University of Groningen
A step forward in running-related injuries Mousavi, Hamed
DOI:
10.33612/diss.131226375
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Publication date:
2020
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Citation for published version (APA):
Mousavi, H. (2020). A step forward in running-related injuries: Risk factors, kinematics and gait retraining.
University of Groningen. https://doi.org/10.33612/diss.131226375
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English summary
Nederlandse samenvatting Acknowledgements
Curriculum vitae
Publications and presentations
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Running is a popular leisure-time sporting activity. Due to its affordability and its significant effects on health, physical fitness and mental factors, the number of runners is rising around the world. Next to health benefits, running just like other sporting activities can cause injuries which may have negative effects on daily life, work, running continuation and popular belief on the benefits of running. Identification of risk factors for running-related injuries (RRIs) is important and a primary step toward reducing RRIs. Besides, knowledge about risk factors is relevant to tailor preventive and treatment programs for RRIs.
This thesis starts with an illustration of known RRI determinants and their relationships based on the conceptual model described by Bittencourt et al. (2016) (Chapter 1).
This so-called web was developed using the current literature on risk factors for RRIs.
An attempted was made to further complete the web by adding the results from the studies described in Chapter 2 and 3 of this thesis.
Chapter 2 of this thesis presents a cross-sectional study investigating risk factors for injuries in recreational runners. 804 runners completed a questionnaire comprising personal characteristics, potential risk factors such as mental aspects, sleep quality, perceived health, training-related factors, and foot arch type. The results of this study showed that several factors are associated with RRIs. More obsessive passion and motivation to exercise, poor sleep quality, lower perceived health, running over 20 km/
week, being overweight, having pes planus or cavus, hard-surface running, running in a group, and following a training program are the most important factors related to RRIs. The regression analysis showed that these factors together explained 30% of the variance in RRIs. Separate regression analysis showed that mental aspects and sleep quality explain 15% of the variance in RRIs. This study highlights the association of mental aspects and sleep quality with RRIs and implies that these factors should be incorporated into the preventive and treatment programs.
Chapter 3 of this thesis presents a systematic review of the studies investigating kinematic risk factors for lower limb tendinopathy in distance runners. Twenty-eight studies were included, of which 9 studies investigated kinematic risk factors for Achilles tendinopathy (AT), 17 for iliotibial band syndrome (ITBS), 2 for plantar fasciopathy (PF), 1 for patellar tendinopathy (PT), and 1 for posterior tibial tendon dysfunction (PTTD) (1).
The meta-analyses showed strong evidence for a relation between ITBS and increased peak knee internal rotation and moderate evidence for the relation between ITBS and decreased peak rearfoot eversion and knee flexion at heel strike and increased peak hip adduction. Moderate evidence revealed increased rearfoot eversion at touchdown
ENGLISH SUMMARY
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APPENDICES ENGLISH SUMMARY
determinants. To modify rearfoot eversion, two gait retraining protocols (Changing FPA and mediolateral COP) were investigated. The results showed that changing FPA or mediolateral COP can serve as potential running gait retraining protocols to modify rearfoot eversion. Change in FPA and mediolateral COP, besides changing rearfoot eversion, is accompanied by unwanted changes in hip adduction and internal rotation.
Therefore, when dealing with an individual with atypical rearfoot eversion, clinicians and researchers should screen lower limb biomechanics before prescribing theses gait retraining protocols. Further research needs to investigate the effect of these protocols on rearfoot eversion in the long term and to find out whether modifying rearfoot eversion can reduce the occurrence of RRIs.
in runners with AT. Very limited evidence revealed increased peak ankle eversion in runners with PF and PTTD, and increased peak hip adduction in PT. Peak rearfoot eversion was the only factor reported as a risk factor for all included lower limb tendinopathies; it is a significant factor in ITBS, PT and PTTD but not in AT and PF. This review demonstrates that kinematic risk factors can play a role in the development of lower limb tendinopathy.
