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Foot Bone Marrow Edema after 10-week Transition to Minimalist Running Shoes

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Feb 27, 2013.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Foot Bone Marrow Edema after 10-week Transition to Minimalist Running Shoes.
    Ridge ST, Johnson AW, Mitchell UH, Hunter I, Robinson E, Rich BS, Brown SD.
    Med Sci Sports Exerc. 2013 Feb 22.
  2. Admin2

    Admin2 Administrator Staff Member

    Runners interested in transitioning to minimalist running shoes, such as Vibram FiveFingers should transition very slowly and gradually in order to avoid potential stress injury in the foot."

    How gradually and how slowly? How do we know (from the above study) that transitioning any more slowly than over a 10 week period should result in any different outcomes? Viz. How can they draw that conclusion from that study? Rather, the conclusion should read something along the lines of: "transitioning to minimalist running shoes over a ten week period results in an increased risk of bone marrow oedema compared to running in traditional running shoes". How many in the traditional group developed bone marrow oedema?
  4. Craig Payne

    Craig Payne Moderator

    Agreed; its a very odd conclusion they made. Even though the conclusion is probably a correct statement, I do not see how it is supported by the research that they actually did.
  5. Hold your horses there Craig, how is it "probably a correct statement"?
  6. Craig Payne

    Craig Payne Moderator

    Its make intuitive sense that you should transition slowly.
  7. Does it? If we believe that the stress reaction occurs in response to excessive stress within the bone, then with graded loading one might expect an increase in bone strength over time. However, there will always be a threshold level of stress that each specific bone is able cope with, without filling with oedema or fracturing. If this loading level is exceeded the bone will always enter the "stressed state". Despite a graded introduction of loading, there will always be an upper stress limit each bone can attain. How do we know that shoes such as Vibrams will not cause the loading on specific foot bones to be in excess of the upper stress limit in a statistically significant majority, regardless of the transitional period? We don't even have any normative data: what would be the level of bone marrow oedema in habitually barefoot runners such as those recruited for the Lieberman study? Which begs the question, how many of those in the study who developed bone oedema displayed any clinical symptoms? Does bone oedema always lead to pathology or is it just part of the bone adaptation process?
  8. I agree with Craig. Generally bone edema is considered to be indicative of microscopic damage to the bone and is also apparent in stress reactions in bones (metatarsals and tibias are most commonly seen sites in athletes) and also commonly correlates to symptoms. MRIs are also now being used as a way to detect bone stress (bone edema) patterns in college level and professional athletes even before symptoms occur.

    Therefore, I see nothing wrong with the authors' conclusion: "Runners interested in transitioning to minimalist running shoes, such as Vibram FiveFingers should transition very slowly and gradually in order to avoid potential stress injury in the foot." Seems like a common sense recommendation, not only from a clinical aspect, but also from the results of the study.
  9. So where is the evidence that transitioning more slowly results in any less bone oedema? How many weeks would you recommend, Dr Kirby?
  10. Interesting point Simon 're bone edema in traditional shoes, until that is know the results of the study have limited meaning.
  11. For those of you who want to familiarize yourselves with the progress being made in understanding the significance of bone marrow edema on MRI in athletes, and nonathletes.



  12. Yep, but with all due respect that doesn't answer the questions, Kevin. To reiterate: how can the above study conclude that: "Runners interested in transitioning to minimalist running shoes, such as Vibram FiveFingers should transition very slowly and gradually in order to avoid potential stress injury in the foot." When they have not looked at transitioning for any longer than 10 weeks? Is there any evidence which you know of which suggests that transitioning over a longer period might result in a lower incidence of bone marrow oedema?

    You stated that this: "Seems like a common sense recommendation, not only from a clinical aspect, but also from the results of the study." Ignoring the fact that the results of the study do not show this, I guess you believe that transitioning over a longer period should result in a lower incidence of bone marrow oedema and potential for clinical symptoms. Can you explain your rationale for that, and provide an indication of the time period which should be allowed for transitioning, please?
  13. Paul Bowles

    Paul Bowles Well-Known Member

  14. Be interesting to know how much bone edema was found in x runners who changed nothing but strike position.

    Ie heel strikers becoming forefoot strikers.

