RUNNING: MAIN INJURIES

In recent years, running has increased its popularity in our society, breaking records of participation in various popular races. In each of our cities we can observe a large number of “runners” alone or in groups trying to improve their brands or simply enjoying the sport.

Most runners have suffered an injury throughout their lives, covering problems from the foot to the cervical level. In this article we will analyze the most common injuries in runners and how to prevent or treat them.

The body gives us warning signs, the following phrases will sound: "Uff, how loaded I am", "today it was difficult for me to get in bed", "I have noticed a pull on the leg"

Physiotherapy can help us not to say these phrases or, if it is too late, to prevent further injury. Listen to your body and consult your physiotherapist with any questions and do not hesitate to call us for any questions.

The most common injuries are: plantar fasciitis, iliotibial girdle, tibial periostitis, tedinopathies, sprains and muscle tears.

- Plantar fasciitis: the plantar fascia is defined as a fibrous and elastic tissue, which covers most of the sole of the foot, and that originates in the calcaneus bone (heel bone), until it is inserted into the base of the metatarsals (fingers) It is responsible for stabilizing and supporting the entire foot assembly; joints and plantar arch.

    There are several causes or risk factors for which it can occur are: the increase in physical or sports load, or sudden change in it; plantar arch alteration, whether increased or decreased (cavus or flatfoot); tension or retraction of the Achilles tendon; inappropriate footwear; Obesity or sudden weight gain.

- Iliotibial waist: it is an inflammation that occurs in the lateral or external area of ​​the knee, caused by the friction caused between the lateral condyle of the femur and the iliotibial waistband. It is usually a very typical pain in runners, due to bad biomechanics of the race when the muscles are fatigued. The main problem is the failure of the gluteus medius in monopodial support causing the knee to go further in each step and the friction described above occurs.

- Shin Splints: pain located along the two distal thirds of the posterior medial tibia during exercise, with pain in the palpation of the tibia. It is caused by overloading of the tibial bone cortex, resulting in an inflammation of the membrane that covers the bone.

       The risk factors by which it can occur are: increase in body mass; non-progressive increase in training; flat foot, a bad biomechanics of tread produces adaptations of other areas of the body and can affect the tibia; lack of range of motion in the ankle; lack of range of movement in the hip: the lack of strength in the gluteus medius triggers a valgus knee and, as a consequence, an incorrect tread; run on hard surfaces.

- Tendinopathies: Tendonitis is a very frequent pathology, which usually appears after excessive efforts, repetitive movements and direct trauma. It consists of the inflammation of the tendons, which are resistant strings of tissue that link the muscles with the bones and help the muscles move the bones.

Avoid repetitive movements and overload, keep the muscles strong and flexible, exercise the upper and lower extremities, without excessively repeating the same movement, alternating different types of movements, with small recovery intervals. Good hydration is also recommended, as it always helps to maintain a better vascularization of the area.

- Sprains: it is an elongation or rupture of the ligaments that slow the inversion of the foot. We must perform balance or proprioception exercises to improve the position of the ankle at the nervous system level and strengthen the muscles that are responsible for maintaining a correct positioning of the foot.

- Muscle tears: it is the separation or lack of congruence of muscle fibers. Whether you are a sports person or if you are more sedentary, a key aspect is to keep the body hydrated. If any sporting activity is carried out, it is essential to perform a good warm-up prior to it, because that way we can prepare the muscles for the activity, so that they can react quickly and correctly.

In addition, resting times are essential. If we do not rest properly between workouts we will have fatigued muscles, so that they will be unable to adapt effectively to the activity to which we are subjected. It is very important to let the muscle recover. In the case of runners, muscle overload can lead to muscle breakage due to changes in pace or high running intensities. That is why it is very important to treat the affected muscles to prevent it from going further. The body is warning us and we must listen.

BAREFOOT VS RUNNING SHOES: BIOMECHANICAL ANALYSIS

Barefoot running vs running shoes

Barefoot running has increased in popularity over recent years, risks and benefits have been widely speculated in current literature. However, there is insufficient evidence on potential advantages and disadvantages of barefoot running. The purpose of this article was to systematically review the recent literature about barefoot running to evaluate the biomechanical measurements and the influence of foot strike modalities compared to shod running.

