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New Trends in the Prevention and Treatment of Running Injury, and a Healthy Dose of Natural Running

Every once in awhile in life you get the feeling that you are part of something big. Something that might really make a difference beyond just the small pool of people that you interact with on a regular basis. That was how I felt as I sat in a darkened conference room at the National Conservation Training Center on Sunday morning, listening to a recap of what I had learned over the previous two days.

Blaise DuboisAs I indicated in my previous post, I spent the past weekend in Shepherdstown, WV attending a three-day course called “New Trends in the Prevention of Running Injuries.” The course is taught primarily by Blaise Dubois (see photo at left), a Canadian physiotherapist from Quebec City, with assistance from Sean Cannon, a physiotherapist and international level sprint canoe racer. I didn’t get a chance to look through course materials prior to arriving, and as such had little idea of what to expect. However, I figured that any knowledge I could glean about running injuries would be helpful, particularly since I am once again teaching Exercise Physiology this semester at my college. What I left with was near complete validation of just about everything I believe in with regard to running injury prevention and running footwear. I can’t tell you how good it feels to be in a room with a diverse group of forty-some people, including health care professionals, academics, shoe designers, writers, athletes, and form coaches who all largely agree that our current approach to running form and footwear is deeply flawed.

I’ll start by saying that Blaise Dubois is an amazingly good speaker, and that he put an immense amount of work into developing the course (this was the first time it has been taught in the United States). He has the ability to mix humor and hard science in a way that makes his presentation engaging, convincing, and easy to follow, and his command of the relevant scientific literature is impressive. Blaise regularly works with top elite runners in Canada, and as evidence of his level of expertise, he recounted a story about how he once worked with Hicham el Guerrouj. If you don’t know who el Guerrouj is, look up who currently holds the world record for the 1500m or mile. Point being – Blaise has been entrusted to care for some of the best runners in the world, and it was reassuring to hear a highly accomplished physiotherapist talk quite honestly and frankly about the problems with modern shoes and how they alter natural running form. Blaise’s partner in teaching the course, Sean Cannon, also did a great job, and the two have a great back-and-forth and kept things light despite the complex nature of the topics being discussed. If you ever get a chance to attend this course, do it – it’s well worth it (for more info, visit the course website here).

The expertise present in the room wasn’t just limited to Blaise and Sean. Other presenters included Jay Dicharry from the University of Virginia SPEED Clinic – quite possibly the most technologically advanced gait analysis lab in the world (check out this video series on Jay’s lab by Running Times). Dr. Ray McClanahan is a podiatrist at NW Foot & Ankle in Portland, Oregon who prefers to try and restore the foot to its natural state rather than rely on orthotic intervention as a first line of treatment for foot pathologies (he’s also a darn good runner with a 5K PR of 13:56!). Dr. Craig Richards, known best for writing the paper that questioned the role of modern running shoes in injury prevention, flew in from Australia to attend and speak. Dr. Mark Cucuzzella, a family physician from Shepherdstown and owner of the TR Treads Natural Running and Walking Store organized and spoke at the course. Other attendees include Danny Dreyer, form coach and author of Chi Running, Ian Adamson from Newton Running, Jeff Horowitz from Competitor.com, and Peter Vigneron from Runner’s World. The course is geared toward medical professionals, and a variety of physical therapists (many from the military), orthopedic physicians, chiropractors, and personal trainers were in attendance. It was really quite a diverse and highly knowledgeable crowd.

There’s really so much that I could recount from the experience, but in this post I simply want to walk through what I found to be some of the main points that I came away with.

1. Running is good for humans – it has been shown to significantly reduce both mortality and disability risk.

2. Running doesn’t ruin our knees, in fact it might actually benefit knee cartilage over the long term (see this NY Times article for more)

3. Lots of runners get hurt – range is 20-80% depending on the study.

4. Most running injuries are overuse injuries that can be attributed to stubborn and obsessive runners doing too much too soon. In doing this, runners exceed their body’s stress threshold and something gives. The end result is an injury. I write a post largely devoted to the topic of overuse injuries in runners a few months ago.

5. Many running injuries are associated with some kind of change in a runner’s training. Could be a change in shoes, running surface (e.g., running on the treadmill all winter then resuming the same mileage on the roads when it warms up, mileage, volume of speedwork, etc).

6. From pre-1970 to today, running shoes have gotten progressively bigger and bulkier, with lots of added cushion, proprietary “technology”, and raised heels.

