The Science of Running Shoes
The design and selection of running shoes does not match the available science. The commonly held beliefs follow this logic: Runners get injured due to impact and excessive pronation, running shoes reduce impact and pronation, and therefore running shoes reduce injury. Unfortunately, every part of this rationale seems to be flawed.
- Injuries due to impact. There is surprisingly little evidence that impact forces cause injuries, and there is even some evidence that lower impact forces are associated with higher injury rates. It's been suggested that excessive impact can result in injury, while more moderate impact can produce important adaptations that are necessary for improved performance.
- Injuries due to over pronation. The science around pronation and injury rates is quite mixed. Part of the problem is science does not generally look at pronation directly, but uses arch height with the assumption that low arches pronate more. There is some evidence that high or low arches have slightly higher injury rates, or that different arch heights have different patterns of injury.
- Running shoes reduce impact. There is good evidence that increased cushioning does not reduce impact forces. Runners who normally run in shoes will have higher impact when initially running barefoot, but after adaptation the impact forces are actually lower without shoes.
- Running shoes reduce pronation. Motion control shoes (the highest level of anti-pronation) only reduce pronation by about 2% when compared with a simple cushioned shoe. It seems unlikely that this is enough to produce any real world affect.
- Running shoes reduce injury. There is no evidence that running shoes reduce injury rates. Assigning shoes based on arch height does not change injury rate, nor is there any indication that more cushioned shoes have a lower injury rates. There is some evidence that motion control shoes cause greater leg pain and more training days lost, and this applies to all arch types.
- Raised heel. Another common feature of running shoes is a raised heel, which is intended to reduce the strain on the Achilles tendon. However there is little evidence that the raised heel actually reduces the strain on the Achilles tendon, and no evidence that the raised heel actually reduces Achilles tendon injuries.
- Barefoot running. The reduced impact seen with barefoot running late in many people (myself included) to believe that this would in turn result in lower injury rates. However, there is no evidence that barefoot runners have a lower injury rates, and they is a growing body of evidence to suggest that the transition to barefoot running is associated with a high injury risk.
1 The Myth of Running Shoe Types
There is good evidence to support the widely held belief that injury rates among runners are quite high, with estimates of injury rates varying between 20% and 80% of runners. It is widely assumed that excessive impact forces, and excessive pronation cause running injuries and shoes are therefore designed to mitigate these problems. This leads to the common recommendation that different types of shoes should be recommended based on a runners arch height. In fact, REI, Zappos, Runners' World, and Road Runner Sports all include this advice.
2 Impact & Injury
The relationship between impact and injury is less clear than one might suppose. It has been suggested that while excessive impact can result in injury, lower levels of impact result in positive adaptation and remodeling and these impacts may be an important part of training. There is evidence that the impact seen in running does not result in injury:
- Impact forces are not related to injury rates in epidemiologic studies.
- The impact forces at the heel are not related to the forces at common injury sites such as the ankle, Achilles, or knee..
- A study of 131 runners showed that injury rates were highest in those with the lowest impact levels.
However, there is also some evidence of a relationship between higher impact and injury:
- A study that compared 20 runners who had never been injured with 20 runners that had prior injuries found that peak impact rates were higher in those that had been previously been injured.
- A study of five female runners who had previously had a stress fracture showed higher peak impact forces than subjects without stress fractures.
- A meta-analysis of 13 studies found that while there was no correlation between rates of stress fracture and impact, there was a relationship for the rate of loading.
3 Pronation, Arch Height & Injury
The evidence for the correlation between pronation and injury is rather mixed. This is compounded by the use of arch height as a proxy for pronation.
- An analysis of 29 studies showed that high or low arched feet had slightly higher risk of injury than normally arched feet.
- There is also evidence for the opposite conclusion, where high or low arched feet have a lower risk of injury.
- One study found that while injury rates are the same for different arch heights, the location of the injuries varies with arch height.
- Another study found that while injury rates are similar for different arch heights, those with low arches had more expensive injuries. (This was a study in the military, where such expenditure is more easily tracked.)