Barefoot running is characterized by the absence of external protection and minimal cushioning against the ground, being its main difference with the cushioned race the part of the foot that first contacts the ground. Barefoot runners usually land with the front foot or forefoot before lowering the heel, but sometimes land with a flat foot or midfoot or, less frequently, with the heel or rearfoot. On the other hand, mostly shod runners, land with the rearfoot facilitated by the raised heel and the padding of modern footwear (1).

Differences in race conditions and foot strike can be related to possible spatio-temporal, kinematic and muscle activity changes between one group and another of runners.

Biomechanics Analysis

The knee must absorb less energy in barefoot running and, on the contrary, the ankle absorbs more energy in barefoot running midfoot and forefoot. The angles of the ankle when landing forefoot are plantar flexion compared to dorsiflexion in the rearfoot strike. The gastrocnemius suffer greater muscular activity in the forefoot and midfoot group, and the tibialis anterior is more active in the rearfoot group. In addition, the centre of mass is more advanced and the cadence increases in barefoot running.

 

Foot strike

Spatio-temporal Variables

In all the reviewed studies there is homogeneity regarding the effect on the speed variable, it was observed that both the footwear and the type of strike do not influence the running speed. However, the stride length was significantly shorter in barefoot running but it is compensated by an increase in the cadence, which results in a decrease in the support and oscillation phase. According to previous studies, it can be considered that the increase in cadence can be an effective strategy to reduce the loads to which the knee is subjected, and it could be useful in the modulation of biomechanical factors that can contribute to patellofemoral pain (2).

Speed - Cadence - Stride phases

The impact and load rate suffered by the body during the race must be distributed by the absorption mechanisms inherently possessed by the body against this potential damage, through active absorption (with joint alignment and muscular forces) or passive absorption (through of the heel pad, synovial fluid, bone and articular cartilage) (3). Studies show that during the road race the knee absorbed more energy than the ankle in all foot strike conditions. However, in barefoot running with support in midfoot and forefoot this absorption is reversed and the ankle becomes the joint that absorbs the most load, better for the knee that absorbs less energy. Since in barefoot running the force of impact and the load rate are lower compared to shod running and with forefoot strike is less than rearfoot, the knee is the most benefited in this condition and this type of foot strike.

The cushioning found in modern footwear is designed to attenuate and reduce the forces of impact, the shoe sole being an element that contributes to reduce pressure by using materials and concrete geometry depending on the pattern of the corridor (34). However, it has been observed that 85% of shod runners use a rearfoot strike, which may derive from the design of the footwear and, ultimately increase the mechanical load in the lower extremity as the rearfoot strike group which has the greatest impact (1, 4, 5).

In contrast, the tibial impact was greater in the barefoot forefoot strike, with high impact rates associated with the appearance of race associated injuries such as tibial stress fracture and tibial periostitis (6, 7), which is why It is necessary to delve into this topic, since only one study showed this information. Similarly, there are discrepancies in the literature because according to Williams et al. (8) the type of forefoot strike reduces the tibial impact in barefoot running, and according to Olin et al. (9) the tibial impact time was significantly shorter in this race modality. In addition, it has been observed that certain types of heel wedges can increase tibial stress (4).

The impulse and the plantar pressure peak are greater in the first and second metatarsals in the barefoot forefoot strike, may be associated with stress fractures when the transition from shod running is made quickly (10). Likewise, the current footwear has reinforcement in the midsole of this region to reduce the impact (4).

Foot strike impact

Cinematic Variables

The biomechanics of the lower limb can be influenced by the type of foot strike and by running conditions. There were significant differences in range of motion of the ankle and knee in both running conditions, but there was no homogeneity in the hip literature. The angles of the ankle at forefoot strike landing are plantar flexion compared to dorsiflexion in the rearfoot strike. In the forefoot strike, the foot lands first with a plantar flexion posture followed by a dorsiflexion movement that is controlled by the eccentric contraction of the leg muscles, serving as a buffer for the runners and this range of motion being greater in the condition barefoot. The angles of the knee when landing forefoot strike are greater in flexion in both barefoot and shod running, in addition the angle of knee more flexed in the initial contact provides a greater cushioning effect. All this is because if the ankle is in a greater plantar flexion in the initial contact, the knee will be more flexed to establish the hitting position closer to the centre of mass projection (8).

