Tackling The 10 Myths Of Barefoot Running

Author(s): 
Nicholas A. Campitelli, DPM, FACFAS

   Good Form Running in association with New Balance provides training to adopt this style of running and we can see that by developing forward momentum, we carry the contralateral limb forward instead of having forefoot propulsion.30 By doing this, we decrease the force present to the forefoot, especially the shear force. Not only is this beneficial for reduction of the shear force but we see a decrease in the ground reactive forces acting on the first metatarsophalangeal joint, which can reduce sesamoiditis.

   I run long distance and cannot do that barefoot. What many of us fail to realize is that we have been running for thousands of years and we know that early runners began running either barefoot or with very minimal shoegear such as moccasins.31 In 1960, Abebe Bikila won the Olympic Marathon in a record time of 2:15:16.2 while running barefoot.32 Zola Budd recorded numerous middle distance world records while running barefoot in the 1980s. Ken Saxton (well known among the subculture of barefoot runners) finished 14 marathons in 2006 unshod and has since completed a total of 56 marathons, including the Boston Marathon, all while running barefoot.33

   You could step on glass. This is my favorite excuse for not running barefoot. Numerous times, people ask me the question of “what happens if you step on glass?” There is debate on this topic among medical professionals as well as early adopters to this style of running. What is my answer? “Don’t step on glass.” This concept of “barefoot running” is not about what you are wearing on your foot. It is about how you are running and allowing the foot to perform the way it was designed and intended to perform. Once the form is perfected and the runner abandons heel strike (which runners can typically learn on a treadmill barefoot), the next step is to protect the skin of our foot while not compromising the proprioceptive feedback from ground.

   There are numerous options available that have recently become known as minimalist shoegear. FiveFingers (Vibram), Minimus (New Balance) and the Trail Glove (Merrell) are just a few of these shoes.

   FiveFingers has quickly become the market share leader due to its ability to allow the toes to function individually and allow full range of motion of the forefoot as well as the midfoot and rearfoot joints with a zero drop.34 Nike as well was one of the very first to introduce a less supportive shoe in 2004 known as the Nike Free.35 While this is a very flexible and non-supportive shoe, it does have a considerable amount of cushioning, which can interfere with feedback and increase muscle recruitment to provide control.

In Summary

Barefoot running is about learning to run the way our body was intended to using the foot as an ideal shock absorber and not relying on a shoe that compromises the anatomical position of the foot and places one at risk for injury. Using a true minimalist running shoe can achieve this and still protect the foot from the environmental dangers.

   Dr. Campitelli is a Fellow of the American College of Foot and Ankle Surgeons. He is board-certified by the American Board of Podiatric Surgery. Dr. Campitelli is in private practice at Northeast Ohio Medical Associates with various offices in Ohio. He is an Adjunct professor at Ohio College of Podiatric Medicine and is a medical Advisor for Vibram USA.

References

Comments

As a long time advocate of barefoot activity, I found this article to be very insightful and well-researched. Dr. Campitelli has clearly done his homework! I look forward to Podiatry Today continuing to explore the remarkable benefits of barefoot activity.

We will continue to see the ego driven fringe of the running community attempting to find an edge on their fellow runners. I can't deny there may be an edge but it is most likely just a psychological boost. Of course, I have no proof. Just my observations of the personality types who present with overuse injuries, minimalist or not.

I have seen otherwise injury-free conditioned runners coming in with new problems after they switched to minimalist shoes. Of course. you need to move into new things slowly and most of the accomplished runners have done so to one degree or another yet minimalist running has given them their first injury, and/or brought back one that has been cured.

If they are injured and running in minimalist shoes, my first instruction is wear the shoe I recommend. Often, they can try them on a treadmill in a running shop. Usually, they remark that the instant stability was remarkable and they could feel less strain on sore areas. After any necessary rest period, their biomechanics are revisited and, if a functional orthotic is indicated, they are casted.