- A year-long study of 927 novice runners showed no correlation between arch height and injury rates.
- A study of 1597 runners found that those with the lowest arches were 2.7x more likely to have knee (patellofemoral) pain than those with the highest arches. (Note that this study used navicular drop as an indicator of pronation, but other factors contribute significantly to navicular drop.)
- A retrospective study found that arch height was not different between runners who had previously been injured and those that had never been injured.
4 Running Shoes & Impact
There is good evidence that increased cushioning does not reduce impact. However, runners who are normally run in shoes have greater impact forces when running barefoot, but this is reversed with barefoot experience.
5 Running Shoes & Pronation Control
A meta-analysis of 5 studies showed that motion control shoes can reduce pronation when compared with barefoot or simple cushioned shoes, but only by about 2%. This seems unlikely to be significant.
6 Running Shoes and Achilles Strain
A common feature in running shoes is for the heel to be thicker than the forefoot, something that is commonly called "drop". In the 1980's a drop of 12-15mm was recommended to prevent Achilles tendon and calf injuries, but there is little evidence to support this:
- No studies have shown raised heels reduce Achilles (or other) injuries.
- Shoes with the different levels of a drop do not change the range of motion of the ankle during running.
- A study of five runners, each running in five different shoes with heel heights of 2.1-3.3cm (5.0 to 9.5 degrees) did not support the idea that heel height changes stress on the Achilles' tendon.
- A drop of 15mm or 7.5mm did not produce a significant reduction in Achilles tendon stress.
7 Injury Rates & Shoes
- A study of 247 runners over 5 months showed no difference in injury rates between firm and softly cushioned shoes.
- Three studies compared assigning shoes based on the shape of the arch with just assigning a single shoe type to runners regardless of their arch. These studies found no difference in injury rates. The studies were done by the US Army (2168 men, 951 women), Air Force (1955 men, 718 women), and Marine Corps (840 men, 571 women).
- A study of 81 women training for a half marathon were randomly assigned cushioned, stability and motion control shoes. The cushioned shoe was a Nike Pegasus, the stability was Nike Structure Triax, and the motion control was Nike Nucleus. The runners were then analyzed based on their arch height.
- The study found that the motion control shoe was associated with the highest levels of pain while running for all foot types, though the difference was only significant for the neutral and pronated foot types.
- All the highly pronated runners wearing the motion control shoe missed a training day due to pain, the highest proportion of any of the subgroups.
- The neutral runners had higher levels of pain in the neutral shoe than the stability shoe, and the pronated runners had levels of pain in the stability shoe than the neutral shoe. This is the opposite of most recommendations for shoe and foot type.
- (Note that while the overall sample size was reasonable (81), each individual subgroup was quite small (5 to 18 runners) and variation within subgroup of results was large. The subgroups also varied significantly in weight, BMI, age, and years of running experience.)
8 Minimalist & Barefoot Running
Most research looks at factors that might be related to injury risk, rather than injury rates directly. I found no studies that evaluated barefoot or minimalist running and injury rates. So while barefoot and minimalist running tends to have lower impact, it's unclear if this will have any bearing on injury rates. Of greater concern is some compelling evidence that the transition to barefoot or minimalist footwear is correlated with higher injury rates, especially stress fractures in the foot.
- A review of 23 studies found moderate evidence for higher Cadence and lower impact, but noted a lack of high quality evidence. Examples include:
- Instances of Metatarsal Stress fractures in minimalist shoes
- A study of 99 runners who were randomly assigned a traditional cushioned shoe (Nike Pegasus), partial-minimalist shoes (Nike Free 3.0 V.2) or minimalist shoes (Vibram 5-Finger Bikila). The runners had a minimum of 5 years' experience and had injuries in the previous 6 months. The runners took part in a 12 week training program in which they gradually adopted their assigned footwear from 10 min (19%) in week 1 to 115 min (58%) in week 12. The two minimalist shoes had a greater rate of injury compared with the traditional shoes, with the partly minimal shoes (Nike Free) having the highest overall injury rate and the minimalist shoes (5 Fingers) having the greatest shin and calf pain.
