Epidemiology of ankle and foot overuse injuries in sports:A systematic review
S. Sobhani1, R. Dekker1,2, K. Postema1, P. U. Dijkstra1,3
1Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands,2Center for Sports Medicine, University Center for Sport, Exercise and Health, University Medical Center Groningen, University ofGroningen, Groningen, the Netherlands, 3Department of Oral and Maxillofacial Surgery, University Medical Center Groningen,University of Groningen, Groningen, the NetherlandsCorresponding author: Sobhan Sobhani, MSc, PT, Hanzeplein 1, PO Box 30.001, CB 41, 9700 RB, Groningen, the Netherlands.Tel: +31 50 3611348, Fax: +31 50 3611708, E-mail: [email protected]
Accepted for publication 24 June 2012
Studies regarding ankle and foot overuse injuries arequite diverse in research methodology, data reporting,and outcomes. The aims of this systematic review were toanalyze the methodology of published studies regardingankle and foot overuse injuries in different sports disci-plines and to summarize epidemiological data of ankleand foot overuse injuries. Four electronic databases,PubMed (MEDLINE), EMBASE, CINAHL, and SPORT-Discus® were systematically searched up to June 2011. Atotal of 89 articles on 23 sports disciplines were includedin this review. Soccer, running, and gymnastics were themost frequently studied sports. Achilles tendinopathy,plantar fasciitis, and stress fracture were the most fre-
quently studied injuries. Study design and reportingmethods were heterogeneous. Most studies suffered froma weak methodology and poor reporting. The mostcommon weaknesses were lack of a clear case definition,describing assessment procedures and reporting samplecharacteristics. Due to methodological heterogeneity ofstudies, inter-sports and intra-sports comparisons andmeta-analysis were not possible. Methodology of moststudies on incidence and prevalence of ankle and footoveruse injuries is insufficient. Based on the results, werecommend authors to clearly define cases, describeassessment procedures and report sample characteristicsadequately.
Many people of different ages and skills participate insports and benefit from it (Pate et al., 1995, 2000).However, sport participation is not always beneficial.Sport injuries occur frequently (Dekker et al., 2000; Sch-neider et al., 2006), and a large portion of these injuries(30–50%) are caused by overuse, requiring treatment(Herring & Nilson, 1987; O’Toole et al., 1989; Pecina &Bojanic, 2003). Overuse injuries have insidious onsetand can restrain athletes from sports temporary or evenpermanently (Van Tiggelen et al., 2008; Bahr, 2009).Lower leg and in particular ankle and foot are highlyinvolved in many sports and are vulnerable to overuseinjuries (Kannus, 1992; Hockenbury, 1999; Sijbrandijet al., 2002; Hreljac, 2004; Wilder & Sethi, 2004;Kennedy et al., 2006; Cosca & Navazio, 2007; Khouryet al., 2007).
In the last three decades, several studies have addressedankle and foot overuse injuries in different types of sports.However, these studies are quite diverse in research meth-odology, data reporting, and study outcomes within aswell as between different sports (Migliorini, 1991; Baket al., 1994; Fallon, 1996; Hickey et al., 1997; Bishop &Fallon, 1999; Kirialanis et al., 2002; Zetou et al., 2006;Tegnander et al., 2008; Cloke et al., 2009).
An overview of the methodological quality of pub-lished studies on ankle and foot overuse injuries is stillmissing.
This systematic review therefore had three aims: (a) tosummarize epidemiological data (incidence and preva-lence) of ankle and foot overuse injuries in differentsports disciplines; (b) to assess methodological qualityof published studies; and (3) if possible, to perform ameta-analysis of the available data.
Materials and methods
Our review followed the Preferred Reporting Items for SystematicReviews and Meta-analyses Statement (Moher et al., 2009).
Literature search
For this systematic literature review, books (Harries, 1998; Pecina& Bojanic, 2003; Bahr et al., 2004; Scuderi & McCann, 2005;Brukner & Khan, 2006; Frontera et al., 2007) in orthopedics andsports medicine were studied to create a comprehensive list ofankle and foot overuse injuries related to sports. This list was usedto develop the search strategy. Four electronic databases, PubMed(MEDLINE), EMBASE, CINAHL, and SPORTDiscus®, weresearched using a combination of related medical subject headings(MeSHs) and free-text words (see Supplementary File 1 for data-
Scand J Med Sci Sports 2013: 23: 669–686doi: 10.1111/j.1600-0838.2012.01509.x
base search strategy). Main keywords used were “sports,” “ankle,”“foot,” and “overuse injuries” in combination with “epidemiol-ogy,” “incidence,” and “prevalence.” Besides “overuse,” otherterms such as “chronic” and “chronic overuse” have been inter-changeably used by authors to address overuse injuries. Becausethere is no clear distinction between the terms “overuse” and“chronic” in the literature, we considered them to be synonyms.The first database search was performed up to 30th April 2010 andupdated on 1st of June 2011. The same inclusion and exclusioncriteria were considered in screening of title, abstract, and full text.Inclusion criteria were studies focusing on one or more sportsactivities, containing epidemiological information of overuse inju-ries of the ankle and foot, and written in English, Dutch, orGerman language. Excluded were studies with a military researchpopulation only, concerning acute injuries only, focusing on bodypart(s) other than ankle and foot, focusing on surgical procedures,treatment modalities, prevention strategies, orthopedic examina-tion and diagnostic methods, and reviews, case reports, or caseseries.
Two authors (SS and RD) independently assessed titles; twoauthors (SS and KP) independently assessed abstracts and fulltexts of English articles; and two authors (RD and PD) assessedGerman articles. Reference lists of all relevant articles werechecked for additional published papers. In addition, correspond-ing authors of congress abstracts were contacted for detailed infor-mation regarding their studies.
Quality assessment
Because there is no standard tool to evaluate external and internalvalidity of observational studies (Sanderson et al., 2007; Sham-liyan et al., 2010), different assessment tools (Loney et al., 1998;Stroup et al., 2000; Sanderson et al., 2007; von Elm et al., 2008;Shamliyan et al., 2010) were consulted, and eight criteria specificto our research question were evaluated: (a) an appropriate sam-pling method, whole population of interest or probability sam-pling; (b) adequate information about participation/follow-up rate;(c) participation rate � 70% (Loney et al., 1998); to calculateparticipation rate for prospective studies, participation rate at thebeginning (refusal rate) and final drop-out rate were both consid-ered (Walter & Hart, 1990; Galea & Tracy, 2007); (4) use ofappropriate study design for primary outcome measure, prospec-tive cohort study for incidence and cross-sectional for prevalence;(5) providing a definition for overuse injury; (6) presentation of atleast one explicit overuse diagnosis; (7) appropriate diagnosticprocedures; orthopedic physical examination was considered asthe most basic and essential diagnostic procedure; and (8) samplesize calculation (Bahr & Holme, 2003; Knowles et al., 2006).These criteria were used to assess sources of bias (selection, attri-tion, information and detection bias) and power of the study.
A checklist (calibrated on 10 excluded papers) was used toidentify relevant information related to quality items (Supplemen-tary File 2). The quality of papers was independently assessed bytwo pairs of authors: English language papers were assessed by SSand RD, and German language papers were assessed by PD andRD. All items were weighted equally and based on the sum of thequality items; studies received a score from “0” (no criteria ful-filled) to “8” (all criteria fulfilled). In all selection and qualityassessment procedures, disagreements were resolved in a consen-sus meeting. If no consensus could be reached, a third observergave the final verdict (PD for English language papers and KP forGerman language papers).
Calculations
Prevalence rate was calculated as the number of existing injuries inthe sample population divided by the total number of participants
at a particular time (point prevalence) or over a specific period oftime (period prevalence). Incidence rate was calculated as thenumber of new injuries divided by the total number of athletesobserved during the time period, and normalized per 1000 athletes.In case of an observation period of several years and to create morehomogeneity within the studies, incidence rates were year-adjusted. Incidence and prevalence rates and 95% confidenceintervals (CI) were calculated using a computer software (Confi-dence Interval Analysis, version 2.1.2; Bryant, University ofSouthampton, Southampton, Southampton, UK) (Altman &Gardner, 2000). The age of the total population was calculated asfollows: per study, the mean age was multiplied by the number ofparticipants. Then these values were added and divided by the totalnumber of participants in all studies providing relevant data.
