ATHLETIC FOOTWEAR AND RUNNING INJURIES

Essay on the harmful effects of modern running shoes.

       (  Written a number of years ago, this piece was published in part in the German ultra magazine Spiridon.)

 
PART 1 - INTRODUCTION   AND  HISTORY

    Look, if anyone displayed brand-loyalty, it was me.  I LOVED my NIKE  AIR MAX  Triax™ runners.  I wouldn’t buy anything else.  Why?  Because they felt good.  I liked the cushioning.  I liked the ride.  I also felt they protected me from the hard road by interposing a layer of air between the sole of my foot and the pavement.   So why was I sidelined with a heel injury for over two months?  I listened to the manufacturer and changed my runners every 400 miles.  Come to think of it, why do I see so many runners with lower extremity injuries in my office?  The traditional answer to these questions has always been overuse often compounded by an underlying mechanical abnormality such as over-pronation or flat-feet. 

    The treatment, along with modification of training, physiotherapy, stretching etc. has always included a close look at the runner's footwear, often with recommendations about motion control, stability, cushioning, orthotics or custom molded insoles.  A growing body of literature in the field of sports medicine, however, is causing a bit of a stir...no, call it PANIC in the running world.  Everything you and I always believed about running shoes and running injuries may be wrong!    Here's the scoop:  The modern running shoe itself may be the major cause of running injuries!  Stated another way, the modern running shoe, presently thought of a protective device, should be reclassified as a "health hazard".  (NIKE, please tell me it ain't so!!!)
    Now relax, get back on your chair and take a deep breath.   We'll take this one step at a time and since we're going to be talking about shoes and feet, I may as well start at the beginning...the very beginning.  Until quite recently in our history, most humans lived out their lives unshod.  S.F.Stewart in his "Footgear - It's History, Uses and Abuses" states that “…all writers who have reported their observations of barefoot peoples agree that the untrammeled feet of natural men are free from the disabilities commonly noted among shod people - hallux valgus, bunions, hammer toe and painful feet.”  So why was footgear developed?  One of the earliest examples of footgear known to us takes the form of sagebrush bark sandals found in caves and rock shelters near Fort Rock, Oregon under a layer of volcanic ash dating back 10,000 years.  The foot surface is smooth and they were held on by bast straps over the instep.  Similar sandals were used throughout the volcanic cordilleras of Meso and South America and the volcanic islands of the South Pacific.  The early Polynesians used sandals to cross old lava flows and when fishing on the razor-sharp coral.  It seems, therefore, that the prime function of the earliest sandals was protection of the sole.

    Although the early Pharaohs are all represented as barefoot, by the first millennium BC sandals in Egypt were common in court and were worn by soldiers.   In Mesopotamian kingdoms sandals were evidently a status symbol with the king known to have worn a wedged sandal in contrast to his flat-soled courtiers.  Very thick-soled low boots are known to have been worn by Greek tragedians to increase their height.  Comedians wore socks or soccus - hence the expression "high tragedy and low comedy".  Thus, the secondary function of footgear appears to have been symbolic.

    From the time of the Greeks, footgear gradually evolved to meet both symbolic and functional needs.  For example, tradition tells us that about the beginning of the present millennium Count Fulk of Anjou introduced long pointed toes to cover up some deformity of his feet, and courtiers quickly adopted the fashion.  The Mongols, who on horseback ravaged the Middle East between Damascus and Moscow from the 12th-14th centuries, are credited for the introduction of the block heel presumably developed to better grip the stirrup plate.  But in the French court of Louis XIV, the rugged Mongolian heel underwent a radical cosmetic transformation eventually leading to the ultimate idiotic expression of modern fashion - the stiletto heel.

    European peasants wore clogs carved from a block of wood.  Mass production seems to have begun prior to the 14th century, for Edward II in 1342 decreed that shoes should be sized.  Their length was measured in barleycorns, 3 to an inch.  This is still the basis of shoe measurements, 1/3 inch to a size in length.  We start sizing from a baseline of 3" in children and 7" in adults.  Widths vary with length; in a given size the widths vary by 1 1/2 inch.  Unpaired shoes were introduced in England in the 15th century when gout became common and these shoes had broad square toes to relieve pressure.  The most recent innovation seems to have been the hard box toe to preserve the appearance of the shoe.

