Damn you injuries! (Photo credit: aaipodpics)
I’ve been part of an interesting email thread over the past few days. I’m not going to discuss any specifics, but the gist of the discussion has revolved around the question of whether shoes can cause running injuries.
The refrain lately in the running community has been that “form trumps footwear” when it comes to running injuries. That is, if you run with “good” form, you can manage to run in just about any pair of shoes. This sounds good and makes intuitive sense, but I think it’s a vast simplification of reality. The other common refrain is “running injures runners,” not their shoes. There is truth in this statement as well, but once again it’s an oversimplification.
So what is it that injures runners. My position is that it is the forces experienced during ground contact that cause running injuries. These forces include passive impact forces that occur at the moment of foot contact, and perhaps even more importantly, the active forces that the body experiences during the remainder of stance phase. If you don’t run, you don’t experience these forces, and thus you won’t suffer a typical running injury. I’m not going to argue at all with that – so yes, running does cause running injuries, but for a runner, not running is rarely a desirable option.
Among people who do run, are there factors that increase injury risk? Absolutely! Studies have looked at this question ad nauseum, and findings are mixed, but the 4 factors which repeatedly pop out as increasing risk include:
1. High mileage
2. Running to compete (i.e., racing and presumably speed training)
3. Limited running experience (i.e., new runners)
4. History of previous injury
These are factors that have been found in epidemiological studies comparing large groups of people. What do all four of these things have in common? Yes, they all involve running, but presumably the people who did not get injured in these studies were also runners. Why is it that these four factors in particular increase injury risk among runners? The answer is quite simple – they all either increase the amount of force applied to the body, or involve a poorer ability to manage the forces that are applied. Higher mileage and greater speed = more force and more wear and tear. New runners = tissues are less adapted to the force that is applied. History of injury = tissues are weakened and less capable of handling force application.
So how does this apply to shoes? When we run a lot of force is applied to the body. With every step we impact the ground with a force equivalent
to approximately 2 to 3 times body weight. To manage the applied forces during stance, our joints compress, our muscles stretch and contract, and our tendons and ligaments tug and rub on surrounding tissues. The average runner takes about 80 to 95 running steps per minute with each foot. Extrapolate that over a thirty-minute run and you are dealing with 2400 to 2850 contacts per foot, per half-hour. That’s a lot of stress to the body!
Now, some runners have no problem handling this amount of force application. They have good structure, good mechanics, good strength, stability and balance. They can run mile after mile without getting seriously hurt because their body works optimally to handle the forces applied. Other people have poor strength, stability, balance, etc. They might have imbalances in structure or muscle strength for example. They might have poor running mechanics. They might have an anatomical abnormality that makes it harder to manage particular types of force applied in particular ways. But here’s the key point – all of these things are force modifiers. They alter how much force is applied at what time during stance, and they influence where specifically forces are applied at the level of tissues. For example, someone with a weak gluteus medius on one side may have a hip instability that causes them to manage forces at the knee in a non-optimal way. This can lead to injury such as ITBS or patellofemoral pain syndrome.
I would group shoes in with all of these other factors as a force modifier because they do alter how forces are applied to the body. They can alter stability, joint torques and the timing and magnitude of force application. They can alter where specifically forces are applied – a good example of this is the increased burden placed on the calf muscles in low-drop shoes. Match the wrong pair of shoes with a runner who is otherwise healthy and the shoes themselves can alter force application in such a way as to precipitate an injury. This can go the other way too – move to less shoe or barefoot, and force application is modified in ways that can be either positive or negative. Which result occurs is highly individual and is dependent on all of the things discussed above (an individual’s inherent strength, stability, structure, etc. – I’d also include past history of shoe wear here). Sometimes runners can adapt to forces over a period of time and new shoe works out fine, sometimes they can’t and the only solution is to ditch the footwear and try something else.