7. There is no scientific evidence supporting the efficacy of “big, bulky shoes” (Blaise’s phrase describing the modern running shoe) with extensive cushioning and a large heel lift for the prevention of running injuries. However, we also have no direct evidence that big, bulky shoes cause injuries, or that minimalist shoes or barefoot running are better at injury prevention. More studies are needed!!!

8. Most “technological features” in modern running shoes are likely nothing more than marketing gimmicks designed to appeal to customers and sell more shoes. Little objective and/or publicly available evidence is available to support the efficacy of proprietary technology in shoes.

9. Big, bulky shoes change how we run. They cause us to run in a very different way than we do when we run barefoot, which is how the human body evolved to run (see Lieberman et al., 2010, Kerrigan et al., 2009, and Squadrone and Gallozi, 2009 for some recent examples of how shoes change our gait). In general, barefoot running causes us to run with a shorter, quicker stride and a forefoot landing. Many additional examples of studies looking at barefoot vs. shod gait are available, and a number of them are cited in this post by Phil Shaw).

10. Higher vertical impact loading rates (how fast impact is applied to the body – think punching a wall with your bare fist vs. a boxing glove) have been linked to injuries like lower extremity stress fractures (see this review paper by Zadpoor and Nikooyan, 2011). Conversely, Nigg, 1997 reports results of what appears to be an unpublished graduate thesis suggesting that impact force and loading rate are not linked to injury, and that increased loading rate was actually associated with fewer injuries. However, this analysis looked at short term injuries and did not look at injuries by specific type. I am hesitant when trying to interpret results from research that has not been published in a peer-reviewed journal, and currently am trying to get ahold of the thesis. In contrast to Nigg’s findings, Davis et al. report results of a prospective study in a conference abstract showing that vertical impact peak and vertical loading rate are linked to a higher incidence of running injury. More studies are needed!!!

11. Forefoot striking has been shown to reduce vertical impact peak (many studies, Lieberman et al., 2010 is a recent example) and vertical impact loading rate (Oakley and Pratt, 1988; Williams et al., 2000) relative to heel striking. Data showing no difference between forefoot and rearfoot impact loading rate is out there (e.g., Laughton et al., 2003), but data are limited that involve people well acclimated to multiple landing types. Data on loading rates are sometimes difficult to interpret if runners are not acclimated to a barefoot running style – for example, De Wit et al., 2000 showed dramatically increased vertical loading rate in barefoot runners compared to shod runners, but their barefoot runners were heel striking. One would fully expect a barefoot heel strike to exhibit a higher loading rate since little cushion other than the heel fat pad is present to slow down force application. Lieberman et al., 2010 showed that habitually barefoot runners overwhelmingly land on the forefoot, which suggests caution when interpreting studies of barefoot heel strikers (who were probably unaccustomed to running barefoot).

12. Big, bulky shoes dramatically increase torques on the knee and hip joints compared to running barefoot (Kerrigan et al., 2009). In particular, running in shoes increases a knee varus torque, which forces the leg into a more bowlegged position and compresses the medial portion of the knee (a primary location for osteoarthritis). We don’t yet know the significance of this to injury risk, or how much additional torque is too much. However, if one can avoid torqueing joints by emulating barefoot running, this might not be a bad thing.

13. Simply increasing cadence (stride rate) may provide positive benefits in terms of joint loading. For example, Heiderscheit et al. 2011 showed that running with a faster cadence/higher stride rate (5-10% increase) reduced loading on the knee and hip, allowed for a more level carriage of the center of mass (less vertical oscillation), shortened stride length, and created less braking impulse. Read my post on the Heiderscheit paper here.

14. Studies that have assigned shoes to runners based on static measures of the foot (e.g., arch height, foot posture index) have shown little benefit when shoes are assigned either appropriately vs. inappropriately based on the static measure (Ryan et al., 2010; Knapik et al., 2009; Knapik et al., 2010a; Knapik et al., 2010b). These results show that either static measures are not a good way to assign shoes (so much for the wet footprint test!), or that pronation control is not a good basis on which to choose a shoe. For summaries of this work, read my post on the pronation control paradigm or a great article on the topic from Gretchen Reynolds of the NY Times.

15. Pronation control is not a good basis on which to choose a shoe, and should not be the foundation upon which such decisions are made (as is currently the situation). Read Nigg, 2001 for more. Benno Nigg also just published a book in which he tears apart the pronation control paradigm.

