Minimalist/Barefoot Running

"Stop Controlling Motion"

Nicholas A. Campitelli, DPM,

FACFASfeet@me.com

Unity Health Network2660 Akron, OH 44333

330-926-3232

Consultant for Medline Foot & Ankle ReconstructionConsultant for Valeant Dermatology

"Self Proclaimed expert?"

-naysayers

1. Shoes2. Form / Biomechanics3. Injury

Shoes

"Shoes do no more for the foot than a hat does for the brain."—Dr. Mercer Rang, legendary orthopedic surgeon

and researcher in pediatric development

"I need a shoe with good support"- our society

1970'sNike Happened

"The Running Shoe Theory"

• Cushion• Support• Motion Control

Gallant JL, Pierrynowski MR. A theoretical perspective on running-related injuries. J Am Podiatr Med Assoc. 2014 Mar;104(2):211-20.

PCECH• P ronation• C ontrol• E levated• C ushioned• H eel

Gallant JL, Pierrynowski MR. A theoretical perspective on running-related injuries. J Am Podiatr Med Assoc. 2014 Mar;104(2):211-20.

Feet are weak• Protection• Cushioning • Support • Pronation Control

Robbins SE, Hanna AM. Running-related injury prevention through barefoot adaptations. Med Sci Sports Exerc. 1987 Apr;19(2):148-56.

The injuries are considered "pseudo-neuropathic" in nature.

1987

Evidence Based

Richards CE, Magin PJ, Callister R: Is your prescription of distance running shoes evidence-

based? Br J Sports Med 43: 159, 2009.

CONCLUSION: This prospective study demonstrated that

assigning shoes based on the shape of the plantar foot surface

had little influence on injuries even after considering other

injury risk factors.

Knapik JJ, Trone DW, Swedler DI, Villasenor A, Bullock SH, Schmied E,

Bockelman T, Han P, Jones BH. Injury reduction effectiveness of assigning running shoes based on plantar shape in Marine

Corps basic training. Am J Sports Med. 2010 Sep;38(9):1759-67.

722 Runners

Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb

soft-tissue running injuries. Cochrane Database Syst Rev. 2011 Jul6;(7)

Overall, the evidence base for the effectiveness of interventions to reduce soft-tissue injury after intensive running is very weak,

with few trials at low risk of bias. More well-designed and reported

RCTs are needed that test interventions in recreational and

competitive runners.

25 Trials 30,252 Runners

1: Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb

soft-tissue running injuries. Cochrane Database Syst Rev. 2011 Jul6;(7)

Found no evidence in military recruits that wearing running shoes based on foot shape,

rather than standard running shoes, significantly reduced rate of running injuries (2 trials; 5795

participants; Rate Ratio 1.03, 95% CI 0.93 to 1.14).

Shoe ParadigmOutdated?

5795 Runners

Cushion

Cushion300-500 miles?

1989

2013

Between 250 and 500 miles the shoes

retained less than 60% of their initial shock absorption capacity.

No differences in shock absorption characteristics were apparent based upon either shoe price or the

manufacturer model.

Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of runningshoes. Am J Sports Med. 1985 Jul-Aug;13(4):248-53.

“foot control seems to improve as cushioning is

lost and foot control accounts for at least half of

running shoe related injuries”

Hamill J, Bates BT. A kinetic evaluation of the effects of in vivo loading on running shoes. J Orthop Sports Phys Ther. 1988;10(2):47-53

As shoe cushioning capability decreases, runners modify their patterns to maintain

constant external loads. The adaptation strategies to shoe degradation were unaffected

by different cushioning technologies, suggesting

runners should choose shoes for reasons other than cushioning technology.

Kong PW, Candelaria NG, Smith DR. Running in new and worn shoes: a comparison of three types of cushioning footwear. Br J Sports Med. 2009 Oct;43(10):745-9.

