Do Runners Need Orthotics?

Nicholas A Campitelli DPM FACFAS

I routinely have runners present to our office demanding orthotics for their shoes. Even more common is the request for replacement orthotics. The question is: Should they even be running in an orthotic?

To begin the discussion, runners who do not even have a biomechanical abnormality commonly overutilize orthotics.1,2 Many runners adhere to the false belief that they need to “support” their arches with an orthotic device to protect from the heavy pounding that occurs from running. Others have simply recovered from an overuse injury and have elected to continue running with orthotics.

What runners and physicians need to be aware of is what exactly they are trying to accomplish with an orthotic. We typically prescribe rigid or semi-rigid orthotics to control excessive pronation occurring in the subtalar joint. Even if the patient does not have a true pes planus deformity, a gait examination may demonstrate increased pronation occurring during heel strike and into midstance. This leads the practitioner to recommend an orthotic device.

With all the recent attention on barefoot running and minimalist running shoes, we have also seen the focus on “proper running form.” This seems to be the most important limiting factor in correcting overuse injuries, more so than the actual shoe or orthotic.

The debate now enters a second arena. Do we advocate striking on our midfoot/forefoot or our heels? There is evidence that demonstrates most elite runners who are finishing first and running faster are landing on the forefoot.3,4 While our focus should remain on being healthy and not just winning, we could extrapolate from these runners that they have adopted an efficient and natural way to run.

A recent study published by Lieberman and colleagues demonstrated a significant increase in injury rates amongst collegiate competitive cross country runners who habitually rearfoot strike in comparison to those who forefoot strike.5 The injury rate associated with those who heel strike was comparatively as large when researchers compared this to other factors thought to influence injury rates such as age, prior injury, body mass index, foot type, lumbopelvic strength, arch type, flexibility, Q angle and neuromuscular control.6-10 Numerous studies also demonstrate minimal, if any, significance for the prescriptive use of orthotics or running shoes for running injuries.11-15

Given the observation that both scientific and anecdotal evidence is pointing toward forefoot/midfoot striking, we now must ask ourselves the question: Where do orthotics play a role in running?

One important concept to understand with forefoot or midfoot striking is that we convert the vertical force of striking the ground into rotational force by lowering the heel to the ground. This occurs by pronation of the entire foot first, then with pronation of the subtalar joint just before the heel lifts off the ground to begin its forward momentum. Accordingly, preventing subtalar joint motion with an orthotic device and heel striking is not a relevant issue. We need the motion that is occurring through the entire process of forefoot strike to heel contact and pronation to absorb the shock adequately.

Does Proper Running Form Negate The Need For Pronation Control?

Obviously, more studies need to examine this concept but it poses a very interesting question: Do we really need to control pronation if we have proper running form?

In my practice, when runners bring up the question of what type of shoe they should be wearing, I explain that they first need to “learn how to run.” Then shoegear and orthotics become irrelevant. We also use the same approach with orthotics. As with any treatment protocol, that “treatment” must be justified via sound evidence-based medicine.

If a runner presenting to our office has dealt with any type of overuse injury that is chronic, we stress the importance of learning proper running form and educating the patient on forefoot striking, proper cadence and proper transitioning from the current running form.

If patients are in mid-season training for a marathon or similar distance event, we educate them on proper running form, but advise them that a drastic change in their gait prior to a race could be detrimental if training time is not sufficient. If the patient is heel striking, we can implement an orthotic temporarily but only until the patient can begin transitioning from a forefoot strike pattern and only if symptoms are present due to the overpronation occurring as a result of heel striking.

References

1. Tuff S. Do you really need an $800 custom insole? New York Times. 2006; Available at http://www.nytimes.com/2006/06/22/fashion/thursdaystyles/22Fitness.html?... .

2. Spiker T. Orthotics for your shoes. Runner’s World. 2004; Available at http://www.runnersworld.com/article/0,7120,s6-240-319-327-7000-0,00.html .

3. Larson P, Higgins E, Kaminski J, et al. Foot strike patterns of recreational and sub-elite runners in a long-distance road race. J Sports Sciences. 2011; 29(15):1665-1673.

4. Hasegawa H, Yamauchi T, Kraemer WJ. Foot strike patterns of runners at the 15-km point during an elite-level half marathon. J Strength Cond Res. 2007; 21(3):888-893.

5. 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; epub Jan 3.

