The Role of Athletic Shoe Gear in Your Biomechanical Practice Derek Anselmo, DPM Case Study The minimalist runner Female mid-20’s with elevated BMI begins a workout routine of explosive plyometric exercises and distance running and develops pain in the lateral midfoot that is debilitating. She has had to scale back work activities. • XR shows stress reaction metatarsal 3 • US confirms 2nd plantar plate tear
Derek Anselmo, DPM Agenda
1 Evolution of Athletic Shoes
2 Motion Control Paradigm
3 Minimalist vs. Maximalist
4 Performance Enhancement 8000 B.C.
Derek Anselmo, DPM 1830 - 1916
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The Motion Control Paradigm Derek Anselmo, DPM Assumptions
1.Too much frontal plane pronation will lead to injury and reduce performance
2.Keeping the lower extremity rectus during motion reduces the incidence and severity of injury
Derek Anselmo, DPM Why Is Pronation Control Important ?
Excessive STJ Pronation Has Been Linked to the Development of:
• Plantar Fasciitis, • Hallux Limitus/Rigidus • Hallux Abducto Valgus, • Neuroma • Sesamoiditis • Patello-femoral pain • Illio-Tibial Band Syndrome • Overuse Injury • Knee Pain • Hip dysfunciton • Lumbar spine Pain
Derek Anselmo, DPM Why Should I Care About This ? • Runners sustain injuries at a rate of 37-56% • Pronation control through high end motion control footwear is a very common conservative clinical treatment approach to LE biomechanical pathology Heel Cup
Heel Flare
Dual Density Midsole
Derek Anselmo, DPM Kirby KA. Biomechanics of the normal and abnormal foot. J Am Podiatr Med Assoc. 2000;90(1):30-34 Are Motion Control Shoes Effective?
“Biomechanical and epidemiological studies have raised significant questions about the capacity of running shoes incorporating either cushioning, heel elevation or subtalar control systems to prevent injury and have identified their potential to cause harm.”
Richards et al, Br J Sports Med 2009 Derek Anselmo, DPM Some Problems
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Stability Support Overpronation
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Motion Control Max Support Stability
Derek Anselmo, DPM
American Podiatric Medical Students’ Association (APMSA) Research Grant Program
Generously sponsored in part by the APMSA Corporate Advisory Board (CAB)
ANNOUNCEMENT FOR 2014- 2015
The APMSA CAB, established in 1985, provides corporations a means to demonstrate commitment and support to podiatric medical student endeavors. The APMSA is appreciative to the following Publicationcompanies who generously support the APMSA: Bias
The 2014 - 2015 APMSA Corporate Advisory Board (CAB)
Aerolase 877-379-2435 Aetrex Worldwide, Inc. 800-526-2739 ASICS America Corporation 800-333-8404 Bako Integrated Physician Solutions 855-4Bako-CTS ComfortFit Labs, Inc. 888-523-1600 CrocsRx 801-455-8558 Darco International, Inc. 800-999-8866 Gill Podiatry Supply and Equipment Company 800-321-1348 Gordon Laboratories 800-356-7870 Langer Biomechanics 800-645-5520 Merz North America 888-296-1852 Moore Medical Corporation 800-234-1464 New Balance Athletic Shoes, Inc. 800-343-4648 Organogenesis 888-432-5232 Performance Health/Hygienic Corporation 800-246-3733 PICA Group 800-251-5727 Present e-Learning Systems 888-802-6888 ProLab Orthotics 800-477-6522 SAS Shoemakers 877-782-7463 Shire Regenerative Medicine 800-828-2088 Straight Arrow Products, Inc. 610-882-9606 Upsher-Smith Laboratories, Inc. 1-800-654-2299 Valeant Pharmaceuticals 866-246-8245
Applications for grants are reviewed by the APMSA Research Grant Review Panel and awarded on a competitive basis with the maximum amount of funding of 3, $1,000 grants. Grants are Derek Anselmo, DPM paid in two equal installments; one in advance, the other upon completion of the research program requirements. Unutilized funds are to be returned to APMSA by July 1, 2016.
A completed application including all supporting materials must be electronically received no later than May 1, 2015. Applications may be obtained through the APMSA website www.apma.org or by contacting Kim Vouzikas [email protected].
Conflicts of Interest from Funding
Acknowledgements: “This study was funded in part by a research grant from Nike. The study sponsors were involved Minimalist shoes perform as in the study design, if the person were barefoot interpretation of data, writing of and the motion control the manuscript, and in the shoes control motion decision to submit the manuscript for publication.”
