Point-Counterpoint: Barefoot Running: Is It Here To Stay Or Just A Passing Fad?

Author(s): 
By David W. Jenkins, DPM, FAAPSM, and Jeffrey A. Ross, DPM, MD

Barefoot running is here to stay.

Although there is no evidence demonstrating that barefoot running reduces injuries or improves performance, this author says many studies suggest unique, beneficial characteristics in the unshod runner.

By David W. Jenkins, DPM, FAAPSM

In the debate regarding barefoot running, advocates tout many advantages. Some of these are supported by evidence and some are anecdotal or based on logic. What follows is an overview of the so-called advantages of barefoot running and the currently available literature to this effect.

   Nonetheless, the final word on this topic is that there is no current evidence that barefoot running either reduces injuries or improves performance. However, there is also no evidence that it does not.

   Although barefoot running has been around as long as man has ambulated, a new interest has recently been stimulated in part by Christopher McDougall’s book, Born to Run: A Hidden Tribe, Superathletes, and the Greatest Race the World Has Never Seen.1

   In the book, he discusses the exploits of the Tarahumara Indians of Mexico and their ability to run ultramarathon distances with simple foot coverings. According to McDougall, the Tarahumara Indians reportedly have had few of the modern “running injuries” so commonplace in modern society.

   In fact, McDougall and other barefoot running advocates point out that the rate of running-related injuries has not improved and may instead be getting worse despite significant improvements in running shoes.2 The interest has also been fueled by Web sites packed with “studies” and much anecdotal testimony to the many benefits of running unshod.3

   Even prior to McDougall’s book, some researchers were investigating their belief that man is structurally designed to ambulate barefoot and biomechanical function is most efficient when unshod. They claim that years of highly supportive, motion-restricting and confining shoe gear have created an atrophy of the feet through disuse. In fact, researchers have noted that wearing shoes has resulted in greater impact forces and reduced proprioception.4-9

A Closer Look At Differences In Gait And Impact Forces

Gait differences. Before discussing some of the claims, it is important to point out that those who run barefoot have profound differences in their gait in comparison to those who run shod.

   The stride rate is higher and stride length is lower. Landing is farther forward with the ankle position more plantarflexed. The hip, knee and ankle all have a decreased range of motion in barefoot runners in comparison to shod runners. Contact and flight time are reduced in barefoot runners. These changes are very well supported by evidence and little argument exists that these changes take place.10-13

   What will become apparent as I review the touted advantages of barefoot running is that some investigators and barefoot running advocates have surmised that if these gait changes are occurring, then barefoot runners must have certain advantages.

   Reduced impact. Barefoot running advocates have claimed that the gait changes result in runners who are “lighter on their feet” and there is accordingly less jarring to the skeletal structure.

   Indeed, some investigators have found reduced ground reactive forces (impact) while runners are unshod and attribute this to an attenuation of forces in the musculature of the legs as well as a conversion of part of the lower limb’s translational kinetic energy into rotational kinetic energy.10,11,13,14

   Kurz and Stergiou believed that impact was in part reduced because an unshod foot, through its superior neurosensory feedback, was so much better at preparing the musculature for the next foot strike — the so-called coordinative strategy.15 They also believed the greater variability in the barefoot condition was a demonstration of this process.16

What The Research Reveals About Differences In Proprioceptive Ability And Plantar Musculature Strength

Increased economy. Running without shoes may result in a reduced energy expenditure of approximately 4.7 percent because of the reduced mass that must accelerate and decelerate during running.17 Likewise, running with a shoe requires energy to deform the shoe.