6. Bennett MR, Harris JWK, Richmond BG, Braun DR, Mbua E, Kiura P, Olago D, Kibunjia M, Omuombo C, Behrensmeyer AK, Huddart D, Gonzalez S. Early Hominin Foot Morphology Based on 1.5-million-year-old footprints from Ileret, Kenya. Science. 2009; 323(5918):1197-1201.

7. Bramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature. 2004; 432(7015):345–352.

8. Frederick EC. Physiological and ergonomics factors in running shoe design. Appl Ergonomics. 1984; 15(4):281-287.

9. Kerr BA, Beauchamp L, Fisher V, Neil R. Footstrike patterns in distance running. In: Nigg BM, Kerr, BA, eds. Biomechanical Aspects of Sports Shoes and Playing Surfaces. Calgary University, Calgary, 1983, pp. 135–142.

10. Williams DS, McClay IS, Manal KT. Lower extremity mechanics in runners with a converted forefoot strike pattern. J Appl Biomech. 2000; 16:210–218.

11. Hume P, Hopkins W, Rome K, Maulder P, Coyle G, Nigg B. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Medicine. 2008; 38(9):759- 779.

12. Knapick 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; 36(9):1469-1475.

13. 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. 2010; 21(6):804-8.

14. Ryan MB, Valliant GA, McDonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial. Brit J Sports Med. 2010; 45(9):715-721.

15. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. A prospective study. Am J Sports Med. 1990; 18(6):636-41.

Comments

The top distance runners in the world are running at a pace that would, for the average runner, be rather fast. Almost without exception, as speed of running increases, so does the likelihood of forefoot striking. I cannot therefore see the relevance in the following statement.

"There is evidence that demonstrates most elite runners who are finishing first and running faster are landing on the forefoot.3,4 While our focus should remain on being healthy and not just winning, we could extrapolate from these runners that they have adopted an efficient and natural way to run."

With respect to "proper "running form, anyone who is winning is clearly adopting an efficient running form. Does that make it more natural? That is quite an extrapolation.

A 10 minute mile runner is unlikely to find forefoot striking more efficient unless it is his or her natural gait.

Just out of interest, does Dr. Campitelli work for a footwear manufacturing company? If so, which one? It wouldn't be related to minimalist or barefoot shoes per chance?

Again, as in a previous blog from Dr. Campitelli, a member of the Vibram FiveFingers Medical Advisory Board, he ignores the available medical and scientific evidence to promote his and Vibram’s agenda of running in minimalist shoes. His blog is a prime example of a technique known as “cherry picking," in which authors disregard the scientific evidence that directly refutes the points they are trying to make and only choose the small bits of weak evidence that support their opinions.

First of all, let’s look at this unreferenced and unsupported statement: “With all the recent attention on barefoot running and minimalist running shoes, we have also seen the focus on 'proper running form.' This seems to be the most important limiting factor in correcting overuse injuries, more so than the actual shoe or orthotic.” How does Dr. Campitelli make this leap of faith in making this statement? Where are the references that support this statement? The reason there are no references is because there is absolutely not a single shred of scientific evidence that using “proper running form” is more important than are shoes and foot orthoses at preventing injury. Dr. Campitelli is simply guessing ... again.

Secondly, Dr. Campitelli intimates that forefoot striking running must be “proper running form” since he claims that “most elite runners who are finishing first and running faster are landing on the forefoot." In making this deceiving claim, Dr. Campitelli has conveniently ignored the scientific study from a group of researchers in Kyoto, Japan that he mentions in his blog that found out of 283 elite runners analyzed at the 9.3 mile mark of a half-marathon, only 1.4% were forefoot strikers, 23.7% of the runners were midfoot strikers and 74.9% of these elite runners were heel strikers (Hasegawa H, Yamauchi T, Kraemer WJ: Foot strike patterns of runners at the 15-km point during an elite-level half marathon. J Strength Cond Res, 21:888-893, 2007).

Additionally, Dr. Campitelli also conveniently ignores the important findings from another research study he references that demonstrated that out of 936 distance runners, 88.9% were heel-strikers, 3.4% were midfoot strikers and a measly 1.8% were forefoot strikers (Larson P, Higgins E et al: Foot strike patterns of recreational and sub-elite runners in a long-distance road race. J Sports Sciences, 29:1665-1673, 2011). The oldest study done on foot strike patterns, done nearly 30 years ago, decades before the “minimalist/barefoot running fad” began, showed that 0.00% of runners were forefoot strikers, 19% were midfoot strikers and 81% were heel-strikers (Kerr BA, Beauchamp L et al: Footstrike patterns in distance running. In Nigg BM (Ed.), Biomechanical Aspects of Sport Shoes and Playing Surfaces, University Press, Calgary, 1983, pp. 135-142).