As a result of perceived protection and comfort in running shoes, runners will not institute shock absorbing behaviors and will

become more susceptible to injury Robbins SE, Gouw GJ. Athletic footwear: unsafe due to perceptual illusions.Med Sci Sports Exerc. 1991 Feb;23(2):217-24.

Robbins SE, Gouw GJ. Athletic footwear and chronic overloading. A briefreview. Sports Med. 1990 Feb;9(2):76-85.

Robbins S, Waked E. Hazard of deceptive advertising of athletic footwear. Br JSports Med. 1997 Dec;31(4):299-303.

Trainers vs Flats?

Logan S, Hunter I, J Ty Hopkins JT, Feland JB, Parcell AC. Ground reaction force differences between running shoes, racing flats, and distance spikes in runners. J Sports Sci Med. 2010 Mar 1;9(1):147-53

“….recommendation that runners transition gradually”

Surfaces"Our feet weren't designed to run on

concrete"

Surfaces

Feehery FJ. The biomechanics of running on different surfaces. Clin Podiatr Med Surg 1986;3(4) 649-59.

Nigg B, Wakeling J. Impact forces and muscle tuning: a new paradigm. Exerc Sport Sci Rev 2001;29(1) 37-41.

Van Gent RN, Siem D, Van Middelkoop M et al. Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. BrJ Sports Med 2007;41(8):469-480.

The evidence that running on hard surfaces causes either an increase in impact forces or

an increase in injury rates is weak

1986

2001

2007

Surfaces

Nigg B, Wakeling J. Impact forces and muscle tuning: a new paradigm. Exerc Sport Sci Rev 2001;29(1):37-41.

The capacity of cushioning to reduce either impact forces or injury rates is also being called

into question.

Surfaces

Robbins S, Waked E. Foot position awareness: The effect of footwear on instability, excessive impact, and ankle spraining. Critical Reviews in Physical and RehabilitationMedicine. 1997;9(1):53-74.

Diminished proprioception has been identified as a significant side effect of

heavily cushioned shoes.

An asphalt running surface decreased mid-portion tendinopathy

risk (RR 0.47, p = 0.02). In contrast, sand increased the relative

risk for mid-portion Achilles tendinopathy tenfold (RR 10, CI 1.12

to 92.8, p = 0.01). Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int. 2008 Jul;29(7):671-6.

Biomechanics

“Generally abnormal pronation during static

stance does not produce major symptomatology.”

Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

“Even during locomotion, however, abnormal pronation

rarely produces symptomatology that is acute

enough to prevent weight bearing”

Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

What is pathologicFlat

Normal

High

Ankle EquinusA structural limitation of ankle joint dorsiflexion.

(Less then 10 degrees of DF)

Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

Subtalar Joint Neutral

Care should be taken not to plantarflex the foot. This will move the narrow end of the talus into the ankle joint mortise increase the range of motion of

the subtalar joint.

Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

Elevated Heel

Jarvinen T, Kannus P, Maffulli N et al. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin 2005;10(2):255-66.

“…since the introduction of the PECH design there has actually been an increase, not a decrease in Achilles tendon injuries.”

2005

Elevated Heel

Sekizawa K, Sandrey MA, Ingersoll CD et al. Effects of shoe sole thickness on joint position sense. Gait Posture 2001;13(3):221-228.

“…heel elevation during stance places the ankle joint in a position where proprioception is inherently poor.”

2001

Elevated Heel

Baycroft CM, Culp V. Running shoes - Design facts and functional fantasies. Chiropractic Sports Medicine 1993;7(1):6-8.

“The capacity of existing levels of heel elevation to increase pronation has also been noted.”

1993

Elevated Heel

Van Gent RN, Siem D, Van Middelkoop M et al. Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. BrJ Sports Med 2007;41(8):469-480.

“…the overall impact on injury rates of running in a shoe with an elevated heel remains untested in clinical trials.”

2007

Achilles Tendon

Wearing SC, Reed L, Hooper SL, Bartold S, Smeathers JE, Brauner T. Running

Shoes Increase Achilles Tendon Load in Walking: an Acoustic Propagation Study.

