Barefoot vs.

Shod Running: An Evidence-Based Review of Ground Reaction Forces at Initial Contact

Ryan Johnson, MS, DPT(c) PT 209-910

Clinical Problem:
Currently there is a significant lack of knowledge surrounding efficient running
What running patterns are most beneficial? Is a heel strike really the best and most healthy running pattern? What are the effects of footwear? How can physical therapy assist runners to reduce injury and increase performance?

Significance of Problem: Growing Trend

Number of PEOPLE interested in BF running
(Fitzgerald M, 2010)

Number of PATIENTS interested in BF running

Physical Therapy Relevance:

Clinicians need Knowledge
Research provides clinicians with an understanding of the biomechanics behind different running patterns

Clinicians are able to make evidencebased decisions for each patient

Physical Therapy Relevance:

Researchers need Inspiration

Clinicians synthesize knowledge to make clinical decisions

Pose questions to researchers to stimulate future studies

Purpose of Review
Compare Shod vs. Barefoot (BF) Running through analysis of Ground Reaction Forces (GRF)

http://www.youtube.com/watch?v=9itkEkcQ8WM&feature=related

Theoretical Constructs
Repetitive impact forces through the body may be detrimental (landing hard after a jump or when stepping off curve, working all day with a jackhammer, FOOSH, etc.).
(Sangha et al. 2000; Hewett et al. 2005; Hreljac et al. 2004; Schamberger et al. 2002)

http://c.photoshelter.com/img-get/I0000KnYFMTjp0dg/s http://gallery.photo.net/photo/3069741-lg.jpg

Theoretical Constructs
The ground reaction force (GRF) upon impact, is considered to be the most basic element which causes running related injuries.(Robbins et al. 1987)

http://jpthermt.com/wp-content/uploads/2010/07/running-injury.jpg

Theory behind BF Running

Current scientists, paleontologists, anatomists and physiologists have been challenging traditional knowledge on running biomechanics Daniel E. Lieberman, PhD Irene Davis, PhD, PT, FACSM Madhusudhan Venkadesan, PhD Mark Bishop, PT, PhD, CSCS Craig Richards, PhD R. Squadrone
http://static.technorati.com/11/02/04/26399/wo man-running221.jpg

Theory behind BF Running

Hypothesizing that landing on the mid-foot rather than a heel-first strike may:
Conserve energy Reduce impact transient forces
(Liberman DE et al., 2010)

Anatomy and Theoretical Constructs

http://www.carifinonline.com/wp-content/uploads/2010/01/heel-strike-compare.jpg

http://www.ceessentials.net/images/critiqueLowerExtremity/image216.jpg

Proposed Benefits to BF Running

The following have been postulated as possible benefits to BF running:
Decreased VO2 consumption Increasing the strength of the ligamentous and muscular support of the arch Increased proprioception Decreased risk of lower extremity injury, including: Lateral Ankle Sprains Plantar Fasciitis Medial Tibial Stress Syndrome Etc.
(Hanson et al. 2011; Squadrone et al. 2009; Jungers et al. 2010; Robbins et al. 1989; Divert C, 2005; Divert C, 1985; Warran et al. 1987)

And Lastly.
It has been proposed that BF running can decrease the transient ground reaction force experienced at initial contact (Liberman et al., 2010)

http://www.stgeorgerunningcenter.com/wp-content/uploads/2011/05/running-barefoot.jpg

Background
Have running shoes ever been proven to reduce the risk of injury? Answer
No There has never been a peer review article published which showed a statistically significant reduction in injury rate for those individuals wearing shoes. (Richards et al., 2008)

Background
Are running related injuries a serious problem in the medical community? Answer:
Yes every year 65-80% of all runners suffer an injury. (McDougall, 2009; Warran et al. 1987)

Terms Defined
(Impact Transient)

Passive Peak

Active Peak

GRF at initial contact (IC-GRF)

Ground Reaction Forces (GRF)

Terms Defined

Heel Strike (HS) or Rear Foot Strike (RFS)

http://4.bp.blogspot.com/_JadSUXnX75Q/S3aD2iNRnsI/AAAAAAAAAT8/sl 8pbmfVQ70/s320/heelstrike.jpg

Non-Heel Strike (NHS) Mid-foot/ Forefoot Strike (FFS)

Gap in the Literature

There has never been a systematic review or meta-analysis addressing the relationship of IC-GRF to both shod/BF and location of first contact.

http://www.superstock.com/stockphotos-images/1598R-38363

QUESTIONS
Primary:
While running, what are the differences in IC-GRF between BF and shod conditions?

