Wednesday, January 4, 2012

The Myths of Minimalist Running and Foot Injury

From time to time, I will write a bit here and there about minimalist running (also called "barefoot" running).  I'll try not to get too preachy, since I know that minimalist running is not for everyone, but I still want to write about it because I think more people should try it.

The online journal Podiatry Today has posted an article called "Tackling The 10 Myths of Barefoot Running."There is a lot of technical language in the article, but it provides a nice summary, from foot doctors' perspective, about barefoot running.  Here is a summary of some of the "myths."2
I can't do barefoot running because I need to wear my orthotics. Orthotics have become more overutilized in the practice of podiatry then ever before. It is very common for me to see runners present in my office with plantar fasciitis, a normal arch, cushioned running shoes and orthotics they have worn. When running barefoot or in a minimalist shoe, we do not need to control motion at the rearfoot because heel striking is not occurring and “excessive pronation,” as described by Root, does not occur. While we have numerous studies that do not support the use of orthotics for running injuries alone, it becomes a challenge to convince the patient they are not needed. 
Orthotics (also called shoe inserts) have become a huge market for runners as we try to squeeze every possible mile out of increasingly injured feet, ankles, knees, and IT bands.  It seems that some people become somewhat addicted to their orthotics (I know that I became very dependent on Powerstep Pinnacle inserts to help provide arch support and relieve plantar fasciitis pain).  Many runners think that they can't switch to barefoot running or minimalist shoes because they won't be able to use their orthotics.  This first myth basically says "so what?"  Because proper running form (which often comes naturally with minimalist running) involves forefoot or midfoot striking, rather than the heel striking that is common with "normal" shoes, there is no need for the motion control that orthotics provide.
I have plantar fasciitis so barefoot running would be too painful. This article was not intended to discuss the pathomechanics or treatment options of plantar fasciitis. However, we are anecdotally seeing resolution of symptoms in those who adopt this style of running. One potential explanation is the development in strength we see to the intrinsic musculature, specifically the abductor hallucis muscle, which is a primary supporter of the arch.

Another overlooked phenomenon is the fact that the majority of running shoes place your ankle into plantarflexion. This forces the body to compensate by increasing lumbar lordosis and increasing pressure to the heel as opposed to having more even distribution throughout the foot.
Plantar fasciitis (PF) sucks (so much so that I titled the one post I wrote about it "The Plantar Fascia - That Fickle Bitch").  It's a chronic injury that sometimes takes forever to go away.  The best treatment for it is just flat out rest, but of course us runners aren't going to just stop running for a month or more.  If you have PF, I totally understand your fear about trying a running style with no cushioning.  

But, in response to this "myth" the article states two points: (1) when you adopt minimalist running, the muscles in your feet get stronger, which in turn provide more support for your arch, which takes pressure of the plantar fascia connective tissue; (2) because "normal" running shoes have heels that are raised relative to the toe (e.g., they have a "drop," usually 12-14 mm (around a half inch)), your foot is permanently flexed (as you see, the article uses the fancy term "plantarflexion," like how your foot is flexed when you are pushing down the gas pedal while driving), which causes your back curve more (increased lumbar lordosis) to compensate, which actually increases pressure on the heal rather than spreading the force evenly.  In short, "normal" shoes actually increase the chances of PF.  Anecdotally, I can say that this has been true in my case.  I used to have moderate PF that sometimes flared to severe.  But since switching to Vibram Five Fingers, I've had absolutely no PF pain at all.
An atrophied fat pad would prohibit barefoot running. This is another common myth that patients acquire from various sources, including medical professionals. Most, if not all, of us have treated a patient who complains of forefoot pain or calluses, and then simply blames the problem on a lack of adipose tissue or cushioning below the metatarsal heads. While this seems to be a possible etiology, there is no evidence to date that the fat pad of the sole of our foot actually atrophies on the forefoot or the heel region.  With common forefoot pathology such as hammertoe deformities, we do see the fat pad migrate distally producing more prominent metatarsal heads but typically, this is in severe cases, such as rheumatoid arthritis.  Patients at this stage of a deformity are typically not runners.
I must admit, I've never heard of this complaint before, but I suspect podiatrists might have.  It sounds like some people worry that the fat pad on the bottom of their feet (either at or near the ball of the foot) will deteriorate from minimalist running.  This "myth" response seems to indicate that this is not the case in runners. 
Barefoot running causes severe calluses. Calluses on our feet form as a result of shear force on the plantar surfaces of the skin that produces excess friction. Shear force that occurs in the horizontal plane is the key to understanding this concept. Direct pressure does not produce calluses or we would see a high preponderance of heel calluses in runners as the majority of runners heel strike.

