Do Running Shoes Still Need Heels?

Has anyone ever pondered the fact that almost every shoe we put on our feet contains a "heel”? This is true whether it is a $200 motion control running shoe or simply a dress shoe that has the ¾-inch heel to accommodate our perfectly hemmed slacks. Let's not leave out the eye catching high heels that we all tell our patients are biomechanically inappropriate.

Surprisingly, it's not simply 1 ½-inch pumps that can be wreaking havoc for our patients’ feet. It may very well be the majority of shoes that most of us are wearing.

Is the heel still necessary, especially in a “running” shoe?

The running shoe has many origins but many agree that athletic shoes began with a canvas top and rubber soled shoe that became known as a sneaker when U.S. Rubber used the brand name Keds to sell the first sneakers in 1917.1 The next major milestone came in the 1970s when William Bowerman and Phil Knight created the Nike running shoe. These early shoes had little if any cushion and for the most part had a negligible heel.

Over the next 40 years, we have seen the height as well as the cushion gradually increase. These developments inadvertently made runners adopt a “heel to toe” gait or “heel strike” when running. Bowerman and W.E. Harris authored a primer entitled Jogging: A Physical Fitness Program for All Ages in 1967.2 In this very popular book, they noted the most efficient way to run should be landing or striking on the heel first. The authors specifically stated that forefoot striking is incorrect and not the proper way to land.

Bowerman and Harris had no scientific basis for this explanation. Several years later, they went on to create a running shoe that contained a cushioned heel. They speculated that in order to run faster, one should stride longer and that by striding longer, runners needed to land on their heels. This is one of the “primitive” reasons for the introduction of a cushioned heel. As far as increasing our speed or becoming an efficient runner, we now know from the work of Daniel and colleagues that longer strides are not as important as cadence.3

This heel height has been referred to as “drop,” the distance in height between the heel of the shoe and the forefoot. Today, traditional running shoes have an average drop of 12 mm with the heel being 24 mm and the forefoot being 12 mm. This design encourages an unnatural gait, resulting in the heel hitting the ground first and followed by a rapid “slapping” of the forefoot.

A literature search will yield numerous articles discussing running biomechanics but unfortunately, we have yet to see any hard evidence as to what is the proper way to run. The majority of Root’s theories about running biomechanics involved heel striking first.4 However, that is simply what they were — theories. I agree that his work and publications are magnificent, wonderful and have meant a lot for our profession. However, we cannot use this as evidence-based medicine to treat our patients’ disorders in every aspect.

This can be very difficult to swallow but pronation as described by Root becomes irrelevant when we describe forefoot striking as we see pronation occurring with the entire foot and then ending just as the heel touches the ground. His definition, although described as movement of the foot, focused on the motion of the subtalar joint.4 Pronation in this manner becomes an ideal shock absorber, utilizing the motion of the midtarsal joints as well as the subtalar joint.

Root's evidence came from previous texts, examination of patients and cadavers to then create what he referred to as “normal values” for the given range of motions. Root never went on to produce any randomized trials or studies that could demonstrate that injury was more likely a result of not having the so-called “normal values.”

Ankle equinus is one specific pathology Root discussed that has become very important when discussing lower extremity injuries. Root described ankle equinus as the inability to obtain at least 10 degrees of dorsiflexion at the ankle joint.4 He also emphasized that when we assess the subtalar joint in a neutral position, the ankle joint should be at 0 degrees with respect to dorsiflexion and pronation. Root also noted that by having the ankle in a plantarflexed position, we see uncovering of the talar head and thus an increase in the propensity for the subtalar joint to become hypermobile.

Interestingly enough, what happens when we place our foot in a traditional running shoe? We plantarflex the ankle joint and function with our foot in ankle equinus. We spend so much time educating patients on the effects of ankle equinus and runners abandon it all within seconds by lacing up a traditional running shoe.

Editor’s note: Dr. Campitelli has disclosed that he is an unpaid Medical Advisor for Vibram USA.

