How (not) to interpret a non-causal association in sports injury science

Objective: To discuss the interpretability of non-causal associations to sports injury development exemplified via the relationship between navicular drop (ND) and running-related injury (RRI) in novice runners using neutral shoes. Design: 1-year prospective cohort study. Setting: Denmark. Participants: 926 novice runners, representing 1852 feet, were included. Main outcome measure: The outcome was “a musculoskeletal complaint of the lower extremity or back caused by running, which restricted the amount of running for at least a week”. Results: Fewer feet with small ND than those feet with a reference ND sustained injuries at 50 (risk difference (RD) = −4.1% [95%CI = −7.9%;-0.4%]) and 100 km (RD = −5.3% [95%CI = −9.9%;-0.7%]). Similarly, fewer feet with a large ND sustained injuries than the feet with a reference drop at 250 (RD = −7.6% [95%CI = −14.9%;-0.3%]) and 500 km (RD = −9.8% [95%CI = −19.1%;-0.4%]). Conclusion: Non-causal associations can help to identify sub-groups of athletes at an increased or decreased risk of sports injury. Based on the current results, those with a small or large navicular drop sustain fewer injuries than those with a reference drop. Importantly, navicular drop does not cause RRIs, but influences the relationship between training load and RRI.