CURRENT TOPICS IN SPORTS PODIATRY

Advising Your Patients about Barefoot Running What should you tell patients when they ask?

By David W. Jenkins, DPM to assist the clinician in advising patients. This article is provided exclusively to Podiatry Management by the Ameri - Barefoot Running: The Hype can Academy of Podiatric Sports Barefoot running is not new. Medicine. The AAPSM serves to ad - Besides the obvious ancient unshod vance the understanding, prevention ancestors, barefoot running was and management of lower extremity showcased with the 1960 Olympic sports and fitness injuries. The Acade - marathon victory by Abebe Bikila, my believes that providing such knowl - as well as world class performances edge to the profession and the public by Herb Elliot, Bruce Tulloh, and will optimize enjoyment and safe par - Zola Budd over the ensuing years. ticipation in sports and fitness activi - Indeed, the author participated in ties. The Academy accomplishes this weekly barefoot running sessions as mission through professional educa - tion, scientific research, public aware - ness and membership support. For ad - ditional information on becoming a Currently, inconclusive member of the AAPSM please visit our website at www.aapsm.org or circle scientific research has #151 on the reader service card. been conducted

Introduction regarding the benefits FIGURE 1: Barefoot runner One of the primary topics for and/or risks of requests for information by the runners regularly cover ultra- media from the American Podiatric barefoot running. marathon distances, either barefoot Medical Association and the Ameri - or in simple sandals. McDougall ob - can Academy of Podiatric Sports serves that the Tarahumara, despite Medicine is barefoot running. To their huge running mileage, do not better deal with the numerous part of track practice in the late appear to suffer from the high de - media queries, APMA and AAPSM 1960s. More recently, however, gree of running-related injuries that developed a position statement on there is a significant interest in those in the civilized world do. barefoot running that concludes, barefoot running which appears Coupling this with an unchanged “Currently, inconclusive scientific motivated by claims of improved injury rate, despite decades of tech - research has been conducted re - performance and reduced injuries. nological improvements in running garding the benefits and/or risks of shoes with regard to motion con - barefoot running.” 1 As will be The Claims trol and cushioning, he makes the noted later, this statement is true It seems much of the impetus claim that shoes are the cause of but does little to help those clini - for the current excitement stems many running-related injuries. Mc - cians unsure of how to best counsel from the current bestselling book Dougall and early work by re - their patients. by Christopher McDougall, Born To searcher Steven Robbins in the What follows is a summary of Run, A Hidden Tribe, Superathletes 1990s, 3,4 claimed that shoes: 1) con - what has been learned about bare - and the Greatest Race the World Has fine and limit foot motion which foot running thus far and is an at - Never Seen 2 that details the exploits results in intrinsic musculature tempt to cut through the claims, of the Tarahumara Indians of the wasting; 2) mask the proprioceptive both positive and negative, in order Copper Canyon of Mexico. These Continued on page 60 www.podiatrym.com NOVEMBER/DECEMBER 2010 • PODIATRY MANAGEMENT 59 Barefoot Running... ioned foot will be subject to os - be argued that most of these seous damage such as stress frac - episodes were the result of inade - interaction of the foot to the ture, listed below are some of the quate adaptation. Though it is un - ground; and 3) encourage an un - other concerns. deniable that surface hazards exist, natural heel strike that increases 1) Surface hazards such as glass, there is really no evidence that they damaging impact forces. These rocks, insects, and temperature ex - pose a risk to those running bare - ideas have been further echoed by tremes foot. Interestingly, the barefoot popular barefoot running web sites 2) Contact with microorganisms condition is favorable to microor - such as Running Barefoot and Bare - and infectious agents ganisms and infectious agents. foot Ted’s Adventures. These sites are 3) Runners with lack of protec - Those running barefoot are at no packed with “how to” information, tive sensation greater risk for plantar verruca, are FAQs and links to studies that ap - 4) Runners who require motion at less risk for tinea pedis, and are pear to support the claims of bare - control shoes and/or orthotics less likely to suffer a pseudomonas foot running advocates. 5,6 5) Increased impact at foot infection as a result of a puncture strike wound. 18-20 There are no studies to The Benefits 6) Achilles and/or triceps surae show that those needing motion Before looking at the evidence, injury from forefoot strike control and/orthotics for diagnosed what are the purported benefits? conditions will be at risk if under - Though not necessarily a benefit , The Evidence-Pro taking barefoot running, but logic profound and undeniable differ - There is little doubt that bare - and clinical experience would say ences are observed in the gait of the foot runners have a distinctly dif - otherwise. Evidence as well as com - barefoot versus the shod runner, mon sense is overwhelming for the and these are said to be responsible high risk of injury for those bare - for some of the stated advantages. foot runners with lack of protective Barefoot runners have a shorter and Though it is sensation. 21-22 One study claimed in - quicker stride and will experience creased impact and another noted less overall ankle, knee, and hip undeniable that an increase of shock transmission motion. The ankle will be plan - surface hazards exist, to the lower back with barefoot tarflexed and foot strike will be running. It appeared that these mid-foot or forefoot (Figure 1). there is really no paradoxical findings were the result Both flight and contact time will be of the subjects being required to reduced. 7 Listed below are the most evidence that they run with a heel strike while un - notable claims of barefoot running pose a risk to those shod. 23,24 advocates. 1) Reduced collision (impact) running barefoot. Minimalist Shoes forces In an effort to be included in 2) Improved proprioception the barefoot running mania, some 3) Stronger plantar intrinsic shoe companies have developed musculature ferent gait than shod runners. Re - shoes that mimic barefoot running 4) Improved energy utilization duced impact with forefoot strike (minimalist shoes). The runner can Claims 1-4 are then said to re - appears to reduce collision forces. 7-9 garner the benefits from utilization sult in reduced injuries and better Numerous studies in the lab under of a barefoot running form but performance. An often-mentioned static (not running) conditions do have some basic protection from example is that those with better demonstrate improved propriocep - surface hazards. The restrictions proprioception would surely experi - tive ability in those who are bare - and confinements of running shoes ence fewer ankle sprains. Addition - foot and that improved foot posi - are eliminated. The Nike Free and ally, the stronger plantar intrinsics tion sense may assist in the ob - Vibram 5 Fingers are currently the and absence of confining shoes are served gait changes responsible for best known, but other companies said to lessen the risk of foot defor - reduced impact. 10-12 Limited studies have released their own models or mities such as pes planus. do support the idea that the bare - have them in development. foot condition may strengthen The Risks and plantar intrinsic, and this in turn The Coaches’ Perspective Contraindications can improve arch structure. 13,14 Last - Although not scientific evidence, Nearly all of the downsides of ly, there is evidence that those run - anecdotal discussion with coaches barefoot running come anecdotally ning shod are less efficient with en - sheds light on some perceived short - from the healthcare provider com - ergy utilization. 15-17 comings as well as pluses to barefoot munity fueled by numerous running. Firstly, a number of coach - episodes of patients who hobble in The Evidence-Con es believe that utilization of barefoot with injuries sustained while bare - There is no evidence that bare - running as part of the overall train - foot running. A number of these foot running causes injuries such as ing program (as the author did in clinicians consider barefoot run - stress fractures or Achilles tendon high school) is beneficial for ning silly and/or dangerous. Besides injuries although clinical experi - strengthening intrinsic musculature the major concern that an uncush - ence would say otherwise—it could Continued on page 62