References

1. Available at http://news.bbc.co.uk/sportacademy/hi/sa/athletics/features/newsid_39350... .

2. Bowerman WJ, Harris WE. Jogging: a medically approved physical fitness program for all ages. Grossett and Dunlap, New York, 1967.

3. Daniels J.T. Daniels’ Running Formula, Second Edition. Human Kinetics, Champaign, IL, 2005.

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



Kevin A. Kirby, DPMsays: January 24, 2012 at 8:25 pm

Dr. Campitelli,

It is interesting that you say, in your article, that "The majority of Root’s theories about running biomechanics involved heel striking first"., referencing the book "Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot, Volume 2. Clinical Biomechanics Corp., Los Angeles, CA, 1977"

Having read Root, Orien and Weed's book, "Normal and Abnormal Function of the Foot" a few times from cover to cover, I don't specifically remember where these authors talked about running biomechanics at all in their book. They discussed walking biomechanics in detail and discussed standing biomechanics but never once, to my recollection, discussed running biomechanics.

Please provide a specific page number from this reference where you can conclusively say that the writing from the text supports your contention that the "majority of Root’s theories about running biomechanics involved heel striking first" from this classic foot and lower extremity biomechanics textbook from Root, Orien and Weed.

Having attended many of Merton Root's lectures, and having read all of his articles and books, I don't believe he ever said or taught this concept that you attribute to him.

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

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Nick Campitellisays: January 25, 2012 at 1:31 pm

Thank you for the comments Kevin as it helps make this all very interesting.

I have to agree with you that Root doesn't specifically discuss running biomechanics in his text. However, if we discuss heel striking in general, we would then refer back to Root's theories of what the foot should or shouldn't be doing. The point that I was making is that for those who believe we should heel strike when we run typically refer back to how Root has described the gait according to heel striking.

You are correct. Root doesn't discuss running biomechanics. But the biomechanical community that I follow does refer to Root's definition of heel striking and phases of gait when they discuss running with a heel strike.

So to summarize, we have taken what Root said with regard to walking, combined it with the shoe industry advocating heel striking and then, with no real evidence-based medicine, have been allowing runners to heel strike as a general rule.

I am sorry to misquote Root. I should have made that statement that we apply his theories of heel striking to running biomechanics in runners who heel strike.

Thank you Kevin. Please continue to comment as it helps provide for continued discussion and reading! I really would like to chat sometime!

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Kevin A. Kirby, DPMsays: January 26, 2012 at 11:40 am

Nick,

We have now established that Root, Orien and Weed did not discuss running biomechanics or heel striking running in the reference you used in your article (Root ML, Orien WP, Weed JH: Normal and Abnormal Function of the Foot. Clinical Biomechanics Corp., Los Angeles, CA, 1977)..

Instead of guessing what a few authors said about proper running form in their book and then finding that they didn't say that at all, let's look at the scientific evidence regarding how runners choose to foot strike during running.

There have now been three fairly large-scale scientific studies that showed that heel striking is the preferred method of foot strike in the vast majority of runners.

Here are the studies:

753 runners were analyzed at 9 km point of 10 km and 20 km point of marathon races: 81% RF strikers, 19% MF strikers & 0% FF 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.)

283 elite runners analyzed at 9.3 mile mark of half-marathon: 74.9% RF, 23.7% MF and 1.4% FF 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.)

936 runners were filmed at 10 km point of ½-full marathon: 88.9% RF strikers, 3.4% MF strikers, 1.8% FF strikers & 5.9% asymmetrical 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.)

Therefore, the scientific research, to date, has clearly shown that between 75 to 90% of runners choose to rearfoot strike (RF) vs. midfoot strike (MF) vs. forefoot strike (FF). The key word here is that they "choose" to run this way. No one has either "allowed" or "not allowed" them to run this way. Runners choose how to run by themselves, not by some higher authority either "allowing them" or "not allowing them" to run with a certain gait pattern. The research generally suggests that runners will choose the most metabolically efficient and/or comfortable kinematic pattern of running gait for a given surface, for a given pair of running shoes (or no shoes) and/or a given running speed.

