Why Minimalist Shoes Do Not Create Injuries

Nicholas A Campitelli DPM FACFAS

The lawsuit against Vibram USA was for making false claims about its footwear product FiveFingers. The website touted many benefits. In particular, Vibram USA claimed your foot can become stronger by wearing FiveFingers. In my opinion, this is a true statement although it was not scientifically proven at the time the claims were made. A 2005 study sponsored by Nike demonstrated a strength gain in the abductor hallucis muscle of the feet after subjects ran six months in the Free shoe.1 We have since seen Miller and colleagues publish a similar study on the New Balance Minimus and Merrell Barefoot Glove, also demonstrating a strength gain in the abductor hallucis.2

My colleagues and I at the Kent State University College of Podiatric Medicine also have scientific data that we collected over the past two years that we are very excited to share as well. While this is a bit too late for this legal battle, it will certainly shed some light on what happens to our feet during normal locomotion in a pair of FiveFingers.

I have been very fortunate to interact with Vibram USA. I spent a lot of time assisting the company in foot education and, with the help of Lieberman, wrote a transition protocol/running brochure for helping others transition to running in this manner.3 I was never employed by Vibram USA nor did the company influence me in any way to endorse their product. I did not sell its product and I do not represent it in anyway.

I reached out to the company five years ago when the barefoot running boom began and explained that this is a great way to protect the feet of those who are running barefoot. It allowed natural running. It was a great product to wear that no one else was making. It was to our feet what gloves are to our hands. The shoes were so simple yet people thought of them as so “weird” looking. However, by wearing them, our feet could function in the normal manner in which they were intended and yet not be considered barefoot.

What Vibram has done for the foot and running industry is truly a milestone. Some may not realize it but they helped change the way we look at running now and, more importantly for me, how we look at foot function.

I was able to resolve a 10-year-old injury, which was the result of ongoing poor biomechanics indirectly related to my motion control running shoes.4 I used FiveFingers as a tool for learning how to run. I had been running since the age of 16 and was able to run professionally at the ages of 37-39 in a 5k, half marathon and marathon. This was not because I was wearing FiveFingers but because I learned how to run.

I guess I shouldn’t 
say I learned how to run because that could be misleading. I realized the previous shoes I was wearing were inhibiting my ability to run naturally and were altering my gait so much that I was slowing down, placing abnormal stress on my forefoot, and living with chronic pain. Eventually, my injury resolved on its own. The stress to my forefoot diminished as I acquired a more natural gait by running in FiveFingers. As with many, it took time, months in fact. But my changes were permanent and I have been pain-free since 2010.

Addressing The Vibram Claims And Lawsuit

So did Vibram make false claims? I do not feel the company did and I will explain why. Vibram was able to break into an industry that for over 40 years made the claim that our feet needed stability, motion control and cushioning to reduce or prevent injury. This industry not only sold this philosophy to the consumer but also to physicians, who then recommended it to their patients. The industry instilled this idea that shoes need to be fitted according to foot type with respect to arch height into all shoe manufacturers and then the idea passed down to specialty running shoe stores, retail sporting good stores, Runner’s World and other periodicals as well as healthcare professionals.

For the naysayers who will respond to this post with articles and claims that there is evidence, then why has the shoe industry changed? Why has the average drop height of shoes decreased by over 20 percent? Why has the flexibility of shoes increased? Why have the majority of all high-end running shoes companies introduced minimalist shoes (New Balance Minimus, Merrell Barefoot Glove, Nike Free, Adidas Adipure, Altra Running Company, Saucony Kinvara, Brooks Pure, and Skechers GOrun and GOMeb)? If the injury rates are still as high as 70 percent in traditional running shoes, then did these companies not make false claims as well?

Are you getting it? The shoes are not the problem. It is the training patterns and the way people run that create injuries.

The traditional running shoes with high cushioned heels and motion control midsoles are severely inhibiting natural running form so badly that a high percentage of runners are getting injured. Pronation has nothing to do with overuse injuries. I can list countless articles that demonstrate this (and will do so in a later blog post).

