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The Pronation Control Paradigm is Starting to Crumble: Review of a Study in the British Journal of Sports Medicine

Adidas shop in Tokyo, Japan (description at fl...Image via Wikipedia

When you walk into a running shoe store, you are typically faced by a wall of colorful, “high-tech” shoes that are neatly grouped into three categories (sometimes four if “cushioned” is included as a distinct category). These categories are: neutral, stability/support, and motion control. How do you choose which shoe is right for you? Well, you might run across the store or on a treadmill for the salesperson, who watches you with an apparently slow-motion equipped eyeball (or if you’re lucky, you get filmed), and they diagnose you as a severe or mild overpronator, a neutral runner, or a supinator. Quick definition – pronation is simply the inward/medial roll of the foot that occurs upon footstrike, whereas supination is when the foot rolls outward rather than inward. Alternatively, they might scan your foot in some way to assess your arch height. One way or another, the goal is to assign you to a shoe from one of the aforementioned categories – high-arched supinators get cushioned shoes, severe overpronators with flat feet are placed in motion control shoes, mild overpronators are placed in stability/support shoes, and neutral runners are placed in neutral shoes. They then bring you a selection of shoes from the appropriate category, you try them on, and you choose the one that feels best. This is the way that it has been done for quite some time, and nearly every shoe manufacturer makes a selection of shoes that fits neatly into one of these groups.

What would you say, however, if you found out that these categorizations of running shoes were meaningless? What if the tests employed by the salesperson weren’t very good at determining pronation to begin with? Even more startling, what if the amount that you pronate wasn’t even related to the likelihood that you might get injured? These are the types of questions that have been addressed in several recent scientific publications, and which were in turn summarized and reported on in a remarkable article by Gretchen Reynolds on the NY Times Well Blog. The results might be shocking to some, not so shocking to others, and they demand a response from those making the shoes that runners rely on to keep them running safe and injury free.

Lets take a look at some of the science. In this post I’m going to focus on a study published on-line in June 2010 by Ryan et al. in the British Journal of Sports Medicine. One of the co-authors of this study, Gordon Valiant, works for the Nike Sports Research Laboratory – he’s the same biomechanist that Alberto Salazar and Dathan Ritzenhein worked with to modify Ritzenhein’s footstrike from heel to midfoot. Keep this in mind as you read this – one of the co-authors works for the biggest sports shoe manufacturer in the world. In their introduction Ryan et al. state the following surprising detail: “…despite over 20 years of stability elements being incorporated in running footwear there is, as yet, no established clinically based evidence for their provision.” They then go on to point out that “Motion control running footwear has yet to be proven to prevent running-related injuries.” Pretty amazing, isn’t it? Makes one wonder if the shoe makers actually have “proprietary data” supporting these designs, or if the whole pronation-control shoe paradigm is nothing more than a giant marketing gimmick.

Their goal in the study, therefore, was to determine how women assigned to the three categories of footwear based on their observed degree of pronation would fare in terms of pain and injury experienced while training for a half marathon.

A total of 105 women were classified as either neutral (51 women), pronated (36 women), or highly pronated (18 women). Now here’s the really interesting part. In a shoe store, the neutral women would be assigned a neutral shoe, the pronated women a stability shoe, and the highly pronated women a motion control shoe – go it? In the study, however, the researchers took each of the three groups of women (neutral, pronated, and highly pronated), and subdivided them into sub-groups so that one-third would get a neutral shoe (Nike Pegasus), one third would get a stability shoe (Nike Structure Triax – incidentally, the Triax was my first “real” running shoe, assigned by one of those slow-motion eyeballs I mentioned earlier), and the final third would get a motion control shoe (Nike Nucleus). This was done for each of the pronation groupings, so that what we have here is some women in each pronation category wearing each type of shoe (i.e., many of them wearing the “incorrect” shoe for their foot).

The women in the study were then sent off to take part in a 13-week training program to prepare for a half-marathon to be run in Vancouver, BC. Estimated weekly training volumes started around 20km and rose to a peak of about 40-45km. Over the course of the training program, researchers recorded the number of missed workouts due to injury by each runner, and reportings of pain at rest, during daily living, and following runs. Ultimately, only 81 of the women wound up completing the study (for a variety of reasons, 24 women dropped out).

The results showed the following:

1. 32% of the women missed training days over the course of the study. Another way to think of this is that there was an injury incidence of 32% in this population of runners, which is in line with other studies on running injury.