With these facts in mind, clearly showing that 75 to 90% of runners choose to heel strike vs. midfoot or forefoot strike during running, a very good argument could be made that heel striking running is the preferred method of running by the vast majority of runners because 75 to 90% of runners' central nervous systems have determined that heel striking running is the most metabolically efficient form of running.

Of course, with running shoes with higher heel height differential (i.e. heel drop), runners will tend to do more heel striking than midfoot or forefoot striking. If they are running barefoot, they will tend to avoid heel strike to avoid plantar heel injury. The central nervous systems of runners will self-select the kinematic pattern of running depending on heel height differential of the shoe, shoe sole stiffness and surface stiffness to name few factors.

It is up to sports podiatrists to therefore understand the biomechanics of running and running injuries so they can give their runner patients the best advice and best treatment to allow them to run comfortably without injury, and not be so fixated with the heel height differential of running shoes as being the most important factor in producing healthy, injury-free runner patients.

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

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Nick Campitellisays: January 28, 2012 at 8:32 am

Dr. Kirby,

Thank you for the references you have provided me.

My vision is that of a healthy athlete, not an "elite" athlete. Sometimes, the assumption is made that elitism is superior. However, it can be a very subjective belief.

In regard to the studies you have provided ...

The Larson study demonstrated recreational runners were more likely to use a rearfoot strike pattern 88.9% of the time and agreed that this form was associated more with slower runners.

Hasegawa provided examples of elite runners who ran with a rearfoot strike 74.9% of the time. In their article, they agreed that more efficient and faster runners had a forefoot or midfoot strike pattern.

Kerr made reference to 81% of runners landing with a heel strike.

None of these studies took into account injury rates associated with the pattern of running. While I am not interested in producing a faster runner, these studies demonstrate that the midfoot or forefoot strike patterned runners do tend to run faster and more efficiently. We do typically associate efficiency with less overuse leading to less injury.

In summary, 75-90% of runners are heel strikers and without quoting every article published on running and injury rates, we know that over the past 40 years, we have seen injury rates gradually increase and have been published as high as 79%. (1. van Gent R.M., Siem D., Van Middlekoop, M. et al. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine. 41, 469 2. van Mechelen, E. Running injuries. (1992). A review of the epidemiological literature. Sports Medicine. 14, 320-335.)

My point is that what were are doing is not greatly helping runners if injury rates remain this high. Runners are not choosing to heel strike, they are forced to by what we have been teaching and allowing with exaggerated cushioned heeled shoes. Even a runner who is capable of forefoot or midfoot striking cannot run efficiently or properly in a traditional running shoe.

I do agree wholeheartedly Kevin that we should focus on producing healthy and injury-free runners. Thanks!

Nick Campitelli, DPM, FACFAS

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Jason Robillardsays: February 1, 2012 at 5:36 pm

Kevin,

I find it surprising that quite a few people quote the three studies you cite as evidence that a rearfoot strike running gait is preferred, but don't consider the effect of shoes on those particular studies. As you mentioned, heel striking seems to increase as a function of heel drop. As such, it seems logical to conclude the three studies are more or less useless as a measure of runner preference. They are heel striking because of the shoes, not because they've experimented and found it to be the most efficient.

It would have been interesting to see the same research conducted prior to the widespread introduction to the raised heel running shoe.

The ideal question should be: "Is one striking pattern superior to the other?" I agree, it is unlikely one pattern or technique could be considered best for all. Still, I seriously doubt rearfoot striking is the ideal for 75 to 90% of all runners.

Interesting discussion though.

-Jason Robillard
Nomadic Running Hobo

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Doug Richiesays: January 25, 2012 at 10:02 am

Dr. Campitelli,

You have misrepresented much of what Root has taught in regard to foot function. Root never speculated about the position of the foot in running gait. Also, you state that Root observed that when the ankle is plantarflexed, "we see uncovering of the talar head and thus an increase in the propensity for the subtalar joint to become hypermobile." Please provide validation that such a statement was ever made by Root in any of his texts or writings.