In my opinion, Vibram made no more claims than did the rest of the industry over the past 40 years. Look how many individuals bought shoes because they had a gel pad or air in the sole. Have you ever cut open an ASICS gel shoe to see the gel pad in it? There is more cushioning in the case for my iPad. If this gel is so crucial, then consider this. ASICS sells you a shoe with gel in the heel for “X” amount of dollars and if you spend a few extra dollars, you can get gel in the forefoot too. Is the company then liable for injuries to those who could not afford a shoe with gel in both the forefoot and the heel?

Who Or What Is To Blame For Injuries?

The same goes for the Nike shoes and all shoe companies. Consider a physician who recommends running shoes to a patient and he buys the “less expensive” model from the same brand. If this patient buys the $80 shoe instead if the $180 shoe, who is responsible for the injury: the shoe company or the physician? In other words, if the $180 shoe with more motion control and stability propaganda is necessary, why do they sell the $80 shoe? Shouldn’t the shoe companies be responsible for the injuries the $80 shoes created?

In my perspective, shoes do not create stress fractures. Overuse and osteoporosis do. Running in FiveFingers does not create plantar fasciitis. Overuse and weak abductor hallucis, abductor digiti minimi and flexor hallucis brevis muscles do.

Chris McDougall’s book Born to Run has sold over a half of million copies worldwide, was in the New York Times bestseller list for over 200 consecutive weeks and Amazon called it one of the 100 books to read in a lifetime. Should we sue him as well?

As we continue to run, we will continue to have injuries. Don’t blame a shoe company for getting injured. Not relying on support or motion control shoes is what makes the foot stronger. It just so happens that Vibram came up with a product that allowed this to occur.

Thanks for reading and we cannot wait to share the results of our findings very soon.

1. Potthast W, Niehoff A, Braunstein B, et al. Changes in morphology and function of toe flexor muscles are related to training footwear. Available at www.staffs.ac.uk/isb-fw/ISBFootwear.Abstracts05/Foot52.Potthast_ChangesI... .
2. Miller EE, Whitcome KK, Lieberman DE, et al. The effect of minimal shoes on arch structure and intrinsic foot muscle strength. J Sports Health Sci. In press. Available at http://www.sciencedirect.com/science/article/pii/S2095254614000374 .
3. Available at s3.amazonaws.com/VibramFiveFingers/Barefoot_Running_Brochure_R13_062211.pdf .
4. Available at http://www.drnicksrunningblog.com/running-with-sesamoiditis-how-i-resolv... .

Editor’s note: Dr. Campitelli has disclosed that he is an unpaid Medical Advisor to Vibram USA. This blog originally appeared at http://www.drnicksrunningblog.com/ .


Again, use of the 'wishful thinking' fallacy.

How then, do you explain all the injuries that happen in those using minimalist shoes??

How do you explain:
Grier et al (2013) looked at 1332 soldiers of which 17% were wearing minimalist running shoes. They found “When controlling for personal characteristics, physical fitness, and a history of prior injury, there was no difference in injury risk in the previous 12 months between soldiers wearing minimalist runners shoes compared to soldiers wearing traditional running shoes“.
Warr et al (2014); 1027 soldiers; no differences in injury rates between heel and forefoot/midfoot strikers
Kleindienst (2003) was a retrospective review of 471 typical runners that found no difference between rearfoot and forefoot strikers concerning the frequency of injury.
Walther (2005) was a retrospective review of 1203 runners that also found no difference in incidence of injury between rearfoot and forefoot strikers in the rate of injury.
Warr et al (2013) assessed 342 soldiers and after assessing their foot strike pattern, 13% were classified as non-heel strikers. They found no differences between the injury rates and days lost from injury between the heel strikers and non-heel strikers.

Of course, Vibram made false claims. Read the judgement from when Vibram filed last year to get the case dismissed. The judge rejected their motion and pretty much accused them of lying and doing so deliberately. Vibram claimed that there was "ample" evidence to support the claims they were making. There have now been 8 formal systematic reviews of the evidence on barefoot/minimalist running vs shod running and every single one of them has reached the same conclusion that there are no generic benefits. Vibram lied about there being "ample' evidence and mislead consumers. It is disingenuous to defend Vibram by attacking the other running shoe companies. They never claimed there was "ample" evidence. Vibram had no choice but to settle to avoid an epic fail and even bigger public relations disaster.

