Maximalist Footwear: A Closer Look At Biomechanical Implications

What kind of impact can maximalist shoes have on an athlete’s biomechanics? With this question in mind, this author discusses the makeup of maximalist footwear, the influence upon foot strike, biomechanical assessment and how all of these factors can impact maximalist shoewear recommendations for athletes.

Maximalist footwear has been an incredible gift for the protection of the foot.

What does maximalist footwear mean? This category of footwear is an experiment of cushioning for the walker, hiker and runner. If we compared a maximalist shoe to a standard running, hiking or walking shoe, the foams look oversized. Sometimes, this means thicker midsoles and maximalist shoes typically provide a wider base of support (20 to 30 percent wider than traditional shoes).¹

If we were to summarize the drop from the heel to the forefoot, the drop for maximalist shoes would range from 0 to 8 mm. Other types of shoes mostly have a 10-14 mm drop. These new midsole foams also tend to be lighter. These foams initially feel great but they can lead to durability problems. Maximalist shoes can have built-in rocker midsoles, which can be helpful for metatarsal issues like sesamoid injuries, metatarsalgia, post-bunion surgeries, etc.

Who are the main maximalist shoe manufacturers?² In no particular order, they include Hoka One One, Brooks, Skechers, Adidas, Puma, Pearl Izumi, Vasque, New Balance, ASICS, Altra, Nike and Scotts.
Maximalist shoes can range from very soft to firm, narrow or wide, flexible or rigid, and very light to heavy. The shoes are neutral to stability, have a 0 to 8 mm heel drop, and can have a rocker or no rocker sole. From a pure biomechanics standpoint, this new category of shoes presents excellent choices to help patients.     

How do we approach this subject? The following 17 criteria can help you with your initial maximalist shoe recommendation. I like to think that every athlete, with all the possibilities we have, could benefit from the wearing of a standard shoe sometimes, wearing a maximalist shoe sometimes and wearing a minimalist shoe sometimes. If you believe in the “tissue stress model” for injuries and if you believe that each type of shoe produces different stresses, our athletes may be able to mix up the stresses by alternating shoes in the same way we teach people to cross-train.³ I think it is very important to remember that there are general rules we use and that I will discuss in the treatment of patients.

I have been practicing sports medicine for 35 years. The minimalist movement taught me two great things and reinforced several others. These lessons can carry over to maximalist shoes, which share many qualities with the minimalist shoes. Minimalist shoes, with their poster child being the Vibram 5 Finger, taught me that it was okay to feel the ground again and that we were probably protecting our patients too much and for too long. They taught me that patients could wear various shoe categories at select times to vary the stresses in the body for an activity.

I relearned what physical therapists have been telling me for years: strengthen the foot. I am an isolation type of guy in general. I believe that in order to strengthen muscles, one should ideally isolate the muscle in question. However, as long as you understand the tissue stress model and talk in layman’s terms to patients about not exercising a muscle past its micro failure zone, the minimalist shoes may help strengthen the foot.

The minimalist folks also taught about the strike on the ground. To be safe, a minimalist shoe wearer should become a ballet dancer with a forefoot strike.⁴ I watched so many of my patients with knee and hip problems feel so much better with less heel strike. I also saw so many of my patients fracture their heel or develop severe shin splints from remaining a heel striker. The maximalist shoe company Altra has a zero drop, which de-emphasizes heel strike, with all of its shoes. Both the minimalists and maximalists believe in having shoes as light as possible and avoiding excess material.