ResultsStudy selection
The primary search resulted in 4314 titles, and afterremoving duplicates, 3004 titles remained. In the titlescreening, we excluded 21 articles because they werewritten in other languages than Dutch, German, orEnglish (two Turkish, one Spanish, five Italian, fiveJapanese, two Polish, three Chinese, one Danish, oneHungarian, and one French). In total, 759 articles wereselected for abstract reading. After reading the abstracts,404 abstracts were excluded because they did not fulfillthe inclusion criteria. No abstract was available for 15articles; therefore, these articles were directly added forthe full-text reading stage. Two of five correspondingauthors of congress abstracts responded stating that nofurther information was available. After assessing arti-cles’ full texts, 86 articles were selected as relevant.Checking the references of selected full-text articlesyielded 22 more articles. Eventually, 108 articles wereselected for quality assessment. The flowchart of theresult from the database search, inclusion of articles, andinterobserver agreement for the different steps of studyselection is presented in Fig. 1.
Throughout the quality appraisal process, 22 of 108primary included articles were excluded for the follow-ing reasons: time of assessment (point or period) was notclear for prevalence rate (three studies) (Maier, 1995;Lozana & Pereira, 2003; McGuinness & Doody, 2006),no specific data for ankle and foot regions (five studies)(Hintermann, 1993; Largiader & Oelz, 1993; Schaferet al., 1998; Gaulrapp et al., 1999; Kauther et al., 2009),unclear injury reporting in graphs (seven studies)(Wiesler et al., 1996; Wikstrom & Andersson, 1997;Rome et al., 2001; Fahlstrom et al., 2002b; Arendt &Kerschbaumer, 2003; Deitch et al., 2006; Trautmann &Rosenbaum, 2008), prevalence reporting based on avail-ability of athletes (missed games/hours) not actualnumber of injured athlete (two studies) (Orchard et al.,1998, 2002), population at risk was not reported (onestudy) (Marfleet, 1991), and number of overuse injurieswas not reported (four studies) (Wilber et al., 1995; Bahr& Reeser, 2003; McKean et al., 2006; Ristolainen et al.,2010). Each database search was updated to 1st of June
2011, and after applying the same inclusion procedure asinitial screening, three more articles were added. There-fore, finally, 89 articles (English language, 81; Germanlanguage, 8) were included in this review with publica-tion year between 1982 and 2010 (see SupplementaryFile 3 for characteristics of the included studies).
Description of the studies
In total, 23 different sports disciplines were investigated.Soccer and running were the most frequently studiedsports. The majority of studies reported incidence rateswith exposure time reported in seven different ways.Period prevalence was reported in eight different ways.
About half of the studies were prospective. Samplingmethod was unclear in 40% of the studies. In moststudies (90%), sample characteristics were incompletelyreported, and in 65% of the studies, participation rateswere not clearly reported. A definition of overuse injurieswas not provided in almost two thirds of the studies. Inalmost half of the studies, the assessment tool was notclearly described, and one third of the studies used aquestionnaire for overuse injury assessment.
Overall, the methodological quality score varied from1 to 6, while the majority of studies (about 80%) had aquality score less than 5. None of the studies received ascore of 7 or 8. Studies with higher scores were mostly insoccer and published in the last decade.
Final Included Articles
89
Titles3004
Abstracts759
Primary Included Articles
86
Titels4314
Articles355
Articles86
Articles108
SPORTDiscus1267
CINAHL869
EMBASE311
PubMed1867
Remove Duplications
Title Screening
K = 0.90AA = 96%
Abstract Screening
K = 0.70AA = 86%
Full-Text Reading
K = 0.62AA = 84%
Quailty Assessment
K = 0.70AA = 79%
Reference Check
Search Update
1310 Excluded
2245 Excluded
404 Excluded
269 Excluded
22 Excluded
22 Added
3 Added
K = Kappa Value AA = Absolute Agreement
Fig. 1. Flow chart of the database search and inclusion procedure.
Ankle and foot overuse injuries
671
Rates and characteristics of the included studies arepresented in Table 1 (incidence) and Table 2 (preva-lence). Four studies presented the number of injuries inpercentage (Watson & DiMartino, 1987; Jakobsen et al.,1992; Hopper et al., 1995a; Nilsson et al., 2001), and forthese studies, calculations were performed based onnumber estimation by the authors of the current paper. Inaddition, incidence rates were year adjusted for sevenstudies (Hopper et al., 1995a; Hickey et al., 1997;Nilsson et al., 2001; Volpi et al., 2003; Price et al., 2004;Maquirriain & Ghisi, 2006; Cloke et al., 2009).
The highest incidence of ankle and foot injury,expressed per 1000 athletes per season, were reported forsports dance (ballet), 338.5 (95% CI: 283.2–401.4);running, 250.0 (95% CI: 100.5–515.1); and gymnastics,188.7 (95% CI: 90.5–347.0). The highest incidence ofankle and foot injury, expressed per 1000 athletes peryear, were reported for orienteering, 381 (95% CI: 217.7–618.6); gymnastics, 380.0 (95% CI: 228.8–593.4); anddance (theatrical), 261.5 (95% CI: 198.0–338.8).
The highest incidence, expressed per 1000 athlete perhour exposure, were reported for soccer, 2.7 (95% CI:0.7–6.9); and rugby, 1.3 (95% CI: 0.8–1.9 game).
The overall 1-year prevalence rate was reported in threesports: dance, 0.5% (95% CI: 0.2–1); rowing, 1.3% (95%CI: 0.5–2.9); and two studies of triathlon with 18.5%(95% CI: 1.1–2.7) and 61% (95% CI could not be calcu-lated due to lack of data). Two studies reported an overallprevalence for 5 years in dance (Morris), 2.2% (95% CI:1.4–3.2) and volleyball, 7.9% (95% CI: 4.2–14.3).
In total, 54 851 athletes were investigated with an agerange of 8–94 years. The mean age was 29.2. Theminimum and maximum of sample sizes were 17 and14 691 athletes, respectively. Participation rates variedfrom 3% to 100%. Different overuse case definitions wereused: gradual or insidious onset of symptoms (18 studies),injury without a known trauma (12 studies), injury causedby repetitive micro-trauma or movements (5 studies), andchronic overload or pain (4 studies). Definitions for somestudies were unique and study specific.
In some studies, only the overall number of injuries wasreported without specifying a diagnosis (28 studies forankle and foot, 4 studies only for ankle, and 2 studies onlyfor foot). Specific diagnosis was reported in 31 (35%)studies. In 24 (27%) studies, both the overall number ofinjuries (ankle and/or foot) and the diagnosis (one ormore) were presented. Achilles tendinopathy was themost frequently investigated injury in 39 (44%) studies(15 sports, mostly running and soccer). Tendinopathy ofother ankle and foot muscles were also investigated com-monly: toe extensors and flexors (seven studies), tibialisanterior and posterior (five studies), and peroneals (fivestudies). Stress fracture and plantar fasciitis were the nextcommonly studied injuries in 16 and 14 sports, respec-tively, stress fracture mostly in basketball and plantarfasciitis in running. Due to heterogeneity across studies interms of population characteristics, overuse definitions,
assessment tools and sampling methods, data pooling anda meta-analysis were not possible.