Med Sci Sports Exerc. 2014 Feb 4.

Peak acoustic velocity in the Achilles tendon was higher with footwear, suggesting that standard running shoes with a 10-mm heel offset increase tensile load in the Achilles tendon. Although further research is required, these findings question the therapeutic role of standard running shoes in Achilles tendinopathy.

2014

Wearing shoes inhibits normal foot joint ROM forefoot

to rear foot

Morio C, Lake MJ, Gueguen N, Rao G, Baly L. The influence of footwear on foot motion during walking and running. J Biomech. 2009 Sep 18;42(13):2081-8.

Wolf S, Simon J, Patikas D, Schuster W, Armbrust P, Döderlein L. Foot motionin children shoes: a comparison of barefoot walking with shod walking inconventional and flexible shoes. Gait Posture. 2008 Jan;27(1):51-9.

2008

2009

The barefoot has the ability to vary

gait and joint position thus reduce

repetitive forces seen in shod foot

that leads to overuse injuries.

Kurz MJ, Stergiou N, Blanke D. Spanning set defines variability in locomotive patterns. Med Biol Eng Comput. 2003 Mar;41(2):211-4. 2003

Soccer Game

7.0 - 9.5 Miles per game

Pronation Articles

Hreljac A, Marshall RN, Hume PA. Evaluation of lower extremity overuse injury potential in runners. Med Sci Sports Exerc. 2000 Sep;32(9):1635-41.

Hreljac A. Etiology, prevention, and early intervention of overuse injuries inrunners: a biomechanical perspective. Phys Med Rehabil Clin N Am. 2005Aug;16(3):651-67, vi. Review.

There has been no consistent association between subtalar motion and running related

injuries. Gallant JL, Pierrynowski MR. A theoretical perspective on running-relatedinjuries. J Am Podiatr Med Assoc. 2014 Mar;104(2):211-20.

2000

2005

Findings support the idea that the ML-GRF have less

to do with pronation than

previous research suggested.

Morley JB, Decker LM, Dierks T, Blanke D, French JA, Stergiou N. Effects ofvarying amounts of pronation on the mediolateral ground reaction forces duringbarefoot versus shod running. J Appl Biomech. 2010 May;26(2):205-14.

2010

Our study does not support the hypothesis that anterior knee

pain is related to excessive foot

pronation.

Hetsroni I, Finestone A, Milgrom C, Sira DB, Nyska M, Radeva-Petrova D, AyalonM. A prospective biomechanical study of the association between foot pronationand the incidence of anterior knee pain among military recruits. J Bone JointSurg Br. 2006 Jul;88(7):905-8.

405 Soldier61 (15%) keen pain

2006

Patellofemoral Pain

Kinetic analysis revealed several significant

discriminators whereas rearfoot movement

variables were not good discriminators between the

groups.Messier SP, Davis SE, Curl WW, Lowery RB, Pack RJ. Etiologic factorsassociated with patellofemoral pain in runners. Med Sci Sports Exerc. 1991Sep;23(9):1008-15. Erratum in: Med Sci Sports Exerc 1991 Nov;23(11):1233.

1991

We conclude that lower-extremity

alignment is not a major

risk factor for running injuries.

Wen DY, Puffer JC, Schmalzried TP. Lower extremity alignment and risk ofoveruse injuries in runners. Med Sci Sports Exerc. 1997 Oct;29(10):1291-8.

304 Runners Marathon training over 12 months

The results of the present study contradict the

widespread belief that moderate foot

pronation is associated with an increased risk of injury among novice

runners taking up running in a neutral

running shoe.

Nielsen RO, Buist I, Parner ET, Nohr EA, Sørensen H, Lind M, Rasmussen S. Footpronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014Mar;48(6):440-7.

927 runners

2014

Based on the review of

literature, there is no definitive link between atypical foot mechanics

and running injury mechanisms.

