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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.

Many of our patients are affected by rough skin around the rim of the heel that cracks or splits.  They can form into heel “fissures”(painful splits that bleed) if severe enough.  The condition is usually worse in the winter when the humidity is lower.  If you suffer from cracked heels here are some do’s and don’ts: -Do wear shoes that cup the bottom of the heel and have a heel counter(where the shoe encloses the back of the heel)-Don’t wear flip flops or backless shoes that allow friction on the skin.  -Do apply a moisturizing cream such as Eucerin or Lubriderm twice daily-Don’t use ointments such as Neosporin or Vaseline(they don’t hydrate the skin)-Lose weight-obesity is common in this condition due to the increased flattening of the natural heel fat pad.-Limit wearing nylon hosiery in the winter.-Do see a podiatrist to see if you have underlying athlete’s foot or eczema. A podiatrist may prescribe a heel insert or orthotic for your heel to cup the fat pad.  The heel fissures may have to be debrided(pared down) and you may require stronger hydrating creams which are by prescription only.

Corns are formations of hard skin that form over bony prominences due to repeated forces of friction and pressure.  They are simply a formed by proliferation of the stratum corneum which is the top or outside layer of the skin.  Corns are usually hard except for corns that occur between the toes.  The corns between the toes stay moist in the web space and as a result are softer and spongier.  They usually occur in the web space near the baby toe or between the big toe and the second toe when  two toes touch and rub together.  It is more common in flatfeet due to toe misalignment or in individuals that wear stylish narrow toe boxed shoes.These corns usually give a painful burning sensation.Home therapy should includes foot powders to keep the web space dry, this will cut down on the burning. Avoid vaseline or ointments between the toes as these increase the rubbing and pain.One may also place cotton or lamb’s wool between the toes or store bought corn pads.A podiatrist can evaluate your soft corn(Heloma molle) by determining what causes the toes to rub. Is it shoes, foot position in gait, or misalignment of the toes themselves(bunions, hammertoes).The corns are removed by simple paring.  The corns will quickly return in most cases if shoes are not the culprit.  Definitive treatment may include altering the bone structure with surgery which may be done with a minimal incision surgery(osteotripsy) or traditional surgery on the toe (arthroplasty).  In cases where the big toe is too close to the second toe a bunion correction surgery may be indicated.

Toenail discoloration commonly comes from a previous injury or the color change could be due to a fungus. The only way to detrmine if it is a fungus is to have a culture taken. The results are usually back within a month.

Fungus nail infections are NOT contagious but may be uncomfortable and unsightly. Treatment is oral medication for three months. This medication is very safe, unlike medications used in the past.

It is VERY rare when topical medications cure a nail fungus. Other “old wive’s tales” include vinegar and other household products. These do NOT work and frequently cause skin irritation.

Diagnosis for treatment should be made by a professional.

Welcome to the PodiatryAffiliates.com blog. Here you will find the latest in podatric news, helpful tips and useful information to keep you informed — and to help you better care for one of your most vital organs - your feet!

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