Interventions for preventing lower limb soft‐tissue running injuries

Simon S Yeung; Ella W Yeung; Lesley D Gillespie

doi:10.1002/14651858.CD001256.pub2

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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Stretching exercises: all stretching interventions, Outcome 1 All lower limb soft‐tissue injuries (risk ratio).

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Analysis 2.1

Comparison 2 Stretching exercises: major lower limb muscle groups vs control, Outcome 1 All lower limb soft‐tissue injuries (risk ratio).

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Analysis 2.2

Comparison 2 Stretching exercises: major lower limb muscle groups vs control, Outcome 2 All lower limb soft‐tissue injuries (rate ratio).

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Analysis 3.1

Comparison 3 Stretching exercises: hamstrings vs control, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 4.1

Comparison 4 Stretching exercises: gastrocnemius and soleus vs control, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 4.2

Comparison 4 Stretching exercises: gastrocnemius and soleus vs control, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 5.1

Comparison 5 Conditioning exercises vs placebo exercises, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 5.2

Comparison 5 Conditioning exercises vs placebo exercises, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 6.1

Comparison 6 Graded running programme vs standard training, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 6.2

Comparison 6 Graded running programme vs standard training, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 7.1

Comparison 7 Reduction in training duration (15‐30 minutes/day) vs 45 minutes/day, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 8.1

Comparison 8 Reduction in training frequency (1‐3 days/week) vs 5 days/week, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 9.1

Comparison 9 Reduction in running distance (walking with weights) vs running, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 9.2

Comparison 9 Reduction in running distance (walking with weights) vs running, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 10.1

Comparison 10 Insoles vs control (no insoles), Outcome 1 Lower limb soft‐tissue injuries by location.

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Analysis 10.2

Comparison 10 Insoles vs control (no insoles), Outcome 2 Lower extremity soreness on day 4 in soccer referees.

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Analysis 11.1

Comparison 11 Insoles: custom‐made vs prefabricated soft foot orthoses, Outcome 1 Lower limb soft‐tissue injuries by location.

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Analysis 12.1

Comparison 12 Insoles: custom‐made biomechanical vs prefabricated semi‐rigid foot orthoses, Outcome 1 Lower limb soft‐tissue injuries by location.

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Analysis 13.1

Comparison 13 Insoles: shock‐absorbing polymer vs non shock‐absorbing, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 13.2

Comparison 13 Insoles: shock‐absorbing polymer vs non shock‐absorbing, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 14.1

Comparison 14 Knee brace vs control (no brace), Outcome 1 Lower limb soft‐tissue injuries by location.

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Analysis 15.1

Comparison 15 Footwear: tropical combat boot vs leather combat boot, Outcome 1 Lower limb soft‐tissue injuries by location.

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Analysis 16.1

Comparison 16 Footwear: prescription of running shoes based on foot shape vs regular running shoe, Outcome 1 All lower limb soft‐tissue injuries (rate ratio).

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Analysis 17.1

Comparison 17 Socks: padded polyester vs regular army sock, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 17.2

Comparison 17 Socks: padded polyester vs regular army sock, Outcome 2 Lower limb soft‐tissue injuries by location.

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Analysis 18.1

Comparison 18 Socks: double layer vs regular army sock, Outcome 1 All lower limb soft‐tissue injuries.

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Analysis 18.2

Comparison 18 Socks: double layer vs regular army sock, Outcome 2 Lower limb soft‐tissue injuries by location.

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Comparison 1. Stretching exercises: all stretching interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries (risk ratio) Show forest plot	6	5130	Risk Ratio (Fixed, 95% CI)	0.85 [0.65, 1.12]

1.1 Stretching prior to exercise	3	2957	Risk Ratio (Fixed, 95% CI)	0.95 [0.67, 1.36]
1.2 Stretching as part of a training programme (3‐4 times/day)	3	2173	Risk Ratio (Fixed, 95% CI)	0.74 [0.49, 1.11]

Comparison 1. Stretching exercises: all stretching interventions

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Comparison 2. Stretching exercises: major lower limb muscle groups vs control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries (risk ratio) Show forest plot	1	1538	Risk Ratio (Fixed, 95% CI)	0.92 [0.60, 1.40]