A Guide To Shoe Recommendation Criteria

The following criteria will represent typically easy evaluation points or other factors relating to runners’ injuries, biomechanics, training experience and weaknesses. As you evaluate the athlete, using whatever skills and questions you have, categorize them by these 17 criteria, which can help you decide on shoe gear recommendations:

• neutral biomechanics
• pronation biomechanics
• supination biomechanics
• poor shock absorption biomechanics
• shock absorption needs
• type of strike (heel, midfoot and forefoot)
• balance issues (proprioception)
• beginning athlete
• experienced athlete
• low mileage or high mileage
• stable or unstable training surfaces
• heel height biomechanics
• width
• forefoot flexibility
• forefoot rigidity
• forefoot rocker
• lightness

So how do we look at the 17 criteria? First of all, I think it should be apparent that no one shoe will be perfect so switching up shoes is important. The athlete loves to be involved in this decision making and can see the validity in these decisions. I think it is important to have our athletes train on different surfaces, use different miles per workout, cross-train and have different shoes for different activities. You can summarize the 17 criteria into six main categories:

• Overall biomechanics
• Type of activity for shoe to be worn
• Injury or weaknesses
• Type of athlete
• Special need from shoe
• Strike pattern

Ascertaining The General Biomechanics Of Runners

The first four criteria should really involve gait evaluation. Simply having the patient stand up and then deciding whether he or she is neutral, a pronator, a supinator or has poor shock absorption does not work well. If you can observe athletes in the activity that they are buying the shoes for, you can usually see if they are neutral, have a tendency to supinate, have a tendency to pronate or have shock absorption issues.

1. Neutral biomechanics. Are the runners neutral? This is an observation to make if they have orthotic devices or not. Basically, you watch them walk and run in what they have been using. Too many of our athletes, especially the pronators, wore anti-pronation stability shoes, even when they were neutral with an orthosis.

Do not forget the benefits of power lacing (also called a runner’s knot or stability knot). Some pronators or supinators became neutral with just power lacing. The problem then lies in overcorrecting someone, thus turning a patient from a pronator into an unstable supinator. We want neutrality in general in which the weight is evenly distributed as runners roll through their metatarsals. So many of these cushy maximalist shoes will take the normal motion of pronation at contact and make runners pronators. I have a significant number of athletes who only really need their orthotics for maximalist shoes to give them stability. I also have athletes who need ranges of pronation control in two or three pairs of orthotics in order to wear maximalist shoes for some benefit.

2. Pronation biomechanics. Do the runners have a tendency to pronate? Pronation can be categorized as mild, moderate or severe. This can be greatly influenced, for good or bad, by whether the patients wear custom or OTC orthotics. The range of shoes that can resist pronation is so extreme now that pronation support from different orthotic devices can be necessary (as I mentioned in #1).

I love to grade my orthotics A, B, C, D and occasionally F for the amount of pronation or supination control I obtained. For example, a few years ago, a runner with plantar fasciitis who pronated got symptom relief from a B orthotic device and a stability shoe. If the runner is now wearing a super cushioned maximalist shoe and the symptoms are returning, the runner may now need more correction to get to an A, A- or B+ orthotic. Yet the patient may just need some better training guidelines, or just taping and power lacing, or a slight varus wedge under the medial aspect of the orthotic device the patient is already wearing.

3. Supination biomechanics. Do the runners have a tendency to supinate? This can be from pes cavus, weak peroneals, unstable lateral columns, tibial varum, etc. For the 10 to 15 percent of runners who are supinators, I have not found over-the-counter orthotics to work well and even custom orthotics (unless they are designed for supination) can put too much pressure on the arch and throw runners laterally. Whereas some pronation is still okay, some supination can be deadly. The same adage is true in both bunion surgery and foot biomechanics: Thou shalt not varus. Again, we can categorize the subtleties of supinators as mild, moderate and severe.

For those of you trained on Root biomechanics, the kinetic wedge or maximal pronation, you will understand a lack of supination. For a neutral patient or pronator, maximalist shoes that are really stacked (some of the Hoka One One shoes I know have a 36 mm midsole) can begin to lean outward (especially due to the durability impact of lateral heel strike, the use of orthotic devices for some symptoms, and the need for the shoe to be light and soft). The photo on page 75 shows this tendency after only 100 miles of use.

