Better late than never! Thank you for your patience as we have been working through the ins and outs of conducting our first pilot study as well as publishing our first research paper over the past (very long) while. We hope you enjoy reading about the study and our findings. Thank you to everyone who volunteered their time and resources to help us make this project happen. From the practicioners doing the before and after testing to the volunteer subjects for joining the study. Thank you so much. Enjoy!
Sarah and Kim
A
comparison of incidence of injury between runners wearing traditional
versus minimal footwear during an introductory run:walk program.
Kim
Senechal
Abstract
The
purpose of this pilot study was to compare the incidence of injury
between runners wearing traditional versus minimal footwear during an
introductory run:walk program. Twenty-seven subjects
were divided into three running groups: beginner minimal (BM),
beginner traditional (BT) and experienced minimal (EM). We recorded
the incidence of injury as reported by subjects during the course of
a ten week progressive run:walk program. The subjects were required
to report any pain experienced and to include the location, severity,
duration and self-treatment. Pain was categorized as a either a
symptom or an injury. A symptom was defined as ‘any physical
discomfort experienced during a run.’ An injury was defined as
‘any symptom experienced that was significant enough to require the
cessation of all running for seven or more days.’ Of the runners
studied, 13 subjects reported 23 symptoms, and 5 subjects had to stop
running due to injury. The subjects in the EM group had the highest
incidence of injury (28.6%). The lowest incidence of reported injury
was found in beginner runners in minimal footwear. However there was
no meaningful difference in incidence of reported symptoms between
groups. A descriptive statistics model showed a high correlation
(0.52) between age and injury. However, low correlations were found
between incidence of injury or reported symptoms, and gender, weight,
experience and type of footwear. This study had several limitations
(small sample size, high attrition rate, lack of randomization
between groups) which preclude making statistical conclusions.
However, this study does suggest that runners who begin running in
minimal footwear from the start of their training may have a lower
risk of injury than both beginner runners wearing traditional
footwear and experienced runners transitioning to minimal footwear
from traditional footwear. Further research is needed further
explore the findings of this study, as well as other variables that
may contribute to running injury.
Introduction
Running
has been an integral part of human movement for as long as we have
lived on earth. The modern running shoe was invented in the 1970si.
Yet prior to
this, runners were either barefoot or wore minimal footwear that
served mainly to protect the foot from environmental hazards such as
ice, sharp rocks, or hot sand. We are born barefoot, yet in many
parts of the world children are frequently shod in a variety of
footwear before they can even walk. These individuals subsequently
progress through life with their feet growing and developing but
becoming very dependent on supportive shoes that provide a barrier
between their bodies and the ground. Changes in how we walk and run
have inevitably resulted, and this has been accompanied by debate as
to whether these changes have truly been progressiveii.
In light of this there has been a trend to move back to a more
natural style of running, either barefoot or in minimal footwear.
The
invention of the modern running shoe or traditional shoe (TS) brought
with it claims of reduced injury ratesiii
and increased athletic performance through cushioning, arch support
and an elevated heel. With the introduction and resultant popularity
of such shoes, alterations were noted in running gait and kinematics.
For example, endurance runners began to land with their heel first
rather than a more natural mid-foot or forefoot strike pattern.1
The
TS design allows rear foot or heel strike running to comfortably
occur as a result of thick cushioning in the heel of the shoe.
Running shoe manufacturers promote the cushioning, rigid structure
and motion control components of the TS's as a way of decreasing
running injuries.
It
has been demonstrated that barefoot or minimal footwear (MF)
naturally
land with a
forefoot or mid-foot strike pattern.1
Recent
research has shown that this landing pattern results in reduced
ground reaction forces and therefore less impact on the body.1
There are many
proposed benefits of MF running including increased strength in the
foot muscles and therefore decreased pronation, decreased energy
expenditure, increased proprioception, and increased comfort.iv
However,
with a growing number of runners switching from TS to MF, some
concerns have arisen within the medical and running communities
regarding injury rates. Anecdotal and case study evidence suggests
that MF runners are at increased risk for Achilles tendinitis, calf
strain and metatarsal stress fracture - (particularly of the second
metatarsal).4,v
While there is little evidence that moving to an increasingly
supportive shoe in the 1970s reduced injury rates in runners, there
are also very few studies that have investigated the incidence of
injury between runners who wear a TS versus MF on a modern running
surfaces such as asphalt.
The
purpose of this study was to compare the incidence of injury between
runners wearing a TS versus MF during a 10 week introductory running
program.
Methods
Data
were collected from 6 male and 21 female volunteers between the ages
of 22 and 65. All of the subjects completed a 10-week progressive
run-walk program wearing either a TS or MF. Each week the subjects
were required to complete a minimum of three training runs including
one weekly group run.
Subjects
were divided into three categories based on their reported running
experience and their footwear selection: Beginner Minimal (BM),
Beginner Traditional (BT) and Experienced Minimal (EM). Running
experience was determined through a pre-assessment questionnaire and
subjects chose their footwear group by self-selection.
