Minimalist Shoes And Injuries: Keys To Diagnosis And Patient Education

Jenny L Sanders DPM

Footwear News reports that the emergent category of minimalist shoes represents between 10 and 20 percent of the business of runner specialty stores.1 Through July 2011, minimalist shoe sales have already totaled $30 million, up nearly twofold from the year-ago period. What this means to podiatrists is the trend toward minimalist shoe purchases is not a temporary flash in the pan phenomenon but rather a groundswell of change, at least for now.

As a result of this, it is incumbent upon podiatrists to familiarize ourselves with the history, major players and potential injuries associated with running in these types of shoes, and educate our patients accordingly.

History. Nike Free debuted in 2004 and Vibram FiveFingers debuted in 2006. However, it was not until the book Born to Run was published in 2009 that barefoot running took off. According to Footwear News, currently 19 distinct brands in the running shoe category offer minimalist styles.1 In addition to Nike Free and Vibram FiveFingers, other popular brands include Saucony ProGrid Kinvara, Saucony Mirage styles and New Balance’s Minimus line.

Players. In addition to retail stores, running clubs, personal trainers, gyms and even physical therapists are jumping on the bandwagon, touting the benefits of minimalist running. Unfortunately, few of these sources are sufficiently knowledgeable to properly evaluate or definitively recommend this type of running. As a result, more serious injuries are occurring than I have previously seen with traditional running shoes.

Injuries. At least once a week, a runner new to minimalist shoes presents to my sports medicine clinic with an insidious onset (usually three to four weeks) of osseous injury. The most common fractures involve the metatarsal bases (see photo at left) or the calcaneus. More severe than typical overuse stress fractures, these injuries almost always require non-weightbearing immobilization with crutches to heal. In 50 percent of the injuries, radiographic findings are unremarkable and magnetic resonance imaging is required for definitive diagnosis (see photo at right). The problem with these injuries is they start out as an annoyance and slowly build from discomfort to pain without a specific inciting event, causing the runners to continue training in spite of injury.

If you treat runners, it is important to know how to talk to them about minimalist running, especially since patients look to us as the experts.

In regard to the scientific research on barefoot versus shod running, Kevin Kirby, DPM, gave a great lecture on this topic and you can view this in four parts on YouTube with the following links:

1. Beaudry JE. How barefoot is changing retail. Footwear News, Sept. 19, 2011. Available at .


Dr. Sanders, in response to your Podiatry Today blog on minimalist shoes/injuries, I suggest
that you (re-) read McDougall's book. Injuries due to the running TECHNIQUE are RARE and never involved the rearfoot. Remember, the Mexican runners didn't even run in shoes but
usually barefoot, or with a piece of leather or tire rubber lashed to their foot. The TECHNIQUE is the secret to their injury-free success and ability to run ultra-marathons, even into their 70s!

They do NOT employ heel strike -- thus your calcaneal fracture above -- but instead strike on
mid- and forefoot, and have a shortened and slightly 'everted' (to the side) leg kick. This
means energy conservation and far less ground reactive force on impact. If American runners continue to run heel-toe in the new Minimalist shoes, bad things WILL happen.

By the way, I've educated many of my runners about this and have eliminated their fasciitis and shin splint pain as a result. 'Minimalist' running is ALL about technique and NOT about the shoes. Proof: truly minimalist running is BAREFOOT. I look forward to your response.


P.S. -- I'm writing a short article on this subject if you care to comment. You are correct that
podiatry is in a position and SHOULD be the ones to teach ... but we must KNOW it to TEACH it.

In response to your comment, barefoot running is an area of great interest for me. In fact, the superior calcaneal stress fracture MRI image is mine. In early November 2009, inspired by reading Born to Run, I decided to try barefoot running. I increased my mileage slowly, block by block, while running barefoot. Admittedly, stress fractures like mine are uncommon but they DO happen as a result of barefoot running. Overwhelmingly, the most common injuries I treat from this running style are metatarsal base fractures.

Since 2009, I have watched over 1,000 patients run both barefoot and shod at my sports medicine clinic and I agree that not all runners appear worse while barefoot. However, at present, there is no conclusive evidence that either proves or disproves the benefits of shoes or barefoot running, or links the mechanical characteristics of barefoot running to a reduced risk of injury.

The currently available literature suggests that barefoot running produces some potentially positive changes, mostly related to alterations in running form and kinetics. That said, it also points to a potentially large group of people who -- when running barefoot --- have a significantly increased risk of injury, especially when initially embarking upon a barefoot running regimen. These are the people who force a forefoot landing that leads to a huge strain on the triceps surae muscles and Achilles. I do agree with your point that some who continue to heel strike when barefoot running experience injury but I see this far less than those injuries sustained due to forced forefoot landing.

The key point is that barefoot running -- and running in general -- should be recognized as a skill, and it is clear that we do not all have the ability to acquire skills equally. Those who do not may be substantially worse off and the time taken to adequately adjust to the change in running form may be considerably longer, possibly leading to further problems.

Therefore, it seems to me that encouraging patients to attempt barefoot running as an alternative when they are dealing with an injury would be considered a reckless suggestion for any physician. Indeed, if they are experiencing injuries while running shod, I'd say it begs the question of whether they should even try barefoot running once they've returned to full health.

It is vital to recognize that huge differences exist between individuals and that some adapt very quickly to minimalist shoes or barefoot running. These people are often the ones who go and preach to everyone else to throw away their shoes. At the other extreme, however, are those who do not respond well and who, in my experience, are far greater in number. For reasons unknown, this group battles to run without traditional shoes and push through all the pain. It is not fully understood why some people adapt faster than others. However, in both cases, it is important to be careful about offering generalized information to patients who seek their physician's guidance.

For those biomechanically gifted individuals, barefoot running does seem a beneficial inclusion to their training regimen. It may be as part of a training program where barefoot running helps with adaptation because it loads the joints differently, activates muscles in different patterns, and therefore provides a good training impulse. For those select few, barefoot running or minimalist shoes will go on to become the "only way." For others, it will remain a training technique and that may be fine too. However, for the vast numbers of patients I treat weekly with significant injuries as a direct result of barefoot running (myself included), it is something to be avoided at all costs if they want to be able to run at all.

I completely agree with Dr. Sanders. Just saw the second stress fracture this week of a runner with plantar fasciitis who took the advice of the minimalistic shoe gurus. Seems Portland, Oregon is a hot bed for this problem. Even some track coaches are telling their runners that the forefoot strike first method eliminates stress on the foot so they couldn't possibly have a stress fracture. They must have the same training as Dr. Webb!

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