Discussion
Meta-analysis and meaningful comparisons within andbetween sports were not possible because of heteroge-neity in definitions, assessment tools, and various expo-sure expressions. Incidence and prevalence rates rangedconsiderably across studies. In three studies on gymnas-tics (Caine et al., 1989; Bak et al., 1994; Kirialanis et al.,2002), incidence rates of the ankle and foot overuseinjuries per 1000 athlete-year ranged from 17.4 to 380.0meaning 22-fold difference in values. Because the expo-sure time period is the same for mentioned studies, suchbig differences in injury rates can only be explained bythe influence of different clinical and methodologicalfactors. For example, the investigation method was inter-view for the study with the highest incidence rate whilefor the other studies, the method was unclear. Clinically,the study population in the study with the highest inci-dence rate was young, elite female gymnasts. In thestudy with the lowest incidence rate, the population con-sisted of mixed group of male and female gymnasts withhigher mean age and of both elite and amateur level.Likewise, incidence rates per 1000 athlete-season fortwo other studies on gymnastics (Wadley & Albright,1993; Harringe et al., 2007) varied with eightfold differ-ence from 23.8 to 188.7. The method of investigation forthe higher incidence rate was unclear, and for the lowerrate, orthopedic physical examination and auxiliarymethods were used. Thus, bias due to unknown methodof assessment should be considered.
The broad range in rate estimation was also present inprevalence studies with the same study period. Forinstance, in two studies on triathlon (O’Toole et al.,1989; Manninen & Kallinen, 1996), with 1-year studyperiod, the prevalence was 18% in one study and 61% inthe other study. For these two studies investigationmethod, skill level, age, and gender of population weresimilar, but overuse definition was unclear. Thus, biasdue to the unclear definition of overuse should be con-sidered. In short, comparing and interpreting data aremeaningless, without considering the uniformity in defi-nitions or method of data collection.
In this review, Achilles tendinopathy, plantar fasciitis,and stress fracture were the most commonly reportedinjuries. Soccer (19 studies), running (10 studies), gym-nastics (six studies), and dancing (six studies) made upalmost half of the studies on ankle and foot overuseinjuries. These findings are not surprising because ankleand foot overuse injuries are more likely to happen insports that have a repetitive component of the lowerextremity, running, or sports with complex movements,soccer, and gymnastics. Overuse injuries usually have achronic nature. Thus, to quantify the impact of overuseinjuries (disease burden), prevalence is more suitable
Sobhani et al.
672
Tabl
e1.
Inci
denc
era
tes
ofan
kle
and
foot
over
use
inju
ries
and
deta
ilsof
the
incl
uded
stud
ies*
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Jorg
ense
nan
dW
inge
(198
7)Ba
dmin
ton
5M
X30
3(1
94/1
09)
24.9
(14–
55)
RN–
Deve
lope
dgr
adua
llyan
dco
uldn
’tbe
expl
aine
dby
asi
ngle
traum
a
–P
Ankl
e&
Foot
128.
7(9
1.5
to17
6.0)
Seas
ons
Achi
lles
Tend
59.4
(35.
2to
93.9
)Se
ason
s
Hick
eyet
al.(
1997
)Ba
sket
ball
2E
49(0
/49)
––
–Ch
roni
cov
erlo
ad–
RAn
kle
&Fo
ot‡‡
54.4
(31.
1to
88.4
)Ye
ars
Stre
ssFr
actu
re‡‡
17.0
(5.5
to39
.7)
Year
s
Dick
etal
.(20
07a)
Bask
etba
ll1
–(-
/0)
–C
––
–R
Stre
ssFr
actu
re¶¶
0.5
¥10
-1
(0.4
¥10
-1to
0.5
¥10
-1)
Expo
sure
s
Agel
etal
.(20
07b)
Bask
etba
ll1
–(0
/-)–
C–
––
RAc
hille
sTe
nd0.
4¥
10-1
(0.3
¥10
-1to
0.5
¥10
-1)
Expo
sure
s
Stre
ssFr
actu
re0.
9¥
10-1
(0.6
¥10
-1to
1.2
¥10
-1)
Gam
e
Expo
sure
s
Stre
ssFr
actu
re0.
9¥
10-1
(0.8
¥10
-1to
1.1
¥10
-1)
Prac
tice
Expo
sure
s
Dann
enbe
rget
al.
(199
6)Cy
clin
g4
A10
94–
WP
65No
n-ac
ute
mus
culo
skel
etal
pain
num
bnes
sor
swel
ling
QP
Ankl
e&
Foot
0.2
¥10
-1
(0.1
¥10
-1to
0.4
¥10
-1)
Expo
sure
mile
s
Wei
ss(1
985)
Cycl
ing
4A
113
(78/
35)
40.8
�11
.1(1
8–71
)W
P86
–Q
CSAc
hille
sTe
nd8.
9(0
.2to
49.3
)Ra
ces
Tuffe
ry(1
989)
Danc
e(M
orris
)3
A14
9–
WP
29In
jury
aggr
avat
edby
danc
ing
eith
erpr
even
ted
danc
ing
orca
used
cons
ider
able
disc
omfo
rt
QCS
Ankl
e&
Foot
0.5
¥10
-1
(0.2
¥10
-1to
1.1
¥10
-1)
Expo
sure
hour
s
Nils
son
etal
.(20
01)
Danc
e(B
alle
t)2
E78
(46/
32)
28.3
(14–
47)
WP
––
–Am
Ankl
e&
Foot
‡‡33
8.5
(283
.2to
401.
4)Se
ason
s
Achi
lles
Tend
‡‡53
.8(3
3.3
to82
.3)
Seas
ons
Pero
neal
Tend
30.8
‡‡(1
5.9
to53
.7)
Seas
ons
Flex
orHa
lluci
sLo
ngus
Tend
‡‡76
.9(5
1.9
to10
9.8)
Seas
ons
Tibi
alis
Post
erio
rTe
nd‡‡
23.1
(10.
6to
43.8
)Se
ason
s
Ankl
eIm
ping
emen
t‡‡28
.2(1
4.1
to50
.5)
Seas
ons
Stre
ssFr
actu
re‡‡
12.8
(4.2
to29
.9)
Seas
ons
Met
atar
salg
ia‡‡
46.2
(27.
4to
72.9
)Se
ason
s
Ankle and foot overuse injuries
673
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Rove
reet
al.(
1983
)Da
nce
(The
atric
al)
1–
218
(56/
162)
––
––
–R
Ankl
e&
Foot
261.
5(1
98.0
to33
8.8)
Year
s
Achi
lles
Tend
151.
4(1
04.2
to21
2.6)
Year
s
Pero
neal
Tend
22.9
(7.4
to53
.5)
Year
s
Toe
Exte
nsor
Tend
41.3
(18.
9to
78.4
)Ye
ars
OsTr
igeo
num
4.6
(0.1
to25
.6)
Year
s
Stre
ssFr
actu
re22
.9(7
.4to
53.5
)Ye
ars
Achi
lles
Burs
itis
18.3
(5.0
to47
.0)
Year
s
Plan
tar
Fasc
iits
9.2
(1.1
to33
.1)
Year
s
Dick
etal
.(20
07b)
Fiel
d-Ho
ckey
1–
(0/-)
–C
––
–R
Achi
lles
Tend
¶¶0.
4¥
10-1
(0.3
¥10
-1to
0.6
¥10
-1)
Expo
sure
s
Wad
ley
and
Albr
ight
(199
3)Gy
mna
stic
s5
–(0
/26)
–W
P–
Grad
ualo
nset
–P
Ankl
e&
Foot
188.
7(9
0.5
to34
7.0)
Seas
ons
Ankl
eIm
ping
emen
t188
.7(9
0.5
to34
7.0)
Seas
ons
Harr
inge
etal
.(2
007)
Gym
nast
ics
4E
42(1
6/26
)19
.4�
2.2§
––
Grad
ually
deve
lope
dov
era
perio
dof
time
OPE&
AxP
Ankl
e&
Foot
23.8
(0.6
to13
2.7)
Seas
ons
Sura
lNer
veEn
trapm
ent
23.8
(0.6
to13
2.7)
Seas
ons
Kiria
lani
set
al.
(200
2)Gy
mna
stic
s3
E18
7(1
00/8
7)12
.3�
2.8§
WP
––
–P
Ankl
e&
Foot
181.
8(1
25.9
to25
4.1)
Year
s
Cain
eet
al.(
1989
)Gy
mna
stic
s3
E50
(0/5
0)12
.6–
–Gr
adua
lons
etI
PAn
kle
&Fo
ot38
0.0
(228
.8to
593.
