When Patients Ask About Barefoot Running And Minimalist Shoes
Chances are that you have had a patient or two ask for your opinion on barefoot running or minimalist shoes. Accordingly, these panelists share their perspectives on the recent surge of interest in these topics, review pertinent keys to patient assessment and discuss common injuries they have seen.
In an intriguing roundtable discussion, these accomplished sports medicine podiatrists (including a couple of longtime runners) discuss various issues related to barefoot running and minimalist footwear. Does barefoot running have a role in the training regimen of elite athletes? What do you say to non-elite athletes or beginning runners who want to try minimalist shoes? How critical is a gradual transition to minimalist shoes? Is there sufficient research to validate the hype or do common injuries like metatarsal fractures suggest otherwise? Without further delay, here is what the panelists have to say.
When patients ask about your opinion on barefoot running and whether or not it may be appropriate for them, what do you tell them?
The majority of the panelists agree that this depends on several factors. Bill Johncock, DPM, says it depends on the type of injuries runners have had in the past, whether they have any current injuries, the types of surfaces they run on, their age, etc. Jenny Sanders, DPM, and Nicholas Romansky, DPM, also ask these patients if they have already tried barefoot running, and whether they had a favorable or unfavorable response. Drs. Johncock, Romansky and Sanders all concur that it is important to determine the patient’s motivation for wanting to run barefoot. Is it fueled by hype, a history of chronic injury or some other factor?
“Understanding a runner’s motivation to want to run barefoot is key to making an informed decision,” points out Dr. Sanders. “Many runners don’t know why they think they should run barefoot and have no plan whatsoever as to how or why to adapt to a new form.”
Richard Blake, DPM, assesses the patient’s biomechanics in order to determine if his or her feet are stable enough to handle barefoot running. However, he notes that “many feet are so unstable that it is hard to recommend such an activity.”
Dr. Romansky says he rarely recommends barefoot running or minimalist shoes for patients or athletes starting to exercise or restarting an exercise program after a layoff. Similarly, Kevin Kirby, DPM, is not likely to recommend barefoot running to beginning runners as he believes it may increase their risk of injury at a time when their body is not quite ready for the extra stress that it will place on their feet and lower extremities.
However, as a sports medicine podiatrist and longtime distance runner, Dr. Kirby does tell runners that barefoot running is “certainly a reasonable way to train for running on a part-time basis as long as it is performed on a safe surface.” He reminds patients there is an extra risk of stepping on sharp objects with barefoot running. Dr. Kirby also notes that he is “more likely” to recommend occasional barefoot running to more experienced runners to allow more training variety and as a method to help them refine their running form.
Doug Richie, Jr., DPM, says the vast majority of his patients have “no interest in running barefoot and look at the movement as a silly fad with potential dangers.” Alternately, he has had many patients ask him about possibly switching from stability running shoes to minimalist running shoes. Dr. Richie says these inquiries are fueled by one of the following reasons: boredom with their current level of training; boredom with their current running shoe; getting swayed by advertising; getting swayed by Internet chatter about the barefoot/minimalist craze; an interest in improving performance; or a nagging injury that isn’t getting better.
Dr. Sanders cautions her patients that definitive scientific evidence (via prospective, randomized, controlled studies) either for or against barefoot running “is still lacking.”1
“Barefoot or minimalist running is neither the savior nor the apocalypse to running injuries,” maintains Dr. Johncock. “The late, great George Sheehan, MD, (a running philosopher and accomplished runner himself) was frequently quoted as saying, ‘We are all a study of one.’ I feel barefoot running is absolutely a subject where this is true.”
How do you evaluate a runner to determine whether he or she is a candidate for barefoot/minimalist running?
Dr. Kirby has observed that runners who are more experienced in distance running, younger, of normal body weight and are frequently barefoot while walking are “much more likely” to tolerate barefoot running than those who are beginners, older, heavier or habitually shod. Dr. Kirby feels that any runner can run barefoot or in minimalist shoes on an intermittent basis. He believes that the main question for the podiatric physician is whether the runner will derive benefit or possibly become injured from running barefoot or in minimalist shoes on a regular basis. Dr. Richie counters that when it comes to giving advice to runners on what biomechanics or characteristics of the feet are better suited for barefoot running, there is insufficient evidence from which to make such recommendations.
