Examining injury risk and pain perception in runners using minimalist footwear

Injuries observed in a prospective transition from traditional to minimalist footwear: correlation of high impact transient forces and lower injury severity

OBJECTIVES

Minimalist running is increasing in popularity based upon a concept that it can reduce impact forces and decrease injury rates. The purpose of this investigation is to identify the rate and severity of injuries in runners transitioning from traditional to minimalist footwear. The secondary aims were to identify factors correlated with injuries.

METHODS

Fourteen habitually shod (traditional running shoes) participants were enrolled for this prospective study investigating injury prevalence during transition from traditional running shoes to 5-toed minimalist shoes. Participants were uninjured, aged between 22-41 years, and ran at least twenty kilometers per week in traditional running shoes. Participants were given industry recommended guidelines for transition to minimalist footwear and fit with a 5-toed minimalist running shoe. They completed weekly logs for identification of injury, pain using Visual Analogue Scale (VAS), injury location, and severity. Foot strike pattern and impact forces were collected using 3D motion analysis at baseline, 4 weeks, and 12 weeks. Injuries were scored according to a modified Running Injury Severity Score (RISS).

RESULTS

Fourteen runners completed weekly training and injury logs over an average of 30 weeks. Twelve of 14 (86%) runners sustained injuries. Average injury onset was 6 weeks (range 1-27 weeks). Average weekly mileage of 23.9 miles/week prior to transition declined to 18.3 miles/week after the transition. The magnitude of the baseline impact transient peak in traditional shoes and in minimalist shoes negatively correlated with RISS scores (r = -0.45, p = 0.055 and r = -0.53, p = 0.026, respectively).

CONCLUSION

High injury rates occurred during the transition from traditional to minimalist footwear. Non-compliance to transition guidelines and high injury rates suggest the need for improved education. High impact transient forces unexpectedly predicted lower modified RISS scores in this population.

Relationship between foot strike pattern, running speed, and footwear condition in recreational distance runners

Compared to competitive runners, recreational runners appear to be more prone to injuries, which have been associated with foot strike patterns. Surprisingly, only few studies had examined the foot strike patterns outside laboratories. Therefore, this study compared the foot strike patterns in recreational runners at outdoor tracks with previously reported data. We also investigated the relationship between foot strike pattern, speed, and footwear in this cohort. Among 434 recreational runners analysed, 89.6% of them landed with rearfoot strike (RFS). Only 6.9 and 3.5% landed with midfoot and forefoot, respectively. A significant shift towards non-RFS was observed in our cohort, when compared with previously reported data. When speed increased by 1 m/s, the odds of having forefoot strike and midfoot strike relative to RFS increased by 2.3 times and 2.6 times, respectively. Runners were 9.2 times more likely to run with a forefoot strike in minimalists compared to regular running shoes, although 70% of runners in minimalists continued to use a RFS. These findings suggest that foot strike pattern may differ across running conditions and runners should consider these factors in order to mitigate potential injury.

Self-Reported Minimalist Running Injury Incidence and Severity: A Pilot Study

INTRODUCTION

Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown.

OBJECTIVES

To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS.

METHODS

Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests.

RESULTS

Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet (P=.03) and knees (P=.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries.

CONCLUSION

After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

Does "transition shoe" promote an intermediate biomechanical condition compared to running in conventional shoe and in reduced protection condition?