60 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010 www.podiatrym.com Barefoot Running... have a distinct gait pattern that is Achilles tendinopathy. quite different from that of a shod * but there is no evidence to and improving form but observed runner. show that reduced impact results in (as did a number of clinicians) their * but there is no evidence to reduced injuries or improved per - runners getting overuse injuries as a show that these changes result in formance. result of overzealous incorporation reduced injuries or improved per - of barefoot running. Ironically, run - formance. 3) Those who are barefoot do ners who procured minimalist shoes have an improved proprioceptive such as Vibram 5 Fingers seemed to feel for the surface and better joint have even more injuries due to a position sense. false sense of “protection” when the Some evidence exists * but there is no evidence to purely barefoot condition would that supports show that this results in reduced in - provide better feedback to take it juries such as ankle sprains or im - easier. (Verbal communication, increased strength and proved performance. Coach Bill Strachan, MS July 2009) size of the plantar 4) Some evidence exists that Advising Your Runners intrinsic musculature supports increased strength and One of your running patients size of the plantar intrinsic muscu - presents to your office with a multi - in those who run lature in those who run barefoot. tude of questions about barefoot * but there is no evidence to running and/or minimalist shoes. barefoot. show that this results in reduced in - He indicates that he is considering juries or improved performance. barefoot running but would like your opinion. Evidence as well as 2) Those running barefoot ap - 5) Some evidence exists that experiences of fellow clinicians can pear to experience reduced impact barefoot running has more efficient be used to guide you. Some basic (collision) forces at foot strike. energy utilization. generalizations follow: * but attenuation of the forces * but there is no evidence to by calf musculature may result in show that this results in reduced in - 1) Those running barefoot do myotendinous injury such as Continued on page 63

62 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010 www.podiatrym.com Barefoot Running... 3 Robbins SE, Hanna AM: Running- index.php?q=/. Accessed July 20, 2009. related injury prevention through bare - 7 Divert C, Mornieux G, Baur H, et juries or improved performance. foot adaptations. Med Sci Sports Exerc al.: Mechanical comparison of barefoot 19: 148, 1987. and shod running. Int J Sports Med 26: 4 6) The evidence is clear that Robbins SE, Gouw GJ: Athletic 593, 2005. footwear: unsafe due to perceptual illu - 8 Squadrone R, Gallozzi C: running barefoot would be risky sions. Med Sci Sports Exerc 23: 217, Biomechanical and physiological for those with loss of protective 1991. comparison of barefoot and two shod sensation. 5 Ken Bob Saxton: Running conditions in experienced barefoot Barefoot Web site. http://running runners. J Sports Med Phys Fitness 7) Although there is no evi - barefoot.org/. Accessed March 27, 49: 6, 2009. dence one way or the other, it 2009. 9 Lieberman D, Venkadesan M, would seem that those patients 6 Barefoot Ted’s Adventures Web Werbel W, et al.: Foot strike patterns successfully treated with motion Site. http://www.barefootted.com/ Continued on page 64 control shoes and/or orthotics for a biomechanically related condi - tion would not be well served to begin a barefoot running pro - gram. Having said that, it is worth mentioning that barefoot running aficionados would counter that the changes in form, strengthening of musculature etc. could eliminate the biomechani - cal weakness or prevent it in the first place.