    My intuitive guess there would be significant edema after 10 weeks
  15. As Paul suggested in regards the Wikipedia reference to Wolff's Law, I would think that it is common knowledge within the podiatric and orthopedic medical professions that bone placed under stress will strengthen over time with repetitive stresses, so long as the repetive stresses are not of such high magnitudes and/or occurring over too short of a duration of time to lead to bone injury. This is a function of magnitude of stress, repetition frequency of the stress and the duration of the applied stresses to the bone. The old adage for running injuries being basically a function of "too much, too fast, too soon" is a corollary of Wolff's Law.

    At the microscopic level, increased stress to the bone will initially increase osteoclastic activity that will iniitially weaken the bone, but then, over time, osteoblastic activity will increase which will, in turn, increase the strength of the bone versus before the bone stress episode(s) occurred. Since these bone adaptive processes are time dependent, then running too much, too fast and in too short of a period of time will increase the risk of bone and soft tissue injury.

    Personally, I don't see how these authors are making a leap of faith in suggesting that the increase in bone edema (i.e probable microfractures) seen in runners trying to transition to minimalist shoes could be lessened by a more gradual and prolonged transition into the changes in bone stress patterns that would occur in running in minimalist running shoes.

    Stress Fractures: Current Concepts

    Mechanical Strain and Bone Cell Function: A Review
  16. But it is a leap of faith because it is an extrapolation beyond their study data set. It is certainly not what their study demonstrated, so why was it their conclusion? It's a hypothesis generated by the study, but it should not have been their conclusion. To the best of my knowledge, no-one has performed a similar study with transitioning over a longer period, so we can guess but we just don't know. What if running in Vibrams exceeds the threshold stress for bone marrow oedema in a statistically significant proportion of runners irrespective of transitional period? How do we know that this is not the case based on the results of this study?
  17. Craig Payne

    Craig Payne Moderator

  18. Craig Payne

    Craig Payne Moderator

    Last edited by a moderator: Sep 22, 2016
  19. Dana Roueche

    Dana Roueche Well-Known Member

    Even a lay person can see how flawed this study is, but whatever.

    I limited my use of VFF to walking for the first two months of transitioning. I then limited their use to running in them one day per week for several months. After that I very gradually added a day per week when it was comfortable to do so and when I felt like wearing VFF to run in. It took me over 2 years to fully transition from traditional running shoes to running in VFF full time. I still wear traditional running shoes but only once or twice per month and most of my walking is done in traditional running shoes. During the transition I found no need to rush, what would be the point? I just used the running shoes I have been wearing all along. For that matter, I really didn't plan on fully transitioning to VFF at the start. I just discovered that the more I wore them, the more I wanted to wear them. The transition happened simply out of desire to wear the shoe that provided the best running experience. In the future, I will also be guided to wear the shoe that I enjoy running in the most. I could care less what the current trend is or what the "experts" think.

    10 weeks is WAY to fast for the body to accommodate a change as big as going from traditional shoes to something like VFF. I don't see the findings as surprising at all. It also seems that they let the subjects interpret and apply the transition on their own instead of by a prescribed succession of steps. How can you have a controlled study when it is left up to the interpretation of it's subjects? What were the subjects doing for the rest of the day when they weren't running and what were they wearing on their feet? Any other factors during the other 23 hours of the day that might have influenced the findings? Vibram's transition plan might be at fault but it also might be the fault of incorrect interpretation.

    If bones are to grow and strengthen from their current state, wouldn't there be some edema as a precursor? Kind of like weightlifting or basic physical training principles that require some tearing down in order to promote building up? Micro tearing of the muscle is a precursor to the muscle growing stronger, it is also a precursor to injury. Can the presence of edema be differentiated between what is the precursor of bone strengthening vs bone injury? The study assumes/implies all bone marrow edema is bad as a part of training, is that true?

    What is an experienced recreational runner? Wouldn't it have been better to describe the runners as having x years of running experience at y miles of running per year and at an average pace of z? For all we know experience was defined as running for 2 months and recreational means they run less than 30 miles per week. Or experienced could mean running more than 10 years at 100 miles/week and they are recreational because they are not elite runners or earning money from running. Who knows?