   Also bear in mind that some stored energy within the foot is lost to cushioning of the shoe. In other words, the shoe material absorbs some of the “spring in step.” When factoring out the reduced mass effect, some investigators have even considered that the actual changes in gait encouraged by the barefoot condition may result in reduced energy expenditure.18,19

   Increased proprioceptive ability. Many studies have demonstrated that an unshod foot has a much better feel for the supporting surface (position sense), which allows for an enhanced ability to adjust and readjust to the variations in terrain.7-9,16

   Increased strength of plantar musculature. Advocates of barefoot running reason that an unencumbered foot encourages a much higher utilization of the plantar intrinsics, which they believe atrophy when confined in a highly controlling and supportive shoe. In their study of children, Rao and Joseph demonstrated that unshod runners have better arch development and attribute it to stronger plantar intrinsics.20 Bruggemann and colleagues found an increase in the size and strength of plantar intrinsics in a test group that did warm-ups in Free (Nike) minimalist shoes.21

   Improved performance. Many of those touting the benefits of barefoot running believe that the changes in gait and energy usage in barefoot runners result in a smoother and more efficient gait. This may in turn lead to a more natural running style and better use of the musculature mechanically for an ultimately superior performance.

Do Barefoot Runners Have Fewer Deformities And Injuries?

Decreased risk of foot deformities. Studies demonstrate that children who go barefoot have better arch structure.20,22 Upon determining that shoe gear appears to constrain the natural motion of the foot, several investigators suggested this may lead to deformities.23-25

   Reduced injuries. If a barefoot runner has better proprioception through a more direct coupling to the ground, it stands to reason that the barefoot runner would be far less likely to suffer injuries related to balance and terrain irregularities (e.g., lateral ankle sprains). Indeed, several investigators have demonstrated that unshod athletes had significantly better lateral stability and ability to discriminate ankle inversion movement.26,27

   If the high rates of plantar fasciitis/fasciosis are due to constrained and resultantly weak plantar intrinsics due to wearing shoes, as barefoot advocates believe, then barefoot running should reduce or eliminate plantar fasciitis/fasciosis.

   For years, many clinicians and investigators believed that the high impact forces in running are responsible for numerous running-related injuries such as medial tibial stress syndrome, osteoarthritis of the knee, low back pathology, etc.28 The aforementioned gait changes as well as improved proprioception that allows for a finer kinesthetic tuning (position sense) to the running surface through adjustments to impact should reduce impact forces and result in theoretically fewer injuries.10 Edwards and co-workers suggested that the shorter strides in the barefoot runner may lead to a reduced likelihood of stress fractures.29

In Conclusion

A number of studies seem to support the aforementioned advantages of barefoot running. However, for the most part, those studies look at the barefoot condition and not barefoot running per se.

   Additionally, despite studies that demonstrate an altered gait pattern, stronger plantar intrinsics, reduced impact forces, improved proprioception and reduced energy expenditure, none of these findings support improved performance or a reduced injury rate. However, it is my opinion that when satisfactory studies can be compiled, those advantages that have thus far been extrapolated to result in reduced injuries and/or improved performance will, in fact, be found to actually do so.

   I believe barefoot running is here to stay because many coaches are increasingly incorporating barefoot running into their training programs in the belief that it does strengthen the feet and improve balance. I also believe future studies will validate some of the current claims made about barefoot running.

   Dr. Jenkins is a Professor of Podiatric Medicine at the Arizona School of Podiatric Medicine at Midwestern University in Glendale, Arizona. He is a Fellow and Board member of the American Academy of Podiatric Sports Medicine.

