Barefoot Running. Ed Mulligan, PT, DPT, OCS, SCS, ATC. Clinical Orthopedic Rehabilitation Education

Transcription

1 Barefoot Running Ed Mulligan, PT, DPT, OCS, SCS, ATC Clinical Orthopedic Rehabilitation Education

2 Not a new concept Nov Olympics

3 Interesting Trivia Abebe Bilika won the 1960 Olympic marathon running barefoot (because his shoes didn t fit)

4 Gained traction in the running community with the release of the 2009 book by Christopher McDougall telling the story of Mexican Tarahumara Indians running style and habit (hundreds of miles/week)

5 What is barefoot running? It doesn t typically mean without shoes

6 Minimalist Shoe Characteristics Lightweight (< 8 oz) Highly flexible Expanded toe box Limited heel elevation Heel toe drop (< 5 cm) Reduced padding Minimal midsole cushion

7 Subdivisions Type Flexibility Heeltoe Drop Cushion Purpose Toe Box Barefoot extremely zero none Plantar protection Very wide or 5 toes Minimalist very 0 3 mm some wide Transitional (neutral) More than traditional shoe 4 8 Soft midsole material Transitional shoe May make sense to transition towards barefoot shoe as gait pattern changes to minimize undue stress on Achilles

8 Shoe Design s Impact on Injury

9 Started with Nike in the 1970s Midsole cushion and waffled outsole to reduce injury

10 General sentiment for the next two decades Motion control shoes planus feet Cushioned shoes cavus feet Stability shoes normal feet however, systematic review concluded that the prescription of shoe type for distance runners is not evidence based Richards CE, et al, Brit J Sports Med, 2009

11 Changing Paradigm Motion control shoes control rearfoot motion better than cushioned shoes and Cushioned shoes attenuate shock better than motion control shoes Independent of arch shape Motion Control New Balance 1122 Butler RJ, et al; Am J Sports Med 2006 Matching shoe type to foot shape made no difference in injury rates Knapik JJ, et al, Am J Sports Med, 2010 Cushioned New Balance 1022

12 Disuse Atrophy? Do traditional running shoes (with their tight toe boxes and arch support) weaken the plantar intrinsic muscles? We know that training these muscles over a 4 wk training period significantly reduces navicular drop Mulligan EP, et al, Man Ther, 2013

13 Most importantly, despite advancements in shoe technology Incidence and prevalence of injuries has not changed over the past 30 years 50% of runners have an annual injury 25% of runners have a current injury Vast majority of injuries are to knee, leg, and foot Hsu A, Foot Ankl Int, 2012 Rixe JA, et al, Curr Sports Med Rev, 2012

14 Maybe the answer isn t the shoe but the gait style

15 General Theory Barefoot gait encourages a minimalist running style characterized by a soft initial contact by the forefoot and quicker, shorter strides Lieberman DE, Nature, 2010

16 Running Injury Epidemiology Study Goss DL, Gross MT, US Army Med J, 2012 Survey of 2500 runners (50% male/female) Shoe selection was significantly associated with footstrike habit Barefoot & minimalist runners reported a more anterior footstrike Traditionally shod runners were 3.4 times more likely to report injuries than experienced minimalist shoe wearers 47% shod vs. 14% minimalist Minimalist shoe wearers also reported fewer injuries at the hip, knee, lower leg, ankle, and foot than traditionally shod runners.

17 Altered impact forces

18 Ground Force Dissipation Vertical ground impact force in unshod condition alters kinematics Minimizes abrupt spike at impact and produces a smoother force transmission Increased ability to disperse impact forces more efficiently

19 However, Barefoot running is a skill that is not instinctively acquired it requires substantial PRACTICE and TIME in order for the body to adapt Even then, it is unclear how this adaptation occurs, and whether every runner can achieve it IMO, the process of adaptation needs to be clearly understood before clinical and training advice is routinely disseminated to runners Tam N, et al, Br J Sports Med 2013 Wilson JD, et al, PM R, 2013

20 Improved plantar proprioception possibility of enhanced sensorimotor interplay between ground and foot allowing improved postural awareness and adaptation to changes in environmental stimuli and balance

21 Any further evidence that this works? Still a NOT PROVEN theory; however, Reduction in tibial stress fractures Crowell H, et al, Clin Biomech, 2011 Case series showing abolishment of CECS symptoms with altered gait pattern Diebal AR, et al, Am J Sports Med, 2012 and Int J Sports Phys Ther, 2011 Harvard Study competitive runners who forefoot strike have a significantly lower rate of overuse stress injuries than those that rearfoot strike Daoud AI, Med Sci Sports Exer, 2011

22 Barefoot Running (Minimalist Shoes) way to early to offer definitive proof of concept

23 What we don t know Impact on injury incidence Impact on performance

24 if it has an impact on injury or performance is it the shoes or the change in gait the shoes promote?

25 Potential Analogy Are minimalist helmets safer? Or do they change the way you play the game?

26 Downside Increased chance for metatarsal stress fractures (case reports) Giulani J, et al, Orthopaedics, 2011 Not all subjects will instinctively adopt a forefoot strike pattern when wearing minimalist shoes Dramatic alteration in mechanics may cause injury if not adequate transition time Lets face it they look stupid

27 Who should not barefoot run Immunosupressed subjects Diabetics Peripheral neuropathies Plantar forefoot wounds or lesions

28 What you should do before you begin minimalist transition 4 6 week program of: Intrinsic strength training (short foot exercise) Eccentric calf training Balance reach training

29 Forefoot Running Verbal/Visual Cues Relax your legs to minimize head bobbing Feel the ground with your feet; run softly Short, consistent stride (decreased step length) 10% decrease with increased cadence to maintain speed Increase turnover (gait cycle cadence) Higher knees in swing pull with hamstrings More flexed knee in landing Slow transition to new running style over weeks to months Listen to your body run is over when mechanical break down occurs Toes extended on contact and flex with propulsion

30 Forefoot Strike Running Gait Drive one knee forward and opposite elbow back. Keep back straight. Imagine stepping over a log. The faster your pace, the bigger the log. Ankle should never extend in front of the foot Knee drive comes from hips and glutes; the rest of the limb is relaxed Position foot for gliding approach. Forefoot strikes first. Heel touches down gently after forefoot. As soon as foot touches begin cycling with opposite leg

31 Warning! Slow progressive transition to new running style over weeks to months

32 Summary At this time only studies (which are limited in methodology and level of evidence) to suggest physiological and biomechanical advantages No conclusive studies at this time to accept or reject any changes in performance or injury rate

33 What I suspect No conclusive studies at this time to accept or reject any changes in performance or injury rate with minimalist shoes Probably, a subset of runners that this is appropriate for just not sure who not sure which injuries It takes weeks (if not months) to make an injury free transition to barefoot running How one runs probably is more important that what is on one s feet but what is on one s feet MAY affect how one runs Lieberman DE, Exerc Sport Sci Rev, 2012

34 Only time will tell if barefoot running goes the way of barefoot kickers