4)Ye
ars
Bak
etal
.(19
94)
Gym
nast
ics
3M
X11
7(5
2/65
)16
(8–2
5)–
–Pa
inor
inhi
bitio
nof
activ
ityw
ithGr
adua
lons
et–
PAn
kle
&Fo
ot17
.4(2
.1to
62.8
)Ye
ars
Lind
ner
and
Cain
e(1
990)
Gym
nast
ics
3M
X17
8(1
78/0
)–
––
Grad
ualo
nset
QP
Ankl
e&
Foot
0.4
¥10
-1
(0.2
¥10
-1to
0.9
¥10
-1)
Expo
sure
hour
s
Olse
net
al.(
2006
)Ha
ndba
ll5
A42
8(1
07/3
21)
–RN
85In
jury
with
agr
adua
lons
etw
ithou
tany
know
ntra
uma
–P
Ankl
e&
Foot
0.2
¥10
-1
(0.0
¥10
-1to
1.3
¥10
-1)
Expo
sure
hour
s
Seil
etal
.(19
98)
Hand
ball
3A
186
(186
/0)
25.8
WP
––
QP
Ankl
e0.
8(0
.5to
1.1)
Expo
sure
hour
sHo
pper
etal
.(1
995b
)Ne
tbal
l3
MX
72(0
/72)
20.6
�3.
6(1
5–36
)–
––
OPE
PAn
kle
&Fo
ot13
.9(0
.4to
77.4
)Se
ason
s
Achi
lles
Tend
13.9
(0.4
to77
.4)
Seas
ons
Hopp
eret
al.
(199
5a)
Netb
all
2M
X11
288
–W
P–
––
PAn
kle
&Fo
ot‡‡
3.1
(2.7
to3.
6)Ye
ars
Knob
loch
and
Vogt
(200
6)No
rdic
Pole
Wal
king
1–
137
(101
/36
or10
2/35
)¶53
.5�
12–
––
QCS
Stre
ssFr
actu
re**
*0.
0(0
.0to
0.1)
Expo
sure
hour
s
Sobhani et al.
674
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Lind
e(1
986)
Orie
ntee
ring
4E
42(2
8/14
)24
(19–
34)
––
Over
use
oftis
sue
stru
ctur
eslo
aded
ina
norm
alm
otor
patte
rn
QP
Ankl
e&
Foot
381.
0(2
17.7
to61
8.6)
Year
s
Achi
lles
Tend
119.
0(3
8.7
to27
7.8)
Year
s
Pero
neal
Tend
119.
0(3
8.7
to27
7.8)
Year
s
Exte
nsor
Digi
toru
mTe
nd23
.8(0
.6to
132.
7)Ye
ars
Plan
tar
Fasc
iitis
47.6
(5.8
to17
2.0)
Year
s
Met
atar
salg
ia71
.4(1
4.7
to20
8.7)
Year
s
Fola
n(1
982)
Orie
ntee
ring
3M
X28
5–
WP
––
–P
Ankl
e&
Foot
3.5
(0.1
to19
.6)
Expo
sure
sAc
hille
sTe
nd3.
5(0
.1to
19.6
)Ex
posu
res
Joha
nsso
n(1
986)
Orie
ntee
ring
3–
89(5
6/33
)17
.5�
1.5
––
–OP
E,Ax
&I
PAn
kle
&Fo
ot15
7.3
(86.
0to
263.
9)Ye
ars
Achi
lles
Tend
67.4
(24.
7to
146.
7)Ye
ars
Back
eet
al.(
2009
)Ro
ck-C
limbi
ng3
MX
355
(249
/106
)30
(9–6
7)RN
63Re
peat
edm
icro
-trau
ma
with
outa
sing
leid
entifi
able
even
t
QCS
Ankl
e&
Foot
0.2
(0.1
to0.
4)Ex
posu
reho
urs
Sank
eyet
al.(
2008
)Ru
gby
5E
546
(546
/0)
––
––
OPE&
AxP
Ankl
e&
Foot
1.3
(0.8
to1.
9)Ga
me
Expo
sure
hour
s
Ankl
e&
Foot
0.7
¥10
-1
(0.4
¥10
-1to
1.2
¥10
-1)
Prac
tice
Expo
sure
hour
s
Achi
lles
Tend
0.8
(0.4
to1.
3)Ga
me
Expo
sure
hour
s
Achi
lles
Tend
0.5
¥10
-1
(0.2
¥10
-1to
0.9
¥10
-1)
Prac
tice
Expo
sure
hour
s
Ankl
eIm
ping
emen
t0.5
(0.2
to0.
9)Ga
me
Expo
sure
hour
s
Ankl
eIm
ping
emen
t0.
2¥
10-1
(0.0
¥10
-1to
0.5
¥10
-1)
Prac
tice
Expo
sure
hour
s
Broo
kset
al.(
2005
)Ru
gby
3E
502
(502
/0)
25.4
�4.
2–
––
–P
Stre
ssFr
actu
re¶¶
0.3
¥10
-1Ex
posu
reho
urs
Bish
op&
Fallo
n(1
999)
Runn
ing
5–
17(1
6/1)
47W
P82
––
PAc
hille
sTe
nd41
1.8
(165
.5to
848.
4)Ra
ces
Tibi
alis
Post
erio
rTe
nd58
.8(1
.49
to32
.7)
Exte
nsor
Digi
toru
mTe
nd17
6.5
(15.
7to
752.
7)M
etat
arsa
lgia
117.
6(1
4.3
to42
5.0)
Ankle and foot overuse injuries
675
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Wen
etal
.(19
98)
Runn
ing
3E
255
–C
–Gr
adua
lons
etor
ase
lf-re
porte
ddi
agno
sis
that
isge
nera
llyco
nsid
ered
asov
erus
ein
jury
–P
Ankl
e&
Foot
109.
8(7
3.0
to15
8.7)
Wee
ks
Lysh
olm
and
Wik
land
er(1
987)
Runn
ing
3M
X60
(44/
16)
27.9
�5.
9§–
––
–P
Ankl
e&
Foot
233.
3(1
27.6
to39
1.5)
Year
s
Achi
lles
Tend
83.3
(27.
1to
194.
5)Ye
ars
Tibi
alis
Post
erio
rTe
nd33
.3(4
.0to
120.
4)Ye
ars
Toe
Exte
nsor
Tend
33.3
(4.0
to12
0.4)
Year
s
Plan
tar
Fasc
iitis
66.7
(18.
2to
170.
7)Ye
ars
Met
atar
salg
ia16
.7(0
.4to
92.9
)Ye
ars
Van
Ginc
kele
tal.
(200
9)Ru
nnin
g3
A12
9(1
9/11
0)39
�10
C–
Mus
culo
skel
etal
ailm
ent
that
caus
esa
rest
rictio
nof
runn
ing
spee
ddi
stan
cedu
ratio
nor
frequ
ency
for
atle
ast1
wee
k
–P
Ankl
e&
Foot
147.
3(8
.9to
230.
0)W
eeks
Achi
lles
Tend
7.8
(3.7
to14
.3)
Wee
ksBe
ukeb
oom
etal
.(2
000)
Runn
ing
3–
25(7
/18)
20.3
§C
––
–P
Ankl
e&
Foot
250.
0(1
00.5
to51
5.1)
Seas
ons
Achi
lles
Tend
107.
1(2
2.1
to31
3.1)
Seas
ons
Met
atar
salg
ia35
.7(0
.9to
199.
0)Se
ason
s
Plan
tar
Fasc
iitis
71.4
(8.7
to25
8.0)
Seas
ons
Talu
sOs
teoc
hond
ritis
Diss
ecan
s35
.7(0
.9to
199.
0)Se
ason
s
Fallo
n(1
996)
Runn
ing
3–
32(2
3–53
)W
P–
––
PAc
hille
sTe
nd68
7.5
(430
.9to
1040
.9)
Race
s
Exte
nsor
Digi
toru
mTe
nd68
7.5
(430
.9to
1040
.9)
Exte
nsor
Hallu
cis
Long
usTe
nd62
.5(7
.6to
225.