Chapter 4 and 5 of this thesis present two studies investigating the effects of changing foot progression angle (FPA) (Chapter 4) and changing mediolateral center of pressure (COP) (Chapter 5) on rearfoot eversion during treadmill running. Participants were 15 healthy female runners. In Chapter 4, real time visual feedback for FPA was provided while running on a big curved screen (a clock’s pointer denoted FPA in real-time). To change FPA, 5° more (toe-out) and less (toe-in) from baseline FPA was considered.
To change COP medially or laterally, participants were asked to run on the medial and lateral side of the foot, respectively, while following their baseline FPA using real- time visual feedback. The results showed that toe-in running and lateralizing COP reduce peak rearfoot eversion, subtalar pronation and medial longitudinal arch angle.
In contrast, toe-out running and medializing COP increase these kinematics. These results suggest that clinicians and researchers may prescribe running gait retraining by changing FPA or mediolateral COP for runners with atypical rearfoot eversion as we showed that this was an important factor for RRIs.
Chapter 6 of this thesis presents a study investigating the validity and reliability of a smartphone motion analysis application (Coach’s Eye) for sagittal plane hip, knee and ankle kinematics and rearfoot eversion during running. The results show that Coach’s Eye can be used as an alternative for 3D motion analysis systems to measure sagittal plane lower limb kinematics and rearfoot eversion, except for hip and ankle angles at touchdown and knee angle at toe-off. The results indicated that Coach’s Eye can be used as a reliable method for measuring selected lower limb kinematics but its measures are not valid for all these kinematics.
In the discussion, Chapter 7, the results presented in this thesis are discussed in a broader perspective along with recommendations for future studies, limitation of this thesis and practical implications for clinicians and runners. Specifically, in the first part of the discussion the web of determinants for RRIs is made more complete based on the results of this thesis. Obsessive passion and motivation to exercise as well as sleep quality were placed in the web as new determinants for RRIs. Based on the results of this thesis, atypical rearfoot eversion was also placed in the web of RRI
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APPENDICES ENGLISH SUMMARY
Hardlopen is een populaire sportieve vrijetijdsbesteding. Vanwege de geringe bijkomende kosten en de belangrijke effecten ervan op gezondheid, fysieke fitheiden psychologische factoren, stijgt daarom het aantal hardlopers over de hele wereld.
Hardlopen geeft behalve gezondheidsvoordelen, net als elke andere sportactiviteit ook een risico op blessures, die invloed kunnen hebben op het dagelijks leven, werk, wel of niet doorgaan met hard lopen en de publieke overtuiging dat lichaamsbeweging gezond is. Identificeren van risicofactoren die invloed hebben op hardloopblessures is van bijzonder belang en een belangrijke eerste stap voor het verminderen van hardloopblessures.
Dit proefschrift begint met een beschrijving van de factoren waarvan bekend is dat zij een rol spelen bij het ontstaan van hardloopblessures De onderlinge relaties van deze factoren worden geïllustreerd in een conceptueel model zoals voorgesteld door Bittencourt en collega’s. 2016 (Hoofdstuk 1). Dit ’web’ is met behulp van de huidige kennis over de risicofactoren voor hardloopblessures samengesteld. Resultaten van de beschreven studies in de hoofdstukken 2 en 3 werden toegevoegd.
Hoofdstuk 2 van deze thesis is een cross-sectionele studie die de risicofactoren voor blessures bij recreatieve hardlopers onderzoekt. 804 hardlopers hadden een vragenlijst met persoonlijke kenmerken ingevuld ivm mogelijke risicofactoren zoals psychologische aspecten, slaapkwaliteit, waargenomen gezondheid en factoren die verband houden met het type training en het type voet. Dit onderzoek liet zien dat verschillende factoren verband kunnen houden met hardloopblessures. Passie en motivatie om te sporten, slechte slaapkwaliteit, lage gezondheidstatus, meer dan 20 km per week hardlopen, overgewicht, hebben van plat– of holvoeten, hardlopen op harde ondergrond, hardlopen in een groep en het volgen van een trainingsprogramma zijn de belangrijkste factoren die verband houden met hardloopblessures. Een regressie analyse toonde aan dat deze factoren 30% van variantie van de hardloopblessures verklaarden. Een afzonderlijke regressie analyse toonde aan dat psychologische aspecten en slaapkwaliteit 15% van de variantie van hardloopblessures verklaarden.
