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Created page with "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 pr..."
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.
=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<ref name="van Gent-2007"/>. It is widely assumed that excessive impact forces, and excessive pronation cause running injuries and shoes are therefore designed to mitigate these problems<ref name="Nigg-2001"/><ref name="HintermannNigg1998"/><ref name="McKenzie-1985"/><ref name="Johnston-2003"/><ref name="Heil1992"/><ref name="Yamashita-2005"/>. This leads to the common recommendation that different types of shoes should be recommended based on a runners arch height. In fact, REI<ref name="www.rei.com"/>, Zappos<ref name="www.zappos.com"/>, Runners' World<ref name="www.runnersworld.com"/>, and Road Runner Sports<ref name="roadrunnersports.com"/> all include this advice.
[[File:The myth of arches and shoe types.jpg|none|thumb|500px|This image probably originated with the "The Running Shoe Book"<ref name="runningshoebook"/>.]]
=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<ref name="Hreljac-2004"/> and these impacts may be an important part of training<ref name="Nigg-1997"/>. 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<ref name="Nigg-1997"/>.
* The impact forces at the heel are not related to the forces at common injury sites such as the ankle, Achilles, or knee.<ref name="Scott-1990"/>.
* A study of 131 runners showed that injury rates were highest in those with the lowest impact levels<ref name="Bahlsen1988"/>.
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<ref name="Hreljac-2000"/>.
* A study of five female runners who had previously had a stress fracture showed higher peak impact forces than subjects without stress fractures<ref name="GrimstonNigg1994"/>.
* 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<ref name="Zadpoor-2011"/>.
=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<ref name="Tong-2013"/>.
* There is also evidence for the opposite conclusion, where high or low arched feet have a lower risk of injury<ref name="Cowan-1993"/>.
* One study found that while injury rates are the same for different arch heights, the location of the injuries varies with arch height<ref name="Williams-2001"/>.
* Another study found that while injury rates are similar for different arch heights, those with low arches had more expensive injuries<ref name="Teyhen"/>. (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<ref name="NielsenBuist2013"/>.
* 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<ref name="Boling-2009"/>. (Note that this study used navicular drop as an indicator of pronation, but other factors contribute significantly to navicular drop<ref name="Mueller-1993"/>.)
* A retrospective study found that arch height was not different between runners who had previously been injured and those that had never been injured<ref name="Hreljac-2000"/>.
[[File:ImpactAndInjuryBahlsen1988.jpg|right|thumb|300px| A graph of peak vertical impact force and the frequency of running-related injuries<ref name="Bahlsen1988"/>.]]
=Running Shoes & Impact=
There is good evidence that increased cushioning does not reduce impact<ref name="Robbins-1990"/><ref name="WrightNeptune1998"/><ref name="ClarkeFrederick2008"/><ref name="NiggBahlsen1987"/>. However, runners who are normally run in shoes have greater impact forces when running barefoot, but this is reversed with barefoot experience<ref name="Robbins-1990"/><ref name="Divert-2005"/><ref name="Robbins-1987"/>.
=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%<ref name="Cheung-2011"/>. This seems unlikely to be significant.
=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<ref name="Clement-1980"/>, but there is little evidence to support this:
* No studies have shown raised heels reduce Achilles (or other) injuries<ref name="van Gent-2007"/>.
* Shoes with the different levels of a drop do not change the range of motion of the ankle during running<ref name="Reinschmidt-1995"/>.
* 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<ref name="Reinschmidt-1995"/>.
* A drop of 15mm or 7.5mm did not produce a significant reduction in Achilles tendon stress<ref name="Dixon-1998"/>.
=Injury Rates & Shoes=
Several studies have found there is no evidence to support the idea that running shoes can reduce injury rates<ref name="RichardsMagin2009"/><ref name="van Gent-2007"/><ref name="van Mechelen-1992"/>.
* A study of 247 runners over 5 months showed no difference in injury rates between firm and softly cushioned shoes<ref name="TheisenMalisoux2013"/>.
* 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<ref name="KnapikTrone2014"/>. 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<ref name="RyanValiant2010"/>. 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.)
=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<ref name="PerkinsHanney2014"/>. Examples include:
** Barefoot running can produce reduce impact forces compared with cushioned shoes<ref name="Divert-2005"/>
** Shoes increase Ground Contact Time compared with barefoot<ref name="Braunstein-2010"/>.
** Compared with barefoot, running shoes reduced the ability to estimate surface angle, with a greater estimation error with thicker shoes<ref name="Sekizawa-2001"/><ref name="Robbins-1995"/>.
* Instances of Metatarsal Stress fractures in minimalist shoes<ref name="GiulianiMasini2011"/>
* 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)<ref name="RyanElashi2013"/>. 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<ref name="RidgeJohnson2013"/>. 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.
=See Also=
* [[Shoes| Running Shoes]]
* [[The Journey to Minimalist Running]]
* [[Toughening Feet]]
* [[Modified Nike Free]]
=References=
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<ref name="roadrunnersports.com">http://www.roadrunnersports.com/rrs/content/choosing-running-shoes/, http://www.roadrunnersports.com/rrs/content/choosing-running-shoes/, Accessed on 26 November 2014</ref>
<ref name="runningshoebook">Peter R. Cavanagh, The running shoe book, date 1980, publisher Anderson World, location Mountain View, CA, isbn 0890371822</ref>
<ref name="Hreljac-2004">A. Hreljac, Impact and overuse injuries in runners., Med Sci Sports Exerc, volume 36, issue 5, pages 845-9, May 2004, PMID [http://www.ncbi.nlm.nih.gov/pubmed/15126720 15126720]</ref>
<ref name="GrimstonNigg1994">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 [http://www.worldcat.org/issn/00219290 00219290], doi [http://dx.doi.org/10.1016/0021-9290(94)90983-0 10.1016/0021-9290(94)90983-0]</ref>
<ref name="Zadpoor-2011">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 [http://dx.doi.org/10.1016/j.clinbiomech.2010.08.005 10.1016/j.clinbiomech.2010.08.005], PMID [http://www.ncbi.nlm.nih.gov/pubmed/20846765 20846765]</ref>
<references/>
[[Category:Science]]
* '''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.
