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An 8-week running training program modifies impact accelerations during running

Abstract
The deceleration of the body at each foot strike during running generates a shock wave that is transmitted from the foot to the head. An elevated magnitude of this wave, measured as impact accelerations, has been associated with increased risk of injury in athletes. Even though a number of training strategies such as real-time feedback have aimed to modify the athlete�s running technique and reduce their injury risk, the instructions given to these runners are vague and difficult to replicate by other runners. Therefore, the aim of this study was to analyse if an 8-week running program specifically focused on improving running technique influenced stride and impact accelerations during running. Twenty-nine recreational runners underwent a supervised program consisting of 3 sessions of 30 minutes per week during 8 weeks. In addition, before and after the running program, participants carried out a 20-min running test at 80% of their individual HRmax where stride and tibial and head impact acceleration parameters were collected. Although the program did not influence stride rate and stride length, a reduction of the tibial and head acceleration magnitudes (by 8% (p=0.023) and 42% (p<0.001), respectively) and acceleration rates (by 16% (p=0.019) and 44% (p<0.001), respectively) were observed after the running program. This study demonstrated that this type of training could not only be improving the athletes running technique, but also potentially reducing their injury risk as a consequence of the lower impact accelerations provoked by the resulting running technique.
Keywords: Tibial Shock, Accelerometry, Running Technique
Introduction
The popularity of running has increased during the last decades due to its numerous benefits for health  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1pb4qhpqhg","properties":{"formattedCitation":"[1]","plainCitation":"[1]"},"citationItems":[{"id":73,"uris":["http://zotero.org/users/local/0A26hjWq/items/FE5DTHJJ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/FE5DTHJJ"],"itemData":{"id":73,"type":"article-journal","title":"American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise","container-title":"Medicine and Science in Sports and Exercise","page":"1334-1359","volume":"43","issue":"7","source":"PubMed","abstract":"The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, \"The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults.\" The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for e"30 min�d on e"5 d�wk for a total of e"150 min�wk, vigorous-intensity cardiorespiratory exercise training for e"20 min�d on e"3 d�wk (e"75 min�wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of e"500-1000 MET�min�wk. On 2-3 d�wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on e"2 d�wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.","DOI":"10.1249/MSS.0b013e318213fefb","ISSN":"1530-0315","note":"PMID: 21694556","shortTitle":"American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Garber","given":"Carol Ewing"},{"family":"Blissmer","given":"Bryan"},{"family":"Deschenes","given":"Michael R."},{"family":"Franklin","given":"Barry A."},{"family":"Lamonte","given":"Michael J."},{"family":"Lee","given":"I.-Min"},{"family":"Nieman","given":"David C."},{"family":"Swain","given":"David P."},{"literal":"American College of Sports Medicine"}],"issued":{"date-parts":[["2011",7]]},"PMID":"21694556"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [1]. However, running yields a high injury incidence. It has been suggested that 19-79% of the runner population will get injured in a given year  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"21a9jvpptm","properties":{"formattedCitation":"[2]","plainCitation":"[2]"},"citationItems":[{"id":77,"uris":["http://zotero.org/users/local/0A26hjWq/items/6T27XMQW"],"uri":["http://zotero.org/users/local/0A26hjWq/items/6T27XMQW"],"itemData":{"id":77,"type":"article-journal","title":"Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review","container-title":"British Journal of Sports Medicine","page":"469-480","volume":"41","issue":"8","source":"bjsm.bmj.com","abstract":"The purpose of this study was to present a systematic overview of published reports on the incidence and associated potential risk factors of lower extremity running injuries in long distance runners. An electronic database search was conducted using the PubMed�Medline database. Two observers independently assessed the quality of the studies and a best evidence synthesis was used to summarise the results. The incidence of lower extremity running injuries ranged from 19.4% to 79.3%. The predominant site of these injuries was the knee. There was strong evidence that a long training distance per week in male runners and a history of previous injuries were risk factors for injuries, and that an increase in training distance per week was a protective factor for knee injuries.","DOI":"10.1136/bjsm.2006.033548","ISSN":", 14730480","note":"PMID: 17473005","shortTitle":"Incidence and determinants of lower extremity running injuries in long distance runners","journalAbbreviation":"Br J Sports Med","language":"en","author":[{"family":"Gent","given":"R. N.","dropping-particle":"van"},{"family":"Siem","given":"D."},{"family":"Middelkoop","given":"M.","dropping-particle":"van"},{"family":"Os","given":"A. G.","dropping-particle":"van"},{"family":"Bierma-Zeinstra","given":"S. M. A."},{"family":"Koes","given":"B. W."}],"issued":{"date-parts":[["2007",1,8]]},"PMID":"17473005"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [2]. Each time the athlete contacts the ground during running, the deceleration of the body produces a shock wave that is transmitted from the foot to the head  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"10mliufu61","properties":{"formattedCitation":"[3]","plainCitation":"[3]"},"citationItems":[{"id":38,"uris":["http://zotero.org/users/local/0A26hjWq/items/WHUF36UR"],"uri":["http://zotero.org/users/local/0A26hjWq/items/WHUF36UR"],"itemData":{"id":38,"type":"article-journal","title":"Spectral analysis of impact shock during running","container-title":"International Journal of Sport Biomechanics","page":"288-304","volume":"8","author":[{"family":"Shorten","given":"M.R."},{"family":"Winslow","given":"D.S."}],"issued":{"date-parts":[["1992"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [3]. This shock wave is dampened by the ground, the shoes, and passive (ligaments, articular cartilage, oscillations of soft tissue)  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a7ltfi367","properties":{"formattedCitation":"[4,5]","plainCitation":"[4,5]"},"citationItems":[{"id":50,"uris":["http://zotero.org/users/local/0A26hjWq/items/AJXDDQTP"],"uri":["http://zotero.org/users/local/0A26hjWq/items/AJXDDQTP"],"itemData":{"id":50,"type":"article-journal","title":"An in vitro simulation study of impulsive force transmission along the lower skeletal extremity","container-title":"Journal of Biomechanics","page":"979-987","volume":"19","issue":"12","source":"PubMed","abstract":"Several investigators have revealed that a relationship exists between articular cartilage deterioration and the mechanical stress that results from transient impulsive forces created in the lower extremity during gait. This study is an investigation of the transmission of impulse waves through the lower extremity and the effect of knee pathology and prosthetic knee replacement on their transmission. An in vitro experiment is performed using human cadaver specimens that are instrumented with accelerometers. The distal end of the tibia is impacted with a vibration shaker to simulate heel strike. The results indicate that the normal knee joint is able to attenuate 59% of the transient peak force applied to it by the tibia. This attenuation capacity is reduced by knee pathology and decreases further with implantation of a knee prosthesis. The results indicate that abnormalities at the knee may increase the risk of degenerative changes at the ankle, hip and in the spine due to increased transient impulsive forces.","ISSN":"0021-9290","note":"PMID: 3818676","journalAbbreviation":"J Biomech","language":"eng","author":[{"family":"Chu","given":"M. L."},{"family":"Yazdani-Ardakani","given":"S."},{"family":"Gradisar","given":"I. A."},{"family":"Askew","given":"M. J."}],"issued":{"date-parts":[["1986"]]},"PMID":"3818676"}},{"id":52,"uris":["http://zotero.org/users/local/0A26hjWq/items/W6VBM5JT"],"uri":["http://zotero.org/users/local/0A26hjWq/items/W6VBM5JT"],"itemData":{"id":52,"type":"article-journal","title":"Musculo-skeletal shock absorption: relative contribution of bone and soft tissues at various frequencies","container-title":"Journal of Biomechanics","page":"237-239","volume":"11","issue":"5","source":"PubMed","ISSN":"0021-9290","note":"PMID: 711772","shortTitle":"Musculo-skeletal shock absorption","journalAbbreviation":"J Biomech","language":"eng","author":[{"family":"Paul","given":"I. L."},{"family":"Munro","given":"M. B."},{"family":"Abernethy","given":"P. J."},{"family":"Simon","given":"S. R."},{"family":"Radin","given":"E. L."},{"family":"Rose","given":"R. M."}],"issued":{"date-parts":[["1978"]]},"PMID":"711772"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [4,5] and active (eccentric muscle contractions, alterations of segments geometry, joint stiffness)  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ua0emj8el","properties":{"formattedCitation":"[6,7]","plainCitation":"[6,7]"},"citationItems":[{"id":54,"uris":["http://zotero.org/users/local/0A26hjWq/items/WIKWBZAT"],"uri":["http://zotero.org/users/local/0A26hjWq/items/WIKWBZAT"],"itemData":{"id":54,"type":"article-journal","title":"The clinical biomechanics award paper 1995 Lower extremity joint loading during impact in running","container-title":"Clinical Biomechanics (Bristol, Avon)","page":"181-193","volume":"11","issue":"4","source":"PubMed","abstract":"OBJECTIVE: The main purpose of this study was to estimate lower extremity joint impact loading in running and the influences of muscles on this loading. DESIGN: A 2D simulation model that included skeletal motion, muscles, and soft-tissue movement was developed in this study. BACKGROUND: Our understanding of joint impact loading has been mainly based on measurable external loading variables. Furthermore, changes in muscular forces have often been neglected, assuming that muscular activation cannot react during the period of impact, which ignores passive muscle properties. METHODS: Kinematics and ground reaction forces were collected for each of five subjects performing heel-toe running. Kinematic and inverse dynamics analyses provided the initial conditions for the simulation models. The motion of each subject was simulated for 50 ms following heelstrike. RESULTS: Motion of body segments following heelstrike reduced the rate of joint impact loading, sometimes substantially, in comparison to the ground reaction force. In addition, substantial changes in muscular forces were sometimes observed that further reduced the rates of joint loading. CONCLUSIONS: The rates of joint impact loading are reduced in comparison to the ground reaction force during normal heel-toe running. Changes in muscular forces may have a relevant effect on joint impact loading and should not be neglected in future studies. RELEVANCE: Repetitive external impact loading has resulted in degeneration of articular cartilage in animal models. However, runners, as a group, do not have a high incidence of osteoarthritis. The present study suggests that there are mechanisms available to the runner that can substantially reduce the rate of joint impact loading relative to the rate of external loading. These mechanisms may be sufficient to prevent overloading and degeneration of the joints.","ISSN":"1879-1271","note":"PMID: 11415619","journalAbbreviation":"Clin Biomech (Bristol, Avon)","language":"ENG","author":[{"family":"Cole","given":"G. K."