2. Motion control shoes “resulted in both a greater number of injured runners and missed training days than the other two shoe categories.” In other words, motion control shoes faired very poorly all-around.

3. Every runner in the highly pronated group who wore a motion control shoe reported an injury. In other words, all runners (yes, 100%) who were supposed to be wearing a motion control shoe based on their degree of pronation got injured. It’s a small sample, but this is simply astonishing. In fact, highly pronated runners actually fared better in neutral shoes!

4. Neutral runners experienced greater pain after runs when wearing neutral shoes than they did when wearing stability shoes. Although the authors point out that the difference may not be clinically significant, it is once again amazing that neutral runners faired better with a shoe that would not have been “prescribed” for them in a shoe store based on their degree of pronation.

5. Pronated runners experienced more pain after runs if wearing a stability shoe than if wearing a neutral shoe. Again, they did better wearing the “wrong” shoe for their feet.

So what can we conclude from all of this? First, although they have an admittedly small sample, it appears that motion control shoes offer little benefit, and in fact are more likely to cause pain and injury than any of the other shoe types. That fact that every single severe overpronator exprienced an injury in their motion control shoes begs the question of why anybody would use them? The authors themselves conclude that “This study is unable to provide support for the convention that highly pronated runners should wear motion control shoes.” Interestingly, Christopher McDougall indicated recently on his blog that the life of the motion control shoe might soon be coming to an end.

Second, this study showed that neutral runners did better in stability shoes, and pronated runners did better in neutral shoes. Try to make sense of that one…

So what do the authors themselves conclude? The final sentence of their paper states: “Current conventions for assigning stability categories for women’s running shoes do not appear appropriate based on the risk of experiencing pain when training for a half marathon.” More clearly, they conclude their abstract with the telling statement that “The findings of this study suggest that our current approach of prescribing in-shoe pronation control systems on the basis of foot type is overly simplistic and potentially injurious.” Now wait a second. If this is true, then why does almost every shoe store on this planet classify shoes based on pronation control (i.e., neutral, stability, motion control, etc…), and place runners in shoes based on their arch height (more on arch height in another post to come soon) or degree of “observed” pronation? This is bewildering stuff, and further strengthens my belief that maybe it’s time for a change in how we choose or “prescribe” our shoes.

I’ll finish by relating a few quotes from Dr. Ryan, the lead author of this amazing study, as reported by Gretchen Reynolds’ on the NY Times Well Blog. When asked how to choose a running shoe given his experimental results, Ryan says (and recall that his co-author is a biomechanics expert at the Nike Sports Research Laboratory – I give Nike a lot of credit if they signed off on publication of this paper, though I have no idea if they had any say in the matter):

If a salesperson says you need robust motion-control shoes, ask to try on a few pairs of neutral or stability shoes, too…” “Go outside and run around the block” in each pair. “If you feel any pain or discomfort, that’s your first veto.” Hand back those shoes. Try several more pairs. “There really are only a few pairs that will fit and feel right” for any individual runner… “My best advice is, turn on your sensors and listen to your body, not to what the salespeople might tell you.

That last quote is right on the money – “turn on your sensors and listen to your body.” Your body evolved to run long distances, and it evolved to do so barefoot. The realist in me knows that most people will likely never run barefoot, so if that’s not your thing, look for as little shoe as you can handle and still run comfortably. Your body will let you know if it’s happy, be mindful and listen.

Update 7/23/2010: I just published a follow up to this post: What is Nike Doing?: Speculating on a Shoe Market in Motion

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About Peter Larson

This post was authored by Peter Larson. Pete is a recovering academic who currently works as an exercise physiologist, running coach, and writer. He's also a father of three and a fanatical runner with a bit of a shoe obsession. In addition to writing and editing this site, he is co-author of the book Tread Lightly, and writes a personal blog called The Blogologist. Follow Pete on Twitter, Facebook, Google+, and via email.

Comments

  1. Triplet3sandra says:

    As a physical therapist serving US Army soldiers, I am fascinated by the latest information coming out about what NOT to recommend for our soldiers.  I am becoming a huge fan of the minimalist shoe, and am beginning to find that the soldiers that I serve, are discovering the JOY and the reduced pain from running in minimalist shoes,even those with severe pronation! More studies!  We need more studies! :) Thanks for sharing

    • Pete Larson says:

      Are minimalist shoes popular among the soldiers you see?

