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August 6, 2010

by Anthony Brooks, NPR 

The latest hot product from the athletic shoe industry is the so-called toning shoe — a fancy sneaker with an unstable sole that’s supposed to make your leg muscles work harder during everyday activities.

Shoe companies say that toning shoes can sculpt your legs and reduce the girth of your backside while you walk, as in a Skechers ad: “Get in shape without setting foot in a gym.” But at least two new studies suggest such claims are untrue.

The Hype

Skechers and companies like Reebok and MBT are all selling versions of toning shoes, from $100 a pair to as much as $245 a pair.

Outside her office in Boston this week, Carin Willis was wearing her MBTs, which have big, thick, curved soles that look like big rubber rockers. “They’re very heavy. They’re very ugly,” she says.

Maybe so — but she says they have helped her sore back.

“I followed the hype of great for your legs, great for all that,” Willis says. “Do I think they’ve resculpted my legs? No. But I do think it has helped with my back and my posture.”

Toning shoes represent the fastest-growing segment of the shoe industry. In the Skechers store in downtown Boston, a manager says the shoes are flying out of his store — even if customer Muhammad Jaffa seems skeptical. “Yeah, the way they look, I don’t like them,” Jaffa says.

“They claim that if you walk in them they tone your muscles — they make your muscles stronger,” the manager says.

“Oh yeah?”

“Yeah.”

“I have no clue about that. You have some research about that?”

The Research

In fact, there is research; it just doesn’t all agree. The latest two studies come from the American Council on Exercise. The nonprofit group compared the benefits of toning shoes from Skechers, Reebok and MBT with ordinary running shoes.

Read The Studies

The American Council on Exercise says there is “simply no evidence to support the claims that these shoes will help wearers exercise more intensely, burn more calories or improve muscle strength and tone.” Skechers released three studies, which it says supports its claims that toning shoes work.

The American Council On Exercise Study

Romkes Study

Kalin Study

Li Study

“Both studies found that there was no significant difference between any of the toning shoes and the standard running shoe,” says ACE’s Todd Galati. Bottom line, says Galati, is that claims that toning shoes help people burn extra calories, improve muscle tone and build strength are bunk.

“These shoes are not a magic pill. It is the walking that will make a difference in your life. Not the shoe,” he says.

But that’s not the way Skechers sees it.

“Well, first of all, I would say that the study that they conducted is deeply flawed,” says Leonard Armato, president of Skechers Fitness Group. He says the ACE studies are too limited. He says they’re contradicted by what he calls “more than a dozen larger and more rigorous studies” — and by customer response.

“Skechers has received 12,000 unsolicited positive reviews of Shape-ups,” Armato says. “And many of these people insist that the benefits they have received have literally transformed their lives for the better.”

But ACE stands by its studies, pointing out that they were conducted by independent researchers at the University of Wisconsin.

Galati of ACE does concede that while toning shoes aren’t magic, they might motivate people to walk and exercise more — and that can only be a good thing.

