SpringerLink
Log in

Lower limb biomechanical factors associated with Achilles tendinopathy in runners: a systematic review

  • Review
  • Published:
Sport Sciences for Health Aims and scope Submit manuscript

Abstract

Background

Variations in lower limb biomechanics can predispose to Achilles tendinopathy (AT). However, evidence on lower limb biomechanical factors associated with AT in runners is limited.

Aims

This review aimed to examine the existing literature systematically to identify lower limb biomechanical factors associated with AT in runners.

Methods

SCOPUS, ScienceDirect, and PUBMED databases were searched in April  2021 to investigate various lower limb biomechanics such as kinetics, kinematics, muscle activity, plantar pressure, and temporospatial parameter variables during running among AT patients.

Results

Ten studies reported significant differences in knee flexion angle, ankle dorsiflexion, ankle eversion, touchdown angle, and plantarflexion moment between runners with and without AT. Plantar pressure and the ground reaction force variables were also found to be significant discriminators. Muscle activity of tibialis anterior, as well as medial and lateral gastrocnemius during various running phases showed significant differences associated with AT. Runners with AT displayed a longer duration of eversion and over-pronation compared to healthy controls. The mechanical effects of orthotic shoes in runners were able to reduce the incidence of AT.

Conclusions

The findings of the current review indicated the biomechanical factors that could contribute to AT among runners. These factors can be assessed in clinical settings to minimise the injury risk among runners. The protocol of the review was registered at PROSPERO (CRD42021237500) on 18th March 2021.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (France)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Availability of data and material

Not applicable.

Code availability

Not applicable.

Abbreviations

AT:

Achilles tendinopathy

GRF:

Ground reaction force

EMG:

Electromyography

VISA-A:

Victorian Institute of Sport Assessment-Achilles questionnaire

SD:

Standard deviation

BW:

Force normalized to subject body weight

CASO:

Customized arch support orthoses

HL:

Orthotic heel lift

PFM:

Plantar flexion moment

Nm:

Moment

W:

Watt

s:

Seconds

kg:

Kilogram

ROM:

Range of motion

References

  1. Van Ginckel A, Thijs Y, Hesar NGZ, Mahieu N, De Clercq D, Roosen P, Witvrouw E (2009) Intrinsic gait-related risk factors for Achilles tendinopathy in novice runners: a prospective study. Gait Posture 29(3):387–391. https://doi.org/10.1016/j.gaitpost.2008.10.058

    Article  PubMed  Google Scholar 

  2. Kujala UM, Sarna S, Kaprio J (2005) Cumulative incidence of Achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 15(3):133–135. https://doi.org/10.1097/01.jsm.0000165347.55638.23

    Article  PubMed  Google Scholar 

  3. Li HY, Hua YH (2016) Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Res Int 2016:6492597. https://doi.org/10.1155/2016/6492597

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Cook JL, Khan KM, Purdam C (2002) Achilles tendinopathy. Man Ther 7(3):121–130. https://doi.org/10.1054/math.2002.0458

    Article  CAS  PubMed  Google Scholar 

  5. Knobloch K, Yoon U, Vogt PM (2008) Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 29(7):671–676. https://doi.org/10.3113/FAI.2008.0671

    Article  PubMed  Google Scholar 

  6. Clement DB, Taunton JE, Smart GW (1984) Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 12(3):179–184. https://doi.org/10.1177/036354658401200301

    Article  CAS  PubMed  Google Scholar 

  7. Lieberthal K, Paterson KL, Cook J, Kiss Z, Girdwood M, Bradshaw EJ (2019) Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners. Phys Ther Sport 39:64–68. https://doi.org/10.1016/j.ptsp.2019.06.006

    Article  PubMed  Google Scholar 

  8. Mousavi SH, Hijmans JM, 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 Posture 69:13–24. https://doi.org/10.1016/j.gaitpost.2019.01.011

    Article  PubMed  Google Scholar 

  9. Mucha MD, Caldwell W, Schlueter EL, Walters C, Hassen A (2017) Hip abductor strength and lower extremity running related injury in distance runners: a systematic review. J Sci Med Sport 20(4):349–355. https://doi.org/10.1016/j.jsams.2016.09.002

    Article  PubMed  Google Scholar 

  10. Munteanu SE, Barton CJ (2011) Lower limb biomechanics during running in individuals with Achilles tendinopathy: a systematic review. J Foot Ankle Res 4:15–21. https://doi.org/10.1186/1757-1146-4-15

    Article  PubMed  PubMed Central  Google Scholar 

  11. Sancho I, Malliaras P, Barton C, Willy RW, Morrissey D (2019) Biomechanical alterations in individuals with Achilles tendinopathy during running and hop**: a systematic review with meta-analysis. Gait Posture 73:189–201. https://doi.org/10.1016/j.gaitpost.2019.07.121

