December 2009

Is Barefoot Running Beneficial Or Detrimental?

By Lauren Grant, Assistant Editor

   With the emergence of new research and more footwear that simulates barefoot running, the debate seems to be intensifying in the podiatry community about the merits of barefoot running.

   In a recent study, published in the Journal of Sports Medicine and Physical Fitness, researchers assessed eight experienced barefoot runners and found that barefoot running led to more plantarflexion at the ankle, which facilitated a reduction in impact forces and shorter stride length. The study authors also found that a lightweight shoe (FiveFingers, Vibram) was “effective in imitating barefoot running conditions while providing a small amount of protection.”

   Another recent study, which appeared in the Journal of Biomechanics, found increased eversion of the forefoot with barefoot locomotion. The study authors also noted that shoes “restrict the natural motion of the barefoot” and “impose a specific foot motion pattern” during the push-off phase.

Assessing The Biomechanical Strengths And Potential Drawbacks

   Could the emergence of shoes that simulate barefoot running have an impact? Two podiatrists see pros and cons with these shoes when it comes to biomechanics and the training regimens of athletes.

    “Increased torsional motion of the foot will likely stimulate activity of the intrinsic musculature of the foot,” explains Doug Richie, Jr., DPM, a Past President of the American Academy of Podiatric Sports Medicine. “Stronger intrinsic muscles in the human foot could conceivably improve foot function and efficiency in running gait. However, this has not been proven in any credible scientific study.”

   Jenny Sanders, DPM, says barefoot running shoes are designed to promote forefoot contact over heel contact.

    “This does two things. It reduces the impact of heel strike, which improves shock absorption throughout the rearfoot and midfoot,” notes Dr. Sanders, who is in private practice in San Francisco. “(These shoes) also alter the center of gravity forward with the feet being centered below the hip, which is a much more stable alignment.”

   In terms of potential weaknesses of these shoes, Dr. Richie says a lack of cushioning may increase the risk of certain injuries. In his clinical experience, he has seen many running injuries that were “impact-related and could be related to shoes with poor cushioning.” However, Dr. Richie concedes that the literature is inconclusive on the cause-effect relationship between impact and running injury.

   He maintains that the lack of torsional stability in minimalist shoes will likely put strain on the plantar aponeurosis and increase the risk of plantar heel syndrome. Dr. Richie adds that the lack of heel elevation in these shoes will cause eccentric loading of the Achilles tendon and calf musculature. “In runners who have not adapted to this footwear design, the risk of Achilles tendon injuries could be expected to increase,” notes Dr. Richie, an Adjunct Clinical Professor of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.

   Dr. Sanders says a significant concern is the possibility that runners may see these shoes as a new fad and train without proper conditioning or assessment.

    “If the running shoe is not a match to your foot type and running biomechanics, injuries will occur,” notes Dr. Sanders. “In addition to shoes, I think too many runners have not been adequately coached in proper form. The best running shoe design in the world coupled with poor running form has little chance of benefitting a runner.”

In Brief

   The “Podiatric Success” interview series features regular interviews with podiatric legends as conducted by Bret Ribotsky, DPM. For information on upcoming programs and access to archived interviews, visit www.podiatricsuccess.com.

Will There Be Cuts To Medicare Reimbursement?

By Brian McCurdy, Senior Editor

   Barring a legislative solution, podiatric physicians may face a 21.5 percent cut in Medicare payments starting in January.

   In October, the Senate failed to pass the Medicare Physician Fairness Act of 2009, which would have averted the Medicare cuts. Several weeks later, the House introduced HR 3961, the Medicare Physician Payment Reform Act of 2009, which would repeal the sustainable growth rate (SGR) and prevent the 21.5 percent cut.

   As this issue went to press, the House Rules Committee had approved the resolution for a full House vote. In the past, Congress has passed emergency bills that delayed projected Medicare cuts for one year and the APMA believes there will once again be such a temporary legislative fix.

   What if the Congressional measures do not pass and the Medicare cuts of 21.5 percent go through? “I do not think I will be able to stay in business,” says Bret Ribotsky, DPM, who notes he has many Medicare patients in his practice in Boca Raton, Fla.

   As Dr. Ribotsky notes, the proposed Medicare payment cuts would not be offset with decreases in other practice costs as DPMs still have to pay full price for expenses like practice rent.

    “The only person who has to absorb the 21 percent pay cut is me,” he says. “I cannot provide quality care on $8 office visits and with a 21 percent pay cut, I would expect to receive an almost 40 percent reduction in my income.”

   If the Medicare cuts do come to fruition, Dr. Ribotsky predicts a “mass exodus from the Medicare system or even the practice of podiatric medicine” as well as protests on the part of doctors. As far as the effect on patients, he foresees a significant increase in amputations and hospital stays. “Foot care still needs to be done and if it is not provided prior to a problem, it will surely be provided once the problem develops, and you can bet it will cost more,” emphasizes Dr. Ribotsky.

   What reform measures might be able to stave off the problems with the Medicare system? Dr. Ribotsky, a Fellow of the American Society of Podiatric Surgeons, suggests being mindful of the costs of defensive medicine and not ordering unnecessary tests such as MRI for a neuroma. He also advocates reasonable tort reform.

In Brief

   Smith & Nephew, Inc., notes that the U.S. Centers for Medicare & Medicaid Services (CMS) has decided to maintain the current, single reimbursement code for negative pressure wound therapy (NPWT) components, including the canister and wound care set. This decision affirms the conclusion by the Agency on Healthcare Research & Quality (AHRQ), which noted that evidence does not exist to determine a significant therapeutic distinction between NPWT systems, according to Smith & Nephew.

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