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By Pete Larson
We spend quite a bit of page-space in Tread Lightly discussing the incidence and possible causes of barefoot/minimalist running transition injuries. Thus, it is with some interest that after reading Steve Magness’ recent post on studies presented at the annual meeting of the American College of Sports Medicine that I hopped onto the meeting website and came across the following presentation:
Running-related Injuries During The Transition From Shod To Barefoot Running
The abstract of the study, conducted by Allison Altman of the University of Delaware and Irene Davis from the Spaulding National Running Center at Harvard Medical School, reads as follows:
There are more than 16 million runners in the United States. Of these runners, up to 79% are injured each year. It has been suggested that an increasing number of runners are converting to barefoot running to avoid injuries by running with a softer landing pattern. However, the alteration in mechanics associated with this conversion may increase the risk of injury during the transition. PURPOSE: To determine the injury patterns associated with the transition from shod to barefoot running. METHODS: 109 barefoot runners were recruited from online advertisements. These runners were between 18-50 yrs and were running at least 10 miles/week. Injuries associated with barefoot transition were reported to a web-based survey. Injuries were divided into musculoskeletal injuries (MS_INJ) and injuries to the plantar surface of the foot (PL_INJ). MS_INJ were further divided into those that were professionally assessed where a clear diagnosis was noted, and those that were self-reported. RESULTS: 17% (18/109) of the runners sustained a MS_INJ during their transition with half of those (9/109) seeking medical attention. 15% (16/109) of barefoot runners sustained PL_INJ. 37 total injuries were reported, with 21 being MS_INJ, and 16 were PL_INJ. The most common MS_INJ were foot, arch, calf and lower leg pain. Of the PL_INJ, blisters were the most common. Cuts, thought to be a significant risk with barefoot running, only occurred in 2/109 runners. CONCLUSION: Overall, the occurrence of transition injuries was relatively low. Conditioning of the arch and lower leg muscles, coupled with a gradual toughening of the plantar surface of the foot should help to reduce these injuries during transition.
And below is the table showing the injury results:
Table 1. Injuries reported during transition to barefoot running.
| Musculoskeletal Injuries | ||||
| Diagnosed | # INJ | Self-reported | #INJ | |
| Plantar fasciitis | 2 | Pain on top of foot | 4 | |
| Posterior tibialis strain | 2 | Achilles pain | 2 | |
| Dorsal foot pain | 1 | Calf pain | 2 | |
| Fibular stress fracture | 1 | Shin pain | 2 | |
| Gastroc-soleus strain | 1 | Arch pain | 1 | |
| Metatarsal stress fracture | 1 | Total (#injuries/#runners) | 11/9 | |
| Ankle joint impingement | 1 | |||
| Iliotibial Band Syndrome | 1 | |||
| Total (#injuries/#runners) | 10/9 | |||
| Plantar Surface Injuries | #INJ | |||
| Blisters | 12 | |||
| Cuts | 2 | |||
| Bruises | 1 | |||
| Stubbed toe | 1 | |||
| Total (#injuries/#runners) | 16/14 |
Now, it’s important to note that meeting abstracts such as the one above are necessarily short, don’t provide a lot of information regarding methodology, and are not equivalent to a peer-reviewed journal article. As such, extreme caution is warranted when it comes to interpretation. But, the results of this study are rather interesting, and I suspect will be fodder for some interesting discussion and debate.
Almost every time I read a news article about barefoot running I see a quote from a medical professional claiming that they are seeing something equivalent to a wave of “barefoot running” related injuries. I put barefoot running in quotes because it’s very difficult to distinguish whether they are talking about people getting hurt while actually running with nothing on their feet, or whether these injuries are occurring in people wearing “barefoot-style” shoes, or even just one particular type of “barefoot-style” shoe. This, to me, is a very important distinction, and is why I hate it when the word barefoot is misused. Barefoot means nothing on the feet. Period.
Now, if I had to guess, and this is totally speculation since I have no data to support this, most of the injuries seen in clinics are probably occurring in people running in barefoot-style footwear. Why? A couple of reasons. First, if my observations at races over the past few years are representative of anything, there just aren’t that many full-time barefoot runners out there. Second, as often pointed out by regular barefooters, barefoot running is a great self-limiter. It is hard to do too much too soon as a new barefoot runner because your plantar skin will let you know very quickly that it has had enough. And if you do go too far and damage your soles, it’s likely that you will need to allow things to heal up before you try again. As such, a very gradual buildup is almost a requirement for true barefoot running.