Doug Richie, DPM

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Nick Campitellisays: January 25, 2012 at 10:37 pm

Dr. Richie,

Thank you for the comment. I realize that you and Dr. Kirby are very much experts in biomechanics and in no way am I attempting to insult your knowledge or expertise.

I think at some point we would all agree that studying biomechanics almost resorts to an interpretation what can or does occur to the foot. We can set or define normal amounts of motion that occur to a joint but when the foot becomes a mobile structure, it is very difficult to definitively measure or analyze that motion.

In volume 1, on page 46, Root states that "Care should be taken not to permit the foot to markedly plantarflex during the examination. Plantarflexion will move the narrow end of the talus in the ankle mortise and permit some frontal plane motion in the ankle. This will produce measurements of increased range of motion ... "

While this increased range of motion is not directly occurring at the subtalar joint, it is creating increased motion in the frontal plane, which can lead to increased motion pronation of the subtalar joint.

In volume 2, page 315, Root discusses hypermobility and states that "Joint instability while the foot is bearing weight is called hypermobility.".

So, interpreting what has been stated above can allow one to make the statement that by plantarflexing the ankle, as seen with equinus, we create frontal plane instability, which during weight bearing could result in hypermobility to the subtalar joint.

Nick Campitelli, DPM, FACFAS

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Doug Richiesays: January 31, 2012 at 3:50 pm

Nick,

Thank you for clarifying your error. Root never stated that plantarflexing the ankle will "uncover the head of the talus" as you originally stated. Now, in this reply to me, you again make an erroneous conclusion about the subtalar joint when quoting Root.

The quote you provide on page 46 is relevant to the biomechanical exam, not at all speculating about how the foot is functioning in running gait. Yes, Root warns that plantarflexing the ankle may allow increased frontal plane motion IN THE ANKLE JOINT while never stating that this position will cause increased frontal plane motion of the subtalar joint. Root has cautioned that this increased frontal plane motion in the plantarflexed ankle joint could distort the findings of the biomechanical exam by giving the FALSE IMPRESSION that this motion was occurring in the subtalar joint. Nowhere in Root's teaching is there a suggestion that plantarflexing the ankle will increase motion in the subtalar joint.

You speculate that there would be increased motion in the subtalar joint when the ankle is plantarflexed and you specultate that this motion would be in the direction of pronation. To my knowledge, there are no kinematic studies of running gait which could substantiate this claim.

Doug Richie, DPM

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Nick Campitellisays: January 31, 2012 at 9:37 pm

Doug,

I did not "clarify" an error. During plantarflexion of the ankle, the talus becomes uncovered dorsally and then narrow portion of the talus in moved into the ankle joint. The term "uncovering" was initially utilized in a blog for the lay person who does not have an extensive background in biomechanics and I chose to keep the wording for the blog. It simply refers to the same process that was described in Root.

Also to clarify my SPECULATION or FALSE IMPRESSION:

1) During ankle plantarflexion, the foot itself becomes unstable. A prime example is increased propensity for an inversion ankle sprain when the foot is plantarflexed.
2) If we were to heel strike with a foot that already has a everted heel, we see a slight shift of the center of gravity medially (Root Vol. 2 page 117) , which will create pronation.
3) Combining instability in the ankle joint in the frontal plane and an everted heel at heel strike, the FOOT will have a greater amount of pronation, thus leading to increased pronation at the subtalar joint.

There are plenty of kinematic studies to support the above three statements.

Sometimes biomechanics aren't always a regurgitation of what is printed in black and white, but an interpretation of what can occur.

The point that I'm alluding to, without leading into my upcoming blogs, is that there is no biomechanical reason to add a heel to a foot that is functioning normal. If the foot is not functioning normally and requires a heel, then it shouldn't be running.

Thanks for the comments. It's a fun discussion!

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Nathansays: February 1, 2012 at 5:02 pm

Nick,
Thanks for your article. I am glad there are some podiatrists thinking along these lines.