One subgroup is the runners who went from a stability shoe with a functional orthotic to minimalist running. This group most often figures it out when their forefoot and or Achilles begins to hurt, and switch back. I hear about it eventually.

If asked, I will give the appropriate cautions to runners who want to try minimalist running and leave it at that. Last year, I saw a increase in the number of minimalist runners presenting with problems. None were new runners. I am looking forward to what this spring brings.

The epidemiology of an injury goes well beyond a few weeks or months of wearing a single type of shoe. If people switch from a cushioned, structured shoe with a heel wedge directly to barefoot or minimalist, they WILL display pain associated with biomechanical injuries that are already present. Injuries that have more than likely been present for years, but have been band-aided by cushions, arch supports and orthotics.

If they have a history of injury which returns upon transition, it merely suggests the injury was never truly resolved, only obfuscated by once again the same band-aid approach, and they did not go through a slow, well thought out transition, preferably using health professionals who are experienced with helping people make this shift.

Switching to a barefoot lifestyle allows the foot to work for itself. As the foundation of posture, this is vitally important in long term postural health and pain free movement. Barefoot running is not a cure-all. Ego driven people will always find ways to injure themselves regardless of what is on their feet. That is not what is being debated. Allowing the body to function naturally in a way that meets its design IS what is being debated. There is more than enough research and anecdotal evidence to prove this.

If you are dead set on maintaining the status quo (not that there is anything wrong with this), then you may not be the best representative for patients who are interested in making a shift to barefoot. You can best serve them by referring them out to a professional who understands the benefits of a barefoot/minimalist lifestyle and can truly help them transition.

Jesse James Retherford
www.tao-fit.com

It would be interesting to ask some of those runners questions about how they made the transition and if they have adapted their running style. While I am not a doctor (well, not a medical doctor), I have observed a number of runners at a local park getting the worst of both worlds. By this I mean, they have ditched their running shoes for VFFs but not altered their running style. It hurts to watch and it would not surprise me if they had more injury.

One metric in my very non-scientific observations is to open my ears. I am a very quiet runner and have to announce my presence to people ahead of me on the trail or they won't notice me until I'm abreast of them and then they about faint. When I get passed, I almost always hear the runner coming a long way away and it is always interesting to try and form a mental picture of the runner and their stride based on the sound I hear.

I wonder if the rise in injury for those in minimal shoes is at least partially explained by an increase in how many run in minimalist shoes.

I largely run barefoot but wear some very light sandals if it is dark (and hence I can't clearly see where I'm stepping) or on a more unknown or known to be bad place (like lots of busy intersections with glass from crashes). My transition was very slow. I went from 10 mile runs in running shoes to 100 yard runs totally barefoot. My increase up to 3-5 miles barefoot was spread out over more than a year. I attribute my lack of injury in the transition to the slowness of the transition and also to adopting a different stride.

VFFs are great but you forgot to mention running sandals/huaraches. They're lighter and more open even than FiveFingers. Several sites sell them preassembled (like lunasandals.com) or as kits that allow you to make your own (invisibleshoe.com).

As a minimalist, I've definitely heard almost all of these. I think you need to expand this to 11 as you forgot to mention the most common myth: "It's bad to run barefoot/minimal on asphalt."

Regarding the flatfoot don't need support thesis:

I've got flatfoot and a slight sprayfoot and started with minimalist running (Vibram FF) in order to see if I can improve my overall foot-shape. Now after nine months of running (two to three times a week, probably 50-60km a month), I had to visit a doctor since my left forefoot started to ache one day. I couldn't walk very well and it felt like I was walking on my metartasal head.

And that was exactly the diagnosis that I got. My third metatarsal head is pointing downward so that I actually walk on my bones when forefoot striking. Resulting in this, I also got an inflammation. I got insoles for my "regular" shoes and was asked to refrain from minimalist running since my feet need support.

