Study Assesses Injuries And Injury Rates Among Barefoot And Shod Runners

A recent study found fewer overall musculoskeletal injuries in barefoot runners but similar injury rates between barefoot and shod runners.

The prospective survey in the British Journal of Sports Medicine encompassed 107 barefoot and 94 shod adult runners. The study authors noted there were fewer diagnosed musculoskeletal injuries overall among barefoot runners although injury rates were not statistically different between the groups. The study showed that barefoot runners sustained a statistically greater number of injuries to the plantar surface of the foot although barefoot runners reported less plantar fasciitis than shod runners. The researchers also noted that the barefoot group had more calf injuries but fewer knee and hip injuries than shod runners.

Brian Fullem, DPM, critiques the study’s conclusion of fewer cases of plantar fasciitis in the barefoot running group. As he explains, the average weekly mileage in the shod group was 25.3 miles per week with the barefoot group running 14.9 miles per week, and notes that running fewer miles would lead to a lesser chance of injury. He also points out that the barefoot runners ran an average of 25 percent of their mileage in minimalist shoes.  

“The numbers are not significant enough to draw a quality conclusion about the incidence of plantar fasciitis,” says Dr. Fullem, a Fellow of the American Academy of Podiatric Sports Medicine, who is in private practice in Tampa, Fla. “If you really want to compare true injury rates, then both groups in the study need to run the same amount and the barefoot group needs to run all their mileage barefoot.”

Richard Blake, DPM, concurs, noting that running under 20 miles per week is a relatively safe zone with injuries increasing over 20 miles per week. He feels the mileage differential is a weakness in the study and points out that the authors note the data evened out when they calculated the injury rate per 1,000 miles.

“To me, it means that if both groups ran the same mileage, the data would have been a lot different,” says Dr. Blake, a Past President of the American Academy of Podiatric Sports Medicine, who is in private practice in San Francisco.

Nicholas Campitelli, DPM, FACFAS, an Adjunct Professor at the Kent State College of Podiatric Medicine, argues that similar injury rates between the two groups are more likely a result of training patterns rather than shoes or poor biomechanics.

That said, removing arch support promotes strengthening of the foot, which may account for less plantar fasciitis in the barefoot group, according to Dr. Campitelli. He says studies have demonstrated an increase in the strength of foot musculature by functioning either barefoot or in minimalist shoe gear, and adds that the Journal of the American Medical Association will publish his similar findings in an upcoming issue. Dr. Campitelli says barefoot runners in this study had fewer overall injuries because they may have minimized strike pattern variations, which allows the body to adopt a more natural running form.

“A runner can certainly run with a ‘natural’ form while wearing a traditional running shoe but thicker and more cushioned heeled shoes with rigid soles will influence the way a person runs,” says Dr. Campitelli. 

What To Recommend To Athletes Interested in Barefoot Running

Dr. Blake only recommends barefoot running in elite runners with more than five years of running experience and good biomechanics. He suggests running barefoot as an adjunct to their training, initially no more than 10 percent and gradually working up to 20 percent of their workouts. 

Dr. Fullem would encourage the athlete interested in barefoot running to use a minimalist type shoe initially and strengthen the foot with exercises every day. After a period of strengthening and successful use of minimalist shoes, he would recommend starting with barefoot strides on a grass field and progressing from there.

Dr. Campitelli encourages barefoot running. He says it can help a runner adopt a more natural stride and strike pattern, which he feels can reduce the chance of injury and make running more fun. Dr. Campitelli adds that many of the minimalist shoes allow people to run as if they were barefoot but provide sole protection and even a bit of cushion for longer runs of 10 miles or so. However, he does emphasize that he tries to educate patients on training patterns first before discussing shoes.

CMS Announces ‘Grace Period’ For ICD-10

By Brian McCurdy, Managing Editor

Those who are dragging their feet on implementing ICD-10 will get a break as the deadline nears. The Centers for Medicare and Medicaid Services recently announced a one-year grace period starting when the new codes take effect October 1.