I would like to know what the other doctors that commented on your article think about heels rather than what they think about your citation skills. There are some barefoot runners that are relaxing their insistence on forefoot/midfoot striking due in part to Pete Larson's work showing just how many people that run barefoot or in Vibrams actually heel strike. Pete L. and Jason Robillard (who teaches running clinics) have indicated that they think that as long as people land with their foot under their center of mass, that it doesn't matter if the heel comes down first. Pete's videos show a possible low impact force in these type of runners.

I am skeptical of this newfound relaxation of the insistence on fore or midfoot striking. I believe heel striking while running to be deleterious, but that might be a topic for later.

With regard to running in shoes ... I read one citation a while back of an older study that took into account the speed and distance runners traveled and showed that as speed increased and distance decreased, the propensity to forefoot strike increased. In essence, slow, long distance runners heel strike. Medium speed and distance runners midfoot strike. And fast, short distance runners forefoot strike.

Jason and Pete might be right. A slower, recreational runner doesn't really need to worry about how he or she is striking the ground as long as he or she is not bouncing up and down (i.e. creating large impact forces). How many runners are like that however? How many do not want to increase their distance and speed/times in the races they are running? I believe the majority of injuries happen when people start to push themselves beyond whatever conditioning level they have achieved. Then once they get faster, will they have the neurological ability to switch to midfoot strike? Or will the impact forces increase on their heels, causing them to buy shoes with more cushion?

I overheard one runner talking about her shoes: "They are like running on a tempurpedic mattress." Running in shoes like that, it is impossible to learn how to run softly and learn to use your natural shock absorbing abilities.

By the way, I love the part in your article where you say that in a forefoot strike pattern pronation becomes irrelevant and even desired as essential in shock absorption.

Keep it up.

Thanks,
Nathan

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Michael Dugansays: February 1, 2012 at 4:49 pm

I have no interest of debating whether or not a misrepresentation of Root's information occurred.

Getting back to the article, I find that there is a striking correlation (puns anyone?) between most modern running shoes and an increase in running related injuries. Were people simply not running prior to the 1970s? Though Root's theories are established and well accepted, I see nothing wrong in challenging the role they play in today's science. Any good evidence will stand up to some prodding.

With regard to the "preferred striking method of runners" in the study referenced here in the comments section by Dr. Kirby, I saw no mention of the type of footwear these runners were wearing. Might the footwear and not the runner dictate how one 'chooses' to foot strike? In other words, wouldn't a running shoe with a heel *encourage* heel striking and a shoe without an elevated heel encourage more of a midfoot strike?

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John Blenio, D.C., A.R.T.says: February 1, 2012 at 4:59 pm

I think Dr. Richie and Dr. Kirby are missing Dr. Campitelli's point in this article. The human foot functions best in its most biomechanically neutral state with neutral being, "without shoes."

Excessive heel strike is a result of excessive padding within the heel of shoes. If we are not wearing shoes ... as nature intends ... gait is (in most cases I'm sure) efficient and proper.

We should be designing shoes (especially for runners) that do not have more padding in the heel that in the forefoot. The padding (or protection) should be the same thickness from heal to toe.

I frequently work with patients who have foot and ankle problems. What I have found in almost all cases, is if they get on a therapeutic "barefoot" walking or jogging plan, their foot and ankle problems resolve rather quickly. As a matter of fact, I prescribe this therapy for people with knee, hip and low back pain issues.

Shoes are a great style compliment to clothing, and of course they provide protection for those who work in a profession where foot damage is a risk, but outside of that, they seem to do a lot of damage.

Why? The impact of excessive heal strike sends excessive force through the calcaneus and upward through the bones of the legs. Moreover, shoes have arch support. Arch support disengages the muscles of the foot, resulting in relative atrophy of very important muscles needed in gait and support.

I often use the following analogy as an example of the effects of muscle atrophy in the foot.