Competing Interests: “Primary “We identified no clinical trials author is a partner in the that assessed the effect of the footwear design company Pronation Control Elevated Barefoot on Grass” Cushion Heel design”
Derek Anselmo, DPM Peltz et all, J Biomechanics, 2014. Ryan et al, Br J Sports Med 2011. Hoffman S et. al, Gait & Posture, 2015 Anselmo et al. 2018
Methods • 25 Female subjects recruited • Subjects screened on the basis of AHI, MVI and BMI • DP and Lat radiographs in barefoot, “neutral shoe”, and “Motion Control” shoe conditions • Osseous relationships evaluated
Anselmo et al. Comparative evaluation of radiographic parameters of foot pronation in two different conditions versus barefoot. J Am Podiatr Med Assoc. Derek Anselmo, DPM Talus-second metatarsal angle Calcaneal-first metatarsal angle
Talonavicular coverage angle
Calcaneal inclination
Murley et al, J. A protocol for classifying normal- and flat-arched foot posture for research studies using clinical and radiographic measurements Foot and Ankle Research 2009 Derek Anselmo, DPM Clarke et al. 1983
Findings: • Maximum pronation was greater in the soft EVA midsole than the medium/hard • A >15o heel flare produced a significant decrease in pronation
Limitations: • The study acknowledges that they are essentially measuring the shank angle to the back of the sneaker assuming that the sneaker and the calcaneus move together and have constant, parallel axes
CLARKE et al. The effects of shoe design parameters on rearfoot control in running. Medicine & Science in Sports & Exercise. 1983 Derek Anselmo, DPM Derek Anselmo, DPM Cheung et al. 2011
Findings: The overall weighted mean change in foot pronation was significantly decreased in motion control footwear (P=0.0002) and the mean reduction in foot pronation was 2.05º (95% CI)
Limitations: Most studies have mixed gender populations, publication bias, very small population sizes, no foot type screening or control
Cheung et al. Efficacies of different external controls for excessive foot pronation: a meta-analysis. British Journal of Sports Medicine. 2011 Derek Anselmo, DPM Fuller et al. 2015
Fuller JT, Bellenger CR, Thewlis D, Tsiros MD, Buckley JD. The Effect of Footwear on Running Performance and Running Economy in Distance Runners. Sports Medicine. 2014 Derek Anselmo, DPM Malisoux et al. 2016
Findings: The overall injury risk was lower among the participants who had pronated foot types and received motion- control shoes • Not all shoes in each category are the same
Limitations: Criteria for injury: “any physical pain located at the lower limbs or lower back region, sustained during or as a result of running practice, and impeding planned running activity for at least 1 day”
Malisoux et al. Injury risk in runners using standard or motion control shoes: a randomised controlled trial with participant and assessor blinding. British Journal of Derek Anselmo, DPM Sports Medicine. 2016 The Minimalist Shoe Dogma 2009
“Cushioned, engineered, structured running shoes are the worst thing that has ever made contact with a human foot.”
“There are no evidence-based studies – not one – that demonstrate that running shoes make you less prone to injury.”
“The only controversy comes from podiatrists.”
Derek Anselmo, DPM
Lafortune et al. 1994
Findings: The results of this study showed that the shoe sole modifications did not produce the expected systematic effects on the test variables
• No significant differences in internal tibiofemoral rotation between normal and varus wedged shoes
Limitations: A lot of inter-subject variation suggests a larger sample size must be used (N=5)
Lafortune et al. Foot inversion-eversion and knee kinematics during walking. Journal of Orthopaedic Research. 1994 Derek Anselmo, DPM Stacoff et al. 2001
Findings: •No significant change in touchdown inversion related to shoe sole modifications • Large lateral heel flares were found neither to increase foot eversion velocity nor internal tibial rotation velocity compared with reduced heel flares.
Limitations: • (N=5) + Considerable inter-subject variability • Measured relation of marker to shoe
STACOFF et al. Effects of shoe sole construction on skeletal motion during running. Medicine and Science in Sports and Exercise. 2001 Derek Anselmo, DPM Richards et al. 2009
Findings: “The clinical efficacy of pronation control systems remains untested, with no longitudinal trials having been reported that compare injury rates in runners wearing shoes with and without pronation control systems. We have identified several studies suggesting that these features either fail to achieve their desired purpose, or worse still, have the potential to cause harm.”
