Point-Counterpoint: Minimalist Running Shoes: A Significant Advance Or Injuries Waiting To Happen?

Nicholas A. Campitelli, DPM, FACFAS, and Kevin A. Kirby, DPM

   When one lands with a forefoot or midfoot strike pattern, the toes are splayed and extended in preparation for landing when they will grip the ground to allow for the rest of the foot to then lower slowly to the ground. The flexor hallucis longus, flexor digitorum longus, flexor hallucis brevis, flexor digitorum brevis, abductor hallucis and abductor digiti minimi all play a crucial role in this process. If the toes are not feeling the surface, this hinders proprioception, making the recruitment of the aforementioned musculature very inefficient. This is the premise of the wider toe box that minimalist shoes tend to have. The less constricted the digits are, the easier it is for them to function.

   Root describes the foot as a mobile adapter when the subtalar joint is allowing for pronation of the foot.2 If a rigid midsole component of the shoe is preventing the “mobile adaptation” from occurring, where does this stress or force go? I would hypothesize it transmits to the lower extremity where the legs muscles have to work harder to absorb the force. The rigid midsole component prevents the mobile adapter from working.3

How Does Overuse Factor Into Injuries Associated With Minimalist Shoes?

If you look at the recent literature published on injuries associated with minimalist shoes, you will find one common theme: overuse.4,5 Despite the argument that we need to address biomechanical deformities with the proper shoe or orthotic, recent case reports suggest that documented injuries in minimalist shoes may be due to overuse without adapting gradually to the shoe gear.4,5

   Early recommendations have emphasized a gradual transition by running with this new style for no more than 10 percent of your weekly mileage and building upon that weekly.6 The premise is that you are learning a new running style and the muscles need to adapt. Putting on a pair of minimalist shoes and running six miles for the first time would be not much different than a person who has never run before putting on a pair of traditional running shoes and running six miles. They both are at risk for stress fractures and overuse injuries.

When The Author Incorporated Minimalist Shoes Into His Practice

Before introducing this philosophy of “shoe gear” to my patients, I obviously spent time reviewing the literature to see what existed with respect to current recommendations for shoe gear as well as running. Surprisingly, I do not feel there is much to support the use of running shoes as we know them today. Were our feet meant to work without shoes or were they meant to work with shoes that support the foot and prevent the necessary motion that should be occurring? It is my observation that if you keep running form constant, shoes shouldn’t matter. Before the 1970s, we didn’t put as much emphasis on shoes. It seems to me that we try to correct running injuries with shoes and inserts (custom or prefabricated) instead of working on form and training patterns.

   At the same time, I had been suffering from sesamoiditis for 10 years that was not responding to orthotics or traditional running shoes. I have come to realize the condition had existed for 10 years not because of the shoes I was wearing but because of the form they were indirectly forcing me to run with. The form — running with an outstretched leg, accentuated heel strike and an upright vertically positioned body — was creating tremendous force on my forefoot.

   After gradually transitioning to a midfoot strike pattern while running on a treadmill in Vibram FiveFingers (given they were the only option for minimalist shoes at that time), I was able to resolve my sesamoiditis after six to eight weeks. I then began introducing the philosophy into my practice.

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