Having myself run in probably more than 75 pairs of shoes over the past 5 years, I can confidently say that there are certain shoes that have caused me pain. My most recent example is the New Balance MT110 – the slanted sole causes my feet to evert excessively just standing in them, and I developed a very tender posterior tibial tendon after a long trail run in the shoes. Never had the pain in any other shoe. Might I have adapted with continued use? Perhaps, but why would I want to adapt to a shoe that causes me pain when there are equivalently built and priced options that don’t cause me trouble? Another example are the Vibram Fivefingers – I often get an ache under my second metatarsal after running long in them, never feel this in other shoes. I suspect it has to do with fit and a resulting reduction in ability of my toes to flex and share the load during take-off (not to mention that the lack of cushion probably increases focal load on the second met head). A third example – before I cut the forefoot band, the New Balance MT10 caused me wicked ITB pain on one side. Never happened in any other shoe, and pain went away after I cut the band. I could go on…
So my point here is that although form seems to be king these days, let’s not forget about footwear (and I haven’t even touched here on the fact that footwear can influence form). Let’s not give shoe makers a free pass to claim user error when a shoe causes a problem. Sometimes the shoe is at fault when a running injury pops up. It may not be all the time, it may not even be often, but to ignore our footwear when it comes to managing pain is misguided. Shoes matter!
You might also like:
Army Study: No Difference in Injury Rates Between Traditionally and Minimally Shod Soldiers
Dr. Mark Cucuzzella’s Reply to Jeff Galloway’s Views on Minimalist Running Shoes and Injuries: Thoughts From a Minimalist Shoe Store Owner
When Shoes Attack (Me): ITB Pain Caused by the New Balance Minimus Trail?
My Interview on Jason Fitzgerald’s Strength Running Blog
About Peter Larson
I had to ditch my NB MT110s too as my ankles hurt after each run. I just wasn’t wiling to risk running in them even more to see if I would adapt. I have the MT10s but I don’t run in them I just use them out and about. I tried running in them but it just wasn’t enough cushion at the time I bought them. I’ve moved to some “transition” shoes and those are working great. I may very well give the MT10s another try when my current shoes wear out as my feet are much stronger than they use to be.
This is a great post and explains what happened to me within the first week of running in Nike 3.0 v.4 – IT pain band. I’d been running fine without ITB pain in my original Nike Free Runs and I switched back immediately, solving the problem.
Good post. Still want to come back to the point that footwear can alter loads in positive ways also. For the vast majority of fun runners this is very pertinent.
I had a pain in one of my toes after running a half-marathon in 1:41 (fast for me) wearing Vibram FiveFingers KSO.
“So my point here is that although form seems to be king these days,
let’s not forget about footwear (and I haven’t even touched here on the
fact that footwear can influence form)”
This. Footwear influences how your foot lands, how it flexes and transitions, which is part of form. Some runners may be able to run in anything, but not all of us, and certainly not I.
G’day Pete, Nice post! As a form guy I do think that running stronger and/or with reasonable form tends to solve more problems than looking at footwear alone. Having said that I agree some shoes are either A. so bad that they cause issues regardless of form and B. those shoes that just don’t suit an individual. Good shoe reviews tend to weed out the former, but trial and error is the best way to eliminate the latter B. grouping. Once onto a good mix of shoes that suit, keep buying in that direction with slight tweaks going forward. Cheers Brian.
Brian – I think we share the same philosophy. My intent was not to diminish the importance of form, but rather to emphasize that all factors need to be considered when it comes to injury, and that shoes are one of those.
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Pete Larson’s Web Links:
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In furious agreement!
The statement that “shoes don’t cause injuries, running does” is as meaningless as the slogan “guns don’t kill people, people do”. I’m pretty confident that anyone who has been running for more than a few years will tell you that running in the wrong shoe can definitely cause injuries. Sometimes after only a single run in them.
Not that the shoe itself directly inflames tendons, tears muscles or fractures bones, but the wrong shoe can cause subtle gait changes that ultimately lead to repetitive stress injuries. Traditional running shoes are a great example. The elevated heels, lack of road feel and arch supports can encourage heel striking, over-striding and long term foot weakness in some runners, eventually leading to a variety of injuries. So yes, it’s form. And yes, shoes affect form.
It seems illogical that the industry would deny this. Since the whole reason cushioned, pronation controlling support shoes exist is to alter form to minimize injuries isn’t it logical to assume that a shoe with the wrong features can alter form to cause them? You can’t have it both ways.
