10/22/15

Transition Carefully !!

Transitioning to BF/minimal

Irene S. Davis, PhD, PT, FACSM, FAPTA, FASB

Director, Spaulding National Running Center Professor, Physical Medicine and Rehab Harvard Medical School

Not weeks, but months!

Why Transition?? New Injuries

Figure 9 Please identify the site of new injuries since Motivation to Run you've started barefoot running: 50 Injury Born to Run 22% More Natural Curiosity Foot Don't Like Ankle Run Better Knee 13 9% Hip Low Back 64% 3% 3 7 None 5 7 N = 85 1% 1%

Altman & Davis, 2012 Dicharry et al, 2014

Rothschild, 2011

Previous Injuries General Transitioning Tips Figure 6 Identify the site of previous injuries that have gone away once you began barefoot running: 50% If you have been a -wearing, heel striker 45% 40% most of your life, it will take patience to switch to 35% barefoot running! 30% 25% 1. Start Slowly – follow transitioning program 20% 15% 2. Pick a smooth paved surface – parks work well 10% 5% 3. Listen to pain!!! 0% 4. DO NOT GO BAREFOOT IF YOU HAVE ANY Foot Ankle Knee Hip Low Back Previously un-injured LOSS OF SENSATION IN YOUR FEET!!!!

509 Barefoot Runners Dicharry et al, 2012

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Clinical Approach

Strengthen lower legs and feet

Wean out of orthotics

Transition to minimal footwear for walking

Running Retraining BF on Treadmill Transition to mild FFS Add minimal footwear at end

Warden SJ, Burr DB, Brukner PD: Repetitive stress pathology: bone. In: Magee DJ, Zachazewski JE, Quillen WS (eds.): Pathology and Intervention in Musculoskeletal Rehabilitation. St. Louis, MO: Saunders Elsevier; 2009, pp. 685-705 [ISBN: Why not simply increase cadence? 978-1-4160-0251-2]

What is at risk? 1. Foundational Strength

Proper FFS

gastroc Stretch

achilles/ soleus

post. tib.

Arch/plant. fascia Strengthen

Always Do Exercises Barefoot!!!

2. Functional Activities 2. Functional Activities

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Single Leg Doming and hopping Box Jumps 2 feet, then 1 foot Square Jumps 2 legs then 1 leg

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3. Retraining Process – Altering Footstrike Timeline for Retraining Requirements 30 single leg heel raises 10 domed hopping 2-4 wks 2-3 wks 2wks** 2wks** 1x/wk 3X/wk 30 Training done BF (to facilitate 25 20 F-up F-up natural FFS pattern) 15 Foundational Retraining* Minutes 10 Strength Metranome/verbal cues as FB 5 Functional 0 Increase cadence by 5-10% 1 2 3 4 5 6 7 8 Activities Session Minimal Treadmill Time Feedback Time footwear Total program (excl f-ups) Shoes added in last session Avg 6 wks, 12 visits

* No running outside of retraining ** Increase running 10%/wk

Total Clinical Approach Can you see the difference?

FFS training Requirements: Realignment training Requirements 30 single leg heel raises 15 aligned single leg squats 10 domed hopping 10 aligned hopping

4 Sessions of BF FFS 8 Sessions of retraining (with FFS) From 10-20 min From 10-30 min Use metranome/verbal Use mirror as FB cues as FB

But What about Shoes ? A Little Bit of History

Are these minimal shoes a fad ? Jeff Johnson – Nike 1965-1983 50-60’s Ran in thin-soled canvas shoes on hard surfaces Well-trained - Had ‘legs of steel’ – injuries rare!

70’s Running Boom – more inexperienced runners – beginning of cushioned shoes (Cortez) RW published first two running injury surveys 1971 800 runners knee injuries 17.9% 1973 1680 runners knee injuries 22.5% Cavanagh published results of injury study 1979 974 runners knee injuries 30%* *(Taunton 2002 – 2000 runners – knee injuries 42%) 80’s Nike invites Drs. Steve Subotnik, Harry Hlavick, Dennis Vixie - prominent sports DPMs. They encouraged more motion control and cushioning

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In 4 Short Decades… Recent changes

2005 2009 2010 2014 1972 2012

2013

Are all minimal shoes the same? Do Partial Minimal Shoes Mimic BF?

Partial Minimal Shoes 1. Bonacci et al, 2013

Partial minimal shoes more similar to traditional shoes than to BF

2. Willy & Davis, 2013

Partial minimal shoes greater impacts than traditional shoes

Have: midsole, heel counter, min heel-toe drop, min arch support Transitional shoes allow for a comfortable heestrike, but offer less damping

“I read the book, bought the shoes and now am a FFS!”

It is difficult to judge one’s own FS pattern in cushioned shoes Results

Goss et al, 2012 “The partial reported a significantly higher rate of injury incidence throughout the 12-week period”

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What Constitutes Minimal Footwear? How do true minimal shoes compare to BF?

No motion control No cushioning Zero drop No arch support No midsole

Minimal shoes similar to BF Shoes of Ron Hill, 1970 Winner of

Squadrone and Gallozzi, 2009

True minimal shoes similar to BF But What Hoka One Shoes ?

High Cadence does not always translate into What about increasing cadence? low impacts!

Cadence 176, VALR 110 bw/s!

Increasing cadence by 7.5% only resulted in an 19% reduction in average and 18% in instantaneous vertical loadrates

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Why not just FFS in traditional shoes Why not just FFS in Cushioned Shoes?

Rates of loading are lowest in all directions in when FFS in min shoes

Rice et al, 2015 Increased PF and INV in runner Footwear Matters! with insertional Dec. PF and INV

What about Highly Cushioned Shoes? Footwear/Footstrike across a marathon

Vertical Instantaneous and Average Loadrates Peak Tibial Shock RFS 10-15 gs * ** MFS 8-12 gs

<5 gs Novice Hoka Users Novice/Habitual FFS Hoka Users Land Harder on Soft Surfaces

Bishop et al, 2006 Ferris et al, 1988, 1999

Eric’s Story May 2007

Underwent bilateral Wick Catheter Very talented 19 yo male runner test for compartment syndrome Recently won a local marathon

Top freshman XC runner in the state Elevated Pressures in all 4 Spring track (07) –pain, burning both legs compartments of both legs! Progressed to foot drop during the runs

Underwent 8 Fasciotomies!

Spent the summer stretching, walking Gradual progression to running

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Spring 2008

Sought MD advice Fall 2007

Great XC Season PB 16:32 5K No Symptoms All Sx returned Spring Track

Fall 2008 Struggled through XC, Trained low intensity, Ran PB of 16:07 Despite 2nd pair of orthotics -legs rock hard and extremely painful after races

Spring 2009 Sx intensified - 3rd pr. orthotics – no relief Incr. hip + knee flex to counter the foot drop 2nd in County for the 2 mile

Couldn’t manage to alter his footstrike pattern

Fall 2009

Recruited for UD XC Running 50 mpw- High intensity Increased to 70 mpw in summer – with Sx Won marathon by 15 min Unable to complete the season Won every race (or PB) he has Dropped off the XC Team run since 4/24/10 Despondent NO SYMPTOMS!!

November, 2009 – Vibrams allowed more natural FS Nothing to lose Addressed the underlying mechanics Progressively increased running

We need to get off of our heels!

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Nothing in Biology Makes Sense Except in the Light of Evolution

Thank You

You can not out-engineer Spaulding Naonal Running Center www.runsnrc.org

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