2 All lower limb soft‐tissue injuries (rate ratio) Show forest plot	1	326	Rate Ratio (Fixed, 95% CI)	0.11 [‐0.68, 0.90]

Comparison 2. Stretching exercises: major lower limb muscle groups vs control

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Comparison 3. Stretching exercises: hamstrings vs control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	298	Risk Ratio (Fixed, 95% CI)	0.57 [0.25, 1.29]

Comparison 3. Stretching exercises: hamstrings vs control

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Comparison 4. Stretching exercises: gastrocnemius and soleus vs control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	2		Risk Ratio (Fixed, 95% CI)	Subtotals only

1.1 Soft‐tissue injuries + stress fractures	1	122	Risk Ratio (Fixed, 95% CI)	0.47 [0.23, 0.96]
1.2 Soft‐tissue injuries alone	1	1093	Risk Ratio (Fixed, 95% CI)	0.87 [0.27, 2.82]
2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Lower leg (shin splints)	1	1753	Risk Ratio (M‐H, Fixed, 95% CI)	1.27 [0.66, 2.43]

Comparison 4. Stretching exercises: gastrocnemius and soleus vs control

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Comparison 5. Conditioning exercises vs placebo exercises

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	1020	Risk Ratio (Fixed, 95% CI)	1.20 [0.77, 1.87]

2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (Fixed, 95% CI)	Subtotals only

2.1 Knee injuries	1	1020	Risk Ratio (Fixed, 95% CI)	1.17 [0.56, 2.45]
2.2 Medial tibial stress syndrome	1	1020	Risk Ratio (Fixed, 95% CI)	0.93 [0.35, 2.45]
2.3 Achilles tendonitis	1	1020	Risk Ratio (Fixed, 95% CI)	3.04 [0.31, 29.93]
2.4 Ankle sprain	1	1020	Risk Ratio (Fixed, 95% CI)	1.21 [0.37, 3.95]

Comparison 5. Conditioning exercises vs placebo exercises

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Comparison 6. Graded running programme vs standard training

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	486	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.72, 1.45]

2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Lower leg (shin splints)	1	1670	Risk Ratio (M‐H, Fixed, 95% CI)	2.02 [1.11, 3.70]

Comparison 6. Graded running programme vs standard training

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Comparison 7. Reduction in training duration (15‐30 minutes/day) vs 45 minutes/day

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.21, 0.79]

Comparison 7. Reduction in training duration (15‐30 minutes/day) vs 45 minutes/day

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Comparison 8. Reduction in training frequency (1‐3 days/week) vs 5 days/week

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.06, 0.66]

Comparison 8. Reduction in training frequency (1‐3 days/week) vs 5 days/week

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Comparison 9. Reduction in running distance (walking with weights) vs running

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	350	Risk Ratio (Fixed, 95% CI)	0.80 [0.51, 1.25]

2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (Fixed, 95% CI)	Subtotals only

2.1 Hamstring, thigh, hip, groin injuries	1	350	Risk Ratio (Fixed, 95% CI)	0.87 [0.19, 4.01]
2.2 Knee injuries	1	350	Risk Ratio (Fixed, 95% CI)	0.47 [0.17, 1.33]
2.3 Lower leg injuries	1	350	Risk Ratio (Fixed, 95% CI)	1.06 [0.19, 5.83]
2.4 Ankle and foot injuries	1	350	Risk Ratio (Fixed, 95% CI)	0.78 [0.30, 2.03]

Comparison 9. Reduction in running distance (walking with weights) vs running

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Comparison 10. Insoles vs control (no insoles)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Lower limb soft‐tissue injuries by location Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Knee problems	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Lower leg (shin splints)	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Ankle sprains	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 Achilles tendonitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Lower extremity soreness on day 4 in soccer referees Show forest plot	1	91	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.53, 0.85]

Comparison 10. Insoles vs control (no insoles)

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Comparison 11. Insoles: custom‐made vs prefabricated soft foot orthoses

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Ankle sprains	1	417	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.51, 1.60]
1.2 Foot injuries	1	417	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.58, 1.31]