Secondary:
While running, what are the differences in IC-GRF between HS vs NHS running patterns?

Both are background questions

Hypothesis & Null Hypothesis

H0:
There is NO statistically significant difference in IC-GRF between:

HA:
There IS a statistically significant difference in IC-GRF between:

1) BF and Shod running conditions 2) HS and NHS running patterns

 Databases (number of results)

PubMed (43) CINAHL (17)

Search Procedures

Search Terms:

barefoot running running barefoot run barefoot jog barefoot barefoot runner(s)

Dates included in search: 1980 2011

Last search performed: April 30th, 2011

All articles were reviewed against the following criteria Inclusion Criteria
1. Must measure GRF with a force plate or 3D force transducer treadmill** 2. Must compare BF running to Shod running 3. Subjects were normals or athletes with no pathology present 4. IC-GRF data must be available

Exclusion Criteria
1. Articles written in languages other than English 2. Only abstract was available 3. Subjects were less than 16 years old 4. GRF data was not able to be correlated with body weight of subjects

**(Low et al., 2010; Mainwald et al., 2008; Belli et al. 2001)

Secondary reviewer confirmed that the 7 studies met the inclusion criteria

All studies: level of evidence 2b

Summary of Included Studies

Statistics
BF vs. Shod running IC-GRF
Effect Size Calculated

Primary Question
High Q-Statistic

Random Effects Model

Recalculated

Results
Barefoot vs. Shod
Random Effects Model

Effect Size: -1.72 Large Effect Size CI (-3.41, -0.04) Significant

Q-Statistic 121.92

Statistics
HS vs. NHS running patterns IC-GRF
Evaluate for difference between HS and NHS means Secondary

Question

z-test

z-test comparing HS and NHS

Heel Strike
Study Hammill et al. Lieberman et al. Squadrone et al. Divert et al. Baur et al. De Wit et al. Dickinson et al. # of HS Subjects Mean 10 26 8 35 14 9 6 1.59 1.74 1.72 1.70 1.62 1.9 1.39 HS SD 0.31 0.45 0.4 0.03 0.15 0.3 0.67

Results

Non-Heel Strike
Study Hammill et al. Lieberman et al. Squadrone et al. # of NHS Subjects Mean 10 26 8 1.40 0.58 1.62 NHS SD 0.31 0.21 0.4

BW IC-GRF Mean HS: 1.67 Mean NHS: 1.20

z-test comparing HS and NHS

Results

Z-test: (95% CI) Upper CI: 0.85 Lower CI: 0.08 Statistically Significant Difference

HS
1.67

NHS
1.20

Results:
H0:
1) There is NO statistically significant difference in IC-GRF between BF and Shod running conditions 2) There is NO statistically significant difference in IC-GRF between HS and NHS running patterns

Discussion
1. Significant heterogeneity of data 2. Possible causes for reduced IC-GRF 3. Implications of reduced IC-GRF

http://www.runningnut.com/wp-content/uploads/2010/09/barefoot-runner.jpg

BF/Shod Comparison - Number Sample ofSize Strides Difference Measured

This image cannot currently be displayed.

Discussion

Discussion BF/Shod Comparison

Possible Explanations for Heterogeneity of Data Distance run during data analysis
6.5 meters vs. 1.2 kilometers
http://farm5.static.flickr.com/4012/4311804925_32cebc0631_o.png

Experience of Barefoot Runners

Adaptations to BF running could take several weeks
http://100daysofmadness.com/wpcontent/uploads/2010/11/Son-Running-Barefoot.jpg

(Robbins et al. 1987, 1989 and 1993)

Discussion BF/Shod Comparison

Possible Explanations for Heterogeneity of Data

Experience of Barefoot Runners

De Wit et al. utilized only habitual shod runners in both BF and Shod conditions
Smaller ES (-0.33)

http://communities.canada.com/calgaryherald/blogs/calgaryrunner/archive/2010/07/07/rac e-preview-canadian-mountain-running-championships.aspx