Dit onderzoek laat zien dat er een associatie is tussen psychologische aspecten en slaapkwaliteit en hardloopblessures en benadrukt dat deze factoren moeten opgenomen worden in preventie- en behandelprogramma’s van hardloopblessures.
Hoofdstuk 3 van deze thesis beschrijft een systematisch review van studies die kinematische risicofactoren voor tendinopathieen van de onderste extremiteit bij lange afstandslopers hebben onderzocht. Er zijn 28 studies gedaan, waaronder 9 studies ivm kinematische risicofactoren voor de achillespees (AT) waren, 17 studies voor het
NEDERLANDSE SAMENVATTING
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heup- en enkelhoeken bij touch-down en de knie hoek bij toe-off. De Coach’s Eye kan als een betrouwbare methode gebruikt worden om selectief kinematica van de onderste extremiteit te meten, maar de metingen zijn niet geldig voor alle kinematische variabelen.
In Hoofdstuk 7 worden de resultaten van de diversie studies in breder perspectief besproken. Ook is er aandacht voor de beperkingen van de studies in dit proefschrift en worden aanbevelingen gegeven voor toekomstige studies, en worden potentiele praktische implicaties voor behandelaars en hardlopers geformuleerd.
In het eerste deel van deze discussie wordt het web van factoren gerelateerd aan hardloopblessures verder ingevuld op basis van de resultaten van deze thesis. Obsessief gepassioneerd en gemotiveerd zijn om te sporten als ook slaapkwaliteit werden als nieuwe determinanten van hardloopblessures toegevoegd. Ook atypische eversie werd toegevoegd. Om eversie te veranderen, werden twee looptrainingprotocollen (verandering van voetprogressiehoek en “center of pressure”) onderzocht welke geschikt lijken om geimplemteerd te worden in kader van looptrainingprotocollen.
Verandering van voetprogressiehoek en “center of pressure” kunnen echtergaan echter ook gepaard gaan met ongewenste veranderingen in de adductie en endorotatie van de heup. Dus behandelaars en onderzoekers moeten wanneer ze te maken hebben met een persoon met een atypische eversie, de biomechanica van de hele onderste extremiteit screenen voordat ze een looptrainingprotocollen voorschrijven. Verdere studies zijn nodig om het lange termijn effect van deze looptrainingprotocollen op eversie te evalueren en om te onderzoeken of de verandering van eversie leidt tot een vermindering het aantal hardloopblessures.
iliotibiaal band syndroom (ITBS), 2 studies voor plantaire fasciopathie (PF) en éént voor patellatendinopathie (PT), en één voor dysfunctie van de tibilais posterior(PTTD).
Meta-analyses toonden een sterk bewijs voor een verband tussen ITBS en verhoogde endorotatie van de knie, alsook een matig bewijs voor een verband tussen ITBS en verminderde piek eversie en flexie van de knie tijdens touch down en verhoogde piek adductie van de heup. Er was matig bewijs voor een toegenomen piek eversie tijdens touch down bij hardlopers met AT. Ook was erzeer beperkt bewijs voor een toegenomen eversie van de enkel bij hardlopers met PF en PTTD eversie, en bij PT voor een toegenomen piek adductie van de heup. Piek eversie was de enige factor die een grote risicofactor was voor alle peesaandoeningen van de onderste extremiteit. Dit is een belangrijke factor bij PT, ITBS en PTTD, maar niet bij AT en PF. Deze studie toont aan dat kinematische factoren een belangrijke rol kunnen spelen bij de ontwikkeling van tendinopathieen van de onderste extremiteit.