8)Pe
rone
alTe
nd62
.5(7
.6to
225.
8)Kn
oblo
chet
al.
(200
8)Ru
nnin
g2
E29
1(2
48/4
1)††
42�
9C
–In
jury
with
agr
adua
lons
etw
hich
influ
ence
dpe
rfor
man
cedu
ring
com
petit
ion
ortra
inin
g
QCS
Achi
lles
Tend
¶¶1.
5¥
10-2
Expo
sure
kilo
met
ers
Plan
tar
Fasc
iitis
¶¶0.
3¥
10-2
Expo
sure
kilo
met
ers
Sobhani et al.
676
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Smith
and
Ludi
ngto
n(1
989)
Skat
ing
3E
4820
.1(1
0.9–
27.9
)–
–Re
petit
ive
mic
ro-tr
aum
a–
PAn
kle
&Fo
ot18
7.5
(85.
7to
355.
9)Se
ason
s
Achi
lles
Tend
41.7
(5.0
to15
0.5)
Seas
ons
Pero
neal
Tend
41.7
(5.0
to15
0.5)
Seas
ons
Tibi
alis
Ante
rior
Tend
20.8
(0.5
to11
6.1)
Seas
ons
Met
atar
soph
alan
geal
Syno
vitis
20.8
(0.5
to11
6.1)
Seas
ons
Mal
leol
arBu
rsiti
s62
.5(1
2.9
to18
2.7)
Seas
ons
Torju
ssen
and
Bahr
(200
6)Sn
owbo
ardi
ng4
E25
823
WP
91In
jury
with
agr
adua
lons
etw
hich
influ
ence
dpe
rfor
man
cedu
ring
com
petit
ion
ortra
inin
g“
ICS
Foot
0.4
(0.2
to0.
6)Ex
posu
res
LeGa
llet
al.(
2008
)So
ccer
6E
119
(0/1
19)
(15–
19)
WP
100
Cons
eque
nce
ofre
petit
ive
mic
ro-tr
aum
a–
PSt
ress
Frac
ture
¶¶0.
2¥
10-1
Expo
sure
hour
s
Ankl
eIm
ping
emen
t¶¶
0.2
¥10
-1Ex
posu
reho
urs
Acce
ssor
yNa
vicu
lar
Synd
rom
e¶¶0.
2¥
10-1
Expo
sure
hour
s
Tegn
ande
ret
al.
(200
8)So
ccer
5E
181
(0/1
81)
23�
4(1
7–34
)W
P10
0Gr
adua
lons
etw
ithou
tany
know
ntra
uma
–P
Ankl
e&
Foot
0.6
x10-1
(0.0
¥10
-1to
2.3
¥10
-1)
Expo
sure
hour
s
Jaco
bson
and
Tegn
er(2
007)
Socc
er5
E19
5(0
/195
)23
�4
(16–
36)
WP
72In
jury
with
outa
nykn
own
traum
a–
PAn
kle
&Fo
ot¶¶
0.2
Expo
sure
hour
s
Wal
den
etal
.(20
05)
Socc
er5
E26
626
�4
–88
Pain
synd
rom
eof
the
mus
culo
skel
etal
syst
emw
ithin
sidi
ous
onse
tand
with
outa
nykn
own
traum
aor
dise
ase
that
mig
htha
vegi
ven
prev
ious
sym
ptom
s
–P
Achi
lles
Tend
0.3
(0.2
to0.
5)Ex
posu
reho
urs
Arna
son
etal
.(20
04)
Socc
er5
E30
6(3
06/0
)24
(16–
38)
WP
85In
jurie
sw
ithan
insi
diou
son
setw
itha
grad
ually
incr
easi
ngin
tens
ityof
disc
omfo
rtw
ithou
tan
obvi
ous
traum
a
–P
Ankl
e&
Foot
0.3
x10-1
(0.1
¥10
-2to
0.2)
Expo
sure
hour
s
Engs
trom
etal
.(1
991)
Socc
er5
E41
(0/4
1)21
(16–
28)
WP
100
Grad
ualo
nset
ofsy
mpt
oms
–P
Ankl
e&
Foot
0.6
(0.2
to1.
5)Ex
posu
reho
urs
Pric
eet
al.(
2004
)So
ccer
5–
4773
(9–1
9)W
P76
––
PSe
ver’s
dise
ase‡‡
6.0
(4.5
to7.
7)Ye
ars
Chom
iak
etal
.(2
000)
Socc
er4
MX
398
19.5
�4.
6(1
4–41
)–
––
OPE&
QP
Ankl
e&
Foot
15.2
(4.1
to38
.8)
Year
s
Achi
lles
Tend
7.6
(0.9
to27
.7)
Year
sSt
ress
Frac
ture
7.6
(0.9
to27
.4)
Year
s
Ankle and foot overuse injuries
677
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Sode
rman
etal
.(2
001a
)So
ccer
4M
X15
3(0
/153
)15
.9�
1.2
(14.
1–19
.2)
C–
Grad
ualo
nset
with
outa
nykn
own
traum
a–
PAn
kle
&Fo
ot0.
3(0
.1to
0.9)
Expo
sure
hour
s
Sode
rman
etal
.(2
001b
)So
ccer
4–
221
(0/2
21)
20.6
�4.
7–
––
–P
Ankl
e&
Foot
0.3
(0.1
to0.
7)Ex
posu
reho
urs
Met
atar
soph
alan
geal
Syno
vitis
0.1
(0.0
to0.
3)Ex
posu
reho
urs
Achi
lles
Burs
itis
0.2
(0.0
to0.
6)Ex
posu
reho
urs
Pete
rson
etal
.(2
000)
Socc
er3
MX
398
(14–
18)§§
––
–OP
EP
Ankl
e&
Foot
0.2
(0.1
to0.
3)Ex
posu
reho
urs
Niel
sen
and
Yde
(198
9)So
ccer
3M
X12
3(1
23/0
)(�
16)
WP
––
OPE
PAn
kle
&Fo
ot2.
7(0
.7to
6.9)
Expo
sure
hour
s
Volp
ieta
l.(2
003)
Socc
er2
E25
0(2
50/0
)(9
–19)
––
––
PAn
kle
&Fo
ot‡‡
6.0
(2.2
to13
.1)
Year
s
Achi
lles
Tend
‡‡2.
0(0
.2to
7.2)
Year
s
Seve
r’sdi
seas
e‡‡4.
0(1
.1to
10.2
)Ye
ars
Clok
eet
al.(
2009
)So
ccer
2E
1469
1(9
–19)
––
–OP
E&Ax
RAn
kle
Impi
ngem
ent‡‡
0.2
¥10
-1(0
.0¥
10-1
to0.
8¥
10-1
)
Year
s
Seve
r’sdi
seas
e‡‡1.
0(0
.8to
2.0)
Year
s
Plan
tar
Fasc
iitis
‡‡0.
1¥
10-1
(0.0
¥10
-1to
0.6
¥10
-1)
Year
s
LeGa
llet
al(2
006)
Socc
er2
E(0
/528
)(<
16)
––
––
PAc
hille
sTe
nd0.
8¥
10-2
(0.1
¥10
-2to
0.3
¥10
-1)
Expo
sure
hour
s
Seve
r’sdi
seas
e0.
4¥
10-2
(0.0
¥10
-2to
2.3
¥10
-2)
Expo
sure
hour
s
Carli
nget
al.(
2010
)So
ccer
2E
––
WP
––
–P
Ankl
e&
Foot
0.6
(0.1
to2.
2)Ex
posu
reho
urs
Mul
ler-
Rath
etal
.(2
006)
Socc
er1
MX
7027
.3(1
6–18
)**W
P–
––
RFo
ot0.
3¥
10-1
(0.0
¥10
-1
to1.