Care to explain why you reach a different conclusion to the overwhelming scientific evidence published in peer reviewed journals? My guess is that it is because: "Dr. Campitelli has disclosed that he is an unpaid Medical Advisor to Vibram USA." I guess this is a really embarrassing position to be in as someone has been giving Vibram some really bad advice about the claims that they were making.

Kevin A. Kirby DPM's picture

I find it rather odd that Dr. Campitelli is distancing himself from Vibram FiveFingers now that Vibram has been slapped with a $3.75 million class action lawsuit in which it was accused of making false health claims for their FiveFingers shoes. Dr. Campitelli previously had his photo on the Vibram FiveFingers Medical Advisory Board webpage. His photo now appears to have been taken down off the Vibram Medical Advisory Board website.

However, curiously enough, Dr. Campitelli still has his Vibram FiveFingers Medical Advisory Board membership listed along with the five "health benefits" of their shoes that Vibram lost their $3.75 million class action suit about for on this Vibram webpage.


In addition, Dr. Campitelli, along with Dan Lieberman, PhD, wrote a 24-page instruction manual for Vibram FiveFingers called "Running in Vibram FiveFingers: A Step by Step Guide".


In this manual, Drs. Campitelli and Lieberman basically instruct runners on how to not get injured by running in their shoes.

For those of you who are not aware of the long history of shoe manufacturing, there has never before in the history of athletic shoe manufacturing, or in the history of any shoe manufacturer for any shoe ever made, been a shoe company that needed to produce a 24-page instruction manual in order to make sure the customers wearing their shoes don't get injured using their product. This has never happened ... ever.

My only guess is that Vibram FiveFingers produced this manual, along with the help of Drs. Campitelli and Lieberman, to prevent even more runners from becoming injured in their shoes since the anecdotal reports of increased incidence of metatarsal stress fractures running in these shoes started four years ago as early as May 2010.


In addition, the scientific research clearly shows that Vibram FiveFingers shoes can cause injury and increase the risk of bone edema in runners.

Giuliani J, Masini B, Alitz C, Owens BO: Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners. Orthopedics, 34(7):e320-e323, 2011.

Salzler MJ, Bluman EM, MD, Noonan S, Chiodo CP, DeAsla RJ: Injuries observed in minimalist runners. Foot Ankle Intl, 33(4):262-266, 2012.

Ridge ST, Johnson AW, Mitchell UH et al: Foot bone marrow edema after 10-week transition to minimalist running shoes. Med Sci Sp Exer, 45(7):1363-1368, 2013.

With this all in mind, I am surprised that Dr. Campitelli can now make the statement about his relationship with Vibram as "....I did not represent it in any way."

If I had been a medical advisor for an instruction manual on a product that was found to be defective and for a company that had made false medical claims to the tune of 3.75 million dollars, I may also start back-pedaling away from my association with this product and company. Certainly, if Dr. Campitelli had advised Vibram to not list those false health claims of Vibram on their website and promotional literature, then he would be in the clear. But, obviously, from reading his blog article, he still doesn’t believe that his being a member of the Vibram FiveFingers Medical Advisory Board and advising Vibram FiveFingers on medical issues, ties him directly to this $3.75 million class action suit against Vibram FiveFingers and its false health claims that he still promotes.

Dr. Campitelli, I am very interested in hearing your explanation of how you can still support your position given the evidence above to the contrary.

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

Despite the fact that your client had to settle a lawsuit for false advertising, you continue to make irresponsible and reckless proclamations in your blog such as this statement:
"The traditional running shoes with high cushioned heels and motion control midsoles are severely inhibiting natural running form so badly that a high percentage of runners are getting injured." The question is: When will consumers begin holding health care professionals accountable for making such false and misleading statements on public forums?

Doug Richie D.P.M. FACFAS
Associate Clinical Professor, California School of Podiatric Medicine

Vibram is not my client. I do not understand that comment. I have provided the company help during a time when it was changing the way we look at shoe gear. Since then and during that time, I helped many other shoe companies as well. You can see this on my blog, where I review and test far more running shoes then FiveFingers.

Also, it is not very professional to wish lawsuits against your colleagues. I am trying to change the way we look at how we look at foot function with running and that controlling motion isn't always the answer. If we remain status quo, we may never see a reduction in running injuries or a decrease in the epidemic of planar fascists in the United States.