    Now, let's focus-in on the running shoe.  It seems that the earliest sports shoes were developed in the 1830's by the Liverpool rubber company owned by John Boyd Dunlop.  Although they were first called sand shoes because they were worn on the beach by the Victorian middle classes, they eventually became known as plimsolls because the lines formed by the rubber and canvas bond looked similar to the Plimsoll line on a ship's hull.  In 1933, Dunlop launched its Green Flash range of trainers.   Adi Dassler (and his brother Rudolf) started making sports shoes in Herzogenaurach, Germany in 1920 and in 1936 Jesse Owens wore a pair of them when he won four Olympic gold medals in Berlin.  ADIDAS (Adi Dassler) was formed in 1948 with the now famous three stripes logo developing from three support leather bands used to bolster the sides.  By the 1956 Olympics, dozens of competitors were wearing ADIDAS shoes.  Rudolf Dassler broke away to form PUMA.  Amidst the first rumblings of the jogging-boom, NIKE (after the Greek goddess of victory) was launched by American Phil Knight, a former track star at the University of Oregon, and his waffle-making coach Bill Bowerman in 1971(Surely you remember the NIKE Waffle Trainer!).  The NIKE  ‘Swoosh’ is arguably the most successful logo in the world and was conceived for Phil Knight by a local Oregon graphic design student, Carolyn Davidson, for a total fee of $35.  (But don't worry about the graphic designer.  In September 1983, NIKE presented Carolyn Davidson with a rather substantial share package as a way of saying "Thank-you.")  ASICS (acronym for Animus Sanus In Corpore Sano, Latin for A Sound Mind In A Sound Body) first introduced its shoes in North America in 1977 while REEBOCK (named after a species of an African gazelle) entered the US Market in 1979 as the running shoe was slowly transforming into a fashion item.  1987 was declared the Year of the Running Shoe by the clothing industry, the same year NIKE launched the 'cross-trainer' and it's flagship running-shoe, the Air Max. After 16 years of research, NIKE introduced its SHOX line of runners in 2000, arguably the first athletic shoe on springs (foam)!
 
 
PART 2 - SHOES AND INJURIES

    For the last fifteen years or so, buying a pair of runners has always been accompanied by a warm fuzzy feeling inside, a feeling that comes from the certain knowledge that you're investing in a high-tech device purpose-designed to protect you from injury and improve your performance.  You can just see all those smart dedicated NIKE mechanical engineers hard at work developing and testing newer and better space-age materials to shield you from the terrible pounding you submit yourself to in order to "Just do it!’  Gel, air, channels, honeycomb, microspheres, super-light materials, foam springs and soon...yes, you guessed it, micro-chips in the soles of your shoes (better than diamonds, I suppose).   New round laces and ribbon eyelets result in that custom-fitted feel supplemented by molded sorbothane insoles or special orthotics from your local prosthetist and you're ready to tackle any distance.

    Now here's the catch.  If all this high-tech stuff is supposed to be preventing running injuries by shielding us from impact, why is it that two out of every three runners are sidelined every year because of a running injury?  Why is it that since the great jogging boom of the mid-seventies, there has been no decrease in the incidence (some authors say there has been an increase) of running injures in spite of yearly 'improvements' in running-shoe technology?  Why is my office filled with runners who have injured knees (26% of running injuries), tibias (13%), Achilles tendons (6%) and plantar fascias (5%)?  The cause of all these injuries is quite evident: cumulative micro-trauma caused by repetitive impact experienced during running.  The heel of a runner upon striking the ground generates a force that can equal 2.5 times body weight at the foot and as much as 7 times body weight at the hip.  Repeat this 1000 times per mile and it's easy to appreciate the stress the old bones are under.  Add to this the hardness of urban roadways compared to naturally deposited surfaces and eventually, something gives, inflammation sets in and pain results...and you end up working at the finish-line pulling bar-codes off finishers.  Now, where's our high-tech shoe in all this?  With all the improvements in recent years, you'd think we'd be seeing a marked decrease in running injuries.  Just keep reading.

    It wasn't till the mid-eighties that some researchers smelled something rotten in the athletic footwear world and it wasn't just dirty socks.  Footwear manufacturers were well aware that impact was the cause of running injuries and reasoned that the way to attenuate impact was to interpose a soft impact-absorbing midsole between the foot and the ground.  The first major problem was the method used by essentially all the footwear development labs to test the impact absorption of footwear mid-soles.  Dr. Benno Nigg from the University of Calgary showed that machine testing of these materials by dropping a 5-kg object onto the shoe-sole and measuring the impact on a pressure-plate did not accurately predict human impact with the same materials.  In fact the correlation turned out to be inverse, that is when you drop a 5-kg ball on materials of increasing softness, you measure decreasing impact.  However, when the impact from a running human is measured, the result is the reverse, and the impact increases with softer materials! WHOOPS! (You'll find out why later.)   

    Next problem.  In 1989, Dr. B. Marti published a paper which still makes the throats of footwear executives go dry.  He studied 5,038 runners who participated in a 16km race and had them fill out an extensive questionnaire about their running in the year preceding the race.  Here's what he found: The incidence of injuries in runners using shoes costing more than $95 was more that twice as great as in runners using shoes costing less than $40. (Note that this result includes correction for other influencing factors such as training mileage and history of previous injury.)  In other words, the fancier (high-tech, advanced) the shoe, the more dangerous it is!  Now a study of over 5,000 runners is not something to thumb your nose at and you would think the shoe manufacturers would have taken some notice.  Not on your life.   Yearly athletic shoe sales were in the billions of dollars and this was no time to fiddle with a successful product.   In any case, it is felt by many observers that by the mid-eighties researchers, in-house or independent, had effectively been forced out of the loop of new product development and that research and development was now exclusively in the hands of the marketing people.  Athletic shoes had become a fashion item and were designed as such, as they are to this day.