      • Triplet3sandra says:

        Minimalist shoes are becoming more popular, and the Vibrams are among the favorites. Since the local commander can determine whether or not the five-finger shoes are allowed, their wear is not widespread.  I am putting together an exercise sheet with recommendations for our soldiers, in celebration of National Physical Therapy Month, as the transition to minimalist shoes requires a different demand on the body than tradional shoes. I have found that the new line of minimalist shoes without toes (toe shoes are not allowed on the Physical Fitness test) are growing in popularity, as word spreads about the reduction in shin, knee, ankle, and foot pain.  If anyone finds any other studies out there that support the wearing of minimalist shoes, I would love to see it.  If I find others who are DOING the studies, I will post as well. Thanks again!

        • I’ve understood that there’s a follow-up study going on (by the same Dr. Ryan), where three neutral shoes with different cushioning and stability are compared: the Nike Pegasus, Nike Free 3.0, and VFF Bikila. 100 runners have been randomly assigned to the shoes and are training 16 weeks for a 10K event. Here’s more info:

          link to youtube.com

          The study started in August so we’ll probably get the results next year. This will be very interesting, since no such studies have been done before!

  2. I think one of the things worth noting is that while there may be work in the background to phase these types of shoes out, the overall perception by the general public is one of “well, I’ve always needed to wear support shoes – that’s what I’ve always been told”.

    Even if the shoe companies start to slim down the number of pronation control options, they’re still going to make the shoes – because realistically, they’re a business, and while many people will try minimal shoes, many others will refuse the idea. All it takes is one MBA to shoot down the push from a whole team of biomechanics folks.

    …which is why great posts like this are even more important. Fantastic stuff Pete.

  3. Dan (Milan, NH) says:

    Awesome post, Pete. Wow, were we all suckers or what?! Now I’m 100% positive my switch to bare-foot/minimalist running was the right decision.

    • Pete Larson says:

      Pretty amazing, isn’t it. Don’t see myself going back to stability shoes
      anytime soon.

      Pete

      • Dan (Milan, NH) says:

        I have fairly high arches so I’m “supposed” to use neutral shoes. I didn’t like all the cushioning so I ran in stability shoes. Now I’m almost 100% switched over to my VFF KSO’s. The funny/sad thing is I just bought a new pair of Asics GT-2150s a week before my KSO’s. I’ve used them twice…

  4. Klara Smith says:

    I am a supinator. My feet roll to the outside. About 10 years age, at age 59, I began experiencing knee pain while walking. In an article by a sports doctor, I read that you can develop knee pain from walking crooked and I have been “walking crooked” all my life. First, I went to the drugstore and bought a pair of Dr. Scholl’s orthotics – small heel inserts that keep your feet straight. The knee pain vanished. Now I wear Nike Air Pegasus(26) athletic shoes. They have built-in orthotics that keep your feet straight. I call them my “Magic Shoes”. I experience no knee or hip pain whatsoever while wearing them.

  5. rideforever says:

    One scientist tells you to wear this shoe.

    One scientist tells you to wear that shoe.

    How stupid are you ? They have turned you into a cash cow and each new invention is just a way of milking you.

    Around here it’s hard to find a runner who hasn’t got a mobile phone strapped to their forehead, and wearing 300 dollars of high-tech space shuttle textiles.

    I thought running was to get away from this ?

  6. Skora Running says:

    Skora minimalist running footwear launches in 2011.

  7. Well well well. I think that it is time for me to get rid of those heavy stability shoes! This is good news for me, I always disliked being forced to buy a select type of shoe and was very suspicious about taking advice from salespeople. Freedom!

  8. Mike Williams says:

    Would the results of this study be any different if they had used men and women?? As a faster runner, it’s very hard to find light shoes with stability.

  9. Paul Fiolkowksi says:

    Those were some good points. The motions in the foot affect the entire lower extremity. The kinetic chain is interlinked, forces transmit all the way through the skeleton. Malalignment of the forefoot-rearfoot is not just the cause of overpronation (and I use that term cautiously)can cause shin splints, knee pain and even low back pain.

    regards
    Paul
    http://independent.academia.ed

  10. gold coast hypnosis says:

    The terms used to describe these foot motions are pronation and supination. These are complex motions taking place in the joints of the foot and lower ankle …

  11. Hmmn, but there is a lot of difference in hip articulation in femal vs male runner, not to mention ratios of mass vs foot area. A study including male runners is surely vital. And yes, of course one involving larger numbers….