This study evaluated if running in a "transition shoe" commercially available results in intermediate mechanical load upon lower extremities compared to conventional shoe and minimalist shoe/barefoot. Kinematic and kinetic parameters while running in different shoe conditions were compared. Fourteen runners (12 men, 2 women; age=28.4±7.3 years), inexperienced in minimalist shoes and barefoot running, ran on an instrumented treadmill within four experimental conditions (conventional shoe - CS, transition shoe - TrS, minimalist shoe - MS, and barefoot - BF). Running was performed at 9km/h for 10min in each experimental condition. Vertical ground reaction force (VGRF) and two-dimensional kinematic variables of lower limbs (both legs) were recorded. Nine data acquisitions (10s) were conducted for each footwear condition. Transition shoe lead to significant changes in VGRF variables related to impact control, while kinematic parameters were little affected. The TrS had smaller first peak of VGRF (Fy1) than CS (p≤0.001) and higher than MS (p=0.050) and BF (p≤0.001). Time to first peak of VGRF (tFy1) of TrS was smaller than CS (p≤0.001) and higher than MS (p≤0.001) and BF (p≤0.001). The TrS and MS induced to lesser knee flexion (p<0.001) and greater dorsiflexion (p<0.001) than CS and BF. Thus, results suggest the transition shoe (TrS) tested seem to promote an intermediate mechanical load condition only for VGRF parameters, presenting values of impact forces between those found for conventional shoe and minimalist shoe/barefoot. Such knowledge could be useful for the transition process from conventional running shoe to minimalist shoe/barefoot.

The effect of footwear and footfall pattern on running stride interval long-range correlations and distributional variability

The presence of long-range correlations (self-similarity) in the stride-to-stride fluctuations in running stride interval has been used as an indicator of a healthy adaptable system. Changes to footfall patterns when running with minimalist shoes could cause a less adaptable running gait. The purpose of this study was to investigate stride interval variability and the degree of self-similarity of stride interval in runners wearing minimalist and conventional footwear. Twenty-six trained habitual rearfoot footfall runners, unaccustomed to running in minimalist footwear, performed 6-min sub-maximal treadmill running bouts at 11, 13 and 15 km·h(-1) in minimalist and conventional shoes. Force sensitive resistors were placed in the shoes to quantify stride interval (time between successive foot contacts). Footfall position, stride interval mean and coefficient of variation (CV), were used to assess performance as a function of shoe type. Long-range correlations of stride interval were assessed using detrended fluctuation analysis (α). Mean stride interval was 1-1.3% shorter (P=0.02) and 27% of runners adopted a midfoot footfall (MFF) in the minimalist shoe. There was a significant shoe effect on α and shoe*speed*footfall interaction effect on CV (P<0.05). Runners that adopted a MFF in minimalist shoes, displayed reduced long-range correlations (P<0.05) and CV (P<0.06) in their running stride interval at the 15 km·h(-1) speed. The reduced variability and self-similarity observed for runners that changed to a MFF in the minimalist shoe may be suggestive of a system that is less flexible and more prone to injury.

Lower-limb dynamics and clinical outcomes for habitually shod runners who transition to barefoot running

OBJECTIVES

Recent investigations have revealed lower vertical loading rates and knee energy absorption amongst experienced barefoot runners relative to those who rear-foot strike (RFS). Although this has led to an adoption of barefoot running amongst many recreational shoe runners, recent investigations indicate that the experienced barefoot pattern is not immediately realized. Therefore, the purpose this investigation was to quantify changes in lower-extremity dynamics and clinical outcomes measures for habitually shod runners who perform a transition to barefoot running.

DESIGN & PARTICIPANTS

We examined lower-extremity dynamics and clinical outcomes for 26 RFS shod runners who performed an 8-10 week transition to barefoot running.

SETTING

Runners were evaluated at the University of Southern California's Musculoskeletal Biomechanics Research Laboratory.

MAIN OUTCOME MEASURES

Foot-strike patterns, vertical load rates, and joint energetics were evaluated before and after the transition using inverse dynamics. Clinical assessments were conducted throughout the transition by two licensed clinicians.

RESULTS

Eighteen of the 26 runners successfully completed the transition: 7 maintained a RFS, 8 adopted a mid-foot strike (MFS), and 3 adopted a forefoot strike (FFS) during novice barefoot running. Following the transition, novice MFS/FFS runners often demonstrated reversions in strike-patterns and associated reductions in ankle energetics. We report no change in loading rates and knee energy absorption across transition time points. Importantly, there were no adverse events other than transient pain and soreness.