Comparison 11. Insoles: custom‐made vs prefabricated soft foot orthoses

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Comparison 12. Insoles: custom‐made biomechanical vs prefabricated semi‐rigid foot orthoses

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Ankle sprains	1	352	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.59, 2.28]
1.2 Foot injuries	1	352	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.43, 1.09]

Comparison 12. Insoles: custom‐made biomechanical vs prefabricated semi‐rigid foot orthoses

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Comparison 13. Insoles: shock‐absorbing polymer vs non shock‐absorbing

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	2	4032	Risk Ratio (Fixed, 95% CI)	1.02 [0.81, 1.29]

2 Lower limb soft‐tissue injuries by location Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Thigh injuries	1	1205	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.47, 3.61]
2.2 Knee injuries	2	1760	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.85, 1.80]
2.3 Lower leg injuries	2	1760	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.55, 1.47]
2.4 Ankle injuries	2	1760	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.64, 1.28]
2.5 Achilles tendonitis	2	1760	Risk Ratio (M‐H, Fixed, 95% CI)	1.56 [0.81, 3.01]
2.6 Foot injuries	1	555	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.56, 2.15]

Comparison 13. Insoles: shock‐absorbing polymer vs non shock‐absorbing

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Comparison 14. Knee brace vs control (no brace)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Lower limb soft‐tissue injuries by location Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Anterior knee pain	2	227	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.24, 0.67]

Comparison 14. Knee brace vs control (no brace)

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Comparison 15. Footwear: tropical combat boot vs leather combat boot

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Lower limb soft‐tissue injuries by location Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Anterior knee pain	1	2841	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.39, 1.24]
1.2 Lower leg (shin splints)	1	2841	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.53, 2.44]
1.3 Achilles tendonitis	2	3627	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.73, 1.95]
1.4 Ankle sprain	2	3627	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.60, 1.44]
1.5 Plantar fascial strain	2	3627	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.33, 2.13]

Comparison 15. Footwear: tropical combat boot vs leather combat boot

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Comparison 16. Footwear: prescription of running shoes based on foot shape vs regular running shoe

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries (rate ratio) Show forest plot	2	5795	Rate Ratio (Fixed, 95% CI)	1.03 [0.93, 1.14]

1.1 Men	2	4123	Rate Ratio (Fixed, 95% CI)	1.00 [0.88, 1.15]
1.2 Women	2	1672	Rate Ratio (Fixed, 95% CI)	1.06 [0.92, 1.23]

Comparison 16. Footwear: prescription of running shoes based on foot shape vs regular running shoe

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Comparison 17. Socks: padded polyester vs regular army sock

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	130	Risk Ratio (Fixed, 95% CI)	0.54 [0.27, 1.08]

2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (Fixed, 95% CI)	Subtotals only

2.1 Knee injuries	1	130	Risk Ratio (Fixed, 95% CI)	0.27 [0.07, 1.00]
2.2 Lower leg (shin splints and tibial stress reactions)	1	130	Risk Ratio (Fixed, 95% CI)	1.0 [0.08, 11.81]
2.3 Achilles tendonitis	1	130	Risk Ratio (Fixed, 95% CI)	1.0 [0.23, 4.26]

Comparison 17. Socks: padded polyester vs regular army sock

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Comparison 18. Socks: double layer vs regular army sock

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All lower limb soft‐tissue injuries Show forest plot	1	124	Risk Ratio (Fixed, 95% CI)	0.91 [0.53, 1.56]

2 Lower limb soft‐tissue injuries by location Show forest plot	1		Risk Ratio (Fixed, 95% CI)	Subtotals only

2.1 Knee injuries	1	124	Risk Ratio (Fixed, 95% CI)	0.80 [0.34, 1.86]
2.2 Lower leg (shin splints and tibial stress syndrome)	1	124	Risk Ratio (Fixed, 95% CI)	0.73 [0.05, 11.48]
2.3 Achilles tendonitis	1	124	Risk Ratio (Fixed, 95% CI)	1.24 [0.31, 5.03]

Comparison 18. Socks: double layer vs regular army sock

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