  12. Davide1114 says:

    Wondering also to what degree the level of cushioning and heel-to-toe ratio had to do with performance. I submit a flatter, firmer neutral shoe is more stable than a cushy, higher heeled neutral shoe.

    • Pete Larson says:

      Yes, it would be great if a study like this included something like the Free
      3.0 and maybe a flat like the Waffle Racer VII. Problem is that everyone is
      used to wearing shoes with big heels and lots of cushion, so soreness is
      almost a given in something less during an initial transition. You’d have to
      give people a transitional program prior to starting a study like this, or
      run it for a much longer period of time.

      Pete

  13. andy-1967 says:

    Once “they” realise that running stores have been selling shoes under false pretences, do you think we could kind of sue them? :-)
    - Be great if we could though, wouldn’t it?

    I know with the banks in the UK they are paying out on the PPI claims because insurance was miss-sold, amounts to the same thing doesn’t it? Being sold something under false pretences. Bit hard to prove a running shoe could be the cause of an injury but we could have the shoe companies for selling under false pretenses (what do you mean, no?) – Didn’t Vibram get sued for having misleading information about their shoes?? Ummm…

    Andy from
    http://www.myrunningtips.com

  14. Steve23 says:

    Given the highly unusual nature of the 100% injury rate- I would think that additional study is needed. Of course that won’t stop the barefoot/ miminalists zealot from declaring victory. Furthermore since NO study exists showing decrease of injury rates of minimal barefoot running, it is a leap to say this study means everyone should go barefoot.

    • yeah man what are you saying?
      trying to bag on the barefoots are ya?
      you sir are a troll.

    • Pete Larson says:

      The point of the study is only that choosing a shoe based on your degree of
      pronation doesn’t seem to have much benefit. It doesn’t say everyone should
      go barefoot. Although I have tried it, I’m not a barefoot runner by any
      means, I just think people need to be better informed about what they are
      paying for when they buy a shoe so that they can make a more informed
      decision.

      Pete

  15. Paul Paulino says:

    this is really a great read . . . ive been following your blog lately and ive learned alot from it and ive even followed your twitter . . . my first running shoe is nike lunar avants and that was what the store recommended to me . . . funny thing is im not using it anymore because it makes the inner arc of my foot painful (like being hit by a hammer) after running in it for more than 5kms . . . ive then switched to an nb739 and a fila dna . . . what suprises me is that ive run better in the fila dna (which i presume nobody knows because its so under the radar) than in the nbs . . . the fila dna is a minimalist and i bought it without knowing it was a minimalist shoe . . . and now ive bought another flats which is the green silence and im enjoying both of them . . . from now on i think ill be only using racing flats which lessens the pain i feel on my foot which is quite odd since racing flats should have less cushioning compared to others . . .

    • Pete Larson says:

      Go with what works – if no pain in flats, then stick with them. I’m
      curious about the FILA DNA, never heard of those.

      Pete

  16. Interesting study and a great post about this important topic. Time and money are both precious – so it is hard for the average runner to experiment… more studies of this kind will be telling indeed.

  17. Justaguess says:

    I think things will change in the running shoe world when this type of data leaves the blogs and enters a magazine like Consumer Reports. This may take another year of data to come out, but once Consumer Reports says that running shoe stability is calculated wrong or is wrong altogether (whatever it ends up being) things will change.

    • Pete Larson says:

      What I’m curious about is just how many runners even pay attention to these
      categorizations to begin with. Hardcore runners do, but does the everyday
      person who runs just once in awhile for exercise? My gut is that people
      buying shoes at a big box sporting goods stores probably just choose what
      looks best without much help from salespeople. Would be a great topic for
      Consumer Reports.

      Pete

  18. Oaknortons says:

    I am fairly confident that the army study does not no the structural parameters of a motion control shoe and this entails knowing the vertical firmness of the midsole under the calcaneous to provide intrinsic rearfoot stability and extrinsic midfoot stability.Midfoot stability is also of secondary importance and is calculated by measuring the torsional structure of the midsole.You might want to visit http://www.opistest.com.No study can be valid without this information.