"The foot is our foundation just like the foundation built under your home. If you got a sink hole under the foundation of your home, what would happen? Your floor would tilt and perhaps even buckle. When the floor (foundation) is compromised, what is usually the next thing you see? You see cracks running up your walls and often to the ceiling of your home.

The foot is similar to the foundation of your home. If you compromise the stability and strength of the foot muscles, the foundation "shifts." Those muscles are your foundation. When they are weak, they improperly maintain stability of the structures above it, and the end result is either foot pain, ankle pain, knee pain, hip pain, and even back pain. Just like the cracks going up the wall of your home with a damaged foundation damage the geometry of the architectural structures, the damaged foundation of your foot causes a change in the geometry of the structures above it as well.

OK. Gotta go. A patient, ironically with foot problems, just walked in.

Cheers,

John Blenio, D.C., A.R.T.

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Elle Myerssays: February 1, 2012 at 8:06 pm

Just a good ole recreational runner here with a quick story:

Years ago, I fractured a bone in the middle of my foot while trail running in a very expensive trail running shoe. I saw an orthopedic specialist and finally a podiatrist. I wore a boot for six weeks and for the next year, I was prescribed every running shoe under the sun with different prosthetics, all at the expense of great pain and absolutely no recovery.

After declining a run with a friend and explaining the whole nightmare, they suggested barefoot running. On a scorching summer day in Houston, I walked out of my building barefoot and went for a full run along the bayou. The blisters (and later calf cramps) were nothing compared to the joy of a happy foot and a pain-free run. The very next day, I purchased a pair of FiveFingers (almost 3 years ago to the month) and ran in them for eight months straight before moving to Colorado in the dead of winter.

Fortunately, I transitioned nicely back into a trail running shoe but I truly believe it's because barefoot running taught me how to run properly. I went from heel striking and rolling to striking with the ball of my foot.

As long as I'm conscious of this in a running shoe, my runs continue to be mostly pleasant. I've noticed that knee aches return, a problem I don't have in the FiveFingers, which I use as much as the weather permits.

And the day they stop making the barefoot shoe, I'll happily go back to blisters.

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Doug Richiesays: February 1, 2012 at 10:57 pm

Nick,

Now I am really confused by your interpretation of "what can occur" in the biomechanics of running gait:

1. You correctly state that in a plantarflexed position of the ankle joint, there is an increased propensity for an INVERSION ankle sprain.
2. You then postulate that "if we were to heel strike" -- now you are suddenly assuming the ankle is in a dorsiflexed position -- with an EVERTED heel strike -- there will be shift of center of gravity medially to "create pronation."
3. You then conclude that the "combined" instability of the PLANTARFLEXED ankle (causing inversion instability) will occur simultaneously with a DORSIFLEXED ankle position at heel strike, and will somehow cause the foot to "have a greater amount of pronation, thus leading to increased pronation at the subtalar joint."

You also say there are plenty of references to support this observation yet none are provided. Forgetting the need for references or "citations" as you supporters suggest, I ask you to provide a sound rationale for foot and ankle function based upon current knowledge.

I guess my simple question is: How can a plantarflexed ankle with inversion instability also have excessive pronation, which would only be associated with a dorsiflexed heel strike pattern?

Doug Richie, DPM

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Dougsays: February 2, 2012 at 10:40 am

Doug,
Please keep in mind that when you heel strike, you have to let your foot come all the way to the ground. Yes, it will be dorsiflexed when you heel strike (initial impact) but the elevated heel causes a plantarflexed foot when your shoe becomes flat on the ground. The elevated heel is what increases the chances of an ankle sprain, not the initial heel strike.

He is not saying you sprain your ankle when your heel hits the ground. You sprain your ankle when your weak ankle can't support your weight in a plantarflexed position because of a squishy shoe with a raised heel.

Sincerely,
Doug

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Doug Richiesays: February 4, 2012 at 9:21 pm

Nick and Doug go to great lengths to condem the elevated heel design of running shoes because this positions the foot into equinus (i.e. a plantarflexed position of the ankle).mThey propose that this is an unstable position of the foot. Yet Nick and the barefoot enthusiasts advocate that a forefoot strike is more natural in running, which is a position of equinus (i.e a plantarflexed ankle)!