    The biggest flaw in all of this is the expectation the VFF are for everyone. They simply aren't. They are fantastic running shoes for those who they happen to work for. That is all there is to it. One size does not fit all and in the case of VFF, patience is the key factor to healthy running. Patience is actually the key factor for all running, regardless of what is worn on the foot.
  20. toomoon

    toomoon Well-Known Member

    No one is questioning your right to do whatever you want and whatever works for you Dana. THIS is what I question.. straight from the VFF website
    "And there is ample evidence that training without shoes allows you to run faster and farther with fewer injuries.'
    No there isn't!
    "It allows you to land on your forefoot, directly below your center of gravity, resulting in optimum balance, increased stability, less impact and greater propulsion.'
    If one lands directly under ones COG, one cannot run! VFF does not necessarily allow you to land on your forefoot either.
    "Running in FiveFingers delivers sensory feedback that improves agility and equilibrium and allows immediate form correction. In addition it stimulates and strengthens muscles in the feet and lower legs."
    I have yet to see a single study supporting these claims in ANY way.
    And I just do not understand why, if wearing VFF is NOT a risk inducing practice for most runners, Vibram has produced a glossy brochure imploring runners to go very slowly.. produced incidentally by Dan Lieberman and nick Campitelli.
    Finally, within this brochure, I wonder why they say the following.."• in the beginning, remember to carry your traditional footwear in your hands as a backup. If you need to stop in
    the middle of a workout, you can put on your cushioned running shoes and return home.'
    yeah.. of course you can,because those shoes won't hurt you!! And what a pain in the butt that is to run carrying your normal shoes!!
  21. Craig Payne

    Craig Payne Moderator

    What flaws might they be?

    I have gone through the paper and can't see anything that is flawed. The inclusion criteria was ok; the randomization process could have been better, but was OK; the baseline and follow-up measures have validity and reliability and were done by blinded observers; the transition protocol followed was the one published on the Vibram website; the stats analysis was appropriate.

    The only issue I can see is how the handled the couple of dropouts and which groups they were in - more detail would be appropriate, but I would hardly call that a flaw.

    Which the judge in the class action suit has certainly ruled last week that Vibram have a case to answer that they were involved in deceptive practices!
  22. Dana Roueche

    Dana Roueche Well-Known Member

    Thanks Simon. The approach Vibram took to sell their shoes is unfortunate. They could have followed a different path. They have something that enhances the running experience in a way that differentiates them from everyone else, which might have been a marketing panacea for them. It is too bad they didn't focus on the experience rather than running farther, faster, being able to leap tall buildings and doing it with less injuries.

    There are runners that exist who do not run for the purpose of running faster, who do not run for the purpose of running further and who are not in the least bit concerned about developing injuries. There are runners out there that run simply because they like to run. They like the running experience and yes, the shoe that is worn, the vehicle that provides the interface between the person and the ground can greatly influence the quality of that experience.

    Based on what I've read on this forum over the years, I suspect few even have a clue with respect to what I'm talking about. I have tried to explain but it has been futile so I'll accept things as they are.

    Have a great weekend.
  23. Dana Roueche

    Dana Roueche Well-Known Member

    Did you read my post? Can you respond to my questions?

  24. Craig Payne

    Craig Payne Moderator

    In answer to your question:
    The study followed the transition protocol and advise that was recommeded on the Vibram website. How is that a flaw?

    It may or may not be too rapid; but researchers have to make judgement calls when it comes to protocols and as long as what they are doing is based on a rational and logical reasoning, then its difficult to fault. Surely following the advice from the Vibram website is logical, makes sense and can easily be defended by the researchers.
  25. Dana Roueche

    Dana Roueche Well-Known Member

    They let the subjects interpret the transition plan with NO control over the interpretation. Who knows if the subjects even followed the plan!