    • Pete Larson says:

      The Air Force and Marine Corps studies both used the New Balance 587
      as the motion control shoe, which after checking out OPIS as you
      suggested, is the second most stable shoe in the OPIS rankings.
      Pete

  19. Jamoosh says:

    It certainly seems that the technology behind running shoes is a myth with respect to injuries. The last time I went shopping for shoes I told the salesperson (“expert”) I wanted a lighter nuetral shoe that promotes running like “this” (“this” being more of a midfoot strike) not one to compensate for my current (horrible) form.

  20. I’m female & neutral/slight pronator/whatever/but no flat feet. and I got close to getting injuried in motion control shoes (don’t ask why I bought motion control shoes). stabiliy shoes didn’t cause such issues

  21. Kind of makes be glad I’ve always ignored pronation when shopping for shoes. I simply go by feel and 90% of the time, it’s worked out great.

  22. I forgot to add: as for minimalist shoes, doesn’t yet work for me on concrete… trails are fine of course. maybe later I’ll get strong enough for running in minimalist shoes on concrete.
    so, I’m not very minimalist but when I was told to try cushioned shoes (when analysis showed normal feet), I tried & disliked those shoes and just went and bought more pairs of stability shoes :))
    PS: haven’t tried barefoot running, so no opinion on that one.

  23. very good review

  24. Kenskier says:

    This is astonishing. 100% of highly pronated women who wore a motion control shoe reported an injury??!!! You couldn’t hurt a higher percentage of runners if you put gravel in their running shoes! I hope this experiment is replicated on a much larger scale, by researchers unaffiliated with the shoe industry.

    I do have one question, though. Your post says “32% of the women missed training days over the course of the study. Another way to think of this is that there was an injury incidence of 32% in this population of runners.” Did these women say they missed training because of an injury? Because if they did not say that, I think it’s a leap to assume that every missed day of training was missed due to an injury. They might have had family or work obligations, or any of a 1000 other reasons, for missing training. Not that this affects the significant results of the study. But I think it’s important to note that missed training days do not necessarily indicate injured runners.

    Great work, as usual!

    • Pete Larson says:

      Ken,

      Yes, 32% missed training due specifically to running-related pain. Here’s
      the quote from the results: “*One hundred and ninety-four missed training
      days due
      to running-related pain were reported by 26 individuals throughout the
      13-week training period, amounting to 32% of the study cohort …*” Most of
      those who missed training for other reasons were omitted from the study,
      hence the final sample of 81 compared to the starting sample of 105.

      Pete

      • Pete:

        I am a longtime reader of your blog. Awesome job. This article on pronation is very timely. I began running about a year ago at age 41 (no prior competitive experience) and, since I was starting slowly, I decided to start “minimal”. I have run about 1000 miles over the last year and 700 were in a pair of red Nike Free 5.0s (the other miles were in a 10 year old pair of Nike Air Pegasus). I have had zero injuries since I began training and I am up to 40 miles a week or so. I have recently retired the 5.0s and moved to 3.0s. I have no idea if I pronate, supinate, have high arches etc…as you stated above, I go to a big box store and buy shoes with no expert analysis.

        The other day I went and actually had a gait analysis done at a very good running store. Treadmill, pressure pads, video tape..the whole works. I find out I have somewhat high arches, I pronate (somewhat), my feet point out when I run (somewhat), I am right foot dominant (more weight on right foot based on pressure pad analysis) and one foot is 1/2 size larger than the other. The recommendation? Stability shoes even though I have been running almost exclusively in Nike Frees injury free for over a year.

    • Pete Larson says:

      Ken,

      I’ll add this – the fact that an industry affiliation is included among the
      authors makes the conclusions carry even more weight in my mind. Very
      interesting stuff…

      Pete

    • Pete Larson says:

      Ken,

      I’ll add this – the fact that an industry affiliation is included among the
      authors makes the conclusions carry even more weight in my mind. Very
      interesting stuff…

      Pete

  25. Churylo says:

    I used to run in Brooks Beast and now run in NB 904 lightweight trainers. No injuries after 750 miles and new PR’s in every race distance. But, I have a wide foot. The 904′s have been discontinued and I am looking at the 905′s. Any recommendations on a minimalist shoe in wide widths? 4E preferred.

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  1. […] injuries. This couldn’t be further from the truth (and luckily I never picked up a pair). Motion control shoes have actually been shown to cause injuries as opposed to preventing them. However, this doesn’t stop people from buying them and running stores from recommending […]

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