Hoofdstukken 4 en 5 van dit proefschrift bevatten twee studies die de effecten van een verandering in de hoek van de voetprogressiehoek (hoofdstuk 4) onderzoeken en verandering van “center of pressure” (hoofdstuk 5) onderzoeken op eversie tijdens hardlopen op een loopband. Deelnemers waren 15 gezonde vrouwelijke hardlopers.
In hoofdstuk 4 wordt een real time visuele feedback voor de voetprogressiehoek aangeboden. Om de voetprogressiehoek te wijzigen, werd vijf graden meer (toe-out) of minder (toe-in) ten opzichte van de basis voetprogressiehoek gebruikt. Om de “center of pressure” naar mediaal of lateraal te verplaatsenwerden de deelnemers gevraagd om op respectievelijk de mediale en laterale zijde van hun voeten te lopen, terwijl ze met behulp van realtime visuele feedback hun basis-voetprogressiehoek volgden.
De studies hebben aangetoond dat toe-in tijdens hardlopen en het lateraliseren van
“center of pressure” zal leiden tot een vermindering van de eversie, subtalaire pronatie en mediale voetboog. Hardopen met toe-out en medialiseren van “center of pressure”, vergroten deze beweging daarentegen. Deze resultaten suggereren dat artsen en onderzoekers door middel van gait retraining de voetprogressiehoek of “center of pressure” van hardlopers met atypische eversie kunnen veranderen hetgeen nuttig is omdat is aangetoond dat dit een belangrijke factor is voor hardloopblessures.
In het 6de hoofdstuk van deze thesis wordt een onderzoek beschreven waarin de validiteit en reproduceerbaarheid van een smartphone motion analysis applicatie (Coach’s Eye) voor heup, knie en enkel kinematica in het sagittale vlak en eversie tijdens hardlopen wordt bestudeerd. ’De Coach’s-eye-applicatie kan als een alternatief worden gebruikt voor 3D analyse systemen voor het in het sagittale vlak meten van de kinematica van de onderste extremiteit en de eversie, met uitzondering van de
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I would like to thank everyone who has contributed to my PhD thesis and walked with me during this fantastic journey. Without your support, motivation, energy, and guidance I would not have been able to achieve my PhD.
SPECIAL THANKS
To my first supervisor, Professor Hans Zwerver. Hans, I would like to express my gratitude to my kind and compassionate supervisor. I have been blessed to have a supervisor who always cared about my work, my life and my family. Whenever I reached a dead end, your ideas were always insightful and inspirational, giving me the opportunity to explore issues from different perspectives. Although my PhD is about to wrap up and we might never meet each other, I am absolutely delighted that I have chosen you as my role model to emulate your distinguished character in my future academic career.
To my second supervisor, Professor Ron Diercks. Ron, I’m deeply grateful to you for giving me this fantastic opportunity to study here and sharing your knowledge with me during several meetings that we had together for my GRAIL projects. You have a great and warm personality.
To my co-supervisor, Dr Juha Hijmans. Thank you for inspiring me and challenging me to grow as a scientist. My research benefited enormously from your ideas and creative suggestions that led me through the different stages of this research.
To my advisor, Professor Reza Rajabi. I am truly fortunate to have you during my PhD.
Your supports and encouragements both before and after starting my Ph.D. gave me the impetus of moving on despite obstacles. Without your support, I would have never been able to achieve my goals.
To Dr Henk van der Worp. You were the first person I met in UMCG. I’ll never forget our first meeting where you were talking about everything necessary to start a PhD here and about the long journey ahead. Now it is the end of that journey. Although we collaborated only for a few months, I learned a lot from you.