    What about bone marrow edema? Isn't it a precursor to building stronger bones? Their interpretation is that it was leading to injury, could it have been leading to stronger bones? Their interpretation of the findings might be totally out to lunch.
  26. It is also a precursor to osteoporosis, which will offer a much weakened structure.
  27. Craig Payne

    Craig Payne Moderator

    That is a good thing! It mimics real life and what probably happens in most transitions!!! It was not a rigid protocol and allowed flexibility based on the response ... based on what Vibram said they should do! All subjects kept training logs, so what they did is documented.
    Bone marrow edema is indicative of injury.
  28. Dana Roueche

    Dana Roueche Well-Known Member

    Maybe the study should have claimed that as well.
  29. Dana Roueche

    Dana Roueche Well-Known Member

    Vibram deserves a slap on the wrist, they deserve to be made to refund the money to their disgruntled customers, they deserve to be made to retract the BS claims and they deserve to be made to pay the small amount in damages that are being asked for. I suppose the $5M is the lawyers cut in this, $1M to each of the vulture firms that jumped on the Sue Vibram bandwagon.

    I hope this ends soon and Vibram can get back to making Fivefingers.
  30. Dana Roueche

    Dana Roueche Well-Known Member

    Craig, give me a break..... on both responses. Wow.

    Have a great weekend.
  31. toomoon

    toomoon Well-Known Member

    Craig is absolutely correct Dana,, vibram does not have people standing in store individually instructing each person that purchases VFF. Vibram makes erroneous and dangerous claims and throws the punter to the wolves knowing full well many people will not even remotely follow their sketchy recommendations. Most people follow human nature, which is, to immediately try out the product they have just outlaid $$$ for.
    The study follows the protocol SET BY VIBRAM.. it seems pretty good to me.
  32. They did not interpret all bone marrow oedema as leading to injury. From the paper: "Bone marrow edema (MES) was scored according to a system based on the method used by Lazzarini et al., as described in Table 1A:

    MES MRI Finding/Appearance Interpretation
    0 No edema Normal
    1 Increased T2 signal in < 25% of the bone Remodelling
    2 Increased T2 signal in 25-50% of the bone Stress Reaction – some cause for

    "It is important to note that for data analysis, subjects with an MES of 0 or 1 were grouped together because a 1 does not necessarily constitute an injury. An MES of 1 could very well be the product of the physiologic phenomenon of osseous remodeling due to stress which is essential to the normal development and maintenance of bone(2).With appropriate application of stress, the remodeling process results in a stronger bone structure – which is visible on the MRI by low levels of bone marrow edema. However, if continued stress occurs more frequently than the remodeling, this can result in an imbalance that renders cortical and trabecular bone weakened(19). Persistent stress could further lead to bone fatigue, injury or fracture; represented by increasing amounts of bone marrow edema, respectively. Edema in 25-50% of the bone (MES= 2) is considered a stress reaction and a potential cause for concern. At this point, running should be limited and cross-training should be encouraged. Edema in more than 50% of the bone length (MES = 3) is considered a stress injury, at which point participation in running should cease. Out of the 19 Vibram group participants, 9 had edema grades of 0 and 1 (non-injured) and 10 had edema grades of 2, 3 or 4 (injured). This is significantly higher compared to the control group, where 16 subjects were considered non-injured and only 1 was considered injured."
  33. Dana Roueche

    Dana Roueche Well-Known Member

    So, what did we learn from the study?

    1) A transition period of 10 weeks is too short.
    2) VFF probably are not the best suited running shoes for everyone.

    Seems rather obvious to me. I personally used a transition period of 10 times as long which I developed long before Vibram had posted a suggested plan on their site. It is pretty much common knowledge that when it comes to running, one size does not fit all and certainly a shoe that is out in the margin would not work on a wholesale basis.

    As a runner, something that comes readily to me is an awareness of what is going on in my body. Using that awareness, I am readily and constantly making adjustments that enable me to avoid injury. This is probably a contributor to why I can safely wear VFF.

    It seems there are many runners that lack the awareness that can help guide them away from injury. As a consequence, they simply run themselves blindly into injury over and over. This runner should never wear something like VFF.
  34. Simon et al.,

    Given that osteopenia or bone marrow oedema is a fairly new classification and is dependent on MRI investigation, it may be that we are some way from accurately determining the causative factors - trauma may produce some oedema within the bone marrow, but the mechanism that produces the oedema may well be different than that which occurs in the post-menopausal female patient that characterises the usual diagnosis of osteopenia.