So, what to do? I was not so pleased by the diagnosis. More because the doctor didn't have any sympathy with minimalist runners than with the fact that my actual foot shape got worse than better. Nonetheless, with wearing the insoles, the inflammation is slowly getting better but I guess there is no way that my metatarsal bones will get back into normal shape so that barefoot or minimalist running won't result into new problems.

When the inflammation has healed, I will have to make the choice whether to wear Five Fingers again or not. I don't actually like insoles since they are nothing more than crutches for your feet but with my metatarsal heads like this, I guess I need them actually. :(

I would like to get another diagnosis from a doctor that is more experienced with barefoot running but it's not so easy to find one here in Germany.

Thanks for this nice and rigorous post Nicholas.

To complete the first myth “Barefoot running leads to stress fractures” ...

According to many authors, traditional cushion running shoes, in comparison to barefoot, increase the load on the skeleton (tibia to lower back) (Rethnam 2011, Hamill 2011, Bergmann 2010, Braunstein 2010, Kerrigan 2009, Shakoor 2006, Divert 2004, Shorten 2002, 1996 Hennig, Bergmann 1995) but decrease the peak pressure on the foot (Rethnam 2011, Tessutti 2010, Wiegering 2009, Wegener 2008, House 2002, Windle 1999, Nyska 1995).

Like you said, if we protect a structure for a long time, those tissues will become less tolerant to the stress … and transferring to minimalism/barefoot/barefoot technic will increase the incidence of injuries if it is done too quickly… for the tissues that are more stressed than usual (foot and post part of the leg). But if it is done gradually, running in minimalist shoes or barefoot will strengthen those tissues (Robbins 1987, Bruggemann 2005, Potthast 2005)

Note that the systematic review of Zadpoor was significant on tibia stress fracture only. Like you, I think that the risk to have metatarsal stress fracture increase on short-term… but decrease on long term by minimalist shoes or barefoot running.

The key words here are “Mechanical Stress Quantification by being gradual for any changes.”

Blaise

There appears to be a double standard here.

We agree that transiting to barefoot will increase the stress on certain parts of the leg and foot, but state that over time these tissues strengthen. Thus, the negative becomes a positive.

By the same token, the higher stresses which barefoot runners claim happen with shod runners / heel strikers -- if indeed this is the case --- should also strengthen those structures.

Can't have it both ways.

Robert Isaacs

I agree. Some runners are training in PECH shoes (Pronation control Elevated Cushioning Heel) for many years with no health problem but biomechanical peculiarities caused by this type of shoes (heel striking, low cadence, increase VLR, more pronation and knee valgus.

The reason is: they are fully adapted!

For me, it's not a good argument to explain why 90 percent of the market is PECH shoes.

The questions here are simpler.
1. If someone starts a running program, which kind of shoe would you recommend to this person?
2. What type do you recommend to children and teenagers who run?
3. Do the PECH shoes prevent from injuries?

Kevin A. Kirby DPM's picture

Blaise:

You are calling Dr. Campitelli's article a "rigorous" posting?! Rather, his article read to me like a classic example of what I call "cherry picking"... only picking the little bits and pieces out of the wealth of research and facts on barefoot versus shod running in order to create a very one-sided analysis of a complex issue ... and done by a member of the "Biomedical Advisory Board for Vibram FiveFingers."

In this fashion, his article was just as one-sided as Chris McDougall's book "Born to Run," a book which is probably best described as an attempt of a non-scientist to attempt to sway people with biased pseudo-science into believing that barefoot running is better than running in shoes. Rather, Chris McDougall with his book has probably single-handedly created what one physical therapist, Matt Fitzgerald, has called an "Stimulus Plan for Physical Therapists."

http://running.competitor.com/2010/05/features/the-barefoot-running-inju...

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

Kevin A. Kirby DPM's picture

Here are some facts that the barefoot running advocates seem to never mention:

1. All the current world records in track, road racing and cross-country were set, not barefoot, but in shoes.

2. No international marathon has been won by a barefoot runner (running the whole race barefoot) for the last 50 years.

3. "Minimalist shoes" are nothing new and they have been continuously available in running shoe stores for the past 40 years. They were called "racing flats" for the past40 years.