With so many variables I’m not sure research will ever get to the true injury risk. Every shoe is going to have an influence on force distribution and joint mechanics in some way, I don’t think that can be argued. Maybe we can debate the magnitude or importance of that effect, but with such a wide variety in the way shoes are constructed how do you predict what that effect is going to be for each individual?. There’s a lot of variety between different runners in terms of their joint structure, strength, mobility, weight, and running mechanics so like you said some runners are going to adapt well to a particular shoe, and some will adapt poorly and end up injured.
Great article. Sums up what I always say, the right shoe for any one person is the shoe they will actually run in. Trends aside, if one shoe hurts and another doesn’t, go with the one that works. Bad form is something a good coach or even the folks in your run club can help with. Putting on shoes to correct form with no other inputs is no more guaranteed than buying a race car giving you a shot at winning daytona. Form requires study and reprogramming and most of all time.
Well put Walter!
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
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Very good article. I just got done helping coach a junior high xc team – 4 girls, 7 boys – and we made it through the season with zero injuries.
The first day of practice we started working with the kids to try and get them into the right kind of shoes for them. I run in everything from barefoot to “performance stability” shoes depending on the type of running I do and where. We also emphasized form from the first practice- not over-striding, getting up to the mid-foot for foot strike, how to run up and down a hill properly and a dozen other little things.
The point was that we didn’t focus on a single issue to prevent injury but took a global view of the process especially since most of the kids were beginning runners with no idea of good form. About half of them were in the “all knees and elbows” phase of junior high growth too which adds in almost daily adjustments for the growth spurts.
Not every child will be the next Pre or Paula but we want them to run for a lifetime and they need to enjoy it for that to happen. You can’t enjoy running if you’re injured.
Sounds like a great approach, and no injuries is fantastic!
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
Twitter: link to twitter.com
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Great post Pete. I would agree with these sentiments completely. If a “stability shoe” is designed to change the way you move, that it wouldn’t do that in all circumstances. There may not be one perfect shoe, but I would make the case there are certain parameters for footwear that encourage a more natural/efficient/controlled running style.
Conversely a more flexible shoe ,with lower drop and lighter in weight doesn’t fix all the flaws in one’s form. The recipe for creating a better running experience that involves training, form and footwear.
Yes, a multifaceted, open-minded approach is best.
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
Twitter: link to twitter.com
Facebook: link to facebook.com…
The idea that you, admittedly, didn’t touch upon is the one that’s least recognized and, I would argue, most dangerous. At the Monfort Human Performance Lab, former USOC doc, Bill Sands, has you run in every pair of shoes you own, video taping you at 500 frames/second. When you look at your running in each different show, it’s sometimes shocking to see how much your gait is affected by the shoe itself.
And there are MANY more design factors other than heel drop that make the difference.
Another realization that hits you when you see the dramatic variance that shoes make is: Orthotics are bullshit!
More specifically, it becomes clear that the same orthotic in different shoes creates a different effect. If you were going to wear orthotics (and that’s a topic *I* won’t touch upon here), you would need a different pair for each pair of shoes you own… and, ideally, they would need to be made based on how each shoe affects your MOVEMENT, not how you stand on the ground.
All great points Steve! I agree, heel-toe drop is only one of many factors that influence form.
Also agree about orthotics – shoes are basically orthotics, so it makes no sense that the same orthotic should work the same way in multiple different shoes.
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
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I don’t understand why there is such a vehement objection to orthotics in some quarters. I have successfully used orthotics for over 25 years. I don’t wear them in all my shoes and currently only use them in racing shoes. Basically, I race faster with them than without. It’s a tool just like anything else. No one with any sense uses a hammer to do the job of a screwdriver. And no one should see a pair of orthotics as a magic pill to be used all the time. But I want to go faster and orthotics help me do so. Some people run faster barefoot but I don’t compare them to bovine excrement.
I agree, and the reality is that shoes are really just orthotic devices themselves. If they are appropriately designed and used, no big deal.
Packrats… see link to nytimes.com… for some insight into your question.
Orthotics sometimes work for some people, but even after decades of research and billions of dollars spent by consumers, there’s no clear understanding of who will get benefit from what type of device.
