Risk Factors For Lower Extremity Injury A Review of The Literature - Dr. Zayadi Zainudin, SP - KFR

Risk factors for
lower extremity
injury : a review
of the literature
dr. Zayadi Zainuddin, Sp.KFR

Introduction
 Musculoskeletal injuries occur when there is an
overload of the musculoskeletal structures that
exceeds the ability of regeneration or adaptation
 Musculoskeletal injuries are common in sport and
among athletes
 Epidemiological studies at international
competitions and Olympic Games found that
most of injuries affect the lower limbs
Orejel Bustos A, Belluscio V, Camomilla V, Lucangeli L, Rizzo F, Sciarra T, Martelli F, Giacomozzi C. Overuse-Related Injuries of the Musculoskeletal
System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques. Sensors. 2021; 21(7):2438.
https://doi.org/10.3390/s21072438
Prieto-González, P.; Martínez-Castillo, J.L.; Fernández-Galván, L.M.; Casado, A.; Soporki, S.; Sánchez-Infante, J. Epidemiology of Sports-Related
Injuries and Associated Risk Factors in Adolescent Athletes: An Injury Surveillance. Int. J. Environ. Res. Public Health 2021, 18, 4857. https://
doi.org/10.3390/ijerph18094857
Introduction
https://doi.org/10.3390/s21072438
Introduction
https://doi.org/10.3390/s21072438
Introduction
 Many injury risk factors both intrinsic (those
from within the body) and extrinsic (those outside
of the body) have been suggested.
https://doi.org/10.3390/s21072438
Introduction
https://doi.org/10.3390/s21072438
Introduction
Saragiotto, B. T., Di Pierro, C., & Lopes, A. D. (2014). Risk factors and injury prevention in elite athletes: a descriptive study of the opinions of
physical therapists, doctors and trainers. Brazilian journal of physical therapy, 18(2), 137–143. https://doi.org/10.1590/s1413-35552012005000147
Introduction
Saragiotto, B. T., Di Pierro, C., & Lopes, A. D. (2014). Risk factors and injury prevention in elite athletes: a descriptive study of the opinions of
physical therapists, doctors and trainers. Brazilian journal of physical therapy, 18(2), 137–143. https://doi.org/10.1590/s1413-35552012005000147
Intrinsic Risk Factor : Age
 Older athletes when compared to younger are
▪ more frequently injured and
▪ more time to recover from injury
 Age-related changes in older athletes, such as :
▪ increased body weight,
▪ declines in muscular strength and flexibility
▪ Other aging change
Six studies15 34–38 showed increased incidence of injury in
older athletes, five11 17 18 39 40 found no association
Intrinsic Risk Factor : Age
Increased injury has been reported with increased age

among soccer players,17 34–36 football players,37 and
recreational sport15
Age was not found to be an injury risk factor among

dancers,39 female soccer players,11 female netball
players,18 or track and field athletes.40
Murphy, D. F., Connolly, D. A., & Beynnon, B. D. (2003). Risk factors for lower extremity injury: a review of the literature. British journal of sports
medicine, 37(1), 13–29. https://doi.org/10.1136/bjsm.37.1.13
Intrinsic Risk Factor : Sex
 Female athletes substantially more knee injuries
than male athletes, specifically ACL injury.
 Why female athletes suffer more serious knee
injuries than male athletes, including :
▪ anatomical,
▪ hormonal, and
▪ neuromuscular factors
 It was established that females :
▪ narrower intercondylar femur notch,
▪ higher-than-average body mass index, and
▪ general joint laxity
Seven studies14 19 34 38 42 50 51 showed female athletes
had an increased incidence of injury, five studies 39 40
Intrinsic Risk Factor : Sex
52–54 found no association
The relation between sex and other types of lower