},{"family":"Nigg","given":"B. M."},{"family":"Den Bogert","given":"A. J.","non-dropping-particle":"van"},{"family":"Gerritsen","given":"K. G. M."}],"issued":{"date-parts":[["1996",6]]},"PMID":"11415619"}},{"id":19,"uris":["http://zotero.org/users/local/0A26hjWq/items/IX764CNB"],"uri":["http://zotero.org/users/local/0A26hjWq/items/IX764CNB"],"itemData":{"id":19,"type":"article-journal","title":"Energy absorption of impacts during running at various stride lengths","container-title":"Medicine and Science in Sports and Exercise","page":"128-135","volume":"30","issue":"1","source":"PubMed","abstract":"PURPOSE: The foot-ground impact experienced during running produces a shock wave that is transmitted through the human skeletal system. This shock wave is attenuated by deformation of the ground/shoe as well as deformation of biological tissues in the body. The goal of this study was to investigate the locus of energy absorption during the impact phase of the running cycle.\nMETHODS: Running speed (3.83 m x s[-1]) was kept constant across five stride length conditions: preferred stride length (PSL), +10% of PSL, -10% of PSL, +20% of PSL, and -20% of PSL. Transfer functions were generated from accelerometers attached to the leg and head of ten male runners. A rigid body model was used to estimate the net energy absorbed at the hip, knee, and ankle joints.\nRESULTS: There was an increasing degree of shock attenuation as stride length increased. The energy absorbed during the impact portion of the running cycle also increased with stride length. Muscles that cross the knee joint showed the greatest adjustment in response to increased shock.\nCONCLUSION: It was postulated that the increased perpendicular distance from the line of action of the resultant ground reaction force to the knee joint center played a role in this increased energy absorption.","ISSN":"0195-9131","note":"PMID: 9475654","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Derrick","given":"T. R."},{"family":"Hamill","given":"J."},{"family":"Caldwell","given":"G. E."}],"issued":{"date-parts":[["1998",1]]},"PMID":"9475654"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [6,7] mechanisms in order to maintain stable the shock wave arriving to the head and thus protect the vestibular and visual systems  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mfti658ur","properties":{"formattedCitation":"[7,8]","plainCitation":"[7,8]"},"citationItems":[{"id":19,"uris":["http://zotero.org/users/local/0A26hjWq/items/IX764CNB"],"uri":["http://zotero.org/users/local/0A26hjWq/items/IX764CNB"],"itemData":{"id":19,"type":"article-journal","title":"Energy absorption of impacts during running at various stride lengths","container-title":"Medicine and Science in Sports and Exercise","page":"128-135","volume":"30","issue":"1","source":"PubMed","abstract":"PURPOSE: The foot-ground impact experienced during running produces a shock wave that is transmitted through the human skeletal system. This shock wave is attenuated by deformation of the ground/shoe as well as deformation of biological tissues in the body. The goal of this study was to investigate the locus of energy absorption during the impact phase of the running cycle.\nMETHODS: Running speed (3.83 m x s[-1]) was kept constant across five stride length conditions: preferred stride length (PSL), +10% of PSL, -10% of PSL, +20% of PSL, and -20% of PSL. Transfer functions were generated from accelerometers attached to the leg and head of ten male runners. A rigid body model was used to estimate the net energy absorbed at the hip, knee, and ankle joints.\nRESULTS: There was an increasing degree of shock attenuation as stride length increased. The energy absorbed during the impact portion of the running cycle also increased with stride length. Muscles that cross the knee joint showed the greatest adjustment in response to increased shock.\nCONCLUSION: It was postulated that the increased perpendicular distance from the line of action of the resultant ground reaction force to the knee joint center played a role in this increased energy absorption.","ISSN":"0195-9131","note":"PMID: 9475654","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Derrick","given":"T. R."},{"family":"Hamill","given":"J."},{"family":"Caldwell","given":"G. E."}],"issued":{"date-parts":[["1998",1]]},"PMID":"9475654"}},{"id":56,"uris":["http://zotero.org/users/local/0A26hjWq/items/DUIWMEFX"],"uri":["http://zotero.org/users/local/0A26hjWq/items/DUIWMEFX"],"itemData":{"id":56,"type":"article-journal","title":"Differential shock transmission response of the human body to impact severity and lower limb posture","container-title":"Journal of Biomechanics","page":"1531-1537","volume":"29","issue":"12","source":"PubMed","abstract":"The shocks imparted to the foot during locomotion may lead to joint-degenerative diseases and jeopardize the visual-vestibular functions. The body relies upon several mechanisms and structures that have unique viscoelastic properties for shock attenuation. The purpose of the present study was to determine whether impact severity and initial knee angle (IKA) could alter the shock transmission characteristics of the body. Impacts were administered to the right foot of 38 subjects with a human pendulum device. Combinations of velocities (0.9, 1.05 and 1.2 m s-1) and surfaces (soft and hard foams) served to manipulate impact severity in the first experiment. Three IKA (0, 20 and 40 degrees) were examined in the second experiment. Transmission between shank and head was characterized by measuring the shock at these sites with miniature accelerometers. Velocity and surface had no effect on the frequency profile of shock transmission suggesting a consistent response of the body to impact severity. Shank shock power spectrum features accounted for the lower shock ratio (head/shank) measured under the hard surface condition. IKA flexion caused considerable reduction in effective axial stiffness of the body (EASB), 28.7-7.9 kNm-1, which improved shock attenuation. The high correlation (r = 0.97) between EASB and shock ratio underscored the importance of EASB to shock attenuation. The present findings provide valuable information for the development of strategies aimed at protecting the joints, articular cartilage, spine and head against locomotor shock.","ISSN":"0021-9290","note":"PMID: 8945651","journalAbbreviation":"J Biomech","language":"eng","author":[{"family":"Lafortune","given":"M. A."},{"family":"Lake","given":"M. J."},{"family":"Hennig","given":"E. M."}],"issued":{"date-parts":[["1996",12]]},"PMID":"8945651"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [7,8]. 
Although the human body is prepared to deal with these impacts and effectively reduce their magnitude during running, the ability of the musculoskeletal system to dampen this loading may decrease with fatigue, thereby increasing the vulnerability of ligaments and articular cartilage to excessive dynamic loading  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bv5rm5mjm","properties":{"formattedCitation":"[9]","plainCitation":"[9]"},"citationItems":[{"id":82,"uris":["http://zotero.org/users/local/0A26hjWq/items/4CW8G74M"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4CW8G74M"],"itemData":{"id":82,"type":"article-journal","title":"Generation and attenuation of transient impulsive forces beneath the foot: a review","container-title":"Gait & Posture","page":"264-275","volume":"10","issue":"3","source":"PubMed","abstract":"At the end of the swing phase of gait, the moving foot generates a transient force, due to the exchange of momentum as it contacts the ground. This review article examines the transient, which is known as the heelstrike in walking and the footstrike in running. The resulting 'shock wave', which passes up the limb, may produce damage, leading to degenerative joint disease and a variety of other pathologies. Protection against transient forces is provided by limb positioning at initial contact, by the anatomical heel pad, by materials used in shoe construction and by the use of viscoelastic shoe inserts.","ISSN":"0966-6362","note":"PMID: 10567759","shortTitle":"Generation and attenuation of transient impulsive forces beneath the foot","journalAbbreviation":"Gait Posture","language":"eng","author":[{"family":"Whittle","given":"M. W."}],"issued":{"date-parts":[["1999",12]]},"PMID":"10567759"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [9]. Taking into account that running 32 km per week will result in 1.3 million foot contacts over a period of one year  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"d1H5uPWN","properties":{"formattedCitation":"[10]","plainCitation":"[10]"},"citationItems":[{"id":65,"uris":["http://zotero.org/users/local/0A26hjWq/items/ECZWWVRA"],"uri":["http://zotero.org/users/local/0A26hjWq/items/ECZWWVRA"],"itemData":{"id":65,"type":"article-journal","title":"Impacts and kinematic adjustments during an exhaustive run","container-title":"Medicine and Science in Sports and Exercise","page":"998-1002","volume":"34","issue":"6","source":"PubMed","abstract":"PURPOSE: To examine the kinematic adjustments that runners make during an exhaustive run and to look at the effects these adjustments have on shock and shock attenuation.\nMETHODS: Ten recreational runners ran to volitional exhaustion on a treadmill at a velocity equal to their average 3200-m running velocity at maximal effort (average time: 15.7 +/- 1.7 min). Head and leg accelerometers, a knee electrogoniometer, and a rearfoot electrogoniometer were attached to each subject. The data were sampled at 1000 Hz at the start, middle, and end of the run.\nRESULTS: The knee became significantly more flexed at heel impact (start: 164.9 +/- 2.3 degrees; end: 160.5 +/- 2.9 degrees; P < 0.05). The rearfoot angle became more inverted at impact (start: 12.2 +/- 1.6 degrees; end: 13.6 +/- 1.9 degrees; P < 0.05). These kinematic changes resulted in a lower extremity that that had a lower effective mass during the impact. This decreased effective mass allowed the leg to accelerate more easily; thus, peak leg impact accelerations (start: 6.11 +/- 0.96 g; end: 7.38 +/- 1.05 g; P < 0.05) and impact attenuation (start: 74.5 +/- 5.4%; end: 77.5 +/- 4.1%; P < 0.05) increased during the progression of the run.\nCONCLUSIONS: The increase in peak impact accelerations at the leg was not considered an increased injury risk because of the decreased effective mass. The altered kinematics may have resulted in increased metabolic costs during the latter stages of the exhaustive run.","ISSN":"0195-9131","note":"PMID: 12048328","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Derrick","given":"Timothy R."},{"family":"Dereu","given":"Darrin"},{"family":"McLean","given":"Scott P."}],"issued":{"date-parts":[["2002",6]]},"PMID":"12048328"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [10], the repetitive and cumulative effect of these impacts could ultimately overload the musculoskeletal system and increase the risk of injury  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"219o7fhqm8","properties":{"formattedCitation":"[11]","plainCitation":"[11]"},"citationItems":[{"id":81,"uris":["http://zotero.org/users/local/0A26hjWq/items/6BJVV683"],"uri":["http://zotero.org/users/local/0A26hjWq/items/6BJVV683"],"itemData":{"id":81,"type":"book","title":"Modeling the foot-strike event in running fatigue via mechanical impedances","publisher":"INTECH Open Access Publisher","author":[{"family":"Mizrahi","given":"J."},{"family":"Daily","given":"D."}],"issued":{"date-parts":[["2012"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [11].