Nicholas Campitelli, DPM, FACFAS
Adjunct Professor, Kent State University College of Podiatric Medicine
Chief of Podiatry Department of Orthopedic Surgery, Robinson Memorial Hospital
Clinical Instructor and Attending Physician, Alliance Community Hospital Residency Program

Dear Dr. Campitelli,

My name is Javier Pascual Huerta. I am a Spanish podiatrist in Madrid and I did my PhD in biomechanics of the lower extremity here in Europe. I have been following the barefoot running discussion for a long time but never participated until reading this paper from you. Now I am forced to say something.

Because of the running barefoot movement, we have got more knowledge of running injuries and biomechanics of running in the last years and that has been a good thing for all of us. Honestly, as a podiatrist with a PhD in biomechanics and a recreational runner (12 finished marathons in the lasts 9 years), I can not believe you still doing the claims you do in your paper. You still claim that with the Vibrams, "feet could function in the normal manner". You perfectly know that talking about normal or abnormal is an impossible definition in the context of foot biomechanics. You talked about lot of scientific data you are getting but the only evidence you give in this paper is your case of foot problems (1 case) supposedly cured with Vibrams, the amount of books Chirs McDougal has sold and the amount of Vibrams sold in the last two years.

With all my respect, Dr. Campitell, that does not support its use in preventing injuries. In other words, that is evidence of nothing in the scientific environment of health sciences we try to move. You should be aware that the assertions you have made could be confounding and misleading for the lay audience.

Podiatry in my country is a small growing profession which is tightly looked after for other medical specialties. We need to work harder, study harder, make better papers and establish better evidence in our practice than any other medical profession in order to be minimally respected. As U.S. podiatry is our main reference here in Spain, I sincerely do not think that this kind of paper help podiatry in your country or mine.

Hope this discussion helps to improve podiatry as a profession and to gain respect from other colleges.


Javier Pascual, PhD, Podiatrist


Thank you for the comments. You are absolutely right with part of your thinking. In my view, there is no normal or abnormal function when speaking about foot biomechanics. That is the point I am trying to make. You picked up on that but misinterpreted just a little. Normal varies from one individual to another. Therefore, what is normal for you may not be normal for me. With that said, controlling motion with an orthotic device in the attempts to make the foot function is not warranted. If we are trying to achieve a specific position or anatomical position with an orthotic device, then we are placing the foot in what would be an abnormal position. You would have to agree as there is no normal position. If this is true, orthotics have no reason for being when it comes to runners and everyday function in patients with no pathology. I think this is where the debate begins. What is truly pathologic. I do not feel that what most say is pathologic and needs to be treated with an orthotics device is really pathologic.

As for my mentioning of scientific evidence, it's pretty apparent that when I list references, no one takes them as references. They are out there. I have listed them multiple times and cited and discussed them multiple times. If you have questions about any of them, please ask, but I do not feel the need to keep listing them. You have to remember, this is a new way of looking at foot function so there is not much literature written in comparison. Accordingly, it is very difficult to make a direct comparison in terms of what has been published in the past on running shoes and orthotics. The evidence out there though for orthotics and stability running shoes is not concrete and has not been shown to reduce injury either. You cannot argue that. There are multiple studies that demonstrate this.

Will this blog help podiatry? It is my hope to get more interest in this subject and help people to realize that by simply changing your running shoe or spending more money on the latest and greatest running shoe will not help a foot injury.

Dear Dr Campitelli,

Thanks for your reply. I would like to point a couple of things. You answered me "controlling motion with an orthotic device in the attempts to make the foot function is not warranted. If we are trying to achieve a specific position or anatomical position with an orthotic device, then we are placing the foot in what would be an abnormal position. You would have to agree as there is no normal position. If this is true, orthotics have no reason for being when it comes to runners and everyday function in patients with no pathology. I think this is where the debate begins. What is truly pathologic. I do not feel that what most say is pathologic and needs to be treated with an orthotics device is really pathologic."