- A study looked at bone marrow edema in runners transitioning to Vibram FiveFingers (VFF) shoes. 36 experienced runners were randomly assigned VFF or their normal running shoes, with the VFF runners gradually transitioning based on the recommendations of the Vibram at that time. Only 1 of the 17 runners in the control group showed signs of a bone marrow edema, compared with 9 of the 19 VFF runners.
9 See Also
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- RN. van Gent, D. Siem, M. van Middelkoop, AG. van Os, SM. Bierma-Zeinstra, BW. Koes, Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review., Br J Sports Med, volume 41, issue 8, pages 469-80; discussion 480, Aug 2007, doi 10.1136/bjsm.2006.033548, PMID 17473005
- BM. Nigg, The role of impact forces and foot pronation: a new paradigm., Clin J Sport Med, volume 11, issue 1, pages 2-9, Jan 2001, PMID 11176139
- Beat Hintermann, Benno M. Nigg, Pronation in Runners, Sports Medicine, volume 26, issue 3, 1998, pages 169–176, ISSN 0112-1642, doi 10.2165/00007256-199826030-00003
- DC. McKenzie, DB. Clement, JE. Taunton, Running shoes, orthotics, and injuries., Sports Med, volume 2, issue 5, pages 334-47, PMID 3850616
- CA. Johnston, JE. Taunton, DR. Lloyd-Smith, DC. McKenzie, Preventing running injuries. Practical approach for family doctors., Can Fam Physician, volume 49, pages 1101-9, Sep 2003, PMID 14526862
- Barbara Heil, Running Shoe Design and Selection Related to Lower Limb Biomechanics, Physiotherapy, volume 78, issue 6, 1992, pages 406–412, ISSN 00319406, doi 10.1016/S0031-9406(10)61525-8
- MH. Yamashita, Evaluation and selection of shoe wear and orthoses for the runner., Phys Med Rehabil Clin N Am, volume 16, issue 3, pages 801-29, Aug 2005, doi 10.1016/j.pmr.2005.02.006, PMID 16005404
- Running Shoes: How to Choose, http://www.rei.com/learn/expert-advice/running-shoes.html, Accessed on 26 November 2014
- http://www.zappos.com/running-shoe-fit-guide, http://www.zappos.com/running-shoe-fit-guide, Accessed on 26 November 2014
- Take This Simple Test To Learn If You Have High or Low Arches, http://www.runnersworld.com/running-shoes/take-wet-test-learn-your-foot-type, Accessed on 26 November 2014
- http://www.roadrunnersports.com/rrs/content/choosing-running-shoes/, http://www.roadrunnersports.com/rrs/content/choosing-running-shoes/, Accessed on 26 November 2014
- Peter R. Cavanagh, The running shoe book, date 1980, publisher Anderson World, location Mountain View, CA, isbn 0890371822
- A. Hreljac, Impact and overuse injuries in runners., Med Sci Sports Exerc, volume 36, issue 5, pages 845-9, May 2004, PMID 15126720
- Nigg, Benno M. "Impact forces in running." Current Opinion in Orthopaedics 8.6 (1997): 43-47.