After Heatstroke, When Is It Safe to Exercise?*By GINA KOLATA 

It was 90 degrees in Buffalo when Douglas Casa stood on the starting line of a track, ready to run 25 laps in a race that was part of the Empire Games, a championship event for high school students. The race began well for him — it was one of the best races of his life. Then, with half a lap to go, he collapsed. He got up, started to run again, and collapsed again, 50 meters from the finish line, in a coma, unresponsive. Even though he was immediately cooled with ice and cold wet towels, and taken by ambulance to a hospital where he was put in a tub of ice, he did not wake up until that evening. That was in 1985, and it turned out to be a life-altering event for Dr. Casa, now the director of athletic training at the University of Connecticut. He had a heatstroke on the track that day and, ever since, heatstrokes have been his obsession. But heatstroke, a potentially deadly consequence of exercising strenuously in the heat, remains poorly understood — misunderstood, some say. Medical experts know it occurs when the body’s temperature soars during exertion on a hot day, damaging tissues and organs. But they cannot agree on one of the most fundamental issues. After someone has a heatstroke, when is it safe to return to the sport? “This is a very controversial area, even more so than concussions,” said Dr. Francis G. O’Connor, president of the American Medical Society of Sports Medicine. He moderated a debate on the topic at a recent meeting of the American College of Sports Medicine. Guidelines on returning to exercise, from the American College of Sports Medicine and the National Athletic Trainers’ Association, are not based on the best scientific evidence, Dr. O’Connor and others say. Instead, they are based on what the guideline committees think makes sense. “There is a lot of reliance on dogma that has never been backed up or tested,” said Lisa Leon, a research physiologist at the United States Army Research Institute of Environmental Medicine. As a person exercises in the heat, blood gets diverted to the surface of the skin for cooling. The hotter the person gets, the more blood is diverted — as much as 25 percent of the body’s blood can end up going to the skin instead of to exercising muscles and to organs like the intestines, kidneys and liver, said Michael Sawka, chief of the thermal and mountain medicine division at the Army environmental medicine institute. One result can be heat exhaustion — the person may collapse, unable to continue exercising. Heatstroke is more serious than heat exhaustion, characterized by delirium or coma. The first thing that should be done is to immediately cool the person, with an ice bath or cold water, or cold towels — the best method is a matter of debate, Dr. O’Connor said. But the real damage can be insidious, researchers say.  “The issue with heatstroke is that most people know that you are exposed to heat, you exercise, and you collapse,” Dr. Leon said. “They don’t know about what happens in the days, weeks and months that follow.” Researchers, including Dr. Leon, discovered that long term damage can occur because the gut, lacking enough blood, gets leaky. Toxic substances excreted by gut bacteria seep out. That results in inflammation that can cause serious damage to other organs, especially the liver and kidneys. For decades, this cascade of events starting with a leaky gut was unappreciated because everyone focused on damage from high body temperatures, Dr. Leon said. “We were so blindfolded for so long,” she added.  And that leads to the question of when is it safe to return to exercise? One school of thought says people who have had heatstroke should get a heat tolerance test — walking on a treadmill in a warm room to see if their body temperature stays in a safe range. Another group of experts, including Dr. Sawka, say the heat tolerance test is based on an old, and incorrect, idea that heatstroke involves damage to the hypothalamus, a brain region that regulates body temperature. When a person has recovered from heatstroke, that theory says, the sign is that they no longer overheat during exercise. But autopsy studies and some MRI scans of people who had heatstroke indicate the hypothalamus is not damaged. Injured brain regions include the cerebellum and the cerebral cortex, which is why people pass out, Dr. Sawka said. He worries about lasting damage to the liver and kidneys. One study of distance runners who had heatstrokes and repeated liver biopsies indicated their livers were still recovering four months later. And a study by the Army’s Research Institute for Environmental Medicine found that 30 years after soldiers had heatstroke they were at increased risk of death from liver failure and other organ damage. “A picture is starting to emerge,” Dr. Sawka said. “Heatstroke causes organ damage, and that organ damage may persist for an unknown amount of time.” “We need to be very careful” about allowing people to return to exercise after heatstroke, Dr. Sawka said. But that does not help physicians and athletes, Dr. O’Connor said. Most doctors follow guidelines from professional organizations that say to wait at least a week after you have left the hospital. Then, if a medical assessment indicates that you seem to have recovered, you can gradually return to exercise. Dr. Casa and others add a heat tolerance test on a treadmill. It is impossible to rule out organ damage with the current guidelines, he agrees, but he said most people who are cooled quickly seem to recover completely. Twenty five years ago, when Dr. Casa had his heatstroke, he had no guidance on how to return to running.  “The first week after my heatstroke I was lethargic, totally out of it,” he said. “It took me two or three weeks to get my energy back.”  But he ran with the cross country team that fall, and did well.  And he has been running ever since. *NY Times, June 14, 2010

The toning shoe has become one of the most talked about products in the footwear industry.  Toning shoes are sometimes called wellness shoes, fitness shoes or rocker bottom or rocker sole shoes but the toning term seems to be the most commonly used especially in the marketing of this type of footwear.  Some analysts predict that the toning category of footwear will grow into a $1 billion market in the next few years.⁸ Realizing that this is likely more than just a passing footwear fad, manufacturers are introducing new models to the market at a pace that is hard to keep up with.

At the high end of the market, price –wise, is MBT which effectively launched the category single handedly in the early 2000’s.  Currently, there are more than 15 manufacturers with toning models and more are being added almost weekly.  Prices vary widely from $30 to more than $250.

Advertising messages tout the benefits of the toning shoes as improving muscle strength and tone, improving balance, improving posture, burning more calories, relieving stress on joints and even eliminating back,  foot or leg pain.  While there are studies supporting some of these claims, toning shoes are not a panacea for gait problems or foot pain.  And research does not suggest that increased muscle activation with their use is adequate to replace other fitness activities.  As is typical in advertising, some manufacturers greatly overstate the benefits and do not fully disclose the risks associated with toning shoes.

Shoe Structure

The design concept of toning shoes is based on a rocker bottom outsole.  Rocker bottom outsoles are not a new invention.  Podiatrists and other medical professionals have been prescribing them for decades to treat gait problems, foot or ankle pain, arthritic conditions and deformities.  Typically, a podiatrist would order custom rocker bottom modifications for a patient’s shoes that would be performed by an orthotist, pedorthist or a skilled shoe repair specialist.