How does one look at this research and then intimate that every runner should be forefoot striking since this is the “proper running form” for each runner?

What this does demonstrate very clearly to me and hopefully to the others reading Dr. Campitelli’s blogs is that Dr. Campitelli is not at all using the available scientific research to objectively analyze a problem and make reasonable,objective conclusions about that problem. Rather, what is occurring here is that Dr. Campitelli has already formed an opinion that he is convinced is right and is selectively and deliberately cherry-picking what bits and pieces of information he can extract from the scientific literature to meet his agenda, the promotion of running in minimalist running shoes.

Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine

In his previous blog, Dr. Campitelli goes to great lengths to explain how the elevated heel position of current running shoes puts the foot at risk for injury. He describes the pathologic equinus position of the foot where the talus becomes "uncovered" and unstable in the ankle joint when positioned in plantarflexion. Now he advocates that runners strike the ground with the foot positioned in plantarflexion at the ankle joint, i.e. an equnius position! This appears to be a clear contradiction by Dr. Campitelli as he attempts to promote the use of Vibram minimalist shoes to the general running population.

Douglas Richie D.P.M. F.A.C.F.A.S.
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine

Within this article, Dr. Campitelli asks the question: "Does Proper Running Form Negate The Need For Pronation Control?

Obviously, more studies need to examine this concept but it poses a very interesting question: Do we really need to control pronation if we have proper running form?"

Within these questions, there are a couple of interesting presumptions. Firstly, that pronation is somehow a "bad thing" that requires "control" in the first place. The evidence here is split, but the balance seems to lie with pronation not being a risk factor for injury.

These two studies suggested pronation was a risk factor for injury. In 2004, Yates and White noted that “Identifying a pronated foot type prior to training may help reduce the incidence of medial tibial stress syndrome by early intervention to control abnormal pronation.” In 1999, Kaufman et al., noted that “risk factors include dynamic pes planus, pes cavus, restricted ankle dorsiflexion, and increased hindfoot inversion.”

The following studies suggested pronation was not a risk factor for injury. According to a 1993 paper, Cowen et al., noted “these findings do not support the hypothesis that low arched individuals are at increased risk of injury.” In 1997, Wen et al., found that “lower-extremity alignment is not a major risk factor for running injuries in our relatively low mileage cohort.” In 2006, Hestroni et al., concluded that “our study does not support the hypothesis that anterior knee pain is related to excessive foot pronation.” In 2001, Rome et al., concluded that “The results demonstrated that traditional risk factors such as excessive foot pronation, ankle equinus, and body weight are not associated with plantar heel pain.” In 2002, Hogan, Staheli found that “flexible flatfeet are not a source of disability. This study is consistent with previous studies and provides additional evidence against the practice of treating flexible flatfeet in children.” In 2009, Ryan et al., noted “The findings of this study suggest that our current approach of prescribing in-shoe pronation control systems on the basis of foot type is overly simplistic and potentially injurious.”

Also consider the findings of the most recent study below:

de Groot R, Malliaras P, Munteanu S, Payne C, Morrissey D, Maffulli N. Foot Posture and Patellar Tendon Pain Among Adult Volleyball Players. Clin J Sport Med. 2012 Feb 14.

OBJECTIVE: We hypothesized that individuals with a normal foot posture would be less likely to experience patellar tendon pain and pathology than those with a pronated or supinated foot.

DESIGN: Observational study.

SETTING: Field-based study among competing athletes.

PARTICIPANTS: Volleyball players competing in the Victorian State League in Australia.

ASSESSMENT OF RISK FACTORS: Patellar tendinopathy (PT) is common in sports involving running and jumping and can severely limit athletes' ability to compete. Several studies have investigated potential etiological factors for the development of PT, but little is known about the association between PT and foot posture.

MAIN OUTCOME MEASURES: Static foot posture index (FPI), patellar tendon pain during single-leg decline squatting, and gray scale ultrasound imaging were measured in 78 recreational to elite volleyball players (48 men and 30 women).

RESULTS: Men with patellar tendon pain were more likely to have a normal foot posture and men without pain were more likely to be pronated according to the FPI (P 0.05).