This is absolute nonsense. I do not know why you are bringing orthotics into this discussion as we are discussing the theoretical benefits of barefoot running and injury prevention. Anyway, I completely agree that position is not pathologic. You know there is a huge amount of evidence that the effect of foot orthotics in foot and lower extremity position is minimal and variable, and there is also good evidence that foot orthoses alter joint moments more significantly than joint positions. Tissue stress is optimal in that approach BUT I do not see the connection with injury prevention in barefoot running.

Regarding the scientific data, I can not believe that in this post you have four references, one from your blog and one from McDougall's book. That is not serious in a scientific health profession and that was the point I meant when I told you that podiatry as a profession needs to be more serious in their papers and assertions, including this blog.

Finally, when you say "The evidence out there though for orthotics and stability running shoes is not concrete, and has not been shown to reduce injury either. You cannot argue that. There are multiple studies that demonstrate this." That is completely false and I can argue that.

Remember that we are seeing a huge increase in running habits and we have passed from marathons of 6,000 participants to marathons of 60,000 participants in 20 years. Now more and more people are training and more people are running. Do you really think that barefoot running would change the injury rates? We have no data (to my knowledge) to say that barefoot running could prevent more injuries than traditional shoes. Craig Payne pointed that nicely. In my personal opinion, barefoot running would probably increase the incidence of running injuries, but that is my personal opinion and I can be wrong. Again, personal opinions are not scientific evidence. Please do not claim something as scientific evidence when it is not because if you continue doing that, the scientific world will never take us seriously.

Thanks again for your response and your time.

Javier Pascual, PhD

Dear Dr. Campitelli,
I read your blog with interest and I have to say that I found no relationship between the title and content. I don't know yet "Why Minimalist Shoes Do Not Create Injuries".

As my colleagues have done, I've been following discussions about minimalist footwear for runners, especially those related with injuries. As you surely know, conflicts always arise among detractors and supporters of a specific product, mainly about products that are in fashion. However, when we are talking about a shoes that can produce an effect on users without a wide knowledge of foot and lower limb (body as well) function, we have to take special care.

There is enough data about related injuries and this kind of footwear (our colleagues have made references above).

One of your suggested questions is: Why have the shoe industries changed? Well, it is simple. They want to sell. The real question for me is: Were those shoe designs made before or after a real study of effects on foot and lower limb biomechanics? Foot and lower limb function is complex enough, and unfortunately there are many examples about claims of good health effects that over time have been not proven. Fashion is only fashion. Health is different.

I will be sure to read with interest the results of your findings that you'll share soon with podiatry community.


Carles Vergés
Department of Podiatry
University of Barcelona

Dear Dr. Campitelli,

I have been following the minimalist/barefoot debate for some time now and there are several items about Dr. Campitelli and this post that I feel demand an explanation and a verdict.

1. Now that Vibram has lost a lawsuit regarding their fatuous claims (which he was in involved in developing and disseminating), Dr. Campitelli appears to be distancing himself and more forcefully proclaiming his absence of a financial relationship with Vibram. A bit disingenuous at this point.

2. Dr. Campitelli seems to write and talk endlessly regarding biomechanics yet doesn’t appear to understand the terms at the basic level. He obviously does not grasp the difference between kinematics and kinetics in reading his previous posts and blogs.

3. “I had finally got it. It has nothing to do with the shoes. It’s how you run.” Why promote a shoe product at all then? Are you saying it isn’t the “maximalist” shoes either, it’s the running “style"? If so, you’ve spent quite a number of years denigrating traditional shoes and now again you are backpedaling and appear to be contradicting your previous writings.

4. “By adapting a midfoot/forefoot strike pattern, with shorter strides and landing with your foot below your body, the force that gets generated to the MPJ is reduced.” Care to show us proof? What about the many articles that disprove that, showing stress fractures and bone edema developing as a result of adopting a forefoot strike pattern?

Energy is neither created nor destroyed.

When you forefoot strike, you aren’t decreasing ground reaction force, you’re merely redistributing it elsewhere. Period.

5. As Craig pointed out, studies are consistently proving that there is no difference in injury rates in shod or barefoot runners.

I could go on and on but let’s begin with these five Dr. Campitelli. Personally, I think you should just apologize and say “we really didn’t know any of what we were saying is true. This is in fact true and now based on the evidence, I apologize if anyone was misled.