Toning shoes are purposely unstable.  They are designed to facilitate sagittal plane motion, or motion from heel to toe.  By rounding the outsole in this direction, the foot and lower leg are “rocked” forward as weight is transferred from heel to toe during gait.  Because of this rocking motion, the forces acting on joints are changed and muscles are activated to control some of the instability.

Instability is, of course, a concern for those who have poor balance or muscle weakness that may make them vulnerable to falls.

The geometric contour of the rocker bottom varies from manufacturer to manufacturer and of course some claim that their particular geometry is superior.  The rocker contour can be to the heel only (not pictured) the forefoot only, or to both heel and forefoot – which is called a double rocker.

The weight of toning shoes can vary significantly.  Some of the more popular models are significantly heavier than conventional shoes. This added weight can be detrimental to some users.  There is increased joint stress and muscle fatigue due to shoe weight. 

Benefits of Toning Shoes

Increased Muscle Activation
Research by Benno Nigg and collegues at the University of Calgary showed that “unstable footwear designs” result in greater muscle work load. ¹ Even when standing, muscle activation is higher in rocker bottom footwear than conventional shoes – primarily because the wearer has to work harder to maintain balance.  This increased muscle activation could strengthen and condition muscles that are underutilized in some conventional footwear.  Other research has substantiated these findings.

Improved Balance
In those who wore rocker bottom shoes over period of 6 weeks, postural sway, a measure of balance during standing, decreased.¹ Another study found older women after wearing unstable footwear for 8 weeks improved on three different measures of balance tests.² The unstable footwear design challenges balance and improves proprioception.

Increased Metabolism
It has been proposed that rocker bottom shoes increase metabolic activity as a result of the increased muscle activation.  In a swiss study financed by MBT⁶, researchers measured oxygen consumption and heart rate in barefoot, conventional running shoes and rocker bottom shoe conditions. They concluded that MBT wearers burned slightly more calories per hour.  The greatest differences in metabolic rate occurred comparing barefoot to MBT and were more pronounced in standing vs. walking.

Altered Weight Distribution
Studies have shown that peak pressure to the plantar surface of the foot is altered with rocker bottom footwear when compared to conventional shoes. However, the pressure change effect is not always predictable. Because there is no uniform standard of rocker bottom geometry, the effect varies from brand to brand and model to model.⁷ Also, study subjects do not respond in a systematic way to footwear interventions. In one study, double rockers decrease peak pressure to the heel, midfoot and metatarsals but increase peak pressure to the plantar digits.⁵ The increased toe pressure is due to “grasping” of the digits as they attempt to stabilize the foot inside the rocking shoe.

This altered plantar surface distribution may provide pain relief to those prone to heel, midfoot or metatarsal conditions. However, one study suggested that because of individual variability, some form of plantar pressure measurement and gait training may be necessary to ensure optimal pressure changes. ⁷

Joint Motion Changes
Studies have shown alterations to joint motion in gait – especially in the saggittal plane.  One study showed a slightly increased flexion (less than 5 degrees) at the hip, knee and ankle during early mid-stance. The greatest changes appear to be at the ankle joint which showed increased dorsiflexion at initial contact and greater plantarflexion at toe-off.^3,4 In terms of forefoot kinematics, one study showed that rocker soles offer advantages over conventional footwear by aiding in forefoot roll-off and simulating dorsiflexion of the digits at the level of the metatarsal phalangeal joints.⁹ This would be beneficial for those with forefoot arthritic conditions or joint fusions.

Risks and Other Considerations
The same features that can provide benefits in some users may have consequences in others.  For example, the unstable design while showing benefits in terms of balance in some users may increase the risk of falls in others.  Those with a history of falls, chronic ankle instability, vertigo or poor balance may not be candidates for toning shoes. 

Other considerations include; because of the increased ankle dorsiflexion in early stance, those with history of Achilles tendonopathy may not tolerate this type of footwear.  Also, manufacturers assume a normal limb alignment for those who may wear these shoes, therefore those with transverse plane deformities such as in-toeing or out-toeing will not have normal heel-to-toe transition in these shoes and could potentially be more prone to tripping or falling.

Mass Marketing of Toning Shoes
While MBT’s were the first to enter this market, there are many newcomers, at varied price ranges that have thrown their shoe into the ring.  Some of the newer brands have incorporated more style features in an attempt to develop shelf appeal.  And, of course, each brand emphasizes certain structural features that are unique to their product.

As mentioned above, there is significant variability in the geometry of the outsole, the weight of the shoe and in the way that individuals gait may be affected by the shoe.  For that reason, it is difficult to recommend one brand or model over another for individual needs.