On the other hand, barefoot-style shoes prevent the friction that can damage the plantar surfaces. Thus, it is easier to do too much too soon because the skin does not act as a limiter, and if you don’t allow time for musculoskeletal adaptation to occur, a more serious injury than a blister is quite possible. This is why an extremely gradual adaption is so critical during a minimalist transition – you need to maintain immense self-discipline to avoid doing too much too soon.
Assuming that all of the 109 individuals followed in this study were running truly barefoot, the results suggest that transition injuries for barefoot runners are in fact fairly uncommon (only 17% of the 109 runners reported one, and only half of those actually had to see a medical professional for their problem). The dreaded metatarsal stress fracture that we hear so much about – only a single case formally diagnosed among the 109 runners. Plantar fasciitis? Only 2 individuals. Not a single diagnosed case of Achilles tendinopathy. Only 4 instances of self-reported calf or Achilles pain. The most common injury reported was, as might be expected, blisters.
It should be emphasized that this study is based on survey data, and we know little about the sample or the exact methodology. I am a bit suspicious by the low incidence of self-reported calf pain, as well as the rarity of blistering, even if it was the most common injury. It is possible that if the study subjects were die-hard barefooters, they might be under-reporting injury incidence. But, given the dire reports of injury risk we sometimes hear from the medical community (almost all anecdotal by the way), one wonders what the truth is. It will be very interesting to read the full study if/when it comes out.
So, rather than go on, I though it might be more interesting to post a few questions relating to this study and barefoot running injury risk and see what you think (wild speculation is encouraged!):
1. Given the results of this study, do you think injury reports coming from the medical community about barefoot running transition injuries might be exaggerated?
2. Do you suspect most injuries (e.g., metatarsal stress fractures) reported by the medical community are happening to barefoot runners, or is the moniker “barefoot runner” being used too loosely to include runners in “barefoot-style” shoes like the Vibram Fivefingers.
3. Do you suspect that injuries are less likely in a true barefoot transition than in a transition to barefoot-style shoes?
4. Do you think that injuries might be under-reported in a study like this (e.g., does the low incidence of blisters or calf pain concern you when it comes to believing these results?).
Any and all thoughts are welcome!
I think this is a great piece of scientific review/journalism and would agree with all your points. I have seen a rise in injuries within my clinics and yet as you state a great many are using minimalist footwear rather than running actually barefoot. I think the debate will go on and on and it is difficult to get a truly objective opinion out of anyone these days as it seems like everyone has chosen a side and sits firmly at either pole. I would welcome healthy debate over the benefits as my distinction has been that if you want to try barefoot running then you would want great mechanics and lack of injury for the last year at least... Then it begs the question why would you start? But just before I get slain, I am intrigued by those going through the process properly and getting good results - I await some longevity to the studies though.
ReplyDeleteThanks for the comment, and I agree. We need more open minds and less of the polarized camps. Barefoot running has a place, but we still really don't know for who and how much. But the same could be said for motion control, etc. It's an exciting time to be following all of this stuff.
DeleteI may argue that a barefoot runner who is running 10 miles per week (assumed barefoot) is past the 'transitional' phase (based on the take it super slow and build approach always suggested). Second, barefoot runners, in my experience as part of the community, are under-reporters of running injury as it degrades the "bfr is better than shod running" argument of many newly converted and very dogmatic barefoot runners. As with many of the studies I have seen on both sides of the issue, I am suspect of any transferrability of results. But I am no scientist, merely an interested layperson.
ReplyDeleteIf your assertion that 'barefoot shoes' were worn when the injuries sustained, then it is not a discussion of barefoot running, but one of minimalist running.