Ferber R, Hreljac A, Kendall KD. Suspected mechanisms in the cause of overuse running injuries: a clinical review. Sports Health. 2009 May;1(3):242-6. 2009

Pronation = Injury??

Strike Patterns

19 Subjects who ran 49 ft.

0.29% of 5k0.04% of a Marathon

Hatala KG, Dingwall HL, Wunderlich RE, Richmond BG. Variation in foot strike patterns during running among habitually barefoot populations. PLoS One. 2013;8(1):e52548. doi: 10.1371/journal.pone.0052548. Epub 2013 Jan 9.

This study did find that there was an increase in impact forces in those who were heel strikers compared to midfoot and forefoot striking

PLOS ONE Journal 72% were Heel strikers

Habitually barefoot population from northern Kenya that does not run very much, and which lives in a very sandy habitat.

1 2

Runners who habitually rearfoot

strike have significantly higher rates of repetitive stress injury than those who mostly

forefoot strike.

Daoud AI, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE. Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc. 2012 Jul;44(7):1325-34.

53 collegiate athletes

2012

Tarahumara population (35 individuals-46% more then

19) 70% of them were either forefoot or mid foot strikers. The remaining

30% that were heel striking were Tarahumaras who have adopted western

running shoes with cushioned, elevated heels,

stiff soles, and toe springs. Lieberman DE, Strike type variation among Tarahumara Indians in minimal sandals versus conventional running shoes, Journal of Sport and Health Science (2014), http://dx.doi.org/10.1016/j.jshs.2014.03.009

46%

1

Spring Theory

Girard O, Millet GP, Slawinski J, Racinais S, Micallef JP. Changes in running mechanics and spring-mass behaviour during a 5-km time trial. Int J Sports Med. 2013 Sep;34(9):832-40

Taylor MJ, Beneke R. Spring mass characteristics of the fastest men on Earth. Int J Sports Med. 2012 Aug;33(8):667-70. doi: 10.1055/s-0032-1306283. Epub 2012 Apr 17. Erratum in: Int J Sports Med. 2012 Aug;33(8):670.

Blickhan R. The spring-mass model for running and hopping. J Biomech. 1989;22(11-12):1217-27.

Injury

Injury Rates

NIELSEN RO, BUIST I, SORENSEN H, ET AL: Training errors and running related injuries: a systematic review. Int J Sports Phys

Ther 7: 58, 2012.

30-85% year85%

15%

Injury Rates

1980 1990 2000 20100

17.5

35

52.5

70

JENKINS DW, CAUTHON DJ: Barefoot running claims and controversies: a review of the literature. JAPMA 101: 231,

2011.

Stress Fractures

Giuliani J, Masini B, Alitz C, Owens BD. Barefoot-simulating footwearassociated with metatarsal stress injury in 2 runners. Orthopedics. 2011 Jul7;34(7):e320-3.

Plantar FasciitisIs it Inflammatory?

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process

(fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003May-Jun;93(3):234-7.

17 shod runnersConverted to

barefoot running Improved arch

 Robbins, S., Hanna, A.M. (1987). Running-related injury prevention through barefoot adaptations. Medicine and Science in Sports and Exercise. Vol

19, No 2, 148–156.

1987

These results suggest that endurance running in

minimal support footwear with 4 mm offset or less makes greater use of the spring-like function of the

longitudinal arch, thus leading to greater

demands on the intrinsic muscles that support the

arch, thereby strengthening the foot.

Elizabeth E. Miller, Katherine K. Whitcome, Daniel E. Lieberman, Heather L. Norton, Rachael E. Dyer, The effect of minimal shoes on arch structure and intrinsic foot muscle strength, Journal of Sport and Health Science, Volume 3, Issue 2, June 2014, Pages 74-85,

Summary

ShoesHow one runs is probably more important than what is on one’s feet, but what is on ones feet may effect

how one runs.

ACSM

Biomechanics

Injury

Thank you.