If orthotics and running shoes are the answer, then why have injury rates not changed in the last 40 years? Why have running shoe companies across the board began manufacturing running shoes with less stability, increased flexibility, less cushioning and lower heel-to-toe drop? This fact cannot be disputed.
It is very obvious that I cannot use literature to prove my point. When I do, people accuse me of cherry picking. Craig Payne has displayed a wonderful example of cherry picking in his comments by pulling articles demonstrating supposed injuries from minimalist shoes.
I have said this multiple times in the past yet it appears that my peers cannot grasp this concept. Running shoes do not create injuries. Running creates injuries. My point is that people are relying on traditional running shoes that contain a cushioned heel for no scientific reason along with motion control and stability that makes it harder for them to run in a more natural manner. One can argue that controlling pronation may reduce injury but again the evidence is inconclusive as I will reference below.
Is excessive pronation even pathologic? It is my opinion that we have for years over-treated this deformity with orthotic devices in an unnecessary manner. I believe there are pathologic situations of abnormally pronated feet in which severe deformities present but in my view, these are rare circumstances that are even rarer in those who are able to run.
Root himself made the statement, “Generally abnormal pronation during static stance does not produce major symptomatology.”1 He went on to say that, “even during locomotion, however, abnormal pronation rarely produces symptomatology that is acute enough to prevent weight bearing.” Root also mentioned that using a functional foot orthoses to control abnormal foot geometry reduces the need for muscles to compensate. I believe that treating the muscles and strengthening them to create a stronger foot can help facilitate a more natural gait and decrease the etiology of abnormal forces.
An example of this is removing the high cushioned heel that places the foot into a plantarflexed position. Root has even suggested that a slightly plantarflexed ankle will create the need for the subtalar joint to increase in pronation to compensate for the lack of dorsiflexion.2 So remove the heel and reduce the slight equinus it is creating. Is there literature that exists to advocate a specific heel height of a running shoe for a foot with no existing injury? There is less strain on the Achilles tendon with a higher heel, which could aid in recovery in cases of Achilles tendonitis. The theory is that the elevated and eventually cushioned heel became part of running shoes to prevent this Achilles strain, but is it necessary? I believe it is not.
This leads to the next topic of how the foot should be striking the ground with a forefoot, midfoot or heel. Until proven otherwise, I feel the heel should not be striking the ground first, especially on an outstretched leg as this may create a transient impact peak that is not present during a midfoot or forefoot strike position. The argument can and continues to be that the majority of runners are heel striking. Just because they are running that way, that doesn't make it right. In their review, Lorenz and Pontillo state, “While minimal data exist that definitively support barefoot running, there are data lending support to the argument that runners should use a forefoot strike pattern in lieu of a heel strike pattern to reduce ground reaction forces, ground contact time, and step length.”3 However, they go on to say there is no positive or negative effect that can be drawn yet based on injury.
Alternately, in a study of 1,991 marathon runners, Kasmer and colleagues found that over 93 percent of the runners were heel strikers and they suggested that one may be able to “predict their injury profile based on the biomechanics of a heel-strike running pattern.”4 They also found that “more elite performers (were) less likely to heel strike."
Also consider that most if not all of the runners in the study were wearing traditional running shoes with a cushioned heel that encourage a heel strike. Lieberman demonstrated the effects that traditional modern running shoes had on a society that typically functions in barefoot or minimalist shoes.5 Thirty percent of runners in the study gravitated toward a rearfoot strike pattern most likely as a result of the shoe’s influence in contrast to 70 percent who were forefoot or midfoot striking when not wearing the modern running shoe.
I have watched Olympic events and marathons and seen the elite runners striking with the midfoot. While I have had discussions with others who say still frame photography reveals runners are heel striking, one must watch a video for an accurate interpretation of the strike pattern. The literature has demonstrated that a higher percentage of faster elite runners land with a midfoot strike.6
There is also evidence to demonstrate that strike patterns among barefoot runners are more of a midfoot or forefoot strike pattern.7
To defend my position, the following articles discuss foot strike patterns and provide no conclusive evidence that landing on the heel reduces injury.
Goss and Gross demonstrated that a midfoot strike associated with a Chi running pattern reduces vertical loading rates and knee extensor work.8 The authors also noted that such runners may also experience increased work at the ankle plantarflexors. This coincides with my theory that with these muscle groups adapting gradually over time, they will absorb the force of impact (Davis’s law).