It's hard for me to tell if that 10 miles piece means 10 miles per week barefoot, or a minimum of ten miles of any kind of running. But, I would agree that those who advocate a particular style are more likely to under-report injury. If I had to guess, injury risk probably falls somewhere between that reported here and the dire prognostications you sometimes read about in the media. And I do suspect that injuries among barefooters are less common than those among ultraminimal runners for reasons discussed in the post. I've never been able to go much more than a mile barefoot before my feet make me stop, and I don't do it frequently enough for the skin on my soles to adapt.
DeleteI will speak from experience, as I would have been eligible for this study ONLY if minimalist shoes were included. I transitioned quickly, going from nothing, to about 1 mile a week within the first 2 months, then up to more than 10 miles in the next two months. I developed shin splints after a fierce run with a heavy bag on my back, while running on concrete. I am sure if a more gradual transition is in place, the injury rate would be quite low, but a quick, unexpected transition would bring about much more numbered injuries.
DeleteAs you state in the article, if you are truly barefoot your brain is going to let you know immediately if what you are doing is going to injure yourself. Because we live in a culture that has systematically unlearned how to move as our structure is designed it is a big transition for most people to change how they balance and move and YIELD in their structure to run. The biggest contributor to injuries is that we run pushing into the ground rather than yielding and letting the ground meet the body. A difficult concept to understand at first but once felt transforming to how we move. Yield from within the structure is key, meaning releasing muscles around joints at critical moments in running stride where impact is the greatest.
ReplyDeleteEasy to intellectualise, very difficult to FEEL for most people.
Wrong website name!
DeleteI just think too many researchers try to hit the news....
ReplyDeleteIf they only surveyed runners who were still barefoot running there is an inherent survivior bias in their results. Those who experienced more significant/persistent injuries are more likely to have given up and gone back to wearing shoes...
ReplyDeleteIs this sort of study useful? Yes in the sense that it shows that some runners can transition to barefoot without significant difficulty. On the other hand its findings can't be used to predict the likelihood that a runner will become injured when transitioning to barefoot.
What we really need is a carefully controlled prospective study, but that will be a lot harder for true barefoot running than for say running in a barefoot-style shoe. I'm really curious to more details about the study sample.
DeleteI suggest a High School Coaching study, where we either divide coaches by their pre-existing styles, or get them to sign on to add some amount of barefoot exercises/mileage to their programs for the duration of the study. (I highly doubt we can go so far as to get coaches set in old ways to teach a totally barefoot method, especially since they won't see the full benefits on race days in the first year.) A High School study would get kids before they'd learned too much incorrect form, and give us a large potential pool of respondents, including dropout data.
ReplyDeletePete, I really enjoy your site, even if it is mostly about shoes (!), and have learned a lot from Steve Magness too.
ReplyDeleteI think first you have to make the distinction between veteran runners who have transitioned to barefoot running from shod running, and people who took up running and barefoot running at the same time.
Second, when comparing injury rates between shod and barefoot running, you have to distinguish between chronic, repetitive stress-type injury, on the one hand, and acute injury, incurred doing a build-up or transition phase, on the other.
So, for example, do people starting running of any sort experience more injury shod or barefoot? And/or do veteran runners experience more chronic injury shod or barefoot?
Right now it seems people are comparing apples and oranges: Mostly chronic injuries among veteran shod runners versus accute injuries among newcomers to barefoot running.
I do agree that there may be some underreporting, but also I would distinguish between calf soreness due to trying something new from calf pain due to doing something wrong, or a little aching due to stress reaction from deabilitating pain from a stress fracture. The former can go away pretty quickly, and almost anyone making the transition is going to feel them, but not report them as an injury.
Anyway, interesting stuff. It'll be interesting to see where we stand in about 5-10 years.
Thanks for the comment Lee, you make some great points, and this is why research is not the only source to go to for answers. I believe anecdotal reports have their value as well.
DeleteOne thing I would disagree with is your distinction between repetitive stress vs. acute injuries. An acute injury is something like a twisted ankle or a break resulting from a fall. It's a sudden, instantaneous injury. Transition injuries are repetitive stress injuries, but they can happen quickly due to lack of tissue adaptation to the new type of stress.
I worked into bare foot running for a year, very careful, I ended up with a stress fracture on m heel bone. NOT fun.
ReplyDeleteI love the feel I get when running bare foot, but when I got up into the 20+ miles.....