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Davesays: February 5, 2012 at 12:24 am

I will only comment on what I have experienced in my years of running. I started running in conventional highly cushioned running shoes from several of the companies we all are familiar with and have spent money on. I was always changing my brand of top of the line shoe in search of a shoe that would end my recurring knee injury. The pain and injury would occur every running season, the last time sidelining me for three months for therapy and recovery.

Then I read Christopher McDougall's book and started barefoot and minimal running. That was two years ago and I have not had an injury since.

My training now includes approximately 10-20% actually barefoot. I find that I need the barefoot time to keep my form natural and correct. The rest of my running includes zero drop shoes weighing 4-6 oz max. By far, my preference is for the barefoot runs but the trail conditions and winter weather make that impractical.

I realize what works for one runner will not work for all but I feel every runner who deals with constant pain and injury should consider starting over as nature intended.

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Robert Scott Steinberg, DPM, DABLES,FACLESsays: February 19, 2012 at 12:29 am

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 you lack a working functional knowledge of Root, Orien and Weed? Your conclusions make little sense 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! (Any surprises, so far?)

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.

John Blenio, D.C, I don't think you fully understand the biomechanics of the foot and ankle. Your flippant comments do not hide that fact. But that's okay. I don't expect you to know. It's not your specialty It's very complex, which is why there is a ... specific ... medical and surgical specialty of the foot and ankle that deals with it. Podiatrists are the only fully trained specialists of the foot and ankle. (And before you jump all over me, I do share offices with two DCs.)

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. Avoid "pseudo" foot "doctors". The biomechanical purists of podiatry do not use foam boxes or quirky 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 who takes care of you. If the first thing an office assistant does when you walk in is say 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.

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Peter Richardssays: November 9, 2012 at 7:40 am

Correct me if I'm wrong but have you not missed the whole point of the article here. It was simply questioning whether there is sound, scientific evidence to validate the inclusion of a heel in athletic footwear. Regardless if the author misquoted Root or not, the reality is there is NO evidence to support its incorporation into the athletic shoe period. You can debate this until you are blue in the face, but until further research comes to light, it is merely speculation that is it of actual use.

The issue with this whole barefoot debate is that is it argued mostly by parties at both extremes of the spectrum. You have the barefoot enthusiasts who for the most part are uneducated, have little to no scientific evidence for their argument and regardless of what others will suggest are deluded by their perception that because our ancestors ran without shoes, then so should everyone in the 21st century.

However in saying this, they are mostly avid runners, who by nature have developed a lifestyle around the activity of running. One could argue that the practical notion of running regularly gives them reasonable insight into what works and what does not.

On the other end, you have old-minded podiatrists, who sorry to rain on your parade, present their case with little to no scientific evidence also. Equally, the practice of podiatry is heavily based on unproven theories such as those originally presented by Root et al., whom by the way I'm sure never intended his framework for biomechanics to be used as gospel but rather to get people thinking.

In saying this, they have had extensive first-hand experience with running-related injuries of the foot and ankle. One could argue that this in itself provides an appropriate platform for their arguments.

Then there are the modern day, open-minded health professionals and running enthusiasts who accept that each individual is highly unique and, depending on their individual circumstances, may or may not be suited to one form of footwear over the other. Equally those who may be better off in a certain footwear approach may be limited by the amount of time they have, financial resources etc., to make significant changes.

So until further research comes to light, this issue isn't really worthy of debate.

I could end this post along the lines of ... "So all the tree hugging hippies stop preaching your mumbo jumbo and all you arrogant, old school health professionals stop grasping onto outdated theories, and throwing your academic title and fellowship abbreviations on the end of an online forum post," but this would devalue anything I have just mentioned in a similar manner to which your ongoing "barefoot debate" has been presented.

I'm quite sure I am not the only one feeling this way.

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