After multiple patients and fellow physicians asked me my opinion as a foot and ankle specialist on the recent barefoot running craze, I finally borrowed the book Born To Run by Christopher McDougall to see what all the fuss was about. I sat down with pen and paper to prove this silliness wrong. A few days later I emerged a partial believer in the idea. Although barefoot running techniques and training have been around for ages, this book has launched a new wave of enthusiasm for barefoot running and maybe for good reason, then again...
Most of the research below was mentioned in McDougall's book:
Runners wearing top-of-the-line trainers are 123 per cent more likely to get injured than runners in inexpensive ones. This was discovered as far back as 1989, according to a study led by Dr Bernard Marti, the leading preventative-medicine specialist at Switzerland's University of Bern.
Dr Marti's research team analyzed 4,358 runners in the Bern Grand Prix, a 9.6-mile road race. All the runners filled out an extensive questionnaire that detailed their training habits and footwear for the previous year; as it turned out, 45 per cent had been hurt during that time. But what surprised Dr Marti was the fact that the most common variable among the casualties wasn't training surface, running speed, weekly mileage or 'competitive training motivation'. It wasn't even body weight or a history of previous injury.
It was the price of the shoe. Runners in shoes that cost more than $95 were more than twice as likely to get hurt as runners in shoes that cost less than $40.
Follow-up studies found similar results, like the 1991 report in Medicine & Science In Sports & Exercise that found that 'wearers of expensive running shoes that are promoted as having additional features that protect (eg, more cushioning, 'pronation correction') are injured significantly more frequently than runners wearing inexpensive shoes.'
Stanford running coach Vin Lananna has been quoted as saying, 'I once ordered high-end shoes for the team and within two weeks we had more plantar fasciitis and Achilles problems than I'd ever seen. So I sent them back. Ever since then, I've always ordered low-end shoes. It's not because I'm cheap. It's because I'm in the business of making athletes run fast and stay healthy.'
Studies have shown that the cheaper and simpler the shoe, the fewer injuries the runner will sustain.
The new Nike Free is a minimalist shoe, approximating the Vibram 5 Finger Shoe. Interesting that Nike is now back pedaling and removing all the gizmos after years of "technology" laden running gear. None of which have been shown to increase performance or decrease injury rates.
Squadrone et all conducted a small study comparing neutral running shoes, Vibram 5 Finger shoes and barefoot running.
Compared to the standard shod condition when running barefoot, the athletes landed in more plantarflexion at the ankle. This caused reduced impact forces and changes in stride kinematics. In particular, significantly shorter stride length and contact times and higher stride frequency were observed (P<0.05). Compared to standard shod condition, V.O(2) and peak impact forces were significantly lower with Fivefingers (P<0.05) and much closer to barefoot running. Lower limb kinematics with Fivefingers was similar to barefoot running with a foot position which was significantly more plantarflexed than in control shoe (P<0.05).
The data of this study support the assumption that changes in the foot-ground interface led to changes in running pattern in a group of experienced barefoot runners. The Fivefinger model seems to be effective in imitating the barefoot conditions while providing a small amount of protection.
(R Squadrone; C Gallozzi. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. Journal of Sports Medicine and Physical Fitness; Mar 2009; 49, 1.)
Other studies have showed that minimalist shoes wearers have increased muscle strength and tone in the foot compared to normal running shoe wearers. Anecdotal evidence around the country is mounting with increasing reports of stress fractures due to patients wearing Vibram 5 Finger Shoes and beginning new training programs. Personally, over the last year I have treated many injuries resulting from minimalistic shoegear and inappropriate training method combinations.
How about a shoe's shape?
This interesting study was conducted on Marine Corps Recruits. After foot examinations, Marine Corps recruits (408 men, 314 women) were provided motion control, stability, or cushioned shoes for plantar shapes indicative of low, medium, or high arches, respectively. A control group (432 men, 257 women) received a stability/neutral shoe regardless of plantar shape. Injuries during the 12 weeks of training were determined from outpatient visits obtained from the Defense Medical Surveillance System. Other known injury risk factors (eg, fitness, smoking, prior physical activity) were obtained. This comparison showed little difference in injury risk between either group. Men (hazard ratio [E/C] = 1.01; 95% confidence interval, 0.82-1.24), women (hazard ratio [E/C] = 0.88; 95% confidence interval, 0.70-1.10).
This prospective study demonstrated that assigning shoes based on the shape of the plantar foot surface had little influence on injuries even after considering other injury risk factors.
FYI: The military has recently announced a new policy stating that "Vibram 5 Finger type shoes" are not approved shoe gear.
Splinting and Bracing:
Anecdotally, Vibram Five Fingers type shoes can be used as a unique type of splint for hammertoes and bunions. This may be a preferred method for kids and some adults compared to traditional splinting and taping. The cost however is many times more compared to cheap bracing/strapping/taping.
So what is the answer? I would definitely recommend at this point that runners wear a protective covering on their feet at all times. I don't care how strong and thick your skin becomes, it will never keep a needle, nail, glass shard or thorn out with your full weight slamming down on it. If you do elect to go with the minimalist Vibram 5 Finger shoe or any of the knock off versions, you will be best served by training with an experienced "barefoot" runner or trainer. Many podiatrists around the country and our own office are reporting increased rates of stress fractures and puncture type wounds from patients who either didn't wear any foot protection, or started an aggressive running program without any thought to changing their running technique. If you continue to run as you did in the expensive Nikes you bought last year when you switch to Vibram's you are likely to injure yourself. I have seen a lot of injuries recently due to minimalist running techniques and/or shoegear. Caution is advised.
Be safe, be smart and do your research before getting too crazy out there. One thing has absolutely been born out through the vast majority of scientific literature, that is the value of exercise in treating almost every chronic condition plaguing America today; Diabetes, high blood pressure, high cholesterol, vascular disease, etc. Under the care of a physician or experienced physical therapist, exercise and weight loss can reverse many of these diseases.
If you include running into your overall health plan, please do it wisely. Injuries do happen however, if they do, give us a visit and we will do our best to fix you up.
Please visit our on-line store to find many useful treatment options for foot and ankle pain.
Dan Preece, DPM & Darren Groberg, DPM