CONCLUSIONS: Men with a normal foot posture were more likely to have PT compared to men with a pronated foot type.

Secondly, Dr. Campitelli intimates within these questions that foot orthoses "work" by "controlling" pronation. The evidence here is again somewhat split:

The following studies reported that foot orthoses don’t change rearfoot kinematics:
e.g. Rodgers & Leveau, 1982; Blake and Ferguson, 1993; Brown et al, 1995; Nawoczenski et al., 1995; Nigg et al. 1997; Butler et al, 2003; Stackhouse et al, 2003; Williams et al, 2003…

These studies reported that foot orthoses do change rearfoot kinematics:
e.g. Bates et al, 1979; Smith et al, 1986; Novick and Kelly, 1990; McCulloch et al, 1993; Stell & Buckley, 1998; Leung et al, 1998; Genova & Gross, 2000; Nester et al, 2001; Woodburn et al, 2003.

Foot orthoses "work" by altering the forces at the foots interface. These kinetic changes result in changes in the stresses within the tissues of the foot and lower limb. If designed well, a foot orthosis can lower the mechanical stresses within a pathological tissue to enable that tissue to heal. While kinetics drive kinematics, pronation does not necessarily need to be "controlled" to achieve this. I am somewhat surprised that the idea of the need to control pronation and moreover, that orthoses need to do this is still being perpetuated in 2012.

Anyway, how many studies of foot orthoses have demonstrated a negative clinical outcome? How many studies of foot orthoses have demonstrated a positive clinical outcome? What does the balance of evidence tell us?

Some excellent points made by Drs. Kirby, Richie and Spooner. The practical application of this argument is that in the U.S. in the last six months, the minimalist shoe market has taken a beating, with a drop in sales of over 40% reported by the American Sporting Goods Buyers Association. The cynic in me tells me that all those people who bought into a fad with no science and not a lot of sense, got injured and never went back to that product.

However, It seems I still cannot open a newspaper or an online running blog without hearing the term “minimalism”. And the problem I have reading about this is that most of what is said is based on folklore and conjecture, with very little or no basis in the hard cold world of footwear science. The cherry picking and confirmation bias is world class.

So, in an attempt to bring some sanity and accuracy to this discussion, let’s try to dissect the argument with some logic.

Firstly, the world of sports medicine and science, and indeed just about every field of human endeavor, likes to work within frameworks and definitions. Frameworks and definitions offer us systems of checks and balances against which we can measure outcomes. Without these, we are merely speculating, or worse, guessing.

So what is the definition of ‘minimalist” or “minimalism”? Well, herein lies one of the biggest challenges of this discussion, because, to put it bluntly, there is no definition, no description, no framework, and so no understanding of what this oft-used term actually means.

Unfortunately, the term minimalism has somehow been endowed with magical powers that promise an athlete injury-free running (see Dr Campitelli's article on this blog), a back to prehistoric man experience, better connection with Mother Earth, and, best of all, an instant transformation to “perfect running form”... whatever the heck that is!

I really would appreciate if Dr. Campitelli could give me a clear definition of what "proper running form" is, and how he is able to apply this to every runner on earth, no matter their body mass, gender, height, athletic ability, injury history, biomechanics etc etc. The absurdity of such a claim should be evident to anyone with an ounce of analytical ability and scientific knowledge.

So let’s get our facts straight here.

1. Every single athlete is an experiment with a sample number of 1. In other words, every athlete is different and will have different requirements in running shoes along the continuum of stability to maximum support, minimalist to barefoot. There is NO one size fits all and there is no magic bullet with any category of running shoe or barefoot running

2. Experimentation is good, and mixing the signals from foot to brain with less structured footwear, worn judicially along with ones usual training shoes, or, even introducing careful running barefoot on grass, is an excellent idea and may be important in injury prevention.

3. The notion that today’s “minimalist footwear” ( i.e. marketed, and marketing is the key word here, as greatly reduced midsole height or even “zero drop” shoes) are somehow substantially different or better than racing flats that have been on the market for many years is false and misleading. Racing flats are extremely lightweight, low to the ground and flexible, and by any sensible description would be considered excellent "minimalist” shoes. There have always been outstanding racing flats available in many company's ranges along with others that offer support, protection and comfort that will never be "minimalist"... whatever that is!,

4. It is critical to understand that these shoes, just like every so-called minimalist shoe on the market, are NOT designed for everyday training.They are racing flats ... designed for racing. it 'ain't rocket science! The risk of injury wearing this type of footwear full-time is just too great. Minimalist shoes are for minimal training and a tool to mix up the training session, or, strictly for race day. Simple as that!