    Article  PubMed  Google Scholar 

  12. Ogbonmwan I, Kumar BD, Paton B (2018) New lower-limb gait biomechanical characteristics in individuals with Achilles tendinopathy: a systematic review update. Gait Posture 62:146–156. https://doi.org/10.1016/j.gaitpost.2018.03.010

    Article  PubMed  Google Scholar 

  13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–e34. https://doi.org/10.1016/j.jclinepi.2009.06.006

    Article  PubMed  Google Scholar 

  14. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JAC, Cochrane Bias Methods Group (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed.) 343(7829):d5928. https://doi.org/10.1136/bmj.d5928

    Article  Google Scholar 

  15. Azevedo LB, Lambert MI, Vaughan CL, O’Connor CM, Schwellnus MP (2009) Biomechanical variables associated with Achilles tendinopathy in runners. Br J Sports Med 43(4):288–292. https://doi.org/10.1136/bjsm.2008.053421

    Article  CAS  PubMed  Google Scholar 

  16. Becker J, James S, Wayner R, Osternig L, Chou LS (2017) Biomechanical factors associated with Achilles tendinopathy and medial tibial stress syndrome in runners. Am J Sports Med 45(11):2614–2621. https://doi.org/10.1177/0363546517708193

    Article  PubMed  Google Scholar 

  17. Bramah C, Preece SJ, Gill N, Herrington L (2018) Is there a pathological gait associated with common soft tissue running injuries? Am J Sports Med 46(12):3023–3031. https://doi.org/10.1177/0363546518793657

    Article  PubMed  Google Scholar 

  18. Creaby MW, Honeywill C, Smith MMF, Schache AG, Crossley KM (2017) Hip biomechanics are altered in male runners with Achilles tendinopathy. Med Sci Sports Exerc 49(3):549–554. https://doi.org/10.1249/MSS.0000000000001126

    Article  PubMed  Google Scholar 

  19. Lee K, Ling S, Yung P (2019) Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift. BMC Musculoskeletal Dis 20(1):535. https://doi.org/10.1186/s12891-019-2898-0

    Article  Google Scholar 

  20. McCrory JL, Martin DF, Lowery RB, Cannon DW, Curl WW, Read HM, Hunter DM, Craven T, Messier SP (1999) Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exer 31(10):1374–1381. https://doi.org/10.1097/00005768-199910000-00003

    Article  CAS  Google Scholar 

  21. Ryan M, Grau S, Krauss I, Maiwald C, Taunton J, Horstmann T (2009) Kinematic analysis of runners with Achilles mid-portion tendinopathy. Foot Ankle Int 30(12):1190–1195. https://doi.org/10.3113/FAI.2009.1190

    Article  PubMed  Google Scholar 

  22. Sinclair J, Isherwood J, Taylor PJ (2014) Effects of foot orthoses on Achilles tendon load in recreational runners. Clin Biomech 29(8):956–958. https://doi.org/10.1016/j.clinbiomech.2014.07.004

    Article  CAS  Google Scholar 

  23. Sobhani S, Hijmans J, van den Heuvel E, Zwerver J, Dekker R, Postema K (2013) Biomechanics of slow running and walking with a rocker shoe. Gait Posture 38(4):998–1004. https://doi.org/10.1016/j.gaitpost.2013.05.008

    Article  PubMed  Google Scholar 

  24. De Jonge S, Van Den Berg C, De Vos RJ, Van Der Heide HJL, Weir A, Verhaar JAN, Bierma-Zienstra SMA, Tol JL (2011) Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med 45(13):1026–1028. https://doi.org/10.1136/bjsports-2011-090342

    Article  PubMed  Google Scholar 

  25. Baur H, Divert C, Hirschmüller A, Müller S, Belli A, Mayer F (2004) Analysis of gait differences in healthy runners and runners with chronic Achilles tendon complaints. Isokinetic Exer Sci 12(2):111–116. https://doi.org/10.3233/ies-2004-0161

    Article  Google Scholar 

  26. Schubert AG, Kempf J, Heiderscheit BC (2014) Influence of stride frequency and length on running mechanics: a systematic review. Sports Health 6(3):210–217. https://doi.org/10.1177/1941738113508544

    Article  PubMed  PubMed Central  Google Scholar 

  27. Nigg B, Hintzen S, Ferber R (2006) Effect of an unstable shoe construction on lower extremity gait characteristics. Clin Biomech 21(1):82–88. https://doi.org/10.1016/j.clinbiomech.2005.08.013

    Article  Google Scholar 

  28. Sobhani S, Zwerver J, van den Heuvel E, Postema K, Dekker R, Hijmans JM (2015) Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy. J Sci Med Sports 18(2):133–138. https://doi.org/10.1016/j.jsams.2014.02.008

