Emphasizing Proper Shoes And Orthoses In Runners

For every foot, there is an athletic shoe that fits correctly. After specializing in sports medicine for over 20 years, I know this is true.

   The barefoot running phenomenon has cycled around three times in the past 30 years: once in the 1960s, again in the 1980s and reappearing in the late 2000s. I have worked many races and have treated thousands of recreational and elite runners. From my perspective, barefoot running is a fad that has never “stuck.”

   It is rare to see any marathon or triathlon race have more than a few barefoot runners. Even the guys who train in the mountains of Africa — who usually win the marathons — use shoes. I have elite runners with “good” feet tell me they would never run barefoot.

   There are lots of articles and anecdotes on the barefoot runner and how the “shod” foot and the “unshod” foot hit the ground very differently. We know this to be true and many studies that use ground reaction force plates and other electrical tracking devices have told us so.1,2 The barefoot experts claim that to run barefoot, you will not get injured and that there no reason for shoes or orthotic devices. I do not think these people have studied biomechanics or have doctorate degrees, and maybe we need to think twice about this.

Reviewing Common Factors That Cause Running Injuries

I have long understood and “studied” my runners from the foot up to the brain. Runners are great patients. They are very mindful of their health and enjoy the mental relief that running affords them, not to mention their medical bills, which are few and far between. They take their sport seriously and when the stakes are high, there will be a price to pay, namely an occasional injury.

   When we educate the runners on what causes traditional “overuse” running injuries, we mention the following factors:
• poor foot alignment mechanics
• strength and flexibility issues
• incorrect shoe gear
• overtraining
• terrain issues

   Granted, other considerations may include old or untreated orthopedic issues, improper nutrition, sleep deprivation and reduction of other stressors that cause injury. However, when we look at the cold hard facts of running injuries, we can certainly become proactive and avoid most injuries. Although there are always going to be runners who sustain injuries, we still have to be mindful of these issues in our exam and educate these runners to the best of our ability in order to get them out of a pattern that may be causing their injuries.

   I know the equation of fixing the underlying problems works as I have been using it for over 20 years. Like many podiatrists, I have runners who come back year after year to say they feel great and they are in just because they need a refurbishing of the orthotics. When they stray away from the orthotics or suggested shoes, many return with injuries and need gentle coaxing back to reality.

   If you do not look at the whole picture, you are missing the point. Regardless of the shoe the runner is wearing, you better fix all of the lower extremity issues or it does not matter. I find that strengthening the whole lower extremity from the hip and core all the way down to the pinkie toe is absolutely paramount. Our biomechanical knowledge tells us that if the foot is in an abnormal position (namely overpronated), the lever and pulley system of the intrinsic and extrinsic muscles will never work to its full capacity.

   This negates the thought that walking around in a proper shoe and/or orthotic device will cause atrophy of the foot muscles. This is the most absurd thing I have ever heard and is absolutely not true. It is just the opposite and I tell patients this when educating them on the use of proper orthotics and shoe gear.

Keeping Minimalist Shoes In Perspective

I love shoes and the shoe industry has fascinated me for many years. When I was a podiatry student, I would visit the biomechanical guys at the Foot Locker test wear center in Illinois, make friends with the biomechanics experts at Brooks footwear in Michigan and visit all the rest of the shoe booths at conferences. I believed in the shoes they were selling as they were working well for my patients and me.

   Yet we still have to remember that the shoe industry is a billion-dollar business. At any shoe booth at a conference or show, the exhibitors will have the expensive rocker shoe right next to the expensive “barefoot” shoe. This suggests to me that shoe manufacturers do not really have one strong opinion either way.

   So what do we do with the newfound fad of barefoot running that surrounds us today when it comes to taking care of runners’ shoe needs?

Ensuring A Sound Biomechanical Solution And Patient Education

In regard to the philosophy of there being a shoe for every foot, it all goes back to taking a really good history and performing thorough physical and biomechanical exams so we can get to the bottom of the problem. We know that if someone has specific forefoot or rearfoot needs, a single shoe cannot change that and that is why custom orthotics are a necessity in many of the patients we treat.

   We all know we can slow down or halt the progression of some forefoot deformities, namely hammertoes, hallux valgus or hallux limitus, with a thoroughly prepared functional orthotic device, not from a wedge or a slit in the sole of a shoe. Depending on the level of fitness, strength, flexibility and biomechanical foot needs, we can assess if the runner needs a lighter shoe with or without an orthosis. We know this takes biomechanical knowledge and a good examination.

   We can also educate our runners on proper form and make sure that the body is just forward of the plumb line and that the foot lands in a more “midfoot” strike position. Doing this will limit overstriding and increased stresses at heel strike. If we keep the cadence to 85 to 90 beats per minute, we can ensure the runner has eliminated overstriding.

In Conclusion

There are groups in the media and on the Internet telling us how to run and what our feet and body should look like. However, in the end, it all boils down to good form, well aligned biomechanics, good strength, flexibility and not doing a foolish 26-mile run if you have not properly prepared for it.

   Dr. Schoene is a triple board-certified sports medicine podiatrist and a certified athletic trainer. She is a Fellow of the American Academy of Podiatric Sports Medicine and the American College of Foot and Ankle Surgeons.

   Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is in private practice in Seal Beach, Ca.

References

1. Divert C, Mornieux G, Baur H, et al. Mechanical comparison of barefoot and shod running. Int J Sports Med. 2005; 26(7):593-8.
2. Lieberman D, Venkadesan M, Werbel W, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010; 463(7280):531-4.