To Professor Behrooz Alizadeh. Your support during my PhD is fully appreciated. You are not only a great mentor, but also a great friend to me.
To the members of the reading committee, Professor Klaas Postema, Professor Evert Verhagen, Professor Han Houdijk. Thank you for your time and effort to read and
ACKNOWLEDGEMENTS
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review my thesis.
To my roommates, Lucas and Oliver. Thank you for sharing your office with me. You are awesome friends. I have unforgettable memories with you during these 4 years. I wish you and your families all the best.
To Laurens, thank you for helping me during the data collection of GRAIL projects. You indeed helped me to improve my knowledge about MATLAB and motion analysis. We had a great collaboration on the GRAIL projects.
To my friends, Laurens, Anton, Sajjad, Ali, Elnaz, Asad, Mahdiyeh, Mohammadreza, Ahmad. Thanks for your friendship. I hope we stay friend forever.
To all individuals who have participated in my studies. Also, all managers of running groups and individuals who have helped me in recruiting recreational runners in Tehran, Mashhad and Shiraz.
To JoAnn and Hans. My family and I met you in the international coffee event where you welcomed us as new members. We will never forget the good time we had together in your house before leaving the Netherlands. We are so pleased to call you our Dutch parents.
To my mother, father, mother -and father-in-law who always motivated and supported me during the past years.
To my children, my dear Arad and Arnika. You have accompanied me during the whole of this journey. Nothing could be better for me when I came back home and look forward to seeing my children in my arm. You are all my life.
Finally, to my love, Forough. I would never be able to thank you as you deserve. You have enriched my life in so many ways. For your unwavering love, unending support and encouragement over the past several years; I am truly thankful to have you in my life. You always empowered me to explore my passions and achieve my dreams.
I could not overcome difficulties without your help, support and encouragement.
Sharing my life with you has been my greatest accomplishment.
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APPENDICES ACKNOWLEDGEMENTS
Seyed Hamed Mousavi was born on 22nd of March 1984 in Kashmar, Razavi Khorasan province, Iran. He completed his diploma in mathematics and physics. He started his bachelor in physical education and sports sciences at the state University of Sistan and Baluchestan in 2004.
He completed his bachelor in 2008 and at the same year he started his master in Corrective Exercises and Sports Injuries in the state University of Esfahan and completed it after 2 years in 2010. He has served as an invited lecturer in Azad and Payame noor Universities from 2010 to 2015 and
taught several courses such as anatomy, kinesiology, sports biomechanics, corrective exercises, sports injuries and statistics. He was ranked first in the PhD entrance exam in 2014 in Iran among 1000 participants in the field of Corrective Exercises and Sports Injuries. He gained a scholarship from the ministry of science in Iran (University of Tehran) to study his PhD abroad. He started his PhD at the University of Groningen, University Medical Center Groningen in 2016. He has been published several ISI and ISC papers. He has presented several oral and poster presentations in national and international conferences.
CURRICULUM VITAE
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Mousavi, S.H., Hijmans, J.M., Rajabi, R., Diercks, R., Zwerver, J., & van der Worp, H.
(2019). Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis. Gait and Posture, 69, 13-24.
Mousavi, S.H., Hijmans, J.M., Moeini, F., Rajabi, R., Ferber, R., van der Worp, H., &
Zwerver, J. (2020). Validity and reliability of a smartphone motion analysis app for lower limb kinematics during treadmill running. Physical Therapy in Sport, 43, 27–35.
Mousavi, S.H., van Kouwenhove, L., Rajabi, R., Zwerver J., Hijmans, J.M. (2020).
The effect of changing mediolateral center of pressure on rearfoot eversion during treadmill running, accepted for publication in Gait & posture.
Mousavi, S.H., van Kouwenhove L., Rajabi R., Zwerver J., Hijmans J.M. (2020). The effect of changing foot progression angle using real-time visual feedback on rearfoot eversion during running, (Submitted to PlosOne, Under revision).