- SH. Scott, DA. Winter, Internal forces of chronic running injury sites., Med Sci Sports Exerc, volume 22, issue 3, pages 357-69, Jun 1990, PMID 2381304
- Alexander Bahlsen, The Etiology of Running Injuries: A Longitudinal, Prospective Study, 1988
- A. Hreljac, RN. Marshall, PA. Hume, Evaluation of lower extremity overuse injury potential in runners., Med Sci Sports Exerc, volume 32, issue 9, pages 1635-41, Sep 2000, PMID 10994917
- Susan K. Grimston, Benno M. Nigg, Veronica Fisher, Stanley V. Ajemian, External loads throughout a 45 minute run in stress fracture and non-stress fracture runners, Journal of Biomechanics, volume 27, issue 6, 1994, pages 668, ISSN 00219290, doi 10.1016/0021-9290(94)90983-0
- AA. Zadpoor, AA. Nikooyan, The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review., Clin Biomech (Bristol, Avon), volume 26, issue 1, pages 23-8, Jan 2011, doi 10.1016/j.clinbiomech.2010.08.005, PMID 20846765
- JW. Tong, PW. Kong, Association between foot type and lower extremity injuries: systematic literature review with meta-analysis., J Orthop Sports Phys Ther, volume 43, issue 10, pages 700-14, Oct 2013, doi 10.2519/jospt.2013.4225, PMID 23756327
- DN. Cowan, BH. Jones, JR. Robinson, Foot morphologic characteristics and risk of exercise-related injury., Arch Fam Med, volume 2, issue 7, pages 773-7, Jul 1993, PMID 7906597
- DS. Williams, IS. McClay, J. Hamill, Arch structure and injury patterns in runners., Clin Biomech (Bristol, Avon), volume 16, issue 4, pages 341-7, May 2001, PMID 11358622
- Teyhen, LTC Deydre S., et al. "Impact of Foot Type on Cost of Lower Extremity Injury."
- R. O. Nielsen, I. Buist, E. T. Parner, E. A. Nohr, H. Sorensen, M. Lind, S. Rasmussen, Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study, British Journal of Sports Medicine, volume 48, issue 6, 2013, pages 440–447, ISSN 0306-3674, doi 10.1136/bjsports-2013-092202
- MC. Boling, DA. Padua, SW. Marshall, K. Guskiewicz, S. Pyne, A. Beutler, A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort., Am J Sports Med, volume 37, issue 11, pages 2108-16, Nov 2009, doi 10.1177/0363546509337934, PMID 19797162
- MJ. Mueller, JV. Host, BJ. Norton, Navicular drop as a composite measure of excessive pronation., J Am Podiatr Med Assoc, volume 83, issue 4, pages 198-202, Apr 1993, doi 10.7547/87507315-83-4-198, PMID 8473991
- SE. Robbins, GJ. Gouw, Athletic footwear and chronic overloading. A brief review., Sports Med, volume 9, issue 2, pages 76-85, Feb 1990, PMID 2180026
- I.C. Wright, R.R. Neptune, A.J. van den Bogert, B.M. Nigg, Passive regulation of impact forces in heel-toe running, Clinical Biomechanics, volume 13, issue 7, 1998, pages 521–531, ISSN 02680033, doi 10.1016/S0268-0033(98)00025-4
- T. Clarke, E. Frederick, L. Cooper, Effects of Shoe Cushioning Upon Ground Reaction Forces in Running, International Journal of Sports Medicine, volume 04, issue 04, 2008, pages 247–251, ISSN 0172-4622, doi 10.1055/s-2008-1026043
- B.M. Nigg, H.A. Bahlsen, S.M. Luethi, S. Stokes, The influence of running velocity and midsole hardness on external impact forces in heel-toe running, Journal of Biomechanics, volume 20, issue 10, 1987, pages 951–959, ISSN 00219290, doi 10.1016/0021-9290(87)90324-1
- C. Divert, G. Mornieux, H. Baur, F. Mayer, A. Belli, Mechanical comparison of barefoot and shod running., Int J Sports Med, volume 26, issue 7, pages 593-8, Sep 2005, doi 10.1055/s-2004-821327, PMID 16195994
- SE. Robbins, AM. Hanna, Running-related injury prevention through barefoot adaptations., Med Sci Sports Exerc, volume 19, issue 2, pages 148-56, Apr 1987, PMID 2883551
- RT. Cheung, MY. Wong, GY. Ng, Effects of motion control footwear on running: a systematic review., J Sports Sci, volume 29, issue 12, pages 1311-9, Sep 2011, doi 10.1080/02640414.2011.591420, PMID 21751855
- DB. Clement, JE. Taunton, A guide to the prevention of running injuries., Can Fam Physician, volume 26, pages 543-8, Apr 1980, PMID 21293616
- C. Reinschmidt, BM. Nigg, Influence of heel height on ankle joint moments in running., Med Sci Sports Exerc, volume 27, issue 3, pages 410-6, Mar 1995, PMID 7752869
- Dixon, Sharon J., and David G. Kerwin. "The influence of heel lift manipulation on Achilles tendon loading in running." Journal of Applied Biomechanics 14 (1998): 374-389.