Kevin A. Kirby DPM's picture

Dr. Campitelli:

I simply don't understand how you can say that foot orthoses have not been shown to reduce injury. Don't you read the scientific literature at all?

Within the scientific research database, there are numerous prospective studies that show that foot orthoses can help heal and help prevent injury. Do you have any small scale or large scale prospective studies that show that minimalist shoes and running with a forefoot striking pattern heals or prevents injury? No. Because there are none.

My only explanation for your lack of confidence in foot orthoses and their therapeutic effects is that your training in foot orthosis therapy was suboptimal or you just must not have been paying attention to your professors. Please don't think that there aren't very many podiatrists around the world who do have the knowledge and technical skills to use both over-the-counter orthoses and custom orthoses to heal the injuries of their patients and also prevent new injuries from occurring, We cure people of their injuries all the time with orthoses, Dr. Campitelli, every day, every week, every year of our practices. I am sorry that you don't have that education or skill that many of us do have, since that education and skill would greatly affect your podiatric practice and your patient's lives.

Here are just a few very well-designed prospective studies which show that foot orthoses prevent and/or heal injuries. Please read them carefully, come back to us with your increased knowledge and then try to justify how you can claim that foot orthoses have not been shown to reduce injuries.

Franklyn-Miller A, Wilson C, Bilzon J, McCrory P. Foot orthoses in the prevention of injury in initial military training. A randomized controlled trial. Am J Sports Med. 39:30-37, 2011.

Collins N, Crossley K et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med. 43:169-171, 2009.

Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot. JAPMA. 96:205-211, 2006.

Finestone A, Giladi M, Elad H, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orth Rel Research. 360:182-190, 1999.

Simkin A, Leichter I, Giladi M, et al. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. 10:25-29, 1989.

Pham T, et al. Laterally elevated wedged insoles in the treatment of medial knee OA: a two-year prospective randomized controlled study. Osteoarthritis Cartilage. 12: 46-55, 2004.

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

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.


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.

Thanks for replying but I will stick to what the preponderance of what the evidence is saying rather than your cherry picking to support your wishful thinking.

The 8 formal systematic reviews that have been published by 8 different groups from 8 different professions in 8 different journals over the last 3 years do not agree with your interpretation of the literature. Not one systematic review or meta-analysis supports your view.

Evidence always tops the propaganda and rhetoric.

Dr. Campitelli:

I find it amazing how you can extract little tid bits from all of this great research to support your unusual point of view as a member of the Vibram Medical Advisory Board and co-author of the "Running in Vibram FiveFingers; A Step by Step Guide" along with Dan Lieberman. I believe you are better than Chris McDougall, the author of "Born to Run," at cherry-picking only the points that support your views. Of course, I do expect you to support Vibram since you gained some recognition by being associated with their website. However, I thought by now you would be more likely to be distancing yourself away from Vibram, like Dan Lieberman currently is, considering the company's current legal troubles.

Yes, minimalist shoes were very, very popular back in the 1970s, 1980s and 1990s, and contrary to your statement, Dr. Campitelli, all of us competitive high school and college distance runners from the 1970s (i.e. four decades ago) ran in minimalist shoes. Dr. Campitelli, you probably weren't born when I and tens of thousands of distance running athletes in this country were wearing minimalist shoes during workouts and during races. Except, Dr. Campitelli, we didn't call them "minimalist shoes," we called them "racing flats".

In addition, we could care less about foot strike patterns since we were only concerned about finishing ahead of the guys next to us, not about their "form" or whether they were rearfoot, midfoot or forefoot striking. By the way, in case you never raced competitively in high school, college or post-collegiately like I did for 40 years, the only thing that matters in racing is your time. You don't get extra points in a race for "style" or "form".

Just look at photos of Jim Fixx on the cover of his book, "The Complete Book of Running" from 1977 or look at Frank Shorter winning the 1972 Olympic Marathon or look at Shigeki Tanaka, the winner of the 1951 Boston Marathon (who won the race in a split toe minimalist shoe), before you start exclaiming that Vibram somehow invented the idea of "minimalist shoes."

Dr. Campitelli, I think it's time for you to review your running shoe history before you start bragging that your generation of barefoot/minimalist running shoe advocates invented something new over the past five years. You didn't invent anything new that has not already been tried and done before in the long history of running and running shoes. Please get your facts straight.