Minimal
footwear was defined as having a difference in stack height of 4mm or
less between heel and forefoot, as well as no more than 15mm of
cushioning in any part of the sole between the foot and ground.
Traditional footwear was defined as having a difference in stack
height of greater than 4 mm between heel and forefoot, as well as
greater than 15mm of cushioning in any part of the sole between the
foot and ground.
Footwear
measurements were collected by the Running Warehouse.
Stack
height was measured from the bottom of the outsole, where the shoe
sits on the ground, to the top of the last (directly underneath the
insole/sock liner). A depth caliper, which was attached to a
chemistry stand using a 90 degree adapter, was used to attain the
stack height measurements. The chemistry stand provided a solid
support, and the depth gauge could be set to any height. For every
shoe, averages of three depth gauge measurements were taken in both
the heel and the forefoot.
Running
experience was based on self-assessment. Beginner runners reported
having no prior running experience or no running for the last 4
months. Experienced runners reported the ability to currently run a
minimum of 20 minutes, 3 days per week, but had never run in minimal
footwear. All runners in both experience level groups confirmed that
they had no running-induced injuries for a minimum of 6 weeks before
the start of the study.
The
run:walk program was based on a gradual learn to run format. The
program began with one minute of light running followed by two
minutes of walking and was repeated over six intervals. Each week
after the second week the time spent running increased while the
walking interval stayed at one minute. The final week of the program
required the subjects to run continuously for 20 minutes. Each
run:walk session began and ended with 5 minutes of walking and the
session concluded with a series of general running stretches.
Stretches were included for the quadricep, hamstring, hip flexor,
gastrocnemius and soleus muscle groups. Stretches were held for 30
seconds each.
Each
week, the subjects were required to complete the run:walk program
under the supervision of study researchers, and 2-3 additional times
on their own. The additional runs were of the same interval duration
as the weekly supervised sessions, and subjects were required to
report these to ensure that they had adhered to the required number
of sessions. The subjects completed all of their runs on a flat
asphalt surface while wearing the same footwear chosen at the
beginning of the study. It was mandatory.
The
subjects were required to report any pain experienced and to include
the location, severity, duration and self-treatment. Pain was
distinguished as a symptom or an injury. A symptom was defined as
‘any physical discomfort experienced during a run.’ An injury
was defined as ‘any symptom experienced that was significant enough
to require the cessation of all running for seven or more days.’
These
data were analysed using descriptive statistics
and correlation to
determine if there was a difference in the incidence of injury or
occurrence of symptoms among the footwear groups or related to
physical characteristics or experience of the subjects during the
10-week running program.
Results
The
study began with 27 subjects. The collective physical
characteristics of subjects in the three groups are presented in
Table 1. There were no meaningful differences in age, height or
weight among the groups. Moreover, the male to female ratio was
similar between the groups.
Table
1: The collective physical characteristics of subjects in the three
groups. Values are means ± SD.
Physical
Characteristics
|
Beginner
Traditional
(n=11)
|
Beginner
Minimal
(n=9)
|
Experienced
Minimal
(n=7)
|
Age
(years)
|
36.9
± 10.5
|
36.9
± 10.5
|
39.7
± 12.0
|
Height
(cm)
|
166.2
± 7.2
|
167.9
± 10.3
|
166.3
± 6.8
|
Weight
(kg)
|
81.9
± 15.3
|
75.4
± 13.6
|
72.7
± 14.6
|
Males
(%)
|
18.2
|
33.3
|
14.3
|
Females
(%)
|
81.8
|
66.7
|
85.7
|
During
the course of the study, five subjects stopped running due to injury
(Table 2). The EM group had the highest incidence of injury as a
percentage of the total but this was not meaningfully significant as
compared to the other groups. Of the five injuries that were
reported during the study, three were in the calf region, one was in
the knee and one was in the foot. There were 23 occurrences of
symptoms reported among the three groups during the course of the
study (Table 3). There were no significant differences in incidence
of reported symptoms among the three groups. The symptoms reported
varied in location over 9 anatomical regions. The occurrence of
these symptoms by region is presented in Table 4.
When
additional factors including the subjects' physical characteristics
were examined, there was a high correlation (r=0.52) between age and
injury. There were very low correlations between the incidence of
injury or the occurrence of symptoms, and gender, weight, experience
and type of footwear.