When patients ask Dr. Richie about switching to minimalist shoes, he points out that the origin of the movement was among elite runners who sought new methods of improving performance and that running barefoot was proposed as a training technique used once a week to supposedly strengthen the feet in elite runners. Then Dr. Richie will ask inquiring patients if they consider themselves to be truly elite runners and whether they have a specific goal of dropping a few seconds off their 10K time. He also asks these patients if their body frame is similar to the Kenyan runners leading the pack at the New York City or Boston marathons. Dr. Richie then reminds them that the Nike Free (Nike) shoe was designed for elite runners.
Dr. Romansky also emphasizes candor about fitness level. He says many patients are not as fit, functional or efficient in using their bodies as they think they are in multiple forms of exercise including running, cycling, Zumba, gym workouts, spin class, etc. Accordingly, Dr. Romansky emphasizes performing a quick but in-depth functional movement screen to evaluate the athletic patient. This evaluation should focus on the patient’s core, balance, proprioception and single leg raise exercise, and compare the right side to the left side. He also asks patients if they’re going to use the minimalist shoes only for running or for other activities such as gym workouts, daily errands or housework. Dr. Romansky also tries to find out what shoes patients have worn in the past.
Shoes come into play with gait assessment in the majority of the runners Dr. Sanders sees. She evaluates every runner she sees by first having the patient run barefoot on a treadmill and then having him or her run shod on the treadmill. In some cases, the runner will look better barefoot. However, in most of these cases, Dr. Sanders says it’s not because a midfoot or a forefoot strike is more efficient, it’s because the runner’s shoes are incompatible with his or her alignment.
“In these cases, I get the patient into a more appropriate shoe and repeat the running analysis. If there is no difference between the patient running barefoot or shod, I see no reason why the patient cannot include barefoot running in his or her overall training regimen as long as the runner takes it slow,” notes Dr. Sanders. “If the patient’s running gait is better in shoes or if he or she has a barefoot running injury, I strongly recommend that the patient avoids barefoot running entirely.”
When it comes to assessment, Dr. Blake says one of the easiest factors to consider is joint flexibility.
“If the runner is loose in various foot joints — and you can imagine a sport like running in which you have to handle two and a half to three times your body weight and high pronation/supination moments — then you have to be very cautious,” explains Dr. Blake.
Dr. Kirby asserts that “so-called minimalist shoes” are far from a new idea as these shoes have been continuously available in running shoe stores as “racing flats” for at least the past four decades. If runners want to wear “thinner-soled shoes with less cushioning and thinner heels,” he doesn’t try to talk them out of it. However, Dr. Kirby does tell them they are more likely to develop Achilles tendinitis, metatarsal stress fractures and/or plantar forefoot injuries as a result of regularly training in those shoes.
Other orthopedic issues may also come into play when assessing whether a patient is a candidate for minimalist shoes or barefoot running, according to Dr. Romansky. He tries to ascertain whether the patient has sufficient glute and leg strength, whether the quadriceps and hamstrings are working efficiently or effectively, whether the patient has total joint replacements and/or whether there are any issues with the lumbosacral spine.
Dr. Johncock emphasizes the importance of the runner’s past injury history. He notes that certain areas of the body appear to have decreased stress in response to barefoot running while other areas have increased stress. One of the key differences between barefoot/minimalist running and “traditional” running shoes is that you land more on the forefoot, according to Dr. Johncock. He says it is interesting to look at the differences between the power absorption and eccentric work done at the knee and ankle when landing on the forefoot versus heel strike.2 Dr. Johncock says landing on the forefoot creates decreased stress to the knee, which is where a significant percentage of people seem to achieve relief.3 However, he emphasizes that stress does not disappear as there is increased stress to the ankle, specifically in the Achilles, and increased impact to the metatarsals.