Munson X-Ray16. Our feet are screwed up. Ray McClanahan talked about how our shoes are too narrow, and narrow shoes disfigure the foot. If you look at your foot and notice the big and little toes pointing toward the middle of the foot, it likely means that your foot has molded to the shape of a shoe with a narrow, pointed toebox. The picture at left from Edward Munson’s book “The Soldier’s Foot and the Military Shoe” provides a very visual example of this. He believes that mis-alignment of the big toe compromises our stability and can lead to problems with the running gait. One simple way to see just how narrow your shoes are – take out an insole and stand on it (weight-bearing). Notice how much your foot spills over the sides of the insole. That is the portion of your foot that gets restricted by your shoe.

I could go on, but in the interest of keeping this post from going too long, I’ll stop here for now. As you can see from what I have written above, there is a lot of interesting science out there that calls into question the efficacy of the ubiquitous modern running shoe, and also questions whether how we run might be contributing to high injury rates in runners. There is a lot we don’t know, and studies linking footwear or lack thereof directly to injury are lacking right now – we need more good research!

One of the things that also came through loud and clear is that barefoot running is our default. It is how we evolved, and modern shoes are a change from that default. Thus, the burden of proof should be to prove that we are better off running in big, bulky shoes. People often seem to think that the notion that we should run in a way that emulates the barefoot gait is radical (whether actually barefoot or in minimal shoes), but in reality it’s what our species has done for nearly 2 million years prior to about 1970. Modern shoes have changed that, and the consequences of this change are what we are all trying to figure out. Is barefoot-style better? Maybe, we really don’t know yet, but science regarding impact, joint torques, etc. seem to suggest that a barefoot-style gait moves things in a positive direction. Should you throw away your shoes? If you are running well and have no injury history, there may be no reason to. However, if you have been saddled with injuries, a change to a minimalist shoe and some form work might be of benefit. Blaise and Sean both prescribe racing flats and advocate gait retraining in their clinical practice – I will talk about their form approach in a subsequent post. Due to anecdotal reports from readers, as well as experience with my own wife (a story for another day), I am a believer in their approach. One key point to make here though, is that any change that is made must be:

GRADUAL AND PROGRESSIVE!

Your body is most likely adapted to wearing big, bulky shoes. Rushing into form change or a minimalist shoe too quickly can be a recipe for disaster. Change needs to be approached as a long term process, and the body will need time to adapt. Again, more on their approach in a future post.

I’ll end this post by putting in another plug for Blaise and Sean’s course – it was a phenomenal experience, and one that I won’t soon forget. If you want to read a bit about their philosophy, they have a short book that goes over many of the things that I have discussed in this post – you can order it from their website at: https://secure.therunningclinic.ca/en/runners-information/ebook.php.

Also, check out their recommended shoe webpage – I particularly like the shoes to avoid tab: http://www.therunningclinic.ca/en/runners-information/recommended-shoes.php

If you have any thoughts, comments, or questions, please leave a comment!

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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. Lonnie Styles says:

    Wow Pete, great synopsis of the conference. I too was “blown away” by not only the information presented, but even moreso by the exchange of ideas and knowledge of all those in attendance. The course dispelled some of the myths about gait, injuries, and rehabilitation of injuries. I feel I’m already a better clinician. I’m confident that this meeting of the minds -so to speak- will ultimately lead to a transformation within the running community.

  2. Free your feet!

  3. Thanks, Pete, for the great summary of the course! I just bought Blaise’s e-book and have begun reading it. It is excellent. I’m looking forward to our Runners Roundtable with yourself, Ian, Steve, and Joe to learn more.

  4. Wow, this is my dream conference come true! Any chance that they’re doing another US conference? Looking forward to more analysis, Pete. I’m in a slow transition to less shoe so this is definitely reassuring. Cheers.

    • Pete Larson says:

      Yes, they already have a waiting list going for another US conference. Check
      their website for details.

      PEte

  5. Blazing Bayou says:

    Great, great stuff here, Pete! I was recently turned onto your blog by two of your faithful readers, Tina and Vicki. How I WISH I could have attended that symposium! I just shared your blog article with all of my coaching clients and with about 20 other people. I am so happy that research is finally supporting how my own Dad taught me to run 35 years ago. I trained in racing flats with a midfoot strike since the late 70s. Here’s what’s remarkable. Despite some early years of 50-80 mile weeks (as a high school and collegiate female runner), long races, a marathon…I have never had ONE overuse or running related injury (except clumsiness injuries!). Now I am teaching my own clients to run this way. So good to have research backing me up, finally. Thank you for posting your summary and YES!! I completely agree in the Gradual and Progressive. Thank you for sharing such great info.
    Coach Robin Judice
    http://www.blazingbayou.com