- C E Richards, P J Magin, R Callister, Is your prescription of distance running shoes evidence-based?, British Journal of Sports Medicine, volume 43, issue 3, 2009, pages 159–162, ISSN 0306-3674, doi 10.1136/bjsm.2008.046680
- W. van Mechelen, Running injuries. A review of the epidemiological literature., Sports Med, volume 14, issue 5, pages 320-35, Nov 1992, PMID 1439399
- D. Theisen, L. Malisoux, J. Genin, N. Delattre, R. Seil, A. Urhausen, Influence of midsole hardness of standard cushioned shoes on running-related injury risk, British Journal of Sports Medicine, volume 48, issue 5, 2013, pages 371–376, ISSN 0306-3674, doi 10.1136/bjsports-2013-092613
- Joseph J. Knapik, Daniel W. Trone, Juste Tchandja, Bruce H. Jones, Injury-Reduction Effectiveness of Prescribing Running Shoes on the Basis of Foot Arch Height: Summary of Military Investigations, Journal of Orthopaedic & Sports Physical Therapy, volume 44, issue 10, 2014, pages 805–812, ISSN 0190-6011, doi 10.2519/jospt.2014.5342
- M. B. Ryan, G. A. Valiant, K. McDonald, J. E. Taunton, The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial, British Journal of Sports Medicine, volume 45, issue 9, 2010, pages 715–721, ISSN 0306-3674, doi 10.1136/bjsm.2009.069849
- K. P. Perkins, W. J. Hanney, C. E. Rothschild, The Risks and Benefits of Running Barefoot or in Minimalist Shoes: A Systematic Review, Sports Health: A Multidisciplinary Approach, volume 6, issue 6, 2014, pages 475–480, ISSN 1941-7381, doi 10.1177/1941738114546846
- B. Braunstein, A. Arampatzis, P. Eysel, GP. Brüggemann, Footwear affects the gearing at the ankle and knee joints during running., J Biomech, volume 43, issue 11, pages 2120-5, Aug 2010, doi 10.1016/j.jbiomech.2010.04.001, PMID 20462583
- K. Sekizawa, MA. Sandrey, CD. Ingersoll, ML. Cordova, Effects of shoe sole thickness on joint position sense., Gait Posture, volume 13, issue 3, pages 221-8, May 2001, PMID 11323228
- S. Robbins, E. Waked, J. McClaran, Proprioception and stability: foot position awareness as a function of age and footwear., Age Ageing, volume 24, issue 1, pages 67-72, Jan 1995, PMID 7762465
- Jeffrey Giuliani, Brendan Masini, Curtis Alitz, Brett D. Owens, Barefoot-simulating Footwear Associated With Metatarsal Stress Injury in 2 Runners, Orthopedics, 2011, ISSN 0147-7447, doi 10.3928/01477447-20110526-25
- M. Ryan, M. Elashi, R. Newsham-West, J. Taunton, Examining injury risk and pain perception in runners using minimalist footwear, British Journal of Sports Medicine, volume 48, issue 16, 2013, pages 1257–1262, ISSN 0306-3674, doi 10.1136/bjsports-2012-092061
- Sarah T. Ridge, A. Wayne Johnson, Ulrike H. Mitchell, Iain Hunter, Eric Robinson, Brent S. E. Rich, Stephen Douglas Brown, Foot Bone Marrow Edema after a 10-wk Transition to Minimalist Running Shoes, Medicine & Science in Sports & Exercise, volume 45, issue 7, 2013, pages 1363–1368, ISSN 0195-9131, doi 10.1249/MSS.0b013e3182874769