“As time moves on, I think we’ll find more and more data demonstrating that certain injuries such as knee pain may be reduced and other injuries such as Achilles tendinitis and metatarsal/forefoot injuries will increase with minimalist shoewear,” posits Dr. Johncock. “I inform my patients who have had chronic knee pain that minimalist shoes are something they may wish to consider. If they have had chronic Achilles tendinitis or repetitive metatarsal stress fractures, they may not be good candidates.”
Have any of your elite running patients switched to barefoot or minimalist running? If so, what was the outcome?
Dr. Richie notes that one patient, a veteran Ironman triathlete, decided to switch to total barefoot running last year so he could “run faster.” He had bilateral cavus feet and had run injury-free for over four years in traditional shoes. Within three months, the patient developed a calcaneal stress fracture, according to Dr. Richie. He notes that this was not just a stress reaction but a complete fracture through the tuber of the calcaneus that was visible on computed tomography (CT) and magnetic resonance imaging (MRI). Dr. Richie says two other patients switched to barefoot running over the past year and have had no problems, but they both mix barefoot running with shod running during their weekly training.
Dr. Johncock notes he has only had one elite athlete who attempted to make the jump to total barefoot running and extreme minimalist shoes (Vibram). He ended up in Dr. Johncock’s office with a metatarsal stress fracture. He does note that a number of his college runners and high-level athletes do a portion of their training on grass barefoot or in minimalist shoes, but this “typically accounts for 10 percent or less of their total training.” Dr. Johncock adds that he has seen a general trend of more elite athletes going with a lighter, less supportive shoe for their training.
Dr. Romansky reports that many of his patients have switched but very few exclusively use minimalist shoes. He says they may alternate with a zero drop shoe type or a lower profile shoe. He adds that some may use minimalist shoes for gym use, daily use around the house, daily errands and light trail walking. Regardless, Dr. Romansky says the use of minimalist shoes or barefoot running “must be a progressive and well thought out plan.”
Over the past 28 years of being a sports medicine podiatrist, Dr. Kirby says all of his elite running patients were already running in “minimalist shoes” as these shoes were called “racing flats” up until a few years ago when the barefoot running fad began. He adds that during his collegiate long-distance running days in the late 1970s, “many of us occasionally ran barefoot as a way to vary the stresses on our feet and lower extremities.
“Therefore, the notion that running in ‘minimalist shoes’ or running barefoot is a new idea is not only false but frankly is comical to anyone who is knowledgeable of the long history of distance running in the United States and other countries around the world,” says Dr. Kirby.
He notes that currently, no barefoot runners hold world records in any track events or long distance running events. Dr. Kirby says elite runners don’t want to increase their risk of injury by running barefoot so they instead wear thin-soled, lightweight racing flats to run their races in, just as they have done so for at least the past half-century.
Dr. Sanders says none of the elite runners she treats have changed from shod running to a minimalist shoe or barefoot running style. If Dr. Blake is treating an elite runner, it is usually due to a foot, ankle or leg injury and “the last thing we are thinking about is changing shoes and technique.”
While Dr. Johncock says he is far from an elite runner, he runs two to four ultra-marathons a year and has seen more of his friends in these ultra-marathons run barefoot or in true minimalist shoes. He notes that has yet to be beaten by any of his barefoot friends in distances over a marathon.
Have you seen an increase in injuries with barefoot/minimalist running? If so, do these injuries differ from other running injuries you have treated in the past?
The majority of the panelists have seen an increase in metatarsal stress fractures and Achilles tendon injuries. Dr. Sanders says these runners typically present with an insidious onset (usually three to four weeks) of osseous injury. In Dr. Sanders’ experience, the most common fractures involve the metatarsal bases. She notes these fractures are more severe than typical overuse stress fractures as these injuries almost always require non-weightbearing immobilization with crutches to heal. In 50 percent of these injuries, radiographic findings are unremarkable and MRI is required for definitive diagnosis, according to Dr. Sanders.
“The problem with these injuries is they start out as an annoyance and slowly build from discomfort to pain without a specific inciting event, causing the runners to continue training in spite of injury,” points out Dr. Sanders.