4. Abebe Bikila won the 1964 Tokyo Olympic Marathon, breaking the world record in a time of 2:12:11, while in shoes, running 7 seconds per mile faster than he had in the 1960 Rome Olympic Marathon where he ran barefoot.

5. Zola Budd, who broke the women’s 5,000 meter world record while barefoot now prefers shoes saying: “: “I no longer run barefoot. As I got older, I had injuries to my hamstring. I found that wearing shoes gives me more support and protection from injuries.”

6. Split-toe, thin-soled running shoes, such as the Vibram FiveFinger, made by a shoe company that Dr. Campitelli is a paid medical advisor for, are nothing new. The 1951 Boston Marathon was won by a Japanese runner, Shigeki Tanaka, wearing a split-toe, thin-soled running made by Onitsuka Tiger (now Asics).

7. Six scientific research studies published in peer-reviewed journals show that barefoot running increases the vertical loading rate compared to shod running (Dickinson, 1985; Komi, 1987; Lees 1988; Oakley, 1988; DeClercq, 1994; DeWit, 2000).

8. Barefoot running causes increased tibial acceleration (McNair PJ, Marshall RN: Kinematic and kinetic parameters associated with running in different shoes. Br J Sp Med, 28:256-260, 1994).

9. The world’s leading researcher in running biomechanics and running shoe biomechanics, Dr. Benno Nigg, did a prospective study that found no significant differences in frequency of running injuries between subjects with high-, medium-, or low-impact peaks and that subjects with higher loading rates had significantly fewer running-related injuries when compared to subjects with lower loading rates (Nigg BM. Impact forces in running. Current Opinion in Orthopedics, 8(6):43-47, 1997). Dr. Nigg further claims that “Currently, there is no conclusive evidence that impact forces during heel-toe running are responsible for development of running-related injuries.” (Nigg BM: Biomechanics of Sports Shoes. University of Calgary, Calgary, 2010. p. 32.)

10. Barefoot running increases internal tibial rotation vs shod running, meaning that rearfoot pronation and injuries associated with excessive rearfoot pronation may be increased in barefoot running (Eslami M, Damavandi M, Allard P: Foot joints and tibial kinematic coupling patterns during stance phase of barefoot versus shod running. J Biomech, 39:S183, 2006.
Fukano M, Nagano Y, Ida H, Fukubayashi T: Change in tibial rotation of barefoot versus shod running. Footwear Science, 1:19-23, 2009.)

11. There is not one shred of scientific research that shows that running barefoot or running in minimalist shoes reduces the risk of injury. However, the rate of stress fractures in the metatarsals is alarming of those runners who switch to running barefoot or running in “minimalist shoes”, such as the Vibram FiveFingers.

http://www.boston.com/lifestyle/health/articles/2011/01/09/youre_crazy/

http://birthdayshoes.com/keith-olbermann-has-stress-fracture-running-in-...

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=48566

http://www.runningbarefootisbad.com/stress-fractures-in-the-vibram-fivef...

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

To clarify, I am NOT paid by Vibram, Vibram USA or Five FIngers.
If anyone has the W2's, please post them.

Interestingly, in reference to the article Dr. Kirby cited ...

"Eslami M, Damavandi M, Allard P: Foot joints and tibial kinematic coupling patterns during stance phase of barefoot versus shod running. J Biomech, 39:S183, 2006."

They actually found NO change in the amount of internal tibial rotation of barefoot runners.

Here is their wording from the article, "No significant differences were noted in the tibial internal rotation excursion between shod and barefoot conditions."

Furthermore, they concluded, "The findings question the rational for the prophylactic use of forefoot posting in foot orthoses."