CONCLUSIONS

These findings indicate that runners do not innately adopt the biomechanical characteristics thought to lower injury risk in-response to an uninstructed barefoot running transition.

The long-term effect of minimalist shoes on running performance and injury: design of a randomised controlled trial

INTRODUCTION

The outcome of the effects of transitioning to minimalist running shoes is a topic of interest for runners and scientists. However, few studies have investigated the longer term effects of running in minimalist shoes. The purpose of this randomised controlled trial (RCT) is to investigate the effects of a 26 week transition to minimalist shoes on running performance and injury risk in trained runners unaccustomed to minimalist footwear.

METHODS AND ANALYSIS

A randomised parallel intervention design will be used. Seventy-six trained male runners will be recruited. To be eligible, runners must be aged 18-40 years, run with a habitual rearfoot footfall pattern, train with conventional shoes and have no prior experience with minimalist shoes. Runners will complete a standardised transition to either minimalist or control shoes and undergo assessments at baseline, 6 and 26 weeks. 5 km time-trial performance (5TT), running economy, running biomechanics, triceps surae muscle strength and lower limb bone mineral density will be assessed at each time point. Pain and injury will be recorded weekly. Training will be standardised during the first 6 weeks. Primary statistical analysis will compare 5TT between shoe groups at the 6-week time point and injury incidence across the entire 26-week study period.

ETHICS AND DISSEMINATION

This RCT has been approved by the Human Research Ethics Committee of the University of South Australia. Participants will be required to provide their written informed consent prior to participation in the study. Study findings will be disseminated in the form of journal publications and conference presentations after completion of planned data analysis.

TRIAL REGISTRATION NUMBER

This RCT has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000642785).

A consensus definition and rating scale for minimalist shoes

BACKGROUND

While minimalist running shoes may have an influence on running biomechanics and on the incidence of overuse injuries, the term "minimalist" is currently used without standardisation. The objectives of this study were to reach a consensus on a standard definition of minimalist running shoes, and to develop and validate a rating scale that could be used to determine the degree of minimalism of running shoes, the Minimalist Index (MI).

METHODS

For this modified Delphi study, 42 experts from 11 countries completed four electronic questionnaires on an optimal definition of minimalist shoes and on elements to include within the MI. Once MI was developed following consensus, 85 participants subjectively ranked randomly assigned footwear models from the most to the least minimalist and rated their degree of minimalism using visual analog scales (VAS), before evaluating the same footwear models using MI. A subsample of thirty participants reassessed the same shoes on another occasion. Construct validity and inter- and intra-rater reliability (intraclass correlation coefficients [ICC]; Gwet's AC1) of MI were evaluated.

RESULTS

The following definition of minimalist shoes was agreed upon by 95 % of participants: "Footwear providing minimal interference with the natural movement of the foot due to its high flexibility, low heel to toe drop, weight and stack height, and the absence of motion control and stability devices". Characteristics to be included in MI were weight, flexibility, heel to toe drop, stack height and motion control/stability devices, each subscale carrying equal weighing (20 %) on final score. Total MI score was highly correlated with VAS (r = 0.91). A significant rank effect (p < 0.001) confirmed the MI's discriminative validity. Excellent intra- and inter-rater reliability was found for total MI score (ICC = 0.84-0.99) and for weight, stack height, heel to toe drop and flexibility subscales (AC1 = 0.82-0.99), while good inter-rater reliability was found for technologies (AC1 = 0.73).

CONCLUSION

This standardised definition of minimalist shoes developed by an international panel of experts will improve future research on minimalist shoes and clinical recommendations. MI's adequate validity and reliability will allow distinguishing running shoes based on their degree of minimalism, and may help to decrease injuries related to footwear transition.