8¥
10-1
)Ex
posu
reho
urs
Dick
etal
.(20
07c)
Socc
er1
–(0
/-)–
C–
––
RAc
hille
sTe
nd¶¶
0.7
¥10
-1
(0.6
¥10
-1to
0.9
¥10
-1)
Expo
sure
s
Agel
etal
.(20
07a)
Socc
er1
–(0
/-)–
C–
––
RAc
hille
sTe
nd¶¶
0.5
¥10
-1
(0.4
¥10
-1to
0.6
¥10
-1)
Expo
sure
s
Loos
liet
al.(
1992
)So
ftbal
l2
–24
(0/2
4)20
(17–
23)
––
Grad
ualo
nset
–CS
Stre
ssFr
actu
re41
.7(1
.1to
232.
2)Se
ason
s
Win
geet
al.(
1989
)Te
nnis
5E
89(6
1/28
)26
.1§
(13–
48)
RN86
Deve
lope
dgr
adua
llyan
dco
uldn
’tbe
expl
aine
dby
asi
ngle
traum
a
–P
Ankl
e&
Foot
56.2
(18.
2to
131.
1)Se
ason
s
Maq
uirr
iain
&Gh
isi
(200
6)Te
nnis
3E
139
(91/
48)
20�
5PP
––
OPE&
AxR
Stre
ssFr
actu
re‡‡
28.8
(12.
4to
56.7
)Ye
ars
Benn
elle
tal.
(199
6)Tr
ack
and
Fiel
d(G
ener
al)
4E
111
(58/
53)
20.3
�2
PP–
–OP
E&Ax
PSt
ress
Frac
ture
63.1
(25.
4to
129.
9)Ye
ars
Sobhani et al.
678
Tabl
e1.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Inci
denc
era
te(9
5%CI
)‡De
nom
inat
orpe
r10
00at
hlet
e
Alon
soet
al.(
2009
)Tr
ack
and
Fiel
d(G
ener
al)
4E
1660
–W
P68
––
PAn
kle
&Fo
ot3.
9(2
.1to
6.6)
Cham
pion
ship
s
Achi
lles
Tend
2.7
(1.2
to5.
1)Ch
ampi
onsh
ips
Alon
soet
al.(
2010
)Tr
ack
and
Fiel
d(G
ener
al)
4E
1486
–W
P–
Repe
ated
mic
ro-tr
aum
aw
ithou
tasi
ngle
iden
tifiab
leev
en
–P
Achi
lles
Tend
6.1
(3.2
to11
.5)
Cham
pion
ship
s
Stre
ssFr
actu
re2.
7(0
.7to
6.9)
Cham
pion
ship
s
Plan
tar
Fasc
iitis
0.7
(0.0
to3.
7)Ch
ampi
onsh
ips
Wat
son
and
DiM
artin
o(1
987)
Trac
kan
dFi
eld
(Gen
eral
)3
–25
715
.8�
1.3
(14–
18)
C–
––
PAn
kle
&Fo
ot38
.9(1
8.7
to71
.6)
Seas
ons
Achi
lles
Tend
3.9
(0.1
to21
.7)
Seas
ons
Tibi
alis
Post
erio
rTe
nd31
.1(1
3.4
to61
.3)
Seas
ons
Met
atar
salg
ia3.
9(0
.1to
21.7
)Se
ason
sJa
kobs
enet
al.
(199
2)Tr
ack
and
Fiel
d(G
ener
al)
2M
X54
(43/
11)
25.3
(22–
28)
––
–OP
EP
Ankl
e&
Foot
74.1
(20.
2to
189.
7)Se
ason
s
Verh
agen
etal
.(2
004)
Volle
ybal
l3
E41
9(1
58/2
61)
24.3
�5.
7§–
26W
ithou
tasu
dden
even
tle
adin
gto
inju
ryQ
PAn
kle*
**0.
0¥
10-1
(0.0
¥10
-1to
0.8
¥10
-1)
Expo
sure
hour
s
Bene
kaet
al.(
2007
)Vo
lleyb
all
2M
X64
9(3
18/3
31)
23.5
�5.
4§–
––
IP
Ankl
e&
Foot
0.8
¥10
-2
(0.0
¥10
-2to
4.3
¥10
-2)
Elite
Expo
sure
hour
s
Ankl
e&
Foot
***
0.0
¥10
-2
(0.0
¥10
-2to
5.1
¥10
-2)
Loca
l
Expo
sure
hour
s
Zeto
uet
al.(
2006
)Vo
lleyb
all
1M
X11
4(6
1/53
)22
.5�
4.6§
–10
–I
CSAn
kle
&Fo
ot0.
3(0
.1to
0.5)
Expo
sure
hour
sAg
elet
al.(
2007
c)Vo
lleyb
all
1–
(0/-)
–C
––
–R
Achi
lles
Tend
¶¶0.
6¥
10-1
(0.5
¥10
-1to
0.7
¥10
-1)
Expo
sure
s
*Tab
leis
sorte
dby
the
nam
eof
spor
ts(a
lpha
betic
ally
),th
equ
ality
scor
e(d
esce
ndin
g)an
dth
eat
hlet
icle
vel(
elite
,mix
edgr
oup,
amat
eur,
and
uncl
ear)
.“–”
,unc
lear
orda
tam
issi
ng;A
,am
ateu
r;Am
,am
bisp
ectiv
e;AT
,as
sess
men
tto
ol;
Ax,
auxi
liary
diag
nost
icto
ols;
C,co
nven
ienc
e;CS
,cr
oss-
sect
iona
l;E,
elite
;F,
fem
ale;
I,in
terv
iew
;M
,m
ale;
MX,
mix
ed;
OPE,
orth
oped
icph
ysic
alex
amin
atio
n;P,
pros
pect
ive
coho
rt;PR
,pa
rtici
patio
n/re
spon
sera
te;P
P,pu
rpos
ive;
Q,qu
estio
nnai
re;Q
S,qu
ality
scor
eof
the
stud
y;RN
,ran
dom
;R,r
etro
spec
tive
char
trev
iew
;SM
,sam
plin
gm
etho
d;Te
nd,t
endi
nopa
thy,
tend
initi
s,te
ndin
osis
;WP,
who
lepo
pula
tion
ofin
tere
st.
† Mea
n�
stan
dard
devi
atio
n(r
ange
).‡ Th
era
tes
and
95%
confi
denc
ein
terv
al(v
alue
sin
the
pare
nthe
ses)
wer
eca
lcul
ated
bycu
rren
taut
hors
for
mos
tstu
dies
.§ Po
oled
data
calc
ulat
edby
curr
enta
utho
rs.
¶ Resu
lting
valu
esw
ere
estim
ated
base
don
perc
enta
ges
inth
eor
igin
alpa
per.
**M
ean
age
was
repo
rted
only
for
seni
orgr
oup
and
age
rang
eon
lyfo
rju
nior
grou
p.††
Ther
eis
am
ism
atch
betw
een
the
repo
rted
num
bers
inth
eor
igin
alar
ticle
.‡‡
Valu
esar
e1
year
-adj
uste
d.§§
Age
rang
ew
ason
lyre
porte
dfo
rth
eyo
uth
grou
p.¶¶
The
data
was
repo
rted
inth
eor
igin
alar
ticle
.**
*The
inci
denc
era
tew
asze
ro.
Ankle and foot overuse injuries
679
Tabl
e2.
Prev
alen
cera
tes
ofan
kle
and
foot
over
use
inju
ries
and
deta
ilsof
the
incl
uded
stud
ies*
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Prev
alen
cera
te%
(95%
CI)‡
Prev
alen
cety
pe
Fahl
stro
met
al.
(200
2a)
Badm
into
n5
E66
(41/
25)
23.4
�4.
3(1
6–34
)W
P88
–Q
CSAc
hille
sTe
nd3.
0(0
.8to
10.4
)5
Year
s
Achi
lles
Burs
itis
6.1
(2.4
to14
.6)
5Ye
ars
Hick
eyet
al.(
1997
)Ba
sket
ball
2E
49(0
/49)
––
–Ch
roni
cov
erlo
adR
Ankl
e&
Foot
32.7
(21.