    The big question: Why are super shock-absorbing athletic shoes causing more running injuries?   Dr. Steven Robbins from the Centre for Studies in Aging at McGill University in Montreal is the man who came up with the answer.  Dr. Robbins pointed out that the human lower extremity is not a delicate, rigid, passive structure requiring 'packaging' to protect it from impact.  This becomes blatantly obvious when one observes the nearly complete absence of foot disorders in unshod populations.  People who go around barefoot just don't get plantar fasciitis or any of the other lower extremity injuries so common in shod populations.  The lower extremity, he points out, is a rugged, flexible, active, well designed (teleologically) structure.  Wire this structure to a spinal cord and a brain and what you've got is a system fully capable of handling the impacts of running.  So, how does this system work exactly and why do modern running shoes screw it up?

    Allow me for a moment to compare the human locomotor apparatus to a modern luxury car.  The bones of the foot, leg, thigh and pelvis act as the frame, linked by joints and all held together by fairly inelastic ligaments and fascia.  The bones and joints are surrounded by contracting muscles which act as the suspension system.  This is especially evident in the arch of the foot which is formed by both the passive, rigid plantar fascia as well as the active, flexible intrinsic muscles.  The bones and muscles are covered by fat and skin within which reside receptors or sensors that send information to both the peripheral computer (the spinal cord) and the central computer (the brain).  The skin on the sole of the foot (glabrous skin) is very well suited to its function possessing about 600% of the toughness of hairy skin (the skin everywhere else on our bodies except our palms).  The receptors in the foot are specially designed to sense both impact (vertical force) and shear (horizontal force).  Add to this information streaming in from pain receptors as well as joint position receptors throughout the lower extremity and you've got a Hummer! (Got carried away a little...sorry.)

    During barefoot running, the ball of the foot strikes the ground first and immediately starts sending signals to the spinal cord and brain about the magnitude of impact and shear, getting most of its clues about this from the skin contact with the surface irregularities of the ground.  Take away this contact by adding a cushioned substance and you immediately fool the system into underestimating the impact. Add a raised heel and the shod runner is forced to land on it. Strap the cushioning on tightly with the aid of a sophisticated lacing system and you block out shear as well, throwing the shock-absorption system even further into the dark.  The system responds by landing harder in an attempt to compress the cushion and 'feel' the ground.  The weight is then transferred to the outside edge of the foot, completely by-passing the skin of the arch.  The heel then touches down and the weight is transferred to the ball again with final push-off through the toes.  While the weight is being transferred, the arch carries out its function as the suspension system of the foot and flattens under the active control of the intrinsic muscles. The ankle, knee and hip joints flex to absorb impact in response to information flowing in from the foot.  The cushioned midsole of the modern running shoe robs the system of important sensory information necessary for ankle, knee and hip response to impact.  The arch support (or orthotic) in modern running shoes not only prevents the arch suspension system from absorbing energy by preventing flattening but eventually leads to intrinsic muscle atrophy and complete loss of active muscular control of the arch leaving only the inelastic plantar fascia as a checkrein to flattening.   The barefoot runner's 'foot position awareness sense' which relies heavily on sensory input from the sole of the foot minimizes his risk of sustaining an ankle sprain on uneven ground.  The shod runner is at marked increased risk of ankle sprains because his 'foot position awareness sense’ is handicapped by the paucity of sensations coming from his soles.  The barefoot runner is constantly alert scanning the ground before him for irregularities and dangers that might cause him injury.  The barefoot runner is a cautious runner and actively changes his landing strategy to prevent injury.  He treads lightly.   The shod runner is bombarded by convincing advertising stating or implying that the shoe he is wearing will protect him well over any terrain and he becomes a careless runner.  He is heavy footed.  Finally, certain diseases in humans can cause a gradual destruction of the sensory nerve endings in the foot (and elsewhere) resulting in a significant increase in lower extremity injuries.  Diabetes and tertiary syphilis are two.  Extremities so affected are termed 'neuropathic'.  The shod runner, because of his sensory deprivation and high risk of injury may be termed as having 'pseudo-neuropathic' feet, a term coined by Robbins.

    The conclusion that shoes are the primary cause of running injuries is strongly supported by the scientific literature.  I've already mentioned Marti's work showing more than twice the incidence of running injuries with expensive shoes compared with cheap ones.  Rao and Joseph (1992) examined 2300 Indian children between the ages of 4 and 13 and found that the incidence of flat feet was more than three times greater in those children who used footwear than in those who did not leading them to conclude that shoe-wearing in early childhood is detrimental to the development of a normal arch.  In 1988, Hamill and Bates showed that as running shoes lose their cushioning through wear and tear, subjects improve foot control on testing and presumably decrease their risk of injury, i.e. shoes get better with age.  Robbins and Gouw showed in 1991 that modern athletic footwear creates a perceptual illusion in subjects whereby they consistently underestimate impact.  Simply adding surface irregularities on the insoles (to simulate barefoot like conditions) markedly improves subjects’ estimates of impact.  Robbins and others (1994) studied the balance ability of men walking along a beam wearing shoes with soles of varying thickness and hardness.  Results confirmed that the thinner and harder the soles, the better the balance. In one of their most elegant and widely publicized studies, Robbins and Waked (1997) examined the effect of advertising on landing impact.   They asked subjects to step down barefoot ten times onto four pressure measuring platforms, the first one being bare and the other three covered by identical shoe sole material made to look different by different colored cloth.  The subjects were given different messages for each of the covered plates: the message for the first covered plate suggested superior impact absorption and protection (deceptive message), the second suggested poor impact absorption and high injury risk (warning message) and the third suggested unknown impact absorption and safety (neutral message).  Results showed that subjects landed with the highest impact when given the deceptive and neutral messages and with the lowest impact when given the warning message or with the bare plate.  The authors conclude that running injury rates are greatest in users of the most expensive shoes because advertising has deceived these users into believing that the shoes provide a superior level of safety thereby inducing an attenuation of impact moderating behavior, increasing impact and injury.  The authors add that deceptive advertising of protective devices is a public health hazard and should be addressed.  Humans are less cautious even when they use truthfully advertised products because of excessively positive attitudes toward new products and wrong impressions of the standards of truth in advertising.