I would recommend a monthly evaluation for patients to check how the shoe is leaning. There are 17-plus common pain syndromes associated with oversupination. Typically, their original symptoms feel better but they can begin to complain of other symptoms like peroneal injury, iliotibial band injury or medial knee compartment injury from jamming.

What You Should Know About Shock Absorption

4. Poor shock absorption. Runners who have poor shock absorption are the “pounders.” Some just have too much heel strike. This does not have anything to do with their weight. They can also be supinators since you need some pronation for shock absorption. They can also function maximally pronated as it is the motion of pronation that absorbs shock, not the position. Some people are good at absorbing excess shock. Sometimes, it is how hard a person hits the ground. Sometimes, it is compensation for having knee arthralgia, hip arthralgia or lower back symptoms, and runners should minimize the pounding. I think the general concept behind maximalist shoes is shock absorption.

5. Shock absorption needs. The ultramarathon participants who wear maximalist shoes believe the added shock absorption is saving their joints during these long runs. I think by definition if you are an ultramarathoner, you are a poor shock absorber. You need the extra protection, which is common sense. However, poor shock absorption may be because the runner or walker has run too much on cement, or has some vitamin D deficiency or other forms of inadequate bone health. It could merely be the novice cross country runner whose bones are not used to the pounding or torqueing.

What Strike Type And Balance Issues Can Indicate

6. Type of strike. Does the runner have a heel strike, midfoot strike or forefoot strike? For years, I have been trying to get my heel strikers to get more solid and stable by landing on their midfoot (really should be on the whole foot). I would refer them to the website or YouTube videos on Chi Running (https://www.youtube.com/watch?v=rYNZUioUdHQ ), which is all about midfoot landing and having a stable body above the foot. With all the variations you will find in maximalist shoes in terms of these wide bulky midsoles and uni-bottoms, Chi Running has helped patients land on a more stable surface.

I usually find midfoot strikers the most stable with the heel strikers and forefoot strikers less predictable as they can be very smooth, violently unstable or something in between. I have had to make custom orthotic devices to stabilize the instabilities more in heel strikers or forefoot strikers, and there is less of the foot to use in a forefoot striker.

7. Balance issues (proprioception). Of course, balance issues can be from many causes. There are five levels to a typical single leg balancing evening routine for our patients to work through. The patient does not have to be in a highly stacked maximalist shoe with balance issues to enjoy the benefits of the cushion. The right photo shows a stable and not too high Adidas NMD CS1. If your patient is really unstable and walks on uneven ground, try one of the maximalist hiking boots.

Other Pertinent Factors In Athlete Assessment

Now one needs to consider the type of athlete the runner is, the level of activity and the training surface.

8. Beginning athlete. Is the athlete a beginner? If the athlete is just starting to walk athletically, he or she should have a good pair of maximalist shoes to wear for longer walks, and traditional neutral running shoes for shorter walks. Running shoes in general have more support and cushioning than walking shoes. Reportedly, only 50 percent of people who start a walking program and 30 percent who start a running program are still going in two years. If runners cannot find a store with a good selection and exchange rate, they should familiarize themselves with Zappos or Road Runner Sports.

9. Experienced athlete. Experienced athletes are typically more aware of their bodies. They can definitely get away with more training errors, like improper shoes, hurried training programs, etc., since their threshold for overuse injury is higher. Experienced athletes should be used to cross-training and already know if they need neutral or stability shoes. I believe all experienced athletes, especially as we age, should get familiar with this latest brand of cushioned shoe. It may be of great help in high stress environments such as ultramarathons or downhill running.

Several of the negatives of being an experienced athlete are that athletes may take more risks, feel a bit too invulnerable and get too set in their ways, and do not vary things up enough. Maximalist shoes can be a way to vary a workout without much psychological change.