  6. Amazing summary Pete. Glad you were taking notes. My main concern was keeping the coffee supply going and snacks fresh.
    The goal was to ground the meeting in the framework of Evidence Based Practice: “Integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

    Here’s a little philosophy and history that highlights the challenges ahead:
    Challenges:
    “I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.” Leo Tolstoy
    “Don’t confuse me with the facts, my mind’s already made up” unknown
    “I wouldn’t believe this crap even if it were true” unknown
    “When I think back on all the crap I learned in high school, it’s a wonder I can think at all” Paul Simon
    “plural of anecdote is not fact” unknown
    The Way Ahead:
    “A man’s (or woman’s) errors are his portals to discovery” James Joyce
    “Many patients do not want to know very much about their injuries or illnesses- they simply want to be made well. Athletes on the other hand, want to know not only exactly what is wrong, but also why it happened and precisely how soon they will be well again. … The first major difference in treating injured athletes is a need for greater communication and patient education… The second difference is a need for more complete and comprehensive rehabilitation- a subject all but ignored in most medical training programs.” Dr. James Garrick circa 1980
    “If athletes were given less care and more thought, the doctors might come up with some original ideas on why illness persists, why injury doesn’t clear up. If more non-physicians– podiatrists and physiotherapists for instance–could be induced to lend their ideas and talents, we might see a completely new approach to sports medicine.” Dr. George Sheehan 1975
    “Don’t be concerned if running or exercise will add years to your life, it will add life to your years” George Sheehan
    “We are each an experiment of one….Listen to your body” George Sheehan

    And Finally …..“Chase after the truth like all hell and you’ll free yourself, even though you never touch its coat tails.” Clarence Darrow
    Mark Cucuzzella MD

  7. David Csonka says:

    Epic post is epic. Great article Pete, I’m glad we are all able to benefit from you having attended this conference. Thanks!

  8. Amby Burfoot says:

    Pete: Thanks so much for the wonderful summary. It seems that the “loading rate” paradigm is building. It might be nice if you could do a concise post on just this topic, and the best studies that have looked into it. Runners have been trained to understand impact and pronation, which might turn out to be red herrings. Fewer understand loading rate/transient or whatever we should be calling it.

    • Pete Larson says:

      Amby,

      Yes, seems that is an interesting and controversial point right now, and
      most definitely worthy of a full post. I’ll get on it!

      Pete

    • Amby,

      Great comment as that is one area we just do not have real injury data on. We’ll try to see if Jay Dicharry has some clinical experience form his lab…often that is all we have to go on.

      Mark Cucuzzella MD

  9. Sean Cannon says:

    Great post Pete, so glad you enjoyed your weekend. I’ve had a difficult time thinking of anything other than what went on over the weekend since I got back. You summarise very well all the thoughts that came out of Shepherdstown…
    It was great to meet you, hope we all get together again soon.

  10. Did you ever see this Dr. Ray McClanahan video.  It is an excellent explanation of why the toes need to spread out.

    link to youtube.com

  11. Misszippy1 says:

    Thanks for sharing so many details here. I wish I could have sat in on this. There’s so much to learn and apply! Hopefully this meeting was just the start of getting runners to where they need to be for healthier running.

  12. I have personal experience with your second point. I have two “bad” knees, each with a torn ACL (one complete) from earlier sports (lacrosse and volleyball) injuries. At the time the orthopedic surgeon suggested knee strengthening exercises rather than surgery. When starting to run seriously a couple of years ago I figured I would be limited to 5Ks and 10Ks. But I have not been limited in any way by knee pain up to a full marathon, unlike pick-up games in most other sports. Furthermore when I have experienced irritation in the knee it has been from running on soft unstable surfaces (snow, mud), but technical trails which are uneven yet solid do not present a problem. Thus I actually avoid over cushioned shoes, and look for a more solid ride.

  13. Great review, thanks Pete. Keep up the good work.

  14. Annabelle says:

    Pete,

    I wish I could have gone to this event. You’re summary is great! 6 months ago this post would have save me from many hours of reading and searching around for full text articles, and much wasted money on shoes. I still like to rotate shoes and there’s nothing like a fresh pair, but the type of shoe I look for has really changed.

    With a long history of foot, ankle, and hip injuries I am finally able to run 40-60 mile weeks after being stuck in the 20′s or lower for years because of pain.

    I am not perfectly consistent yet but I have gotten much closer to finding my mid-foot and increasing my cadence.

    I would like to put a link to this post on my own blog (http://annabellewinters.wordpr…), if you don’t mind. ?