2to
46.6
)6
Year
s
Stre
ssFr
actu
re10
.2(4
.4to
21.8
)6
Year
s
Pfei
fer
etal
.(19
92)
Bask
etba
ll2
–47
3(3
10/1
63)¶
26.8
––
Chro
nic
over
load
orin
corr
ect
load
QCS
Ankl
e††30
.95
Year
s
Wal
lset
al.(
2010
)Da
nce
(Iris
h)5
E18
(8/1
0)26
(21–
32)
WP
100
–Q&
AxCS
Achi
lles
Tend
7.7
(5.4
to9.
1)Po
int
Plan
tar
Fasc
iitis
3.8
(2.0
to6.
1)Po
int
Tuffe
ry(1
989)
Danc
e(M
orris
)4
A14
9–
WP
29In
jury
aggr
avat
edby
danc
ing
whi
chei
ther
prev
ente
dda
ncin
gor
caus
edco
nsid
erab
ledi
scom
fort
QCS
Ankl
e&
Foot
0.5
(0.2
to1.
0)1
Year
Bow
ling
(198
9)Da
nce
(The
atric
al)
3E
141
(61/
80)
(�18
)C
75–
QCS
Ankl
e&
Foot
1.2
(0.7
to1.
8)6
Mon
ths
Aren
dtan
dKe
rsch
baum
er(2
003)
Danc
e(B
alle
t)2
E77
(35/
42)
26.1
(20–
34)§
––
Repe
titiv
em
icro
-trau
ma
orov
erlo
ador
inco
rrec
tloa
dQ
CSAn
kle
&Fo
ot2.
2(1
.4to
3.2)
5Ye
ars
Gosh
eger
etal
.(2
003)
Golf
2M
X70
3(5
10/1
93)
46.2
�17
.3RN
––
QCS
Ankl
e&
Foot
1.6
(0.9
to2.
8)Sp
orts
Care
er
Purn
elle
tal.*
*(2
010)
Gym
nast
ics
3M
X73
(4/6
9)13
.7�
3.9§
(8–2
6)C
–an
inju
ryw
hich
curr
ently
affe
cts
acro
batic
gym
nast
ics
train
ing
orpe
rfor
man
cean
dha
sgi
ven
you
cont
inui
ngpr
oble
ms
for
3m
onth
sor
mor
e
QCS
Ankl
e&
Foot
6.8
(2.9
to15
.1)
Poin
t
Crea
ghan
dRe
illy
(199
8)Or
ient
eerin
g4
MX
28(0
/28)
–C
100
–Q
CSAc
hille
sTe
nd‡‡
0.0
(0.0
to1.
2)1
Year
Back
eet
al.(
2009
)Ro
ckcl
imbi
ng4
MX
355
(249
/106
)30
(9–6
7)RN
63Re
peat
edm
icro
-trau
ma
with
out
asi
ngle
iden
tifiab
leev
ent
QCS
Ankl
e&
Foot
3.1
(1.7
to5.
5)1.
5Ye
ars
Smol
jano
vic
etal
.(2
009)
Row
ing
3E
398
(231
/167
)18
C67
Chro
nic
long
–la
stin
gpa
inus
ually
conn
ecte
dto
spor
tac
tivity
for
whi
chth
ero
wer
sco
uld
notr
epor
tasp
ecifi
cin
citin
gev
ent
Q&I
CSAn
kle
&Fo
ot1.
3(0
.5to
2.9)
1Ye
ar
Jaco
bsan
dBe
rson
(198
6)Ru
nnin
g5
MX
451
(355
/96)
33.5
(8–6
4)§
RN87
–Q
CSAc
hille
sTe
nd2.
9(1
.7to
4.9)
2Ye
ars
Plan
tar
Fasc
iitis
2.4
(1.4
to4.
3)2
Year
sM
arti
etal
.(19
88)
Runn
ing
5–
4358
(435
8/0)
(�17
)W
P84
–Q
CSAc
hille
sTe
nd2.
1(1
.7to
2.6)
1Ye
arHi
rsch
mul
ler
etal
.(2
010)
Runn
ing
2–
953
(656
/297
)42
.3�
10.4
(18–
73)
––
–Ax
&I
CSAc
hille
sTe
nd33
.1(3
0.1
to36
.1)
Poin
t
Barr
owan
dSa
ha(1
988)
Runn
ing
2–
241
(0/2
41)
––
––
QCS
Stre
ssFr
actu
re12
.9(9
.2to
17.7
)Sp
orts
Care
er
Sobhani et al.
680
Tabl
e2.
(con
tinue
d)
Auth
ors
(yea
r)Sp
ort
QSLe
vel
Num
ber
(M/F
)Ag
e†SM
PR (%)
Over
use
defin
ition
ATDe
sign
Prev
alen
cera
te%
(95%
CI)‡
Prev
alen
cety
pe
Dubr
avci
c-Si
mun
jak
etal
.(20
06)
Skat
ing
6E
528
(14/
514)
19.4
(15–
32)c
WP
100
Nosp
ecifi
coc
curr
ence
time
QCS
Achi
lles
Tend
2.8
(1.7
to4.
6)Sp
orts
Care
er
Plan
tar
Fasc
iitis
2.7
(1.6
to4.
4)Sp
orts
Care
erAn
kle
Impi
ngem
ent1
.9(1
.0to
3.5)
Spor
tsCa
reer
Peci
naet
al.(
1990
)Sk
atin
g2
E42
––
––
QCS
Stre
ssFr
actu
re16
.7(8
.3to
30.6
)Sp
orts
Care
er
Clok
eet
al.(
2009
)So
ccer
2E
1469
1(9
–19)
––
–OP
E&Ax
RSe
ver’s
Dise
ase
0.6
(0.5
to0.
7)6
Year
sAn
kle
Impi
ngem
ent0
.1¥
10-1
(0.3
¥10
-2to
0.4
¥10
-1)
6Ye
ars
Plan
tar
Fasc
iitis
0.6
¥10
-2
(0.1
¥10
-2to
0.3
¥10
-1)
6Ye
ars
Mul
ler-
Rath
etal
.(2
006)
Socc
er1
MX
7027
.3(1
6–18
)***
WP
––
–R
Foot
1.4
(0.3
to7.
7)1
Year
Hill
etal
.(20
04)
Softb
all
2–
181
(0/1
81)
(18–
26)
–18
–Q
CSAn
kle
1.7
(0.6
to4.
8)1
Year
Kuhn
eet
al.(
2004
)Te
nnis
1M
X11
0(8
6/24
¶ )37
.5§
(16–
68)
––
–Q
PAc
hille
sTe
nd3.
6(1
.4to
9.0)
2Ye
ars
Plan
tar
Fasc
iitis
3.6
(1.4
to9.
0)2
Year
sLo
ngo
etal
.(20
09)
Trac
kan
dFi
eld
(Gen
eral
)3
E17
8(1
10/6
8)53
.2�
10.9
(35–
94)§
C3
–Q
CSAc
hille
sTe
nd4.
7(4
.0to
5.5)
Poin
t
Colli
nset
al.(
1989
)Tr
iath
lon
3M
X25
7(1
97/6
0)32
–45
–Q
CSAn
kle
10.5
(7.3
to14
.9)
1Ye
arPl
anta
rFa
sciit
is3.
9(2
.1to
7.0)
1Ye
arO’
Tool
eet
al.(
1989
)Tr
iath
lon
3M
X95
(75/
20)
35.2
§–
9–
QCS
Ankl
e&
Foot
††61
1Ye
arM
anni
nen
&Ka
lline
n(1
996)
Tria
thlo
n2
MX
92(7
0/22
)31
.3�
7.4
(19–
56)
C55
–Q
CSAn
kle
&Fo
ot18
.5(1
.1to
2.7)
1Ye
ar
Mig
liorin
i(19
91)
Tria
thlo
n1
E24
26�
5–
––
––
Achi
lles
Tend
8.3
(2.3
to25
.8)
4Ye
ars
Plan
tar
Fasc
iitis
8.3
(2.3
to25
.8)
4Ye
ars
Sesa
moi
ditis
4.2
(0.7
to20
.2)
4Ye
ars
Zeto
uet
al.(
2006
)Vo
lleyb
all
1M
X11
4(6
1/53
)22
.5�
4.6§
–10
–I
CSAn
kle
&Fo
ot7.