Range of motion barefoot landing phase

Muscle Activity

For the normally runners with shoes, the biggest challenge in the change to the forefoot strike may be the increasing activity of the gastrocnemius during the support phase. Based on electromyographic signals (9, 11, 12), the gastrocnemius show a significantly higher forefoot strike than rearfoot strike activity in preactivation and support phases. Considering the observed results, it is necessary to advise the runners to carry out an adequate training of the gastrocnemius to provide adequate cushioning. However, excessive training could cause a high load of this musculature increasing the risk of suffering injuries to the Achilles tendon (13).

Muscle activity

Injuries

The main question in the mind of runners, coaches and physiotherapists is whether the barefoot running has any effect on the ratio of injuries. The positive effects of the barefoot running have been widely speculated, but there is an ongoing debate about the advantages and potential dangers of the barefoot running and the adaptation of a barefoot running style. The interpretation of this type of studies comparing barefoot running with modern shoes is that the loads are lower in certain areas, but higher in others. For example, Shih et al. (11) showed that the load on the knee was lower running barefoot, but the load on the ankle was greater. While Thompson et al. (14) showed that the heel impact was reduced by running barefoot and Olin et al. (9) indicated that the tibial load was greater in the group of barefoot runners. This means that the load is transferred from one place to another, there being no systematic benefit of one over the other. This can have specific individual benefits, not extrapolated to everyone. A higher load on one type of tissue may increase the risk of injury in some individuals, but not in others.

Patients with knee pain would benefit more from one style than another due to the loads. If the shod runners manifest an increase in symptoms on or around the knee, you should consider changing your foot strike to a mid-forefoot pattern or even attempting the barefoot running. Conversely, barefoot running tends to increase the impact load around the lower leg and ankle, which increases the risk of injury in this anatomical region.

In this scenario, the runner should be advised to change to a rearfoot strike or even try different shoes. Finally, the transition to the barefoot running from the road must proceed with caution to avoid injury.

Knee injuries

Conclusion

The barefoot running can modify biomechanical parameters of the race compared to shod running; being the most remarkable: the cadence, the load rate, the absorption of energy, the ROM of the ankle in the support phase and the muscular activity of the gastrocnemius.Possibly, the most relevant factor in the biomechanical modifications that are observed in the barefoot running is the type of foot strike, which is normally done with forefoot.

Forefoot strike

Rearfoot strike

Bibliography 

1. Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D'Andrea S, Davis IS, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan 28;463(7280):531-5.

2. Lenhart RL, Thelen DG, Wille CM, Chumanov ES, Heiderscheit BC. Increasing running step rate reduces patellofemoral joint forces. Med Sci Sports Exerc. 2014 Mar;46(3):557-64.

3. Ly QH, Alaoui A, Erlicher S, Baly L. Towards a footwear design tool: influence of shoe midsole properties and ground stiffness on the impact force during running. J Biomech. 2010 Jan 19;43(2):310-7.

4. Fernández Villarejo M, Gijón Nogueron G. Factores del calzado deportivo de carrera que influyen en la práctica deportiva: revisión sistemática. Arch med deporte. 2014:105-10.

5. Lieberman DE, Castillo ER, Otarola-Castillo E, Sang MK, Sigei TK, Ojiambo R, et al. Variation in Foot Strike Patterns among Habitually Barefoot and Shod Runners in Kenya. PLoS One. 2015;10(7):e0131354.

6. Milgrom C, Finestone A, Segev S, Olin C, Arndt T, Ekenman I. Are overground or treadmill runners more likely to sustain tibial stress fracture? Br J Sports Med. 2003 Apr;37(2):160-3.

7. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance

8. Williams DS, 3rd, Green DH, Wurzinger B. Changes in lower extremity movement and power absorption during forefoot striking and barefoot running. Int J Sports Phys Ther. 2012 Oct;7(5):525-32.

9. Olin ED, Gutierrez GM. EMG and tibial shock upon the first attempt at barefoot running. Hum Mov Sci. 2013 Apr;32(2):343-52.

10. Murphy K, Curry EJ, Matzkin EG. Barefoot running: does it prevent injuries? Sports Med. 2013 Nov;43(11):1131-8.

11. Shih Y, Lin KL, Shiang TY. Is the foot striking pattern more important than barefoot or shod conditions in running? Gait Posture. 2013 Jul;38(3):490-4.