During the grace period, CMS will not reject payment of claims for not being specific enough, according to Medscape. The article notes that if physicians use an ICD-10 code from the correct family of codes, they will not be penalized for not including more minor details.

“There is no question that way too many physicians are not ready for ICD-10,” asserts Jeffrey Lehrman, DPM, a Fellow of the American Academy of Podiatric Practice Management.  

Dr. Lehrman notes the highest hurdles in adopting ICD-10 are physician and staff training and the time required to do so as training will require courses, lessons, practice and collaboration. He notes appropriate and thorough training may require some increased work hours, overtime and maybe even seeing fewer patients over a period of time.

“Offices need to be prepared to make short-term compromises now for long-term success and efficiency in the future,” adds Dr. Lehrman.

Dr. Lehrman does note it is unclear just how wrong the code can be with the clinician still receivng reimbursement. He says there is ambiguity in regard to what the “same family” is as far as the new codes although the American Podiatric Medical Association (APMA) Coding Committee, of which he is a member, is trying to get clarification on the issue. For example, Dr. Lehrman says an initial encounter for a closed, non-displaced fracture of the proximal phalanx of the left second toe coded to the highest specificity in ICD-10 is S92.515A and questions if the same family would be S92, S92.5 or S92.51.

“Any degree of less specificity required in coding will make the transition to ICD-10 easier,” says Dr. Lehrman. “The less specificity needed, the easier the transition will be in coding for CMS patients.”

Study: Apligraf Superior To EpiFix For DFUs

By Brian McCurdy, Managing Editor

A new study in Wound Repair and Regeneration finds that a bioengineered living cellular product provides better healing of diabetic foot ulcers (DFU) than an amnion/chorion membrane allograft.

Researchers compared the effectiveness of a bioengineered living cellular construct (Apligraf, Organogenesis) with a dehydrated human amnion/chorion membrane allograft (EpiFix, MiMedx) in treating diabetic foot ulcers (DFUs). The study focused on 218 patients with 226 DFUs and included wounds that were smaller than 25 cm², were less than one year in duration, and did not reduce by 20 percent or more in the first 14 days of treatment.  

The median time to closure for Apligraf for the 163 DFUs was 13.3 weeks in comparison to 26 weeks for the 63 DFUs treated with EpiFix, according to the study. In the Apligraf group, authors noted 48 percent of wounds had healed at 12 weeks while 72 percent had healed by 24 weeks. In contrast, the study notes in the EpiFix group, 28 percent of wounds had healed by 12 weeks and 47 percent of wounds healed by 24 weeks.

Lee C. Rogers, DPM, has used both Apligraf and EpiFix, and notes each has its place in treating diabetic foot ulcers. He notes Apligraf’s living tissue has fibroblasts and keratinocytes, producing growth factors to promote wound healing. One can use EpiFix, a minimally processed human amniotic membrane, in the clinic or the OR, according to Dr. Rogers, the Executive Medical Director of the Amputation Prevention Center at Sherman Oaks Hospital in Los Angeles. He notes EpiFix has the added benefit of being able to cover exposed bone or tendon.

“Insurers are becoming keen to the large amounts of wastage present with some bioengineered (such as Apligraf) and non-bioengineered tissues, and I look for them to soon favor size-appropriate grafts (such as EpiFix),” notes Dr. Rogers.

Dr. Rogers argues that while the study contained a reasonable sample size, as a retrospective review, it is only Level III evidence. He notes the Wound Repair and Regeneration study would not carry as much weight as Apligraf’s early Level I study for its FDA approval or EpiFix’s multiple Level I studies. Specifically, Dr. Rogers cites a head-to-head trial last year in the International Wound Journal, in which researchers found EpiFix to be superior to Apligraf.

In Brief
The Food and Drug Administration (FDA) is strengthening existing cardiovascular warnings on the labels of prescription non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs), and is also requesting updates to the labels of over-the-counter NSAIDs. The new warnings will reflect factors such as elevated risk of heart attack, stroke or heart failure, according to the FDA.