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Lower Limb Alignment and Running Injuries

10 Aug 2016
Randall Cooper
Running is a simple and inexpensive form of exercise enjoyed by millions of people all over the world. The health benefits of running are significant, however the prevalence of running related injuries is reasonably high. ‘Poor’ leg, knee, and foot alignment have long been associated with running related injuries, however there is mixed evidence on whether this is actually the case. A recent study has shed some further light on the issue, with some interesting results.

There are many factors that may contribute to a running related injury (RRI). A past history of a previous injury is significant risk factor (1), and a high Q-angle has also been associated with running injuries in a recent systematic review (2) – see Figure 1. Other lower limb alignment characteristics such as leg length, foot arch high, and subtalar (rear foot) angle may also contribute to running injuries.

Figure 1 – Q-angle (Image:

A study recently published in the European Journal of Sport Science (3) has added to the pool of evidence with some interesting results.

A group of 89 Brazilian recreational runners (average age 44 years, 35 km per week, 76% male) were recruited for a 12-week prospective study.

Runners were assessed at baseline for;

  • Baseline survey (demographics, previous injury, running experience, frequency, mileage, duration, velocity, & shoe type)
  • Leg length discrepancy (ASIS to medial malleolus)
  • Q-angle (goniometer)
  • Subtalar angle (Digital photo analyzed with AutoCAD software)
  • Plantar arch index (digital photo on a podoscope analyzed with AutoCAD software)

Runners also had to meet some inclusion criteria; including that they were over 18 years of age, had been running on a regular basis for at least 6 months prior to the study, and that they were free of any health conditions that precluded them from running – including any musculoskeletal injuries.

The runners were followed up six times over the 12-week study period. During the trial, runners ran on average 3 times per week with a median distance of 29 kms per week.

This study also demonstrated a high RRI incidence with 55% of participants having had a previous running related injury. During the 12-week trial, 27% of the runners sustained an RRI, with a little over ¼ of these ‘new’ injuries being recurrences of old injuries. Muscle injuries and tendinopathies were the main type of injuries observed.

The main aim of this study was to assess any relationship between lower limb alignment and RRI. No significant relationship was observed between an injury and any measure of ‘alignment’ – limb length, Q-angle, subtalar angle, or plantar arch index (foot position).

There are a couple of important things to note about this study. Firstly, the participants are ‘recreational’ runners, running only 30-35km per week, so the injury profile of this group may be different to marathoners or elite runners. Secondly, the study only recruited and assessed 89 people – not bad, but it may not have enough power and sensitivity to detect the relationship between some injuries and lower limb alignment.

What I like about this study is that it used common clinical measures to assess lower limb alignment. Many health practitioners use some of these static measures such as foot position, altered leg length, or a high Q-angle as a reason for a running related injury. The results of this study suggest that’s not the case in recreational runners.

If you'd like to listen to more information on running related injuries, I spoke with physiotherapist and running injury expert Dr Christian Barton live on our Facebook page.


1. Junior, Luiz Carlos Hespanhol, Leonardo Oliveira Pena Costa, and Alexandre Dias Lopes. "Previous injuries and some training characteristics predict running-related injuries in recreational runners: a prospective cohort study." Journal of physiotherapy 59.4 (2013): 263-269.

2. Saragiotto, Bruno Tirotti, et al. "What are the main risk factors for running-related injuries?." Sports medicine 44.8 (2014): 1153-1163.

3. Hespanhol Junior, Luiz Carlos, et al. "Lower limb alignment characteristics are not associated with running injuries in runners: Prospective cohort study." European Journal of Sport Science (2016): 1-8.

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