Unfortunately Dr. Campitelli is pushing a dangerous trend in support of a company whose shoes were designed for water and adventure sports, but somehow morphed into a running product. That fact along should render this discussion completely void.

Simon Bartold said: "I really would appreciate if Dr. Campitelli could give me a clear definition of what "proper running form" is ... "

I too am intrigued by this notion of "proper" presumably as opposed to "improper running" form.

Of interest here is the research on leg stiffness during running. In their 1998 paper "Running in the real world: adjusting leg stiffness for different surfaces" Ferris, Louie and Farley demonstrated that leg stiffness (kleg) is modulated in response to variation in surface stiffness (Ksurf). In light of this and other studies such as the Kerdock et al. 2002 study (Energetics and mechanics of human running on surfaces of different stiffnesses), it becomes pretty clear that the body subconsciously alters Kleg in response to variation in Ksurf in order to maintain a metabolically efficient gait and a fairly constant displacement pattern of the center of mass.

In order to do this, the body alters the lower limb kinematics, for example by increasing knee flexion on stiffer surfaces and decreasing knee flexion on more compliant surfaces. If "running form" is somehow related to the movement pattern of a runner, then such "form" is partly dependent upon the environment (the environment being all non-genetic factors and includes running shoes, foot orthoses, terrain, etc.) and may alter as the runner transitions between environments, types of shoes, etc.

If we accept Simon Bartold's contention that each runner is basically unique, then we could say that "proper running form" (P), if it were quantifiable, should be seen as a function of the genotype of the runner (G) and the environment (E). From this, we can provide a simple additive quantitative genetic-type model:

P= G + E + (GxE) in which (GxE) represents interaction between the genotype and environment.

Thus, proper running form should not be seen as constant and is unique to the individual in a given environment at a certain time.

Since it would seem reasonable that the body doesn't want to injure itself, and that the natural, subconscious, self-selected "running form" appears to be metabolically efficient for a given environment, it might also be reasonable to suppose that conscious attempts to modify this "form" might increase metabolic cost and the risk of injury. But I shall await the prospective studies to dispute this hypothesis before proclaiming that changing running form is either a good or bad thing in terms of injury prevention.

Of all the runners I see in my clinics, it is fair to say I have never seen two who are identical. Individuals seldom have the same structural anatomy nor the same dynamic/functional movement patterns. They also tend to have differing training regimes and goals.

It is also well documented that variation between people in foot kinematics is high and normal (full reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695812/pdf/1757-1146-2-18.pdf)

With between-subject variation so unequivocally clear, please do forgive me if I seem reluctant to accept that any one way of running could possibly be the panacea for all. To suggest that forefoot striking is the best way for everyone to run is ill-informed at best (and dangerous at worst).

To answer the question for a second time, as well as to reiterate the disclosure that has now been mentioned twice by Podiatry Today, I am an unpaid Medical Advisor for Vibram USA but I do not work for Vibram USA, New Balance, Newton Running, Merrell, Nike, Vivobarefoot, Saucony, or any other running shoe company that manufactures minimalist shoegear.

So what is the driving force behind my agenda? Enthusiasm and the Hippocratic Oath. My life was changed by learning how to run efficiently and properly and I wish to help others achieve this.

Obviously, we have created a discussion board to make allegations about who is right or who has cited or not cited references properly.

I wish I had the time to respond to each and every critique that was posted in regard to this latest blog but unfortunately I can't at the level of thoroughness that I strive for.

What I would like to say is:

1.  I am not selectively choosing articles (or as it has been referred to as "cherry picking") to promote an agenda for Vibram USA. They have no influence or prior knowledge of anything that I write or publish.  

2.  I have not contradicted myself with respect to striking with a plantarflexed foot. When a positive drop heel is introduced to a foot that is already plantarflexed, it inhibits the ability of the "foot" (not subtalar joint) to pronate and convert direct force to rotational force. It is simple physics.

3.  In response to the allegations that I made an unreferenced statement in regards to focus on proper running form, New Balance has popularized and trademarked Good Form Running, which is being taught and discussed worldwide.  

Finally, we all have a right to an opinion and I appreciate everyone's interests and comments to my blogs. My opinions are not being influenced by monetary contributions from any shoe company and I ask that those allegations please stop as it is a waste of time on this valuable topic. Instead, I ask that you take the time and read the literature that I am referencing and ask questions.