    Thanks,
    Annabelle

  15. I’m putting together a clinic for ‘broken’ and ‘uncomfortable’ runners, and when it comes to getting non-runners running, I’m developing a rather basic recipe:

    1. You don’t start running by running. You start running by performing stationary exercises to build leg strength, then dynamic exercises to develop/improve the muscle firing patterns needed for running. Simply being able to walk is NOT enough.

    2. The #1 thing that matters in running shoes is HOW THE SHOES FEEL WHEN YOU RUN IN THEM! Unless you are an experienced runner, buying shoes without running at least 1/4 mile in them is foolish. It’s like buying a car without a test drive at freeway speeds. Of course, this requires that you KNOW HOW TO RUN BEFORE BUYING RUNNING SHOES! Which by inference means that we should learn to run WITHOUT running shoes! Huh? What?

    3. Learn to run in a manner where the SHOE DOESN’T MATTER. Let’s get some old-school sneakers, like Vans or Converse, or perhaps some flat deck shoes, with a comfy fit that doesn’t bind the toes. Next, develop the skills needed to run slowly with a high cadence and short stride by starting with stationary running drills. When the legs are ready, start running slowly on a soft surface, such as a football field or a padded track. Slowly build distance until you can run a mile non-stop (however long it takes).

    4. Then go shopping for running shoes. With fresh legs. Try out LOTS of shoes, like 20 pair or so, over several shopping trips. Develop a feel for what shoe features matter, which ones don’t matter, and which ones don’t work for you at all. Take notes, and keep them with you. Buy the cheapest shoe that has no significant faults. If some one-pound over-engineered shoe works for you, then that’s all that matters, isn’t it?

    5. Now we’re ready to gradually add both distance and speed! Within a month or two, your shoe needs will change. Repeat the prior step.

    -BobC

  16. TheRunningGator says:

    Pete,
    Ya know I cannot help but notice how repeated it is that an individual does not go too fast or too far too soon. Why than with that being such a solid knowledge do so many runners just brush it off and try to be the next overnight sensation when it comes to breaking a running record? I have switched to the minimalist style and at times see what my running times are and yes I feel a bit embarrassed. However I have never had pain or injury and over the past couple of years my time is getting faster (even though I have had to train myself to not stress about time). To me I just do not care as much about speed as I do trying to get as many years as I can running. Is it possible that on top of so many problems that are from the actual running gear, that the biggest problems runners run into is their own head?

    http://www.therunninggator.com

    • Pete Larson says:

      Excellent points, and I would probably say that what you point out is
      the primary reason runners get hurt by a wide margin. We are obsessive
      and push ourselves too hard, often ignoring warning signs of impending
      injury. Gear is secondary, our approach to running may be the biggest
      problem.

      Pete

      On Thursday, February 3, 2011, Disqus

  17. Joe Garland says:

    It seems that you enjoyed the programs and I look forward to hearing more about them.

    I’m not clear what you mean by “big, bulky shoes.” Are they all running shoes or simply those that fall beyond certain parameters? Also, while the programs were on injury-prevention, was there a discussion about speed?

    • Pete Larson says:

      Joe,

      This was not a conference about barefoot running. By big bulky shoes, they
      mean most of the shoes you’d find on a typical shoe store wall – the motion
      control and stability stuff with the big heels and lots of cushion. The idea
      is that most people will necessarily run in shoes, so how can we make that
      sustainable if they run into injury trouble. Performance was not really a
      topic that was discussed much since the course is oriented toward health
      care providers. Lots of PTs and docs who regularly deal with broken runners
      and are trying to get them back on the road.

      Pete

  18. Pete,
    It was nice to meet you briefly on Friday. I really enjoyed the panel. If Mark puts this on again, I think I’ll stay for the whole thing!
    Owen

  19. Andrew W. Lischuk says:

    Really in depth, great discussion. Wish I was there. Looking forward to more on the topic. Wonder if you’d be willing to post a “training” schedule for those who are trying to make the transition to a minimalist style. I know your past posts have alluded to it, but something in the form of a weekly schedule would be great. Looking forward to more commentary.

    • Pete Larson says:

      Andy,

      Thanks, and I will have something coming on your question soon. There aren’t
      really any firm “plans” so to speak, but many approaches. We’re all a bit
      different in our adaptation process and stress tolerance, so it is really
      incumbent on a person making a change to listen to their body and proceed
      with caution.

      Pete

  20. Greg Strosaker says:

    Great summary, thanks Pete. The key point of making changes gradually is one that most of us struggle to remember, due to the natural impatience to see progress. I am as guilty as any, and am temporarily paying the price. Thanks for the reinforcement of the lesson I learned the hard way.

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