    I wonder how many of the experienced runners were post menopausal woman ?
  35. Craig Payne

    Craig Payne Moderator

    OMG!, I just did a surf of a number of barefoot/minimalist blogs and can't believe what I was reading. You want to see the extraordinary lengths that they are going to, to try and discredit this study (epic fail).

    ...textbook eg of cherry picking and confirmation bias

    The paradox is that you do not see them putting the studies that they blindly accept as supporting barefoot/minimalism under the same scrutiny - they like having it both ways! (at least here at Podiatry Arena, we critically appraise all studies regardless of what they support!)

    The fan boys are focusing on the 10wk transition as a flaw (its not a flaw as it was the transition protocol recommended by Vibram). And the focusing on really trivial issues such as the handling of the drop outs (which is a minor issue and does not invalidate the study); the sample size (again showing their ignorance of sample size calculations and power etc); the compliance with the protocol (but it reflected reality, so is a good thing); a total misunderstanding of what bone marrow edema is; etc ... ie grasping at straws.

    Yes, I agree, there are some issues with the study. Those issues are not catastrophic and do not invalidate the study.

    This study clearly shows that if you follow the protocol that was recommended by Vibram to transition to their shoes you are more likely to get an injury. Its that simple. No matter how you try to spin and cherry pick the minor flaws, the study still shows that. This does not auger well for the class action suit against Vibram.
  36. Dana Roueche

    Dana Roueche Well-Known Member

    Craig, is this all really that important? The court will sort things out and everyone will move on. Let us know if the lawyers think that study is strong enough to use in court.
  37. Dana Roueche

    Dana Roueche Well-Known Member

    Something just didn't feel right with respect to this study and what Vibram had written on their web site. Here are some quotes from the getting started section of the FiveFinger site:

    1) "So, how are we supposed to do this minimalist/barefoot thing? The truth is, there isn’t a single correct approach – it’s probably more complicated than that."

    2) " And while we do love our Vibram FiveFingers®, we don’t believe it is the only footwear you will ever need. There are many times when you need the protection and security of a shoe or boot. Like all things in life, there is a balance"

    3) " Listen to your feet! Switching to Vibram FiveFingers® from traditional shoes is a transition that may take time. For some, it is a matter of weeks, for others months, and for a few it could be a year or more." "Listen to your body."

    4) "Stop if your arches or the top of your foot is hurting, or if anything else hurts!"

    5) "Stop and let your body heal if you experience pain. Sore, tired muscles are normal; bone, joint, or soft-tissue pain is a signal of injury."

    6) "There is no single training and transition program that is suitable for everyone. You should try to discover what works for your body in order to make this transition safe and successful."

    7) "Give yourself the gift of time and patience as you explore this “new” way of running and moving. Forget about splits, time, distance and PRs for a little while and focus on running for the pure joy of connecting to your body, and your environment in a new way."

    8) "Whichever surface you choose, make sure to select a controlled, familiar environment to begin your training. Don’t venture too far from your starting point in case you need to stop and pack it in for the day. "

    9) "Always be patient, and build gradually. It can take several months to a year to make the transition to running in FiveFingers.It takes time for your feet and lower legs to increase strength and mobility."

    10) "A gradual transition doesn’t mean a setback in your training. Running in Vibram FiveFingers requires a significant increase in lower leg and foot strength. A gradual transition is critical to avoid overuse injuries. If running is your primary form of exercise, gradually increase the proportion of forefoot or mid-foot striking by about 10% per week over the course of several months as you reduce running in your old style. Remember, this is an experiment to find something that suits you. To make a clean break from traditional heel striking, supplement running with biking, swimming, cardio machines, and fitness classes to maintain your fitness level, while giving primary running muscles a chance to recover."

    11) In their actual training plan for weeks 5-12: "Each week, increase your FiveFingers running by no more than 10% of your distance from the previous week. Continue to run no more than once every other day.*"

    12) In their actual training plan for weeks 13 and on: "At this stage you may be able to experiment with your distance, speed, and frequency. Continue to gradually increase your distance, but listen to your body every step of the way."

    I just have to question if the subjects of the study actually even read any of this, it's obvious that it was ignored. I have no idea where the idea of a 10 week plan came from, it's not from Vibram.