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

VFF and Dr. Campitelli did in fact invent something new: footwear that is shaped like natural human feet. None of the racing flats that Dr. Kirby is referring to were shaped like feet. They all got narrower from the ball to the tips of the toes. Dr. Kirby, how do you justify recommending running in shoes that are not shaped like human feet? Do you actually know what natural adult human feet are supposed to be shaped like? Of course you don't because you keep stating there is definitive evidence that orthotics "cure" injuries, but you always fail to control for the shoes, which deform natural foot shape.

Dr. Kirby, you need to learn some fundamentals of natural foot health, which are directly observable with the naked eye, without the need to look to the literature.
The footwear that you and most podiatrists put your orthotics into has been shown to have no evidence of effectiveness at reducing running injury. You are familiar with Craig Richard's study on PCECH running shoes so why do you still claim there is evidence in your current practice when there is not?

Too many of you have far too much invested in maintaining the deeply flawed current practices to be open to learning anything new.


I don't want to begin addressing my thoughts on this debate as it has gone to quite some length already. I think there is currently evidence both ways, which makes it pretty equivocal. One important consideration however is to make a CLEAR difference between what is being discussed here.

By that, I mean are we talking about HABITUAL barefoot and shod runners, or those that have transitioned/are transitioning/are new to barefoot running. I often hear the argument and we have seen several case studies of injuries as a result of running barefoot or in minimalist shoes, suggesting that "these shoes or running barefoot is dangerous".

This is true of course. Any NEW activity that redistributes the loads on the body and changes the point and rate of contact forces will be dangerous.

However, we have absolutely no long-term prospective evidence that running in EITHER conventional running shoes OR barefoot or minimal shoes can result in any higher rate of injury than another shoe.

Until then, your debate back and forth is irrelevant, since most of the claims are based from acute studies, retrospective analysis or indirect measures of injury.

Joe Warne


I agree with your comment that there are no long-term prospective studies that running in either conventional running shoes, minimalist shoes, or running barefoot results in higher injury rates.

However, we do have some short-term controlled scientific studies that clearly show that switching to minimalist shoes does cause increased injury rates. This scientific evidence certainly explains the recent increase in my office, and many other sports podiatrists offices, with runners who have become injured by listening to the barefoot/minimalist shoe zealots and then believing that running in minimalist shoes or running barefoot is better and produces fewer injuries than running in traditional running shoes.

I trained occasionally barefoot and in minimalist shoes as a collegiate long-distance running athlete in the 1970s, four decades before this barefoot/minimalist running fad took hold, and have been following running shoe design ever since. My experiences both as a competitive distance runner and sports podiatrist for decades have told me that there is no one best shoe for every runner and that the barefoot/minimalist shoe advocates simply didn't know what they were talking about.

With my running experience and clinical experience, I have no problems with runners deciding to either run barefoot, in minimalist shoes, traditional shoes or maximalist shoes. In fact, I tell my runner-patients that it is helpful to train in a variety of different shoes, or even run barefoot occasionally, to help them determine what works best for our bodies.

What I do have a problem with is individuals preaching that barefoot running or running in minimalist shoes produces fewer injuries and is somehow the best way to run. In addition, I have a problem with individuals preaching that rearfoot striking is a bad way to run and "proper running form" involves either midfoot or forefoot striking.

These individuals seem to have all drank the minimalist/barefoot Kool-Aid promoted by the half-truths writtten by Chris McDougall in his book Born to Run and then started preaching this Born to Run semi-fiction as the gospel truth to the masses without even considering the larger body of scientific evidence which clearly shows that running biomechanics, running shoe biomechanics and the biomechanical etiology of running injuries are much more complicated than telling everyone to ditch their running shoes and start running "naturally" like our ancestors did.

I am happy, however, that the barefoot/minimalist running shoe fad is now swirling down into the toilet of infamy. It is also good to see that a more reasoned approach to running biomechanics and running shoe biomechanics is now taking hold. All I can say is good riddance to the barefoot/minimalist shoe zealots that injured so many runners in their blind crusade to "return runners to nature." The scientific evidence continues to pile up against their ideas and they will hopefully not be hurting any more people any more as a result.

Kevin A. Kirby, DPM

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