Initiating a long-term conservative treatment plan for any patient can be a very difficult and challenging process for both the physician and the patient. When we ask runners to back off their mileage or stop running altogether for a period of time to overcome an overuse injury, they often look for other treatment options. Many times, this treatment option becomes a new running shoe. As these runners were presenting to my office with their bags of shoes and esthetics, and asking for new options, I felt it may be time to consider introducing the concept of "less shoe gear" and begin stressing proper form as a treatment option. This was two years ago. Since then, I have helped transition many runners into wearing a minimalist shoe and helped them overcome chronic injuries.  I would like to present a case study of a 35-year-old patient who wanted to begin training for her first marathon. Like many runners, she had an understanding of minimalist shoes but was not sure they were right for her. At the time of presentation, she had been running in an ASICS traditional running shoe with custom orthotics that were prescribed for her bilateral rearfoot valgus deformity, which was much worse on the right leg. She did not have a specific overuse injury. However, she was bothered by chronic low back pain and tightness as well as knee pain that increased in severity in correlation with an increase in mileage. She also ran with a traditional rearfoot striking pattern. To initiate this protocol to patients, the first step I take is education. I briefly review the current literature that demonstrates we have not correlated shoegear to reducing or preventing injury in runners. I encourage the runners to pick one shoe they are currently running in and continue to use this shoe throughout the entire transition process, regardless of how old the shoe is or how many miles it has been through. In my experience working with runners, cushion degradation becomes less relevant when runners assume a forefoot or midfoot strike pattern so the age of the shoe has little, if any, importance in preventing injury. If the patient continues to heel strike, this can potentially be detrimental in the long term.  I discuss running form with patients and in my practice, I have collaborated with a physical therapy center to perform a gait analysis and help patients to understand and change to a forefoot or midfoot strike pattern. This patient was heel striking so we first stressed the importance of learning to eliminate this and land on the forefoot. We advised her to continue her current training regimen but begin running portions of her runs without her orthotics as she was adapting to this style. Patients can best do this at the beginning of the run when the muscles are less fatigued. Midway through the runs, she had instructions to place the orthotic back in and finish the run. As the run nears completion, continuing to think about forefoot striking is important but not crucial as the body is still adapting so heel striking can be okay during this part of the transition. She admitted to doing more runs completely without the orthotic than we had suggested, but was not experiencing discomfort and had adopted the forefoot striking pattern rather easily.
At the same time, we had introduced minimalist shoegear to her. She chose two different types FiveFingers (Vibram) and the Minimus (New Balance) trail version. I advised her to follow a regimen that I had helped devise with Vibram USA for its educational literature for FiveFingers shoes. This program had her increase the amount of running in the minimalist shoe by 10 percent each week at the beginning of each run when fatigue is less likely to compromise form. Within approximately six weeks, she was able to run three miles comfortably and completely in each of the shoes she was wearing. Her preference became the Minimus because the FiveFingers were irritating her great toe where she had an incurvated nail plate. She was still doing her long runs (10 miles) at this point in her ASICS traditional running shoe, which had acquired close to 1,500 miles by then. Given the fact that she had now adapted a forefoot strike pattern, the cushion was not as important so she was able to continue wearing it. She did note, however, that it was becoming increasingly uncomfortable because the shoe was heavier and did limit her ability to maintain a forefoot strike as she sometimes found herself heel striking as she became fatigued on a long run.  After four months, she was ready to begin a marathon training program, which was of intermediate level and was over a four-month timeframe. Her question at this point was which shoe should she use for her long runs and eventually for the marathon. We had discussed switching to a more cushioned and supportive version of a minimalist shoe, but the need for adaptation to change arose again and she had greatly adapted to the Minimus thus far. We decided to continue progressing her long runs in the Minimus and during the 12- to 15-mile runs, and she would finish in her Asics. During this phase, she switched her primary shoe to the New Balance Minimus Zero street version and eventually had progressed to wearing it full time, and on shorter six- to eight-mile runs, she occasionally wore FiveFingers. At the present time, her mileage is maxing out at 40 miles a week and her long runs have progressed to 20 miles. She is comfortably running in the Minimus Zero, no longer is experiencing low back and knee pain and is maintaining a slightly sub-9:00 mile pace. Her progression is not unique nor is it coincidental. In my practice, I have seen many others achieve this transition in the last two years. What I find most fascinating in this particular case is that she has a moderate biomechanical deformity that one typically treats with a corrective orthotic. In this case, she was able to eliminateher back and knee pain, for which she had previously received a corrective orthotic. She also suffers from a mild genu valgum deformity and orthotics typically treat the medial knee pain that can be associated with this.
In this case, as a patient’s gait changes to a forefoot or midfoot strike pattern, what used to be considered a severe biomechanical deformity now becomes non-contributory in predisposing to injury. Obviously, this is one case presentation and more long-term randomized studies need to occur before this approach becomes more recognized. However, this case demonstrates that the transition to minimalist shoes can happen without injury in a patient with a flatfoot deformity. Editor’s note: Dr. Campitelli has disclosed that he is an unpaid Medical Advisor to Vibram USA.