    "So," you think, "is this guy telling me that NIKE, REEBOCK and all those big corporations just put this new stuff out on the market without any proof that its safe?  Can't be!"   Well, that's exactly what I'm telling you.  I can be a real pain in the ass when I try, and some years back, I was in the mood.  I got on the phone and tried to talk to the directors of research at all the big athletic footwear companies.   I tell you, getting to talk to one of these guys is harder than talking to the Pope.  I finally got to speak with Mr. Gordon Valiant, then director of research at the NIKE Sports Research Lab in Beaverton, Oregon.    JF:" Mr. Valiant.  My name is Dr. Froncioni and I'm an orthopedic surgeon.  I treat a lot of runners and I was just wondering what your thoughts were on the whole issue of running injuries possibly being caused by your running shoes."  ...long pause...GV:"Umm...well...I'm afraid I'm not at liberty to discuss that matter."   SAY WHAT!!!??  JF:"Mr. Valiant, in case you missed it, I'm NOT a reporter.  I'm just an orthopedic surgeon who's looking for some answers for his patients.  Let me rephrase.  Surely you have data to support the injury protection claims you make about your running shoes....surely sir.."   GV: "Well...I could refer you to our marketing people and I'm sure they could send you something."  Nope.  We're not on the same wavelength at all.  I'm sure the lawyers have given these guys a gag order.  JF: "Mr.Valiant, your marketing people send me stuff all the time; it's all over the Runner's World I get every month.  Anyway, nice talking to you."

    I've also had a few chats with Dr. Steven Robbins.  He feels very strongly that the athletic footwear manufacturers are painting themselves into a very tight corner by not acting on the available information.  After all, it is within their power to effect changes in their shoe design based on the available data and in doing so decreasing the running injury rate by up to 55%.  By not acting now, Dr. Robbins predicts the footwear manufacturers may end up in the same situation as the tobacco companies with massive class-action lawsuits brought against them.
 
PART 3 - NEW DIRECTIONS

    So, what do we do now?  For starters, NO, I do not recommend that you run your next half-marathon barefoot.  But certainly, I predict that sooner or later, changes will come about in both shoe design and training.  From the medical establishment's point of view, the prevention and treatment of running injuries must change to incorporate the concepts outlined above.  In fact I view the ideas I've presented here as a major paradigm shift in sports medicine, the likes of which I have not seen in the last fifteen years.  Of course, the major shoe companies have to own up and start introducing better shoes into their lines.  Why not do this gradually and introduce just one shoe that incorporates some of the recommended changes.  Dr. Robbins is already testing shoes that use a thinner, less resilient midsole material that provides the comfort but not the impact absorption and of course has no arch support.  I'm sure the marketing boys at NIKE could handle it.

    Without being too radical, there are some changes that are worth introducing without further delay and they are as follows:

            1-Young children should be encouraged to spend as much time as possible barefoot.  We know that this is especially important for the proper formation of the foot arch in the first six years of life.  So, moms, trash the WEEBOCKS  and let your kids develop strong healthy feet just as they were meant to.

            2-Runners should consider incorporating sessions of barefoot running into their training.  In an article in the October 1997 Runner's World, Adam Bean gives the following advice:  "Running barefoot a couple of times per week can decrease your risk of injury and boost your 'push-off' power."  You can run on any surface you like as long as you're careful of sharp objects and pebbles.  Soft sand is probably the least desirable surface because it is unstable and after your heel has dug-in, you will weight bear on your arch.  Paved roads are fine and dangerous objects are easy to spot.  But remember, your feet will need to toughen-up so start with small doses.  Kick your shoes off as soon as you get home and spend your evenings and weekends barefoot.

    Is it possible to rehabilitate the weakened muscles of a normally shod runner?  It certainly is according to another excellent study by Dr. Robbins (1987).  He asked 17 normally shod recreational runners to gradually increase barefoot activity both at home and outdoors over a period of several weeks and to maintain barefoot activity for about four months.  The runners' feet were examined, measured and x-rayed at regular intervals to detect changes.  Results showed marked improvement in the anatomy and function of the arch.  The authors concluded that the normally shod foot is capable of rehabilitation of foot musculature.  Very good news indeed for all of us.