Brands:

• MBT
• Skechers Shape Ups
• Reebok Easy Tone*
• Cogent
• Ryn
• Mephisto Sano
• Earthshoe
• Fitflops
• Avia iBurn
• Z7
• Springboost
• Orthaheel
• New Balance Rock and Tone
• Dansko
• Chung Shi
• Champion Pace

*The Reebok Easy Tone is not considered a true rocker sole shoe because it does not use the rocker concept but is included in this list because it is designed to be unstable to mimic some of the effects of rocker sole shoes.

Information published on www.aapsm.org

Sources:

1. Landry, SC, Nigg BM, Tecante, KE, Standing in an unstable shoe increases postural sway and muscle activity of selected smaller extrinsic foot muscles, Gait & Posture, corrected proof online May 2010.
2. Ramstrand, N, Thuesen, HA, et al. Effects of an unstable shoe construction in women over age 50 years, Clinical Biomechanics, Vol 25, #5, June 2010, 455-460
3. Long, JT, Klein JP et al. Biomechanics of the double rocker sole shoe: Gait Kinematics and kinetics, Gait & Posture, Volume 40, Issue 13, Pages 2882-2890 (2007)
4. Myers KA, Long JT, Klein JP, Wertsch JJ, Janisse D, Harris GF, Biomechanical implications of the negative heel rocker sole shoe: gait kinematics and kinetics. Gait & Posture. 2006 Nov;24(3):323-30. Epub 2005 Nov 21
5. L. Stewart, J.N.A. Gibson, C.E. Thomson, In-shoe pressure distribution in “unstable” (MBT) shoes and flat-bottomed training shoes: A comparative study Gait & Posture, Volume 25, Issue 4, Pages 648-651 (April 2007)
6. Gasser, BA, Stauber AM, et al. Does wearing shoes with unstable shoe construction stimulate metabolic activity in lower limbs? University of Bern Switzerland, 2008
7. van Schie C, Ulbrecht JS, Becker MB, Cavanagh PR, Design criteria for rigid rocker shoes, Foot Ankle Int. 2000 Oct;21(10):833-44
8. Sitek, T, Healthy Feet,  Footwear Insight, Formula 4 Media, March/April 2010
9. Wuab, WL Rosenbaum, D,  Su, FC, The effects of rocker sole and SACH heel on kinematics in gait, Medical Engineering & Physics, Volume 26, Issue 8, Pages 639-646 (October 2004)

There are currently more than 24 million known persons with diabetes in America, and the number grows by approximately one-half million annually.  It has been estimated that an equal number of persons with diabetes remain undiagnosed.  A person develops diabetes when their body is unable to maintain a normal level of sugar in the blood.  Insulin, the hormone that regulates the level of sugar, is either not used properly by the body or it is produced in inadequate amounts.  When this occurs, diabetes is the result.

Juvenile or, more appropriately, people with Type 1 diabetics, respond to treatment with daily insulin injection and represent 10% of the diabetic population.  The remaining 90% of diabetics are adult-onset or Type 2, typically over 35 years of age, often overweight, and can be treated with diet, exercise, oral anti-diabetic medications and/or insulin.

Frequent signs of the presence of diabetes are:

1. ✦increased thirst

2. ✦frequent urination

3. ✦chronic fatigue

4. ✦rapid unexplained weight loss

5. ✦slowly healing sores and cuts

6. ✦frequent infection

7. ✦blurred vision

8. ✦sweating from the waist up with dry skin from the waist down

9. ✦tingling and numbness in the hands and feet

The long-term presence of elevated blood sugar levels commonly result in damage to the eyes, kidneys, heart and feet.  Due to damaged small blood vessels and cataract formation, loss of vision may occur.  Vascular disease increases the potential for heart disease and stroke. It may impair kidney function, and in the feet, it may result in diminished circulation along with reduced ability to fight off infection and heal wounds. Damage to nerves, known as neuropathy, may result in a lack of sensation.

These factors often result in complex foot problems that may require major foot surgery or even amputation of the foot or leg.  Small cuts, skin cracks, burns, sores, sore corns, ingrown nails, bunions and other common foot problems caused by ill-fitting shoes may become infected and result in gangrene.  These patients, due to the neuropathy (lack of sensation), are often unaware of the existence of these problems until it is too late to reverse the complications.