To conclude, there is clearly no medical evidence to support the use of traditional running shoes in a manner that prevents injury to the foot. I am in no way placing my patients at risk by educating them on running form. I treat a large number of runners in my practice and take pride in helping them and reducing potential for injury. If I were doing more harm then good, I am pretty sure I would be able to recognize that. Also, I have no financial gain by recommending a New Balance Minimus and changing someone's gait, as compared to profiting from a custom or off the shelf orthotic. 

Nick Campitelli, DPM, FACFAS

A study which examined the differences in kinematics and kinetics in forefoot strike (FFS) and rearfoot strike running (RFS) can be found in full text here: http://w4.ub.uni-konstanz.de/cpa/article/viewFile/451/391

I quote: "It was shown that increased knee abduction and knee external rotation moments are directly linked to the incidence of Patellofemoral Pain Syndrome (PFPS) (Stefanyshyn et al., 2001). Consequently, FFS seems to be more risky regarding the development of PFPS than RFS. With reference to the peak power absorption in the MTP and ankle joint, the FFS may overwork the gastrocsoleus muscle group and increase the risk for injury such as Achilles tendinitis (Williams et al. 2000, Walther, 2005). Conversely, FFS reveals less peak power absorption and eccentric work at the knee compared to RFS, which may result in lower demands of the quadriceps muscle group (Williams et al. 2000)."

So, clearly these authors believed that FFS running may increase the risk of certain injuries and lower the risk of other types of injury, which makes sense when one considers the change in internal and external joint moments and the stresses induced in the tissues in response to these differing kinematic patterns. But what does the evidence tell us?

Dr. Campitelli cited a study in his original post, which "demonstrated a significant increase in injury rates amongst collegiate competitive cross country runners who habitually rearfoot strike in comparison to those who 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; epub Jan ).

However, the results of that study are in contrast to two large-scale studies that are discussed within the Kleindienst paper which I linked to above. They state: "Within a medical anamnesis of 471 runners, Kleindienst (2003) could not detect differences between RFS and FFS concerning the frequency of running-related injuries. The same is valid for the incidence of foot deformities. However, the location of foot deformities depends on the strike pattern and the related forces and loads. Based on an epidemiological survey, analyzing 1,203 runners, Walther (2005) came to a similar finding. There are no differences in the incidence of running-related injuries between FFS and RFS."

Thus, the risk of injury did not appear to ameliorated by FFS running in these two studies. Yet: " the location and the kind of injury and complaints are different".

This final quote reflects what I and I'm sure many of my colleagues who deal with running-related injuries see on a daily basis in clinical practice. Different kinematic patterns place elevated stresses on differing tissues. In other words, there's no such thing as a free lunch. It is through better understanding of this that one may improve clinical outcomes by working with patients in gait re-training, not by prescribing a FFS pattern as a panacea to all. It's all about picking the right horses for the right courses. Some people might benefit from forefoot strike running while others should perhaps avoid it like the plague. I have no doubt that gait retraining can be a useful adjunct but to suggest that forefoot strike running should be adopted by all is, in my opinion, shear lunacy.

Which brings us onto another concept within the "handbook of proper running form," that of cadence. The idea being that a runner should run at 180 steps per minute. I think this is based on the observations of Jack Daniels (a running coach, not the drink, yet one wonders) that runners above a certain distance tended to run at 180 steps per minute. How exactly does this protect a runner from injury?

Drs. Kirby and Richie are considered by most podiatrists to be today's premier podiatric biomechanical experts.

Dr. Campitelli, your conclusions seem to be a leap of faith, not based on accepted science. Maybe it is your lack of a working functional knowledge of Root, Orien and Weed? Your conclusions make little sense to me and fly in the face of the reality my patients bring to my office. It seems to me that you have gotten caught up in all the hype that comes along with most fads. Don't get me wrong. There is something to like about these fads. They have generated new patients. Even with that benefit to my practice, I can't, in good conscience, recommend these fad shoes, which appear to be less expensive to make but more expensive to buy!

If the free or minimal shoes are so great, why am I seeing more and more patients who say they did not have any problems running until they went from stability shoes to low heel minimal "powerpuff" shoes? Why is it that when my patients switch from all sorts of cushioned shoes (free and minimal, as well) to stability shoes, many of their foot, ankle and knee problems disappear? And the ones that don't, do, when they get a functional orthotic made from a plaster slipper impression?