Root discussed the formation of forefoot calluses secondary to shearing forces associated with propulsion as well as to the central metatarsals due to increased loading for an excessive period of time and abnormal shear.  Root's observations hold true for someone who heel strikes when running as we see increased force placed upon the forefoot during what he described as the propulsion phase. Observation of the gait of a barefoot runner or one who strikes with the forefoot/midfoot demonstrates that the propulsion phase as described by Root becomes very minimal in existence, if it even occurs at all.

 Good Form Running in association with New Balance provides training to adopt this style of running and we can see that by developing forward momentum, we carry the contralateral limb forward instead of having forefoot propulsion.  By doing this, we decrease the force present to the forefoot, especially the shear force. Not only is this beneficial for reduction of the shear force but we see a decrease in the ground reactive forces acting on the first metatarsophalangeal joint, which can reduce sesamoiditis. 
I guess people are worried about having really bad calluses on their feet.  This "myth" response seems to indicate that calluses do not form in any greater degree for minimalist runners than for runners in "normal" shoes.  Personally, I have found that I get calluses on my feet, but I have no idea if that is just natural to me or a result of using minimalist shoes.  I suspect the fact that I often run without socks (which you can do in minimalist shoes) has more to do with that than my style of running.  Also, I don't mind getting calluses.  That means I generally won't get blisters.  Blisters suck.  Calluses are just ugly. 
I run long distance and cannot do that barefoot. What many of us fail to realize is that we have been running for thousands of years and we know that early runners began running either barefoot or with very minimal shoegear such as moccasins.  In 1960, Abebe Bikila won the Olympic Marathon in a record time of 2:15:16.2 while running barefoot.  Zola Budd recorded numerous middle distance world records while running barefoot in the 1980s. Ken Saxton (well known among the subculture of barefoot runners) finished 14 marathons in 2006 unshod and has since completed a total of 56 marathons, including the Boston Marathon, all while running barefoot.
I suspect this is the one that scares away a lot of runners.  Besides the examples provided above, I can personally attest that I have had no issues with running longer distances in minimalist shoes.  I have run numerous 10 mile runs in them, a couple 12 mile long runs, a 13 mile long run, a 14 mile long run, a 15 mile long run, and a 10 mile race in them.  I will be running the Disney Half Marathon in them.  As long as you build up your mileage slowly (so that your feet and calves get used to it), you can do any distance in them.  I know there are ultramarathoners who run in Vibram Five Fingers.  This fear is just ignorance.
You could step on glass. This is my favorite excuse for not running barefoot. Numerous times, people ask me the question of “what happens if you step on glass?” There is debate on this topic among medical professionals as well as early adopters to this style of running. What is my answer? “Don’t step on glass.” This concept of “barefoot running” is not about what you are wearing on your foot. It is about how you are running and allowing the foot to perform the way it was designed and intended to perform. Once the form is perfected and the runner abandons heel strike (which runners can typically learn on a treadmill barefoot), the next step is to protect the skin of our foot while not compromising the proprioceptive feedback from ground.
I like the snarkiness of this response... "don't step on glass."  But the main point is still valid... minimalist running "is not about what you are wearing on your foot, it is about how you are running and allowing the foot to perform the way it was designed and intended to perform."  Moreover, minimalist running causes you to be more aware of the ground (which you really should be anyway) and to look/sense a "cleaner" path.

Finally, as the article goes on to mention, there are lots of options for someone who wants to do "barefoot" running while still protecting the foot.  The most obvious is Vibram Five Fingers, but there has been an explosion of other options in the past year or so, such as Vivobarefoots (which I also use), Merrell Barefoot shoes (my next planned purchase), New Balance Minimus shoes, and numerous others (check out Barefoot Running University, the Maple Grove Barefoot Guy, or Barefoot Angie Bee (just to name a few minimalist bloggers) for lots of information on minimalist shoe options).

I short... if you're worried about increased risk of injury from minimalist running, don't.  Minimalist running tends to decrease the risk of injury (at least from the more common running injuries).  That isn't to say that there isn't still risk of injury, and that injury can occur in minimalist shoes that wouldn't necessarily happen in "normal" shoes, because those injuries can happen, but those tend to be more freak accidents.

Enough ranting for today.  Have a great hump day!

1 If you count the actual "myths" from the article, there are only six... I don't know why they said ten. I guess it sounds better.
2 As a disclaimer, I'm not a podiatrist or a doctor of any kind.  I'm a patent attorney, so these summaries are just my attempt to make the language from the article a little more accessible.  Please let me know if any of my descriptions are inaccurate.

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