In other words, orthotics, by some, are considered no better than a placebo (i.e. a generic Dr. Scholl’s might perform no better than a custom-fitted $500 insole). And those same people resent the cost of an unreliable “solution.”
There are others who have different objections (some biomechanical, some philosophical, some anecdotal) to orthotics. I’m trust that I don’t have to point you to their arguments ;-)
What’s interesting is that you could replace “orthotics” with “running shoes” in every instance in your response and it would be just as accurate :)
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
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Steven, It’s interesting how two people can read the same article and each thinks it supports their point of view. The NYT article, to me, further reinforces the idea that orthotics are a tool just like anything else. Some don’t need the tool and run barefoot. Others like myself find them useful for a specific purpose, and so on. I also agree with what Pete said about replacing the term, “orthotics” with “running shoes” and be just as accurate. You could take it even further and replace “running shoes” with “cross training” or “12 x 400m track intervals at 2000-meter race pace” for that matter. There are people who tell me that I should stop running because it will kill my knees. Just like those who argue against orthotics, they are entitled to their opinion.
I really like the way you are looking at this Pete. Form matters but as soon as we change the circumstances in which our body hits the ground we have to evaluate those circumstances (shoes) for possibly being the cause of injury. If we all ran barefoot then yes, form would be the predominant factor related to subsequent injuries. Once we put shoes on that all changes. I also agree that we shouldn’t give shoe manufacturers a free ride but there are many other factors related to injuries that are often over looked. Diet, sleep quality, stress level, and mental attitude are just some of the things that come to mind for me. I look forward to reading more of your posts of this topic in the future.
Nicely written article as always Pete.
Another factor that I suggest plays an important part in trainer choice is your level of proprioception.
For people with heightened proprioception (be it through specific stability training or otherwise), stability tends to improve when no shoe is worn as the sole of your foot feeds back information to the brain, increasing agility, balance & control. For these people, it figures that a minimilistic shoe will encourage such natural feedback and allow the body to react accordingly to terrain and incline changes. However, if you have low proprioceptive skills, feedback will not be facilitated by a more minimalistic trainer, you won’t be able to manage the ground strike forces, and chances are you will injure yourself.
Conclusion: Your choice of trainer will depend on your proprioceptive skills. Develop these (alongside suitable flexibility & strengthening conditioning) and you could feasibly start to benefit from your body’s natural ability to handle ground forces.
I’d suggest we modify #formbeforefootwear to #proprioceptionbeforeformbeforefootwear, but I fear that would leave us little room for much else!
I can attest to this; I lost my inner ear and had brain damage due to a virus infection, it took me over a year to re-learn how to walk and start “running” again. Plagued with foot and leg injuries (my balance was seriously affected and I kept wobbling) I ditched my shoes out of sheer desperation and it was like the sky opened for me. Going barefoot not only improved my balance significantly, as I could now determine my position in space better with the help of all the sensors on the bottom of my feet, but also helped rewire my brain, perhaps because of all the extra sensory input and subsequent processing. I’m still not out of the woods completely, but if I had not gone barefoot I wouldn’t have improved the way I did.
Sounds a lot like the experience of Deacon Patrick, who I’ve come to know via a forum we both are active on: http://www.mindyourheadcoop.or…
He has severe vertigo but has found that he can run by going barefoot, pretty amazing!
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
Twitter: link to twitter.com
Facebook: link to facebook.com…
Thanks Matt! I know Jay Dicharry talks a lot about this in his book – we often neglect the role of the nervous system, and that is a mistake.
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Pete Larson’s Web Links:
My book: Tread Lightly – link to ow.ly
Blog: https://runblogger.com
Twitter: link to twitter.com
Facebook: link to facebook.com…
I enjoyed reading this very much and I like the neutral stance you took while writing. Shoe selection is definitely specific to each runner but having someone properly educate the runner about what they should be looking for (positive and negative) in a shoe, an overview of running shoe terminology, an educated look at their foot mechanics and tendancies, is an important piece. Hopefully, the person fitting the runner with shoes is as knowledgable and unbiased as you are and can put runners in shoes that fit their individual mechanics acurately.