12. Sinclair J, Atkins S, Richards J, Vincent H. Modelling of Muscle Force Distributions During Barefoot and Shod Running. J Hum Kinet. 2015 Sep 29;47:9-17.

13. Lieberman DE. What we can learn about running from barefoot running: an evolutionary medical perspective. Exerc Sport Sci Rev. 2012 Apr;40(2):63-72.

14. Thompson MA, Lee SS, Seegmiller J, McGowan CP. Kinematic and kinetic comparison of barefoot and shod running in mid/forefoot and rearfoot strike runners. Gait Posture. 2015 May;41(4):957-9.

Barefoot vs running shoes Running shoes Barefoot running Running Shod running Biomechanics Foot wear Forefoot strike Midfoot strike Rearfoot strike Strike Cinematic Injuries Injury Muscle activity Spatio-temporal

WHAT I SHOULD PUT ON, HEAT OR COLD?

In the event of injury, is it better to apply cold or, on the contrary, what should we use is heat? It is one of the most asked questions in consultation, so we would like to resolve this question in a generalized way.

Image 1: heat or cold

As a general rule:

- If the injury occurs in the back or we are sure it is a muscle contracture, we will apply heat to the area.

- After physical exercise apply cold.

- In case of traumatic injuries such as blows, sprains or breaks, follow the following advice:

• Acute injuries: (less 3 days from the injury)

We will apply cold until 72 hours after traumatic injuries if we notice that we have red, bulging or reddened area. Maintain the application of cold 20 minutes being able to repeat the operation 3 and 5 times a day allowing at least 2 hours between each one.

• Subacute injuries: (between 3rd day and 1 month since the injury)

We will alternate cold and heat by direct application (bags or gels), containers with cold and hot water or in the shower. The application will be 3'calor + 2'frío + 3'calor + 2'frío + 3'calor. Being able to repeat the operation 3 and 5 times a day allowing at least 2 hours between each of them. Remember that if we do physical exercise and we notice swelling or redness we will apply cold immediately afterwards.

• Chronic injuries: (more than 1 month since the injury)

Apply heat for 20 minutes and can repeat the operation 3 and 5 times a day allowing at least 2 hours between each. Also, remember that if we do physical exercise and we notice swelling or redness we will apply cold immediately afterwards.

Image 2: cold contraindications

Cold contraindications:

- Raynaud's syndroms
- Heart problems
- Alterations of circulation
- Hypersensitivity or allergy to cold
- Acute inflammation of unknown origin or fever

Image 3: heat contraindications

Heat contraindications:

- Heart problems
- Alterations of sensitivity
- Wounds, ulcers, burns
- Fever
- Varicose veins
- Lymphedema
- Diabetes

sciatica pain relief hot or cold

BEFORE DOING PHYSICAL EXERCISE ... TO STRETCH OR NOT TO STRETCH? ... THAT IS THE QUESTION

The static stretching is held in a stretch of the muscle at rest until a certain position and maintaining the position for 15 - 30 seconds. It is commonly practiced by athletes as part of a routine prior to exercise and as part of a continuous exercise program.

Every weekend I can see that, before a race, a lot of athletes do this type of stretching, which makes me think if I should imitate them or not. With this article I want to scientifically verify if static stretches before physical exercise fulfill the benefits that most people believe they have:

· Improve flexibility,
· Improve physical performance and / or,
· Prevent injuries in the musculotendinous unit.

FLEXIBILITY

There is consistent evidence that static stretching increases flexibility in the short term, although gains in flexibility decrease relatively quickly, so that they are lost in 30 minutes 1-5. But there is also consistent evidence that stretches performed regularly over several weeks produce significant improvements in the range of motion ^6-11.

The mechanism of how this increase in range of motion occurs is subject to debate, which may be changes in neurophysiological factors (for example, changes in the tolerance to stretching) or mechanical factors (for example, viscoelastic changes).

Several studies have shown that static stretching does not change the mechanical properties of the musculotendinous unit ^10,12-18. This would suggest that the increase in range of motion is due to a greater tolerance to stretching, rather than to any mechanical alteration in the tissues.