Kevin A. Kirby DPM's picture

Dr. Campitelli:

Here is a quote from their results: "Results: High rearfoot eversion/tibial internal rotation ratio was found in running with shoes (2.13°±1.14). This finding contributed significantly to decrease
in tibial rotation excursion in the shod condition (4.27°±2.04) when compared to the barefoot running (16.02°±10.38) (p

Conclusion: Running with shoes could reduce excessive transverse tibial
rotation during first 50% of stance phase."

(Eslami M, Damavandi M, Allard P: Foot joints and tibial kinematic coupling patterns during stance phase of barefoot versus shod running. J Biomech, 39:S183, 2006.)

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

Kevin A. Kirby DPM's picture

Dr. Campitelli:

You receive or have received in the past no free shoes, no paid lectures or any compensation in any form from Vibram in return for you being the leading member of the "Vibram Advisory Board"?

http://www.vibramfivefingers.com/about_vibram_fivefingers/medical_adviso...

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

Dr. Kirby,

In regards to your #11 point, you're forgetting to mention that there is no shred of scientific evidence that running in running shoes will decrease your chance of injury. Since there is no evidence that running shoes decrease injury, it's only logical to stick with what's natural or what we've had for millions of years. Perhaps when there is a shred of evidence to support shod running, I may switch over. Until then, I'll be happily running barefoot, thanks.

Kevin A. Kirby DPM's picture

Paul:

It is certainly your right to run barefoot if you desire. I actually was running intervals barefoot back in 1977 as an member of the UC Davis Aggies Cross Country team so I have no problems with barefoot running. In fact, I was running in minimalist shoes (we called them racing flats) in the early 1970s as a high school distance runner (I ran a 2:39 marathon in high school in what you probably call "minimalist shoes") and have no problems with running in thin-soled shoes that are lightweight.

Just a question, since you say "it's only logical to stick with what's natural or what we've had for millions of years", then I also assume you do not use a cell phone, don't drive a car, don't ride a bike, don't wear any synthetic fabrics, don't fly in airplanes, don't take antibiotics when you have an infection and don't ever wear shoes for any purpose (i.e. not just running).

By the way, Paul, how did you manage to write this e-mail ... using a stone tablet? ;-)

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

Kevin,

You're missing my point. All that stuff you mentioned -- cell phones, cars, bikes, synthetic fabrics, airplanes and, for sure, antibiotics -- have been tested and have been proven to be safe if not beneficial. For example, in the case of antibiotics, I happen to know there is very rigorous testing that is done to prove its effectiveness and possible apparent harm. All one has to do is pick up the most recent CPS to see all the case studies and tests that were done. If a drug is shown to be harmful, it would not be released to the public and would therefore not be taken. The default stance is to always not take the drug until it has proven to be a benefit.

This has never been the case with modern day running shoes. They were first introduced 50 or so years ago without any sort of testing to determine if they were actually better then what runners were presently using. Where is this evidence? Where is the accountability to the public?

In short, I'm not suggesting people barefoot run because it's really old so it must be good. What I'm saying is there's no testing that has been done with modern day running shoes so why should I wear something that hasn't been properly tested yet?

Dr. Kirby,

I am very interested in your response to Paul W's assertion that there haven't been studies that indicate modern running shoes are better than racing flats (or going barefoot). This answer to this question is fundamental to addressing this controversy.

Kevin,

Any actual study showing that regular running shoes are better than running naturally barefoot, or do I assume your silence is an indication that there is nothing to show?

What I believe we forget to mention, as foot specialists, is that every patient is different. While running barefoot for some is fine, for others it would be a disaster. Any practitioner who sees a lot of sports medicine will tell you they can see the same injury occur with runners who run barefoot as those who run with the most structured shoes.

There are always going to be those runners with great mechanics who could run with paper under their feet while other cannot walk down the street without a rigid, functional foot orthotic.

What I do know is that since the barefoot running phenomenon began, I have see an increase in metatarsalgia, stress fractures, sesamoiditis and plantar fasciitis.

The biggest problem is that there is a lack of education and instruction for runners who change over or start with barefoot runners. Running "through" pain with these shoes is the number one instruction that should be given to immediately cease and seek attention.