Lorenz and Pontillo’s review shows no increase in injury rates with a forefoot strike pattern and actually revealed that there is an improvement in running efficiency.3 The authors did note that there is not enough evidence to make any conclusions about whether forefoot striking has a positive or negative effect in runners. This study along with Lieberman’s groundbreaking study revealed a reduction in impact peak forces in barefoot runners.9
Ogueta-Alday conducted a study, which I’m sure those opposed to this concept of forefoot striking will attempt to use in favor of heel striking.10 Although the study used a small sample size of 20 runners (10 rearfoot and 10 midfoot), the conclusion was that rearfoot strikers were more economical despite the fact that there was no difference in anthropometrics, VO2max or anaerobic threshold. The reason for the conclusion was that rearfoot strikers showed a longer contact time and shorter flight time than midfoot strikers. I am not really sure why this makes someone more economical, especially when step rate and strike length did not differ between the groups.
Even more surprising is that in 2007, Hasegawa and colleagues demonstrated that contact time was clearly increased in slower runners and this was associated with a heel strike pattern.6 That study authors suggested that short contact time and higher frequency of inversion at foot contact may contribute to a higher running economy.
If you look at the recent literature on this topic of strike patterns and economy, evidence is demonstrating that adopting a forefoot strike pattern may actually enhance performance.11 After evaluating strike patterns of 40 recreational runners, Ahn and colleagues concluded that earlier and longer activation of the plantarflexors will likely increase the capacity for the passive structures of the foot to store elastic energy and enhance performance of the active muscle by increasing the storage of this elastic energy.11 So one can see that it is more about using the body as it was intended to store and use energy as opposed to relying on nonscientific attempts of accomplishing this with shoegear. This study also coincides with my discussion of the spring mechanism in running, which I will mention below.
Kasmer and colleagues showed that trail runners, albeit less than road runners, prefer a rearfoot strike pattern (85 percent, which is less than road marathon runners) and that the faster runners were more likely to be forefoot strikers in minimalist shoes, suggesting that minimalist shoes may represent a training modification to improve performance.12 Again, it is not the shoe, it is the way the individual runs, which is directly related to the shoe in some cases.
Although Larson and coworkers showed that more recreational runners (88.9 percent) heel strike during a marathon, most of them initially began with a midfoot or forefoot strike pattern and then as they fatigued later in the miles, they adopted a heel striking pattern.13 What can we draw from this study? Not much, in my opinion, other than the observations of how the individuals were running. As I have said before, if you look at the majority of shoes being sold, they are traditional running shoes and therefore encourage a rearfoot strike pattern so I would expect to see this in any race. A recent study published by Chambon and colleagues reveals that midsole thickness in a shoe and even the upper of the shoe can significantly change one’s running pattern.14
Another point worth mentioning is in regard to foot position during landing, which has become known as the spring mechanism of the lower extremity. This is a concept that nobody discussed in podiatry school 10 years ago. In simplistic terms, one can think of the leg as a spring with three points of ability to absorb shock: the hip, the knee and the ankle. Simple physics will demonstrate that the more points of coil in the spring, the more shock it will absorb. This is Hooke’s law. In the case of the leg, the muscles acting about the respective joints will absorb the shock. If a runner lands on the heel of an outstretched leg, the only joints that can bend to absorb this shock at the point of impact are the knee and the hip. If one lands on the forefoot, the ankle joint can dorsiflex and eccentrically load the gastrocsoleus complex/Achilles and absorb shock in addition to the knee and hip. This is why we see a higher incidence of Achilles injuries to those who do not transition slowly over time to a minimalist shoe. It is not the direct result of the shoe. It is the form that the runner changed to which eccentrically loads the gastrocsoleus complex. Davis’ law of soft tissue adaptation demonstrates the tissue will respond to this stress gradually over time. So eventually, a stronger Achilles tendon will absorb the shock.
Researchers have demonstrated that there is no significant direct link between overuse injuries and excessive pronation or faulty foot biomechanics.15-25 Eight peer-reviewed articles discuss that orthotics alone are not responsible for preventing or treating running injuries.26-33
Despite the fact that I have said this numerous times, I have no underlying agenda with Vibram USA and the company has never paid me. For those who are unable to comprehend what my functions are as a medical advisor, the company gave me this title and I was simply advising it on foot function. If anyone has visited my running blog, you will certainly see that I have reviewed and worn far more shoes than those from Vibram USA.
I have not distanced myself from Vibram since this lawsuit has become apparent to those reading this. This lawsuit is three years old. Nothing has changed in what I have done in the last five years in regard to this topic. I never created the five health benefits that the company listed. That was Vibram USA. I advised on the gradual transition to avoid injury and I will stand by this.
Kevin, please be aware that the post (
http://vibram5fingers.weebly.com/2/post/2012/04/vibram-advisory-board.html ) is not a Vibram USA website and has information from 2012, which Vibram USA is not currently posting. This site is from a Weebly free hosted website.
