.

Br J Sports Med 2018 Dec 23;52(24):1552-1553. Epub 2018 Oct 23.

Division of Physical Therapy and Health Sciences, University of Montana, Missoula, Montana, USA.

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http://dx.doi.org/10.1136/bjsports-2018-100117DOI Listing
December 2018

ALTERING CADENCE OR VERTICAL OSCILLATION DURING RUNNING: EFFECTS ON RUNNING RELATED INJURY FACTORS.

Int J Sports Phys Ther 2018 Aug;13(4):633-642

Rutgers University, School of Health Professions, Department of Rehabilitation and Movement Sciences, Physical Therapy Program - North, Newark, NJ, USA.

Background: Wearable devices validly assess spatiotemporal running parameters (cadence, vertical oscillation and ground contact time), but the relationship between these parameters and lower limb loading parameters (loading rate, peak vertical ground reaction force [vGRF] and braking impulse) is unknown.

Purpose: To characterize changes in lower limb loading parameters in runners instructed to run with increased cadence or low vertical oscillation, and to determine whether the change in spatiotemporal parameters predicted the changes in lower limb loading parameters.

Study Design: Cross Sectional Cohort Study.

Methods: Twenty healthy runners completed three running trials in three conditions: baseline, high cadence, and low vertical oscillation. Spatiotemporal parameters were measured with a wearable device and lower limb loading was measured using an instrumented treadmill. Spatiotemporal and loading parameters were analyzed between running conditions via a repeated measure ANOVA. A hierarchical regression model was used to determine if changes in spatiotemporal parameters predicted the change of loading parameters during conditions.

Results: High cadence and low oscillation conditions reduced average vertical loading rate (p = 0.013 and p = 0.002, respectively), instantaneous vertical loading rate (p = 0.022 and p = 0.001, respectively), and peak vGRF (p = 0.025 and p < 0.001, respectively). Braking impulse was significantly lower in the high cadence condition compared to baseline (p < 0.001), but not during the low oscillation (p = 1.000). The increase in cadence during the high cadence condition predicted the reduction of instantaneous vertical loading rate (r = 0.213, p = 0.041) and braking impulse (r = 0.279, p = 0.017). The reduction in vertical oscillation was more predictive of the change of peak vGRF in both running conditions (high cadence, r = 0.436, p = 0.009; low oscillation r = 0.748, p < 0.001).

Conclusion: While both higher cadence and lower vertical oscillation resulted in reduced loading rates during running, cueing to reduce vertical oscillation was more successful in reducing peak vGRF and only the higher cadence condition reduced braking impulse. These findings will inform clinicians who wish to use wearable devices for running gait modification to select injury-specific gait retraining cues.

Level Of Evidence: Level 3.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088121PMC
August 2018

Innovations and pitfalls in the use of wearable devices in the prevention and rehabilitation of running related injuries.

Authors:
Richard W Willy

Phys Ther Sport 2018 Jan 6;29:26-33. Epub 2017 Oct 6.

School of Physical Therapy and Rehabilitation Sciences, University of Montana, Missoula, MT, USA. Electronic address:

Running-related injuries are common and are associated with a high rate of reoccurrence. Biomechanics and errors in applied training loads are often cited as causes of running-related injuries. Clinicians and runners are beginning to utilize wearable technologies to quantify biomechanics and training loads with the hope of reducing the incidence of running-related injuries. Wearable devices can objectively assess biomechanics and training loads in runners, yet guidelines for their use by clinicians and runners are not currently available. This article outlines several applications for the use of wearable devices in the prevention and rehabilitation of running-related injuries. Applications for monitoring of training loads, running biomechanics, running epidemiology, return to running programs and gait retraining are discussed. Best-practices for choosing and use of wearables are described to provide guidelines for clinicians and runners. Finally, future applications are outlined for this rapidly developing field.
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http://dx.doi.org/10.1016/j.ptsp.2017.10.003DOI Listing
January 2018

Individuals Post Achilles Tendon Rupture Exhibit Asymmetrical Knee and Ankle Kinetics and Loading Rates During a Drop Countermovement Jump.

J Orthop Sports Phys Ther 2018 01 26;48(1):34-43. Epub 2017 Oct 26.