In summary:
· Static stretching increases flexibility in both the short and long term.
· The mechanism through which static stretching achieves greater flexibility is still debatable. While a greater tolerance to stretching is likely and mechanical changes are very unlikely.

PHYSICAL PERFORMANCE

Effect on explosive strength, power and muscular performance.

Several recent reviews and meta-analyzes ^19-22 have agreed that, static stretching maintained for more than 45 seconds immediately before exercise:

· Influences negatively on maximum strength, power, explosive muscular performance (for example, jumping and running), balance and agility or,

· It has no effect on performance.

In other words, none of the reviews showed a beneficial effect of static stretching on explosive muscle performance.

Effect on endurance performance

The influence of stretching on activities such as running and cycling is less clear. A recent review 23 described how several studies ^24-27 show a negative influence, while others ^23,28-30 show no change in performance. Very few studies 60 report improvements in endurance performance after stretching.

In summary

· Stretching should be avoided for more than 45 seconds immediately prior to participation in activities where strength or power are important, since performance is likely to be reduced without any clear benefit to justify continued use.
· In endurance activities, stretching is difficult to justify immediately before participation, since performance can be reduced without clear benefits that justify continued use.

INJURY PREVENTION

It seems intuitively to make sense that stretching should help prevent injuries or help speed up the return to activity. However, the relationship between the reference flexibility and the future risk of injury is complex, and many studies ^31,32 show that there is no relationship between the two.

In fact, several systematic reviews have evaluated the effect of stretching on the risk of injury ^33-35, concluding that:

- "There is insufficient evidence to support or interrupt routine stretching before or after exercise to avoid injury among competitive or recreational athletes" ³³ and

- "In light of these findings, routine stretching exercises before the start of sports activities are not a proven and effective method to reduce injury rates" ³⁶.

In summary:

· Static stretching does not seem to reduce the risk of injury.

CLINICAL IMPLICATIONS

It is difficult to justify the use of stretching for any of the objectives examined in this article:

· Flexibility: stretching is very effective both in the short and long term. However, flexibility is not as important a factor in performance and injury prevention as was previously thought.

· Short term performance: stretching can decrease performance, especially when performed immediately before explosive activities.

· Injury prevention: there is very little evidence that stretching is effective.

Therefore, the only area in which static stretching seems to offer a specific advantage is in the one with the greatest flexibility. There may be times when the most important goal is to improve flexibility (for example, ballet) by being only in these isolated circumstances in which static stretching may be justifiable.

BIBLIOGRAPHY

1.            de Weijer VC, Gorniak GC, Shamus E. The effect of static stretch and warm-up exercise on hamstring length over the course of 24 hours. J Orthop Sports Phys Ther 2003; 33:727-733.

2.            DePino G, Webright W, Arnold B, Duration of maintained hamstring flexibility after cessation of an acute static stretching protocol. J Athl Train 2 2000; 35:56-59.

3.            Spernoga SG, Uhl TL, Arnold BL, Gansneder BM. Duration of maintained hamstring flexibility after a one-time, modified hold-relax stretching protocol. J Athl Train 2001; 36:44-48.

4.            Ford P, McChesney J. Duration of maintained hamstring ROM following termination of three stretching protocols. J Sport Rehabil 2007; 16:18-27.

5.            O'Sullivan K, Murray E, Sainsbury D. The effect of warm-up, static stretching and dynamic stretching on hamstring flexibility in previously injured subjects. BMC Musculoskelet Disord 2009; 10:37.

6.            Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Int2002; 7:1-13.

7.            Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med 2006; 40:870-875.

8.            Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther 1998; 27:295-300.

9.          Chan SP, Hong Y, Robinson PD. Flexibility and passive resistance of the hamstrings of young adults using two different static stretching protocols. Scand J Med Sci Sports 2001; 11:81-86.

10.          Reid DA, McNair PJ. Passive force, angle, and stiffness changes after stretching of hamstring muscles. Med Sci Sports Exerc 2004; 36:1944-1948.

11.          Decoster LC, Cleland J, Altieri C, Russell P. The effects of hamstring stretching on range of motion: a systematic literature review. J Orthop Sports Phys Ther 2005; 35:377-387.