While you did identify that an unstable STJ will cause excessive pronation in mid-stance, you failed to say that excessive pronation increases at heel-off. You didn't even touch forefoot misalignment.

I'll close with a few suggestions. Runners, be very careful who you pick to take care of your feet and ankles. Find a doctor who is an athlete. The biomechanical purists of podiatry do not use foam boxes or computer scans to make orthotics (where offices are given free scanners if they generate enough orthotics per month). We know plaster slipper casts are superior. Our patients prove it every day.

Podiatrists respectful of their patients do not hand their patient off to an assistant either. Casting is very difficult to learn and, in my opinion, cannot be taught to an office assistant. You are paying to see the doctor. Insist that it is he/she that takes care of you. If the first thing an office staffer does when you walk in is say that he or she needs to scan your feet (while someone is checking your insurance coverage), run, even if limping, to a podiatric sports medicine specialist.

Do running shoes still need heels? Of course they do, and laces too. And yes, wear socks for Pete's sake.

Dr. Campitelli,

I am somewhat bemused that you would make the statements you have above. Let's spend a few moments examining your original posting and the gross misrepresentations you have made.

You stated, "There is evidence that demonstrates most elite runners who are finishing first and running faster are landing on the forefoot.3,4 " You have referenced the Hasegawa (2007) and Larson (2010) studies as support for this statement.

Let us be clear. Both Hasegawa et al. (2007) and Kerr et al. (1983) observed more midfoot strikes among the faster runners in their samples. Although midfoot strikers had the fastest mean time to the half marathon point of the Manchester City Marathon, statistical analysis indicated that speed differences observed here among foot strike groups were NOT
SIGNIFICANT for either the 10 km or 32 km samples. Therefore .. there is NO such evidence as you state, and you absolutely have cherry picked the data to suit your own hypothesis.

Furthermore, the Larson study (2011) at NO POINT classified their cohort according to running speed. They made general observations in relation to previous studies and their finding that of 936 recreational runners, 88.9% were rearfoot strikers at the 10 km point , 3.4% were midfoot strikers, 1.8% were forefoot strikers, and 5.9% of runners exhibited discrete foot strike asymmetry, but the study never examined running speed. What this study DID find was that a comparison of foot strike patterns at the 10 km and 32 km race locations indicates that a high percentage of runners switched from a midfoot or forefoot strike to a rearfoot strike late in the race, presumably due to fatigue.

In other words, the authors presume that switching to a rearfoot strike pattern reduces fatigue. You call forefoot and midfoot striking "an efficient and natural way to run". How can that be if it increases fatigue as asserted by Larson et al.?

In your original posting, you mention "proper running form" six times. You still have not given me a definition of 'proper running form." You go on the make the extraordinary claim that "proper running form is the most important limiting factor in correcting overuse injuries." Really? Can you please provide me with the evidence for this statement?

You go on to state that "If a runner presenting to our office has dealt with any type of overuse injury that is chronic, we stress the importance of learning proper running form and educating the patient on forefoot striking." In the absence of your ability to define "proper running form," I would assert in the strongest possible terms that applying this logic to all runners is dangerous and irresponsible.

You go on to offer, as evidence of the teaching of running form, the comment that "In response to the allegations that I made an unreferenced statement in regard to focus on proper running form, New Balance has popularized and trademarked Good Form Running, which is being taught and discussed worldwide." The New Balance (NB) website is hardly an academic forum and the font of all wisdom in relation to "proper running form," a term incidentally that New Balance never, at any point, uses. The are espousing the term "good running form," and in no way is the company indicating it is the gold standard or somehow carved in stone.

An extract directly from the NB website states, "Landing on the midfoot, rather than the ankle, not only reduces impact on the knee – a common source of pain and injury – but also works with the other principles to encourage forward momentum for the body ... Landing on the midfoot (neither heel nor ball) helps to avoid injury caused by impact."

Wow! God help me if I land on my ankle for starters. Secondly, there is no evidence whatsoever that landing on the midfoot reduces impact on the knee. There is a thing called limb stiffnes that modulates that no matter what. Thirdly, there is absolutely no evidence that landing on the midfoot "helps avoid injury caused by impact." It does not and this is a case by case scenario anyway. Fourthly, the NB site talks only about midfoot striking. It never, EVER mentions forefoot striking but you teach that? Why?

In short, if you are taking the NB website as gospel, you have a way to go in terms of runner education.