    The message I get from this is that the transition can be long and if it hurts, STOP. I don't know were the study came up with the idea of 10 weeks but it doesn't follow what Vibram suggests and is a huge flaw with the study. It not only wasn't long enough to allow transition and I'm getting the impression that the subjects of the study failed to stop running when they felt any pain or discomfort per Vibrams recommendations.

    For the life of me, I don't know why people can't just continue wearing their traditional running shoes and simply go for an occasional short, slow run in Vibrams or any other minimal shoe and gradually transition from traditional shoes to Vibrams/minimal shoes if and only if, that is what is desired by the runner. Instead, people want to just want to jump right into a pair of Vibrams, completely replace their traditional running shoes and continue on at the same level training. An injury destined to happen.

    Training fundamentals 101 tells us that if you want to make a change, it is imperative that it is incorporated into a training plan slowly and gradually. That applies to distance, speed work, long runs, terrain, etc.
  38. Dana Roueche

    Dana Roueche Well-Known Member

    Based on the Vibram website, the study completely ignored the protocol recommended by Vibram and it is probably why their findings are what they are. Not Cherry picking, Vibram says it could take months or even more than a year to transition, not 10 weeks. They also say if there is pain, STOP RUNNING.

    I re-read the class action suit. It isn't about injury at all. Valerie Bezdek feels she was duped into buying a pair of FiveFingers because of the claims Vibram was making. As a result, she wants her money back!

    This comes directly from the complaint:

    "As a result of Defendants’ deceptive claims, consumers--including Plaintiff and the other members of the proposed Class--have purchased a product that has not been proven to perform as advertised. Moreover, Defendants have been able to charge a significant price premium for FiveFingers over other conventional running shoes. This action seeks to obtain redress for purchasers of FiveFingers, and to enjoin Defendants’ deceptive and unlawful advertising."

    This is what she wants:

    A. An order certifying this case as a class action and appointing Plaintiff and her counsel to represent the Class;
    B. Individual restitution to Plaintiff and each member of the Class;
    C. An order requiring Defendants to immediately cease their wrongful conduct as set forth above;
    D. For reasonable attorneys’ fees and the costs of this action;
    E. For statutory pre-judgment interest; and
    F. For such other relief as this Court may deem just and proper.

    She has got to be kidding! All of this because she is not happy with the Bikilas she bought which has a $90 list price! I have to wonder, who is Valerie Bezdek? Is she an actual runner? Did she actually wear the shoes? What has been her experience with buying and wearing running shoes in the past? The whole thing seems a bit extreme over not being happy with a $90 pair of shoes. Bring them back to the store for a refund for crying out loud!

    An interesting tidbit relating the study is that one of the complaints in the lawsuit is that it takes a long time to transition to Vibrams.

    22. Because FiveFingers require a running style that is different from traditional running shoes, runners must change the way they run when running in FiveFingers. However, as indicated in the recent ACE Study, changing one’s running form to use FiveFingers can be an extremely long and complicated process.8 Given that most runners have always worn traditional running shoes, they have “been ‘programmed’ to run in the conventional heel-strike manner.”9 As Dr. Cedric Bryant, the chief science officer for the American Council on Exercise stated, ‘“[t]he key thing our study seems to suggest is that it’s really important you take some time to really adjust your running form or running style.”’10
  39. Craig Payne

    Craig Payne Moderator

    The study DID follow the advice that was on the Vibram website! Vibram have since changed the advice that is on their website!
  40. Indeed, the paper clearly states that:

    "The transition protocol used in this study was modeled from suggestions for transitioning to VFF published on the Vibram FiveFingers website in January 2011 (the suggestions on the website have changed since then)(22)."

    I wonder why they decided to change the information on their website? :rolleyes:

    I wonder how long it will be before the boxes of running shoes come with similar health warnings on them as cigarette packets, for example- "running causes stress fractures"; "running causes infertility" etc; how long before they are legally obliged to package their products without branding and replace their logo's with pictures of injured runners on them? Running shops being legally obliged to have their shoes concealed within shuttered cupboards that can only be opened when the customer requests a specific style and brand... http://www.youtube.com/watch?v=VvUduUeNfUw

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