If you are diabetic, make sure you see a podiatrist for a detailed foot examination at least once each year

If you have diabetes and you’re searching for new footwear, it is important to first ask a few questions of yourself.
1. Do you have diabetic neuropathy (loss of feeling)
YES: You need shoes that are wide enough and deep enough not to rub on your feet. This may be hard to detect since you have lost some feeling in your feet. Best to see a podiatrist or orthotist and purchase some recommended non-custom shoes.
NO: You can purchase sensible shoes over the counter. Find a comfortable sneaker or tennis shoe.
2. Are you feet deformed? (Do you have hammertoes, bunions, high or flattened arches)
YES: If you answered NO to question 1, then you can follow the advice posted there. If you do have neuropathy and deformity, it is very important to have a custom shoe prescription.
NO: You will need extra-depth shoes that are wide enough in the toe box to accommodate your feet. They don’t have to be custom shoes.
3. Have you ever had a diabetic foot ulcer or sore on your feet?
YES: You are at highest risk for having another ulcer. Best to be evaluated by a podiatrist to see what is best to prevent another ulcer.
NO: You can follow the advice of the previous 2 questions.

The newly formed PPE Coalition for Youth Sports and Safety held a press conference at the National Press Club in Washington, DC on May 13, 2010. A Past President of The American Academy of Podiatric Sports Medicine,  Steve Pribut, DPM, attended this event as a representative of the AAPSM. The American Academy of Podiatric Sports Medicine is one of the founding members of the coalition and was recognized at the event along with the other founders.

This event launched an initiative to standardize and upgrade the pre-participation physical evaluation. This was done in conjunction with the publication of a new edition of the PPE Pre-participation Physical Evaluation, written with the collaboration of 6 medical societies, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. A standard and thorough pre-participation physical evaluation is vital for the health and safety of young athletes. The purpose of the Coalition is to encourage the use of a standard PPE. Currently, there are no national standards to use in evaluating an athlete for participation in sports. Mandates on the PPE requirements vary from one state to the next. To provide a safer environment for the athletes, the coalition is pressing to create a specific standard. A website has been established to promote the initiative. The new standardized PPE H&P form is freely downloadable from their website at: http://www.ppesportsevaluation.org/ . Among the speakers was Jim Ryan, was the first high school runner to run a mile in under 4 minutes. He set a high school record of 3:55.3 for the mile, which stood for 36 years. Former Congressman Ryan also held the world record in the mile, 1500-meter, and 880 yard runs. He participated in three summer Olympic games in 1964, 1968, and 1972. He won the silver medal in the 1500 meter run in 1968. Recently ESPN declared him to be the best high school athlete ever, finishing ahead of Lew Alcindor (Kareem Abdul-Jabbar). Jim Ryan spoke of the importance of having physical education included within a revised “no child left behind” law. With the rise in childhood obesity there is no reason to have only one year of PE required in the 4 years of high school. To much amusement he told of not making the baseball or basketball team, but being able to join the cross country team. With a rapid increase from no running to up to 60 miles per week, he found that his first injury was an incredibly painful case of shin splints. Also speaking was Congressman Mike McIntyre of North Carolina. He is the founder of the Congressional Caucus on Youth Sports. As a member of the “Blue Dog Coalition” he attempts to forge a bipartisan agreement on health and fitness related issues. His feelings were strong on the importance of safely encouraging youth health and fitness. He spoke of how what we teach our children is our message to a far-off future that we will not be around to see. Included in the initiative was recognition of the importance of serving children with special needs an including these special athletes in all of the initiatives that are now set in motion. The AAPSM has long supported initiatives along this line as evidenced by the Special Olympics “Fit Feet” project.