Limitations: Disclosed conflict of interest
Derek Anselmo, DPM Richards et al. Is your prescription of distance running shoes evidence based? Br J Sports Med 2009 Knapik et al. 2014
Knapik et al. Injury-Reduction Effectiveness of Prescribing Running Shoes on the Basis of Foot Arch Height: Summary of Military Investigations. Journal of Orthopaedic & Sports Physical Therapy. 2014 Derek Anselmo, DPM Findings: • No significant difference in injury rate • Recruits with low arches who wore “stability” shoes had injury rates similar to those who wore “motion-control” shoes
Limitations: • Studied only young, active individuals completing a variety of physical tasks with a non-specific definition of injury • Only reported correlation to incidence of injury • Compliance was not required or controlled
Derek Anselmo, DPM What do the radiographic studies say? Peltz et al. 2014 Findings: • Ankle ROM 20-32º in barefoot vs. 10-21º the 2 shoed conditions • No significant differences in STJ sagittal, frontal, or transverse plane motion **However, STJ was significantly more inverted at 20% than in the free
Limitations: • (N=12) with large inter-subject variation
Peltz et al. Effects of footwear on three-dimensional tibiotalar and subtalar joint motion during running. Journal of Biomechanics. 2014 Derek Anselmo, DPM Hoffman et al. 2015
Findings: • Footwear condition was not found to have a significant effect on the magnitude of navicular drop • Motion-control shoes had a slower navicular drop RATE than running barefoot or in minimalist shoes • Static assessments of navicular drop and foot posture were found to be poor predictors of dynamic navicular drop in all footwear conditions
Limitations: • Pilot study • (N=12) led to inconsistent results i.e. a different subject produced their individual lowest arch height in each condition at least once
Hoffman et al. Dynamic in-vivo assessment of navicular drop while running in barefoot, minimalist, and motion control footwear conditions. Gait & Posture. 2015 Derek Anselmo, DPM Firminger & Edwards 2016
Findings: • MTPJ loading increased 7.3% • Ankle loading increased 5.9% • Knee loading decreased 7.3%
No significant interactions between shoe and stride length were observed
Limitations: • No accommodation period ?
Firminger CR, Edwards WB. The influence of minimalist footwear and stride length reduction on lower-extremity running mechanics and cumulative loading. Journal of Derek Anselmo, DPM Science and Medicine in Sport. 2016 More Muscle ?
Miller et al. The effect of minimal shoes on arch structure and intrinsic foot muscle strength. J. Sport Health Sci. 2014
Johnson et al. The effects of a transition to minimalist shoe running on intrinsic foot muscle size. Int. J. Sports Med 2015
Campitelli et al. Effect of Vibram FiveFingers Minimalist Shoes on the Abductor Hallucis Muscle. Journal of the American Podiatric Medical Association. 2016
Chen et al. Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume. Clinical Biomechanics. 2016
Ridge et al. Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine & Science in Sports & Exercise. 2018
Derek Anselmo, DPM More Injuries?
Salzer et al. 2012: case series (N=10) of experienced runners who all sustained an injury after transitioning to a minimalist shoe/style → 8 metatarsal stress fx, 1 PF rupture, 1 calc stress fx
Ryan et al. 2013: RCT (N=99) 12 wks of training in Nike® free, Nike® Pegasus, or Vibram® 5 finger → 3x higher injury rate in Nike® free, higher incidence of shin/ calf pain in 5-finger - Only required 58% of training in assigned shoe (97% compliance)
Salzer et al. 2016: (N=14) experienced runners transitioned to 5- finger shoe → 12 (86%) sustained injury, mostly calf and arch pain
All Athletes. All used recommended transition protocol.
Ryan et al. Examining injury risk and pain perception in runners using minimalist footwear. British Journal of Sports Medicine. 2013 Salzler et al. Injuries Observed in Minimalist Runners. Foot & Ankle International. 2012 Derek Anselmo, DPM Salzler et al. Injuries observed in a prospective transition from traditional to minimalist footwear: correlation of high impact transient forces and lower injury severity. The Physician and Sportsmedicine. 2016 Derek Anselmo, DPM
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The Maximal Performance Movement “80 per cent of the runners tested saw a reduction in knee motion”
Derek Anselmo, DPM Mientjes & Shorten 2011
Subjects used visual force feedback to maintain a constant, approximately even heel-forefoot weight distribution while standing on a force plate with difference density heel cushions with different amount of contour. A 2-way ANOVA, using surface modulus and surface radius as factors was conducted.
Results: contoured footbeds should distribute force similarly to proportionate changes in surface compressibility.