Study Design Cross-sectional laboratory study. Background Asymmetrical knee loading during jogging and hopping has been reported in individuals who have ruptured their Achilles tendon. No studies have examined knee loads in individuals post Achilles tendon rupture during high-demand tasks, such as single-limb landings. Objectives We sought to determine whether individuals post Achilles tendon rupture demonstrated asymmetrical knee loads and impact forces during drop countermovement jumps (CMJs). Methods Achilles tendon length and the single-leg heel-rise test for endurance were assessed in 34 individuals (31 male) 6.1 ± 2.0 years post Achilles tendon rupture. Movement patterns were assessed during a drop CMJ. Data were analyzed via repeated-measures analyses of variance, with comparisons between limbs and prior treatment history (surgery versus nonsurgery). Results An 8.6% longer Achilles tendon (P<.001) was found in the involved limb. During the single-leg heel-rise test, the involved limb demonstrated 22.4% less endurance and 14.6% lower heel-rise height (all, P<.001). During the landing phase of the drop CMJ, the involved limb exhibited 39.6% greater loading rate (P<.001), 16.8% greater eccentric knee power (P = .048), but 21.6% lower eccentric ankle power (P<.001). During the take-off phase, the involved limb exhibited 12.1% lower jump height and 19.9% lower concentric ankle power (both, P<.001). Conclusion Elevated eccentric knee joint power and higher loading rates during a drop CMJ in individuals who experienced Achilles tendon rupture several years earlier may be a compensation pattern for reduced plantar flexor function. This movement pattern may place individuals who have had an Achilles tendon rupture at greater risk for knee injuries. J Orthop Sports Phys Ther 2018;48(1):34-43. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7684.
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http://dx.doi.org/10.2519/jospt.2018.7684DOI Listing
January 2018

Sex-specific kinetic and kinematic indicators of medial tibiofemoral force during walking and running.

Knee 2017 Dec 1;24(6):1317-1325. Epub 2017 Oct 1.

Department of Physical Therapy, East Carolina University, 2410 Health Sciences Building, Greenville, NC 27834, United States. Electronic address:

Background: Our aims were to (1) Evaluate sex-specific contributions of peak knee flexion moment (pKFM) and peak knee adduction moment (pKAM) in medial tibiofemoral joint (TFJ) force during walking and running; (2) identify kinematic variables to estimate peak medial TFJ force.

Methods: Eighty-seven runners participated (36 females, 51 males; age=23.0±3.8years (1 standard deviation)). Kinematics and kinetics data were collected during treadmill walking (1.3m/s) and running (3.0±0.4m/s). Peak medial TFJ contact force was estimated using a musculoskeletal model. Linear regression analyses were used to assess the contribution of pKFM, pKAM and kinematic indicators to estimated joint forces.

Results: During walking and running, pKAM and pKFM accounted for 74.9% and 64.5% of peak medial TFJ force variance (P<0.001), respectively. Similar pKAM contribution was found between males and females during walking (51.8% vs. 47.9%), as opposed to running (50.4% vs. 26.8%). Kinematic indicators during walking were peak knee flexion and adduction angles, regardless of sex. During running, indicators were ankle dorsiflexion at foot strike and center of mass (COM) vertical displacement in females (R=0.364, P=0.012), and peak knee abduction angle and step length in males (R=0.508, P=0.019).

Conclusion: We conclude from these results that pKAM and pKFM make significant but potentially sex-specific contributions to peak medial TFJ force during walking and running. Clinically, peak medial TFJ force during walking can be estimated using peak knee flexion and adduction angles in both sexes. During running, ankle dorsiflexion at foot strike and COM oscillation are best indicators among females, while knee abduction and step length are best among males.
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http://dx.doi.org/10.1016/j.knee.2017.08.054DOI Listing
December 2017

Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury.

Am J Sports Med 2017 Nov 7;45(13):3060-3068. Epub 2017 Aug 7.

Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Background: It is unknown whether the height of a heel-rise performed in the single-leg standing heel-rise test 1 year after an Achilles tendon rupture (ATR) correlates with ankle biomechanics during walking, jogging, and jumping in the long-term.