The Great Shoe Flap: Is Barefoot ‘Better’?*

The running community has lately been very attentive to the barefoot running/minimalist shoe movement. More broadly, we see a lot of attention paid right now to those making claims about the body’s natural biomechanics, often by exploring running through academic disciplines like history and anthropology. But are the claims and conclusions they buttress always accurate? Are we ready to say that the sometimes-beneficial practice of barefoot running—is better?At the center of this debate are studies and books revealing that arguments on each side are complicated, and occasionally even compromised by factors outside the realm of good science. Those factors may include the monetary interests of shoe manufacturers who sometimes fund the studies, and even researchers seeking private-sector benefit, but also more benign influence such as a zeitgeist right now that romanticizes running through the lens of our species’ history. The latter factor is due in no small part to the bestselling book Born to Run. The Amazon blurb for this interesting book begins: “Full of incredible characters, amazing athletic achievements, cutting-edge science, and, most of all, pure inspiration, Born to Run…sets off to find a tribe of the world’s greatest distance runners…and in the process shows us that everything we thought we knew about running is wrong.”This tendency toward hyperbole is part of the problem. While author Chris MacDougall has certainly written a unique and inspirational memoir that may make you rethink running or find new inspiration in the elegant simplicity of it, it is simply not the case that “everything we thought we knew about running is wrong.” It is just this kind of slightly sensational blurb copy that cheapens an interesting argument by overreaching with an extraordinary claim.In an interview on Amazon, MacDougall says, “We treat running in the modern world the same way we treat childbirth—it’s going to hurt, and requires special exercises and equipment, and the best you can hope for is to get it over with quickly and with minimal damage.” Most every experienced runner knows that these statements about running are not true. But it certainly makes a good sound bite.Sound Bite Medicine
In December, a study called The effect of running shoes on lower extremity joint torques reported that linear forces up through the knee were greater in shod runners than barefoot ones. There are a few significant problems with this small study of 68 subjects. Mainly, linear ground-reaction forces were the only ones measured; there are other measures, such as stability forces, that need to be considered as part of the overall effect of running on the knees. Second, only one type of cushioned shoe was measured in the study. As Running & FitNews® Clinic advisor Ben Pearl, DPM, a consultant at the National Institutes of Health with a private practice in Arlington, VA, points out, it’s already somewhat accepted that “there’s a point where you can get into a running shoe with too much cushioning.” But it is, to be frank, less than optimal to learn of this from someone who has designed and is presently trying to sell a cushionless running shoe. The study was conducted by D. Cassy Kerrigan, MD, and this is true of her; her private-sector email address listed in the abstract is at a shoe company: dckerrigan@oeshshoes.com. The study is listed on PubMed as generating not from a university but from an entity called JKM Technologies, LLC. Unfortunately, this matters. The abstract concludes with a vague tie-in to knee osteoarthritis risk, itself followed by several strong caveats:“The findings at the knee suggest relatively greater pressures at anatomical sites that are typically more prone to knee osteoarthritis, the medial and patellofemoral compartments. It is important to note the limitations of these findings and of current 3-dimensional gait analysis in general, that only resultant joint torques were assessed. It is unknown to what extent actual joint contact forces could be affected by compliance that a shoe might provide, a potentially valuable design characteristic that may offset the observed increases in joint torques.”Are there benefits to running barefoot? There is some data that injury risk may be reduced in certain, specific situations. But the problem with “sound bite medicine,” as Pearl calls it, is that things are usually more complicated than sound bites. And whatever else it is, the Internet can sometimes be a bizarre echo chamber for questionable assertions. The top link listed after a Google search on this study’s title led to a self-styled “health blogger” who wrote:“[A] new study published in the prestigious Journal of American Academy of Physical Medicine and Rehabilitation found that barefoot running puts less damaging torque on our hip, knee, and ankle joints than wearing supportive running shoes…The study used the most technologically advanced non-invasive techniques to asses the biomechanics of running. For thousands of years Man ran without supportive footwear. It is only in the last few decades that some people, mostly shoe companies, told us our feet needed support, control, and stability.” The “prestigious” PM&R Journal referred to above was in its very first year of existence, 2009, when Kerrigan’s study was published. Regardless, this blogger would have you believe the only reason any of us are walking around shod is because we’ve been mass-brainwashed by corporate marketing. Respected anthropologists such as Harvard professor Daniel Lieberman have recently offered more compelling theories. Experience, Performance, and Other Factors
Lieberman believes that the human foot developed to run barefoot. His other central hypothesis is that we were uncannily built for endurance running. But these are really different arguments.Lieberman writes, “Our research shows that habitually barefoot or minimally shod humans tend not to land on their heels and instead strike the ground in a way that leads to very low collision forces, even on very hard surfaces.”That’s as may be, but we must be careful assuming biological history trumps all. After all, This is the way we’ve always done it, and so we should is as weak an argument as This is the way we are currently doing it, and so we should continue. There’s potential for a stand-off here that can only be broken by designing and repeating studies that look at hard injury data.Surely in studying the “habitually barefoot” Lieberman is aware he is studying a very small minority of humans walking around today. If you’re among this group and have been running that way your whole life, as your family has for generations, certain positive adaptive outcomes might be expected. Are we really to conclude from this that we all should run without shoes?Remember, too, that even research on cultures that finds association between injury and wearing shoes may be mitigated by other factors: perhaps in developing countries barefoot runners may be too poor to seek medical attention; also, shod runners may wear shoes because they have problems running barefoot.There are leaps here that if Lieberman himself is not quite making, others certainly are eager to make. Several companies have weighed in with their versions of a running shoe which simulates barefoot running. Adidas’ approach was to try and copy the shape of the foot. The idea for the Nike Free came after researchers visited Stanford, where athletes were running barefoot as part of their training regimen. Nike had students test it and those using the Free for six months had greater flexibility and strength in the foot. But, again, is it right for everybody, always?After initially pushing very hard for their Free shoe line, Nike has since backed off a bit, perhaps to avoid short-changing their cushioned shoes until the debate is settled. The fact that Nike isn’t taking sides, Pearl thinks, is a good reflection of market forces at work for a change. If published research influences consumer desire for one shoe over another, then the need is truly great for nuanced, objective work that contributes to sorting this out correctly, and the dangers of sound bite medicine truly great as well.Again, Pearl admits, “We can see some indicators that if you have a heavily cushioned shoe you get a delayed second-peak of force that is transmitted into