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01-12-2014 | Review | Uitgave 1/2014 Open Access

Journal of Foot and Ankle Research 1/2014

Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis

Journal of Foot and Ankle Research > Uitgave 1/2014
Bradley S Neal, Ian B Griffiths, Geoffrey J Dowling, George S Murley, Shannon E Munteanu, Melinda M Franettovich Smith, Natalie J Collins, Christian J Barton
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Electronic supplementary material

The online version of this article (doi:10.​1186/​s13047-014-0055-4) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

GSM, MMFS, BSN, IBG, CJB, SEM and NJC conceived the idea for this review. GSM, MMFS, BSN, IBG designed and piloted the search strategy. GJD undertook the search. Title and abstracts were reviewed by BSN and IBG. Quality appraisal was undertaken by BSN and IBG. Study information extracted by BSN and IBG. Data was extracted and meta-analysis was completed by BSN and CB. The manuscript was drafted by BSN, IBG, CJB, GJD, GSM, MMFS, SEM and NJC. All authors have read and approved the final manuscript.



Static measures of foot posture are regularly used as part of a clinical examination to determine the need for foot level interventions. This is based on the premise that pronated and supinated foot postures may be risk factors for or associated with lower limb injury. This systematic review and meta-analysis investigates foot posture (measured statically) as a potential risk factor for lower limb overuse injuries.


A systematic search was performed using Medline, CINAHL, Embase, SportDiscus in April 2014, to identify prospective cohort studies that investigated foot posture and function as a risk factor for lower limb overuse injury. Eligible studies were classified based on the method of foot assessment: (i) static foot posture assessment; and/or (ii) dynamic foot function assessment. This review presents studies evaluating static foot posture. The methodological quality of included studies was evaluated by two independent reviewers, using an adapted version of the Epidemiological Appraisal Instrument (EAI). Where possible, effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data. Meta-analysis was performed where injuries and outcomes were considered homogenous.


Twenty-one studies were included (total n = 6,228; EAI 0.8 to 1.7 out of 2.0). There was strong evidence that a pronated foot posture was a risk factor for medial tibial stress syndrome (MTSS) development and very limited evidence that a pronated foot posture was a risk factor for patellofemoral pain development, although associated effect sizes were small (0.28 to 0.33). No relationship was identified between a pronated foot posture and any other evaluated pathology (i.e. foot/ankle injury, bone stress reactions and non-specific lower limb overuse injury).


This systematic review identified strong and very limited evidence of small effect that a pronated foot posture is a risk factor for MTSS and patellofemoral pain respectively. Evaluation of static foot posture should be included in a multifactorial assessment for both MTSS and patellofemoral pain, although only as a part of the potential injury risk profile. Whilst the included measures are clinically applicable, further studies are required to determine their relationship with dynamic foot function.

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Extra materiaal
Additional file 1: PRISMA statement checklist. (DOC 62 KB)
Additional file 2: Search strategy. (DOCX 23 KB)
Additional file 3: Epidemiological Appraisal Instrument used to rate the quality of the 21 included studies. (PDF 283 KB)
Additional file 4: Results from quality assessment using the Epidemiological Appraisal Instrument (21 included studies). (PDF 221 KB)
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