Analysing impact accelerations (such as tibial accelerations) provides a more accurate measurement of the loading effects of these impacts over a given musculoskeletal structure rather than measuring the summation of forces experienced by the entire body (e.g. ground reaction forces)  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dsu9c3g7h","properties":{"formattedCitation":"[3]","plainCitation":"[3]"},"citationItems":[{"id":38,"uris":["http://zotero.org/users/local/0A26hjWq/items/WHUF36UR"],"uri":["http://zotero.org/users/local/0A26hjWq/items/WHUF36UR"],"itemData":{"id":38,"type":"article-journal","title":"Spectral analysis of impact shock during running","container-title":"International Journal of Sport Biomechanics","page":"288-304","volume":"8","author":[{"family":"Shorten","given":"M.R."},{"family":"Winslow","given":"D.S."}],"issued":{"date-parts":[["1992"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [3]. Impact accelerations during running have become a very important variable due to its potential association with injury  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ak0rJLHz","properties":{"formattedCitation":"{\\rtf [12\\uc0\\u8211{}14]}","plainCitation":"[12�14]"},"citationItems":[{"id":46,"uris":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"itemData":{"id":46,"type":"article-journal","title":"Biomechanical factors associated with tibial stress fracture in female runners","container-title":"Medicine and Science in Sports and Exercise","page":"323-328","volume":"38","issue":"2","source":"PubMed","abstract":"PURPOSE: Tibial stress fractures (TSF) are among the most serious running injuries, typically requiring 6-8 wk for recovery. This cross-sectional study was conducted to determine whether differences in structure and running mechanics exist between trained distance runners with a history of prior TSF and those who have never sustained a fracture.\nMETHODS: Female runners with a rearfoot strike pattern, aged between 18 and 45 yr and running at least 32 km.wk(-1), were recruited for this study. Participants in the study were 20 subjects with a history of TSF and 20 age- and mileage-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected during overground running at 3.7 m.s(-1) using a six-camera motion capture system, force platform, and accelerometer. Variables of interest were vertical impact peak, instantaneous and average vertical loading rates, instantaneous and average loading rates during braking, knee flexion excursion, ankle and knee stiffness, and peak tibial shock. Tibial varum was measured in standing. Tibial area moment of inertia was calculated from tibial x-ray studies for a subset of runners.\nRESULTS: The TSF group had significantly greater instantaneous and average vertical loading rates and tibial shock than the control group. The magnitude of tibial shock predicted group membership successfully in 70% of cases.\nCONCLUSION: These data indicate that a history of TSF in runners is associated with increases in dynamic loading-related variables.","DOI":"10.1249/01.mss.0000183477.75808.92","ISSN":"0195-9131","note":"PMID: 16531902","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Milner","given":"Clare E."},{"family":"Ferber","given":"Reed"},{"family":"Pollard","given":"Christine D."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2006",2]]},"PMID":"16531902"}},{"id":58,"uris":["http://zotero.org/users/local/0A26hjWq/items/6MCHG4UG"],"uri":["http://zotero.org/users/local/0A26hjWq/items/6MCHG4UG"],"itemData":{"id":58,"type":"article-journal","title":"Relationship between lower limb dynamics and knee joint pain","container-title":"Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society","page":"398-405","volume":"9","issue":"3","source":"PubMed","abstract":"To test the hypothesis that appropriate and timely neuromuscular control of limb motions plays an important role in the preservation of joint health, we kinematically and kinetically examined the behavior of the legs of young adult subjects at heel strike during natural walking. We compared a group of 18 volunteers, who, we presumed, were preosteoarthrotic because of mild, intermittent, activity-related knee joint pain, with 14 age-matched asymptomatic normal subjects. The two groups of subjects exhibited similar gait patterns with equivalent cadences, walking speeds, terminal stance phase knee flexion, maximum (peak) swing angular velocity, and overall shape of the vertical ground reaction. However, our instrumentation detected statistically significant differences between the two groups within a few milliseconds of heel strike. In the knee pain group, the heel hit the floor with a stronger impact in this brief interval. Just before heel strike, there was a faster downward velocity of the ankle with a larger angular velocity of the shank. The follow-through of the leg immediately after heel strike was more violent with larger peak axial and angular accelerations of the leg echoed by a more rapid rise of the ground reaction force. This sequence of events represents repetitive impulsive loading, which consistently provoked osteoarthrosis in animal experiments. We refer to this micro-incoordination of neuromuscular control not visible to the naked eye as \"microklutziness.\"","DOI":"10.1002/jor.1100090312","ISSN":"0736-0266","note":"PMID: 2010844","journalAbbreviation":"J. Orthop. Res.","language":"eng","author":[{"family":"Radin","given":"E. L."},{"family":"Yang","given":"K. H."},{"family":"Riegger","given":"C."},{"family":"Kish","given":"V. L."},{"family":"O'Connor","given":"J. J."}],"issued":{"date-parts":[["1991",5]]},"PMID":"2010844"}},{"id":48,"uris":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"itemData":{"id":48,"type":"article-journal","title":"Side-to-side differences in overuse running injury susceptibility: a retrospective study","container-title":"Human Movement Science","page":"888-902","volume":"27","issue":"6","source":"PubMed","abstract":"Despite the number of studies examining factors associated with overuse running injury, little is known about why an individual gets injured on a particular side of the body. Abnormal levels of several strength, structural, kinetic, and kinematic factors have been attributed to injury susceptibility. However, while most studies have compared the injured limb of injured runners to an arbitrary limb of healthy controls, there is some evidence to suggest that injury risk is related to characteristics on both sides of a runner. Therefore, the purpose of this study was to investigate how bilateral characteristics of strength, structural, kinetic, and kinematic factors relate to overuse injury. The first purpose was to compare these factors between the injured and uninjured limbs of runners with a history of injury on only one side of their bodies. The results showed that hip internal rotation range of motion and peak tibial acceleration were both elevated on the side with a history of injury. The second purpose was to compare asymmetry levels between the injured runners and runners who had never sustained a running-related injury. Asymmetry levels were similar between groups for all variables, which suggests that some level of asymmetry is normal. The final purpose of the study was to compare bilateral values of these factors between the injured and uninjured runners. The results showed that hip internal rotation range of motion, as well as the deviation from normal arch height index, were bilaterally elevated in the injured runners. Although peak tibial acceleration was different between sides of the injured runners, it was not bilaterally elevated compared to the uninjured runners. These results support the notion that injury risk may be related to risk factors on both sides.","DOI":"10.1016/j.humov.2008.03.007","ISSN":"0167-9457","note":"PMID: 18639948","shortTitle":"Side-to-side differences in overuse running injury susceptibility","journalAbbreviation":"Hum Mov Sci","language":"eng","author":[{"family":"Zifchock","given":"Rebecca Avrin"},{"family":"Davis","given":"Irene"},{"family":"Higginson","given":"Jill"},{"family":"McCaw","given":"Steven"},{"family":"Royer","given":"Todd"}],"issued":{"date-parts":[["2008",12]]},"PMID":"18639948"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [12�14]. In this sense, previous studies observed that athletes with a history of tibial stress fractures showed greater tibial accelerations compared to uninjured athletes and highlighted the role that controlling and reducing impact accelerations play in the prevention of running-related injuries  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MgymIk2p","properties":{"formattedCitation":"[12,14]","plainCitation":"[12,14]"},"citationItems":[{"id":46,"uris":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"itemData":{"id":46,"type":"article-journal","title":"Biomechanical factors associated with tibial stress fracture in female runners","container-title":"Medicine and Science in Sports and Exercise","page":"323-328","volume":"38","issue":"2","source":"PubMed","abstract":"PURPOSE: Tibial stress fractures (TSF) are among the most serious running injuries, typically requiring 6-8 wk for recovery. This cross-sectional study was conducted to determine whether differences in structure and running mechanics exist between trained distance runners with a history of prior TSF and those who have never sustained a fracture.\nMETHODS: Female runners with a rearfoot strike pattern, aged between 18 and 45 yr and running at least 32 km.wk(-1), were recruited for this study. Participants in the study were 20 subjects with a history of TSF and 20 age- and mileage-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected during overground running at 3.7 m.s(-1) using a six-camera motion capture system, force platform, and accelerometer. Variables of interest were vertical impact peak, instantaneous and average vertical loading rates, instantaneous and average loading rates during braking, knee flexion excursion, ankle and knee stiffness, and peak tibial shock. Tibial varum was measured in standing. Tibial area moment of inertia was calculated from tibial x-ray studies for a subset of runners.\nRESULTS: The TSF group had significantly greater instantaneous and average vertical loading rates and tibial shock than the control group. The magnitude of tibial shock predicted group membership successfully in 70% of cases.\nCONCLUSION: These data indicate that a history of TSF in runners is associated with increases in dynamic loading-related variables.","DOI":"10.1249/01.mss.0000183477.75808.92","ISSN":"0195-9131","note":"PMID: 16531902","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Milner","given":"Clare E."},{"family":"Ferber","given":"Reed"},{"family":"Pollard","given":"Christine D."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2006",2]]},"PMID":"16531902"}},{"id":48,"uris":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"itemData":{"id":48,"type":"article-journal","title":"Side-to-side differences in overuse running injury susceptibility: a retrospective study","container-title":"Human Movement Science","page":"888-902","volume":"27","issue":"6","source":"PubMed","abstract":"Despite the number of studies examining factors associated with overuse running injury, little is known about why an individual gets injured on a particular side of the body. Abnormal levels of several strength, structural, kinetic, and kinematic factors have been attributed to injury susceptibility. However, while most studies have compared the injured limb of injured runners to an arbitrary limb of healthy controls, there is some evidence to suggest that injury risk is related to characteristics on both sides of a runner. Therefore, the purpose of this study was to investigate how bilateral characteristics of strength, structural, kinetic, and kinematic factors relate to overuse injury. The first purpose was to compare these factors between the injured and uninjured limbs of runners with a history of injury on only one side of their bodies. The results showed that hip internal rotation range of motion and peak tibial acceleration were both elevated on the side with a history of injury. The second purpose was to compare asymmetry levels between the injured runners and runners who had never sustained a running-related injury. Asymmetry levels were similar between groups for all variables, which suggests that some level of asymmetry is normal. The final purpose of the study was to compare bilateral values of these factors between the injured and uninjured runners. The results showed that hip internal rotation range of motion, as well as the deviation from normal arch height index, were bilaterally elevated in the injured runners. Although peak tibial acceleration was different between sides of the injured runners, it was not bilaterally elevated compared to the uninjured runners. These results support the notion that injury risk may be related to risk factors on both sides.","DOI":"10.1016/j.humov.2008.03.007","ISSN":"0167-9457","note":"PMID: 18639948","shortTitle":"Side-to-side differences in overuse running injury susceptibility","journalAbbreviation":"Hum Mov Sci","language":"eng","author":[{"family":"Zifchock","given":"Rebecca Avrin"},{"family":"Davis","given":"Irene"},{"family":"Higginson","given":"Jill"},{"family":"McCaw","given":"Steven"},{"family":"Royer","given":"Todd"}],"issued":{"date-parts":[["2008",12]]},"PMID":"18639948"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [12,14]. 