            3-Runners may want to consider switching to a lightweight shoe that provides less cushioning and no arch support.  The only shoes on the market that come close to these characteristics are racing flats.  I use the 6.5 oz. ASICS Gel-Magic Racer.  For you diehard NIKE  fans, consider the Air Streak II, Air Streak Spectrum Plus or the Air Streak Vapor IV but most shoe manufactures make a flat.  A shoe that Nike has just introduced this year, the NIKE FREE also looks like a step in the right direction (I have not actually seen this shoe myself yet).  Moreover, a look at the NIKE FREE web page give me a bit of hope that this company may finally have seen the light.  If you do change to flats, I recommend you wean into them slowly.  Remember that you live in a developed country and that your feet have been shielded from natural stresses your entire life, i.e. you’ve got wimpy feet, buddy. The intrinsic muscles of your feet are asleep and need to wake up slowly. The first thing that will strike you in a racing flat is the lightness of the shoe (Most runners today run in shoes that weigh as much as 14 oz.)   Then, you will quickly realize that for the first time, you start to feel the ground you are walking on.    Oh…and one more thing: don’t listen to the guy at the running store.  He’s there to sell shoes and is under the spell of the powerful shoe industry advertising machine. He has become well and truly brainwashed with the traditional concepts that we all need cushioning and arch support.  He will try to dissuade you from buying a racing flat and he may even go as far as telling you that they are for elite runners and are meant to be used for one marathon only.  Don’t believe him.   I keep my flats for at least 400 – 500 miles with no problem.

    Finally, some radicals among you may wish to become full-time barefoot runners.  Barefoot running clubs are springing-up all over America and Europe.  Point your search engine to 'barefoot running' or go to www.runningbarefoot.org to get more information.  I also welcome anyone who wishes more information on any of the quoted materials to contact me and it would be my pleasure to provide you with copies ([email protected]).

Joseph Froncioni

 

READING LIST

1. BEAN, A. “Expert Advice”.  Runner’s World, Oct 1997; 100-101.

2. BENSON, R. “Trainerspotting”.   Electronic Telegraph, 6th December 1997.

3. BRUNET, M.E., COOK, S.D., BRINKER, M.R., DICKINSON, J.A. “A survey of running injuries in 1505 competitive and recreational runners”.  Journal of Sports Medicine and Physical Fitness, Sept.1990; Vol 30, No 3, 307-315.

4. CLEMENT, D.B.,  TAUNTON, J.E., SMART, G.W., McNICOL, K.L. ”A Survey of Overuse Running Injuries”.  The Physician and Sportsmedicine, May 81; Vol 9, No 5, 47-58.

5. CUDICIO, R., “L’étude Qui Fait Peur Aux Géants”.  Sport et Vie, Jan Feb 1998, No 46.

6. D’ASSCHE, G. “History of the trainer”.  Electronic Telegraph, 6th December, 1997.

7. GREGORIADIS, X. “Will this one run and run?”  The Independent on Sunday 1st  February 1998.

8. GWYTHER, M. ”Smelly old trainers, £300”.  Electronic Telegraph, 15th February, 1997. 

9. HAMILL, J., BATES, B.T.  “A Kinetic Evaluation of the Effects of In Vivo Loading on Running Shoes”.  Journal of Orthopaedic and Sports Physical Therapy, 1988, Vol 10, No 2, 47-53.

10. LEBOW, F., AVERBUEN, G., AND FRIENDS.  “The New York Road Runners Club Complete Book of Running (Updated Edition)”.   New York Road Runners Club, 1994.

11. MARTI, B. “Relationships Between Running Injuries and Running Shoes – Results of a Study of 5,000 Participants of a 16-km Run – The May 1984 Berne ‘Grand Prix’”.   In: Segesser B., Pforringer W., eds.  The shoe in sport.  Chicago: Year Book Medical Publishers, 1989: 256-265.

12. McNITT-GRAY, J.L., TAKASHI, Y., MILLWARD, C. “Landing Strategy Adjustments Made by Female Gymnasts in Response to Drop Height and Mat Composition”.  Journal of Applied Biomechanics, 1993, 9, 173-190 by Human Kinetics Publishers.

13. RAO, U.B., JOSEPH, B. “The Influence of Footwear on the Prevalence of Flat Foot, a Survey of 2300 Children”.  The Journal of Bone and Joint Surgery,  July 1992, Vol 74-B; No. 4, 525-527.

14. ROBBINS, S.E., GOUW, G.J. “Athletic Footwear and Chronic Overloading A Brief Review”.  Sports Medicine 1990, 9 (2):  76-85.

15. ROBBINS, S.E., GOUW, G.J. “Athletic footwear: unsafe due to perceptual illusions”.  Medicine and Science in Sports and Exercise, 1991, Vol 23, No2, 217-224.

16. ROBBINS, S.E., GOUW, G.J., HANNA, A.M.  “Running-related injury prevention through innate impact-moderating behaviour”.  Medicine and Science in Sports and Exercise.  1989, Vol 21, No2, 130-139.

17. ROBBINS, S., GOUW, G.J., McCLARAN, J., WAKED, E.  “Protective Sensation of the Plantar Aspect of the Foot”. Foot & Ankle, July/August 1993, Vol 14, No 6, 347-352.

18. ROBBINS, S., HANNA, A.M.  “Running- related injury prevention through barefoot adaptations”.  Medicine and Science in Sports and Exercise.  1987, Vol 19, No 2, 148-156. American  College of Sports Medicine©.

19. ROBBINS, S.E., HANNA, A.M., GOUW, G.J.  “Overload protection: avoidance response to heavy plantar surface loading”.  Medicine and Science in Sports and Exercise.  1988, Vol 20, No 1, 85-92.   American College of Sports Medicine©.