Comparison of minimalist footwear strategies for simulating barefoot running: a randomized crossover study

Possible benefits of barefoot running have been widely discussed in recent years. Uncertainty exists about which footwear strategy adequately simulates barefoot running kinematics. The objective of this study was to investigate the effects of athletic footwear with different minimalist strategies on running kinematics. Thirty-five distance runners (22 males, 13 females, 27.9 ± 6.2 years, 179.2 ± 8.4 cm, 73.4 ± 12.1 kg, 24.9 ± 10.9 km.week^-1) performed a treadmill protocol at three running velocities (2.22, 2.78 and 3.33 m.s^-1) using four footwear conditions: barefoot, uncushioned minimalist shoes, cushioned minimalist shoes, and standard running shoes. 3D kinematic analysis was performed to determine ankle and knee angles at initial foot-ground contact, rate of rear-foot strikes, stride frequency and step length. Ankle angle at foot strike, step length and stride frequency were significantly influenced by footwear conditions (p<0.001) at all running velocities. Posthoc pairwise comparisons showed significant differences (p<0.001) between running barefoot and all shod situations as well as between the uncushioned minimalistic shoe and both cushioned shoe conditions. The rate of rear-foot strikes was lowest during barefoot running (58.6% at 3.33 m.s^-1), followed by running with uncushioned minimalist shoes (62.9%), cushioned minimalist (88.6%) and standard shoes (94.3%). Aside from showing the influence of shod conditions on running kinematics, this study helps to elucidate differences between footwear marked as minimalist shoes and their ability to mimic barefoot running adequately. These findings have implications on the use of footwear applied in future research debating the topic of barefoot or minimalist shoe running.

A Survey of Runners' Attitudes Toward and Experiences With Minimally Shod Running

OBJECTIVE

To investigate the characteristics, perceptions, motivating factors, experiences, and injury rates of runners who practice minimally shod running.

DESIGN

Survey.

SETTING

web-based questionnaire.

PARTICIPANTS

Five-hundred sixty-six members of the Chicago Area Runner's Association.

METHODS

A link to a 31-question online survey was e-mailed to members of Chicago Area Runner's Association. Questions covered demographic information, use of minimalist-style running shoes (MSRS), injury rates, and change in pain.

MAIN OUTCOME MEASURES

Use of MSRS, occurrence or improvement of injury/pain, regions of injury/pain, reasons for or for not using MSRS.

RESULTS

One-hundred seventy-five (31%) respondents had practiced minimally shod running, and the most common motivating factor was to decrease injuries and/or pain. Fifty-one respondents (29%) suffered an injury or pain while wearing MSRS, with the most common body part involved being the foot. Fifty-four respondents (31%) had an injury that improved after adopting minimally shod running; the most common area involved was the knee. One-hundred twenty respondents (69%) were still using MSRS. Of those who stopped using MSRS, the main reason was development of an injury or pain. The most common reason that respondents have not tried minimally shod running is a fear of developing an injury.

CONCLUSION

This survey-based study demonstrated that the use of MSRS is common, largely as the result of a perception that they may reduce injuries or pain. Reductions and occurrences of injury/pain with minimally shod running were reported in approximately equal numbers. The most common site of reported injury/pain reduction was the knee, whereas the most common reported site of injury/pain occurrence was the foot. Fear of developing pain or injury is the most common reason runners are reluctant to try minimally shod running.

The re-emergence of the minimal running shoe

The running shoe has gone through significant changes since its inception. The purpose of this paper is to review these changes, the majority of which have occurred over the past 50 years. Running footwear began as very minimal, then evolved to become highly cushioned and supportive. However, over the past 5 years, there has been a reversal of this trend, with runners seeking more minimal shoes that allow their feet more natural motion. This abrupt shift toward footwear without cushioning and support has led to reports of injuries associated with minimal footwear. In response to this, the running footwear industry shifted again toward the development of lightweight, partial minimal shoes that offer some support and cushioning. In this paper, studies comparing the mechanics between running in minimal, partial minimal, and traditional shoes are reviewed. The implications for injuries in all 3 conditions are examined. The use of minimal footwear in other populations besides runners is discussed. Finally, areas for future research into minimal footwear are suggested.