References
1. McDougall C. Born To Run: A Hidden Tribe, Superathletes, and the Greatest Race the World Has Never Seen. First edition. Ch. 2, Alfred A. Knopf/Random House, New York, 2009, pp. 16.
2. Van Mechelen W. Running injuries. A review of the epidemiological literature. Sports Med. 1992; 14(5):320-35.
3. Available at http://runningbarefoot.org/.
4. Robbins SE, Hanna AM. Running-related injury prevention through barefoot adaptations. Med Sci Sports Exerc. 1987; 19(2):148-56.
5. Robbins SE, Gouw GJ. Athletic footwear: unsafe due to perceptual illusions. Med Sci Sports Exerc. 1991; 23(2):217-24.
6. Robbins SE, Gouw GJ. Athletic footwear and chronic overloading. A brief review. Sports Med. 1990; 9(2):76-85.
7. Robbins S, Waked E, McClaran J. Proprioception and stability: foot position awareness as a function of age and footwear. Age Ageing. 1995; 24(1):67-72.
8. Robbins S, Waked E, Gouw GJ, et al. Athletic footwear affects balance in men. Br J Sports Med. 1994; 28(2):117-122.
9. Robbins S, Waked E, Rappel R. Ankle taping improves proprioception before and after exercise in young men. Br J Sports Med. 1995; 29(4):242-7.
10. Divert C, Mornieux G, Baur H, et al. Mechanical comparison of barefoot and shod running. Int J Sports Med. 2005; 26(7):593-8.
11. Squadrone R, Gallozzi C. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. J Sports Med Phys Fitness. 2009; 49(1):6-13.
12. De Wit B, De Clercq D, Aerts P. Biomechanical analysis of the stance phase during barefoot and shod running. J Biomech. 2000; 33(3):269-78.
13. Lieberman D, Venkadesan M, Werbel W, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010; 463(7280):531-4.
14. Divert C, Baur H, Mornieux G, et al. Stiffness adaptations in shod running. J Appl Biomech. 2005; 21(4):311-21.
15. Kurz MJ, Stergiou N. Does footwear affect ankle coordination strategies? JAPMA. 2004; 94(1):53-58.
16. Kurz M, Stergiou N, Blanke D. Spanning set defines variability in locomotive patterns. Med Biol Eng Comput. 2003; 41(2):211-4.
17. Avaailable at http://jhsearch.library.jhu.edu/databases/database/JHU03693
18. Divert C, Mornieux G, Freychat P, et al. Barefoot-shod running differences: shoe or mass effect? Int J Sports Med. 2008; 29(6):512-8.
19. Webb P, Saris WH, Schoffelen PF, et al. The work of walking: A calorimetric study. Med Sci Sports Exerc. 1988; 20(4):331-7.
20. Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br. 1992; 74(4):525-7.
21. Bruggemann G, Potthast W, Braunstein B, et al. Effect of increased mechanical stimuli on foot muscles functional capacity. Presented at the ISB Congress - ASB 29th Annual Meeting. Cleveland, OH: American Society of Biomechanics; 2005:553. Available at http://www.asbweb.org/conferences/2005/pdf/0553.pdf.
22. Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br. 1995; 77(2):254-7.
23. Wolf S, Simon J, Patikas D, et al. Foot motion in children- A comparison of barefoot walking with shod walking in conventional and flexible shoes. Gait Posture. 2008; 27(1):51-59.
24. Staheli L. Shoes for children: a review. Pediatrics. 1991; 88(2):371-5.
25. Morio C, Lake MJ, Gueguen N, et al. The influence of footwear on foot motion during walking and running. J Biomech. 2009; 42(13):2081-8.
26. Stacoff A, Steger J, Stüssi E, et al. Lateral stability in sideward cutting movements. Med Sci Sports Exerc. 1996; 28(3):350-8.
27. Waddington G, Adams R. Football boot insoles and sensitivity to extent of ankle inversion movement. Br J Sports Med. 2003; 37(2):170-4.
28. Hreljac A. Impact and overuse injuries in runners. Med Sci Sports Exerc. 2004; 36(5):845-9.
29. Edwards WB, Taylor D, Rudolphi TJ, et al. Effects of stride length and running mileage on a probabilistic stress fracture model. Med Sci Sports Exerc. 2009; 41(12):2177-84.

Barefoot running is a passing fad.

While the author encourages podiatrists to evaluate and pre-screen those who want to run barefoot on a case-by-case basis, he says changes in biomechanics and a lack of time to adapt to those changes can lead to injuries. He adds there is an elevated risk of other injuries with the exposed feet.

By Jeffrey A. Ross, DPM, MD

Barefoot running has become a popular new subset in the running community. Running barefoot is not a new experience for runners and, in fact, has been around for many years. Indians in South America would run from village to village barefoot. Long distance runners and even Olympic runners, Zola Budd–Pieterse from South Africa and the late Abebe Bikila from Ethiopia, come to my mind as barefoot runners.