Mousavi, S.H., Hijmans, J.M., Minoonejad, H., Rajabi, R., Zwerver, J. (2020). Risk factors associated with injuries in recreational runners: a cross-sectional survey including mental aspects and sleep quality. (Submitted to Internation Journal of Sports Medicine, Under revision).
Jafarnezhadgero, A.A., Mousavi, S.H., Madadi-shad, M., Hijmans, J.M. (2020).
Quantifying lower limb inter-joint coordination and coordination variability after four- month wearing arch support foot orthoses in children with flexible flat feet. Human Movement Science, 70, 102593.
Jafarnezhadgero, A.A., Mousavi, S.H., AlaviMehr, S.M., Madadi-Shad, M. (2020). The long-term wearing of foot orthoses can change the frequency domain of ground reaction forces in children with flexible flat feet. Journal of Prosthetics and Orthotics.
Accepted for publication 12-02-2020.
Jafarnezhadgero, A.A., Oliveira, A. S., Mousavi, S.H., & Madadi-Shad, M. (2018).
Combining valgus knee brace and lateral foot wedges reduces external forces and moments in osteoarthritis patients. Gait and Posture, 59, 104–110.
Mousavi, S.H., Ghasemi, B., Faramarzi, M. (2009). The Relationship between Internal Longitudinal Foot Arch with Static and Dynamic Balance of 12-14 years Male Students, Journal of Sport Medicine, issue 2, Autumn 2009, Page 107-23.
PUBLICATIONS
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mediolateral center of pressure on rearfoot eversion during treadmill running. Mousavi, S.H., van Kouwenhove L., Rajabi R., Zwerver J., Hijmans J.M.
Mousavi, S.H., Ghasemi, B., Davodi, M. (2012). The Relationship between internal longitudinal foot arch with Cardiorespiratory Endurance and Agility in Male Students (12-14 Years Old), Journal of Sport Medicine (ISC), issue 2,Autumn 2012, Page 49-65.
Mousavi, S.H. (2013).The survey of evolutionary and comparison of the plantar arch indexes between the ages of 3 to 12 years old, Journal of Sport Medicine Review, No (12), page 63-80.
Moeini, F., Aghayari, A., Mousavi, S.H. (2014). The effect of functional fatigue on dynamic balance in girl students with different plantar arch, J of Sport Medicine, issue 1, Spring 2014, Page 131-151.
Ghofrani, M., Mousavi, S.H. (2012). Injury mechanism in boys’ amateur epical athletes in Kyokushin ka, Karate and Aikido. Life Science Journal. 9(4),2593-2597.
Ghofrani, M., Mousavi, S.H. (2012). The comparison of injuries in boys’ amateur epical athletes in three fields: Kyokushin ka, controlling Karate and Aikido. Life Science Journal. 9(4),1365-1371.
INTER(NATIONAL) PRESENTATIONS
8Th world congress on Biomechanics (2017, Dublin). Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis.
Mousavi, S.H., Hijmans, J.M., Rajabi, R., Diercks, R., Zwerver, J., & van der Worp, H.
European College Sport Science (ECSS, 2018, Prague). Validity and reliability of a smartphone motion analysis app for lower limb kinematics during running. Mousavi, S.H., Hijmans, J.M., Moeini, F., Rajabi, R., Ferber, R., van der Worp, H., & Zwerver, J.
IOC World Conference (2020, Monaco). The effect of changing foot progression angle using real-time visual feedback on rearfoot eversion during running. Mousavi, S.H., van Kouwenhove, L., Rajabi, R., Zwerver, J., Hijmans, J.M.
Scandinavian Sports Medicine Congress (2020, Copenhagen). Survey of running- related injuries in Iranian recreational runners. Mousavi, S.H., Hijmans, J.M., Minoonejad, H., Rajabi, R., Zwerver, J.
European College Sport Science (ECSS, 2020, Sevilla). The effect of changing
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