20. ROBBINS, HANNA, A., JONES, L.A.  “Sensory Attenuation Induced by Modern Athletic Footwear”.  Journal of Testing and Evaluation. 1988, Vol 16,  412-416. American Society for Test and Materials©.

21. ROBBINS, S., WAKED, E. “Balance and Vertical Impact in Sports: Role of Shoe Sole Materials”.  Arch Phys Med Rehabil May 1997, Vol 78, 463-467.

22. ROBBINS, S., WAKED, E. “Factors Associated with Ankle Injuries Preventative Measures” Sports Med. 1998 Jan: 25 (1): 63-72.

23. ROBBINS, S., WAKED, E.  “Foot Position Awareness: The Effect of Footwear on Instability, Excessive Impact, and Ankle Spraining”.  Critical Reviews in Physical and Rehabilitation Medicine, 1997, 9 (1):53-74.

24. ROBBINS, S., WAKED, E. ”Hazard of deceptive advertising of athletic footwear”.  Br. J. Sports Med 1997; 31:299-303.

25. ROBBINS, S., WAKED, E., GOUW, G.J. McCLARAN, J. “Athletic footwear affects balance in men”.  British Journal of Sports Medicine 1994; 28(2) 117-123. 

26. STEWART, S.F.  “Footgear – Its History, Uses and Abuses”.  Clinical Orthopaedics and Related Research.  Oct 1972, No 88, 119-130.

27. WARBURTON, M.  “Barefoot Running”, Sportscience 5(3), sportsci.org/jour/0103/mw.htm, 2002

Comments

[Craig]

Doc,
I own a shoe store and half of our business is referrals from podiatrists and PT's. Most of them want their patients in motion control and stability shoes. Why is there such a disparity in your logic and theirs? I trail run and always run on the balls of my feet and have no problems. My wife is having knee pain and the PT told her to read your article. It has helped so far. But, I still question why the medical community is so far apart.

[Laura]

hey, thanks so much for this article. i'm actually working on a persuasive paper for a class and i'm taking the direction of how technological advancements are harmful sometimes and the effects of shoes on our feet is one of my points. i was thrilled to find an article like this one that took almost the exact direction i had in mind.

this totally explains why i feel so much better after running 24 100ms on the football field in track practice than running 16 in my shoes on our brand-new rubberized track.

i have recently bene developing some minor injuries all along my lower body, so my next pair of shoes, i will look for a flatter one. thanks.

[DaeJa Napier]

I don't know how to find information posted about others that have injured their knees from wearing Masai shoes. Do you have any information or suggestions concerning this?

Thank you,

DaeJa Napier

[steven robbins]

The figures related to injury incidence Marti gave were corrected for age, gender, training mileage, previous injury and a host of other factors. No data are available that have ever related diet and training method to injury frequency. It seems to me that the only explanation available that can explain improved running times with highly competitive runners then and now is performance enhancing drugs. As far as the recreational runner is concerned, I am aware of no difference over time, except the current runner seems more skeptical about the claims regarding protection offered by athletic footwear manufacturers. Hence runners currently seem to take seriously even the first signs of injury, rather than running with injuries after purchasing new shoes.

[Running Curmudgeon]

A very intriguing article! Thanks for exposing the work of Robbins and Marti to a wide audience. You've certainly made a splash in the running blogosphere. I get the feeling that the number of runners who feel that they've been sold down the river by trend-focused shoe manufactuers is not insignificant. A review of this article's comments provides further anecdotal evidence that something is amiss with modern trainers and that those of us who have returned to more basic "flats" are seeing longstanding injury and gait problems resolved.

A couple of questions about the research:

1) Regarding the incidence of injury now and then, is it statistically appropriate to compare the populations of runners during the first boom to current runners? Age, sex, mileage, training methods and history, and diet are a few potential differences that come to mind.

2) How did Marti account for differences in his populations' mileage and history of injury?

Thanks for the informative and important article. And for the thorough bibliography!

[AndyF]

Danny Dreyer is right about needing a synthesis of shoe and technique. ChiRunning is an excellent technique for decreasing impact on the lower body. I'm glad to hear Danny agrees with you, Joe, on footwear.

Andy

[Danny Dreyer]

A friend sent me your blog about running shoes and I can whole heartedly agree. I have been teaching runners the mid-foot strike as a way of reducing leg injuries, for over 10 years now and the results are incredible. When I'm asked what shoes I can recommend for the technique I teach, I usually recommend that runners work on altering their running form to a mid-foot strike over a period of time until they can gradually "graduate" themselves to less and less of a shoe.

We are currently working with New Balance shoes to develop a shoe that specifically meets the needs of someone looking for a shoe WITHOUT a big cushioning heel. So, at least one shoe manufacturer is hip to the problem.

I would suggest a book to add to your reading list; ChiRunning: A Revolutionary Approach to Effortless, Injury-free Running.

It's a revolution that is begging to happen.

All the best,
Danny Dreyer

[Cancer]

I now understand why white children in Africa are always running around barefoot. It's healthy. The next step in emancipating children from the shoe should be to get floor polish banned, especially in big department stores. You never know how much carcinogenic materials go into its manufacture!