That is only a piece of my rant but I have flat feet, so what do I know?

There does exist education and instruction for those interested in transitioning to barefoot style running (unshod and minimalist style shoes) but it is hard to find and often results in the individual having to learn on his or her own. This lack of knowledge can be a recipe for injury. Think of trying to perform dead lifts without proper instruction.

I believe it is not the fact that running in a barefoot style causes injury, rather it is the *transition* from shod to barefoot style -- from consistently high structural support to no structural support -- where the problems occur. Perhaps some fine DPMs, especially those who have no issues running in minimalist shoes (or racing flats as Dr. Kirby calls them) could work on devising a How To guide on successful transition.

This might be the best piece of writing in this whole string of comments and article! I'm a physical therapist and have been a runner since I was 7 years old, so running and running form is an area in which I love to geek out.

With all the reading of research, reading Born To Run (which was definitely one-sided but interesting), and analyzing the running form of countless people (patients and non-injured runners), I have realized what every medical professional hopefully comes to learn -- every patient is an individual with his or her own unique set up and should be treated as such.

Some people are built for running and look as though they could run on a cloud, and others clod along, looking as though they are unaware of what their feet and arms should be doing. Just as each person has his or her own unique biomechanics, some people are also more aware of how their bodies are moving, which also makes a difference in whether they should be running barefoot.

I also agree with you that there is a severe lack of education and instruction. I find that most people who want to run barefoot are hearing a lot of hype and think it is the magic pill for running injuries. The shoe industry has marketed it well and the shoes themselves are just weird enough that people want to try them. It is concerning when the dreadlocked, granola salesman at REI is the person who is educating people on barefoot running.

Aloha,

Roy, please take the advice of one of the best and nicest podiatrists I know, YOURSELF.
Do not start training in non-supportive shoes! Your poor tibialis posterior tendon and subtalar joint may not hold up against modern hard surfaces and the heightened impacts caused by “impacting” them. I don’t want you to be saying “Hello” to Mr. Fusion in your “older days”.

Kevin, mahalo. Your depth of medical science-sport history is second to none.

Running flatfooted is not the same as caveman barefooted. We know this. What is the biomechanical difference from running with Chuck Taylor All Stars, Pro Keds, Japanese Tabi’s, Ascics Matflex or Ascics Split Second V’s and Vibrams? Flat is flat.

The current EVA based shoe is 22mm of EVA in the rearfoot and 12 mm at the forefoot and 2 mm at the toes. Why? Why is there a heel on a cowgirl’s boot?

Simple machine physics — we create a declining plane. The foot will fall forward on the shoe, increasing forward velocity over a shorter distance. It is the inverse of an inclining plane. The problem is that when we use foam as the shock mediator, we have to make it thicker like a high heel. Cowgirls don’t run marathons in their boots for this reason. So are we cavemen or cowgirls?

A Hui Hou,
Steven King, DPM

P.S. -- As a natural minimalist, I try to wear as little of clothing as possible as much as possible, especially while sleeping and playing golf. Good thing I live in Hawaii.

Note* I have financial and professional interest in what I say and do.

Soon after my transition to a minimalist shoes and a forefoot strike gait two years ago, I encountered an injury that felt just like a metatarsal stress fracture. X-rays showed no obvious fracture, which my MD said was common with stress fracture X-rays. After six weeks recovery, I was fine.

When the injury was repeated six months later, again with nothing visible on X-rays, I requested a podiatric consult. In the first 10 seconds, the podiatrist said, 'You've never had a stress fracture. It's a lateral metatarsal tendon detachment or tear." Unlike a stress fracture, tendon injuries take a month and a half to recover.

I run in low-drop shoes with about 10 mm of foam in the sole, mainly because part of my run is on sharp gravel. To improve the flexibility of my forefoot, once or twice a week, I do some light barefoot running (without shoes) on grass. I have been injury-free since then.

Bob C.

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