As a result, a number of interventions aiming to reduce these accelerations during running have been studied including the use of insoles  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ti6fc5h8m","properties":{"formattedCitation":"[15]","plainCitation":"[15]"},"citationItems":[{"id":84,"uris":["http://zotero.org/users/local/0A26hjWq/items/JZTVXMVX"],"uri":["http://zotero.org/users/local/0A26hjWq/items/JZTVXMVX"],"itemData":{"id":84,"type":"article-journal","title":"Effect of cushioned insoles on impact forces during running","container-title":"Journal of the American Podiatric Medical Association","page":"36-41","volume":"98","issue":"1","source":"PubMed","abstract":"BACKGROUND: The use of cushioned or shock-absorbing insoles has been suggested as a mechanism to reduce the impact forces associated with running, thereby protecting against overuse injuries. The purpose of this study was to determine whether the use of cushioned insoles reduced impact forces during running in healthy subjects.\nMETHODS: Sixteen recreational runners (9 females and 7 males) ran at a self-selected pace for five trials with and without the use of cushioned insoles. During each trial, ground reaction forces, tibial accelerations, lower-extremity kinematics, and subject-perceived comfort were recorded. All variables were tested with the level of statistical significance set at alpha = .05.\nRESULTS: The use of cushioned insoles resulted in significant reductions in mean vertical ground reaction force peak impact (6.8%) and ground reaction force loading rate (8.3%), as well as peak tibial acceleration (15.8%). Spectral analysis of the tibial acceleration data in the frequency range associated with impact accelerations (12-25 Hz) revealed no change in the predominant frequency or the power of the predominant frequency. The knee flexion angle at initial contact and perceived comfort were similar for the two conditions.\nCONCLUSIONS: This study demonstrates the effectiveness of one type of cushioned insole in reducing peak impact force and tibial acceleration at initial foot-ground contact during running. The impact reduction observed was independent of knee kinematic adjustments or changes in perceived comfort. Further study is required to determine whether the reduction in loading that accompanied the use of the cushioned insoles can affect the incidence of running-related injuries.","ISSN":"8750-7315","note":"PMID: 18202332","journalAbbreviation":"J Am Podiatr Med Assoc","language":"eng","author":[{"family":"O'Leary","given":"Katherine"},{"family":"Vorpahl","given":"Kristin Anderson"},{"family":"Heiderscheit","given":"Bryan"}],"issued":{"date-parts":[["2008",2]]},"PMID":"18202332"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [15], compressive garments  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1atmbccld1","properties":{"formattedCitation":"[16]","plainCitation":"[16]"},"citationItems":[{"id":3,"uris":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"uri":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"itemData":{"id":3,"type":"article-journal","title":"Effect of 3 Weeks Use of Compression Garments on Stride and Impact Shock during a Fatiguing Run","container-title":"International Journal of Sports Medicine","page":"826-831","volume":"36","issue":"10","source":"PubMed","abstract":"Excessive and prolonged exposure to impact acceleration during running is associated with increased injury rate. Acute use of compressive garments has been speculated to improve attenuation. However, it is unknown how longer interventions of compressive garments influence attenuation in running. 40 runners trained with compressive and placebo stockings for 3 weeks. Perception of comfort, stride parameters (rate, length) and impact acceleration (head and tibial peak acceleration, magnitude, acceleration rate and attenuation) were measured every 5	 min during a fatigue run (30	 min at 80% of the individual's maximal aerobic speed). Compressive stockings reduced tibial peak acceleration and magnitude compared to placebo stockings at every minute (p<0.05) except for the initial measurement (p>0.05). Moreover, compressive stockings led to a lower rate of increase in tibial peak acceleration (14%, p<0.005) and magnitude (16%, p<0.001) as a result of the development of fatigue compared to placebo stockings (24% and 26% increase, p=0.014 and p=0.003, respectively). Similar perception of comfort was reported for both garments. Training with compressive stockings for 3 weeks reduced impact acceleration and the rate of increase in acceleration compared to placebo stockings. These findings suggest that compressive stockings may play a protective role by reducing impact accelerations during running.","DOI":"10.1055/s-0035-1548813","ISSN":"1439-3964","note":"PMID: 26090880","journalAbbreviation":"Int J Sports Med","language":"eng","author":[{"family":"Lucas-Cuevas","given":"A. G."},{"family":"Priego-Quesada","given":"J. I."},{"family":"Aparicio","given":"I."},{"family":"Gim�nez","given":"J. V."},{"family":"Llana-Belloch","given":"S."},{"family":"P�rez-Soriano","given":"P."}],"issued":{"date-parts":[["2015",9]]},"PMID":"26090880"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [16], or gait retraining programs  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"27l15gt1bk","properties":{"formattedCitation":"[17]","plainCitation":"[17]"},"citationItems":[{"id":67,"uris":["http://zotero.org/users/local/0A26hjWq/items/BTP8ZQCZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/BTP8ZQCZ"],"itemData":{"id":67,"type":"article-journal","title":"Reducing impact loading during running with the use of real-time visual feedback","container-title":"The Journal of Orthopaedic and Sports Physical Therapy","page":"206-213","volume":"40","issue":"4","source":"PubMed","abstract":"STUDY DESIGN: Single-subject with repeated measures.\nOBJECTIVES: To determine if runners can use real-time visual feedback from an accelerometer to achieve immediate reductions in tibial acceleration and vertical-force loading rates.\nBACKGROUND: Stress fractures are a common injury among runners. Previous studies suggest that runners with higher than normal tibial acceleration and vertical-force loading rates are at increased risk for tibial stress fractures. If these runners can be trained to reduce the loading on their lower extremities, it may reduce their risk of stress fractures.\nMETHODS: Five subjects participated in this study. All subjects ran on a treadmill, instrumented with force transducers, during a single 30-minute session that was divided into warm-up, feedback, no-feedback, and cool-down periods. During running, the subjects also wore an accelerometer taped to their distal right tibia. Peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical-force loading rates were assessed at the end of the warm-up, feedback, and no-feedback periods.\nRESULTS: Single-subject analysis revealed that 4 of the 5 subjects had significant reductions in their peak positive acceleration at the end of the no-feedback period compared to the warm-up. In addition, all of the subjects had significant decreases in impact peak and vertical ground reaction force loading rates at the end of the no-feedback period.\nCONCLUSION: In a single session of training with real-time visual feedback, it appears that most runners can reduce the types of lower extremity loading associated with stress fractures. This may lead to training programs that reduce the risk of stress fractures for runners.","DOI":"10.2519/jospt.2010.3166","ISSN":"0190-6011","note":"PMID: 20357417","journalAbbreviation":"J Orthop Sports Phys Ther","language":"eng","author":[{"family":"Crowell","given":"Harrison Philip"},{"family":"Milner","given":"Clare E."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2010",4]]},"PMID":"20357417"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [17]. Of particular interest is the study by Crowell and Davis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1l916i0rmn","properties":{"formattedCitation":"[18]","plainCitation":"[18]"},"citationItems":[{"id":69,"uris":["http://zotero.org/users/local/0A26hjWq/items/I6K4VGMU"],"uri":["http://zotero.org/users/local/0A26hjWq/items/I6K4VGMU"],"itemData":{"id":69,"type":"article-journal","title":"Gait retraining to reduce lower extremity loading in runners","container-title":"Clinical Biomechanics (Bristol, Avon)","page":"78-83","volume":"26","issue":"1","source":"PubMed","abstract":"BACKGROUND: tibial stress fractures, which are among the most common running related injuries, have been associated with increased lower extremity loading (i.e., peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates) during initial contact. This study was conducted to evaluate the efficacy of a gait retraining program designed to reduce this loading during running and to assess the short-term persistence of these reductions.\nMETHODS: ten runners (six females and four males) with peak positive tibial acceleration greater than 8g, measured in an initial screening, participated in the retraining program. During the retraining sessions, subjects ran on a treadmill and received real-time visual feedback from an accelerometer attached to their distal tibias. Tibial acceleration and vertical ground reaction force data were collected from subjects during overground data collection sessions held pre-training, post-training, and at a 1-month follow-up.\nFINDINGS: peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates were all reduced immediately following the gait retraining. The decrease in tibial acceleration was nearly 50%. The reductions in vertical force loading rates and vertical force impact peak were approximately 30% and 20%, respectively. These reductions were maintained at the 1-month follow-up.\nINTERPRETATION: subjects were able to run with reduced tibial acceleration and vertical force loading immediately following completion of the gait retraining program and at the 1-month follow-up evaluation. This may reduce their risk of stress fractures.","DOI":"10.1016/j.clinbiomech.2010.09.003","ISSN":"1879-1271","note":"PMID: 20888675\nPMCID: PMC3014399","journalAbbreviation":"Clin Biomech (Bristol, Avon)","language":"eng","author":[{"family":"Crowell","given":"Harrison Philip"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2011",1]]},"PMID":"20888675","PMCID":"PMC3014399"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [18], who observed that a retraining program based on real-time visual feedback reduced tibial accelerations in ten runners both immediately after the 2-week program as well as after one month of the training intervention. However, the instructions given to participants in this study were to run softer, to make their footfall quieter, and to keep the acceleration peaks below the 50% of their initial peak acceleration values. 