   I remember covering the Jamaican Marathon for my Inside Texas Running magazine and watching the co-leader from St. Lucia kicking off his shoes at the halfway point and running alongside the Italian winner for the remainder of the race. I interviewed him after the completion of the race, saw those beat-up feet and wondered how he did it? He had been used to running barefoot and walking barefoot all his life. His feet were like leather yet the road and 13 miles still took its toll.

   Since the publication of Christopher McDougall’s best selling book Born to Run: A Hidden Tribe, Superathletes and the Greatest Race the World Has Ever Seen, the controversy continues.1 I do not wish to diminish the benefits already documented in a number of articles and studies on running barefoot. However, in particular instances, many runners would be at considerable risk running barefoot.

   I agree with Cheskin that the biomechanics of the runner’s foot strike are most important.2 With minimalist shoes or barefoot forefoot striking, the forefoot needs to achieve stability in order for the foot to resupinate and engage in propulsion. The midfoot and medial column also need to develop a rigid lever arm in order to create stability in midstance. If this stability does not occur (in certain foot types and runners), then compensatory conditions may develop in the knees, hips and lower back.

   Running on the ball of foot is not a new concept. Racers in training flats have been running that way for well over 100 years. The minimalist footwear, such as the Five Fingers (Vibram), the Newton or the Free 5.0 (Nike), does help to improve proprioception and balance, increase the strength of the plantar musculature, reduce impact forces and improve energy utilization.3,4

A Closer Look At The Risks Of Running Unshod

However, there are a number of potential risks to barefoot running. One is time to adapt. After having run with shoes all your life, there has to be a timeframe for adaptation to running barefoot or in minimalist shoes. Thirty minutes of daily barefoot locomotion is recommended in the beginning to allow for thickening of the sole of the foot and adaptation of muscles and ligaments.5 Researchers have also recommended that after increased barefoot walking, patients begin a slow progression to jogging and then slowly increase the intensity and duration.6

   In the case of a rigid cavus/forefoot supinatus type of foot, there is an increased risk of developing stress fractures when these people run barefoot.

   There are other concerns as well. When people run barefoot, there is no protection from glass, rocks, nails, cracks in the road, root stumps, insects and extreme thermal road temperatures as in the summer months. In the winter, the foot is exposed to cold temperatures and hazardous road surfaces (ice, snow), and frostbite could develop.

   Tendinitis conditions (Achilles, peroneals, posterior tibial) can develop due to a change in the biomechanics. For those with tight gastroc-soleus and hamstring muscle groups, as well as limited ankle joint dorsiflexion, Achilles tendon injuries or calf muscle strains can occur when patients remove the shoe heel. Runners with a history of osteopenia or osteoporosis are also at high risk for bone stress injury while running barefoot or with minimalist shoes. Young women who suffer from the female triad are also subject to a higher incidence of stress fractures in barefoot running and one should regard this as a contraindication.

   Runners with decreased foot sensation (neuropathy) are also vulnerable for injury and infection when they are barefoot. Therefore, barefoot walking and running is not recommended in this population.7 Runners with peripheral arterial disease and diabetes would be at high risk when running barefoot.

   Blisters are another problem to keep in mind. When people run barefoot, there is a greater chance for blister development since the foot, accustomed to socks and protection, now is developing increased friction and abrasion.

What Precautions Should Barefoot Runners Take?

When it comes to runners who intend to run barefoot, I believe one should evaluate and pre-screen these patients on a case-by-case basis. What may be a positive experience for one runner with the “perfect” biomechanics and foot type may be an injury waiting to happen for another. Training, preparation and core strengthening are imperative. The runner who is accustomed to running with a traditional heel strike will now find running with a forefoot strike completely different. This will take time to adjust and re-educate new muscle groups.

   For extreme pronators, particularly those with equinus, going without that midfoot support can result in strain of the plantar fascia and lead to plantar fasciitis and chronic arch pain. Patients with atrophy of the plantar fat pad, plantarflexed metatarsal heads and neuromas may develop increased pressure due to the forefoot strike. This may result in metatarsalgia/capsulitis and exacerbated neuroma pain.