extremity injury is unclear.
Intrinsic Risk Factor : Phase of the
menstrual cycle
 Hormonal fluctuations within menstrual cycle
increased risk to women of ACL injury
 Most likely because of
▪ the increase in estradiol and
▪ the decreased concentration of progesterone
influencing the composition of the ACL
ligament
 Oestrogen and progesterone receptors have been
identified on the ACL
Two studies14 55 found risk of sustaining an ACL injury
Intrinsic Risk Factor : Phase of the
56
near the onset of menstruation, and one reported
menstrual
increased cycle
risk during the ovulatory phase
Intrinsic Risk Factor : Previous injury
 Several reasons explain the increased risk of
incurring the same type and location of injury
in subjects with an injury history :
▪ proprioceptive defects (functional instability),
▪ muscle strength impairment and imbalance,
▪ diminished muscle flexibility and joint
movement, and
▪ persistent ligamentous laxity (mechanical
instability),
▪ the presence of localised scar tissue, which
produces discomfort.
Intrinsic Risk Factor : Previous injury
 Previous injury may lead to an increased risk of
sustaining future injury by contributing to
▪ fear of re-injury that could cause
• the athlete to use altered muscle
recruitment strategies
• and lose focus causing an inability to
maintain attention to appropriate visual
cues.
Intrinsic
Seven studiesRisk
8 13 17Factor
20 22 26 39 :have
Previous injury injury
found previous
toand 21 52 61 reported no association
inadequate
be a risk factor, three rehabilitation
Intrinsic Risk Factor : Aerobic fitness
 A strong association between higher levels of
aerobic fitness and decreased risk of injury
 Diminished aerobic fitness may cause
▪ fatigue alter muscle recruitment patterns.
▪ fatigue leading to reduction in protective
effect of musculature on skeletal structures.
An association
Intrinsic Riskbetween
Factormeasures of aerobic
: Aerobic fitnessfitness and
injury was shown in five studies,17 18 38 51 65 and two 20 35
found no association.
Intrinsic Risk Factor : Body
composition
 Body composition has been analysed in risk
factor studies in a number of ways including :
 height and weight,
 lean muscle mass,
 body fat content,
 body mass index (BMI)
 These variables have been considered as risk
factors for injury because an increase in any one
produces a proportional increase in the forces
that articular, ligamentous, and muscular structures
must resist
Body size has been implicated as an injury risk factor in
Intrinsic
four studies
Risk
20 34 37 65
Factor : Body size
whereas no association was found
in nine studies 7 22 35 38–40 52 53 66
Therefore, the relation between

body size and injury still controversial
Intrinsic Risk Factor : Limb
dominance
 The dominant leg may be at increased risk of
injury because :
▪ more preferentially used
▪ more frequency used
for kicking, pushing off, jumping, or landing.
 The non dominant libm fuction as stabilizing to
▪ resist external forces to maintain posture and
▪ transfer mechanical energy through the
proximal-to-distal segmental motion of the
lower (most often dominant) limb
Four studies17 37 52 67 have reported an association
Intrinsic
between Risk
limb Factor and
dominance : Limb
injury. In contrast, three
studies 6 26 53 reported no association
dominance
Therefore, the relation between

limb dominance and injury remains unclear
Intrinsic Risk Factor : Flexibility
 Athletes with joint hypermobility and muscle
thigtness often present with increased injuries
 Joint hypermobility impaired proprioception may
play a role in increased risk of lower extremity
joint injury
 Tight muscle had a lower stretch tolerance, as
indicated by the lower maximal angle, torque,
and energy.
Two studies11 35 reported a greater incidence of injury
among women with increased generalised joint laxity,
one68 found a greater incidence of injury among men with
Intrinsic generalised
decreased Risk Factor : Flexibility
joint laxity values, and four
studies18 52 53 70 showed no association
Four studies22 38 68 73 have reported an association