9(4
.2to
14.3
)5
Year
s
*Tab
leis
sorte
dby
the
nam
eof
spor
ts(a
lpha
betic
ally
),th
equ
ality
scor
e(d
esce
ndin
g)an
dth
eat
hlet
icle
vel(
elite
,mix
edgr
oup,
amat
eur,
and
uncl
ear)
;**T
heon
lyst
udy
with
sam
ple
size
calc
ulat
ion;
“–”,
uncl
ear
orda
tam
issi
ng;A
,am
ateu
r;AT
,ass
essm
entt
ool;
Ax,a
uxili
ary
diag
nost
icto
ols;
C,co
nven
ienc
e;CS
,cro
ss-s
ectio
nal;
E,el
ite;F
,fem
ale;
I,in
terv
iew
;M,m
ale;
MX,
mix
ed;O
PE,o
rthop
edic
phys
ical
exam
inat
ion;
P,pr
ospe
ctiv
eco
hort;
PR,p
artic
ipat
ion/
resp
onse
rate
;Q,q
uest
ionn
aire
;QS,
qual
itysc
ore
ofth
est
udy;
R,re
trosp
ectiv
ech
artr
evie
w;R
N,ra
ndom
;SM
,sam
plin
gm
etho
d;Te
nd,t
endi
nopa
thy,
tend
initi
s,te
ndin
osis
;WP,
who
lepo
pula
tion
ofin
tere
st.
† Mea
n�
stan
dard
devi
atio
n(r
ange
).‡ Th
era
tes
and
95%
confi
denc
ein
terv
al(v
alue
sin
the
pare
nthe
ses)
wer
eca
lcul
ated
bycu
rren
taut
hors
for
mos
tstu
dies
.§ Po
oled
data
calc
ulat
edby
curr
enta
utho
rs.
¶ Resu
lting
valu
esw
ere
estim
ated
base
don
perc
enta
ges
inth
eor
igin
alpa
per.
***M
ean
age
was
repo
rted
only
for
seni
orgr
oup
and
age
rang
eon
lyfo
rju
nior
grou
p.††
The
data
was
repo
rted
inth
eor
igin
alar
ticle
.‡‡
The
prev
alen
cera
tew
asze
ro.
Ankle and foot overuse injuries
681
than incidence (Bahr, 2009). In this review, only 26studies reported prevalence, and from these studies, onlytwo studies reported the point prevalence that is lessprone to recall bias, than period prevalence especially forthe longer periods.
When comparing injury incidence, the format of theathlete exposure time is an important factor becausedifferent conclusions can be drawn from differentformats (Brooks & Fuller, 2006). Rate expressions inyears or seasons do not provide detail about the actualamount of time that athlete has been exposed. The mostappropriate method to express the incidence rate is toreport exposure per hour or minute (Phillips, 2000;Knowles et al., 2006). However, because these reportingmethods might not be appropriate in all sports, it isrecommended to report rates using multiple denomina-tors (Lystad et al., 2009). Reporting rates using multipledenominators will allow for greater inter- and intra-sportcomparisons and study of the exposure as a risk factorfor sports injuries.
In this review, 24 (27%) studies (mostly soccer andrugby) reported the rates per athlete-hour exposure. Thispromising trend in studies on soccer and rugby indicatesthe feasibility of collecting exposure data in hour despiteits difficulties. We encourage researchers in other sportsareas to use the same approach.
Forty-two percent of studies focused on elite athletes.Only four papers (4%) focused on amateur groups, thusdata on amateur groups is very scarce. Insufficient infor-mation on level of amateur sports does not allow com-paring injury rates between amateur and professionalgroups to assess sports level as a factor in developingoveruse injuries.
Methodological information was missing or providedpoorly in most studies. Lack of adequate description ofpopulation characteristics, sampling method, and partici-pation rate makes it impossible to generalize results torelevant populations. Furthermore, because the internalvalidity of the data is strictly related to the method ofinvestigation and definitions, any variation in thesefactors can affect the outcomes considerably. Forexample, using magnetic resonance imaging in detectingstress fractures is more sensitive than using plain radio-graphs. Consequently, incidence rate of stress fracturedetected with these two different tools can be different(Snyder et al., 2006). If the aim of science is to share theknowledge, poor and ambiguous reporting should beavoided. Adequate information about the exact proce-dure should be provided, and words such as examinationor assessment without further details should be avoided.In this review, some studies were excluded because thenumber of injuries was presented only in graphs withoutpresenting the actual numbers. For some studies, theauthors of this review had to calculate incidence, preva-lence, and corresponding confidence intervals based onnumber estimation because in the paper, the percentageof injuries was reported and not the actual numbers.
Classification of lower extremity parts was not consist-ent across studies. We recommend authors to use theOrchard Sports Injury Classification System for bodyclassifications (Rae & Orchard, 2007). According to con-sensus statements, for soccer (Fuller et al., 2006) andrugby (Fuller et al., 2007), overuse injury is defined as“one caused by repeated micro-trauma without a single,identifiable event responsible for the injury.” Despite thisconsensus, none of the included studies on rugby orsoccer (published after consensus meetings) used theconsensus definition. This definition was only used inrock climbing and track and field (Backe et al., 2009;Alonso et al., 2010). However, the consensus definitionis not sufficient to address all overuse injuries. In case ofstress fracture, it is possible that one athlete/researcherconsiders an identifiable event, one step or jump, respon-sible for the injury (Bahr, 2009). Although the term“chronic” has been widely used to address overuse inju-ries, it is in fact a broader term than “overuse” only. Thisterm includes also long-lasting conditions such aschronic ankle instability that is primary due to an acutetraumatic incident. A consensus should be reached toavoid more confusion and diversity in definition andterminology concerning overuse injuries.
In this review, the term “recurrent” was not used as asearch term because it usually describes acute injuriesthat occur multiple times (Knight, 2008). Studies withonly military as research population were excludedbecause this population is exposed to various trainingprograms and not restricted to sports activities only.
To our knowledge, this is the first systematic reviewthat assessed methodology of studies reporting incidenceand prevalence of overuse injuries of ankle and foot indifferent sports. An extensive search was performed infour databases, and two observers were involved in allselection and quality assessment procedures. For allstages, a substantial or perfect agreement was achieved(Kappa = 0.62–0.90) (Viera & Garrett, 2005). Due tolanguage barrier, we were not able to review articles witha language other than English, Dutch, and German, andhence our review is prone to selection bias. The appraisalchecklist for quality assessment was developed specifi-cally for our research question, with an unknown valid-ity. The criteria used were based on performing soundresearch, preventing selection bias, information bias, andinadequate reporting. In conclusion, meta-analysis andmeaningful comparisons within and between sportswith regard to ankle and foot overuse injuries are notpossible at the moment. The main reasons include het-erogeneity in definitions, assessment tools, and exposureexpressions.
Perspectives
Overuse injuries of the ankle and foot are common inathletic population. In this systematic review, we sum-marized available epidemiological data to provide an
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overview of the extent of the problem. Due to heteroge-neity in methodology and study population, meaningfulcomparisons and robust conclusions were not possible.Moreover, reporting methods of most studies are insuf-ficient. The methodology and data reporting methodsneed to be standardized in future research in this area ofsports medicine.
No sources of funding were used to assist in the preparation of thisreview.
Supporting Information
Additional Supporting Information may be found in theonline version of this article:
Supplementary file 1: Search strategy in four databases;Medline, Embase, CINAHL and SPORTDiscus.Supplementary file 2: Checklist to identify relevantinformation related to quality items.Supplementary file 3: Overview of characteristics ofthe 89 included studies.
Please note: Wiley-Blackwell are not responsible for thecontent or functionality of any supporting materials sup-plied by the authors. Any queries (other than missingmaterial) should be directed to the corresponding authorfor the article.
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