[steven robbins]

Hi Joe:

Just came across this blog. I can tell you a story about an orthopedic surgeon who was an avid recreational runner. He developed persistent plantar fasciitis, that did not respond to practices prevalent at that time - he thus was unable to treat himself. Rather than providing his patients with treatment methods in which he had no confidence, he turned to the scientific literature in hopes of discovering a better treatment. At about this time a series of scientific papers began appearing in sports medicine journals dealing with the bare foot during running, and potential hazards of modern footwear. This surgeon initiated a series of extended long-distance calls from his home (on an island paradise known for banks and millionaires), and my office in Montreal. It wasn’t long before I received ecstatic calls regarding the healing of his problems, and similar disorders in many others through application of a large dose of barefoot activity, along with firm racing flats (“buy last years models – they give them away and are no different than the current model except for color”). He never could understand why such simple and effective health related practices failed to alter shoes, or information coming from sources of information to athletes, such as magazines. I am, or course talking about you, Joe (excuse errors from my recall).

Finally things are changing. My solution to problems associated with thick layers of high resiliency shoe materials, was the use of low resiliency materials. A U.S. patent was awarded in 2002. Initially there was little interest shown in this by insole and running shoe makers. But much has changed – infringing on this patent (sometimes willingly) is in fashion. Most examples of “memory foam” insoles appear to fall under my patent, as does “memory foam” used in host of footwear from many (perhaps most) manufacturers. This infringement is being handled through the typical legal channels. There is now a high probability that footwear will become safer in terms of impact and balance. None of this replaces the benefit possible through barefoot activity, and the use of “minimalistic shoes”, as described in this blog.

Regards

Steve

[Marc]

Exellent article Doc! Many thanks for your insight.

Some questions/thoughts that immediately spring to mind after reading it are:

1) Is there a trade-off we have to take into consideration when running on unnatural man made hard surfaces no mater how correct good your running technique is? (ie: some forefoot cushioning in shoes)

2) Can we place any faith in orthopaedic surgeons who prescribe orthodontics for runners? If the theory of this essay is correct, it would imply that even the specialist might have an incorrect understanding on how the feet respond and deal with impact stress when applied to a sport such as running and also corrective prescription.

3) The implications that modern day running shoes are no good for you, weather in the short or long term, by simply not being at all effective in doing anything to either "re-educate" or strengthen any foot muscle weakness/imbalance, making our already Lazy feet muscles even lazier, impairing the bodies natural feet to brain sensory feedback system that has been given to us by natural evolution over many thousands of years is quite profound, especially to a runner. So bearing this in mind, where does the average Joe now turn to for the best advice?

I appreciate that the main things to sort out to reduce any risk of repetitive impact related injuries is to start off with learning how to run with the correct technique first and foremost, but it begs the question of how far does a modern day running shoe inhibit this process and why is this not front page news on all running sites/organizations etc across the globe?

To me, implications of this article is as shocking as hearing that the earth might actually be round instead of flat...(ok maybe not quite that shocking)

[bud4wiser]

The article proposes several interesting theories.

Unfortunately, this article is like so much popular "junk science." just because there is "some truth" in a statement, hardly means the statement is accurate or without any error.

There is no doubt that "high tech" footwear both contributes and diminishes the possibility of injury among runners. Similarly, running barefoot on modern surfaces is dangerous as well.

If runners train stupidly because they have purchased expensive shoes, perhaps we should remind them that fast-food will make them fat and that penis-enhancement drugs don't really work.

The rest of us don't need a doctor to tell us train smartly, and select running shoes carefully.

[Ewa]

Thank you for putting so eloquently what I've felt and believed ever since I started running. I've been running almost exclusively in Nike Free shoes and while they don't provide the true barefoot feeling I know my 49 year old feet and knees are much stronger than those of many 30 yo runners. After reading your article I am tempted to try racing flats.
Thank you for putting all this information together. I hope you don't mind I pass your blog to other runners. The more vocal we all become the more running shoe companies will listen.

[TasterSpoon]

Thought provoking. Drosser's comment begs a question in the back of my mind, though, which is, could the increased (or sustained) incidence of running-related injuries in recent years have something to do with how advancements in running shoes (to correct for flat feet, pronation, whatever) make running POSSIBLE for many who otherwise wouldn't be running at all?

Are problems necessarily the fault of the shoe, or might not the shoes just expand the field of participants to otherwise marginalized would-be athletes such that use injuries will also go up?

[Ryley]

This is a great article. I am a sophomore in highschool and have, over the course of a year, worked down from normal trainers, to lightweight trainers, to Nike Frees, to Nike Streak XC flats, to Puma H-street flats. I am currently running in the Puma H-streets and am thinking of the Vibram FiveFingers next. I had no idea about any of this information until the Nike Free came out, so at least Nike did something right. Another great article on this issue (along with others) is: https://tullyrunners.com/Articles/RaucciArticle.htm
It has been tough trying to convince brainwashed coaches and parents that I am not crazy and this article is a big help, especially when it is written by an orthopedic surgeon (what I someday hope to become).