Finally, you have made the statement, "There is clearly no medical evidence to support the use of traditional running shoes in a manner that prevents injury to the foot."

Man, am I tired of this stuff. Please review the literature. Traditional running shoes have been shown by numerous peer reviewed scientific studies to change:
joint moments
torques
pressure
accelerations
shock
input frequencies and force.
All have been implicated in the generation of overuse injuries. To ignore this fact is cherry picking at its worst. There is also no evidence that forefoot striking, "proper running form" (whatever that is) or minimalist footwear in any way prevents injury to the foot or any other part of the body. Time to stop.

Heel strikers tend to have a longer stride length than midfoot strikers even when running at the same pace per mile. Thus, the higher cadence. At the same pace, midfoot strikers have less of an impact spike with each stride. The hypothesis is that this results in less injury.

For a clear demonstration of the differences in ground reaction forces (impact transients?) between heel and midfoot strikers, watch the short video from Nature.com. (Harvard Professor Daniel Lieberman) Jump in at about 1:50 to see the force plate measurements.
www.youtube.com/watch?v=7jrnj-7YKZE

Also, in regard to Simon Bartold's comment above:
"In the U.S. in the last six months, the minimalist shoe market has taken a beating, with a drop in sales of over 40% reported by the American Sporting Goods Buyers Association."

There is no American Sporting Goods Buyers Association that I could find in a Google search. Could you please cite the source of your statement?

Hi there,

I just wanted to clarify this quote in regard to the references: "There is evidence that demonstrates most elite runners who are finishing first and running faster are landing on the forefoot.3,4:" It appears that from the references, that is not true.

From reference number 3: "Among marathon runners, we found no significant relationship between foot strike patterns and race times."

From reference number 4: "The percentage of MFS was higher in the faster runners group."

Cheers,

Darren

From Reference 3: Rearfoot striking was more common among our sample of mostly recreational distance runners than has been previously reported for samples of faster runners.

Extrapolates to my inference that they are not forefoot (or midfoot striking - symantics) striking as the faster / elite runners are.

No, it does not!

You are simply making the features fit your own theory! You cannot extrapolate your own "inference" to someone else's published research. You have to do the research yourself to prove or disprove an hypothesis. That is the way science and research works, Dr. Campitelli.

Vern Walther wrote: "Heel strikers tend to have a longer stride length than midfoot strikers even when running at the same pace per mile. Thus, the higher cadence. At the same pace, midfoot strikers have less of an impact spike with each stride. The hypothesis is that this results in less injury."

That is indeed supposed to be the theory. However, a 2003 study by Laughton, McClay Davis, and Hamill (full text here: http://www.udel.edu/PT/davis/Strike_pattern_orthotic_shock.pdf ) reported that: "increased tibial accelerations were found in the FFS pattern along with increased peak vertical and anteroposterior GRF, greater anteroposterior GRF load rates, greater leg stiffness, and greater knee stiffness."

Obviously, the shorter stride length also means that these increased impact forces occur with greater frequency per mile in forefoot striking runners.

Simon,

One cannot extrapolate that FFS patterns have a greater GRF and this has been demonstrated numerous times in various studies. Specifially, Lieberman in 2010 demonstrated that the GRF in midstance is equal in both a RFS and FFS, with the absence of a transient impact in FFS leading to impact force being as much as 7 times less.

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 Jan 28;463(7280):531-5.

I am not extrapolating anything. Rather, I am quoting the results of a scientific study of differences in FFS and RFS running. I reiterate, Laughton, McClay Davis, and Hamill (2003) state:

"increased tibial accelerations were found in the FFS pattern along with increased peak vertical and anteroposterior GRF, greater anteroposterior GRF load rates, greater leg stiffness, and greater knee stiffness."

http://www.udel.edu/PT/davis/Strike_pattern_orthotic_shock.pdf

Your comment "these increased impact forces" does not accurately describe their findings as it is a generalization. There is more to it then just saying "impact force." But your point is well taken.

How is it a generalization? They reported higher peak vertical and anterior posterior shear forces and higher anterior posterior loading rates with forefoot strike running compared to rearfoot strike running. How are these forces not impact forces? They occur during the first half of stance due to the body impacting with the ground. Viz they are "impact forces."

The higher active vertical peak and higher anterior posterior shear forces and higher anterior posterior loading rates were also reported by Kleindienst et al. (2007), which begs questions of the notion that "braking" is reduced when running with "proper form."

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