In Conclusion

There are a number of anecdotal cases of barefoot runners that many of our colleagues have witnessed, including myself. I do not wish to claim that due to these observations, shod versus non-shod is correct.

   I do agree that using studies with evidence-based comparisons is truly the way to proceed before issuing a verdict on barefoot running. Utilizing computerized pressure and gait analysis to make an even argument may be one of the ways to research this topic scientifically.

   I have conducted a two-year research study looking at overweight youngsters and predicting their potential for developing overuse injuries with computerized gait analysis. Due to my research, I would suggest that barefoot running would put these overweight youngsters at increased risk for injury, particularly in cases of faulty lower extremity biomechanics.

   As a marathon runner who has completed 25 marathons and an orthotic wearer, I know what has “worked” for my feet. I remember being able to run barefoot when I was younger without difficulty. As we age and lose flexibility and the ability to compensate for our biomechanical imbalances, barefoot running may not be advisable.

   After having just completed the Houston Half Marathon recently, I saw a young female runner who had just completed the event and noticed she was wearing a pair of minimalist shoes. I asked how she did. Her response was, “I did fine until 10 miles. After that, it was brutal. I had a lot of pain.” Her explanation was that she had not adapted to the hard surfaces or the increased mileage with these shoes.

   Yes, I have seen stress fractures in patients using these shoes but I have seen these fractures with runners in traditional shoes as well. We should, however, advise our patients accordingly based upon scientific evidence, our experience in biomechanics and sports medicine, as well as our medical intuition. Advising our runner patients to make the right decision can afford them the enjoyment and benefits of running while helping to avoid injury.

What The APMA Advises About Barefoot Running

The following is a recent statement on barefoot running from the American Podiatric Medical Association.8

   Barefoot running has become an increasing trend, and a possible alternative or training adjunct to running with shoes. While anecdotal evidence and testimonials proliferate on the Internet and in the media about the possible health benefits of barefoot running, research has not yet adequately shed light on the immediate and long-term effects of this practice.

   Barefoot running has been touted as improving strength and balance, while promoting a more natural running style. However, risks of barefoot running include a lack of protection — which may lead to injuries such as puncture wounds — and increased stress on the lower extremities. Currently, inconclusive scientific research has been conducted regarding the benefits and/or risks of barefoot running.

   Dr. Ross is an Associate Clinical Professor of Medicine and Chief of the Diabetic Foot Clinic at Ben Taub General Hospital in Houston. He is a Fellow of the American College of Foot and Ankle Surgeons.

References

1. McDougall C. Born to Run: a Hidden Tribe, Superathletes, and the Greatest Race the World has Never Seen. First edition. Alfred A. Knopf/Random House, New York, 2009.
2. Cheskin M. The bare facts about bare footwear. Pod Mgmt. 2010; 29(8):139-147.
3. Nigg BM. Barefoot shoes, energy return and future development. Footwear Sci. 2009; 1(1):80-82.
4. Divert C, Mornieux G, Baur H, et al. Mechanical comparison of barefoot and shod running. Int J Sports Med. 2005; 26(7):593-8.
5. Robbins S, Gouw G, McClaran J, Waked E. Protective sensation of the plantar aspect of the foot. Foot Ankle. 1993; 14(6):347-52.
6. Yessis M. Explosive Running: Using the Science of Kinesiology to Improve Your Performance. McGraw-Hill, New York, 2000.
7. Hafner J, Burg G. Dermatological aspects in prevention and treatment of the diabetic foot syndrome. Schweizerische Rundschau fur Medizin Praxis. 1999; 88(27-28):1170-1177.
8. Available at http://www.apma.org/MainMenu/News/MediaRoom/PositionStatements/APMA-Posi...

Additional References

9. Warburton M. Barefoot Running. Sportscience. 2001; 5(3). Available at
http://www.sportsci.org/jour/0103/mw.htm
10. Jenkins DW. Advising your patients about barefoot running. Pod Mgmt. 2010; 29(9):59-64.
11. Ross JA. Osteoporosis-the fall that causes the fracture. Pod Mgmt. 2009; 28(5):195-204.

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