between muscle tightness and injury, whereas one30
did not find an association
Intrinsic Risk Factor : Muscle
Strength and Imbalance
 The relationship between muscle injury and
agonist-antagonist balance disruption has been
frequently reviewed in the literature
 Muscle imbalance occurs when overused muscles
become stronger than less active muscles
 When the weaker muscles can’t match the
strength and endurance of the stronger ones, they
fatigue more easily and causing the stronger
muscles to work harder
Two studies11 52 found an association between
muscular
Intrinsicimbalance and injury,
Risk Factor and one67 reported an
: Muscle
association between decreased muscle strength and
Strength, and Imbalance
injury, three studies20 35 53 showed no association
Intrinsic Risk Factor : Postural
stability
 The ability of athletes to control the position of
their centre of gravity has received attention as a
potential risk factor for lower extremity injury
 Increased variation in postural stability is :
▪ associated with an altered neuromuscular
control strategy,
▪ increased intersegmental joint forces, and
▪ corresponding increased forces developed
about the articular, ligamentous, and
musculature structures.
Intrinsic Risk
Three studies Factor
11 76 : Postural
77 have reported an association
between diminished balance and injury, and two18 53
stability
have found no association.
Intrinsic Risk Factor : Anatomical
alignment
 The intersegmental joint forces and the
structures that must resist—for example,
articular surfaces, ligaments, and musculature—are
related through anatomical alignment of the
joints and skeletal system.
 Therefore, alignment of the hip, knee, and ankle
has received substantial interest as a potential risk
factor for lower extremity injury.
Five studies20 53 75 81 82 reported an association between
Intrinsic Risk Factor : Anatomical
abnormal anatomical alignment and injury, whereas
alignmenttwo11 66 found no association
Abnormal anatomical alignment that associated injury

include narrower femoral intercondylar notch,
increased Q angle, tibia valgum, and leg length
discrepancy
Intrinsic Risk Factor : Foot
morphology
 Like anatomical alignment of a joint, foot
morphology has an important effect on the relation
between the ground reaction force and the axes
of rotation of the ankle, knee, and lower
extremity as well as the corresponding forces
developed on these structures.
 Several studies have reported a relation between
foot morphology and injury.
Five studies 73 84–87 have reported an association
Intrinsic Risk Factor : Foot
between foot morphology and injury,whereas four21 53
morphology66 82 have shown no association.
Foot morphology that associated injury include high arch,

pes planus or cavus foot, and pronated/supinated foot
Extrinsic Risk Factor : Level of
competition
 There is general agreement that injury incidence
is greater during competition than in training
sessions
Extrinsic
All Risk
studies6-15 haveFactor
reported:an
Level of
association between
competition level competion and injury.
All studies6-15 have reported injury during game

compared with practice.
Extrinsic Risk Factor : Skill level
 Higher skill level groups may play at a more
aggressive intensity than lower skill levels
thereby increasing the risk of injury
 In addition, less skilled athletes may not compete
for as long as those in higher skill level groups.
Two studies16 17 have shown that athletes in low skill
level groups are at increased risk of suffering injury,
Extrinsic
and two18 19Risk Factor
reported :Skill in
that athletes level
high skill level
groups are at increased risk of suffering injury
Extrinsic Risk Factor : Playing surface
 Artificial turf has been implicated as an injury
risk factor
 Stiffness of a surface affects impact forces and
can result in overload to tissues such as bone,
cartilage, muscle, tendon, and ligament.
Two studies29 30 have reported that there is an increased
Extrinsic
incidence Risk on
of injury Factor : Playing
artificial surface
turf compared with grass
and gravel
CONCLUSIONS
 Many intrinsic and extrinsic risk factors have
been implicated for lower extremity injury
 No single risk factor alone causes lower extremity
injuries
 A key step in evidence-based injury prevention is
to identify possible risk factors for injury
 Understanding modifiable risk factors is
necessary for the design of effective & targeted
risk mitigation strategies
THANKYOU

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Risk factors for

dr. Zayadi Zainuddin, Sp.KFR

Increased injury has been reported with increased age

Age was not found to be an injury risk factor among

The relation between sex and other types of lower

Therefore, the relation between

Therefore, the relation between

Four studies22 38 68 73 have reported an association

Abnormal anatomical alignment that associated injury

Foot morphology that associated injury include high arch,

All studies6-15 have reported injury during game

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