10. Low mileage or high mileage. Low mileage is less stressful and there is less need for the added cushion of a maximalist shoe. High mileage walkers, hikers or runners need to daily vary the terrain, the distance and the type of shoes they wear. Experienced (more than three years) high mileage athletes tend to do great with a workout or two a week with minimalist shoes.

11. Stable or unstable training surfaces. Does the athlete train on stable or unstable environments? This is where I can get nervous with a stacked high maximalist shoe on a patient with unstable ankles on uneven terrain. The problem typically comes when athletes did not expect the terrain change. All the maximalist shoes can accommodate an ankle brace when necessary.

Recognizing Other Attributes Of Maximalist Shoes In Addressing Individual Needs And Injuries

Finally, maximalist shoes can meet a wide variety of individual needs when one is dealing with injuries. There are times we want heel height or no heel height, very wide or narrow shoes, forefoot flexibility or rigidity, a forefoot rocker, or very light or standard shoes. There are maximalist shoes that fit all these specs.

12. Heel height biomechanics. Most agree with the minimalists that metatarsal, knee and sometimes hip pain feel better in a shoe with a low heel. Those with Achilles tendon problems, plantar fasciitis and shin splints love a higher heel. The maximalist shoe advocates are all over this with cushioning and high 8 mm heels, and zero drop heels (like one sees with the complete line of Altra shoes).

13. Width. In general, I personally think maximalist shoes are either too wide (Altra line) or too narrow (Hoka One One line). With power lacing, orthotics, etc., I can typically make it work. Most biomechanics people I know believe the front of the maximalist shoe can be a little loose as long as the mid-part of the shoe is stable on the foot.

14. Forefoot flexibility. The image at right shows the forefoot flexibility test that was standard for traditional shoes. Some maximalist shoes are very flexible and this can be an important factor in helping to address someone’s injury.

15. Forefoot rigidity. You make the shoe rigid so it acts like a cast. You can have your patients buy a carbon graphite plate, like those sold at Otto Bock, if they already have the shoe they want. The more rigid the forefoot is, the more stable the overall shoe becomes.

16. Forefoot rocker. This is different than just being rigid. A forefoot rocker actually allows for the normal roll of the foot like a removable boot. For some conditions, like sesamoid issues, this roll can allow the boot wearer to get into shoes more quickly. It needs a high stack, however, so the negatives of some instability and durability issues may be of concern. The removable boots we have our patients wear actually prolong the weightbearing of the heel and forefoot versus traditional shoes sometimes increasing pain in these areas you are trying to fix. The same possibility is present when you use a rocker shoe.

17. Lightness. This new batch of foams that make maximalist shoes are light. Who doesn’t love that? It’s probably great for joints but watch out for durability issues.

Dr. Blake is a Past President of the American Academy of Podiatric Sports Medicine. He is in private practice in San Francisco.

References

1.     Metzler B. Sole Man: 12 things about maximalist shoes. Available at https://running.competitor.com/2014/05/shoes-and-gear/sole-man-12-things-about-maximalist-shoes_94938 . Published May 7, 2014.
2.     Beer B. Hoka running shoe review-hype or helpful? Available at https://www.pogophysio.com.au/blog/hoka-running-shoe-review/ . Published June 28, 2015.
3.     McPoil TG, Hunt GC. Evaluation and management of foot and ankle disorders: present problems and future directions. J Orthop Sports Phys Ther. 1995; 21(6):385–88.
4.     Ellingsen L. Barefoot/minimalist running basics. Available at https://www.rei.com/learn/expert-advice/basics-of-barefoot-minimalist-running.html . Published March 22, 2016.

For further reading, see the DPM Blog “Getting An Athlete With A Sesamoid Fracture Back To Running Safely” by Dr. Blake at https://tinyurl.com/hm2kmyr or the DPM Blog “Assessing Current Running Shoe Trends” by Nicholas Campitelli, DPM, FACFAS at https://tinyurl.com/qbpudxx .