[EdBiew]

link correction [without the full stop] re shoes / treadmill / fracture?
https://crazykmw.blogspot.com/2007/02/slug-no-more.html

[EdBiew]

Hi Everyone, one of my concerns is the possible link between shoes and stress fracture/s of the foot and/or ankle. Karen mentioned her experience of such a fracture at https://crazykmw.blogspot.com/2007/02/slug-no-more.html.
What's your opinion as to the role of the treadmill and/or has Anyone experienced a similar fracture whilst wearing a particular shoe design? warm thanks, EdBiew

[Fred]

I really enjoyed reading the article. I solved ALL my problems related to running injuries, by learning the 'Pose method of running' by Dr. Romanov, the shoes that he reccomends is minimalist like the Puma High Street or the Fivefingers.

[Joe]

Amazing article. I read it twice and passed it on.

[Julie A]

Loved the post on running shoes!

I'm a middle aged woman, my activity level varies from sedentary to low level activity. I golf regularly and walk once in awhile. I'm also a bit overweight so often found myself with an achy and tired lower back after a half hour or so.

Until I found MBTs.

https://www.swissmasai.com

Apparently these shoes were derived from the barefoot gait of the Masai tribe. I have 2 pair and wear them as often as I can. My back actually feels stronger and I no longer get the achiness and fatigue.

Anyway, check them out!

Thanks again,

[peteopia]

IN GENERAL
Besides a couple of details the general story is pretty sound, however I would not suggest people run barefoot on hard man made surfaces - pavements etc. You WILL damage yourself if you train extensively like this. A nice viewpoint is to apply logical thinking and think how humans evolved. We evolved running on soft (sand) and hard surfaces (dried compacted mud). so you can run on the pavement I hear you say.. well no. Even though you might not feel it, there is a lot of cushioning even on a dry mud surface when compared to concrete pavement. These fancy cushion style running shoes started life by trying to reintroduce some of this cushioning, but as usual man has taken it to the n'th degree, such that it is now detrimental as the article points out.

THE DETAILS
A couple of the facts in your story have been miss interpreted but as I said in general the message is pretty good, so don’t take this the wrong way. for instance the argument about people in third world countries not having problems and not wearing footwear is a bit of a leap of faith - you are assuming a correlation between two factors in a massively complex and multi-factorial system. there are MANY other POSSIBLE explanations. EG their cultures are such that they are less likely to admit pain and/or are more likely to put up with pain than have a major operation. This final point in also evident in Japan where rates of joint replacement in patients under 70 are extremely low when compared to European and the US. When you ask the patients/surgeons why, the answer is purely because they do not think it a good idea. In European and the US we have become so demanding, we expect to live longer and to be able to do the same things. If something breaks then it must be fixed – this is crazy culture and evident in the way we must sue someone for any action possible. If trip in the street we sue the government for make a poor foot path .. etc etc.

A GENERAL RANT
As for the marketing machine I agree totally and utterly, but that’s life. If you see anything just in our western world I’d be amazed. From cosmetics to cars to health care products.. they are all using the Freud’s psychology to make sure we buy buy buy! On a functional basis there are v few things that we need, but the world economy would stop if we didn’t buy a new car every three years, get that new phone, drink that health shake, little to say what our neighbours would think! Unfortunately we have chosen the wrong social model, and it’s going to take a long time for us to bounce back in the right direction! Pants I hear you say, well yes for most people, but just use your brain as the author of this article has done. Don’t believe everything you hear, and most of all come to your own conclusions.

PS I’m not saying become a hippy (heaven forbid) just educate yourself. Read about social science, body language, etc etc and it becomes pretty obvious that we can rectify some of these issues, on a personal level at least, then is a couple of generations we’ll be back on track :D

[John]

As a member of the Pose Method community and occasional barefooter, it was wonderful to read this article. Because of the frigid temps out here on the east coast, I have been running in the New Balance RC750 racing flat...yeah, training and racing in them. Can't wait for the warmer weather so I can kick off the shoes a few times a week.

[Where to learn more?]

I would also like to ask about the rigid orthopedic arch supports (you put them in your shoes like the Dr.Scholl's implants). I was given them because my arch supposedly does not support itself, but I never wore them because they were too uncomfortable (blisters etc). I'm not sure what this means in respect to the information presented. Can anyone shed some light on this?

So do you minimalist shoe wearers wear socks too? If so, what kind?

I'm also curious: What kind of shoes do the Olympics sprinters use?

Since I've never come in contact with this information before, I'm not sure where else I would ask these questions. Thanks.

[Milt]

I had to quit running due to permanent nerve damage in my left foot. Now, I mostly wear dress shoes with no cushioning and little arch support and I've noticed an improvement. I also recommend going barefoot as much as possible.

[Lars Nielsen]

Great article. I've been thinking along the same lines for the last couple of years. 2½ years ago I switched to really minimalistic shoes (Puma h-streets) and learned how to run in those. After 15 years of constantly recurring achilles-injuries, I haven't had an injury since, despite the fact that I've been training both longer and more intensive than before.

[Duncan Domingue]

I've had similar ideas about shoes for a long time. I've always been a fan of light, flat, and hard shoes like Converse All Stars and used them for everything. I even wore them when I skateboarded for six years, and I must say that my feet never hurt from being pounded on all day and I could feel the board much better than the when I wore "proper" skateboarding shoes for a brief period. I no longer skateboard, but still enjoy minimal shoes, and currently wear Chucks and kung fu shoes available at any martial arts store. At $6 a pair, you really can't beat the kung fu shoe.