In his experience, Dr. Johncock has found that the majority of the metatarsal and Achilles injuries occur in patients who are older (over the age of 30), those who changed their shoe style too quickly in his opinion or a combination of both.
“The key to reinforce to your patients who wish to try this is it must be a very gradual transition and the older you are and the longer you have run with traditional shoes, the longer this transition will be. Think months/years, not weeks,” says Dr. Johncock.
Form and function will change, emphasizes Dr. Romansky. When people run barefoot or with minimalist shoes, he says they will be using muscles and joints more or less than with previous shoes. Dr. Romansky maintains that a change of shoe changes how you run and subsequently new horizons of function create new injury patterns.
“Changes in the form and function of a shoe ultimately dictate injury pattern,” emphasizes Dr. Romansky.
In addition to the aforementioned metatarsal fractures and Achilles tendon injuries, Dr. Romansky has seen a lot of soft tissue injuries, proximal “up the line” injuries including a high hamstring at the origin of the buttocks, distal hamstring issues at the insertion of the posterior knee, injury to the medial head of the gastrocnemius recession and injury to the sacroiliac joint. Dr. Kirby has also seen gastrocnemius/soleus muscle injuries as well as metatarsophalangeal joint capsulitis/plantar plate injuries in addition to the aforementioned metatarsal stress fractures and Achilles tendon injuries. He says these specific injuries result from barefoot runners landing more on their forefoot than their rearfoot.
“Since the only three scientific studies that have been done on this subject have shown that 75 to 89 percent of runners are rearfoot strikers, I tell runners it is a mistake for them to try to run in a totally different manner than what is natural for them,” explains Dr. Kirby.4-6 “In other words, runners shouldn’t go from rearfoot striking to forefoot striking just because some ‘expert’ on the Internet said that rearfoot striking and thicker-soled shoes are harmful.”
While Dr. Blake says he has no basis with which to judge if there has been an increase of injuries with the recent barefoot running/minimalist shoe movement, the injuries he has seen have been a combination of minimalist shoes not providing good support or protection, and the athletes being careless about their training regimen with these shoes. For example, Dr. Blake cites an elite runner who switched to minimalist shoes and broke her heel bone, but notes that she also did not change her technique. He says another runner in Vibram Five Fingers stepped up onto a curb and developed severe turf toe in the second toe. “(This) would not have happened in normal shoes,” notes Dr. Blake.
Dr. Richie says the biggest problem he has seen with the barefoot/minimalist shoe movement is the use of “flimsy lightweight shoes” by overweight, untrained athletes who are taking fitness classes such as Cross Fit and Zumba, or who are exercising at home to videos such as Insanity Workout or P90X.
“This trend has sent a large number of patients to my office with stress fractures, Achilles tendinopathy and plantar heel pain in numbers like I have never seen in 32 years of running a sports medicine practice,” notes Dr. Richie.
Dr. Richie says many novice athletes have good intentions when starting a fitness program but they can be swayed when going to an athletic shoe store or department store. Given that minimalist shoes are softer and lighter with the initial fitting in comparison to standard shoes, minimalist shoes are an easy sell for the shoe salesman, notes Dr. Richie.
“The victim is the unsuspecting future patient who succumbs to the cool look and ultra lightweight feel of the minimalist shoe,” says Dr. Richie.
Describing himself as a 170-pound moderate overpronator who had typically worn stability shoes with custom orthotics, Dr. Johncock attempted his own “study of one” two years ago with a six-month transition to less supportive shoes and ceasing to use his orthotics. He wound up with an Achilles injury. He is 48 years old, has been running for 35 years and has a past history of Achilles injuries. However, as a result of his “experiment,” Dr. Johncock has moved into a more “neutral shoe” and wears lighter weight shoes for his speedwork and races just as he did during his younger days. Dr. Johncock notes that he returned to wearing his orthotics.
“I did not feel the risk of total transition to minimalist shoes was worth the potential benefit for me,” notes Dr. Johncock. “If I wake with knee pain tomorrow, I may change my mind.”
Are you seeing more runners or fewer runners interested in barefoot running?
