When Patients Ask About Barefoot Running And Minimalist Shoes

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

Q:

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?

A:

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.”

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Brian Fullem, DPMsays: May 6, 2013 at 2:25 pm

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

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Kevin A. Kirby DPMsays: May 20, 2013 at 11:30 am

Brian:

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.

Cheers,

Kevin A. Kirby, DPM

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Patrick Johnsonsays: June 14, 2013 at 6:27 am

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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