Discussion BF/Shod Comparison

Possible Explanations for Heterogeneity of Data

Experience of Barefoot Runners

Squadrone et al. utilized experienced BF runners in both shod and barefoot conditions
Smaller ES (-0.25)

http://www.barefootrunning.fas.harvard.edu/3RunningBeforeTheModernShoe.html

Discussion BF/Shod Comparison

Possible Explanations for Heterogeneity of Data

Experience of Barefoot Runners

Lieberman et al. utilized habitually shod vs. habitually BF runners
Larger ES (-3.44)

http://www.healthynomics.com/wp-content/uploads/2009/08/barefoot-running1.jpg

The BF condition & FFS running pattern decrease IC-GRF

Discussion

Causes?
http://barefootted.com/uploaded_images/Sportsllustrated Barefoot01-719926.jpg http://gearjunkie.com/images/1825.jpg

Causes of Decreased IC-GRF

Superior neurosensory feedback preparing musculature for next stride (Kurz and Stergiou, 2004)

Discussion

http://www.ransacker.co.uk/wp-content/uploads/2010/08/A-barefoot-runner-in-Hyde-001.jpg

Causes of Decreased IC-GRF

BF condition tends to equal NHS running pattern
(Lieberman et al. 2010; Squadrone et al. 2009; Divert et al. 2005)

Discussion

http://4.bp.blogspot.com/_JadSUXnX75Q/S3aD2iNRnsI/ AAAAAAAAAT8/sl8pbmfVQ70/s320/heelstrike.jpg

Causes of Decreased IC-GRF

Stretching of arch first half of FFS second half of RFS No energy return and no dampening of forces
2010) (Lieberman et al.

Discussion

http://www.youtube.com/watch?v=r6YhVN_YIUk

Causes of Decreased IC-GRF

Change in stride length
(Lieberman et al. 2010; Squadrone et al, 2009; Divert et al, 2005; De Wit, 2000; Edwards et al. 2009, etc.)

Discussion

Greater vertical compliance, leading to lower rate of loading

(Lieberman et al. 2010)

Reduced IC-GRF

Discussion

Implications?

http://signaturestyleblog.com/wp-content/uploads/2011/03/girl_running_on_beach.jpg

Harm and Cost Effects

Not examined in any primary article
BF running reduces IC-GRF, theoretically there could be a reduction in stress-induced injuries If stress induced injuries are reduced, theoretically health care costs could be reduced

http://ravenessences.files.wordpress.com/2011/03/barefo ot_tefe_dancing.jpg?w=218&h=247

Possible Precautions/Contraindications
Osteoporosis/Osteopenia Peripheral Neuropathy Peripheral Arterial Disease Rigid midfoot Cold/Hot Temperatures Obstacles on ground
Broken glass Nails Needles
(Squadrone et al. 2009; Jenkins and Ross, 2011)
http://shodless.com/wp-content/uploads/2010/01/michael_sadler_barefoot_winter.jpg

Shoes for forefoot strike?

Vibram Fivefingers Tarra Plana Evo Merrell Trail Glove New Balance Minimus Kigo Edge Nike Free
http://kayakshed.blogspot.com/2010/07/ kigo-improves-its-minimalist-shoes.html http://www.vibr amget.com/ima ges/729013%5B 1%5D.jpg http://www.treeh ugger.com/Terraplana-evobarefoot-runningshoe-photo.jpg

http://www.sho pnewbalance.co m/products/MT 10GY_lg.jpg

http://runningti mes.com/rt/ima ges/201012/Trail Shoe_MerrellTrail-Glove-.jpg

http://www.nike freerunshop.co m/images/nike_ free_run_men_b lack_red.jpg

Implications for Practice

Educate patients on evidence available at this point Decreased IC-GRF with BF running
Effect size -1.72 = 41% BW

NHS also reduces IC-GRF

http://www.voxy.co.nz/userfiles/running%20barefoot%20shoes.jpg

PT interventions?