Table
2: The number (incidence) and proportion of subjects who reported
injuries within the three groups
Group
|
Number
reporting injury
|
Percentage
of group
|
Beginner
Traditional
|
2
|
18.2
|
Beginner
Minimal
|
1
|
11.1
|
Experienced
Minimal
|
2
|
28.6
|
Total
|
5
|
18.50%
|
Table
3: The number (incidence) and proportion of subjects who reported
symptoms within the three groups
Group
|
Number
of subjects reporting symptoms
|
Percentage
of group
|
Beginner
Traditional
|
8
|
34.8
|
Beginner
Minimal
|
7
|
30.4
|
Experienced
Minimal
|
8
|
34.8
|
Table
4: Occurrence of symptoms by anatomical region within the three
groups
Anatomical region
|
Symptoms
|
Group
|
Number
|
Percentage
|
Beginner
Traditional
|
Beginner
Minimal
|
Experienced
Minimal
|
Calf
|
6
|
26.1
|
3
|
3
|
Foot
|
4
|
17.4
|
2
|
1
|
1
|
Shin
|
4
|
17.4
|
3
|
1
|
0
|
Heel
|
2
|
8.7
|
1
|
0
|
1
|
Knee
|
2
|
8.7
|
1
|
0
|
1
|
Hip
|
2
|
8.7
|
0
|
2
|
0
|
Achilles
|
1
|
4.3
|
0
|
0
|
1
|
Thigh
|
1
|
4.3
|
0
|
0
|
1
|
Ankle
|
1
|
4.3
|
1
|
0
|
0
|
TOTAL
|
23
|
100
|
8
|
7
|
8
|
Discussion
When
we examined the reports of injury between runners wearing a
traditional running shoe versus minimal footwear during a 10 week
introductory running program we found that experienced runners
running in minimal shoes for the first time had a higher incidence of
injury than beginner runners in traditional shoes. The lowest
incidence of reported injury was found in beginner runners in minimal
footwear. Experienced runners who switch to minimal footwear may
have a higher chance of getting injured due to a tendency to run
faster or further. In this study, while all participants
self-reported that they completed their weekly unsupervised runs, the
experienced group actually ran more by combining their regular
running in TS to the study runs in MF. Experienced runners in TS may
have established motor pathways that determine running gait patterns.
This could mean that they may be less likely to adapt to MF that
allows the foot to function very differently (ie. Heel drop and less
rigidity). In contrast, a beginner runner would not likely have a
predetermined running gait nor strong motor programming and may adapt
more easily to MF. Beginner runners also tend to run more slowly.
We recommend that experienced runners who are considering switching
to minimal shoes allow their body to adapt to the new footwear over a
gradual period of time (ie longer than 10-weeks). Based on the
results of this study, beginner runners who choose minimal footwear
may reduce their chance of injury as compared to those who choose
traditional shoes, provided they follow a gradual run:walk program.
Of
note, calf injuries were only reported from the two MF groups and not
from the TS group. As a population, North Americans typically wear
shoes from an early age and likely adapt to the support of footwear
that frequently includes elevated heels of variable heights as well
as arch support and rigidity. Running in MF may place additional
stress on the calf musculature of populations that have adapted to
TS, for both running and daily living, over the course of their
lives.
It
is notable that there was a strong correlation between age and
injury. However, there was a very low correlation between footwear
type or running experience, and incidence of injury overall.
Firstly,
there was a lack of random assignment to groups. Since random
assignment is considered the strongest way to account for the many
variables that may lead to differences in results among groups,
without it we can only conjecture on possible reasons for these
differences.
Secondly,
the study was comprised of a small sample size. A
large sample size is more representative of the population, limiting
the influence of outliers or extreme observations. A sufficiently
large sample size is also necessary to produce results among
variables that are significantly different.
Finally,
this study did not include a control group for the Experienced
runners. With no Experienced Traditional group, it is unknown how
the incidence of injury rates would have compared with the
Experienced Minimal runners.
Conclusion
Statistically significant conclusions were not made due to the limitations of this study. However, interesting trends were of note and can be used to generate discussion. Based on the results of this study, beginner runners who choose minimal footwear may reduce their chance of injury as compared to those who choose traditional shoes, provided they follow a gradual run:walk program. Experienced runners who ran in minimal shoes for the first time had the highest incidence of injury and caution is advised when transitioning to minimal footwear. Further research is needed to explore other variables that may contribute to incidence of injury such as biometric measurements including calf length and strength, arch height, and great toe extension, foot strike patterns, running speed and psychosocial factors.
Lieberman, D.E. et al. Foot strike patterns and collision forces in
habitually barefoot versus shod runners. Nature 08723, 1-5
(2010)
ii
Warburton, M. Barefoot running. Sportscience. Sportsci.org.
http://www.sportsci.org/jour/0103/mw.htm
iii
Schwellnus, M.P., Stubbs, G. Does running shoe prescription alter
the risk of developing a running injury? International SportMed
Journal. Vol.7 No. 2. 138-153 (2006).
iv
Barefoot Training Tips.
http://barefootrunning.fas.harvard.edu/5BarefootRunning&TrainingTips.html
v
Giuliani, J. Masini, B. Alitz, C. Owens, BD. Barefoot-simulating
footwear associated with metatarsal stress injury in 2 runners.
Orthopedics. Vol. 34 No. 7 e320-323. (2011)
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