The majority of the panelists say patient interest in barefoot running has significantly declined. Dr. Johncock still has a number of patients asking about barefoot running but notes that it has “tapered off from the exponential increase of one to two years ago.”
“Most runners are starting to realize that the poorly designed research studies that come from those who received monetary compensation from minimalist shoe companies were biased toward selling more five-toed shoes and not toward allowing runners to train more, run faster and have fewer injuries,” asserts Dr. Kirby.
However, Drs. Sanders, Richie and Blake are still seeing curiosity and interest in minimalist shoes. Dr. Sanders says the new questions from runner patients tend to be on minimalist shoes versus structured running shoes and ascertaining the ideal, heel-to-toe differential. When it comes to his runner patients, Dr. Richie says there is growing interest in trying minimalist shoes and changing their foot strike pattern in running in the hopes of improving their performance.
“This trend is definitely growing and so is my practice,” claims Dr. Richie.
“Runners will always want to try to reduce injury and improve performance. Podiatrists will always be part of this conversation. This is a good thing,” asserts Dr. Sanders.
Dr. Johncock says it is “ill-advised” for podiatrists to vilify barefoot runners just as he feels it is wrong for barefoot running advocates to attempt to make podiatrists villains for prescribing orthoses that they feel will benefit their patients. Dr. Romansky concurs, noting that many individuals have blamed current injury patterns on a shoe type or a shoe company. He feels answers will come through ongoing research on the subject.
“With time, we will (and have already begun) to build a new injury database noting the pattern, type and severity of injuries associated with barefoot running and/or the minimalist shoe movement,” notes Dr. Romansky. “We would be shortsighted or narrow-minded not to think so.”
Drs. Kirby, Romansky and Johncock says there are other silver linings to the recent barefoot running/minimalist shoe movement.
“Overall, the whole barefoot running fad has been a valuable lesson for many runners and many sports medicine podiatrists in that it has clearly demonstrated that popular books and shoe company-sponsored research are no match for the hard facts that come from good science,” notes Dr. Kirby.
“The barefoot running debate has forced me to rethink my perspective on what’s good and what’s bad,” concedes Dr. Johncock. “Let us reexamine the available data. Let us create new studies to look at the risks and benefits of new running techniques, shoe types and barefoot running. Do minimalist shoe wearers need orthotics or do these shoes change the type of orthotic which would be beneficial? Will minimalist shoes give better results for those with a neutral gait pattern versus an overpronator?”
Dr. Romansky agrees that the minimalist footwear trend has forced physicians and healthcare providers to “revisit, revamp and reevaluate” current perceptions, and consider what the future holds for shoe technology, shoe design, training habits, training routines and programs of athletes.
“It is a work in progress and an evolution to find the ultimate shoe but we should continue to look at the total athlete,” emphasizes Dr. Romansky. “Certain shoe types will bring out the individual athlete’s weaknesses, muscle/joint imbalances and compensation mechanisms of multiple body parts.”
Dr. Blake is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is affiliated with the Center for Sports Medicine at the St. Francis Memorial Hospital in San Francisco.
Dr. Johncock is a Fellow of the American Academy of Podiatric Sports Medicine and is board-certified by the American Board of Podiatric Surgery. He is in private practice in Hickory, N.C.
Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. Dr. Kirby is board-certified by the American Board of Podiatric Medicine, and lectures nationally and internationally on barefoot and shod running biomechanics. He is in private practice in Sacramento, Calif.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. He is in private practice in Seal Beach, Calif. Dr. Richie writes a monthly blog for Podiatry Today. One can access his blog at www.podiatrytoday.com/blogs/301 .
Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is the team podiatrist for the United States Olympic and World Cup Men’s and Women’s soccer teams. Dr. Romansky is in private practice in Media and Phoenixville, Pa.
Dr. Sanders is an Adjunct Clinical Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. She is board-certified by the American Board of Podiatric Medicine. Dr. Sanders is in private practice in San Francisco. She writes a monthly blog for Podiatry Today. One can access her blog at www.podiatrytoday.com/blogs/jenny-l-sanders-dpm/feed .
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