the body. You don’t have the same shock absorption as with forefoot strike, the natural barefoot form.” But he points out that even if that modified foot strike leads to better shock absorption, there is the issue of running performance that needs to be addressed. He says, “This is a second, extremely important issue—because you are losing stride length.” And surely whenever you have even the potential for compromised performance, you’re going to have a major downside as far as competitive running is concerned.It can also be very difficult for some people to maintain good form with forefoot running. The studies that look only briefly at running form and shock absorption on a treadmill don’t give us a lot of real-world info to make an informed shoe choice for actual races. What may be really efficient over a short interval of time might in the long run be a bad choice. Pearl reiterates that there is simply not much new information being published on differentiating, epidemiological studies that support either side as better. Pearl respects Lieberman’s work, but fears it is sometimes prone to a certain reductionism that does not serve the big picture. “You have a bunch of variables to be interpreted a variety of ways,” he says. “You have to be careful about pigeonholing things into your scenario. It’s just that—one scenario.”“Right now we don’t have anything study-wise to confirm that barefoot running is better than wearing shoes,” says Pearl. He calls for “randomized, controlled studies showing physical evidence of syndromes like stress fractures that are not subjective.”Natural Compromise
The science is clear, however, that unstable surfaces, whether hard or soft, can increase injury. And repetitive motion appears to be another factor in increased injury risk. It would seem, then, that there is room for the promotion of trail running in this argument. Once you can personally establish a conservative progression into this type of natural training, there are benefits.In trail running, the varied terrain causes you to slow down, land differently, and avoid the “autopilot” that can make you less aware of pain worth attending to. There are long-term adaptations in the muscles of the legs and feet that are more diverse than if you were hitting in the same place all the time. And here is an important point: Trail running is like these historically natural forms, yet no one goes out trail running barefoot. In fact trail shoes have more strongly enforced toe boxes and increased ankle stability than even regular running shoes.Lieberman’s earlier review article on running and human evolution, published a few years ago in Nature, seems in some ways more thoughtful and less reaching, and is in fact very inspiring stuff. He proposes, along with Dennis Bramble, that the human form was shaped by our species’ unique ability and need to run long distances.The authors note that endurance running is entirely unique to humans among primates. The fact that such distances are unheard of among apes and chimps makes it all the more remarkable: humans run long distances very well, despite a primate ancestry.The spring-like tendons that developed in humans are not nearly as apparent in early hominids and apes. Walking does not rely on a spring mechanism, but rather on a pendulum motion. The development of these muscles and tendons, therefore, cannot be explained through walking alone.Similarly, stride length is a key component of increasing speed without increasing aerobic requirement. Humans have long legs—much longer than Australopithecus, as determined by fossil femur length. The authors even argue that sweating, hairlessness, and cranial cooling systems found in the human species, though certainly useful for walking, are essential for endurance running in hot climes.Room for Inspiration?
In similar works like the book Why We Run by Bernd Heinrich, the lyrical is combined with the scientific in ways that combine the disciplines of biology, anthropology, psychology, and philosophy to great inspirational effect. The work that authors like MacDougall, Lieberman, and Heinrich are doing—call it pop anthropology—has a poetic side to it. And romanticizing something like running has its upside. It is surely positive for our wider health culture that Born to Run appears on the New York Times nonfiction bestseller list. Pearl has a constant stream of people coming into his clinic now with all kinds of questions about barefoot running, and his conversations with personal trainers reveal that he is not alone. People find inspiration in the natural arguments, and this is good; questions, too, are good. But the very same people that may be lured—inexperienced newcomers who never felt at home in athletics or competition—are the ones in the greatest danger of succumbing to the oversimplification of this topic in the media, and therefore at greatest risk of injury. They are also the least biomechanically ready to try something as radical as shoeless running. In fact, Pearl sees a lot of injured patients at his practice that are exactly like Chris MacDougall, the so-called Clydesdale runners whose extra bulk can make them so prone to injury. Running & FitNews Clinic advisor Melvin Williams is a Groundpounder, a name given to people who have run every Marine Corps Marathon since its inception in 1976. He is in his 70s, and has been regularly running on the beach barefoot for decades. Mel has a lifetime of good biomechanics to call upon to make his septuagenarian marathoning possible. The questions to be answered for every runner individually are: Should I tackle a minimalist shoe? How much running in it should I at first attempt? How soon should I escalate this training, and by how much?Arguments for Sometimes Training Barefoot
When it comes to foot problems shoes are there to help, but they can also act as enablers. By constantly wearing shoes, our culture has created a weaker foot that relies on artificial support to maintain its integrity.A study at the Department of Movement and Sport Sciences at the University of Ghent in Belgium found that barefoot runners create a softer landing and quickly learn to avoid a heel-first strike method, which is not the ideal way to spread ground reaction forces over the entire sole. They also found that barefoot runners employed a significantly higher leg stiffness during landing. In another study of ankle coordination, subjects ran either in a hard shoe, a soft shoe, or unshod. No significant differences in coordination were found between the two shoe conditions. However, significant differences in ankle coordinative strategies existed between the shoe conditions and the barefoot condition. These adaptive strategies contribute to better running economy and protect against injury. But to safely get the most out of barefoot running, remember to start gradually. First increase the frequency with which you walk around the house barefoot. You will overstress your Achilles tendon and plantar fascia if you jump out there barefoot right away. When it comes to cushioning, one extreme or the other is not, as of yet anyway, the answer. The bones of our ancestors may be shaped in a certain way that favors barefoot running. Certain unshod cultures flourish on foot. But simple conclusions remain out of reach. As Pearl puts it, “Even if we say we were once more forefoot runners, that’s still just how we run when we run barefoot.” The unanswered question is: Should we go back to that, or not bother so much with it because we do wear shoes now? We are nowhere near the body of evidence needed to decide yet. Yet one can’t help but notice that today’s runners aren’t competing barefoot. When it comes to racing, you go with what works.Amazon Exclusive: A Q&A with Christopher McDougall, http://www.amazon.com/Born-Run-Hidden-Superathletes-GreatestJ. Phys. Med. & Rehab., 2009, Vol. 1, No. 12, pp. 1058-1063, http://www.ncbi.nlm.nih.gov/pubmed/20006314Michael Nirenberg, Jan. 12, 2010, http://stanford.wellsphere.com/life-as-a-doc-article/original-research-running-barefoot-may-be-safer-for-your-hip-knee-and-ankle-joints/942902Daniel E. Lieberman, Harvard University
http://www.fas.harvard.edu/~skeleton/danlhome.htmlNature, 2004, Vol. 432, Nov. 18, pp. 345-352, http://www.nature.com/nature/journal/v432/n7015/abs/nature03052.htmlRunning & FitNews, Mar/Apr 2005, “Barefoot in the Park”