8) It would seem that the most important advice you can give your patient would be 1) choose a safe surface and 2) build up activi - ty as slowly as one beginning a jogging program who has never jogged before, so as to allow the osseous and soft tissue structures time to adapt.

Key Point A common theme in the above conclusions is that there is no evi - dence to support that barefoot running reduces injuries or im - proves performance, but it is very important to point out that the ev - idence does not support that bare - foot running increases injury or re - duces performance. Some of the claims may very well pan out to be true, but much more research is needed. I

References 1 American Podiatric Medical Asso - ciation/American Academy of Podiatric Sports Medicine Position Statement on Barefoot Running. APMA Website. http://www.apma.org/MainMenu/News /MediaRoom/PositionStatements/ APMA-Position-Statement-on-Barefoot- Run Accessed November 9, 2009. 2 McDougall C: Born to Run: A Hid - den Tribe, Superathletes, and the Great - est Race the World Has Never Seen. 1st edition, Alfred A. Knopf/Random House, New York, 2009. www.podiatrym.com NOVEMBER/DECEMBER 2010 • PODIATRY MANAGEMENT 63 Barefoot Running... thotics on VO2 and selected frontal Gunethilleke B, et al.: Is walking bare - plane knee kinematics. Med Sci Sports foot a risk factor for diabetic foot dis - Exerc 17: 158, 1985. ease in developing countries? Rural Re - and collision forces in habitually bare - 16 Catlin MJ, Dressendorfer RH: Ef - mote Health 7: 692, 2007. foot versus shod runners. Nature 463: fect of shoe weight on the energy cost 23 Komi PV, Gollhofer A, Schmidt - 531, 2010. of running. Med Sci Sports Exerc 11: 80, bleicher D, et al.: Interaction between 10 Robbins S, Waked E, McClaran 1979. man and shoe in running: considera - J: Proprioception and stability: foot 17 Flaherty R: Running economy tions for a more comprehensive mea - position awareness as a function of and kinematic differences among run - surement approach. Int J Sports Med 8: age and footwear. Age Ageing 24: 67, ners with foot shod, with the foot bare, 196, 1987. 1995. and with the barefoot equaled for 24 Ogon M, Aleksiev AR, Spratt KF, 11 Robbins S, Gouw GJ, McClaran J: weight. [abstract].1994 [cited June et al.: Footwear affects the behavior of Shoe sole thickness and hardness influ - 2009]. Available in SPORTDiscus with low back muscles when jogging. Int J ence balance in older men. J Am Geriatr full text. Sports Med 22: 414, 2001. Soc 40: 1089, 1992. 18 van Haalen FM, Bruggink SC, 12 Kurz MJ, Stergiou N: Does Gussekloo J, et al.,: Warts in primary footwear affect ankle coordination schoolchildren: prevalence and relation Dr. Jenkins is a strategies? JAPMA 94: 53, 2004 with environmental factors. Br J Derma - Professor at the 13 Rao UB, Joseph B: The influence tol 161: 148, 2009. Arizona School of footwear on the prevalence of flat 19 Laughlin TJ, Armstrong DG, Ca - of Podiatric foot. A survey of 2300 children. J Bone porusso J, et al.: Soft tissue and bone in - Medicine-Mid - Joint Surg Br 74-B: 525, 1992. fections from puncture wounds in chil - western Univer - 14 Brugemann G,, Potthast W, dren. West J Med 166: 126, 1997. sity as well as a Braunstein B, et al.: Effect of increased 20 Pallar, A: Getting a Jump on Ath - Fellow and mechanical stimuli on foot muscles letes Foot. Dermatology Insights 3: 30, Board Member functional capacity [online abstract]. 2002. of the American In: ISB XXth Congress—ASB 29th An - 21 Lavery LA, Walker SC, Harkless Academy of Po - nual Meeting. Cleveland, OH: Ameri - LB, et al.: Infected puncture wounds in diatric Sports Medicine. He is also the can Society of Biomechanics; diabetic and nondiabetic adults [erra - Clinical Director for the Special 2005:553. tum in: Diabetes Care 19: 549, 1996]. Olympics Arizona Fit Feet Program and 15 Burkett LN, Kohrt WM, Buch - Diabetes Care 18: 1588, 1995. Podiatric Consultant for the Los Angeles binder R: Effects of shoes and foot or - 22 Jayasinghe SA, Atukorala I, Dodgers.

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