When Patients Ask About Barefoot Running And Minimalist Shoes

Moderator: Jenny Sanders, DPM Panelists: Richard Blake, DPM, Bill Johncock, DPM, Kevin Kirby, DPM, Doug Richie Jr., DPM, FACFAS, and Nicholas Romansky, DPM, FACFAS

   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.”


Excellent discussion with many salient points. I have seen a lot of minimalist and even a few true barefoot runners here in Tampa. I think the injury rate is similar to those runners in traditional shoes but different areas - cuboid, sesamoid and metatarsal stress fractures are the most common. I have noted in the last 6 months a decrease in those using Vibrams or other similar shoes and an increase in the use of shoes such as the Brook Pure series or New Balance Minimus, which as Dr Kirby correctly pointed out are not much different from the road racing shoes of the 1960s-1980s.

Brian W. Fullem, DPM
Tampa, FL

Kevin A. Kirby DPM's picture


Thanks for your comments.

As an older runner with 40 years of distance running under my belt, probably one of the most bizarre things I have seen in this "barefoot-minimalist shoe fad" is the claim by the barefoot-minimalist shoe advocates that they have somehow created a new shoe: the minimalist running shoe.

During my high school and college years of competing in cross-country, track and road races from 1972-1979, myself and many other runners in Northern California often wore racing flats that were thinner soled and lower heeled than today's "minimalist shoes." This was over three decades before the barefoot crowd proclaimed that they had invented a new type of running shoe ... the minimalist shoe. Amazing!

I am all for more running shoe selection for the public but I just hope we can put down this nonsense that minimalist shoes are anything more than a return to racing flats for training ... something which many of us were regularly doing back in the 1970s!

Nothing new under the sun.


Kevin A. Kirby, DPM

Most advocates of barefoot running are advocating a change in form as much as they are advocating throwing away the shoe. One basic characteristic of this form is that the foot strikes the ground under the body rather than in front. It is difficult to strike under the body with the heel, thus the change to the midfoot or forefoot strike. The biomechanical evidence supporting this form and foot strike is very compelling. This way of coming down with the foot eliminates a sharp impact peak that is present with the heel strike in front of the body.

If you run barefoot, you feel this impact peak more so you naturally change your form to avoid it. Alternatively, you can learn this way of running with a regular shoe and practice.

Then there is the second very interesting discussion about the anthropological history of running barefoot (I.e. were we meant to wear shoes with big heels?).

These are logical arguments from both a scientific and common sense perspective, and should be taken seriously.

Of course, if you are changing your form and your shoes, you need to build up slowly. Most people have very little sense of what building up slowly means. I personally switched to minimalist shoe running over a period of two years starting with short 2-5 minute runs during my lunch break. My calves and Achillies were often sore at the start and needed to be built up. I wouldn't recommend any other approach. My motivation was that I could not previously run due to knee injuries.

Running barefoot and/or minimalist shoes are not new ideas. That is the point. Often an old idea gains popularity for new reasons. The new reasons are those mentioned above.

I find the whole discussion extremely interesting and more than just a fad. This is a debate that has engaged elite runners, Harvard scientists, anthropologists, as well as bloggers and everyday joggers.

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