Limitations
Heterogeneous studies
Heterogeneous subjects Inconsistent distance run in experiment Small sample sizes

Developing area of research

HS vs NHS required

Only included articles in English Not enough data to determine interaction effect between BF and NHS

Directions for Further Research

Define normative values for specific sub-groups of runners Further examine differences between habitually shod and barefoot runners Investigate whether minimalist shoes mimic the positive aspects of BF running Investigate BF vs Shod running patterns at longer distances

Directions for Further Research

Investigate injury rates in both BF and shod running populations Investigate which body types and structures are most successful for both shod and barefoot running Role of BF/NHS running in injury prevention

Conclusions
Statistically Significant difference in IC-GRF between BF/Shod and HS/NHS Further research needs to be completed before making large clinical decisions This literature review is just one step towards understanding the vast differences between running barefoot and running shod
http://www.goodhousekeeping.com/cm/goodhousekeeping/i mages/qZ/ghk-canyon-spotting-lg.jpg

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Sangha O., Epidemiology of rheumatic diseases. Rheumatology (Oxford). 2000 Dec; 39 Suppl 2:3-12. Schamberger, W. The malalignment syndrome, implications for medicine and sport. Churchill Livingstone 2002. Sekizawa K, Sandre MA, Ingersoll CD, et al. Effects of Shoe Sole Thickness on Joint Position Sense. Gait Posture 2001; 13: 221-8. Serink MT, Nachemson A, Hansson G. The effect of impact loading on rabbit knee joints. Acta Orthop Scand 1977; 48: 250-62. Squadrone R, Gallozzi C. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. J Sports Med Phys Fitness. 2009 Mar; 49: 6-13. Stacoff A, Nigg BM, Reinschmidt C, Bogert AJ, Lundberg A. Tibiocalcaneal kinematics of barefoot versus shod running. J Biomech. 2000; 33: 13871395. Stacoff A, Steger J, Stssi E, Reinschmidt C. Lateral stability in sideward cutting movements. Med Sci Sports Exerc. 1996 Mar; 28: 350-8. Stacoff A, Denoth J, Kalin X, and Stussi E. Running injuries and shoe construction: some possible relationships. Int. J. Sport Biomech. 1988; 4: 342-357. Staheli L. Shoes for children: a review. Pediatrics. 1991; 88(2):371-5. Stefanyshyn DJ, Nigg BM. Influence of midsole bending stiffness on joint energy and jump height performance. Med Sci Sports Exerc. 2000 Feb; 32, 471-6. Taunton JE, Ryan MB, et al., A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002 Apr; 36: 95-101. Trinkaus E. Anatomical evidence for the antiquity of human footwear. J Archaeol Sci. 2005; 32: 1515-1526. Van Gent RN, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med, 2007; 41: 469-80. Voloshin A, Wosk J. An in vivo study of low back pain and shock absorption in the human locomotor system. J Biomech. 1982; 15: 21-7. Waddington G, Adams R. Football boot insoles and sensitivity to extent of ankle inversion movement. Br J Sports Med. 2003 Apr; 37(2):170-4. Warren BL, Jones CJ. Predicting plantar fasciitis in runners. Med Sci Sports Exerc. 1987 Feb; 19: 71-3. Warburton M. Barefoot Running. Sportsci. 2001; 5(3), sportsci.org/jour/0103/mw.htm. Watkins J, (2007). An Introduction to Biomechanics of Sport and Exercise. Churchill Livingstone. ISBN 0-44310-282-1. Wolf S, Simon J, Patikas D, et al. Foot motion in children- A comparison of barefoot walking with shod walking in conventional and flexible shoes. Gait Posture. 2008; 27(1):51-59. American Podiatric Medical Association Website: http://www.apma.org/MainMenu/News/MediaRoom/PositionStatements/APMA-PositionStatement-on-Barefoot-Running.aspx Yessis M. Explosive Running: Using the Science of Kinesiology to Improve Your Performance. McGraw-Hill, New York, 2000.

Thank You
Diane Allen, PT, PhD Arlene McCarthy, PT, DPT, MS, NCS Ali Legakis, MS, DPT(c) Emily Hellmuth, MS, DPT(c) Pete Rumford, MS, DPT(c), CSCS Sara Tanza, MS, DPT(c) Naomi Hosking, MS, DPT(c) Janeen Gray, MS, DPT(c) UCSF/SFSU, DPT Class of 2011

Videos if Time Allows

Barefoot Kenyan runner http://www.youtube.com/watch?v=pgkWhca pWLU