Enhancing peroneal longus activity through gentle heel strike running: Biofeedback-guided gait modification to prevent lateral ankle sprains

Background: Lateral ankle sprains (LAS) are common among recreational runners, particularly those who run outdoors. These injuries can significantly affect performance and lead to a higher risk of recurrence. The peroneus longus (PL), which is the primary muscle responsible for ankle eversion, plays a crucial role in stabilizing the ankle and preventing LAS. Running gait modifications, such as the gentle heel strike (GHS) technique combined with biofeedback, may enhance PL activity and reduce the risk of LAS. This thesis investigates whether GHS running, guided by real-time visual biofeedback, can effectively change running biomechanics to improve PL activation and prevent LAS.

Methods: Gait modification programs were conducted to evaluate the immediate and training effects of GHS running on healthy recreational runners. In the first study, 20 participants received real-time visual biofeedback on their plantar pressure distribution while running on a force plate treadmill equipped with a VICON motion capture system and wireless electromyography (EMG) to monitor kinetic and kinematic changes. The second study examined the effects of an 8-session GHS gait retraining program on 14 participants, measuring biomechanical and neuromuscular changes over multiple time points.

Results: Immediate Effects: GHS significantly reduced heel impact forces and shifted plantar pressure distribution towards the forefoot, transitioning participants from a rearfoot strike to a midfoot or forefoot strike. Ankle kinematics showed greater plantar flexion at initial contact, and PL activity increased during the mid to late stance phase. Training Effects: After completing eight gait retraining sessions, participants adopt to mid-foot strike (Foot strike angle = 0.09 ±5.74) and exhibited a sustained reduction in loading rates, but did not improve peroneal activation.

Conclusion: GHS running, facilitated by visual biofeedback, effectively modifies running mechanics by reducing heel impact forces and promoting a midfoot strike. However, the anticipated increase in PL activation was not observed, indicating that GHS running alone may not fully enhance peroneal longus activity. Although the biomechanical adaptations observed could contribute to an overall reduction in injury risk, further research is necessary to determine whether other neuromuscular interventions or feedback strategies could more effectively target PL activation and improve ankle stability. Future studies should explore the integration of biofeedback with strength training or alternative gait modifications to optimize injury prevention strategies.

Implication: Further research is essential to fully understand the long-term effects of GHS running and biofeedback on the incidence of injuries. Wearable devices can be developed to simplify monitoring systems. This ongoing research shows promise for enhancing gait retraining and reducing running-related injuries.

Publications:

1. Shen W, Yifan, Y, Jose, F.B, Patrick C. Wheeler, and Daniel T.P. Fong. 2024. Enhancing Running Injury Prevention Strategies with Real-time Biofeedback: A Systematic Review and Meta-analysis. Journal of Sports Sciences

2. Shen, W, Hou, Zongchen, Wheeler, Patrick C., & Fong. Daniel T.P.. (2025). Minimizing Running Load via Gentle Heel Strike Techniques: A Gait Modification Study. Journal of Sport Rehabilitation. https://doi.org/10.1123/jsr.2024-0269.

3. Shen W, White,M, Fong,DTP. The Immediate Effect of a Gentle Heel Strike on Peroneal Muscle Pre-landing Activation During Prolonged Treadmill Running in Males. ISBS2022Vol. 40 (2022) > Iss. 1

Non-contained within this thesis

4. Hou Z, Shen W, Fong DTP, Winter SL. Anticipation of landing leg masks ankle inversion orientation deficits and peroneal insufficiency during jump landing in people with chronic ankle instability. Scand J Med Sci Sports. 2024 Feb;34(2):e14585. doi: 10.1111/sms.14585. PMID: 38356438.

Plangtaisong, Parichad, Wei Shen, Patrick C. Wheeler, and Daniel T.P. Fong. 2021. “Effect of Exercise Interventions and Prophylactic Devices on Reducing Peroneal Muscle Reaction Time by Sudden Ankle Perturbation: A Systematic Review and Meta-Analysis.” Medicine in Novel Technology and Devices. https://doi.org/10.1016/j.medntd.2021.100082.