Although successful, these instructions remain too vague and can be interpreted in a large number of ways by the athlete, thereby making it difficult for other athletes and coaches to replicate them when aiming to reduce impact accelerations. As a result, it would be of great interest to test whether a typical training program similar to those developed in recreational and competitive running clubs would benefit the athlete in a similar manner. Therefore, the aim of the present study was to analyse if an 8-week running training program based on a set of commonly used exercises focused on improving the running technique influences impact accelerations during running. Taking into account that runners were expected to improve their running technique throughout the program, we hypothesised that a reduction of the impact accelerations would be observed at the end of this training program.

Methods
Participants
Twenty-nine recreational runners (age 35.48 � 6.48 years, height 174.78 � 8.20 cm, body mass 72.36 � 8.24 kg, running training 27.8 � 5.8 km/week) agreed to participate and gave written informed consent. Inclusion criteria included no history of lower extremity injuries within the last year. The study procedures complied with the Declaration of Helsinki and were approved by the University ethics committee.

Study Protocol
Participants underwent a supervised 8-week training program consisting of three sessions/week with an average duration of thirty minutes per session. For each session, participants went to a running track where the same experienced running coach supervised the development of the session. The training program consisted of a battery of twenty exercises commonly used to improve running technique (Figure 1). Each exercise was performed twice for 30 seconds and a 30-second break was allowed between exercises. 
On the other hand, participants performed a running test on a treadmill (TechnogymSpA, Gambettola, Italy) before and after the 8 weeks of the training program. The running test consisted of a 10-min warm-up run at 65% HRmax followed by a 20-min run at 80% HRmax. Stride and impact acceleration parameters were collected for 15 seconds during the last minute of the 80% HRmax running test in order to allow participants to familiarise with the running environment as well as to measure the variables of interest under a certain level of fatigue, which is a situation commonly experienced during their habitual trainings and it is when most injuries occur  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2g7vqqnbeq","properties":{"formattedCitation":"[19]","plainCitation":"[19]"},"citationItems":[{"id":135,"uris":["http://zotero.org/users/local/0A26hjWq/items/4S4S5ZQZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4S4S5ZQZ"],"itemData":{"id":135,"type":"article-journal","title":"Impact and overuse injuries in runners","container-title":"Medicine and Science in Sports and Exercise","page":"845-849","volume":"36","issue":"5","source":"PubMed","abstract":"Forces that are repeatedly applied to the body could lead to positive remodeling of a structure if the forces fall below the tensile limit of the structure and if sufficient time is provided between force applications. On the other hand, an overuse injury could result if there is inadequate rest time between applied forces. Running is one of the most widespread activities during which overuse injuries of the lower extremity occur. The purpose of this article is to review the current state of knowledge related to overuse running injuries, with a particular emphasis on the effect of impact forces. Recent research has suggested that runners who exhibit relatively large and rapid impact forces while running are at an increased risk of developing an overuse injury of the lower extremity. Modifications in training programs could help an injured runner return to running with decreased rehabilitation time, but it would be preferable to be able to advise a runner regarding injury potential before undertaking a running program. One of the goals of future research should be to focus on the prevention or early intervention of running injuries. This goal could be accomplished if some easily administered tests could be found which would predict the level of risk that a runner may encounter at various levels of training intensity, duration, and frequency. The development of such a screening process may assist medical practitioners in identifying runners who are at a high risk of overuse injury.","ISSN":"0195-9131","note":"PMID: 15126720","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Hreljac","given":"Alan"}],"issued":{"date-parts":[["2004",5]]},"PMID":"15126720"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [19]. Ratings of perceived exertion  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1tso5brrj2","properties":{"formattedCitation":"[20]","plainCitation":"[20]"},"citationItems":[{"id":133,"uris":["http://zotero.org/users/local/0A26hjWq/items/VGEQT8K7"],"uri":["http://zotero.org/users/local/0A26hjWq/items/VGEQT8K7"],"itemData":{"id":133,"type":"article-journal","title":"Psychophysical bases of perceived exertion","container-title":"Medicine and Science in Sports and Exercise","page":"377-381","volume":"14","issue":"5","source":"PubMed","abstract":"There is a great demand for perceptual effort ratings in order to better understand man at work. Such ratings are important complements to behavioral and physiological measurements of physical performance and work capacity. This is true for both theoretical analysis and application in medicine, human factors, and sports. Perceptual estimates, obtained by psychophysical ratio-scaling methods, are valid when describing general perceptual variation, but category methods are more useful in several applied situations when differences between individuals are described. A presentation is made of ratio-scaling methods, category methods, especially the Borg Scale for ratings of perceived exertion, and a new method that combines the category method with ratio properties. Some of the advantages and disadvantages of the different methods are discussed in both theoretical-psychophysical and psychophysiological frames of reference.","ISSN":"0195-9131","note":"PMID: 7154893","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Borg","given":"G. A."}],"issued":{"date-parts":[["1982"]]},"PMID":"7154893"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [20] were also reported during the last minute of the test. 
Stride parameters and body accelerations were registered by two triaxials accelerometers (Sportmetrics, Spain; sampling frequency 500 Hz) firmly attached to the forehead and the anterodistal aspect of the tibia [21]. The vertical axis of the accelerometer was aligned to be parallel to the long axis of the shank. The acceleration signal was filtered (Butterworth, second-order, low-pass, cut-off frequency = 50 Hz) using Matlab (MathWorks, MA, USA) and the following variables were calculated  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"24ss80s8t0","properties":{"formattedCitation":"[16]","plainCitation":"[16]"},"citationItems":[{"id":3,"uris":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"uri":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"itemData":{"id":3,"type":"article-journal","title":"Effect of 3 Weeks Use of Compression Garments on Stride and Impact Shock during a Fatiguing Run","container-title":"International Journal of Sports Medicine","page":"826-831","volume":"36","issue":"10","source":"PubMed","abstract":"Excessive and prolonged exposure to impact acceleration during running is associated with increased injury rate. Acute use of compressive garments has been speculated to improve attenuation. However, it is unknown how longer interventions of compressive garments influence attenuation in running. 40 runners trained with compressive and placebo stockings for 3 weeks. Perception of comfort, stride parameters (rate, length) and impact acceleration (head and tibial peak acceleration, magnitude, acceleration rate and attenuation) were measured every 5	 min during a fatigue run (30	 min at 80% of the individual's maximal aerobic speed). Compressive stockings reduced tibial peak acceleration and magnitude compared to placebo stockings at every minute (p<0.05) except for the initial measurement (p>0.05). Moreover, compressive stockings led to a lower rate of increase in tibial peak acceleration (14%, p<0.005) and magnitude (16%, p<0.001) as a result of the development of fatigue compared to placebo stockings (24% and 26% increase, p=0.014 and p=0.003, respectively). Similar perception of comfort was reported for both garments. Training with compressive stockings for 3 weeks reduced impact acceleration and the rate of increase in acceleration compared to placebo stockings. These findings suggest that compressive stockings may play a protective role by reducing impact accelerations during running.","DOI":"10.1055/s-0035-1548813","ISSN":"1439-3964","note":"PMID: 26090880","journalAbbreviation":"Int J Sports Med","language":"eng","author":[{"family":"Lucas-Cuevas","given":"A. G."},{"family":"Priego-Quesada","given":"J. I."},{"family":"Aparicio","given":"I."},{"family":"Gim�nez","given":"J. V."},{"family":"Llana-Belloch","given":"S."},{"family":"P�rez-Soriano","given":"P."}],"issued":{"date-parts":[["2015",9]]},"PMID":"26090880"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [16]: stride rate, stride length, peak acceleration (maximum value of the acceleration signal), acceleration magnitude (difference between the negative and the positive acceleration peak), and acceleration rate (slope from ground contact to peak acceleration).
Figure 1. Description of the training program.

Statistical Analysis
Statistical analyses were performed using SPSS (SPSS Inc., Chicago, IL, USA). After checking the normality of the variables (Kolmogorov-Smirnov), Student t-tests with training as independent factor (pre-training vs post-training) and stride and impact acceleration parameters as dependent variables were performed. Effect sizes were assessed by means of the Cohen�s d  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1non3cc8vo","properties":{"formattedCitation":"[21]","plainCitation":"[21]"},"citationItems":[{"id":125,"uris":["http://zotero.org/users/local/0A26hjWq/items/GWRHW5SE"],"uri":["http://zotero.org/users/local/0A26hjWq/items/GWRHW5SE"],"itemData":{"id":125,"type":"book","title":"Statistical Power Analysis for the Behavioral Sciences","publisher":"Lawrence Erlbaum Associates","publisher-place":"Hillsdale, NJ.","number-of-pages":"594","edition":"2nd ed","source":"Google Books","event-place":"Hillsdale, NJ.","abstract":"This non-technical guide to power analysis in research planning provides users of applied statistics with the tools they need for more effective analysis. Expanded and updated, the book uses the same approach and organization as the previous edition, but includes a chapter covering power analysis in set correlation and multivariate methods, a chapter considering the effect size, psychometric reliability and the efficacy of qualifying dependent variables, and expanded power and sample size tables for multiple regression/correlation.","ISBN":"978-0-8058-0283-2","language":"en","author":[{"family":"Cohen","given":"J."}],"issued":{"date-parts":[["1988"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [22]. Results are presented as mean � standard deviations (SD).