12.          Halbertsma JP, Goeken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil 1994; 75:976-981.

13.          Klinge K, Magnusson SP, Simonsen EB, Aagaard P, Klausen K, Kjaer M. The effect of strength and flexibility training on skeletal muscle electromyographic activity, stiffness, and viscoelastic stress relaxation response. Am J Sports Med 1997; 25:710-716.

14.          Magnusson SP, Simonsen EB, Aagaard P, Boesen J, Johannsen F, Kjaer M. Determinants of musculoskeletal flexibility: viscoelastic properties, cross‐sectional area, EMG and stretch tolerance. Scand J Med Sci Sports 1997; 7:195-202.

15.          Gajdosik RL, Allred JD, Gabbert HL, Sonsteng BA. A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol 2007; 99:449-454.

16.          Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther 2010; 90:438-449.

17.          Konrad A, Gad M, Tilp M. Effect of PNF stretching training on the properties of human muscle and tendon structures. Scand J Med Sci Sports 2014.

18.          Ben M, Harvey L. Regular stretch does not increase muscle extensibility: a randomized controlled trial. Scand J Med Sci Sports 2010; 20:136-144.

19.          Behm D, Bambury A, Farrel C, Power K. Effect of acute static stretching on force, balance, reaction time, and movement time. Med Sci Sports Exerc 2004; 36:1397-1402.

20.          Kay AD, Blazevich AJ. Effect of acute static stretch on maximal muscle performance: a systematic review. Med Sci Sports Exerc 2012; 44:154-164.

21.          Simic L, Sarabon N, Markovic G. Does pre‐exercise static stretching inhibit maximal muscular performance? A meta‐analytical review. Scand J Med Sci Sports 2013; 23:131-148.

22.          Winchester JB, Nelson AG, Landin D, Young MA, Schexnayder IC. Static stretching impairs sprint performance in collegiate track and field athletes. J Strength Cond Res 2008; 22:13-18.

23.          Peck E, Chomko G, Gaz DV, Farrell AM. The effects of stretching on performance. Curr Sports Med Rep 2014; 13:179-185.

24.          Wilson JM, Hornbuckle LM, Kim JS, Ugrinowitsch C, Lee S-R, Zourdos MC, et al. Effects of static stretching on energy cost and running endurance performance. J Strength Cond Res 2010; 24:2274-2279.

25.          Lowery RP, Joy JM, Brown LE, Oliveira de Souza E, Wistocki DR, Davis GS, et al. Effects of static stretching on 1-mile uphill run performance. J Strength Cond Res 2014; 28:161-167.

26.          Wolfe AE, Brown LE, Coburn JW, Kersey RD, Bottaro M. Time course of the effects of static stretching on cycling economy. J Strength Cond Res 2011; 25:2980-2984.

27.          Esposito F, Cè E, Limonta E. Cycling efficiency and time to exhaustion are reduced after acute passive stretching administration. Scand J Med Sci Sports 2012; 22:737-745.

28.          Mojock CD, Kim JS, Eccles DW, Panton LB. The effects of static stretching on running economy and endurance performance in female distance runners during treadmill running. J Strength Cond Res 2011; 25:2170-2176.

29.          Hayes PR, Walker A. Pre-exercise stretching does not impact upon running economy. J Strength Cond Res 2007; 21:1227-1232.

30.          Allison SJ, Bailey DM, Folland JP. Prolonged static stretching does not influence running economy despite changes in neuromuscular function. J Sports Sci 2008; 26:1489-1495.

31.          Bennell K, Tully E, Harvey N. Does the toe-touch test predict hamstring injury in Australian Rules footballers? Aust J Physiother 1999; 45:103-109.

32.          Wang HK, Chen CH, Shiang TY, Jan MH, Lin KH. Risk-factor analysis of high school basketball–player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Arch Phys Med Rehabil 2006; 87:821-825.

33.          Thacker SB, Gilchrist J, Stroup DF, Kimsey CJ. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004; 36:371-378.

34.          Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ 2002; 325:468.

35.          Shrier I. Does stretching improve performance? A systematic and critical review of the literature. Clin J Sport Med 2004; 14:267-273.

36.          Schiff MA, Caine DJ, O'Halloran R. Injury prevention in sports. Am J Lifestyle Med 2010; 4:42-64.

stretch

stretch before or after exercise