=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<ref name="van Gent-2007"/>. It is widely assumed that excessive impact forces, and excessive pronation cause running injuries and shoes are therefore designed to mitigate these problems<ref name="Nigg-2001"/><ref name="HintermannNigg1998"/><ref name="McKenzie-1985"/><ref name="Johnston-2003"/><ref name="Heil1992"/><ref name="Yamashita-2005"/>. This leads to the common recommendation that different types of shoes should be recommended based on a runners arch height. In fact, REI<ref name="www.rei.com"/>, Zappos<ref name="www.zappos.com"/>, Runners' World<ref name="www.runnersworld.com"/>, and Road Runner Sports<ref name="roadrunnersports.com"/> all include this advice.
[[File:The myth of arches and shoe types.jpg|none|thumb|500px|This image probably originated with the "The Running Shoe Book"<ref name="runningshoebook"/>.]]
=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<ref name="Hreljac-2004"/> and these impacts may be an important part of training<ref name="Nigg-1997"/>. 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<ref name="Nigg-1997"/>.
* The impact forces at the heel are not related to the forces at common injury sites such as the ankle, Achilles, or knee.<ref name="Scott-1990"/>.
* A study of 131 runners showed that injury rates were highest in those with the lowest impact levels<ref name="Bahlsen1988"/>.
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<ref name="Hreljac-2000"/>.
* A study of five female runners who had previously had a stress fracture showed higher peak impact forces than subjects without stress fractures<ref name="GrimstonNigg1994"/>.
* 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<ref name="Zadpoor-2011"/>.
=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<ref name="Tong-2013"/>.
* There is also evidence for the opposite conclusion, where high or low arched feet have a lower risk of injury<ref name="Cowan-1993"/>.
* One study found that while injury rates are the same for different arch heights, the location of the injuries varies with arch height<ref name="Williams-2001"/>.
* Another study found that while injury rates are similar for different arch heights, those with low arches had more expensive injuries<ref name="Teyhen"/>. (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<ref name="NielsenBuist2013"/>.
* 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<ref name="Boling-2009"/>. (Note that this study used navicular drop as an indicator of pronation, but other factors contribute significantly to navicular drop<ref name="Mueller-1993"/>.)
* A retrospective study found that arch height was not different between runners who had previously been injured and those that had never been injured<ref name="Hreljac-2000"/>.
[[File:ImpactAndInjuryBahlsen1988.jpg|right|thumb|300px| A graph of peak vertical impact force and the frequency of running-related injuries<ref name="Bahlsen1988"/>.]]
=Running Shoes & Impact=
There is good evidence that increased cushioning does not reduce impact<ref name="Robbins-1990"/><ref name="WrightNeptune1998"/><ref name="ClarkeFrederick2008"/><ref name="NiggBahlsen1987"/>. However, runners who are normally run in shoes have greater impact forces when running barefoot, but this is reversed with barefoot experience<ref name="Robbins-1990"/><ref name="Divert-2005"/><ref name="Robbins-1987"/>.
=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%<ref name="Cheung-2011"/>. This seems unlikely to be significant.
=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<ref name="Clement-1980"/>, but there is little evidence to support this:
* No studies have shown raised heels reduce Achilles (or other) injuries<ref name="van Gent-2007"/>.
* Shoes with the different levels of a drop do not change the range of motion of the ankle during running<ref name="Reinschmidt-1995"/>.
* 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<ref name="Reinschmidt-1995"/>.
* A drop of 15mm or 7.5mm did not produce a significant reduction in Achilles tendon stress<ref name="Dixon-1998"/>.
=Injury Rates & Shoes=
Several studies have found there is no evidence to support the idea that running shoes can reduce injury rates<ref name="RichardsMagin2009"/><ref name="van Gent-2007"/><ref name="van Mechelen-1992"/>.
* A study of 247 runners over 5 months showed no difference in injury rates between firm and softly cushioned shoes<ref name="TheisenMalisoux2013"/>.
* 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<ref name="KnapikTrone2014"/>. 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<ref name="RyanValiant2010"/>. 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.)
=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<ref name="PerkinsHanney2014"/>. Examples include:
** Barefoot running can produce reduce impact forces compared with cushioned shoes<ref name="Divert-2005"/>
** Shoes increase Ground Contact Time compared with barefoot<ref name="Braunstein-2010"/>.
** Compared with barefoot, running shoes reduced the ability to estimate surface angle, with a greater estimation error with thicker shoes<ref name="Sekizawa-2001"/><ref name="Robbins-1995"/>.
* Instances of Metatarsal Stress fractures in minimalist shoes<ref name="GiulianiMasini2011"/>
* 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)<ref name="RyanElashi2013"/>. 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<ref name="RidgeJohnson2013"/>. 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.
=See Also=
* [[Shoes| Running Shoes]]
* [[The Journey to Minimalist Running]]
* [[Toughening Feet]]
* [[Modified Nike Free]]
=References=
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[[Category:Science]]