 
Results
The average speed at which the running conditions were analysed (80% HRmax) was 2.75 � 0.48 m/s. Rating of perceived exertion was 12.17 � 1.01. No differences were observed in stride length (pre vs post: 2.07 � 0.33 vs 2.10 � 0.36 m/stride) and stride rate (pre vs post: 1.36 � 0.07 vs 1.34 � 0.08 stride/s) as a result of the training (p > 0.05). On the other hand, the training program reduced the tibial (p = 0.023, ES = 0.34) and head (p < 0.001, ES = 1.26) acceleration magnitude, as well as the tibial (p = 0.019, ES = 0.38) and head (p < 0.001, ES = 1.03) acceleration rate (Figure 2).

Figure 2. Mean (SD) of the impact acceleration parameters before (Pre) and after (Post) the 8-week running training program. * Significant difference (p < 0.05). ** Significant difference (p < 0.001).

Discussion
The present study analysed the influence of an 8-week supervised running program on stride and acceleration parameters during running. The main finding of this study was that participants reduced their tibial and head acceleration magnitudes and acceleration rates during running as a result of the training program. Therefore, this type of training could not only be improving the athletes running technique, but also potentially reducing their injury risk as a consequence of the lower impact accelerations provoked by the resulting running technique.
A number of strategies have been tested to positively influence running technique in order to reduce the injury risk of the runner. Among those, of particular relevance and effectiveness are the training programs based on real-time feedback  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sRImim5i","properties":{"formattedCitation":"[17,18,22,23]","plainCitation":"[17,18,22,23]"},"citationItems":[{"id":129,"uris":["http://zotero.org/users/local/0A26hjWq/items/NG47DW3K"],"uri":["http://zotero.org/users/local/0A26hjWq/items/NG47DW3K"],"itemData":{"id":129,"type":"article-journal","title":"Influence of tibial shock feedback training on impact loading and running economy","container-title":"Medicine and Science in Sports and Exercise","page":"973-981","volume":"46","issue":"5","source":"PubMed","abstract":"PURPOSE: The purpose of this study was to determine whether real-time feedback (RTF) training would reduce impact loading variables previously linked with tibial stress fracture risk and whether these adaptations would influence running economy.\nMETHODS: Twenty-two male runners were randomly assigned to RTF (n = 12) and control (n = 10) groups. The RTF group received feedback based on their peak tibial axial accelerations (PTA) during six 20-min treadmill runs for 3 wk, whereas the control group adhered to the same training but without feedback. Unilateral three-dimensional kinematic and kinetic analysis and running economy measurements were conducted before, after, and at 1 month posttraining.\nRESULTS: The RTF group had significant reductions (P < 0.01) in PTA and average and instantaneous vertical force loading rates after training as compared with no changes in the control group. These modifications in impact loads were only maintained in PTA 1 month after the training. A significant increase (P = 0.0033) in ankle plantarflexion at initial contact and a significant change (P = 0.030) in foot strike pattern from a rearfoot to midfoot strike pattern and a significant decrease (P = 0.008) in heel vertical velocity at initial contact appeared to be the primary mechanical strategies adopted by runners to reduce impact loading after RTF training. Despite these gait adaptations, running economy was unaffected.\nCONCLUSIONS: The results of this study suggest that gait retraining using RTF is an effective means of eliciting reductions in impact loading without negatively affecting running economy. However, with loading rate reductions not being maintained 1 month posttraining, further research is required to determine how these reductions in impact severity can be retained long term.","DOI":"10.1249/MSS.0000000000000182","ISSN":"1530-0315","note":"PMID: 24121245","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Clansey","given":"Adam Charles"},{"family":"Hanlon","given":"Michael"},{"family":"Wallace","given":"Eric S."},{"family":"Nevill","given":"Alan"},{"family":"Lake","given":"Mark J."}],"issued":{"date-parts":[["2014"]]},"PMID":"24121245"}},{"id":69,"uris":["http://zotero.org/users/local/0A26hjWq/items/I6K4VGMU"],"uri":["http://zotero.org/users/local/0A26hjWq/items/I6K4VGMU"],"itemData":{"id":69,"type":"article-journal","title":"Gait retraining to reduce lower extremity loading in runners","container-title":"Clinical Biomechanics (Bristol, Avon)","page":"78-83","volume":"26","issue":"1","source":"PubMed","abstract":"BACKGROUND: tibial stress fractures, which are among the most common running related injuries, have been associated with increased lower extremity loading (i.e., peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates) during initial contact. This study was conducted to evaluate the efficacy of a gait retraining program designed to reduce this loading during running and to assess the short-term persistence of these reductions.\nMETHODS: ten runners (six females and four males) with peak positive tibial acceleration greater than 8g, measured in an initial screening, participated in the retraining program. During the retraining sessions, subjects ran on a treadmill and received real-time visual feedback from an accelerometer attached to their distal tibias. Tibial acceleration and vertical ground reaction force data were collected from subjects during overground data collection sessions held pre-training, post-training, and at a 1-month follow-up.\nFINDINGS: peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates were all reduced immediately following the gait retraining. The decrease in tibial acceleration was nearly 50%. The reductions in vertical force loading rates and vertical force impact peak were approximately 30% and 20%, respectively. These reductions were maintained at the 1-month follow-up.\nINTERPRETATION: subjects were able to run with reduced tibial acceleration and vertical force loading immediately following completion of the gait retraining program and at the 1-month follow-up evaluation. This may reduce their risk of stress fractures.","DOI":"10.1016/j.clinbiomech.2010.09.003","ISSN":"1879-1271","note":"PMID: 20888675\nPMCID: PMC3014399","journalAbbreviation":"Clin Biomech (Bristol, Avon)","language":"eng","author":[{"family":"Crowell","given":"Harrison Philip"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2011",1]]},"PMID":"20888675","PMCID":"PMC3014399"}},{"id":67,"uris":["http://zotero.org/users/local/0A26hjWq/items/BTP8ZQCZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/BTP8ZQCZ"],"itemData":{"id":67,"type":"article-journal","title":"Reducing impact loading during running with the use of real-time visual feedback","container-title":"The Journal of Orthopaedic and Sports Physical Therapy","page":"206-213","volume":"40","issue":"4","source":"PubMed","abstract":"STUDY DESIGN: Single-subject with repeated measures.\nOBJECTIVES: To determine if runners can use real-time visual feedback from an accelerometer to achieve immediate reductions in tibial acceleration and vertical-force loading rates.\nBACKGROUND: Stress fractures are a common injury among runners. Previous studies suggest that runners with higher than normal tibial acceleration and vertical-force loading rates are at increased risk for tibial stress fractures. If these runners can be trained to reduce the loading on their lower extremities, it may reduce their risk of stress fractures.\nMETHODS: Five subjects participated in this study. All subjects ran on a treadmill, instrumented with force transducers, during a single 30-minute session that was divided into warm-up, feedback, no-feedback, and cool-down periods. During running, the subjects also wore an accelerometer taped to their distal right tibia. Peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical-force loading rates were assessed at the end of the warm-up, feedback, and no-feedback periods.\nRESULTS: Single-subject analysis revealed that 4 of the 5 subjects had significant reductions in their peak positive acceleration at the end of the no-feedback period compared to the warm-up. In addition, all of the subjects had significant decreases in impact peak and vertical ground reaction force loading rates at the end of the no-feedback period.\nCONCLUSION: In a single session of training with real-time visual feedback, it appears that most runners can reduce the types of lower extremity loading associated with stress fractures. This may lead to training programs that reduce the risk of stress fractures for runners.","DOI":"10.2519/jospt.2010.3166","ISSN":"0190-6011","note":"PMID: 20357417","journalAbbreviation":"J Orthop Sports Phys Ther","language":"eng","author":[{"family":"Crowell","given":"Harrison Philip"},{"family":"Milner","given":"Clare E."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2010",4]]},"PMID":"20357417"}},{"id":141,"uris":["http://zotero.org/users/local/0A26hjWq/items/3MD6HF8D"],"uri":["http://zotero.org/users/local/0A26hjWq/items/3MD6HF8D"],"itemData":{"id":141,"type":"article-journal","title":"Effects of three feedback conditions on aerobic swim speeds","container-title":"Journal of Sports Science & Medicine","page":"30-36","volume":"8","issue":"1","source":"PubMed Central","abstract":"The purpose of this study was twofold: (a) to develop an underwater chronometer capable to provide feedback while the athlete is swimming, as well as being a control tool for the coach, and (b) to analyse its feedback effect on swim pace control compared with feedback provided by the coach and with no feedback, in 25 m and 50 m swimming pools. 30 male swimmers of national level volunteer to participate. Each swimmer swam 3 x 200 m at aerobic speed (AS) and 3 x 200 m just under the anaerobic threshold speed (AnS), each swam repetition with a different feedback condition: chronometer, coach and without feedback. Results (a) validate the chronometer system developed and (b) show that swimmers pace control is affected by the type of feedback provided, the swim speed elected and the size of the swimming pool., \n          \n            \n              Key points\n            \n            \n              \n                Providing concurrent feedback to swimmers improves theis swimming pace control.\n              \n              \n                It is more important to provide feedback to control swim pace when the swimming pool is 50m long.\n              \n              \n                Technological development as this chronometer system, could offload coach work, so coach can focus its time and attention on other performance aspects or other swimmers.\n              \n              \n                Technological developments are more accepted by coaches when they don�t interfere on swimmers execution, that is, whet it is not necessary to implement the swimmer with cables and apparatus.","ISSN":"1303-2968","note":"PMID: 24150553\nPMCID: PMC3737802","journalAbbreviation":"J Sports Sci Med","author":[{"family":"P�rez","given":"Pedro"},{"family":"Llana","given":"Salvador"},{"family":"Brizuela","given":"Gabriel"},{"family":"Encarnaci�n","given":"Alberto"}],"issued":{"date-parts":[["2009",3,1]]},"PMID":"24150553","PMCID":"PMC3737802"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [17,18,23,24]. These studies demonstrated that 6-8 sessions of real-time feedback were able to reduce peak accelerations during running. However, contrary to those studies, peak impact accelerations were not modified in the current study. This could be explained by the fact that these studies measured participants with high initial tibial peak accelerations (greater than 8-9 G). Moreover, since the values of the tibia peak accelerations were used as the feedback parameter and the training was specifically focused on reducing this variable, participants were expected to change their running technique until these accelerations were reduced.