Every doctor who has ever said to me, "Barefoot running is bad for you; I'm seeing more injuries than ever!" has been confused about the following:
ReplyDelete1) An increase incidence of injuries in his office bears no relationship to the total number of injuries, especially on a percentage basis (if more people try ANYTHING, there will be more injuries... remember 40 years ago, when doctors made the same comment about RUNNING SHOES?)
2) The difference between barefoot vs. minimal -- I always ask, "Did you check to see if your patient was wearing any shoes, or if they were truly barefoot?" They never say Yes.
3) The whole "form issue." -- I ask, "Have you checked their running form to see if that's the actual issue, and not something about being barefoot?" Never.
4) The statistics about shod runners. -- They have no problem making a living off the "up to 79%" who get injured without saying "Running is bad!"
5) The statistics about runners who make the transition without a problem -- nobody goes to the doctor to say, "I'm fine!"
well I think people just go at it too at too quickly, especially if you have been wearing shoes all your life. I do wonder if genetics play a role. Let's say you're of european/western culture descent and that your ancestors have used shoes for the last 20 generations, maybe your foot will be narrower since you body has adapted and inherited a shoe wearing culture, now when a person is a second or third generation of a barefoot culture he might have a wider foot and stronger foot muscles. although this is my own theory I could be wrong.
DeleteGood points Steve!
ReplyDeleteHey Pete, great book and great blog! Here is my 2 cents as a long time runner that successfully transitioned to minimal shoes.
ReplyDelete1) I agree with the previous poster that statements by doctors about seeing an increase in the number of barefoot injuries are completely meaningless. What would be surprising is if there were not an uptick in barefoot injuries given the growth in the number of barefoot runners since Born to Run became a bestseller. And I'm sure they still see far more shod runners with injuries.
I don't understand why the focus is on just transition injuries either. It would be far more interesting to find out if long term injury rates for runners that made the transition to barefoot running had gone down, up or stayed the same. I've not seen any research on this question yet.
I would also be interested to know how many transition injuries may have been caused by years of wearing heeled, arch-supporting shoes that weakened the arches or shortened the calf/achilles. My fellow high school cross country teammates in the early 70s didn't seem to have any problem doing an occasional barefoot workout.
2) Good question. I haven't seen any attempt by the medical community to even quantify, let alone analyze, the data so it's impossible to know.
3) If you exclude Vibram FiveFingers, no. I think transition injuries would be less likely in ultra-minimal shoes, but Vibrams are a special case due to their design peculiarities.
4) I don't really consider blisters and sore calves to be injuries, unless they force you to take time off of running. I would be more interested in how rates of form-related repetitive stress injuries compare.
Thanks for the comment! I agree - we don't have much hard data on injury rates as a fraction of the total population, and docs will only see those who do get injured. Good point on long-term patterns, but we've got awhile to go before most people have been doing this stuff long-term.
ReplyDeleteI think you hit on something very important with your observation about our history of shoe wear. It's quite possible that injuries in transition to barefoot occur because we have been adapted to shoes for so long!
It would indeed be ironic if the root cause of the barefoot transition injuries we are being warned about turned out to be long term usage of the supportive, cushioned shoes that are supposed to be the safer alternative.
DeleteIt shouldn't be too difficult for someone to design a study that narrows down the reasons why some people have difficulty in the transition while others can just step out of their traditional running shoes and keep running the same mileage. I suspect that it has a lot to do with what kind of footwear (or lack of) they grew up in and wear when they aren't running.
If you want to be a barefoot runner, the key is to strengthen the muscles that resist the impacts which I call the landing muscles, the spring suspension system muscles or the pronation supination cuff muscles
ReplyDeleteHere are my last three articles you might find helpful:
How Does The Body Spring Back Safely From Impacts Of Running and Walking?
http://teamdoctorsblog.com/2012/06/13/video-tutorial-12-is-running-bad-for-knees-how-the-body-springs-back-safely-from-impacts-of-running/
Self-Tests & Exercises To Reduce Over Pronation and Over Supination From Impacts During Walking and Running
http://teamdoctorsblog.com/2012/06/18/video-tutorial-28-the-impact-absorbing-landing-muscles-of-the-human-spring-mechanism-testing-and-training-the-spring-suspension-muscles/