    Article  Google Scholar 

  29. Hutchins S, Bowker P, Geary N, Richards J (2009) The biomechanics and clinical efficacy of footwear adapted with rocker profiles-evidence in the literature. Foot 19(3):165–170. https://doi.org/10.1016/j.foot.2009.01.001

    Article  CAS  Google Scholar 

  30. Hunt AE, Smith RM (2004) Mechanics and control of the flat versus normal foot during the stance phase of walking. Clin Biomech 19(4):391–397. https://doi.org/10.1016/j.clinbiomech.2003.12.010

    Article  Google Scholar 

  31. Kader D, Saxena A, Movin T, Maffulli N (2002) Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 36(4):239–249. https://doi.org/10.1136/bjsm.36.4.239

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Mündermann A, Nigg BM, Humble RN, Stefanyshyn DJ (2003) Foot orthotics affect lower extremity kinematics and kinetics during running. Clin Biomech 18(3):254–262. https://doi.org/10.1016/S0268-0033(02)00186-9

    Article  Google Scholar 

  33. Nielsen RØ, Parner ET, Nohr EA, Sørensen H, Lind M, Rasmussen S (2014) Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther 44(10):739–747. https://doi.org/10.2519/jospt.2014.5164

    Article  PubMed  Google Scholar 

  34. Satterthwaite P, Norton R, Larmer P, Robinson E (1999) Risk factors for injuries and other health problems sustained in a marathon. Br J Sports Med 33(1):22–26. https://doi.org/10.1136/bjsm.33.1.22

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Fields KB, Sykes JC, Walker KM, Jackson JC (2010) Prevention of running injuries. Curr Sports Med Rep 9(3):176–182. https://doi.org/10.1249/JSR.0b013e3181de7ec5

    Article  PubMed  Google Scholar 

  36. Jamaludin NI, Sahabuddin FNA, Raja Ahmad Najib RMN, Shamshul Bahari MLH, Shaharudin S (2020) Bottom-up kinetic chain in drop landing among university athletes with normal dynamic knee valgus. Int J Environ Res Public Health 17(12):4418–4427. https://doi.org/10.3390/ijerph17124418

    Article  PubMed Central  Google Scholar 

  37. Mohd Azhar N, Affandi NF, Mail MSZ, Shaharudin S (2019) The effects of foot position on lower extremity kinematics during single leg squat among adolescent male athletes. J Taibah Univ Med Sci 14(4):343–349. https://doi.org/10.1016/j.jtumed.2019.06.007

    Article  PubMed  PubMed Central  Google Scholar 

  38. Affandi NF, Mail MSZ, Mohd Azhar N, Shaharudin S (2019) Relationships between core strength, dynamic balance and knee valgus during single leg squat in male junior athletes. Sains Malays 48(10):2177–2183. https://doi.org/10.17576/jsm-2019-4810-13

    Article  Google Scholar 

  39. Mail MSZ, Mohd Azhar N, Affandi NF, Shaharudin S, Agrawal S, Chee LM (2019) Relationship between isokinetic leg strength and knee frontal plane projection angle during single leg squat among male junior athletes. J Health Trans Med 22(2):43–48. https://doi.org/10.22452/jummec.vol22no2.7

    Article  Google Scholar 

Download references

Funding

The study was funded by Universiti Sains Malaysia RUI Grant (1001/PPSK/8012364).

Author information

Authors and Affiliations

  1. Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, 16150, Kota Bharu, Malaysia

    Fara Liana Zainuddin, Nur Athirah Abd Rahman & Shazlin Shaharudin

  2. Centre for Sport and Exercise Sciences, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Rizal Razman

Authors
  1. Fara Liana Zainuddin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nur Athirah Abd Rahman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rizal Razman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shazlin Shaharudin
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

F.L.Z. and N.A.A.R. wrote the main manuscript. F.L.Z. prepared Tables 2-7 and Figure 2-3. N.A.A.R. prepared Table 1 and Figure 1. F.L.Z., N.A.A.R., R.R. and S.S. drafted and reviewed the manuscript. S.S. obtained the research funding, provided subject matter expertise and support throughout all stages of manuscript writing. We confirm that the manuscript has been read and approved by all named authors before the manuscript was finalized. There are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that all have approved the order of authors listed in the manuscript.

Corresponding author

Correspondence to Shazlin Shaharudin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zainuddin, F.L., Abd Rahman, N.A., Razman, R. et al. Lower limb biomechanical factors associated with Achilles tendinopathy in runners: a systematic review. Sport Sci Health 18, 27–38 (2022). https://doi.org/10.1007/s11332-021-00862-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11332-021-00862-4

Keywords

Search

Navigation