By training their running technique, participants in this study reduced their tibial and head acceleration magnitudes (by 8% and 42%, respectively) and acceleration rates (by 16% and 44%, respectively). The acceleration magnitude is calculated considering not only the positive peak but also the negative peak, thereby providing a measure of the difference in acceleration  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"14lj258ub9","properties":{"formattedCitation":"[16]","plainCitation":"[16]"},"citationItems":[{"id":3,"uris":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"uri":["http://zotero.org/users/local/0A26hjWq/items/2WFCZE6U"],"itemData":{"id":3,"type":"article-journal","title":"Effect of 3 Weeks Use of Compression Garments on Stride and Impact Shock during a Fatiguing Run","container-title":"International Journal of Sports Medicine","page":"826-831","volume":"36","issue":"10","source":"PubMed","abstract":"Excessive and prolonged exposure to impact acceleration during running is associated with increased injury rate. Acute use of compressive garments has been speculated to improve attenuation. However, it is unknown how longer interventions of compressive garments influence attenuation in running. 40 runners trained with compressive and placebo stockings for 3 weeks. Perception of comfort, stride parameters (rate, length) and impact acceleration (head and tibial peak acceleration, magnitude, acceleration rate and attenuation) were measured every 5	 min during a fatigue run (30	 min at 80% of the individual's maximal aerobic speed). Compressive stockings reduced tibial peak acceleration and magnitude compared to placebo stockings at every minute (p<0.05) except for the initial measurement (p>0.05). Moreover, compressive stockings led to a lower rate of increase in tibial peak acceleration (14%, p<0.005) and magnitude (16%, p<0.001) as a result of the development of fatigue compared to placebo stockings (24% and 26% increase, p=0.014 and p=0.003, respectively). Similar perception of comfort was reported for both garments. Training with compressive stockings for 3 weeks reduced impact acceleration and the rate of increase in acceleration compared to placebo stockings. These findings suggest that compressive stockings may play a protective role by reducing impact accelerations during running.","DOI":"10.1055/s-0035-1548813","ISSN":"1439-3964","note":"PMID: 26090880","journalAbbreviation":"Int J Sports Med","language":"eng","author":[{"family":"Lucas-Cuevas","given":"A. G."},{"family":"Priego-Quesada","given":"J. I."},{"family":"Aparicio","given":"I."},{"family":"Gim�nez","given":"J. V."},{"family":"Llana-Belloch","given":"S."},{"family":"P�rez-Soriano","given":"P."}],"issued":{"date-parts":[["2015",9]]},"PMID":"26090880"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [16]. On the other hand, the acceleration rate indicates how fast the acceleration rises to the peak acceleration and it is also considered a parameter to take into account when looking at injury risk in runners  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2ns0oeo2jt","properties":{"formattedCitation":"[12,24]","plainCitation":"[12,24]"},"citationItems":[{"id":46,"uris":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"itemData":{"id":46,"type":"article-journal","title":"Biomechanical factors associated with tibial stress fracture in female runners","container-title":"Medicine and Science in Sports and Exercise","page":"323-328","volume":"38","issue":"2","source":"PubMed","abstract":"PURPOSE: Tibial stress fractures (TSF) are among the most serious running injuries, typically requiring 6-8 wk for recovery. This cross-sectional study was conducted to determine whether differences in structure and running mechanics exist between trained distance runners with a history of prior TSF and those who have never sustained a fracture.\nMETHODS: Female runners with a rearfoot strike pattern, aged between 18 and 45 yr and running at least 32 km.wk(-1), were recruited for this study. Participants in the study were 20 subjects with a history of TSF and 20 age- and mileage-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected during overground running at 3.7 m.s(-1) using a six-camera motion capture system, force platform, and accelerometer. Variables of interest were vertical impact peak, instantaneous and average vertical loading rates, instantaneous and average loading rates during braking, knee flexion excursion, ankle and knee stiffness, and peak tibial shock. Tibial varum was measured in standing. Tibial area moment of inertia was calculated from tibial x-ray studies for a subset of runners.\nRESULTS: The TSF group had significantly greater instantaneous and average vertical loading rates and tibial shock than the control group. The magnitude of tibial shock predicted group membership successfully in 70% of cases.\nCONCLUSION: These data indicate that a history of TSF in runners is associated with increases in dynamic loading-related variables.","DOI":"10.1249/01.mss.0000183477.75808.92","ISSN":"0195-9131","note":"PMID: 16531902","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Milner","given":"Clare E."},{"family":"Ferber","given":"Reed"},{"family":"Pollard","given":"Christine D."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2006",2]]},"PMID":"16531902"}},{"id":131,"uris":["http://zotero.org/users/local/0A26hjWq/items/RXWE6ZQH"],"uri":["http://zotero.org/users/local/0A26hjWq/items/RXWE6ZQH"],"itemData":{"id":131,"type":"article-journal","title":"The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review","container-title":"Clinical Biomechanics (Bristol, Avon)","page":"23-28","volume":"26","issue":"1","source":"PubMed","abstract":"BACKGROUND: lower-limb stress fracture is one of the most common types of running injuries. There have been several studies focusing on the association between stress fractures and biomechanical factors. In the current study, the ground reaction force and loading rate are examined. There is disagreement in the literature about whether the history of stress fractures is associated with ground reaction forces (either higher or lower than control), or with loading rates.\nMETHODS: a systematic review of the literature was conducted on the relationship between the history of tibial and/or metatarsal stress fracture and the magnitude of the ground reaction force and loading rate. Fixed-effect meta-analysis techniques were applied to determine whether or not the ground reaction force and/or loading rate are different between the stress fracture and control groups.\nFINDINGS: thirteen articles were identified through a systematic search of the literature. About 54% of these articles reported significantly different vertical ground reaction force and/or loading rate between the stress fracture and control groups. Other studies (~46%) did not observe any significant difference between the two groups. Meta-analysis results showed no significant differences between the ground reaction force of the lower-limb stress fracture and control groups (P>0.05). However, significant differences were observed for the average and instantaneous vertical loading rates (P<0.05).\nINTERPRETATION: the currently available data does not support the hypothesis that there is a significant difference between the ground reaction force of subjects experiencing lower-limb stress fracture and control groups. Instead, the vertical loading rate was found to be significantly different between the two groups.","DOI":"10.1016/j.clinbiomech.2010.08.005","ISSN":"1879-1271","note":"PMID: 20846765","shortTitle":"The relationship between lower-extremity stress fractures and the ground reaction force","journalAbbreviation":"Clin Biomech (Bristol, Avon)","language":"eng","author":[{"family":"Zadpoor","given":"Amir Abbas"},{"family":"Nikooyan","given":"Ali Asadi"}],"issued":{"date-parts":[["2011",1]]},"PMID":"20846765"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [12,25]. In this sense, previous studies have suggested that rapidly applied loads could imply a higher stress to the musculoskeletal system than similar or even greater loads applied slowly  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cqiq8i2co","properties":{"formattedCitation":"[13]","plainCitation":"[13]"},"citationItems":[{"id":58,"uris":["http://zotero.org/users/local/0A26hjWq/items/6MCHG4UG"],"uri":["http://zotero.org/users/local/0A26hjWq/items/6MCHG4UG"],"itemData":{"id":58,"type":"article-journal","title":"Relationship between lower limb dynamics and knee joint pain","container-title":"Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society","page":"398-405","volume":"9","issue":"3","source":"PubMed","abstract":"To test the hypothesis that appropriate and timely neuromuscular control of limb motions plays an important role in the preservation of joint health, we kinematically and kinetically examined the behavior of the legs of young adult subjects at heel strike during natural walking. We compared a group of 18 volunteers, who, we presumed, were preosteoarthrotic because of mild, intermittent, activity-related knee joint pain, with 14 age-matched asymptomatic normal subjects. The two groups of subjects exhibited similar gait patterns with equivalent cadences, walking speeds, terminal stance phase knee flexion, maximum (peak) swing angular velocity, and overall shape of the vertical ground reaction. However, our instrumentation detected statistically significant differences between the two groups within a few milliseconds of heel strike. In the knee pain group, the heel hit the floor with a stronger impact in this brief interval. Just before heel strike, there was a faster downward velocity of the ankle with a larger angular velocity of the shank. The follow-through of the leg immediately after heel strike was more violent with larger peak axial and angular accelerations of the leg echoed by a more rapid rise of the ground reaction force. This sequence of events represents repetitive impulsive loading, which consistently provoked osteoarthrosis in animal experiments. We refer to this micro-incoordination of neuromuscular control not visible to the naked eye as \"microklutziness.\"","DOI":"10.1002/jor.1100090312","ISSN":"0736-0266","note":"PMID: 2010844","journalAbbreviation":"J. Orthop. Res.","language":"eng","author":[{"family":"Radin","given":"E. L."},{"family":"Yang","given":"K. H."},{"family":"Riegger","given":"C."},{"family":"Kish","given":"V. L."},{"family":"O'Connor","given":"J. J."}],"issued":{"date-parts":[["1991",5]]},"PMID":"2010844"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [13].