Why We Run by Bernd Heinrich, 2001, HarperCollins, New York, NY, 292 pp.

Running & FitNews, Jul/Aug 2009, “Barefoot Running, or Just a Minimalist Shoe?” by Ben Pearl, DPM

*From “Running and Fitness News”, March, 2010

Tendinitis is often used incorrectly as a generic term for overuse tendon injuries. The term that should be used is tendinopathy. Tendinitis and tendinosis both refer to microscopic changes that are seen on biopsy. Even spelled as “tendonitis”, it is still incorrect. The current view is that long term overuse tendon injuries display little to no inflammation. While the original meaning of the word inflamation refers to something feeling like it is “on fire”, the medical term refers to histopathology and microscopic examination. While it may still hurt and in a sense feel as bad as if it were on fire, we need to start calling the injury tendinopathy. Of course the biggest problem is that when a doctor tells you that your problem is “tendinopathy” it will take a 20 minutes of discussion to define what is meant by that.

  Gout is an acute arthritic disease which causes a sudden onset of intense pain usually in the big toe joint.  The  ”attack”(as it is called) commonly starts overnight with intense pain, localized heat and swelling around the big toe.  Gout is caused by the deposit of crystals composed of uric acid in the joint of the body.  Other joints may suffer attacks of gout but the big toe joint is the most common.  Uric acid is a breakdown product of protein metabolism by the body.  Foods high in amino acids called purines and pyrimidines are broken down into uric acid in the blood.  When the level of uric acid becomes too concentrated in the blood it starts to “settle out” in crystal form.  When these crystal deposit in the joint it starts a dramatic inflammatory response by the immune system. How is gout diagnosed? Gout may be diagnosed by a combination of clinical history and exam, blood tests, diagnostic imaging, or joint fluid analysis. Who gets gout? Gout affects men six times more frequently than women.People who have a diet high in foods that contain purines and pyrimidines.  These are red meat, organ meats, shellfish, sardines, and red wine are a few examples.Alcohol consumption can cause gout due to its diuretic(increase in urination) effect which ups the concentration of uric acid.Diuretics(water pills) such as furosemide (Lasix) also can increase the possibility of gout. Is gout dangerous?Repeated attacks or untreated cases can lead to permanent joint destruction with subsequent osteoarthritis.Gout can lead to kidney stone formation also.