Purpose: To explore the differences in ankle biomechanics, tendon length, calf muscle recovery, and patient-reported outcomes at a mean of 6 years after ATR between 2 groups that, at 1-year follow-up, had less than 15% versus greater than 30% differences in heel-rise height.

Study Design: Cohort study; Level of evidence, 3.

Methods: Seventeen patients with less than 15% (<15% group) and 17 patients with greater than 30% (>30% group) side-to-side difference in heel-rise height at 1 year after ATR were evaluated at a mean (SD) 6.1 (2.0) years after their ATR. Ankle kinematics and kinetics were sampled via standard motion capture procedures during walking, jogging, and jumping. Patient-reported outcome was evaluated with Achilles tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS), and Foot and Ankle Outcome Score (FAOS). Tendon length was evaluated by ultrasonography. The Limb Symmetry Index (LSI = [Injured Side ÷ Healthy Side] × 100) was calculated for side differences.

Results: The >30% group had significantly more deficits in ankle kinetics during all activities compared with patients in the <15% group at a mean of 6 years after ATR (LSI, 70%-149% and 84%-106%, respectively; P = .010-.024). The >30% group, compared with the <15% group, also had significantly lower values in heel-rise height (LSI, 72% and 95%, respectively; P < .001) and heel-rise work (LSI, 58% and 91%, respectively; P < .001) and significantly larger side-to-side difference in tendon length (114% and 106%, respectively; P = .012). Achilles tendon length correlated with ankle kinematic variables ( r = 0.38-0.44; P = .015-.027) whereas heel-rise work correlated with kinetic variables ( r = -0.57 to 0.56; P = .001-.047). LSI tendon length correlated negatively with LSI heel-rise height ( r = -0.41; P = .018). No differences were found between groups in patient-reported outcome ( P = .143-.852).

Conclusion: Height obtained during the single-leg standing heel-rise test performed 1 year after ATR related to the long-term ability to regain normal ankle biomechanics. Minimizing tendon elongation and regaining heel-rise height may be important for the long-term recovery of ankle biomechanics, particularly during more demanding activities such as jumping.
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http://dx.doi.org/10.1177/0363546517717698DOI Listing
November 2017

Reduced step length reduces knee joint contact forces during running following anterior cruciate ligament reconstruction but does not alter inter-limb asymmetry.

Clin Biomech (Bristol, Avon) 2017 Mar 10;43:79-85. Epub 2017 Feb 10.

Department of Physical Therapy, East Carolina University, 2405A Health Sciences Building, Greenville, NC 27834, United States. Electronic address:

Background: Anterior cruciate ligament reconstruction is associated with early onset knee osteoarthritis. Running is a typical activity following this surgery, but elevated knee joint contact forces are thought to contribute to osteoarthritis degenerative processes. It is therefore clinically relevant to identify interventions to reduce contact forces during running among individuals after anterior cruciate ligament reconstruction. The primary purpose of this study was to evaluate the effect of reducing step length during running on patellofemoral and tibiofemoral joint contact forces among people with a history of anterior cruciate ligament reconstruction. Inter limb knee joint contact force differences during running were also examined.

Methods: 18 individuals at an average of 54.8months after unilateral anterior cruciate ligament reconstruction ran in 3 step length conditions (preferred, -5%, -10%). Bilateral patellofemoral, tibiofemoral, and medial tibiofemoral compartment peak force, loading rate, impulse, and impulse per kilometer were evaluated between step length conditions and limbs using separate 2 factor analyses of variance.

Findings: Reducing step length 5% decreased patellofemoral, tibiofemoral, and medial tibiofemoral compartment peak force, impulse, and impulse per kilometer bilaterally. A 10% step length reduction further decreased peak forces and force impulses, but did not further reduce force impulses per kilometer. Tibiofemoral joint impulse, impulse per kilometer, and patellofemoral joint loading rate were lower in the previously injured limb compared to the contralateral limb.

Interpretation: Running with a shorter step length is a feasible clinical intervention to reduce knee joint contact forces during running among people with a history of anterior cruciate ligament reconstruction.
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http://dx.doi.org/10.1016/j.clinbiomech.2017.02.004DOI Listing
March 2017