In regard to filing a lawsuit against me as a professional for claims made on my blog, my blog simply lists my beliefs. I am not selling any services on my blog. I did self-publish a book regarding minimalist running. It contains many references, videos and demonstration of how the body absorbs shock while running both in traditional shoes and in minimal issues. I never marketed this book as scientific evidence nor did I state it was scientific evidence. If you do not want to buy this book, do not buy it. I do not have hidden agendas to make money off my beliefs. I am simply enthusiastic about helping people with their running and helping others understand basic foot function as we now know it in the 21st century.
It is pretty clear from the comments that I am seeing that others who choose to remain status quo are against moving forward in understanding a new realm of biomechanics. Kevin Kirby, DPM, has cited references in regard to the benefits of orthotics for those who have diabetes and rheumatoid arthritis. Really? This is about running and understanding form and foot function. This has nothing to do with people who have diabetes.
At one point four years ago, Vibram FiveFingers was the largest selling athletic shoe in the United States. It changed the way we look at shoe gear and running. We cannot dispute this. The entire shoe industry now has minimalist shoes. Kevin, you can call them whatever you want or say they have been around for years as racing flats, but they were never as popular as they are today. Furthermore, if had you handed a podiatrist a racing flat five years ago, the podiatrist would bend it and say it’s too flexible and has no support. Five years ago, it was Vibram that opened a lot of people’s eyes to what we can put on our feet. Now every shoe company is creating a minimalist shoe. There were no options prior to this other then FiveFingers.
Craig, I will discuss your references.
The study by Grier and colleagues had nothing to do with shoe gear.34 It was evaluating the Advanced Tactical Athlete Conditioning (ATAC) program so to draw conclusions from this based on shoegear worn obviously does not look at training patterns or form, therefore making it irrelevant for your argument.
Warr and colleagues conducted a study of runners asking whether or not they had an overuse injury in the prior 12 months to assessing their striking pattern.35 Again, training patterns and form were not factors in this study and these are two very important variables in regard to running injury. You cannot simply look at one’s foot strike pattern and ask him or her whether he or she has an injury. A physician did not evaluate these runners and there were no discussions of X-rays or ancillary tests to define the injury. It is not that easy.
Furthermore, you stated this comment on your blog: “Obviously, we are assuming that those wearing minimalist shoes were more likely to be a non-heel striker.” You cannot assume that because one is wearing a minimalist shoe, one will not heel strike. If someone’s form has been accustomed to heel striking as a result of the influence of a traditional running shoe, the runner may be more likely to continue this form and heel strike in the minimalist shoe, which, yes, could lead to injury. This is why I write my blog and educate runners on transitioning.
In regard to these two references:
Walther in 2005 conducted a retrospective review of 1,203 runners that also found no difference in incidence of injury between rearfoot and forefoot strikers in the rate of injury.36 Warr and colleagues assessed 342 soldiers and after assessing their foot strike pattern, 13 percent were classified as non-heel strikers.35
Craig is drawing the same inference. Although it is extremely easy to do, you cannot simply draw any conclusion in regard to injury solely based on strike patterns. These articles are simply assessing striking patterns and not controlling variables. Just because someone is running in a traditional running shoe and reporting he or she is heel striking does not mean he or she will not be injured. Sure, these runners may be able to run this way and not report an injury, but the recent evidence is suggesting more force being distributed to the lower extremity, which, over time, could be detrimental when heel striking.37-39
Craig has simply listed handpicked articles and drawn conclusions. Variables were not controlled and one cannot say that heel striking or forefoot striking alone can predict an injury. He has done nothing different than how I present my case. I present references and make my point, but people call me a cherry picker.
References
1. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, 1977, p. 296.
2. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot -Volume 2. Clinical Biomechanics Corp., Los Angeles, 1977, pp. 297-298.
3. Lorenz DS, Pontillo M. Is there evidence to support a forefoot strike pattern in barefoot runners? A review. Sports Health. 2012;4(6):480-484.
4. Kasmer ME, Liu XC, Roberts KG, Valadao JM. Foot-strike pattern and performance in a marathon. Int J Sports Physiol Perform. 2013 May;8(3):286-92.
5. Lieberman DE. Strike type variation among Tarahumara Indians in minimal sandals versus conventional running shoes. J Sport Health Sci. Epub April 24, 2014.
6. Hasegawa H, Yamauchi T, Kraemer WJ. Foot strike patterns of runners at the15-km point during an elite-level half marathon. J Strength Cond Res. 2007;21(3):888-93.
7. Larson P. Comparison of foot strike patterns of barefoot and minimally shod runners in a recreational road race. J Sport Health Sci. Epub April 18, 2014.
8. Goss DL, Gross MT. A comparison of negative joint work and vertical ground reaction force loading rates in Chi runners and rearfoot-striking runners. J Orthop Sports Phys Ther. 2013;43(10):685-92.
9. Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D'Andrea S, Davis IS, Mangeni RO, Pitsiladis Y. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010; 463:531-535.
10. Ogueta-Alday A, Rodríguez-Marroyo JA, García-López J. Rearfoot striking runners are more economical than midfoot strikers. Med Sci Sports Exerc. 2014;46(3):580-5.
11. Ahn AN, Brayton C, Bhatia T, Martin P. Muscle activity and kinematics of forefoot and rearfoot strike runners. J Sport Health Sci. Epub April 24, 2014.
12. Kasmer ME, Liu XC, Roberts KG, Valadao JM. The relationship of foot strike pattern, shoe type, and performance in a 50-km trail race. J Strength Cond Res. Epub July 15, 2013.
13. Larson P, Higgins E, Kaminski J, Decker T, Preble J, Lyons D, McIntyre K, Normile A. Foot strike patterns of recreational and sub-elite runners in a long-distance road race. J Sports Sci. 2011;29(15):1665-73
14. Chambon N, Delattre N, Guéguen N, Berton E, Rao G. Is midsole thickness a key parameter for the running pattern? Gait Posture. 2014;40(1):58-63.
15. Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Phys Med Rehabil Clin N Am. 2005;16(3):651-67, vi.
16. Hreljac A, Marshall RN, Hume PA. Evaluation of lower extremity overuse injury potential in runners. Med Sci Sports Exerc. 2000;32(9):1635-41.
17. Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc. 1988;20(5):501-5.
18. Messier SP, Davis SE, Curl WW, et al. Etiologic factors associated with patellofemoral pain in runners. Med Sci Sports Exerc. 1991;23(9):1008-15.
19. Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther. 2010;40(2):59-66.
20. Morley JB, Decker LM, Dierks T, Blanke D, French JA, Stergiou N. Effects of varying amounts of pronation on the mediolateral ground reaction forces during barefoot versus shod running. J Appl Biomech. 2010;26(2):205-14.
21. Hetsroni I, Finestone A, Milgrom C, Sira DB, Nyska M, Radeva-Petrova D, Ayalon M. A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits. J Bone Joint Surg Br. 2006;88(7):905-8.
22. Wen DY, Puffer JC, Schmalzried TP. Lower extremity alignment and risk of overuse injuries in runners. Med Sci Sports Exerc. 1997;29(10):1291-8.
23. Nielsen RO, Buist I, Parner ET, Nohr EA, Sørensen H, Lind M, Rasmussen S. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440-7.
24. Chevalier TL, Chockalingam N. Foot orthoses: a review focusing on kinematics. J Am Podiatr Med Assoc. 2011;101(4):341-8.
25. Ferber R, Hreljac A, Kendall KD. Suspected mechanisms in the cause of overuse running injuries: a clinical review. Sports Health. 2009;1(3):242-6.
26. Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013; epub Nov 13.
27. Rodrigues P, Chang R, TenBroek T, Hamill J. Medially posted insoles
consistently influence foot pronation in runners with and without anterior knee pain. Gait Posture. 2013;37(4):526-31.
28. Radzimski AO, Mündermann A, Sole G. Effect of footwear on the external knee adduction moment - A systematic review. Knee. 2012;19(3):163-75.
29. Mattila VM, Sillanpää PJ, Salo T, Laine HJ, Mäenpää H, Pihlajamäki H. Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects. Scand J Med Sci Sports. 2011;21(6)
30. Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of running injuries. Curr Sports Med Rep. 2010;9(3):176-82.
31. Loudon JK, Dolphino MR. Use of foot orthoses and calf stretching for
individuals with medial tibial stress syndrome. Foot Ankle Spec. 2010;3(1):15-20.
32. Murley GS, Landorf KB, Menz HB, Bird AR. Effect of foot posture, foot
orthoses and footwear on lower limb muscle activity during walking and running: a systematic review. Gait Posture. 2009;29(2):172-87.
33. Chevalier TL, Chockalingam N. Foot orthoses: a review focusing on kinematics. J Am Podiatr Med Assoc. 2011;101(4):341-8.
34. Grier T, Canham-Chervak M, McNulty V, Jones BH. Extreme conditioning programs and injury risk in a US Army Brigade Combat Team. US Army Med Dep J. 2013:36-47.
35.
http://www.researchjunkie.com/foot-strike-pattern-and-injury-rates
36. Walther M. VorfuBlaufen Schutzt nicht vor Uberlastungsproblemen. Orthopadieschuhtechnik, 6,34.
37. Goss DL, Gross MT. A review of mechanics and injury trends among various running styles. US Army Med Dep J. 2012 Jul-Sep:62-71.
38. Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D'Andrea S, Davis IS, Mang'eni RO, Pitsiladis Y. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;28;463(7280):531-5.
39. 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. Epub 2013 Jan 9.
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