As a result, the lower tibial acceleration magnitude and rate observed after the training indicates not only a reduction of the absolute tibial acceleration load which could be reducing the athletes� injury risk  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"o3a8sbdmj","properties":{"formattedCitation":"[12,14]","plainCitation":"[12,14]"},"citationItems":[{"id":46,"uris":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"uri":["http://zotero.org/users/local/0A26hjWq/items/4U8ZEG4Q"],"itemData":{"id":46,"type":"article-journal","title":"Biomechanical factors associated with tibial stress fracture in female runners","container-title":"Medicine and Science in Sports and Exercise","page":"323-328","volume":"38","issue":"2","source":"PubMed","abstract":"PURPOSE: Tibial stress fractures (TSF) are among the most serious running injuries, typically requiring 6-8 wk for recovery. This cross-sectional study was conducted to determine whether differences in structure and running mechanics exist between trained distance runners with a history of prior TSF and those who have never sustained a fracture.\nMETHODS: Female runners with a rearfoot strike pattern, aged between 18 and 45 yr and running at least 32 km.wk(-1), were recruited for this study. Participants in the study were 20 subjects with a history of TSF and 20 age- and mileage-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected during overground running at 3.7 m.s(-1) using a six-camera motion capture system, force platform, and accelerometer. Variables of interest were vertical impact peak, instantaneous and average vertical loading rates, instantaneous and average loading rates during braking, knee flexion excursion, ankle and knee stiffness, and peak tibial shock. Tibial varum was measured in standing. Tibial area moment of inertia was calculated from tibial x-ray studies for a subset of runners.\nRESULTS: The TSF group had significantly greater instantaneous and average vertical loading rates and tibial shock than the control group. The magnitude of tibial shock predicted group membership successfully in 70% of cases.\nCONCLUSION: These data indicate that a history of TSF in runners is associated with increases in dynamic loading-related variables.","DOI":"10.1249/01.mss.0000183477.75808.92","ISSN":"0195-9131","note":"PMID: 16531902","journalAbbreviation":"Med Sci Sports Exerc","language":"eng","author":[{"family":"Milner","given":"Clare E."},{"family":"Ferber","given":"Reed"},{"family":"Pollard","given":"Christine D."},{"family":"Hamill","given":"Joseph"},{"family":"Davis","given":"Irene S."}],"issued":{"date-parts":[["2006",2]]},"PMID":"16531902"}},{"id":48,"uris":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"uri":["http://zotero.org/users/local/0A26hjWq/items/KFCV3PQZ"],"itemData":{"id":48,"type":"article-journal","title":"Side-to-side differences in overuse running injury susceptibility: a retrospective study","container-title":"Human Movement Science","page":"888-902","volume":"27","issue":"6","source":"PubMed","abstract":"Despite the number of studies examining factors associated with overuse running injury, little is known about why an individual gets injured on a particular side of the body. Abnormal levels of several strength, structural, kinetic, and kinematic factors have been attributed to injury susceptibility. However, while most studies have compared the injured limb of injured runners to an arbitrary limb of healthy controls, there is some evidence to suggest that injury risk is related to characteristics on both sides of a runner. Therefore, the purpose of this study was to investigate how bilateral characteristics of strength, structural, kinetic, and kinematic factors relate to overuse injury. The first purpose was to compare these factors between the injured and uninjured limbs of runners with a history of injury on only one side of their bodies. The results showed that hip internal rotation range of motion and peak tibial acceleration were both elevated on the side with a history of injury. The second purpose was to compare asymmetry levels between the injured runners and runners who had never sustained a running-related injury. Asymmetry levels were similar between groups for all variables, which suggests that some level of asymmetry is normal. The final purpose of the study was to compare bilateral values of these factors between the injured and uninjured runners. The results showed that hip internal rotation range of motion, as well as the deviation from normal arch height index, were bilaterally elevated in the injured runners. Although peak tibial acceleration was different between sides of the injured runners, it was not bilaterally elevated compared to the uninjured runners. These results support the notion that injury risk may be related to risk factors on both sides.","DOI":"10.1016/j.humov.2008.03.007","ISSN":"0167-9457","note":"PMID: 18639948","shortTitle":"Side-to-side differences in overuse running injury susceptibility","journalAbbreviation":"Hum Mov Sci","language":"eng","author":[{"family":"Zifchock","given":"Rebecca Avrin"},{"family":"Davis","given":"Irene"},{"family":"Higginson","given":"Jill"},{"family":"McCaw","given":"Steven"},{"family":"Royer","given":"Todd"}],"issued":{"date-parts":[["2008",12]]},"PMID":"18639948"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [12,14], but also a slower development of the acceleration load. Of special relevance is the reduction of the head accelerations. The body is constantly damping the accelerations arriving to the head in order to prevent the disruption of the vestibular and visual systems  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"me026fre","properties":{"formattedCitation":"[25,26]","plainCitation":"[25,26]"},"citationItems":[{"id":137,"uris":["http://zotero.org/users/local/0A26hjWq/items/WIS786QU"],"uri":["http://zotero.org/users/local/0A26hjWq/items/WIS786QU"],"itemData":{"id":137,"type":"article-journal","title":"Musculoskeletal attenuation of impact shock in response to knee angle manipulation","container-title":"Journal of Applied Biomechanics","page":"502-510","volume":"28","issue":"5","source":"PubMed","abstract":"Shock waves resulting from the foot-ground impact are attenuated by biological tissues within the body. It has been suggested that the primary site for shock attenuation is the knee joint. The purpose of this study was to determine if knee flexion affects the filtering characteristics of the musculoskeletal system in response to impacts. Impacts were delivered to 10 participants during inline skating on a treadmill at 2.0 m/s. Four knee angle conditions (0, 10, 20, and 30 degrees) were investigated using real-time visual feedback of motion capture data. Shock attenuation between the leg and head was determined using accelerometry. The cutoff frequency of the body was determined by progressive filtering of the leg acceleration until differences between head acceleration and filtered leg acceleration were minimized. A nonlinear increase in shock attenuation (p < .001) and a nonlinear decrease in the cutoff frequency of the body (p < .001) were observed as the knee became more flexed. These results suggest that the knee joint acts as a low-pass filter allowing greater shock attenuation with increased knee flexion. Flexing the knee may shift the shock-attenuating responsibilities away from passive biological tissue toward active muscular contraction.","ISSN":"1065-8483","note":"PMID: 22695111","journalAbbreviation":"J Appl Biomech","language":"eng","author":[{"family":"Edwards","given":"W. Brent"},{"family":"Derrick","given":"Timothy R."},{"family":"Hamill","given":"Joseph"}],"issued":{"date-parts":[["2012",11]]},"PMID":"22695111"}},{"id":139,"uris":["http://zotero.org/users/local/0A26hjWq/items/5NG2I7NA"],"uri":["http://zotero.org/users/local/0A26hjWq/items/5NG2I7NA"],"itemData":{"id":139,"type":"article-journal","title":"Head stabilization during various locomotor tasks in humans. II. Patients with bilateral peripheral vestibular deficits","container-title":"Experimental Brain Research","page":"208-217","volume":"85","issue":"1","source":"PubMed","abstract":"This experiment, which extends a previous investigation (Pozzo et al. 1990), was undertaken to examine how head position is controlled during natural locomotor tasks in both normal subjects (N) and patients with bilateral vestibular deficits (V). 10 normals and 7 patients were asked to perform 4 locomotor tasks: free walking (W), walking in place (WIP), running in place (R) and hopping (H). Head and body movements were recorded with a video system which allowed a computed 3 dimensional reconstruction of selected points in the sagittal plane. In order to determine the respective contribution of visual and vestibular cues in the control of head angular position, the 2 groups of subjects were tested in the light and in darkness. In darkness, the amplitude and velocity of head rotation decreased for N subjects; these parameters increased for V subjects, especially during R and H. In darkness, compared to the light condition, the mean position of a line placed on the Frankfort plane (about 20-30 degrees below the horizontal semi-circular canal plane) was tilted downward in all conditions of movement, except during H, for N subjects. In contrast, this flexion of the head was not systematic in V subjects: the Frankfort plane could be located above or below earth horizontal. In V subjects, head rotation was not found to be compensatory for head translation and the power spectrum analysis shows that head angular displacements in the sagittal plane contain mainly low frequencies (about 0.3-0.8 Hz). The respective contribution of visual and vestibular cues in the control of the orientation and the stabilization of the head in space is discussed.","ISSN":"0014-4819","note":"PMID: 1884759","journalAbbreviation":"Exp Brain Res","language":"eng","author":[{"family":"Pozzo","given":"T."},{"family":"Berthoz","given":"A."},{"family":"Lefort","given":"L."},{"family":"Vitte","given":"E."}],"issued":{"date-parts":[["1991"]]},"PMID":"1884759"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} [26,27]. In this study, the head acceleration parameters were significantly reduced after the training program, which could imply that runners may have improved their technique in a way that would allow for a better dampening of the impacts experienced during running. However, the clinical and performance implications of this finding remain unknown.
It is worth noting that the running tests in this study were carried out on a treadmill, which could be considered a limitation. However, a treadmill test was chosen in order to better control the running conditions of the study (speed, slope, properties of the running surface). For this reason, future studies should investigate the effects of running training programs during overground running. Moreover, no objective measure of improvement of running technique was taken in this study. As a result, it would be of great interest to further investigate the influence of this type of training programs on the running technique, as well as to determine if there are specific exercises within these training programs that could be playing a more effective role in the reduction of impact accelerations.

Conclusion
In conclusion, an 8-week training program focused on improving running technique in recreational runners reduced tibial and head acceleration magnitudes and acceleration rates. Taking into account that increased values of impact accelerations have been previously associated to a higher risk of injury, the findings of this study could imply that athletes engaging into running programs may benefit not only by improving their running technique, but also by potentially reducing the injury risk as a consequence of the lower impact accelerations provoked by the resulting running technique.

Conflict of interests: None.

References
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Crowell HP, Davis IS. Gait retraining to reduce lower eOPQZ	>	


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