Derek Anselmo, DPM Derek Anselmo, DPM Derek Anselmo, DPM
Hannigan & Pollard. 2019
(N=20) Loading rate, impact peak, and active peak of the GFRv were measured at the beginning and end of a 6 week accommodation period to maximalist footwear. (8 forefoot strikers excluded)
Results: • Runners were still everted at toe-off and landed with less dorsiflexion, on average, in the maximal shoe. • Loading rate and impact peak were higher in the maximal shoe. • 6 week accommodation period yielded no change.
Derek Anselmo, DPM Hannigan JJ, Pollard CD. A 6-Week Transition to Maximal Running Shoes Does Not Change Running Biomechanics. The American Journal of Sports Medicine. 2019 Pollard et al. 2018
(N=15) female “heel strike” runners ran on a force plate for 5 sets of data collection→ ran a 5k on a treadmill→ then completed another 5 sets of data collection on the force plate
Results: Impact peak and loading rate were greater in the maximal shoe compared with the traditional neutral shoe.
**Subjects relying more heavily on the shoe to attenuate impact forces, which in turn resulted in a higher impact peak
Derek Anselmo, DPM Pollard et al. Influence of Maximal Running Shoes on Biomechanics Before and After a 5K Run. Orthopaedic Journal of Sports Medicine. 2018 Kulmala et al.
(N=12 M heel strikers) VICON motion capture was used along with plantar force plates to record skin marker positions and ground reaction force data simultaneously in both a maximalist and conventional cushion shoe.
Results:
• GRFv impact peak and loading rate were 10.7% and 12.3% greater, respectively, in the maximalist shoe. • Increased “Leg Stiffness” in Maximalist shoe
Kulmala et al. Running in highly cushioned shoes increases leg stiffness and amplifies impact loading. Scientific Reports. 2018 Derek Anselmo, DPM The Future
Derek Anselmo, DPM Derek Anselmo, DPM Shoe Feature Effect Stiff Midsole Improve economy, reduce VO2 and energy lost at MTPJ Soft Midsole Reduce impact force and loading rate Thick Midsole Reduce feedback and proprioception Minimalist Increase muscle mass→ strength, increased loading at ankle joint and MPTJs Lacing Pattern Heel-Toe Drop Negligible Heel Counter Upper
Derek Anselmo, DPM Comparing Studies on Motion Control Shoes
Don’t Work Do Work Kinda Work Richards et al. Cheung et al. Cheung et al. Knapik et al. Clarke et al. Hoffman et al. Peltz et al. Malisoux et al. Ryan et al. Why the Disagreement ?
• Inherently difficult to study • Inconsistent methods of measurement • Inconsistent endpoints • Conflicts of interest from funding • Publication bias
Derek Anselmo, DPM
Martyn Shorten
• Subjective assessments of fit, comfort and shock attenuation are generally reliable guides to the actual mechanical properties of the shoes.
• Stability properties of shoes cannot be perceived reliably
• Runners who need pronation control must therefore rely on identifying features, such as firm cushioning, medial posting and heel fit, that are known to influence pronation.
RUNNING SHOE DESIGN: PROTECTION AND PERFORMANCE Martyn R. Shorten, Ph.D. BioMechanica, LLC Derek Anselmo, DPM Nigg et al. 2015
Comfort Filter Paradigm: If athletes select a product they perceive as comfortable, it will automatically reduce injury risk.
Preferred Movement Path: A “good” running shoe allows the skeleton to move in the “preferred movement path” demand minimal muscle activity to ensure that the skeleton moves in the correct path.
Nigg BM, et al. Br J Sports Med 2015;49:1290–1294 Derek Anselmo, DPM Not Evidence Based
Derek Anselmo, DPM Biomechanical Controlled Clinical Lab Outcome Theory Studies Data
Derek Anselmo, DPM Science Pseudoscience - Marketing =
Derek Anselmo, DPM Tips & Tricks: What Works For Me Derek Anselmo, DPM Derek Anselmo, DPM Static Exam Dynamic Exam Correlation Re-evaluation
Modified Chief Cohen Complaint Index
Derek Anselmo, DPM https://drleecohen.com/blog/2018/12/26/cohen-index NIGG BM, NURSE MA, STEFANYSHYN DJ. Shoe inserts and orthotics for sport and physical activities. Medicine & Science in Sports & Exercise. 1999;31 Derek Anselmo, DPM Derek Anselmo, DPM Derek Anselmo, DPM Thank You